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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320378
Report Date: 07/31/2025
Date Signed: 07/31/2025 09:15:06 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/03/2025 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20250403105629
FACILITY NAME:SAVANT OF SANTA MONICAFACILITY NUMBER:
198320378
ADMINISTRATOR:NATHANIEL VENZONFACILITY TYPE:
740
ADDRESS:1447 17TH STREETTELEPHONE:
(310) 829-5904
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:174CENSUS: 93DATE:
07/31/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:ADMINISTRATOR NATHANIEL VENZONTIME COMPLETED:
09:15 AM
ALLEGATION(S):
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Facility staff did not meet resident's incontinence care needs
INVESTIGATION FINDINGS:
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On 07/30/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Savant of Santa Monica Facility and met with Administrator Nathaniel Venzon (S1). LPA Calderon explained that the purpose of this visit is to deliver an updated investigation report that supersedes the investigation report that was delivered on 04/09/2025. The findings have changed to substantiated.

The investigation consisted of the following: On 04/08/2025 LPA Calderon interviewed witness W1. On 04/09/2025 LPA Calderon interviewed 5 staff (S1-S5) and 9 residents (R1-R9). LPA Calderon obtained the following records: Physician report (dated 01/11/2024), incident report (dated 04/01/2025), shower logs (dated 02/10/2025 to 04/07/2025), Service plan (dated 09/06/2024), and Providence Saint John medical records (dated 04/02/2025).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
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 3
Control Number 11-AS-20250403105629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SAVANT OF SANTA MONICA
FACILITY NUMBER: 198320378
VISIT DATE: 07/31/2025
NARRATIVE
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The investigation revealed the following: Regarding the Allegation: Facility staff did not meet residents’ incontinent care needs. It is alleged that residents’ Urinary Tract Infection (UTI) was a result of staff not meeting residents’ incontinent care needs. Records reviewed indicate the following: Physician report dated 01/10/2024 indicates that R1 is non-ambulatory, is not able to care for own toileting needs and requires continuous bed care. The service plan dated 09/06/2024 indicates that R1 needs full assistance with toileting. Incident reports indicate that R1 was taken to the hospital on 04/02/2025 and evaluated with a urinary tract infection (UTI). Saint John records indicate that R1 was diagnosed with a UTI on 04/02/2025. Interviews indicate the following: 5 out of 5 staff denied the allegation. 7 out of 9 residents denied the allegation. 2 out of 9 residents agree with the allegation. R1 indicated that staff do not change R1 diaper prior to 12 noon most of the time. R2 indicates that R2 witnessed that staff does not change R1 diaper prior to 12 noon. W1 indicates that on 03/29/2025 W1 witnessed that R1 diaper was not changed and was full. Based on interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the allegation “Facility staff did not meet residents’ incontinent care needs.” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are being cited on the attached LIC 9099D. Per Title 22 Regulation 87761(c)(1) Penalties a civil penalty is being cited please see LIC421IM.

An exit interview was conducted, and a copy of the Complaint Investigation Report, Civil Penalty Assessment and Appeal Rights were provided to the Administrator Nathaniel Venson (S1).

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20250403105629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SAVANT OF SANTA MONICA
FACILITY NUMBER: 198320378
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/01/2025
Section Cited
CCR
87625(b)(3)
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Managed Incontinence. In addition to …, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidence by:
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License agreed to update R1’ and Physician Report (LIC602A) and Appraisal/Needs and Service Plan (LIC625). And agreed to conduct staff training based on 87625(b)(1-10) Managed Incontinence. Proof of Correction will be emailed to jose.calderon@dss.ca.gov
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Based on observations and interviews conducted, the licensee did not ensure that R1 was clean and dry, which caused R1 to be taken to the hospital with a UTI. This poses an immediate health and safety and personal rights risk for 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: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
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