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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603330
Report Date: 01/30/2023
Date Signed: 01/30/2023 01:31:24 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
05/13/2022 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220513175354
FACILITY NAME:GARDEN SILVER TOWNFACILITY NUMBER:
198603330
ADMINISTRATOR:KIM, STEVEFACILITY TYPE:
740
ADDRESS:2830 FRANCIS AVETELEPHONE:
(213) 384-7305
CITY:LOS ANGELESSTATE: CAZIP CODE:
90005
CAPACITY:72CENSUS: 53DATE:
01/30/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Steve KimTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident sustained injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced subsequent complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Steve Kim and explained the reason for the visit.

The investigation consisted of: During the initial visit conducted on 5/17/22, LPA Gonzalez collected copies of Staff and Resident rosters. LPA also conducted a tour of entire facility inside and out with Caregiver Jung. LPA observed the residents to identify any signs of neglect, abuse or other immediate Health and Safety threats. LPA did not observe any immediate Health & Safety concerns during the visit.

The investigation for this complaint was conducted by Investigator Robert Kujawa.


(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
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 28-AS-20220513175354
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GARDEN SILVER TOWN
FACILITY NUMBER: 198603330
VISIT DATE: 01/30/2023
NARRATIVE
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During the course of the investigation, Investigator Kujawa obtained copies of the following documents pertaining to Resident 1 (R1): Physician’s Report For Residential Care Facilities for the Elderly (RCFE) (LIC602A) dated 5/4/22, two (2) Unusual Incident/ Injury Reports (LIC624) dated 5/5/22 and 5/10/22, Death Report (LIC624A) dated 5/19/22, Urgent Care medical documents dated 5/5/22, and R1’s Advance Directives. Investigator Kujawa interviewed Facility Administrator Steve Kim, facility staff (S1-4), facility Resident 2 (R2), and R1 Family Member (R1 FM1). Investigator Kujawa additionally requested medical records from St Mary Medical Center for R1.

The investigation revealed the following: Regarding allegation of, Resident sustained injuries while in care, during this investigation, the Department of Social Services Investigation Bureau, Investigator Kujawa, interviewed facility administrator and S1-4 and their statements revealed that R1 was provided proper care while living in the facility. Interview with R1 FM1 also revealed that the facility was providing proper care to R1 and they did not believe the facility neglected or abused R1. R1 FM1 also stated that they met with the facility administrator who showed R1 FM1 all the video footage the facility had. Investigator Kujawa interviewed R2 who did not recall the incident that occurred on 5/9/22. Interviews conducted with S1-4 revealed that R1 did not require any special care requirements for supervision or to harm themselves. Investigator Kujawa reviewed R1’s Physician’s Report which revealed that R1 did not require any special care requirements for supervision, or tendencies to harm thyself. Document also states that R1 was ambulatory, independent, not suicidal and did not pose any risk of self-harm. Investigator Kujawa reviewed video footage that was captured on 5/9/22 and observed that the footage showed R1 going into R2’s room and then R2 exit the room approximately 11 minutes later, R2 returned to their room a few minutes later but was not able to go in as the room was locked so R2 walked away. R2 attempts to go into their room again a few minutes after the first attempt but was still not able to open the door. Interview conducted with Administrator Kim revealed that the video camera that is located in the back of the facility was broken at the time of the incident and was not working properly. Per Investigator Kujawa, the facility had no way to know or prevent R1’s accident as the incident was unforeseen. Investigator Kujawa stated that there was insufficient evidence to support the allegation of Neglect/ Lack of Supervision led to R1 sustaining injuries while in care. Based on the investigation and supporting information obtained, this allegation is not corroborated.

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 held. A copy of the report was provided to Administrator Steve Kim.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
05/13/2022 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220513175354

FACILITY NAME:GARDEN SILVER TOWNFACILITY NUMBER:
198603330
ADMINISTRATOR:KIM, STEVEFACILITY TYPE:
740
ADDRESS:2830 FRANCIS AVETELEPHONE:
(213) 384-7305
CITY:LOS ANGELESSTATE: CAZIP CODE:
90005
CAPACITY:72CENSUS: 53DATE:
01/30/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Steve KimTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility did not follow resident's Advance Directive resulting in resident's hospitalization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Steve Kim and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Administrator Steve Kim, and Staff 4 (S4). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file and collected copies of documents pertaining to the investigation.



(See LIC9099C for continuation)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220513175354
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GARDEN SILVER TOWN
FACILITY NUMBER: 198603330
VISIT DATE: 01/30/2023
NARRATIVE
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The investigation revealed the following: In regard to the allegation, Facility did not follow resident’s Advance Directive resulting in resident’s hospitalization, it is alleged that 911 was called on 5/9/22. 911 instructed facility staff to perform CPR on Resident 1 (R1) although R1 was breathing on their own. R1 sustained three (3) broken ribs from the emergency procedure. It is alleged that R1 has an Advance Directive for R1 not to have CPR performed but CPR was performed anyway.

Interviews conducted with Administrator Steve Kim and S4 revealed that staff follow all resident's Advance Directives at all times. Administrator and S4 stated that R1 has suffered an accident at the facility and had lost consciousness and that staff (S4) had to react very fast to the incident. S4 stated they immediately called 911 due R1 needing urgent emergency assistance. S4 stated that they did not have enough time to pull R1's file and review their Advance Directive and only followed all the instructions that they were getting from 911 emergency personnel. Administrator and S4 stated that Advance Directives are followed but in this particular incident everything happened so fast and S4 just did what was directed by 911 personnel.

Based on interviews conducted with facility staff and review of documents, the preponderance of evidence standard has been met, therefore the above stated allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on attached LIC9099D.

Exit interview was conducted with Administrator Steve Kim. A copy of the report and appeal rights were provided to Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220513175354
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARDEN SILVER TOWN
FACILITY NUMBER: 198603330
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
87469(c)(1)
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Advanced Directives and Requests Regarding Resuscitative Measures
(c) If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following::
(1) Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel and identify the resident as the person to whom the order refers.
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Administrator will conduct in-service training regarding Advance Health Directives and/or other similar forms that need to be reviewed/ provided to emergency personnel at the time of an emergency. POC to be submitted to MP RO CCLD by POC due date.
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This requirement is not met as evidenced by: LPA interviews with facility staff revealed tha Advance Directive was not followed on 5/9/22. This poses an potential health and safety risk to residents in care.
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***Administrator provided LPA with proof of in service training regarding Advance Health Directives dated 1/30/23.
***Citation was cleared at the time of the visit.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5