198603330-1-3-2023-28-AS-MVAO-CMZU4Z-20230112141558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603330
Report Date: 01/03/2023
Date Signed: 01/03/2023 02:51:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2022 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221228154942

FACILITY NAME:	GARDEN SILVER TOWN		FACILITY NUMBER:	198603330
ADMINISTRATOR:	KIM, STEVE		FACILITY TYPE:	740
ADDRESS:	2830 FRANCIS AVE		TELEPHONE:	(213) 384-7305
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90005
CAPACITY:	72	CENSUS: 52	DATE:	01/03/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator Steve Kim		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility did not provide adequate supervision to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted an initial complaint investigation for the allegation listed above. LPA met with Administrator Steve Kim and the purpose of the visit was discussed.

On todays visit LPA conducted the following: Interviewed Staff#1-#4 (S1-S4), interviewed Residents #1-#5 (R1-R5), toured the physical plant, observed the food supply, collected documents from resident #1's file and collected a copy of the staff and resident roster.

The investigation revealed the following: In regards to the allegation "facility did not provide adequate supervision to resident" it was alleged that a resident had an unwitnessed fall when attempting to leave the facility. (4) of (4) Staff interviewed denied the allegation. (5) of (5) Residents interviewed could not collaborate the allegation....

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

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 28-AS-20221228154942

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARDEN SILVER TOWN	FACILITY NUMBER: 198603330
	VISIT DATE: 01/03/2023

NARRATIVE

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Interviews do not show that any residents had unwitnessed falls. File review did not show documentation of resident falls in the last month. LPA was not provided the name of the alleged resident who fell or of staff who assisted resident. Based on LPA's interviews, observations, and documents reviewed; 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 allegation is unsubstantiated.

Exit interview conducted with Steve Kim and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

LIC9099 (FAS) - (06/04)

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