<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610403
Report Date: 11/12/2024
Date Signed: 01/30/2025 11:36:09 AM

Document Has Been Signed on 01/30/2025 11:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GARDEN OF PALMS LAFACILITY NUMBER:
197610403
ADMINISTRATOR/
DIRECTOR:		HIRSCH,RENAFACILITY TYPE:
740
ADDRESS:1025 N FAIRFAX AVETELEPHONE:
(323) 656-7900
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 130CENSUS: 108DATE:
11/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Adam Syncheff, Executive Director TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This is an amendment to the original report issued on 11/12/2024. Additional information was added to clarify the investigation.
Licensing Program Analysts (LPAs) Huma Rahimi and Angela Panushkina, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240215114434. LPAs met with the Executive Director and explained the reason for the visit.

On 02/15/2024 the Regional Office (RO) received a complaint and on 02/20/2024, LPA conducted an initial complaint visit. On 07/16/2024, LPA conducted a subsequent complaint visit. During the initial and subsequent visits, LPA reviewed R1's Physican's reportfacility file, Physician's report, and conducted interviews. According to the Physician report, R1 was on a special diet (Soft Mechanical) that the facility provided; however, R2 denied and controlled R1's food. Furthermore, LPA conducted a file review of R1 and observed that R2 is not the Power of Attorney or a conservator on R1's decision making. The facility staff did not report the abuse to the appropriate authorities. Based on interviews and record review It was determined that an additional deficiency will be issued.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is cited and noted on LIC809-D.

Exit interview conducted, appeal rights and copy of report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/30/2025 11:37 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/30/2025 08:56 AM


Created By: Huma Rahimi On 11/12/2024 at 12:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN OF PALMS LA
FACILITY NUMBER: 197610403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87211(c)

1
2
3
4
5
6
7
Reporting Requirements: (c) Any suspected abuse that does not result in serious bodily injury... ...shall be reported to the local ombudsman, the corresponding licensing agency... ...within twenty-four (24) hours.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee agreed to provide a refresher course in Mandated Reporting to all staff by an approved Vendor and submit to LPA by the due date.
8
9
10
11
12
13
14
Based on interviews and records review facility staff failed to report R2 withheld food from R1. This poses/posed a potential risk to the health and personal rights of a resident in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2