197608200-7-19-2021-31-AS-DPEA-C5DNK7-20210729103129

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608200
Report Date: 07/19/2021
Date Signed: 07/19/2021 12:06:00 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,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2019 and conducted by Evaluator Martha Guzman-Chavez

COMPLAINT CONTROL NUMBER: 31-AS-20191202150048

FACILITY NAME:	ALTA VISTA GARDENS		FACILITY NUMBER:	197608200
ADMINISTRATOR:	STACI MARMERSHTEYN		FACILITY TYPE:	740
ADDRESS:	829 NORTH ALTA VISTA BLVD.		TELEPHONE:	(323) 937-1940
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	70	CENSUS: 70	DATE:	07/19/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Deborah Dapson-MedTech		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident 1 (R1) sustained severe injuries resulting in hospitalization.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted a subsequent complaint investigation to the above facility. The purpose of the visit is to deliver findings for the above allegation. Initial visit was conducted on 12/03/2019 by LPA Brian Balisi. LPA met with MedTech Deborah Dapson who oversees facility while Administrator is on vacation. Entrance interview conducted.

On 12/02/2019 the Department received a complaint in which it was alleged that Resident 1 (R1) sustained severe injuries resulting in hospitalization. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Laura Garcia.

Continuation on LIC 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

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 31-AS-20191202150048

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ALTA VISTA GARDENS	FACILITY NUMBER: 197608200
	VISIT DATE: 07/19/2021

NARRATIVE

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Continuation from LIC 9099

On 12/03/2019 at 1:28 p.m. LPA Brian Balisi conducted the initial complaint visit, interviewed the Administrator Staci Marmershteyn, and obtained copies of pertinent documents relevant to the investigation. Investigator Garcia conducted interviews with R1’s relative on 01/25/2020 at approximately 1000 hours, the Administrator on 01/15/2020 at approximately 1130 hours, caregivers on 04/13/2020 at approximately 1828 hours and on 04/14/2020 at approximately 1320 hours, and R1’s case manager on 04/13/2020.

Medical records were also obtained and reviewed. Information contained in the records revealed that R1 was diagnosed with bone cancer and initially misdiagnosed at the hospital with a hip and rib fracture. After further evaluation during a pre-operative procedure for the alleged hip fracture, blood work detected metastasized cancer cells in the bones. A hip fracture was noted however, per the report, the fracture was highly suggestive of metastatic disease leading to brittle bones.

Caregivers interviewed denied R1 falling or injuring self while under their care and supervision. Prior to R1 complaining of leg pain, R1 slept through the night without any pain, complaints or incidents. On 11/28/19 at approximately 0800 hours the resident began to complain of pain in the leg area and was immediately transported to the hospital for medical evaluation. Tests conducted at the hospital revealed findings highly suggestive of cancer.

Based on the information and documentation obtained and review, the Department does not have sufficient evidence to support the above allegation. Therefore, the above allegation is deemed Unsubstantiated at this time.

Exit interview conducted and a copy of report given.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

LIC9099 (FAS) - (06/04)

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