198320378-7-2-2025-11-AS-JHAD-DK4RHD-20250731130209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320378
Report Date: 07/02/2025
Date Signed: 07/02/2025 12:22:33 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/15/2025 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20250115134552

FACILITY NAME:	SAVANT OF SANTA MONICA		FACILITY NUMBER:	198320378
ADMINISTRATOR:	NARINE MERTKHANYAN		FACILITY TYPE:	740
ADDRESS:	1447 17TH STREET		TELEPHONE:	(310) 829-5904
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90404
CAPACITY:	174	CENSUS: 111	DATE:	07/02/2025
		UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Executive Director Nathaniel Venzon		TIME COMPLETED:	12:24 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident developed a pressure injury while in care.
Staff do not ensure residents bathing needs are being met.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 7/2/25 at 9:45am Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Executive Director Nathaniel Venzon as the purpose of the visit was explained.

The investigation consisted of the following: On 01/22/25 LPA requested copies of the following: resident and staff rosters, list of residents receiving hospice, home health, and/or wound care services, and shower log for January 2025. On 01/22/25 LPA also requested the following documents for resident #1 (R1): emergency ID form, admission agreement, physicians report, physicians’ orders, needs and service plan, pre-appraisal, and home health paperwork. On 01/22/25 between 11am- 1:05 pm LPA conducted interviews with residents #2-10 (R2-R10), LPA unable to interview R1 as R1 is currently admitted at Cedar Sinai hospital. On 01/30/25 LPA obtained copies of staff and resident rosters, shower logs for January 2025, and conducted interviews with ED, and staff #1-5 (S1-S5).
The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

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 2

Control Number 11-AS-20250115134552

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SAVANT OF SANTA MONICA	FACILITY NUMBER: 198320378
	VISIT DATE: 07/02/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Resident developed a pressure injury while in care

It is being alleged that facility staff were not assisting resident in care with repositioning which resulted in resident developing a pressure injury. On 01/22/25 between 11am- 1:05 pm LPA conducted interviews with R2-R10 regarding the allegation above, 7 of 9 residents interviewed denied the allegation above, 2 of 9 residents interviewed reported obtaining wounds in the past but could not provide a time frame. On 01/22/25 LPA unable to interview R1 as R1 was receiving care at Cedar Sinai hospital. On 1/30/25 LPA unable to interview R1 as R1 was receiving treatment outside of Savant Of Santa Monica. On 1/30/25 LPA conducted interviews with ED, and S1-S5 regarding the allegation above, 6 of 6 staff interviewed denied the allegation above and reported that residents that require repositioning are checked out and repositioned every 2 hours. On 7/2/25 LPA conducted a review of R1s physician report and appraisal, LPA observed there is no order that R1 needed to be re positioned. There is no documentation that R1 had a pressure injury upon admission to Savant Of Santa Monica. On 7/2/25 LPA reviewed medical records obtained from Cedar Sinai hospital, per medical records Injury was observed at the hospital but never staged.

Allegation: Staff do not ensure residents bathing needs are being met.

It is being alleged that facility staff are not providing showers to residents in care. On 01/22/25 between 11am- 1:05 pm LPA conducted interviews with R2-R10 regarding the allegation above, 5 of 9 residents interviewed denied the allegation above and reported receiving showers 2 times a week. 3 of 9 residents interviewed reported they do not require assistance from staff for showers. 1 of 9 residents interviewed confirmed the allegation above and reported going more than 2 days without shower assistance from staff. On 01/22/25 LPA unable to interview R1 as R1 was receiving care at Cedar Sinai hospital. On 1/30/25 LPA unable to interview R1 as R1 was receiving treatment outside of Savant Of Santa Monica. On 1/30/25 LPA conducted interviews with ED, and S1-S5 regarding the allegation above. On 1/30/25 LPA conducted interviews with ED, and S1-S5 regarding the allegation above, 6 of 6 staff interviewed denied the allegation above and reported that that showers are provided 2 times a week. 3 of 6 staff interviewed reported that a resident may go more than 2 days without a shower if the resident refuses. On 7/2/25 LPA conducted a review of shower logs and observed documentation indicating showers are done twice a week, LPA also observed documented refusals from residents.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2