Inspection Reports for Atria Park of Pacific Palisades
15441 Sunset Blvd, Pacific Palisades, CA 90272, United States, CA, 90272
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on June 19, 2024, which was clean with no citations issued. Earlier reports showed some isolated issues, such as inadequate safeguards for resident property and missing warning signs for hot water in the kitchen in June 2023, and a substantiated illegal eviction with a related deficiency in May 2022. More serious concerns appeared in April 2022 when a resident developed pressure injuries due to staff neglect, resulting in a $500 civil penalty. Several complaint investigations were unsubstantiated, including allegations about staffing, supervision, and communication. The facility’s record shows improvement over time, with recent inspections being free of deficiencies after addressing earlier issues mainly related to resident rights, supervision, and safety.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
62% occupied
Based on a June 2024 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 37
Capacity: 60
Deficiencies: 0
Jun 19, 2024
Visit Reason
An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean, sanitary, and appropriately furnished with no observed deficiencies. All inspected areas, including resident rooms, bathrooms, kitchen, and safety equipment, were in good condition and compliant with regulations. No citations were issued.
Report Facts
Resident rooms inspected: 6
Bathrooms inspected: 6
Residents' service files reviewed: 5
Staff personnel files reviewed: 5
Medication Administration Records reviewed: 3
Fire/Disaster Drills date: Jun 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joe Saldana | Executive Director | Met with Licensing Program Analyst during inspection and received the Facility Evaluation Report |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection visit |
| Eva M Alvarez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 38
Capacity: 60
Deficiencies: 2
Jun 2, 2023
Visit Reason
An unannounced annual required inspection was conducted using the full CARE Inspection Tool to evaluate compliance with licensing regulations for the facility.
Findings
The facility was generally found to be sanitary, appropriately furnished, and compliant with many regulations, including medication administration and storage of hazardous materials. However, two deficiencies were cited: inadequate safeguards for resident property and valuables, and failure to properly identify water temperature above 125°F in the industrial kitchen.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to have safeguards of property and valuables present for one resident, posing a potential health, safety or personal rights risk. | Type B |
| Water temperature above 125°F in the industrial kitchen was not properly identified by warning signs, posing an immediate health, safety or personal rights risk. | Type A |
Report Facts
Deficiencies cited: 2
Water temperature: 126.8
Capacity: 60
Census: 38
Hospice waiver capacity: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Remon Pagels | Executive Director | Met with Licensing Program Analysts during inspection and named in plan of correction for water temperature deficiency |
| Antonine Richard | Licensing Program Analyst | Conducted inspection and authored report |
| Mario Leon | Licensing Program Analyst | Conducted inspection |
| Ulysses Coronel | Licensing Program Manager | Supervisor of Licensing Program Analysts |
| Brian Larios | Administrator | Facility administrator mentioned in report header |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 60
Deficiencies: 0
May 17, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2022-05-27 regarding inadequate supervision, dietary needs not being followed, presence of pests, and hazardous cords hanging from windows.
Findings
The investigation found no evidence to substantiate any of the allegations. Observations and interviews with residents, staff, and the administrator confirmed adequate supervision, dietary needs being followed, no pests observed, and no hazardous cords present.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate supervision, dietary needs not followed, facility pests, and hazardous cords. The investigation included facility tours, document reviews, and interviews with staff and residents, all of which did not support the allegations.
Report Facts
Capacity: 60
Census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martessa Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Brian Larios | Administrator | Facility administrator interviewed during investigation |
| Remon Pagels | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 60
Deficiencies: 0
Nov 16, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that the licensee did not bring changes in a resident's condition to the attention of the resident's physician in a timely manner and a questionable death.
Findings
The investigation found that despite the allegations, there was not a preponderance of evidence to prove the alleged violations occurred. Medical records showed consistent communication among care providers and the resident's family, and the questionable death was determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegation #1 regarding failure to timely notify the physician was found unsubstantiated based on thorough communication documented among medical providers and family. Allegation #2 regarding questionable death was also unsubstantiated after review of medical records and interviews.
Report Facts
Facility capacity: 60
Census: 28
Dates related to Resident #1: 3
Dates related to Resident #1: 6
Date: May 14, 2020
Date: May 18, 2020
Date: Jun 4, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Remon Pagels | Executive Director/Administrator | Facility representative met during the investigation |
| Amy Berggreen | Community Business Director | Greeted the investigator upon arrival |
| Edward Hector | Department of Social Service Investigator | Conducted a separate investigation including medical record review and interviews |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 60
Deficiencies: 1
May 2, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including illegal eviction, resident injury, resident UTI, and staff failing to meet resident needs.
Findings
The investigation substantiated the allegation of illegal eviction due to failure to properly notify and obtain approval from the licensing agency. The other allegations regarding resident injury, UTI, and staff failing to meet resident needs were found to be unsubstantiated based on interviews, record reviews, and observations.
Complaint Details
The complaint alleged illegal eviction of resident #1, resident injury, resident UTI, and staff failing to meet resident needs. The illegal eviction allegation was substantiated due to improper notification and approval process failures. The other allegations were unsubstantiated due to lack of evidence.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform Community Care Licensing Division (CCLD) of the 30-Day Notice to Terminate on 03/15/22, making the notice invalid and posing potential health risks to residents. | Type B |
Report Facts
Capacity: 60
Census: 34
Deficiency count: 1
POC Due Date: May 11, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation |
| Remon Pagels | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Amy Berggreen | Community Business Director | Participated in inspection visit |
| Brian Larios | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 60
Deficiencies: 4
Apr 20, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident developed a pressure injury while in care.
Findings
The investigation substantiated the allegation that a resident developed pressure injuries due to staff neglect and a break in home health coverage. The resident was admitted to the hospital with multiple pressure injuries, posing an immediate health and safety risk to residents in care.
Complaint Details
The complaint was substantiated. The resident developed pressure injuries due to staff neglect and a break in home health coverage from 1/16/2020 to 2/3/2020. An immediate civil penalty of $500 was imposed.
Severity Breakdown
Type A: 2
Type B: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Civil Penalty: Any violation that the department determines resulted in the injury or illness of a resident. | Type A |
| It was observed through records review and interview that on 2/12/2021 Resident 1 was admitted to hospital with pressure injuries. This poses an immediate health and safety risk to residents in care. | Type A |
| Personal Rights of Residents in all Facilities: Residents in all residential care facilities for the elderly shall have safe, healthful and comfortable accommodation, furnishings and equipment. This requirement was not met as evidenced by failure to provide timely medical/home health services and proper documentation. | Type B |
| It was observed through records review and interview that on 2/12/2021 Resident 1 was admitted to hospital with pressure injuries. This poses a potential health and safety risk to residents in care. | Type B |
Report Facts
Civil Penalty: 500
Capacity: 60
Census: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation. |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation. |
| Amy Bergreen | Business Director | Facility representative present during exit interview. |
| Jose Santana | Investigator | Conducted investigation into the allegations. |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 60
Deficiencies: 0
Feb 23, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to an allegation that the facility did not permit the formation of a resident council.
Findings
The investigation found no evidence to support the allegation. The facility had both a resident council and a family council, with posted meeting notices and resident and staff confirmation. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that residents’ families had not been made aware of a family council until an email sent by the new Executive Director. The investigation included interviews with staff and residents, review of facility records, and observation. The allegation was found unsubstantiated.
Report Facts
Capacity: 60
Census: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Kirk Brooks | Executive Director | Facility representative interviewed during investigation |
| Brian Larios | Administrator | Named as facility administrator |
| Eva M Alvarez | Licensing Program Manager | Oversaw licensing program |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 60
Deficiencies: 0
Feb 16, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility does not have sufficient staff to meet the residents' needs.
Findings
The investigation included facility tours, file reviews, and interviews with staff and residents. All interviewed residents and staff stated the facility had sufficient staff to meet residents' needs. The department found no evidence to support the allegation, and the complaint was unsubstantiated.
Complaint Details
The complaint alleged insufficient staffing due to staff not knowing their work schedules. Interviews with the Resident Services Director and staff confirmed schedules were posted weekly and staffing levels were adequate. Residents and staff all confirmed sufficient staffing. The allegation was unsubstantiated.
Report Facts
Capacity: 60
Census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Kirk Brooks | Executive Director | Met with Licensing Program Analyst during inspection |
| Brian Larios | Administrator | Facility administrator mentioned in report |
| Tinatin Darchia | Resident Services Director | Spoke about staff scheduling and staffing levels |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 60
Deficiencies: 0
Feb 3, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that the facility was not allowing visitors, mismanaged resident's medication, and did not communicate with resident's responsible party.
Findings
The investigation found no sufficient evidence to support the allegations. The facility had restricted visits during a Covid-19 lockdown but allowed outdoor visits, provided sufficient medications to residents when they left the facility, and maintained communication with residents' families. Therefore, all allegations were unsubstantiated.
Complaint Details
The complaint investigation was triggered by allegations that the facility was not allowing visitors despite vaccinations and negative Covid-19 tests, mismanaged resident's medication during family visits, and failed to communicate with residents' responsible parties. The investigation concluded these allegations were unsubstantiated.
Report Facts
Capacity: 60
Census: 36
Staff interviewed: 5
Residents interviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Stacey Groman | Quality Enhancement Director | Facility representative met during the investigation and exit interview |
| Brian Larios | Administrator | Facility administrator |
| Tinatin Darchia | Nurse | Spoke about facility lockdown and visitor restrictions |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Jan 12, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to multiple allegations received on 10/25/2021 regarding resident care issues including timely changing, dietary requirements, hygiene, showering, activities, staffing, and feeding.
Findings
The investigation found insufficient evidence to support most allegations including residents not being changed timely, dietary requirements not followed, hygiene needs unmet, showering not timely, insufficient staffing, and residents not fed timely. However, the allegation that the facility does not have activities for residents was substantiated. Additionally, the allegation that staff did not adequately supervise a resident who was sucking on a window blind cord was substantiated, resulting in a cited deficiency.
Complaint Details
The complaint investigation was triggered by allegations including residents not being changed timely, staff not following dietary requirements, residents' hygiene needs not met, residents not showered timely, lack of activities, insufficient staffing, residents not fed timely, and inadequate supervision resulting in a resident sucking on a window blind cord. Most allegations were unsubstantiated except for the lack of activities and inadequate supervision allegations, which were substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Basic services shall at a minimum include care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by a resident being left unsupervised and trying to consume an inedible item. | Type B |
Report Facts
Facility capacity: 60
Number of residents interviewed: 6
Number of staff interviewed: 6
Number of witnesses interviewed: 2
Plan of Correction due date: Jan 26, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Brian Larios | Administrator | Facility administrator named in the report |
| Vladimir Kaplan | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Adrienne Craig Aziz | Executive Director | Interviewed during investigation regarding allegations |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 60
Deficiencies: 2
Nov 3, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that residents did not receive medication on a timely basis and that the facility did not have sufficient staff to meet residents' needs.
Findings
The investigation substantiated both allegations, finding that on October 24, 2021, 28 residents did not receive their morning medications due to staffing shortages, and that the facility was understaffed, impacting resident care and safety.
Complaint Details
The complaint was substantiated based on evidence that residents did not receive timely medication and that the facility was understaffed. The preponderance of evidence standard was met, and citations were issued under California Code of Regulations, Title 22, Division 6, and Chapter 8.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide personal assistance and care as needed, including assistance with taking prescribed medications. | Type A |
| Facility personnel were not sufficient in numbers and competent to provide the services necessary to meet resident needs. | Type B |
Report Facts
Residents not receiving morning medications: 28
Facility capacity: 60
Census: 36
Plan of Correction Due Dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adrienne Craig Aziz | Executive Director | Interviewed regarding medication delays and staffing issues. |
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation. |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation report. |
Inspection Report
Annual Inspection
Census: 37
Capacity: 60
Deficiencies: 0
Jun 29, 2021
Visit Reason
An unannounced annual required visit was conducted with a primary focus on Infection Control measures using the new CARE Inspection Tool.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with infection control practices. No deficiencies were cited during this inspection visit.
Report Facts
Licensed capacity: 60
Current census: 37
Hospice waiver capacity: 10
Inspection duration: 4
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the inspection and observed infection control practices |
| Adrienne Craig-Aziz | Executive Director | Met with Licensing Program Analyst during inspection and received report |
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