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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320378
Report Date: 03/02/2026
Date Signed: 03/04/2026 11:45:36 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
11/04/2024 and conducted by Evaluator Troy Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241104144122
FACILITY NAME:SAVANT OF SANTA MONICAFACILITY NUMBER:
198320378
ADMINISTRATOR:NARINE MERTKHANYANFACILITY TYPE:
740
ADDRESS:1447 17TH STREETTELEPHONE:
(310) 829-5904
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:174CENSUS: 135DATE:
03/02/2026
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:JOE SALDANA - ADMINISTRATOR TIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Staff did not seek timely medical care for resident.
Staff did not notify authorized representative of incident.
Due to lack of supervision, resident fell resulting in a fracture.
INVESTIGATION FINDINGS:
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** This report dated 03/02/2026 supersedes report dated 01/30/2026 and changes the findings for one allegation **

On 03/02/2026, Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit to deliver finding for the allegations listed above.The purpose of this visit was explained to the Administrator Joe Saldana and LPA Troy Watson was allowed entry into the facility.

Investigation consisted of the following:

On 11/05/2024 LPA Troy Watson requested and obtained the following: Facility Census 11/05/2024, Staff Schedule: October 2024, Unusual Incident Reports, VITAS Continuous Care Shift Care Notes for R1 dated 11/01/2024-11/03/2024, ID and Emergency Information for R1, Face Sheet for R1.

CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
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 11-AS-20241104144122
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: 03/02/2026
NARRATIVE
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Internal Occurrence Reports, Residence and Care Agreement for R1, California General Durable Power of Attorney for R1, Facility Census (11/05/2024), Physician’s Report for R1 (04/24/24). Physician Orders for Life‑Sustaining Treatment (POLST) for R1, Individual Service Plan from Assisted Living Waiver (ALW) Program (4/23/2024), Durable Power of Attorney for R1, and Assessment Tool generated by Carling Connection for the Assisted Living Waiver Program for R1 (4/23/2024). LPA Troy Watson interviewed Staff #1-#5 (S1-S5) and Residents #2-13 (R2-R13). An attempt to interview Resident#1 was made but (R1) was not available at the facility during the time of visit.

Investigation revealed the following:

Allegation:Staff did not seek timely medical care for a resident

It is being alleged that facility staff failed to provide timely medical care after R1 experienced a fall, which resulted in hospitalization for a leg fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (A1). During the interview conducted on 11/17/2024, Administrator Narine Mertkhanyan (A1) stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. A1 also reported that R1 was in hospice prior to being admitted and continued hospice with a nurse periodically checking on her throughout the night. On 12/23/2025, LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 4 out of 5 staff members denied the allegation. On 12/23/2025, LPA Troy Watson interviewed Residents #2–13 (R2–R13). Out of those interviewed 12 out of 12 residents denied the allegation. LPA Troy Watson obtained and reviewed facility and medical records for R1. Per R1’s Face Sheet, R1 was admitted to the facility on 10/29/2024. A Facility Internal Occurrence Report dated 10/31/2024 states that a caregiver reported R1 had an unwitnessed fall, after which the Wellness Coordinator assessed R1 and noted scratches to the hand but no other injuries. Facility Notes and Alert Charting dated 11/01/2024 indicate that the caregiver reported that on 10/31/2024, R1 was found on the floor. The 11/01/2024 charting also notes that a body check was completed, revealing no injuries other than to the left hand, although R1 complained of leg pain. Facility Notes and Alert Charting dated 11/02/2024 documents that the hospice agency requested an X-ray.

Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D

CONTINUED ON LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20241104144122
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: 03/02/2026
NARRATIVE
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Allegation: Staff did not notify authorized representative of incident.

This complaint alleges that staff failed to contact R1’s authorized representative after R1 was found on the floor. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (A1) regarding the facility’s response to R1’s fall. A1 stated that the fall in question was the only documented fall R1 experienced during her stay at the facility. On 12/23/2025, LPA Watson interviewed Staff #1–#5 (S1–S5). Out of those interviewed 5 of 5 staff members denied the allegation. On 12/23/2025, LPA Watson interviewed Residents #2–#13 (R2–R13). Out of those interviewed 12 out of 12 residents denied the above allegation. LPA Watson obtained and reviewed documentation and medical records pertaining to R1. Per facility notes / Alert Charting dated 11/04/2024, R1’s family was present at the facility on that date; however, no documentation was provided indicating that the facility contacted or notified R1’s authorized representative regarding R1’s fall. LPA Watson requested verification of communication to R1’s responsible party, but the facility was unable to provide any records showing that such notification occurred. Based on the lack of documentation confirming that R1’s authorized representative was notified of the fall, the allegation that staff failed to contact R1’s authorized representative is substantiated.
Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

Allegation: Due to lack of supervision, a resident fell resulting in a fracture.

It is being alleged that facility staff did not complete a proper assessment of resident#1 (R1) and had no knowledge of R1 being a fall risk, which led to R1 falling and sustaining a fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (administrator 1-A1) regarding the circumstances surrounding R1’s fall. A1 stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. LPA Troy Watson reviewed facility records. Facility provided department with a copy of the Assisted Living Waiver Individual Service Plan dated 04/23/2024, when R1 still lived in their own home, and it identified R1 as a fall risk. LPA Watson requested from the facility a Needs and Service Plan, Fall Risk Plan and Preplacement Appraisal but none were provided. On 12/23/2025 LPA Troy Watson interviewed Staff #1–5 (S1–S5).

CONTINUED ON LIC9099 - C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20241104144122
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: 03/02/2026
NARRATIVE
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 Out of those interviewed 4 out of 5 staff members denied the above allegation. On 12/23/2025 LPA Troy Watson interviewed Residents #2-#13 (R2-R13). Out of those interviewed 12 out of 12 residents denied the above allegation. LPA Troy Watson obtained and reviewed records for R1. Facility Internal Occurrence report dated 10/31 states caregiver reported that R1 had an unwitnessed fall. R1 was checked by Wellness Coordinator who noted scratches to R1’s hand but no other injuries. Per medical records from Ronald Reagan UCLA Medical Center, R1 was admitted to Ronald Reagan UCLA Medical Center on 11/04/2024 with a diagnosis of an acute distal fibular diaphysis transverse fracture with half-shaft-width lateral displacement of the distal fracture fragment. R1 was discharged to a skilled nursing facility on 11/08/2024. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. A $500 civil penalty was assessed previously on 01/15/2026.

An exit interview was conducted with Administrator Joe Saldana and copies were provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20241104144122
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: 03/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2026
Section Cited
CCR
87465(a)(1)(g)
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Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
This requirement is not met as evidenced by:
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The licensee shall ensure that all staff are retrained on the facility’s policies and procedures regarding responding to changes in a resident’s condition and seeking timely medical care. Licensee will submit training plan to submitted to the Department via email or fax by POC due date.
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Based on interviews and records review, R1 experienced an unwitnessed fall on 10/31/2024, and despite telling staff their leg was injured, R1 was not seen by a physician until they were admitted to Ronald Reagan UCLA Medical Center on 11/04/2024 and diagnosed with a distal tibial and fibular diaphysis fracture. This violation posed an immediate health, and safety risk to residents in care.
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Type A
03/02/2026
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities
In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement was not met as evidenced by:
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The licensee shall retrain all staff on intake assessments, appraisals and monitoring residents who are at risk of falls. Licensee will submit training plan to submitted to the Department via email or fax by POC due date.
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Based on interviews and record review, the licensee did not ensure adequate supervision for Resident 1. Staff failed to provide the level of care and supervision necessary to meet the residents’ needs, which resulted in R1 experiencing a fall that caused a fracture. This lack of supervision posed an immediate health and safety risk to the 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20241104144122
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: 03/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2026
Section Cited
CCR
87211(a)(1)(b)
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Reporting Requirements. Requires the licensee to report specified incidents and to notify the resident’s authorized representative of events affecting the resident.
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The licensee shall ensure that all incidents requiring notification are reported to the resident’s authorized representative in accordance with 87211. The Administrator will provide proof of staff training and reporting procedures, shall be submitted to CCL by the POC due date.
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Based on interviews and record review, the licensee did not notify Resident 1’s authorized representative after R1 was found on the floor, as required by 87211.On 11/05/2024 LPA Watson obtained and reviewed facility records and found no documentation that indicated that R1’s responsible party was contacted and made aware of R1’s fall on 10/24/2024.This violation posed an immediate 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6