198320378-8-19-2026-11-AS-PMAA-DXBS6F-20260826133553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320378
Report Date: 08/19/2026
Date Signed: 08/19/2026 05:39:29 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
07/20/2026 and conducted by Evaluator Regina Cloyd

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20260720122129

FACILITY NAME:	SAVANT OF SANTA MONICA		FACILITY NUMBER:	198320378
ADMINISTRATOR:	JOE SALDANA		FACILITY TYPE:	740
ADDRESS:	1447 17TH STREET		TELEPHONE:	(310) 829-5904
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90404
CAPACITY:	174	CENSUS: 125	DATE:	08/19/2026
		UNANNOUNCED	TIME BEGAN:	01:41 PM
MET WITH:	Joe Saldana		TIME COMPLETED:	05:49 PM

ALLEGATION(S):

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Staff are mismanaging resident's medication resulting in resident being hospitalized.
Staff are not checking resident's insulin levels.
Staff does not have a qualified skilled professional to provide resident with injections.

INVESTIGATION FINDINGS:

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On 08/19/26, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather additional information regarding the above allegations. This report does not change the findings delivered on 07/28/26. LPA met with Executive Director Joe Saldana and Health & Wellness Director.

Investigation consisted of the following: On 07/27/26, The Department obtained Personnel Record, Register of Residents, Resident #1 - #8 Notes and Incidents, After Visit Summary, July 2026 Work Schedule. LPA interviewed Staff #1 – 5 and Resident #1 – 6. On 07/28/26, the Department obtained R1’s Medication Administration Records (May 2026 – July 2026), Physician’s Telephone Order, R1’s Face Sheet and Emergency Info, Physician Order Form, Physician’s Report for Residential Care facilities for the Elderly, New Prescription Summary, After Visit Summary (03/03/26, 06/03/26, 07/10/26), Besht Wellness (02/26/26), Clinical Requisition (07/20/26), Medication Technicians’ Trainings, and interviewed Staff #6 - #10, Residents #7 - #10, and Witness #1. On 08/19/26, the Department obtained Personnel Record, Register of Residents, R1’s Medication Administration Record (July 2026) and interviewed Staff #5. Continue to LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260720122129

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: 08/19/2026

NARRATIVE

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Allegation: Staff are mismanaging resident's medication resulting in resident being hospitalized. It is alleged staff administered discontinued medication instead of the most recent prescribed (07/10/26) medication to Resident #1 (R1).
Record review revealed the following: After Visit Summary (07/10/26) revealed R1’s active medications: Dorzolamide-timolo PF2-0.5%, Latanoprost 0.005%, and Lubricant eye drops 0.5%. Review of R1’s Notes & Incidents revealed R1 complained of blurry eyesight on 07/12/26 9:52 PM. Review of Clinical Requisition (07/20/26) revealed all eye drops to be discontinued except for Artificial tears, Cosopt eye drops 2-0.5%, and Latanoprost 0.005%. Review of Medication Administration Record (July 10, 2026 to July 31, 2026) revealed Dorzol/Timol Sol 2-0.5% Solution was administered 0 times after 07/10/26 and 11 times after 07/20/26. Medication was held from 07/13/26 06:13 to 07/24/26 16:03. Genteal Tear Sol Mod was give 16 times after 07/10/26 and 15 times after 07/20/26. Miebo Dro 1.3GM.ML was given 23 times after 07/10/26 and 0 times after 07/20/26. Simbrinza Sus 1-0.2% was given 6 times after 07/10/26 and 0 times after 07/20/26. Lantanoprost Sol 0.005% was administered 2 times after 07/10/26 and 10 times after 07/20/26. Hold until 07/20/26. Rhopressa Sol 0.02%. was administered 2 times after 07/10/26 and 0 times after 07/20/26. Lubricnt eye drop 0.5%. was administered 0 times after 07/10/26 and 0 times after 07/20/26 (hold 07/13/26 - 07/20/26).Email Correspondence (08/08/26) revealed R1 saw the ophthalmologist on 07/28/26 and the PRN Lubricnt Eye Drop was placed on hold 07/28/26 by the Primary Care Physician (PCP). On 07/28/26, LPA observed two of the three medications in stock. The PRN Artificial tears was out of stock.
Interviews revealed the following: Eight out of eight staff interviews (S2 – S6, S9 – S10) disagree with the allegation. The Resident Service Director (S5) indicated the facility has to wait for the Primary Care Physician (PCP) to discontinue the medication and the PCP work directly with the pharmacy. In addition, the Pharmacy will place certain medications on hold until it is approved by the PCP, including hospital orders. In regards to the PRN artificial tears, S5 indicated the pharmacy did not have a refill order and received a verbal discontinuation by the Nurse Practitioner on 07/28/26. S5 indicated the Nurse Practitioner visits R1 monthly and also reviews the medication list. R1 goes to a lot of different specialists and they will prescribe different medications and send it directly to the pharmacy. Eight out of ten residents (R1 – R10) indicated they have not experienced staff medication errors that resulted in hospitalization. R1 indicated that the medication irritated R1’s eye because it was the wrong medication.
Regarding the allegation, “Staff are mismanaging resident's medication resulting in resident being hospitalized,” based on record review, interviews, and observation, the preponderance of evidence standard has not been met, therefore the above allegation(s) is found to be unsubstantiated. 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. Continue to LIC9099-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260720122129

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: 08/19/2026

NARRATIVE

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Allegation: Staff are not checking resident's insulin levels. It is alleged staff does check Resident #1 (R1) glucose levels before meals. Record review revealed the following: Review of R1's Physician Order Form (printed 02/25/26) revealed R1’s blood sugar is to be tested three times a day before meals and every day at bedtime (start 07/16/25). Interviews revealed the following: Seven out of eight staff interviews (S2 – S6, S8 – S10) disagree with the allegation. The Resident Service Director (S5) indicated residents have to go to the medication room to get tested before mealtime. R1 is independent, had a glucose testing machine in room, and also receive reminders to test glucose levels when R1 eats in room. S5 indicated the glucose levels are not recorded in the system. S6 indicated R1 does not come to down for breakfast sometimes S6 has to test R1’s glucose levels in R1’s room. Four out of five residents (R1 - R2, R4 – R6) indicated they disagree with the allegation. R7 – R10 does not have their glucose levels checked. Witness #1 (W1) indicated checking R1’s glucose weekly.
Regarding the allegation, “Staff are not checking resident's insulin levels,” based on record review and interviews, the preponderance of evidence standard has not been met, therefore the above allegation(s) is found to be unsubstantiated. 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.
Allegation: Staff does not have a qualified skilled professional to provide resident with injections
Record review revealed the following: Review of Register of Residents revealed eight residents receive insulin injections. Interviews revealed the following: Five out of seven residents (R1– R7) indicated they do their own injections or a nurse comes to the facility to administer the injections. R1 indicated the MedTechs and Nurse assist with R1’s injections. Eight out of eight staff interviews (S2 – S6, S8 – S10) disagree with the allegation. The Resident Service Director (S5) and S6 indicated residents are responsible for their own injections with the exception of a few who see a Home Health Nurse. S5 indicated many residents are taking metformin. Interview with Licensed Vocation Nurse (W1) indicated W1 visits the facility weekly to assist seven to eight residents with injections, including R1. R1 receives Ozempic injections on Thursdays.
Regarding the allegation, “Staff does not have a qualified skilled professional to provide resident with injections,” based on record review and interviews, the preponderance of evidence standard has not been met, therefore the above allegation(s) is found to be unsubstantiated. 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.
No deficiencies cited.
An exit interview was conducted and a copy of this report was provided to the Executive Director Joe Saldana.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2026

LIC9099 (FAS) - (06/04)

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