Alta View Post Acute in Los Angeles: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, CDPH made an unannounced visit on October 16, 2023, for a recertification survey. CDPH found the facility did not care for four residents with diabetes (Residents 22, 27, 33 and 54) as its own policies required. Inspectors found staff did not notify a physician when the residents' blood sugar stayed above 200, did not enter physician orders for a dietitian consult in their charts, had no system to make sure the dietitian knew about those orders, and did not carry out the diabetic care plans for diet and monitoring.

The citation lists HbA1c results (a test of average blood sugar over two to three months, with a reference range of 5.7 to 6.4 percent) between 8.2 and 13 percent for the four residents. According to the citation, 120 of Resident 27's 121 blood sugar readings in July 2023 were above 200. CDPH determined the four residents were placed at increased risk of complications such as nerve damage, eye damage and diabetic ketoacidosis (a life-threatening complication of diabetes).

The 2567 report states inspectors called an Immediate Jeopardy (a finding that noncompliance has caused or is likely to cause serious harm) on October 20, 2023, and removed it on October 22 after verifying the facility's removal plan. The plan included medical director and dietitian reviews of the four residents, endocrinologist (diabetes specialist) referrals, a review of all diabetic residents that found one more affected resident, and nurse training. CDPH issued a Class A citation with a $25,000 penalty, and the federal survey cited F684 (quality of care) at severity J.

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According to the 2567 report, inspectors found the facility failed to protect two residents (Resident 1 and Resident 2) from physical abuse when they punched each other on October 22, 2023, at about 3:45 p.m. Resident 2's care plan noted a potential for aggression related to anxiety, with episodes of screaming and yelling. Resident 1 used a wheelchair and had intact thinking skills.

According to the report, Resident 1 told inspectors that Resident 2 unplugged his TV without asking, and that when he told Resident 2 not to come near his things, Resident 2 hit him on the cheek and they both started punching each other. Resident 1 said he was sitting in his wheelchair and Resident 2 was standing. LVN 1 told inspectors he heard screaming, found the two fighting, separated them right away and reported it to the director of nursing. The assistant director of nursing told inspectors physical abuse happened between the two residents and should not have occurred under the facility's abuse policy.

Inspectors found Resident 1 had facial bruises and a cut on his face, and Resident 2 had skin tears on his forehead and upper left cheek. The 2567 report states Resident 1 later told a psychiatrist he was in pain and anxious after the incident, and he was prescribed Ativan (an anxiety medication). He told inspectors he did not feel safe in the facility. The federal survey cited F600 (free from abuse and neglect) at severity G.

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According to the 2567 report, Resident 1 was at risk for elopement (leaving without staff knowledge) and wandering, and had epilepsy (a brain disorder that causes seizures). Inspectors found that on November 11, 2023, at 1:05 p.m., he tried to leave the facility. Staff did not report the attempt to the charge nurse or director of nursing as facility policy required, did not complete a change of condition report to alert other staff, did not hold an interdisciplinary team meeting, and had not developed a care plan with strategies to keep him safe.

The 2567 report states Resident 1 left the facility at 2:20 p.m. the same day and was missing for over three days. Police found him more than 14 miles away, and he was returned to the facility on November 15, 2023, with abrasions (scrapes) on his right hand and leg. Inspectors called an Immediate Jeopardy (a finding that noncompliance has caused or is likely to cause serious harm) on November 15.

According to the report, the facility's removal plan included elopement risk assessments for all residents, a care plan for Resident 1 with a one-on-one caregiver 24 hours a day, new care plans for three other residents at risk, staff training on reporting changes in condition and elopement attempts, and daily and weekly audits, including random reviews of entrance and exit video. The report states the MDS nurse and the receptionist were suspended pending investigation. Inspectors verified the plan and removed the Immediate Jeopardy on November 17, 2023. The federal survey cited F689 (accident hazards, supervision and devices) at severity J.

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According to the citation, CDPH made an unannounced visit on August 30, 2023, to investigate a facility-reported incident about Resident 1, a 74-year-old woman with osteoporosis (weak, brittle bones) and paralysis on one side of her body after a stroke. Her assessments and care plan said she needed two or more staff to help her transfer between the wheelchair and the bed. CDPH found her osteoporosis care plan had no interventions to prevent injury during transfers.

CDPH found that on August 18, 2023, CNA 1 transferred Resident 1 from her wheelchair to her bed alone after physical therapy. According to the citation, LVN 2 heard her yelling in pain, and she pointed to her right leg and tried to explain she had hit her knee during the transfer. An X-ray showed a fracture of the femur (thigh bone) just above the knee. She was sent to a hospital and returned with a soft splint, but later complained of unrelieved pain and was sent to a second hospital, where she had surgery with screws or plates to repair the bone (open reduction and internal fixation) on August 27. LVN 1 told inspectors the fracture happened after CNA 1 transferred her alone, and the director of nursing said an accident may occur if two people are not assisting.

According to the citation, CDPH issued a Class A citation with a $25,000 penalty that was trebled to $75,000. The related federal survey cited F689 (accident hazards, supervision and devices) at severity G.

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According to the 2567 report, Resident 2 was a 63-year-old man with paraplegia (paralysis of the lower body), diabetes, a Stage IV pressure ulcer (a deep bed sore that reaches muscle or bone) on his left sit bone, and cellulitis (a skin infection) of the right lower leg. He made his own decisions. On June 6, 2023, the facility discharged him to a board and care home, a lower level of care that does not provide medical or nursing care.

Inspectors found the facility's May 3 discharge notice had no effective date or location, and a second notice dated May 10 named a different home and date. According to the report, the facility learned at 4:16 p.m. on June 5 that the board and care home would accept him, and moved him at noon the next day, less than 24 hours later. Inspectors found the facility did not make sure that home could meet his care needs, did not give him enough time to make an informed decision, and did not send a copy of the notice to the long-term care ombudsman (a residents' advocate), so the ombudsman could not help him with his discharge rights.

The 2567 report states that on June 11, 2023, five days after the discharge, staff at the board and care home sent him to a hospital with untreated severe pain. He was admitted for a right lower leg wound infection and fever and received intravenous antibiotics and morphine. The federal survey cited F622 (transfer and discharge requirements), F623 (notice before transfer or discharge) and F624 (preparation for a safe transfer or discharge), all at severity G.

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According to the citation, CDPH made an unannounced visit on February 23, 2023, to investigate a complaint about Resident 1's care. Resident 1 had chronic obstructive pulmonary disease (COPD, a lung disease that blocks airflow), respiratory failure and sleep apnea, and depended on oxygen. She returned from a hospital on February 10, 2023. Her care plan called for watching for breathing problems, reporting them to the physician, and giving 15 liters of oxygen per minute by non-rebreather mask (a mask that delivers high-concentration oxygen) when needed.

CDPH found that on the night of February 10, nurses noted her oxygen level was dropping at 9:30 p.m. but did not record how much oxygen was given or her oxygen level. The paramedics were called at 9:50 p.m. According to the citation, a paramedic report said a family member visiting found her unresponsive with a low oxygen level, for an unknown length of time. Paramedics found her in bed on a BiPAP machine (a breathing machine that pushes air through a face mask) with no oxygen supply and an oxygen saturation of 76 percent. After they put her on a non-rebreather mask, her level rose to 100 percent. The citation states she did not respond to pain.

CDPH determined the facility failed to give Resident 1 high-flow oxygen while waiting for paramedics and did not carry out her care plan for monitoring her breathing, which delayed lifesaving care. According to the citation, she was admitted to a hospital intensive care unit for six days. CDPH issued a Class A citation with a $25,000 penalty, and the federal survey cited F695 (respiratory care) at severity G.

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