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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610403
Report Date: 12/11/2025
Date Signed: 01/09/2026 01:03:28 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2024 and conducted by Evaluator Raymond Comer
COMPLAINT CONTROL NUMBER: 31-AS-20240215114434
FACILITY NAME:GARDEN OF PALMS LAFACILITY NUMBER:
197610403
ADMINISTRATOR:HIRSCH,RENAFACILITY TYPE:
740
ADDRESS:1025 N FAIRFAX AVETELEPHONE:
(323) 656-7900
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:130CENSUS: 116DATE:
12/11/2025
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Adam Syncheff-AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not prevent resident from having bed bugs
Staff are not transporting resident to appointments.
Staff are not providing resident with housekeeping services.
Staff are not meeting resident(s) dietary needs:
Staff are not providing laundry services to residents.

INVESTIGATION FINDINGS:
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This is an adendum to the reports issued 07-16-2024 and 01-30-2025.
Based upon further review, citations issued for Staff did not prevent resident from having bed bugs, Staff are not transporting residents to appointments, Staff are not providing housekeeping services, Staff are not meeting resident’s dietary needs, have been dismissed. Findings for the allegations have been changed from substantiated to unsubstantiated.
On 12/011/25, Licensing Program Analyst Ray Comer met with the Administrator and reason for the visit was explained.
On 02-20-2024 LPA Huma Rahimi initiated the complaint. At 10:40 am LPA made request for records, which include but not limited to resident roster, progress notes and documentation from the exterminator. LPA interviewed five (5) staff, and nine (9) out of ten (10) residents. At 10:45 am, LPA conducted a sample tour of 10 rooms and interviewed residents and staff. Other visits were conducted 05-13-25, 07-23-25 and 09-11-25 by LPM Eva Miller and LPA Raymond Comer for additional staff and resident interviews, and to gather additional information. [LIC9099C]-Continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026
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 31-AS-20240215114434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/11/2025
NARRATIVE
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Allegation: Staff did not prevent resident(s) from having bed bugs.

The complainant’s concern is that a resident’s room is infested with bed Bugs. LPA toured rooms and did not observe any infestation of bed bugs and or any other pests. LPA requested to review the pest control records from March 2023 to Feb 27, 2024. The licensee contracted with Bug Free Central 06-5-2023, Harvey’s Pest control January 13 and January 18, 2024, and currently contracts with Orkin Pest control for bed bugs or any other pest control services that are needed. Services are provided monthly or more if necessary. Inspections are assisted with K9(dog) trained to sniff out bed bugs. All rooms are inspected. A findings log is produced at the end of the inspection to indicate areas of problem. Upon review it was noted that visual inspections for bed bugs were performed for residents who were bed bound or had cluttered rooms. This limited the search for bed bugs in the resident’s room. Facility progress notes from the same period noted refusals of services for (1) out of the ten (10) rooms sampled at times. Alternate schedule for service was made to continue the inspection for bed bugs. No proof of active bed bugs was found.

Therefore, upon review of the information gathered the allegation is unsubstantiated at this time.

Allegation: Staff are not transporting resident(s) to appointments.

The complainant’s concern is that the facility did not provide transportation to appointments resulting in missed medical appointment. A facility file review was conducted for transportation policy. Transportation notes and the Residents Handbook were reviewed. Per review the licensee will provide and/or arrange transportation.

LPA obtained a copy of the transportation schedule for residents dated Dec 3, 2023, to March 3, 2024. LPA reviewed the Resident’s handbook. At 10:45 am LPA conducted a sample of 10 resident and 5 (five) staff interviews. On 07-16-2024 the Administrator was interviewed and revealed that the facility driver had recently quit and was looking to fill the position. In the interim, the Administrator stated that third-party transportation services (i.e. Access, Uber, Lyft, Taxi, private ambulance service, etc.) were provided for residents.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20240215114434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/11/2025
NARRATIVE
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 LPA reviewed the transportation schedule. The schedule was noted with residents’ names, dates, time, and location of appointments. Interviews with 8 out of 10 residents indicate there was no issue with the facility providing transportation. Two of 10 residents stated that a request for transportation must be made, when reviewing the documentation LPA was unable to verify their request and could not determine whether any medical appointments were missed. Therefore, after review of the information gathered the allegation is unsubstantiated at this time.

Allegation: Staff are not providing housekeeping services:

The complainant’s concern is that staff are not providing housekeeping services. At 10:45 am LPA conducted a sample tour of 10 rooms (111, 119B,122, 207A,208A, 210A, 210B,214A, 214B, 215) and interviewed residents and staff. LPA conducted a file review for housekeeping policy. LPA reviewed the Resident Handbook and collected a copy of the housekeeping schedule. According to the Resident Handbook, housekeeping is responsible for providing a weekly deep cleaning including changing bed sheets. Additional housekeeping is available for an additional charge. According to the admissions agreement, Housekeeping will make beds and take out trash daily. Weekly services include dusting, vacuuming, and cleaning the bathroom. LPA collected a copy of 5 Housekeeping schedules. The schedules are noted with resident room numbers and the day of the week on which housekeeping services were provided.

Interviews with 8 out of 10 residents reveal that housekeeping is conducting weekly cleaning but were not happy with the quality of their work. Residents state that housekeeping overall does a poor job in cleaning. Two out of 10 residents state there are no complaints about housekeeping.

Per LPA’s observation during the visit, the first and second floor had a noticeable odor of urine. All rooms were noted to have visible thick dust on or under furniture. Room 214A, 214B, and 208A was observed to be cluttered with many boxes; a possible safety hazard for falls. Rooms 214A and 214B were noted to have dirty clothing on the floor. During the visit LPA also observed housekeeping going in and out of rooms with cleaning sprays, towels, and trash bags providing services.Therefore, after review of the information gathered the allegation is unsubstantiated as housekeeping services are being provided but the quality of service is poor which will be addressed separately.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20240215114434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/11/2025
NARRATIVE
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Allegation: Staff are not meeting resident(s) dietary needs:

The complainant’s concern is that the facility staff are giving food that the residents cannot eat due to dietary restrictions. LPA conducted sample interviews with residents and food service staff. LPA reviewed the regular and alternate menu. Alternate menus are prepared with low salt and low sugar to promote overall health. LPA reviewed Facility Registered Dietician Approval of Menus dated 01-5-2024. LPA conducted resident file review to determine any doctors order for any dietary restrictions. LPA requested food service training and documentation.

A review of R1 and R2s Clinical Requisition report which indicates dietary changes, food modifications, allergies and food restrictions. Per review of the documentation R1 is on a special NAS (No Salt Added) diet. Per staff interviews, meals are prepared with low sodium and sugar options. Interviews with eight (8) out of ten (10) residents confirmed that dietary services are followed if necessary and did not express any concerns regarding this allegation. On 07/16/2024, an additional interview with the Executive Chef was conducted and LPAs were informed that the facility provides required dietary service to residents to meet their specific needs. Kitchen staff are informed daily about any changes to a resident’s dietary requirements from the facility nurse. Furthermore, they offer alternatives upon request from a resident. After review of the information gathered the facility has provided R1 and other residents with meals per their dietary orders.

Therefore, after review of the information gathered the allegation is unsubstantiated at this time.

Exit interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2024 and conducted by Evaluator Raymond Comer
COMPLAINT CONTROL NUMBER: 31-AS-20240215114434

FACILITY NAME:GARDEN OF PALMS LAFACILITY NUMBER:
197610403
ADMINISTRATOR:HIRSCH,RENAFACILITY TYPE:
740
ADDRESS:1025 N FAIRFAX AVETELEPHONE:
(323) 656-7900
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:130CENSUS: DATE:
12/11/2025
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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It is alleged that R1’s wheelchair was either missing or stolen at the facility. Several residents also reported missing personal items such as hygiene products, creams, money, and laundry. To investigate this allegation on 02/20/24 and 07/16/25, LPA Rahimi conducted interviews with Executive Director and staff. It was revealed that R1 and R2 res left their wheelchairs out of their room. The facility staff removed the wheelchair for being a potential hazard and placed it in the storage room to safeguard without notifying residents. Upon request, the facility returned wheelchairs to R1 and R2. Additionally, during the initial visit on 02/20/2024, LPA observed wheelchairs in R1’s and R2’s room and R2 verified that their wheelchairs were returned as soon as they requested. Although facility returned residents wheelchairs, interviews with eight (8) out of ten (10) residents revealed that their personal items/belongings were reported missing. Staff interviewed during investigation were unable to recollect any information about residents missing items. No documents were available during investigation to verify how the facility is safeguarding residents’ personal belongings. Inventory logs for personal items were missing or incomplete.
Based on interviews and information gathered, this allegation is SUBSTANTIATED.Deficiency cited on LIC9099-D. Exit Interview conducted, appeal rights explained and copy of this report signed and delivered.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
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 31-AS-20240215114434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2024
Section Cited
CCR
87217(b)
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Safeguards for Resident Cash, Personal Property, and Valuables: (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables...
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On 11/12/24, Licensee/Administrator conducted in-service training with all staff regarding this Section and submitted proof of training will be submitted to LPA.
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This requirement is not met as evidenced by: Based on interviews, licensee did not comply with the section sited above. Eight (8) out of ten (10) residents confirmed their personal items/belongings had gone missing, which poses a potential health and 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6