Inspection Reports for Garden of Palms

An unannounced case management visit was conducted to review the facility's medical training documentation for medication technicians.

No health and safety issues were observed during the physical plant tour. The Licensing Program Analyst reviewed medical training documentation for ten medication technicians and requested verification of required training hours.

The inspection visit was conducted as a continuation of the required annual inspection initiated on 08/14/2025 to review multiple domains including medications, laundry, bedrooms, bathrooms, outdoor areas, staff records, and resident records.

The facility was found to be in compliance with licensing requirements with no immediate health and safety hazards observed. Medications were properly stored and labeled, laundry and bedrooms were secure and clean, bathrooms were sanitary with required safety fixtures, and staff and resident records were complete and current.

An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements and assess the physical plant, safety systems, and infection control measures.

The facility was found to be generally compliant with licensing requirements, including fire safety systems, kitchen cleanliness, and infection control plans. No deficiencies were explicitly stated in the report, and the facility maintains proper safety and health protocols. The inspection was not fully completed due to time constraints and will be finished at a later date.

An unannounced complaint investigation visit was conducted to investigate allegations that facility staff were not properly transferring a resident to their wheelchair, resulting in injury.

The investigation included interviews with staff and review of records related to the alleged incident. The allegation was found to be unsubstantiated as there was insufficient evidence to verify improper transfer or injury. No immediate health or safety issues were observed during the visit.

The complaint alleged that facility staff were not properly transferring a resident to their wheelchair, resulting in injury. The resident was reported to have slid down from their chair in the shower area but was assisted to the floor in a controlled manner. The resident showed no signs of injury or pain, and the incident was properly reported by the facility. The allegation was unsubstantiated based on interviews, record review, and observations.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-03-18 regarding staff not following resident's doctor recommended dietary needs, not meeting bathing needs, call button disrepair, lack of dignity and respect, and failure to comply with reporting requirements.

The investigation found insufficient evidence to corroborate any of the allegations. Observations, interviews with staff, residents, and family members confirmed that dietary needs, bathing assistance, call button functionality, respectful treatment, and reporting requirements were adequately met. Therefore, all allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included failure to follow dietary recommendations, bathing neglect, call button disrepair, disrespectful staff behavior, and failure to comply with reporting requirements. Each allegation was investigated through interviews, observations, and document review, resulting in no substantiation.

An unannounced complaint investigation visit was conducted to investigate allegations that facility staff did not ensure that a resident had an adequate amount of food and access to a phone.

The investigation found that the allegations were unsubstantiated. The resident was on hospice care with a liquid diet per doctor's orders, and the family member was withholding food, not the facility. Regarding phone access, the resident's phone was taken by family on doctor's advice due to anxiety, and the facility provides cordless phones accessible to all residents.

The complaint was unsubstantiated based on interviews and record reviews. The resident's family member was withholding food, and the phone was removed on doctor's advice due to resident's anxiety and non-responsiveness.

An unannounced complaint investigation visit was conducted to investigate an allegation that staff do not ensure that a resident's bed is in good working order.

The investigation found no sufficient evidence to prove the alleged violation occurred. Interviews with the resident, staff, and observations confirmed that the resident's hospital electric bed was in good working order and no health or safety hazards were noted. The allegation was determined to be unsubstantiated.

The complaint alleged that resident #1's hospital electric bed rolled up on top of them like an accordion three times. After inspection and interviews with the resident, Executive Director, Maintenance Director, and staff, no evidence supported the allegation. The bed was functioning properly and the resident had not reported any issues. The allegation was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that residents contracted a viral infection due to neglect and that a resident received hospice services without consent.

The investigation found insufficient evidence to substantiate the allegations. Interviews with staff, residents, and the facility administrator, as well as document reviews, indicated no known viral infections or outbreaks and confirmed resident consent for hospice services. No health and safety hazards were noted at the time of the visit.

The complaint investigation was unsubstantiated. Allegations included neglect causing residents to contract a viral infection and a resident receiving hospice services without consent. Both allegations were found unsubstantiated based on interviews and records review.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-08-21 regarding communication barriers, unsanitary resident rooms, unmet medical needs, inconsistent service provision, and incontinence management at the facility.

The investigation included interviews with staff and residents, review of resident files, and physical observations. All allegations were found to be unsubstantiated due to lack of preponderance of evidence, with observations and interviews indicating satisfactory communication, clean and sanitary rooms, proper medical care, consistent service provision, and timely incontinence management.

The complaint investigation addressed multiple allegations including staff communication barriers with residents, unsanitary resident rooms, unmet medical needs such as hydration and diet, inconsistent provision of services, and inadequate management of incontinence. After thorough investigation including interviews with three staff and seven residents, review of resident files, and direct observations, all allegations were determined to be unsubstantiated.

The visit was conducted to investigate a complaint alleging that the facility was not in compliance with the approved Hospice Waiver, specifically regarding the admission of residents receiving hospice care services.

The investigation found that the facility had four residents receiving hospice care with appropriate documentation including approved hospice waivers, terminal diagnoses, and signed agreements for room sharing. Based on interviews and record reviews, there was insufficient evidence to substantiate the alleged violation, and the complaint was deemed unsubstantiated.

The complaint alleged non-compliance with Title 22 regulations regarding admission of residents receiving hospice care. The allegation was unsubstantiated due to insufficient evidence.

An unannounced complaint investigation visit was conducted to investigate allegations that staff do not ensure residents' care plans are being followed.

The investigation found that the allegation was unsubstantiated. Observations, document reviews, and interviews with staff and residents confirmed that care plan services were being provided as required.

The complaint alleged that staff did not provide Resident #1 with a juice beverage, did not elevate the resident's legs when sitting in a recliner, and did not charge the resident's smart watch. The investigation found these allegations unsubstantiated based on interviews, observations, and care plan documentation.

The visit was conducted to investigate a complaint alleging that staff were not assisting a resident in a timely manner, specifically that staff took an average of two hours to respond to Resident #1's call button activation.

Observations, interviews with staff, residents, and a family member revealed that caregiver staff responded to call buttons within 2 to 7 minutes on average, with most residents reporting satisfactory response times. The allegation that staff failed to respond timely was unsubstantiated.

The complaint alleged that staff took an average of two hours to respond to Resident #1's call button. The investigation included observations and interviews, and the allegation was deemed unsubstantiated.

The inspection was conducted as an unannounced complaint investigation related to a complaint received on 02/15/2024 concerning potential abuse and failure to report by facility staff.

The facility failed to report suspected abuse involving a resident's food being withheld by another individual who was not authorized to control the resident's food or decision making. This posed a potential risk to the resident's health and personal rights.

The complaint was substantiated based on interviews and record review. The facility staff failed to report that R2 withheld food from R1, who was on a special diet, and R2 was not the Power of Attorney or conservator for R1.

The inspection was conducted as a case management visit in conjunction with a complaint alleging that staff were not providing laundry services to residents.

The complaint alleging that laundry services were not provided was found to be unfounded after interviews, record review, and observation of laundry operations. The facility provides weekly laundry services as part of basic services to all residents.

The complaint was substantiated initially but later found to be unfounded and dismissed after further investigation and case management.

The visit was an unannounced complaint investigation initiated due to allegations that staff left a resident soiled in urine resulting in a rash and that the call button was not accessible to the resident.

The investigation included interviews, observations, and records review. The allegations were found to be unsubstantiated as there was insufficient evidence that the resident was left soiled for an extended period and staff responded promptly to call button activation.

The complaint involved two allegations: 1) staff left a resident soiled in urine causing a rash, and 2) the call button was not accessible to the resident, causing long wait times. Both allegations were investigated through interviews, observations, and document reviews and were deemed unsubstantiated.

The visit was conducted as an unannounced complaint investigation following allegations received on 07/23/2024 regarding staff not safeguarding residents' personal property and licensee retaliation against staff for reporting.

The investigation found no preponderance of evidence to substantiate the allegations. Interviews with residents and staff did not support claims of theft or retaliation, and no health and safety issues were observed during the facility tour.

The complaint involved allegations that staff do not safeguard residents' personal property and that the licensee retaliates against staff for reporting such incidents. Both allegations were found to be unsubstantiated based on interviews and records review.

The visit was an unannounced complaint investigation conducted in response to an allegation that the facility's signal system was not consistently functional, specifically that Resident 1's service call system did not work consistently and staff response times were delayed.

The Licensing Program Analyst observed the facility's service call system and activated Resident 1's call button, which was responded to within two minutes. Interviews with staff and six out of seven residents confirmed timely responses to service calls. No health or safety issues were observed. The allegation was found to be unsubstantiated.

The complaint alleged that the facility signal system was not consistently functional, with Resident 1's call system failing to work consistently and staff taking a minimum of 25 minutes to respond. The allegation was investigated and found to be unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by an allegation that residents' concerns were ignored by staff at the facility.

The investigation found that 10 out of 11 residents interviewed reported receiving timely service and not being ignored by staff. Observations during lunch showed staff serving residents appropriately and accommodating their requests. The allegation was deemed unsubstantiated.

The complaint alleged that staff often ignored residents who requested additional services such as soup or coffee. The investigation included interviews with residents and staff, a physical plant tour, and observation during meal service. The complaint was found unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate allegations that staff were not administering medications as prescribed, not ensuring residents' dietary restrictions were met, and not responding timely to residents' requests for assistance.

Based on interviews, observations, and record reviews, there was no pertinent information to support the allegations. The complaints regarding medication administration, dietary restrictions, and response times to resident requests were all deemed unsubstantiated at this time.

The complaint investigation was triggered by allegations that staff were not administering medications properly, not honoring dietary restrictions, and were slow to respond to resident requests. Interviews with residents, staff, and review of records found no evidence supporting these allegations. The complaint was determined to be unsubstantiated.

An unannounced complaint investigation was conducted to investigate allegations that staff do not assist residents with ambulation, do not provide sufficient living accommodations, do not serve food of good quality, and do not assist a resident with managing behaviors.

The investigation found no evidence to support the allegations. Interviews, observations, and record reviews indicated that residents are assisted with ambulation, sufficient chairs are available, food quality is adequate, and the alleged resident with behavioral issues was not a current or former resident. All allegations were deemed unsubstantiated or unfounded with no health and safety hazards noted.

The complaint investigation was unannounced and addressed multiple allegations including lack of assistance with ambulation, insufficient living accommodations, poor food quality, and failure to manage a resident's behaviors. The allegations were found to be unsubstantiated or unfounded based on interviews, observations, and record reviews.

The inspection visit was conducted as a continuation of the required 1 Year Annual Inspection to evaluate compliance with licensing requirements.

The inspection found no immediate health and safety hazards. Fire detection and protection systems, laundry, common areas, resident bedrooms, bathrooms, and outdoor areas were observed to be in good condition and compliant with safety standards. Staff records were complete and current.

An unannounced annual inspection was conducted by Licensing Program Analyst Raymond Comer to evaluate the facility's compliance with licensing requirements.

The facility was inspected for cleanliness, safety, infection control, kitchen conditions, medication storage, and resident records. No deficiencies or violations were noted, but the annual inspection was not completed due to time constraints and will be finished at a later date.

The visit was an unannounced complaint investigation triggered by an allegation that staff was unlawfully evicting a resident while in care.

The investigation found no sufficient information to verify the allegation of unlawful eviction. The resident had received a 30-day eviction notice due to default of payment, but the facility and owner indicated no intention to evict. The allegation was unsubstantiated and no immediate health or safety hazards were noted.

The complaint alleged that staff unlawfully evicted a resident while in care. The investigation included interviews, document reviews, and a physical plant tour. It was found that the resident's responsible party had payment issues due to the pandemic, but eviction procedures were communicated and no unlawful eviction occurred. The allegation was unsubstantiated.

An unannounced complaint investigation was conducted to investigate the allegation that staff do not accurately manage residents' medications, specifically that staff do not track or record residents' expired medications.

The Licensing Program Analyst observed the medication room as clean, organized, and secure, conducted an audit of medications for sixteen residents with no discrepancies found, reviewed medication destruction records with no discrepancies, and interviewed staff who confirmed proper tracking and destruction of expired medications. The allegation was unsubstantiated and no deficiencies were cited.

The complaint alleged that staff do not accurately manage residents' medications by failing to track or record expired medications. The investigation found no discrepancies and the allegation was unsubstantiated.

This was an unannounced complaint investigation visit triggered by allegations received on 02/15/2024 regarding staff not preventing bed bugs, not providing housekeeping services, not transporting residents to appointments, not meeting dietary needs, and not safeguarding residents' personal belongings.

The investigation substantiated multiple allegations including presence of bed bugs, inadequate housekeeping services, failure to provide timely transportation causing missed appointments and hospitalizations, failure to meet dietary needs due to unauthorized control of resident's food by another resident, and failure to safeguard residents' personal belongings. One allegation regarding providing a comfortable environment was unsubstantiated.

The complaint investigation was substantiated. Allegations included failure to prevent bed bugs, inadequate housekeeping, failure to provide transportation leading to missed appointments and hospitalizations, failure to meet dietary needs due to unauthorized control of food, and failure to safeguard personal belongings. One allegation about uncomfortable environment was unsubstantiated.

An unannounced complaint investigation was conducted to investigate allegations that the licensee/administrator made misleading representations of the facility, including operating under a different name and staff representing themselves as employees of another entity.

The investigation found sufficient evidence to substantiate the allegation that the licensee/administrator made misleading representations by changing the facility name and signage without proper approval and staff wearing clothing advertising a different facility name, posing potential risks to residents.

The complaint alleged that the licensee/administrator made misleading representation of the facility by operating as Savant and staff representing themselves as employees of Savant. The allegation was substantiated based on interviews, observations of signage and staff clothing, and confirmation that the name change paperwork had not been approved by the licensing department.

An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not safeguard a resident's personal belongings.

The investigation found insufficient evidence to substantiate the allegation that the facility failed to safeguard residents' personal belongings. Interviews with staff and residents indicated that belongings were stored in residents' rooms and no confirmed missing items were found.

The complaint alleged that Resident #1's passport and computer were missing after returning to the facility on 01/04/2024. Interviews with staff and residents revealed no evidence supporting the allegation. The complaint was deemed unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including non-functioning call buttons, delayed response to call buttons, communication barriers, incontinence care, odor issues, and failure to follow resident care plans.

The investigation substantiated the allegation that the call button system was not consistently functioning, posing a potential health and safety risk. Other allegations including delayed response to call buttons, communication barriers, incontinence care, odor issues, and failure to follow care plans were found to be unsubstantiated based on interviews and observations.

The complaint investigation was substantiated for the allegation that staff do not ensure that residents have a working call button. Other allegations including staff not answering call buttons timely, communication barriers, incontinence care, odor issues, and failure to follow care plans were unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate allegations that staff did not prevent a resident from entering another resident's room and did not prevent inappropriate interactions between residents.

Based on interviews with staff and residents, there was insufficient evidence to verify the allegations. All interviewed residents and most staff stated that interactions were consensual and no inappropriate behavior was observed. The allegations were determined to be unsubstantiated.

The complaint involved allegations that Resident #2 entered Resident #1's room and said inappropriate things, and that Resident #1 was being sexually harassed by Resident #2. After interviewing three staff members and eleven residents, the allegations were found to be unsubstantiated.

The inspection visit was conducted to investigate a complaint alleging that due to insufficient staffing, the food served to residents gets cold.

The investigation found that there are three servers scheduled at every meal, with additional staff assisting in serving, and interviews with residents indicated that most received food on time. Based on the gathered information, the allegation was deemed unsubstantiated.

The complaint was unsubstantiated after investigation. The allegation was that insufficient staffing caused food to be served cold, but evidence showed adequate staffing and timely food service.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff did not prevent a resident from spitting on surfaces in common areas.

The investigation substantiated the allegation that Resident #1 was spitting on floors, napkins, bowls, and common areas, and staff did not adequately prevent this behavior. Interviews with residents and staff confirmed the behavior, and the facility had attempted redirection despite language barriers. The resident is ambulatory with no mental issues.

The complaint alleged that staff did not prevent Resident #1 from spitting on surfaces in common areas. The allegation was substantiated based on interviews with ten residents and six staff members, observations, and record review. One citation was issued related to this allegation.

An unannounced complaint investigation visit was conducted to investigate an allegation of unlawful eviction at the facility.

The investigation found that the eviction notice was issued for failure to pay rent, but the resident was still living at the facility and denied the allegation, stating they checked into a hotel. The allegation was deemed unsubstantiated based on interviews, record review, and observation.

The complaint alleged unlawful eviction of a resident. The eviction notice was for a 30-day notice issued on 01/25/2024 due to unpaid rent totaling $2,767.05 and additional room and board charges of $1,398.07. The resident denied the allegation and stated they voluntarily left to stay at a hotel. The allegation was unsubstantiated.

An unannounced complaint investigation was conducted in response to an allegation that staff were not addressing residents' health conditions while in care.

The investigation included interviews with staff and residents, review of facility records, and a physical plant tour. All interviewed residents and staff denied mistreatment, and the allegation was deemed unsubstantiated based on gathered information.

The complaint alleged that Resident #1 was being treated poorly and that their health conditions were worsening. The investigation found that Resident #1 was admitted with hospice and home health services, and staff logs documented relevant care activities. Interviews with staff and 12 residents confirmed respectful care was provided. The allegation was unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate the allegation that staff unlawfully evicted a resident.

The investigation found insufficient information to verify the allegation. Staff stated the resident is currently in a mental health facility and will not be readmitted due to posing an immediate danger to self and others. No health and safety hazards were noted.

The allegation that staff unlawfully evicted a resident was unsubstantiated based on interviews and record review.

An unannounced complaint investigation visit was conducted to investigate allegations that staff did not properly address multiple residents' falls at the facility.

The investigation found that three residents experienced multiple falls, but all available measures and precautions were exercised by the facility. Staff stated that the increase in falls correlated with the census increase. Based on record review and interviews, there was not enough information to verify the allegation, and it was deemed unsubstantiated. No health and safety hazards were noted.

The complaint alleged that staff did not properly address multiple residents' falls. The allegation was unsubstantiated after investigation.

The inspection was conducted as an unannounced complaint investigation visit following a complaint received on 2023-09-29 alleging that staff refused to accept a resident back from the hospital.

The Licensing Program Analyst conducted interviews, document reviews, and a physical plant tour. The allegation was found to be unsubstantiated as the resident was scheduled for release and the administrator confirmed acceptance of the resident upon release.

The complaint alleged that staff refused to accept Resident #1 back from the hospital. The investigation found this allegation unsubstantiated based on interviews and record review.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not maintaining the facility in a clean condition, not ensuring the facility was free from pests, and not ensuring residents had air conditioning.

The investigation found the facility to be generally clean, with no evidence of pest infestation, and air conditioning functioning properly with residents reporting no issues. Based on interviews, observations, and record reviews, the allegations were deemed unsubstantiated at this time.

The complaint investigation was unsubstantiated. Allegations included unclean facility conditions, presence of pests (bed bugs), and issues with air conditioning. Interviews with nine residents and staff, physical inspections, and record reviews did not support the allegations.

The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations received on 2023-08-11 regarding resident space sharing, emotional blackmail, medication replacement, comfort environment, and safeguarding of personal belongings.

The allegation that staff did not ensure equal sharing of living space was substantiated with deficiencies cited related to personal accommodations and personal rights. All other allegations including emotional blackmail, medication replacement, comfortable environment, and safeguarding personal belongings were unsubstantiated based on interviews and observations. No health and safety hazards were noted during the visit.

The complaint investigation was substantiated for the allegation that staff did not make sure resident had equal share of space in the room. Other allegations including emotional blackmail, failure to replace medication, uncomfortable environment, and not safeguarding personal belongings were unsubstantiated.

The inspection was conducted as a complaint investigation regarding allegations that staff were mismanaging resident medication.

The investigation found that Resident 1's pain medication was delayed due to pending doctor authorization for a refill, but the medication was eventually provided as prescribed. Interviews with other residents revealed no complaints about medication management. The allegation was deemed unsubstantiated.

The complaint alleged staff mismanagement of resident medication. The allegation was investigated and found unsubstantiated based on interviews and record review confirming proper refill procedures.

The visit was an unannounced complaint investigation triggered by allegations received on 08/30/2023 regarding staff not preventing physical altercations between residents and the facility not providing a menu for residents in care.

The investigation found that the allegation of staff not preventing physical altercations was unsubstantiated as the incident involved a minor scratch with no further medical attention required and no ongoing issues. The allegation that the facility does not provide a menu was also unsubstantiated, as menus were observed posted in multiple locations and residents confirmed receiving menus in newsletters.

The complaint investigation was unsubstantiated. Allegation #1 involved a minor incident between two residents with no physical altercation confirmed. Allegation #2 regarding menu provision was disproven by observations and resident interviews.

The visit was conducted as part of a change of ownership (CHOW) application process for licensing evaluation of the facility.

The applicant and administrator participated in a COMP II interview to verify understanding of community care facility licensing laws, including facility operation, admission policies, staffing requirements, health conditions, emergency preparedness, complaints reporting, and pre-licensing readiness.

An office meeting was held to discuss the pending application for a change of ownership for the Garden of Palms LA facility and to review management efforts and regulatory conformity.

The meeting covered the facility's history, staffing improvements including hiring a Wellness Director and contracting staffing agencies, a new dining contract, and working with a consultant to ensure regulatory compliance. Open communication with the regional office was encouraged.

An unannounced prelicensing visit was conducted due to a change of ownership and to perform Component III orientation for the facility Garden of Palms LA.

The facility was found to be compliant with regulations including safety, maintenance, operational requirements, cleanliness, medication storage, and food safety. No corrections were needed at the time of the visit.

The visit was an office type evaluation involving the applicant/administrator's participation in COMP II to verify understanding of community care facility licensing laws and readiness for licensing.

The applicant/administrator demonstrated understanding of licensing laws, facility operation, admission policies, staffing requirements, emergency preparedness, complaints reporting, and pre-licensing readiness during the COMP II interview.