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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320184
Report Date: 01/12/2023
Date Signed: 03/23/2023 11:55:58 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230104163518
FACILITY NAME:AVENIR MEMORY CARE WESTSIDEFACILITY NUMBER:
198320184
ADMINISTRATOR:DRINKHOUSE-QUINTA, MARISSAFACILITY TYPE:
740
ADDRESS:7501 OSAGE AVETELEPHONE:
(424) 282-0040
CITY:LOS ANGELESSTATE: CAZIP CODE:
90045
CAPACITY:88CENSUS: 27DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:DIRECTOR JODI KANOWITZTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
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5
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7
8
9
Resident was physically assaulted by a resident in care.
Facility did not safeguard resident's money.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 01/12/2023

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Avenir Memory Care Westside on 01/12/2023 at around 10:00 AM and was greeted by Director S1. LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20230104163518
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AVENIR MEMORY CARE WESTSIDE
FACILITY NUMBER: 198320184
VISIT DATE: 01/12/2023
NARRATIVE
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10-day visit on 01/12/2023 approximately around 10:00 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Director (S1). On 01/06/2023 LPA Calderon could not interview W1 for complaint as W1 is anonymous. On 01/12/2023 LPA Calderon requested copies of the following: Staff and Resident rosters, needs and service plan, pre-placement orders, physician report on R1. On 01/12/2023 LPA Calderon interviewed S2-S5 for complaint. On 01/12/2023 LPA Calderon interviewed R1 for complaint and attempted to interview R2-R3 but due to mental health issues LPA Calderon could not ask residents questions regarding their care.

Regarding Allegation #1: Resident was physically assaulted by a resident in care.

On 01/06/2023 LPA Calderon could not interview W1 for complaint due to W1 reporting the complaint anonymous. On 01/12/2023 LPA Calderon interviewed S1 who states that S1 just started the job, and the prior administrator took reports and facility reports. S1 states that there was an issue 4 or 5 months ago when R1 was scratched on the arm by R2, S1 states that R1 was taken to the hospital for evaluation and R2 was evicted. On 01/12/2023 LPA Calderon interviewed S2-S5 all staff state that R1 is not an aggressive resident and gets along with other staff and residents. S2-S5 state that there was a minor issue 4 to 5 months ago when R1 was scratched on the arm by R2. R1 was taken to the hospital for evaluation due to R1 age. S2-S5 state that R1 was not assaulted by another resident. On 01/12/2023 LPA Calderon interviewed R1 for complaint. R1 states that when R1 was moved into the facility 4 or 5 months ago R1 was in the dinning room and witness R2 was attacking R3 with a fork and R1 stepped in to stop the attack and R2 scratched R1 right arm. R1 states that the police were called but no arrest was made. R1 states that due to R1 age R1 was taken to the hospital for evaluation. R1 states that since that incident had happened no other resident has attacked R1. On 01/12/2023 LPA Calderon attempted to interview R2-R3 but due to communication issues R2-R3 were not able to answer any questions from LPA Calderon. On 01/12/2023 LPA Calderon reviewed R1 facility records to include Needs and Service plan, Physician Report, Care plan, Preplacement Report, LPA noted mild cognitive impairment, mixed Alzheimer’s, and vascular dementia.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20230104163518
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AVENIR MEMORY CARE WESTSIDE
FACILITY NUMBER: 198320184
VISIT DATE: 01/12/2023
NARRATIVE
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2
3
4
5
6
7
8
9
10
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Regarding Allegation #2: Facility did not safeguard residents’ money.

On 01/06/2023 LPA Calderon attempted to interviewed W1 for complaint but due to W1 reporting the complaint anonymous no interview could be taken. On 01/12/2023 LPA Calderon interviewed S1 for complaint. S1 states that the facility does not handle any cash for residents and there is no additional cost to residents and S1 states there is no reason for a resident to have money while inside the facility, and this is documented in the admission agreement. S1 states to have no knowledge of any person taking or stealing R1 money. On 01/12/2023 LPA Calderon interviewed S2-S5, staff state that the facility does not handle any money or cash for residents and there is no need for a resident to have cash while inside the facility. S2-S5 state that they have no knowledge of any resident or staff taking or stealing money from R1. On 01/12/2023 LPA Calderon interviewed R1 for complaint. R1 states that 4 or 5 months ago when R1 moved into the facility R1 had money in R1 purse and staff stole R1 money, but R1 has no proof the money was stolen by staff. On 01/12/2023 LPA Calderon attempted to interview R2-R3 but due to communication issues R2-R3 were not able to answer any questions from LPA Calderon. On 01/12/2023 LPA Calderon reviewed R1 facility records to include Needs and Service plan, Physician Report, Care plan, Preplacement Report, LPA noted mild cognitive impairment, mixed Alzheimer’s, and vascular dementia.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of “Resident was physically assaulted by a resident in care” “Facility did not safeguard residents’ money” is found to be UNSUBSTANTIATED.



An exit interview was conducted and copy of the Complaint Report was provided to the Director S1
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3