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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603220
Report Date: 04/25/2024
Date Signed: 04/25/2024 03:47:50 PM

Substantiated


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
08/01/2022 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20220801112329
FACILITY NAME:CITY VIEW LA, LLCFACILITY NUMBER:
198603220
ADMINISTRATOR:YONATAN ISAACSFACILITY TYPE:
740
ADDRESS:515 N LA BREA AVETELEPHONE:
(323) 938-2131
CITY:LOS ANGELESSTATE: CAZIP CODE:
90036
CAPACITY:166CENSUS: DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Mendy GinsburgTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Resident sustained a fracture while in care.
Facility did not seek resident timely medical attention
INVESTIGATION FINDINGS:
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On 04/25/024 Licensing program analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit to render investigation finding. LPA met with Executive Director Mendy Ginsburg as the purpose of today’s visit was explained.

The investigation consisted of the following: On 08/02/2022 Licensing Program Analyst (LPA) Antonia Alvizar initiated a complaint investigation for the allegation listed above. LPA Alvizar obtained copies of the roster for resident roster, Needs and Services Plan, Physician Report, Admission Agreement, Incident Report, Hospice Notes, Case Notes, Medication Logs, Emergency and Identification Information for residents #1-#3(R1-R3). LPA also obtained a copy of staff Personnel Records, Trainings, Staff write-up's and Employment Application for staff #1-#3 (S1-S3). LPA reviewed and obtained facility documentation pertinent to the allegations. On 08/01/2022 the case was referred to California Department of Social Services (CDSS) Investigations Branch, the case was assigned to IB Investigator Douglas Real. On 09/21/2022 investigator Douglas Real interviewed Resident #1-3 (R1-R3), and staff #1-4 (S1-S4). On 08/04/23 Licensing program
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
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 6
Control Number 11-AS-20220801112329
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: 04/25/2024
NARRATIVE
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analyst (LPA) Lizeth Villegas conducted a subsequent visit regarding the above allegation. LPA met with Executive director Mendy Ginsburg. LPA Villegas obtained copies R1's complete file, S1's employee file, S1's training verification, menus for the month of June, July and August 2022, a copy of Food handlers’ certificate, and a list of all incontinent residents and Incontinence Care Procedures. On 08/04/23 LPA Villegas interviewed Residents # 2-8 (R2-R8), Executive Director (ED), and staff #2-5 (S2-S5). On 03/22/24 LPA Villegas interviewed support staff #1-3 (SS1-SS3). On 04/25/24 LPA Villegas interviewed R9-R12.

Allegation: Resident sustained a fracture while in care

It is alleged on 7/28/2022, Caregiver #1 assisted Resident #1 with transferring from R1 wheelchair to the toilet so that R1 could use the restroom. Once CG1 placed R1 on the toilet R1 fell forward which resulted in R1 sustaining bruising and a fracture. As apart of the investigation IB investigator conducted a review of R1 file which revealed R1 was admitted to the facility on 6/6/2022 and was admitted in the memory care unit based on R1 medical diagnosis. According to R1 Physicians Report dated 5/21/2022 indicates R1 required full assistance with toileting. Review of R1 Wellness Assessment dated 6/5/2022 revealed R1 required weight bearing assistance with to get in and out of bed, chair, car and etc. The file review also revealed R1 was a fall risk due to R1 falls that occurred prior to R1 admission to the facility. On 09/21/2022, IB investigator interviewed Caregiver #1-#4 (CG1-4) regarding the allegation and 1 of 4 caregivers interviewed denied working the day of the incident and denied witnessing the incident; 3 of 4 caregivers interviewed Were working during the incident and confirmed being aware R1 had an incident in the bathroom. 3 of 4 caregivers interviewed stated they usually use 2 caregivers to transfer and assist residents that could not assist with the transfers from Wheelchair, bed or toilet. CG #1 was interviewed and stated CG1 witness the incident and stated she took R1 to use the toilet by herself because the other Caregiver was assisting another resident and R1 requested to use the restroom. CG1 stated she transferred R1 from wheelchair to the toilet and when CG1 attempted to assist R1 with R1 pants the resident leaned forward to get toilet paper and fell into the wall. CG1 asked R1 if R1 was ok and R1 replied yes and CG1 took R1 to the bed.

Allegation: Facility staff failed to seek timely medical attention.

It is alleged on 7/28/2022, Caregiver #1 assisted Resident #1 with transferring from R1 wheelchair to the toilet so that R1 could use the restroom. Once CG1 placed R1 on the toilet R1 fell forward which resulted in R1 hitting R1 head and falling. CG1 did not seek any medical attention with the knowledge R1 had hit R1 head and had an injury to the face. As apart of the investigation IB investigator conducted a review of R1

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20220801112329
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: 04/25/2024
NARRATIVE
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file which revealed R1 was admitted to the facility on 6/6/2022 and was admitted in the memory care unit based on R1 medical diagnosis of Dementia. According to R1 Physicians Report dated 5/21/2022 indicates R1 required full assistance with toileting. Review of R1 Wellness Assessment dated 6/5/2022 revealed R1 required weight bearing assistance with to get in and out of bed, chair, car and etc. The file review also revealed R1 was a fall risk due to R1 falls that occurred prior to R1 admission to the facility. On 09/21/2022, IB investigator interviewed Caregiver #1-#4 (CG1-4) regarding the allegation and 1 of 4 caregivers interviewed denied working the day of the incident and denied witnessing the incident; 3 of 4 caregivers interviewed Were working during the incident and confirmed being aware R1 had an incident in the bathroom. 3 of 4 caregivers interviewed stated they usually use 2 caregivers to transfer and assist residents that could not assist with the transfers from Wheelchair, bed or toilet. CG #1 was interviewed and stated CG1 witness the incident and stated she took R1 to use the toilet by herself because the other Caregiver was assisting another resident and R1 requested to use the restroom. CG1 stated she transferred R1 from wheelchair to the toilet and when CG1 attempted to assist R1 with R1 pants the resident leaned forward to get toilet paper and fell into the wall. CG1 asked R1 if R1 was ok and R1 replied yes and CG1 took R1 to the bed. IB investigator interviewed Witness #1 (W1) and W1 stated when W1 arrived to the facility during dinner on 7/29/2022 W1 asked staff to take R1 to the emergency room due to severe bruising to the face.

Based on interviews conducted and records reviewed staff failed to ensure R1 received timely medical attention after a fall in which R1 hit R1 and the next day once bruising became more prominent staff still did not seek medical attention until urged to do so by R1 responsible party.

Based on Investigators interviews which were conducted with Program Manager, residents, staff and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

Civil Penalties Assessed in the amount of 500 dollars.

Exit interview conducted, appeal rights were discussed, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20220801112329
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2024
Section Cited
CCR
87468.2
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Additional Personal Rights of Residents in All Facilities
… Residents in All Facilities…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff...
This requirement is not met as evidence by:
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Licensee shall ensure all staff that provide direct care receive training from an appropriate profession in Care for Persons with Dementia, Emergency Procedures and Personal Rights of Residents. Licensee shall submit the plan for the trainings and submit sign in sheets
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Based on interviews conducted and records reviewed as a part of the investigation the facility staff failed to properly supervise a resident who was at risk for falls to prevent injuries which resulted in the resident sustaining a fracture to the right arn and bruising to face.
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to LPA once trainings are completed. AN IMMEDIATE 500 CIVIL PENALTY IS ASSESSED.

Type A
04/26/2024
Section Cited
CCR
87466
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Observation of the Resident-The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation...
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Licensee will shall submit a plan to the department of the steps the Licensee will take to ensure all residents receive timely medial attention to LPA by POC due date. Licensee shall ensure all staff receive training in emergency procedures and submit sign in sheet by POC due date.
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This requirement is not met as evidence by: Based on interviews and records review staff observed R1 had head injuries and bruising after a fall and failed to immediately ensure R1 received medical attention timely. This is an immediate health & safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
08/01/2022 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20220801112329

FACILITY NAME:CITY VIEW LA, LLCFACILITY NUMBER:
198603220
ADMINISTRATOR:YONATAN ISAACSFACILITY TYPE:
740
ADDRESS:515 N LA BREA AVETELEPHONE:
(323) 938-2131
CITY:LOS ANGELESSTATE: CAZIP CODE:
90036
CAPACITY:166CENSUS: DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Mendy GinsburgTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Food is not of good quality.
Facility staff failed to meet resident incontinence needs.
INVESTIGATION FINDINGS:
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3
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5
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10
11
12
13
On 04/25/024 Licensing program analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit to render investigation finding. LPA met with Executive Director Mendy Ginsburgas the purpose of today’s visit was explained.
The investigation consisted of the following: On 08/02/2022 Licensing Program Analyst (LPA) Antonia Alvizar initiated a complaint investigation for the allegation listed above. LPA Alvizar obtained copies of the roster for resident roster, Needs and Services Plan, Physician Report, Admission Agreement, Incident Report, Hospice Notes, Case Notes, Medication Logs, Emergency and Identification Information for residents #1-#3(R1-R3). LPA also obtained a copy of staff Personnel Records, Trainings, Staff write-up's and Employment Application for staff #1-#3 (S1-S3). LPA reviewed and obtained facility documentation pertinent to the allegations. On 08/01/2022 the case was referred to California Department of Social Services (CDSS) Investigations Branch, the case was assigned to IB Investigator Douglas Real. On 09/21/2022 investigator Douglas Real interviewed Resident #1-3 (R1-R3), and staff #1-4 (S1-S4). On 08/04/23 Licensing program analyst (LPA) Lizeth Villegas conducted a subsequent visit regarding the above allegation. LPA met with Executive director Mendy Ginsburg. LPA Villegas obtained copies R1's
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20220801112329
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: 04/25/2024
NARRATIVE
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complete file, S1's employee file, S1's training verification, menus for the month of June, July and August 2022, a copy of Food handlers’ certificate, and a list of all incontinent residents and Incontinence Care Procedures. On 08/04/23 LPA Villegas interviewed Residents # 2-8 (R2-R8), Executive Director (ED), and staff #2-5 (S2-S5). On 03/22/24 LPA Villegas interviewed support staff #1-3 (SS1-SS3). On 04/25/24 LPA Villegas interviewed R9-R12.

Allegation: Food is not of good quality

It is alleged that the food being served at the facility is not of good quality. On 08/04/23 LPA Villegas interviewed ED regarding the above allegation, Ed denied the allegation above. Per ED the facility serves different types of food daily, the menu is reviewed by dietician monthly and dietary meetings are held once a month. On 08/04/23 LPA Villegas interviewed S2-S5 regarding the above allegation, 3 of 4 staff interviewed denied the allegation above. 1 of 4 staff interviewed reported being unaware of kitchen protocols. On 08/04/23 interviewed Residents # 2-8 (R2-R8) regarding the above allegation, 7 of 7 residents interviewed denied the allegation above and reported they are accommodated with food substitutions when needed. LPA was unable to interview R1 as R1 is no longer receiving care at the facility.

Allegation: Facility staff failed to meet resident incontinence needs

It is being alleged that staff leave residents in soiled diapers. On 08/04/23 LPA Villegas interviewed ED regarding the above allegation, ED denied the allegation above and stated residents are being checked on every 2 hours. Per ED the number of times residents are being changed depends on their level of care. On 08/04/23 LPA Villegas interviewed S2-S5 regarding the above allegation, 4 of 4 staff interviewed reported residents are changes multiple times a day. 08/04/23 interviewed Residents # 2-8 (R2-R8) regarding the above allegation, 7 of 7 residents interviewed reporting not requiring assistance with incontinence needs. On 04/25/24 LPA Villegas interviewed R9-R12, 4 of 4 residents interviewed reported staff are assisting with incontinence needs every 2 hours.

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.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6