198603220-10-10-2024-11-AS-EMAZ-DA7227-20241018170017

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603220
Report Date: 10/10/2024
Date Signed: 10/10/2024 10:34:11 AM

Unsubstantiated

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
11/27/2023 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20231127094216

FACILITY NAME:	CITY VIEW LA, LLC		FACILITY NUMBER:	198603220
ADMINISTRATOR:	GINSBURG, MENDY		FACILITY TYPE:	740
ADDRESS:	515 N LA BREA AVE		TELEPHONE:	(323) 938-2131
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90036
CAPACITY:	166	CENSUS: 99	DATE:	10/10/2024
		UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Mendy Ginsburg		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained pressure injuries while in care
Staff places double diapers on resident in care
Resident in care was illegally evicted

INVESTIGATION FINDINGS:

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

On 10/10/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit to deliver findings for the above allegations. LPA met with Executive Director, Mendy Ginsburg, and the purpose of today’s visit was explained.
During a subsequent visit on 09/13/24, LPA interviewed Staff S1, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Identification and Emergency Information form, R1’s Face Sheet, R1’s Staff Notes, Special Incident Report (SIR) for R1, Physician Admission Orders, emails, Service Receipt, Statement, Resident Assessment, and Admission Agreement.
During an initial visit conducted on 12/05/23, LPA toured the facility, interviewed Staff (S1-S7), interviewed Resident (R2-R10), and received documents pertinent to the investigation. The documents received and reviewed were the Staff Roster, Resident Roster, Incontinent Resident List, Resident Admission Agreement, resident Appraisal, Needs and Service Plan, Physician’s Report, and Nurse Notes.
The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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 5

Control Number 11-AS-20231127094216

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: CITY VIEW LA, LLC	FACILITY NUMBER: 198603220
	VISIT DATE: 10/10/2024

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 sustained pressure injuries while in care
The complaint allegation alleges that a resident had redness and was bleeding when being cleaned and was taken to the hospital and was treated for an open sore.

During record review, LPA reviewed R1’s Physician Report, dated 10/25/23, that indicates R1 does not have a history of skin condition or breakdown. LPA received and reviewed R1’s medical records from Kaiser Permanente-West Los Angeles from R1’s Emergency Room visit on 11/02/23 that stated in the ED Notes on 11/03/23 at 0345 “Noted pt (patient) to have mild excortication on coccyx,” on 11/03/23 at 1325 “Assessed Pt buttocks no redness noted,” and on 11/04/23 at 0703 “No blood noted in brief. No skin breakdown noted.” Additionally, in the Final Emergency Department Assessment on 11/03/23 at 1222 states R1 was treated for a rash. LPA did not observe a diagnosis of a pressure injury.

During interviews with Staff S1-S7, were asked how often incontinent and non-ambulatory residents are checked for pressure injuries, seven (7) out of seven (7) stated residents are checked regularly for pressure injuries, during changing, bathing, and dressing.

During interviews with Residents R2-R10, were asked if they have gotten pressure wounds by not being changed or being turned, seven (7) out of nine (9) stated they have not gotten any pressure wounds. Additionally, two (2) of the nine (9) residents stated they do not require assistance with changing or turning.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20231127094216

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: CITY VIEW LA, LLC	FACILITY NUMBER: 198603220
	VISIT DATE: 10/10/2024

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: Staff place double diapers on resident in care
The complaint allegation alleges that a resident was placed in double diapers.

During record review, LPA reviewed R1’s Physician’s Report and Staff Notes and did not observe a notation of Resident R1 being placed in double diapers. LPA received and reviewed staff training regarding care for residents who require incontinent care.

During interviews with Staff S1-S7, were asked if any residents are placed in double diapers, seven (7) out of seven (7) stated they do not place residents in double diapers. S6 stated some residents like to put a pad in their diapers. Additionally, during interviews, staff were asked how often incontinent residents are assisted with changing, seven (7) out of seven (7) stated incontinent residents are changed every two (2) hours but there are a few who require additional checking and changing.

During interviews with Residents R2-R10, were asked if they have been placed in a double diaper, four (4) out of nine (9) stated they have not been placed in double diapers. Additionally, five (5) out of nine (9) stated they do not require assistance with incontinent care and do it themselves.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20231127094216

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: CITY VIEW LA, LLC	FACILITY NUMBER: 198603220
	VISIT DATE: 10/10/2024

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 in care was illegally evicted
The complaint allegation alleges that the facility could not take a resident back into the memory care unit because the unit was full, saying the family discharged the resident from the facility.

During record review, LPA did not observe an eviction notice for any residents in October, November, or December 2023. LPA received and reviewed emails from 11/06/23 that stated R1 was not returning to facility and the family is requesting a refund. Additionally, LPA received and reviewed a Service Report dated 11/06/23 for R1 that indicates R1 was taken to the hospital on 11/02/23 and the Responsible Person decided not to bring R1 back to the facility. LPA received and reviewed the Statement which indicates the family was provided with a refund (check # 1318) on 11/06/23. Additionally, LPA received and reviewed medical records from Kaiser Permanente West Los Angeles Medical Center, that indicates, on page 33, the Responsible Person of R1met with the Social Worker on 11/03/23 at 4:52pm and the ED Case Management Notes states the “Responsible Person wishes to have the patient placed in a different facility…because it wasn’t a good fit for the patient.”

During an interview with Staff S1, was asked if there have been any residents who have been evicted in the past 2 months, S1 stated no, there have been no evictions in the past few months. Additionally, S1 was asked if there were any residents who have left or been discharged from the facility in the past month, S1 stated R1 was transferred to the hospital and the family decided not to bring R1 back.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20231127094216

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: CITY VIEW LA, LLC	FACILITY NUMBER: 198603220
	VISIT DATE: 10/10/2024

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

During interviews with Residents R2-R10, were asked if they have been threatened or given an eviction notice while living in the facility, seven (7) out of nine (9) stated they have not been threatened or given an eviction notice.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Executive Director, Mendy Ginsburg, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5