198603220-2-6-2026-11-AS-JHAD-DR9VW9-20260213154734

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603220
Report Date: 02/06/2026
Date Signed: 02/06/2026 09:00:35 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
01/20/2026 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20260120103235

FACILITY NAME:	CITY VIEW LA, LLC		FACILITY NUMBER:	198603220
ADMINISTRATOR:	GINSBERG, 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: 120	DATE:	02/06/2026
		UNANNOUNCED	TIME BEGAN:	08:07 AM
MET WITH:	Marcia McKay & Mendy Ginsberg		TIME COMPLETED:	03:58 PM

ALLEGATION(S):

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Staff caused injuries to a resident.

INVESTIGATION FINDINGS:

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On February 06, 2026, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Mendy Gingsberg Executive Director and Marcia McKay, Wellness Director greeted the (LPA). (LPA) explained the purpose of the visit is to investigate the allegation mentioned above.

The investigation included a collection of records, and an observation of the facility. The Department obtained several documents, including the Personnel Report LIC 500 (dated 01/17/26), the Resident Roster (dated 01/21/26), service records for Resident #1-#3 Identification and Emergency Information LIC 601, Face Sheet & Emergency Info, Service Plan, Resident Appraisal LIC 603A, Medical Assessment for Residential Care Facilities for the Elderly LIC 602A, Incident Report LIC 624, and other pertinent records associated with this complaint.

(Evaluatiion Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026

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-20260120103235

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: CITY VIEW LA, LLC	FACILITY NUMBER: 198603220
	VISIT DATE: 02/06/2026

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff caused injuries to a resident.
It is alleged that staff caused injuries to Resident #1 (R1). Reports suggest that due to staff negligence, the staff member caused (R1) to fall out of the wheelchair and sustained head, knee, and fracture injuries. According to the report, (R1) was being pushed in a wheelchair by staff who took a fast turn, causing (R1) to fall out of the wheelchair. The incident occurred at City View on January 15, 2026, requiring emergency hospitalization. No additional details regarding this allegation have been provided.

On February 06, 2026, between 10:00 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of five (5) cannot corroborate this claim of (R1’s) fall was due to staff negligence in care. (S1) clarified that the fall did not occur due to any negligence on (S1's) part. On January 15, 2026, (R1) was being wheeled into the activity room when (R1) leaned forward and subsequently slipped out of the wheelchair before (S1) had the opportunity to assist. (S1) confirmed that (S1) had made a turn to navigate around oncoming obstacles, noting that the turn was executed carefully and was not a sharp or reckless turn. (S1) reported that (R1) received immediate medical assistance for a head injury and was uncertain about any injuries to the lower body at that time since (R1) was fully clothed. (S1) through (S5) confirmed (S1)'s account of the incident and were unaware that (R1) had sustained additional injuries to the knee, including a fracture, until the hospital provided this information. (S2-S3) noted that (R1) is on medications that increase sensitivity and the risk of injury due to the prescribed medication. (S2-S3) verified that (R1) had not been assessed as a fall risk and had never experienced a fall while at the facility. (S1 and S4-S5) verified completion of mandated staff training including fall prevention, proper positioning, back injury prevention, hoyer lift usability, and timely response to call lights.

On February 06, 2026, between 10:35 AM and 02:00 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Nine (9) out of ten (10) cannot support this claim. All nine residents require assistive devices and report that staff are careful and attentive when assisting with mobility. Furthermore, none of the nine residents have experienced falls or injuries due to staff negligence or lack of care.

Resident #1 (R1) was interviewed, but due to (R1’s) health condition, (R1) was unable to engage in a conversation.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260120103235

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: CITY VIEW LA, LLC	FACILITY NUMBER: 198603220
	VISIT DATE: 02/06/2026

NARRATIVE

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On February 04, 2026, between 11:02 AM and 12:20 PM, the Department interviewed witnesses identified as Witness #1 and Witness #2 (W1-W2). Two (2) out of two (2) witnesses could not corroborate this claim. (W1) is close to (R1) and noted that (R1) sometimes slips out of (R1's) wheelchair. (W1) asked (R1's) doctor about using a seat belt, but the doctor did not approve it. (W1) also mentioned that (R1) takes several medications that can make (R1) less stable and affect (R1's) skin condition, which increases the risk of injuries. (W2) provided extra care services two times a week from November 2025 to January 2026. (W2) said that (R1) was not assessed for fall risk and that there were no falls or injuries during the care. (W2) worked alongside the facility staff and never observed any negligence or neglect in the care provided by the staff.

On January 21, 2026, the Department inspected the area of the activity room where the incident occurred and did not observe any health or safety issues.

A review of Resident #1 (R1’s) service record included Medical Assessment for Residential Care Facilities for Elderly LIC 602A (dated 006/05/25), Identification and Emergency Information LIC 601 (dated 03/19/18), Face Sheet and Emergency Info (dated 08/21/24) Service Plan (dated 10/12/25), Resident Appraisal LIC 603A (dated 10/27/22), Morse Fall Scale (dated 10/227/22), OC Hospice Care , Inc Record (dated 11/11/25), Unusual Incident Report LIC 624 (dated 01/20/26 & 10/12/25) Facility Progress Report (dated 01/28/26). Further review of Medication Administration Record (dated 12/01/25 – 12/31/25) revealed (38) medications are prescribed, with (19) significantly increasing the risk of falls. Additionally, (2) medications thin the blood, making individuals more prone to injuries (ref: National Institute of Health NIH).

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

No deficiencies were cited

An exit interview was conducted with Marcia McKay, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026

LIC9099 (FAS) - (06/04)

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