198320378-2-29-2024-11-AS-UCOL-D4D2E5-20240415171923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320378
Report Date: 02/29/2024
Date Signed: 02/29/2024 12:48:25 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
02/09/2024 and conducted by Evaluator David Espana

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240209152909

FACILITY NAME:	HOLIDAY VILLA		FACILITY NUMBER:	198320378
ADMINISTRATOR:	ZENOU, ADAM		FACILITY TYPE:	740
ADDRESS:	1447 17TH STREET		TELEPHONE:	(310) 829-5904
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90404
CAPACITY:	174	CENSUS: 56	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Administrator, Rudy Cruz		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Facility staff are not assisting resident with bathing
Facility staff are not assisting the resident with toileting
Facility staff are not providing resident with an accessible toilet
Facility staff are not providing resident with an accessible shower

INVESTIGATION FINDINGS:

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On 02/29/2024 at 8:00 am Licensing Program Analyst (LPA) David España conducted a subsequent complaint continuation investigation visit for the allegation listed above to deliver findings. Upon arriving at the facility, LPA met with the Administrator Ruby Cruz and MarieAnn Chan, Business Office Manager who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections.

During the records review on 02/15/2024, LPA observed and requested copies of the annual staff training for residents' personal rights. Also, LPA observed the rights posted on the facility walls. In addition, LPA observed and requested copies of the personal rights in the resident's admissions agreement; with signatures of representatives upon moving into the facility.
Complaint Investigation Report LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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 8

Control Number 11-AS-20240209152909

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: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 02/29/2024

NARRATIVE

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LPA requested copies of the following: Three (3) months copies of (1) The number of residents receiving in incontinent, diapers changed; (2) The number of residents receiving daily cleaning of their bathroom (log); (3) The number of residents who have received their showers, sinks or toilets repaired; (4) The amount of residents being provided assistant for incontinent care, diapers changes; (5) The facility log or record keeping of reported repairs of any bathroom within the facility; (6) The timeline of how long it takes to repair bathroom fixture; and (7) The list of residents in care who have not received services they have requested (i.e., outstanding).

On 02/29/2024 LPA interviewed, observed, and reviewed facility room numbers #68, #24, #23, and #30 (photos) were found within Title 22 regulations. On 02/15/2024 LPA interviewed, observed, and reviewed facility room numbers #37, #86, #72, #28, and #29 were found within Title 22 regulations. At 10:30 am LPA confirmed that there are Fifty-One (51) residents in care at the time of visit. At 10:30 am LPA confirmed that there are Twenty-Six (26) staff members at the time of visit. LPA interviewed Five (5) out of Fifty-One (51) residents. LPA interviewed Five (5) out of Twenty-Six (26) staff members. LPA interviewed One (1) Witness (W#1) for the alleged Four (4) complaints listed.

Allegation # 1: Facility staff are not assisting resident with bathing. It is alleged residents’ bathing needs are not being met. On 02/13/2024 LPA España at 10:10 am Licensing Program Analyst (LPA) David España met with Witness #1 (W1) to discuss the complaint investigation. Complaint Investigation Report LIC9099-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 11-AS-20240209152909

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: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 02/29/2024

NARRATIVE

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W1 explained that W1 finally reached the Executive Director on 12/19/23 and explained the needs for the modification W1 further stated that the facility would address the grab bars and look into a gray toilet, but they (facility) would not be able to pick up the vanity or install anything else that the resident could use. W1 stated that Adam (owner of the facility) did not address the shower. On 02/29/2024 LPA interviewed, observed, and reviewed facility room numbers #68, #24, #23, and #30 (photos) that were found within Title 22 regulations. On 02/15/2024 LPA interviewed, observed, and reviewed facility rooms numbers #37, #86, #72, #28, and #29 that were found within Title 22 regulations. LPA interviewed Five (5) out of Fifty-One (51) residents. LPA interviewed Five (5) out of Twenty-Six (26) staff members. During the records review, LPA reviewed staff yearly training regarding residents' personal rights. All staff have taken the training. During an interview with the Executive Director, Narine Mertkanyan and Five (5) out of Twenty-Six (26) staff members, per Executive Director, Narine Mertkanyan stated that all staff know the residents' rights and do annual training. During interviews with Four (4) out Fifty-One (51) residents stated that they personally have not had issue with a staff member at the facility, and facility staff are assisting resident with bathing. During interviews with W1, they disagreed facility staff are assisting resident with bathing. During interview(s) with Executive Director, Narine Mertkanyan,“Savant senior living has a motion in place, and it will be addressed on Monday 02/26/2024 with regional maintenance regarding our wheelchair bound residents and their bathroom sinks. Here are the following Rooms that will need to be worked on #68, #24, #23, and #30.” Complaint Investigation Report LIC9099-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 11-AS-20240209152909

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: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 02/29/2024

NARRATIVE

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Based on interviews, observations, record reviewed there is insufficient evidence to support the allegation: Facility staff are not assisting resident with bathing. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is Unsubstantiated.

Allegation # 2: Facility staff are not assisting the resident with toileting.

It is alleged facility staff are not assisting the resident with toileting. It was reported that the staff is not providing proper toileting services to the residents. When interviewed Five (5) out of Twenty-Six (26) staff members and Four (4) out Fifty-One (51) residents all denied the allegation. During interviews with Four (4) out Fifty-One (51) residents stated that the resident’s toilet work and if assistance was needed, they (residents) believe they would receive it from staff members. Five (5) out of Twenty-Six (26) staff members also stated that they were not aware of other residents having issues with sanitary wipes, toileting, and that the facility has more than enough for the residents. R1 did not confirm those stated, LPA took photos of the bathroom and did not observe a portable toilet in R1’s bedroom or room. Four (4) out Fifty-One (51) residents reported that they are not considered incontinent and do not require those types of services. During an interview with the Executive Director, Narine Mertkanyan and Five (5) out of Twenty-Six (26) staff members, per Executive Director, Narine Mertkanyan stated that all staff know the residents' rights and do annual training. During interviews with Four (4) out Fifty-One (51) residents stated that they personally have not had issue with a staff member at the facility, and facility staff are assisting resident with toileting. Cont'd LIC-9099-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 11-AS-20240209152909

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: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 02/29/2024

NARRATIVE

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Per W1 the facility stated that they (facility) were working on the other toilet seat, and they (facility) were unlikely to modify anything else. W1 followed up with the resident in February and found out that the grab bars were installed and nothing else. On 02/29/2024 LPA interviewed, observed, and reviewed facility room numbers #68, #24, #23, and #30 (photos) that were found within Title 22 regulations. On 02/15/2024 LPA interviewed, observed, and reviewed facility rooms numbers #37, #86, #72, #28, and #29 that were found within Title 22 regulations.

Per Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87307 Personal Accommodations and Services, LPA has observed toilets and bathrooms conveniently located. LPA observed at least one toilet and washbasin for each six (6) persons, which include residents, family and personnel. LPA observed at least one bathtub or shower for each ten (10) persons, which includes residents, family and live-in personnel. LPA observed individual privacy being provided in all toilet, bath and shower areas. LPA observed space and safety provisions provided by the facility. LPA observed each room that accommodates residents being served in a comfort and safety environment. LPA observed the premises being maintained in a state of good repair and is providing a safe and healthful environment.

Based on interviews, observations, record reviewed there is insufficient evidence to support the allegation: Staff is not providing proper toileting services to resident in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is Unsubstantiated. Cont'd LIC-9099-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 11-AS-20240209152909

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: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 02/29/2024

NARRATIVE

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Allegation # 3: Facility staff are not providing residents with an accessible toilet.

It is alleged staff are not providing residents with an accessible toilet. On 02/13/2024 at 10:10 am Licensing Program Analyst (LPA) David España interviewed Witness #1 (W1) to discuss the complaint investigation. The interview with W1 revealed that the grab bars, raised toilet seat and bathroom counter have not been addressed or corrected. Per W1 CEO Adam stated that the facility believed that the facility would address the grab bars and possibly the toilet seat, but it is unlikely the facility would take out the vanity and install a new sink. On 02/29/2024 LPA interviewed, observed, and reviewed facility room numbers #68, #24, #23, and #30 (photos) that were found within Title 22 regulations. On 02/15/2024 LPA interviewed, observed, and reviewed facility room numbers #37, #86, #72, #28, and #29 that were found within Title 22 regulations. When interviewed Five (5) out of Twenty-Six (26) staff members and Four (4) out Fifty-One (51) residents all denied the allegation. During interviews with Four (4) out Fifty-One (51) residents stated that the resident’s toilet is accessible and if assistance needed, they (residents) believe they would receive facility help. Five (5) out of Twenty-Six (26) staff members also stated that they were not aware of other residents having issues accessing their toilet.

Based on interviews, observations, record reviewed there is insufficient evidence to support the allegation: Facility staff are not providing residents with an accessible toilet. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is Unsubstantiated. Cont'd LIC-9099-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 11-AS-20240209152909

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: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 02/29/2024

NARRATIVE

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Allegation # 4: Facility staff are not providing resident with an accessible shower.

It is alleged staff are not providing residents with an accessible shower. LPA interview with Resident 1 (R1) who stated that the alleged violation “Facility staff are not providing resident with an accessible shower,” has occurred and location. R1 stated they (facility) agreed to move R1 to another room because of accessibility concerns. LPA took photos of R1 wheelchair accessibility while interviewing. Based on interviews, observations, and record reviewed, and the facility (i.e., Adam Zenou) acknowledged progress at the facility which has been made due to rebranding of the facility, namely, the restrooms being wheelchair accessible at the facility. W1 stated that the resident is unable to maneuver in his wheelchair and the bathroom. On 02/29/2024 LPA interviewed, observed, and reviewed facility room numbers #68, #24, #23, and #30 (photos) that were found within Title 22 regulations. On 02/15/2024 LPA interviewed, observed, and reviewed facility rooms numbers #37, #86, #72, #28, and #29 that were found within Title 22 regulations. The R1 stated they required assistance getting into the shower and required a shower seat to use in the restroom. R1 stated services are being provided, caregivers are accessible for showers “they are great and hard working.” When interviewed Five (5) out of Twenty-Six (26) staff members and Four (4) out Fifty-One (51) residents all denied the allegation. During interviews with Four (4) out Fifty-One (51) residents stated that the resident’s showers are accessible and if assistance needed, they (residents) believe they would receive facility help. Five (5) out of Twenty-Six (26) staff members also stated that they were not aware of other residents having issues accessing their showers.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 11-AS-20240209152909

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: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 02/29/2024

NARRATIVE

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Based on interviews, observations, record reviewed there is insufficient evidence to support the allegation: Facility staff are not providing resident with an accessible shower. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is Unsubstantiated.

No deficiencies were cited. A exit interview was conducted with AnnMarie Chan, Business Office Manager and hard copy of the report was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

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