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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320378
Report Date: 08/13/2024
Date Signed: 08/13/2024 04:18:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
05/20/2024 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20240520092651
FACILITY NAME:SAVANT OF SANTA MONICAFACILITY NUMBER:
198320378
ADMINISTRATOR:RUBY CRUZFACILITY TYPE:
740
ADDRESS:1447 17TH STREETTELEPHONE:
(310) 829-5904
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:174CENSUS: 75DATE:
08/13/2024
UNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Narine MertkhanyanTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not ensure resident's showering needs were met
INVESTIGATION FINDINGS:
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***This amended report supersedes the report dated 5/24/2024. This report is being created to remove unsubstantiated allegation “Staff did not ensure resident's showering needs were met." This unannounced subsequent complaint inspection is being conducted on 08/13/24 by Licensing Program Analyst (LPA) Wendy Gibbs, for the purpose of delivering findings for the investigation into the above identified complaint allegation. The LPA met with facility Administrator, Narine Mertkhanyan, and the purpose of today's visit was explained.
On previous visits conducted on 05/24/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced 10-day complaint visit. LPA met with Administrator, Ruby Cruz, and the purpose of the day’s visit was explained.
During the visit, LPA toured the facility, interviewed Staff S1-S5, interviewed Residents R1-R7, and received documents pertinent to the investigation. The documents include a Staff Roster, Resident Roster, Shower Log, Resident’s Physician Reports, Resident’s Pre-appraisal Evaluation, Resident Needs and Service Plan, and Staffing Notes for the past three (3) months.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
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 4
Control Number 11-AS-20240520092651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SAVANT OF SANTA MONICA
FACILITY NUMBER: 198320378
VISIT DATE: 08/13/2024
NARRATIVE
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Allegation: Staff did not ensure resident’s showering needs were met
The allegation alleges a resident, who is a fall risk, did not receive assistance with a shower for 1 ½ months despite asking for assistance.
During record review of the shower schedule for residents who require assistance, LPA observed that residents are scheduled with an assisted shower 1 to 3 times a week. LPA reviewed four (4) Residents Physician’s Report, Needs and Service Plan, and Appraisal to see they type of assistance Residents require. During record review of R1’s Admission Agreement, LPA observed under Basic Services, R1 initialed number 9 indicating the acceptance of services, which include assistance with bathing. Additionally, LPA reviewed R1’s Service Plan that indicates R1 will be assisted once a week with showering and bathing. LPA reviewed the facility Shower Schedule which indicates R1 is to be assisted with a shower once a week. During review of the facility Staff Notes, LPA did not see any notes regarding R1 receiving assistance with a shower.
During interviews with Staff S1-S5, were asked if residents who require assistance with a shower receive assistance, five (5) out of five (5) stated residents who require assistance with a shower receive assistance. Additionally, five (5) out of five (5) stated if a resident who requires assistance with a shower requests a shower on a non-scheduled day the staff will accommodate the resident as soon as they are available, unless it is related to incontinence.
During interviews with Residents R1-R7, were asked if they receive assistance with a shower, four (4) out of seven (7) stated they receive assistance with showers when scheduled and when need or requested. Additionally, Residents R1-R7,
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 11-AS-20240520092651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SAVANT OF SANTA MONICA
FACILITY NUMBER: 198320378
VISIT DATE: 08/13/2024
NARRATIVE
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were asked if there was a time, they not receive assistance with a shower, three (3) out of seven (7) stated they require assistance and was not provided with it. Additionally, two (2) out of the seven (7) stated they have either gotten into the shower without assistance or have taken a shower without assistance while being a fall risk.
During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator, Narine Mertkhanuan, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240520092651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SAVANT OF SANTA MONICA
FACILITY NUMBER: 198320378
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2024
Section Cited
CCR
87464(f)(4)
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87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and... as specified in Section
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Administrator will ensure residents receive assistance with showering according to resident’s Needs & Service Plan and keep shower log notes indicating residents take a shower or refused and email shower log to LPA, at wendy.gibbs@dss.ca.gov, by POC date.
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87608, Postural Supports.
This was not met based on interviews and record review Administrator did not ensure resident R1 received assistance with a shower as indicated on Admission Agreement and Service Plan which could be a health and safety risk to the resident.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4