The Preserve at Woodland Hills

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Angela Barutyan and Quoc Huynh conducted an unannounced Case Management - Incident visit at 09:49 AM. The purpose of this visit was to conduct an investigation regarding a self-reported incident that occurred on 08/01/2026. LPAs met with Executive Director (ED) Susan Weisbarth and explained the reason for the visit. During today’s visit, LPAs conducted a physical plant tour to ensure there are no immediate health and safety hazards, conducted interviews with three (3) staff members, and reviewed and obtained copies of pertinent documents. On 08/10/2026, the Department received an incident report stating that on 08/01/2026 around 06:30 PM, Resident #1 (R1) eloped through their bedroom window. R1 refused dinner that evening and returned to their room. Caregivers and front desk staff continued routine monitoring throughout the evening. During safety checks, the receptionist observed that R1's bedroom window was open. Staff searched R1’s room, the facility, and the surrounding grounds but were unable to locate R1. The facility proceeded to call 9-1-1 to report R1 missing and law enforcement responded and initiated a search. R1’s responsible party was also notified of the incident. While searching the surrounding neighborhood, a bystander reported seeing the resident walking with a shopping cart in the area. Staff continued the search and located R1 lying on the ground near a small market approximately 0.4 miles away from the facility. Law enforcement and Emergency Medical Services (EMS) responded to the location, assessed the resident, and transported R1 to the hospital for further medical evaluation. It was reported that R1 was out of the community for approximately forty-five (45) minutes. Staff interviews stated that R1 did not have any visible injuries or reported falls; however, R1 refused water and may have been dehydrated. Report Continued on LIC809-C. At 10:38 AM, LPAs conducted a tour of the facility. LPAs observed R1’s room at 10:42 AM. Windows were screened and no immediate health and safety hazards were observed or noted. Staff indicated that R1 has the cognitive capacity to move furniture and bypass the window stoppers in order to remove the window screen and exit to the facility parking lot. R1 is no longer residing at the facility and LPAs observed R1’s room free of belongings. LPAs interviewed staff who stated that R1 had previously exhibited exit-seeking behavior. R1 attempted to exit through their bedroom window on 06/30/2026 but staff prevented R1 before they could get out through the window. Record review also indicates that R1 exhibited exit-seeking behavior on 07/31/2026 by attempting to exit the facility through the front entrance. Staff redirected R1 and prevented R1 from exiting unassisted. LPAs reviewed R1’s physician’s report signed and dated 06/30/2026 which documents that R1 is unable to leave the facility unassisted. Staff stated that R1’s responsible party was notified and the option to move R1 to a bedroom with a window facing the facility’s enclosed outdoor courtyard was provided, which they declined. Staff also stated that R1 would regularly express that they wanted to leave the facility. Interviews confirmed that facility staff were aware of R1’s exit-seeking behavior. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. An additional report may follow if warranted. Exit interview conducted. Appeal rights and a copy of the report were provided.the state’s words, verbatim · CDSS document, Aug 12, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(a) · Plan of correction due date: Aug 19, 2026

1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as R1 eloped from the facility while under the care of staff and was found away from the facility approximately 45 minutes later which poses a potential safety risk to clients in care.the state’s words, verbatim · CDSS document, Aug 12, 2026

Plan of correction: Management stated that residents with exit-seeking behaviors will not be in rooms with windows leading outside of the facility. Management also stated that staff will get additional training to respond to the facility's Vigil signal system which notifies staff of restlessness. Proof of training and exit- seeking procedures will be sent to CCLD by due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Angela Barutyan and Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 09:49 AM. The LPAs met with Health and Services Director (HSD) Tony Nunez and Executive Director (ED) Susan Weisbarth and explained the reason for the visit. Entrance interview conducted. At 10:38 AM, the LPAs and HSD toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: The facility is a one-story building that contained a lobby, offices, kitchen, storage, and employee lounge which was inaccessible to residents. The remainder of the facility had a dining room, activity room, day room, activity office, salon, medication room, and an outdoor courtyard. The LPAs observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. Areas that posed a safety risk to residents were observed to be locked. Required postings were found in the lobby and throughout the facility hallways. There were fire extinguishers throughout the facility, which were fully charged and last serviced 05/18/2026 and contained emergency flashlights. There are three (3) delayed egress doors throughout the facility. LPAs tested a delayed egress door at 11:53 AM which functioned properly. Staff responded to the alarm promptly at 11:53 AM. The courtyard contained a raised garden bed, activities for residents, and furniture in good condition with shade. Emergency food and water were stored in an outdoor utility closet along with general storage. The LPAs also observed the emergency side exits. Report Continued on LIC 809-C. RESIDENT ROOMS: Beginning at 10:42AM, the LPAs observed ten (10) randomly selected resident rooms. Appropriate furniture and sufficient lighting were observed in the units. LPAs observed signal systems installed in the resident bathrooms. Resident restrooms were clean, with properly installed grab-bars and slip-resistant surfaces. Hot water temperature was measured in resident restrooms and was between 105.2-112.5 degrees F, which is within the required range. At 10:49 AM, LPAs tested the bathroom pull cord in room 147. LPAs waited for twenty (20) minutes with no staff response. LPAs informed staff and the signal was cleared at 11:13 AM, approximately twenty-four (24) minutes later. Staff stated that they review pull cord signals, however seven (7) different staff members were observed passing by room 147 with no response to the pull cord. LPAs tested the bathroom pull cord in room 102B at 11:16 AM and staff cleared the signal at 11:20 AM. Lastly, LPAs tested the bathroom pull cord in room 133B at 11:44 AM. LPAs waited for a response for eleven (11) minutes and by 11:56 AM, there was no staff response. LPAs reviewed response time records which documents that staff responded in eighteen (18) minutes to LPAs’ test signal. Further review of pull cord response times from 08/09/2026-08/12/2026 document staff response times to bathroom pull cords as long as eleven (11) hours. KITCHEN: The facility’s kitchen was inspected and found to be in compliance with Title 22 regulations. The facility receives food deliveries two (2) times a week from US Foods. There was a sufficient supply of perishable and non-perishable food. Food in the freezer and refrigerator were observed to be of good quality. MEDICATION REVIEW: Medications are centrally stored and locked in the facility’s medication office. Beginning at 03:30 PM, LPAs reviewed medications for five (5) residents. All medications reviewed were stored and documented per regulation. RECORD REVIEW: Beginning at 03:42 PM, LPAs reviewed five (5) resident files and four (4) staff files for documents including but not limited to: resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident records reviewed were in compliance with regulation at the time of the visit. Two (2) out of four (4) staff files were incomplete as both were missing a health screening and TB test and one (1) was also missing first aid certification. Report Continued on LIC 809-C. INFECTION CONTROL/DISASTER PREPAREDNESS: During today’s visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. All items reviewed were in compliance. The facility conducts emergency disaster drills quarterly, with the most recent drill documented on 07/22/2026. The community’s smoke detectors and carbon monoxide detectors are hardwired and were last tested on 12/18/2025 by GFP Services and approved by the Los Angeles Fire Department. Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, Aug 12, 2026

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff confine resident to facility

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above at 10:30AM. Upon arrival, LPA met with Resident Care Coordinator (RCC) Angel Caton. Entrance interview conducted. During today's visit, LPA interviewed three (3) staff and one (1) resident, conducted a physical plant tour, reviewed and obtained copies of pertinent documents relevant to the investigation, and discussed allegation with ED telephonically. REPORT CONTINUED ON LIC9099-C. Unsubstantiated It was alleged that Resident #1 (R1) was being held in the facility against their will and they were unable to move out. LPA interviewed staff who stated that on 06/14/2026, R1 was attempting to leave the facility unassisted to board a flight. Staff stated that R1’s physician had determined that R1 is unable to leave the facility unassisted and R1 requires assistance with activities of daily living (ADLs). LPA interviewed R1 who stated that their physician determined that R1 has the capacity to live independently and that on 06/14/2026, R1 was attempting to leave the facility independently. LPA reviewed a letter from R1’s primary care physician signed and dated on 12/30/2024 that states that “due to medical conditions, [R1] is unable to manage [their] own affairs/estate, including all medical and financial responsibilities. [R1’s] care requires structured assisted living care.” LPA observed a letter from a second physician signed and dated 01/06/2025 that documents that “due to [R1’s] cognitive decline, [R1] is unable to manage [their] personal, legal, and financial affairs.” LPA reviewed R1’s most recent physician’s report by their primary care physician signed and dated 04/15/2025 that documents that R1 has “dementia” and is unable to “leave the facility unassisted.” LPA observed a letter from a third physician signed and dated 11/19/2025 stating that R1 “has major neurocognitive impairment that has rendered [R1] unable to manage instrumental activities of daily living including but not limited to [their] personal, legal, and financial responsibilities.” Lastly, LPA observed a neuropsychological assessment by a fourth physician, R1’s neuropsychologist, signed and dated 03/27/2026 stating that R1 “has the capacity to make basic financial and health care decisions” and “ongoing monitoring and support from trusted advisors will be beneficial.” The assessment further states that due to R1’s “variable difficulties with memory and other cognitive challenges, [R1] may benefit from some support for [their] safety and decision-making.” R1 stated that they will now be moving from the facility with assistance from a responsible party. LPA did not observe documentation from R1’s physician(s) indicating that R1 is able to leave the facility unassisted. Per regulation, “’Elopement’ occurs when a resident who is at risk of harm due to their cognitive condition leaves the facility unsupervised, or while in the licensee's care, leaves another safe location unsupervised.” R1’s documentation from licensed medical professionals document that R1 is at risk if they leave the facility unassisted. Therefore, based on interview and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff confine resident to facility” is deemed UNSUBSTANTIATED at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 23, 2026 · control 29-AS-20260615122439

Allegation investigated: Staff do not ensure that outside vendors are not video recording/taking pictures of residents

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above at 10:05AM. Upon arrival, LPA met with Executive Director (ED) Susan Weisbarth. Entrance interview conducted. During today's visit, LPA interviewed three (3) staff, five (5) residents, and one (1) visitor, conducted a physical plant tour, reviewed and obtained copies of pertinent documents relevant to the investigation, and discussed allegation with ED. REPORT CONTINUED ON LIC9099-C. Unsubstantiated It was alleged that an outside vendor recorded videos and pictures of residents and subsequently posted the content to their online social media accounts. LPA reviewed the vendor’s social media accounts and found no videos or pictures posted that were taken at this facility. LPA interviewed three (3) staff members, including the activities director, who all stated that the outside vendor was hired for one performance in 2024 by previous management. The staff did not remember encountering the vendor but stated that activity vendors do not take pictures and videos of residents and vendors are not left unsupervised with the residents. LPA interviewed five (5) residents and one (1) visitor and all interviews stated that there were no concerns of the activities, outside vendors, or pictures and videos without consent. LPA reviewed the activity schedule for March and April 2026 and did not observe the vendor scheduled. During the visit, LPA observed residents participating in an exercise activity at 11AM in the common area which was supervised by the activities coordinator. LPA also randomly selected five (5) resident files and reviewed their records to observe signed and dated photo consent and release forms. Based on interviews, observation, and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff do not ensure that outside vendors are not video recording/taking pictures of residents” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 29-AS-20260326091512

Allegation investigated: Staff are not allowing resident to receive gifts while in care Staff did not prevent resident from developing pressure ulcers

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above at 12:02PM. LPA met with Health and Services Director (HSD) Tony Nunez and Executive Director (ED) Susan Weisbarth who arrived shortly thereafter. Entrance interview conducted. During today’s visit, LPA interviewed two (2) staff members and obtained copies of pertinent documents. During the initial visit on 01/12/2026, LPA interviewed three (3) staff, one (1) resident, and three (3) witnesses, conducted a physical plant tour, reviewed and obtained copies of pertinent documents relevant to the investigation, and discussed the allegations. Report Continued on LIC9099-C. Unsubstantiated It was alleged that the facility was preventing Resident #1 (R1) from receiving gifts, specifically multiple flower deliveries and a book. LPA interviewed four (4) facility staff who stated that staff will bring any deliveries for R1 to their room and R1 has the choice to receive or decline. Two (2) staff members stated that flowers were delivered to R1 but they were unsure if R1 kept them. One (1) staff member stated that R1 received a book and kept it. LPA interviewed R1 and three (3) witnesses who all confirmed that R1 received the flowers but did not wish to keep them so they gave the flowers away. R1 and witnesses also confirmed that facility staff bring deliveries to R1's room and R1 decides to accept or decline. LPA reviewed photographic evidence confirming the flower delivery to R1. LPA reviewed the facility’s delivery logs and observed multiple package deliveries to R1. R1 and R1’s responsible parties interviewed had no concerns of R1 being prevented from receiving gifts or deliveries. Based on interview and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff are not allowing resident to receive gifts while in care” is deemed UNSUBSTANTIATED at this time. It was further alleged that R1 sustained multiple pressure injuries on their legs and heels possibly due to staff neglect. LPA reviewed records and observed that R1 was hospitalized from 12/22/2025-01/02/2026. LPA interviewed staff, R1, and witnesses who stated that R1 did not develop any pressure injuries under the care of the facility. All interviews confirmed that R1 did have some discoloration on their heel, but that this was a pre-existing condition prior to R1’s admission to the facility and not an open wound. Interviews also confirmed that during R1’s hospital stay, R1 developed minor redness/blister on their back but R1’s condition began improving after hospital discharge. LPA did not observe any open wounds on R1 during the initial visit. LPA was unable to observe R1 during today’s visit as R1 no longer resides at the facility. Record review of R1's care plan, physician's report, and appraisals contained no evidence of R1 developing pressure injuries while at the facility. Based on interview, observation, and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not prevent resident from developing pressure ulcers” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 29-AS-20260106091314

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Angela Barutyan and Licensing Program Manager (LPM) Kristin Heffernan arrived at the facility unannounced to conduct a Case Management – Health and Safety Check visit at 11:43AM to ensure there were no immediate health and safety hazards following the facility’s court appointed Receivership. LPA and LPM met with Executive Director (ED) Susan Weisbarth and explained the purpose for the visit. Entrance interview conducted. At 12:24PM, LPA, LPM and ED conducted a tour of the physical plant areas inside and outside to ensure compliance with Title 22 regulations, which included a tour of resident rooms, common spaces, outdoor area, and main kitchen. No immediate health or safety concerns were observed during the visit. On 11/20/2025, the Woodland Hills North Regional Office (WHN RO) received notice from the court appointed receiver of the facility’s Receivership Order which went into effect on 10/30/2025. The Licensee failed to inform the Department of the receivership. The receiver notified families on 11/07/2025. Per California Health and Safety Code section 1569.686, you are hereby notified that a $100 civil penalty is being assessed per day. The total civil penalty for a continuous violation shall not exceed $2000. You will receive an invoice in the mail. Payment is due when billed. Payments must be made by a personal business or cashier's check or money order made payable to the "California Department Of Social Services". Please write the facility number and invoice number on your check and include copy of your invoice with the payment. You will find the invoice number on your invoice. DO NOT SEND CASH. Report Continued on LIC809-C... The Licensee was notified that a civil penalty is being assessed for failure to comply with this section and/or failure to report specified events, in writing, within two (2) business days to the Department, the State Long-Term Care Ombudsman, all residents, and their representatives. Deficiency cited under Health and Safety Code 1569.686. Pursuant to Health and Safety Code, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted/ Citations issued/ Civil Penalty assessed/ Appeal Rights discussed/ A copy of report was issued.the state’s words, verbatim · CDSS document, Nov 24, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.686(a)(1) · Plan of correction due date: Dec 1, 2025

1569.686 (a) A licensee shall notify the department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their legal representatives, in writing, within two business days... (1) A notice of default... This requirement is not met as evidenced by: Based on interview and record review, Licensee failed to ensure The Department, LTCO, residents and their responsible parties were notified of the default received by Licensee, which caused a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 24, 2025

Plan of correction: The court appointed receiver notified The Department and residents of the default. ED will review the section cited, as well as Health and Safety Code 1569.482 and submit a statement of understanding to CCL by the due date. Civil penalty is assessed for violation of this section [Health and Safety code 1569.686(c)].

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 11:22AM. The purpose of this visit is to conduct an investigation regarding three (3) self-reported incidents that occurred on 09/11/2025 and on an unknown date approximately two (2) months ago. Upon arrival, the LPA met with staff and Executive Director (ED) Susan Weisbarth. Entrance interview conducted. During today’s visit, LPA Barutyan conducted a brief physical plant tour to ensure there are no health and safety hazards, conducted interviews with three (3) staff members and attempted interviews with two (2) residents, and reviewed and obtained copies of pertinent records. On 09/11/2025, the Department received an incident report and SOC341 stating that on an unknown date approximately two (2) months ago, Staff #1 (S1) pushed Resident #1 (R1) onto their toilet causing it to break. The incident was reported by Staff #2 (S2) on 09/10/2025. R1 was assessed for injuries immediately after the incident was reported and observed no injuries on R1. R1’s responsible party, the Department, the Long-Term Care Ombudsman, and Adult Protective Services were notified. The facility conducted an internal investigation during which S1 and S2 were suspended and are no longer employed at the facility. ED stated it is unknown if the incident actually occurred due to conflicts and retaliation between S1 and S2. LPA discussed mandated reporting requirements and ED stated that a formal mandated reporter training will be conducted with all staff. LPA also attempted an interview with R1. On 09/16/2025, the Department received an incident report stating that on 09/11/2025 at 08:26AM, Staff #3 (S3) mistakenly administered Resident #2’s (R2) morning medications to R1 due to confusion of the residents’ similar room numbers. Report Continued on LIC 809-C. The medications administered to R1 consisted of Allopurinol 100mg, Atorvastatin 40mg, Gabapentin 100mg, Losartan 25mg, Quetiapine Fumarate 25mg and 50mg, and Sertraline HCL 100mg. R1 receives Quetiapine Fumarate 25mg in the evening, no other medications that were administered to R1 were on their medication list or orders. S3 observed the mistake immediately and notified facility management. R1’s primary care physician and responsible party were notified. Primary care physician advised for facility to monitor symptoms and not administer R1’s prescribed morning medications for the day. R1 was monitored for changes and did not have adverse effects besides increased sleepiness. S3 received additional medication administration training via online and in-person. LPA interviewed S3 who was knowledgeable in medication administration and verification techniques. The facility was previously cited within the last 12 months on 03/11/2025 and 04/24/2025 for medication administration errors. On 09/16/2025, the Department received an incident report stating that on 09/11/2025 at 11:55PM, Resident #3 (R3) left the facility unassisted through the back egress door, door #3, which leads to the exit gate. Staff heard the alarm ring and immediately went to the door where they observed R3 standing outside of the community perimeter gate on the sidewalk. Interviews stated that R3 was not outside of the facility for more than one (1) minute and R3 did not wander off the sidewalk. R3 had no injuries. R3 was diagnosed with a urinary tract infection (UTI) which contributed to R3’s confusion and wandering. Facility management held a meeting with NOC shift staff to discuss wandering prevention techniques as R3 tends to wander at nights. Staff have increased their supervision and sit with R3 in the dining room to keep busy as R3 enjoys their company and does not tend to wander if they are not alone. Facility management also conducted an in-person elopement training on 09/25/2025. On 01/07/2025, the facility was previously cited for two (2) elopement incidents and have since increased the delayed egress time from 15 seconds to 30 seconds and replaced the alarms to louder ones that can be heard from the other side of the facility. LPA tested door #3’s delayed egress at 12:16PM which was functional and operating. Staff responded to the alarm immediately and cleared the alarm at 12:17PM. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Civil penalty was assessed in the amount of $250 for repeat violation. Administrator was informed that failure to correct deficiency may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(4) · Plan of correction due date: Oct 2, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as Resident #1 (R1) was administered Resident #2’s (R2)’s morning medications by Staff #3 (S3). This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: S3 received training on medication administration after the error and will receive additional training. Administrator stated that staff will receive vendored training by Guardian Pharmacy and will provide proof of the scheduled in-service to LPA by the due date.

Allegation investigated: Staff are not allowing resident to have visitors Staff are not allowing resident to have phone calls

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation at 10:22AM. Upon arrival, LPA met with Executive Director (ED) Susan Weisbarth. Entrance interview conducted. During today’s visit, LPA Barutyan interviewed two (2) staff between 10:29AM-11:23AM and reviewed and obtained copies of pertinent documents between. During the initial visit on 07/25/2025, LPAs Barutyan and Q. Huynh conducted a physical plant tour between 10:30AM-12:15PM, interviewed three (3) staff, five (5) residents, and one (1) visitor between 10:08AM-12:45PM, reviewed and obtained copies of pertinent documents relevant to the investigation between 12:30PM-04:00PM, and discussed allegations with ED at 03:50PM. Report Continued on LIC 9099-C. Unsubstantiated It was alleged that the facility staff were preventing Resident #1 (R1) from receiving phone calls or visitors on behalf of R1’s responsible party’s request, rather than R1’s decision. On 07/25/2025, LPAs interviewed R1 and R1 expressed that they were aware of their visitor and call requests. R1 stated they told facility staff to consult their responsible party. LPAs explained to R1 that they have their own personal rights and that if they want to receive any calls or visitors, R1 can do so without getting their responsible party’s consent. R1 stated they understood and that there were no concerns. LPA interviewed R1’s responsible party and facility staff throughout the course of the investigation and all interviews confirmed that facility staff ask R1 first if they want to receive their calls or visitors, and that the choice is entirely up to R1. On 07/28/2025, ED Weisbarth broadcasted an announcement to all residents’ family members/responsible parties stating that “Residents have rights to have visitors and calls at any time. Please make sure residents are told they have a call or a visitor.” An in-service training was also conducted on 08/01/2025 with all staff regarding personal rights and that residents should be asked if they want visitors or calls. LPA observed documentation of two attempted calls, one on 07/31/2025 and another on an unknown date within the same week; R1 declined to speak with the calling parties on both occasions. A wellness check was conducted by police and by other outside agencies who interviewed R1, and no concerns about R1 receiving visitors or calls were noted. Resident and visitor interviews conducted also did not have evidence that supported allegations regarding visitation or phone call access. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the above allegations “Staff are not allowing resident to have visitors” and “Staff are not allowing resident to have phone calls” are deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 29-AS-20250721143816

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a Case Management - Annual Continuation visit at 10:22AM continuing the inspection that began on 07/25/2025. LPA met with Executive Director (ED) Susan Weisbarth and explained the purpose of the visit. RECORD REVIEW: Beginning at 10:37AM, five (5) staff records were reviewed for documents including, but not limited to: health screening, TB test, training records, fingerprint clearance, and first aid/CPR training. All staff files reviewed were complete and were observed to be in compliance. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: Beginning at 11:48AM, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 07/08/2025. The community’s smoke detectors and carbon monoxide detectors are hard wired. Fire systems, including smoke detectors, sprinklers, and alarms, were last tested on 11/14/2024 by GFP Guard Fire Protection INC and approved by the Los Angeles Fire Department. During today’s visit, LPA obtained a copy of the facility’s liability insurance. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 13, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Quoc Huynh and Angela Barutyan arrived unannounced at 9:55AM for a required one year visit. The LPAs met with Health and Services Director (HSD) Tony Nunez and Executive Director (ED) Susan Weisbarth and explained the reason for the visit. Entrance interview conducted. At 10:30AM, the LPAs and HSD toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The facility’s kitchen was inspected and found to be in compliance with Title 22 regulations. The facility receives food deliveries four (4) times a week from different vendors. There was a sufficient supply of perishable and non-perishable food. The food in the freezer and the refrigerator were observed to be of good quality. COMMON AREAS: The facility is a one-story building that contained a lobby, offices, kitchen, storage, and employee lounge which was inaccessible to residents. The remainder of the facility had a dining room, activity room, day room, activity office, salon, medication room, and an outdoor courtyard. The LPAs observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. Areas that posed a safety risk to residents were observed to be locked. Report Continued on LIC 809-C Required postings were found in the lobby and throughout the facility hallways. There were fire extinguishers throughout the facility, which were serviced 04/28/2025 and contained emergency flashlights. The courtyard contained a raised garden bed, activities for residents, and furniture in good condition with shade. Emergency food and water were stored in an outdoor utility closet along with general storage. The LPAs also observed the emergency side exits. In the rear of the facility, the LPAs, ED, and HSD observed a window screen leaning against the building that belonged to a resident’s window above it. The ED and HSD identified the resident’s unit and had maintenance secure the window screen onto the window. RESIDENT ROOMS: Beginning at 10:40AM, the LPAs observed ten (10) randomly selected resident rooms. Appropriate furniture and sufficient lighting were observed in the units. The LPAs did not observe signal systems installed in the resident rooms. The HSD stated that resident rooms were equipped with motion sensors that detect resident movement and potential falls, however, no system is in place for residents to call for help from their room. LPAs observed some residents wearing pendant buttons which transmit signals to the facility laptop. The HSD stated that not every resident gets a pendant. The pendants currently being used identify which resident enacted the call. At 12:30PM, the LPAs and HSD tested three (3) randomly selected pendant buttons which were not operational at the time as there were no signals received by the laptop. One (1) of the pendants flashed a red light indicating it was not operational. Staff interviews revealed that response times to pendant calls have been an issue at the facility and staff have gotten multiple warnings and in-service training to improve response times. Interviews with two (2) residents revealed concerns of the facility’s signal system and staff response times. LPAs reviewed call logs for Resident #1 (R1) between 07/01/2025-07/25/2025 and observed response times ranging from 6 minutes to 2 days. There were seventy-six (76) calls total, of which fifteen (15) were accidental repeat calls by R1, making a total of sixty-one (61) calls by R1. Call logs revealed only ten (10) out of sixty-one (61) pendant calls had response times under fifteen minutes. Report Continued on LIC 809-C Resident restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Water temperature was tested throughout the units and measured between 95 degrees F and 128.5 degrees F, which is not within the required range per regulation. R1 was observed to have cleaning supplies stored under their restroom sink which included disinfectants, bathroom foam cleaner, and multi-purpose cleaner. Resident #2’s (R2) restroom vanity handle on the right bottom cabinet was observed to need repairs. The HSD stated they would check in with the facility’s maintenance to have it repaired. Resident #3 (R3) was observed to have oxygen administered and did not have signage outside their unit. The HSD confirmed R3 was receiving oxygen and had facility Staff post the signage. Resident #4 (R4) had access to two (2) electric razors in their restroom, which the HSD and ED secured during the visit. Record review revealed R1 and R3 were at risk and should not have access to these items. R3’s Physician’s Report specifically identifies R3 should not have access to razors. MEDICATION: Medication review began at 12:11PM. The LPAs reviewed medications for five (5) residents. Medications were inaccessible in locked medication carts and in the medication room. Five (5) out of five (5) resident medications reviewed were documented and stored in compliance with regulation at this time. RESIDENT RECORDS: Resident records were reviewed at 3:25PM. The LPAs reviewed five (5) files for, but not limited to: admissions agreements, medical assessments, and appraisals. Resident records reviewed were in order at this time. Due to time constraints the annual visit will continue at a later date. Three (3) Staff and five (5) residents were interviewed. No complaints noted. Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). The ED designated the HSD to sign today's report. Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, Jul 25, 2025

Allegation investigated: Staff do not ensure a facility door is safe for the residents while in care

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above 11:54AM. Upon arrival, LPA met with staff and Executive Director (ED) Susan Weisbarth. Entrance interview conducted. During today's visit, LPA conducted a physical plant tour of the common areas at 11:54AM, interviewed four (4) staff members between 12PM-12:30PM, reviewed and obtained copies of pertinent documents relevant to the investigation between 12:20PM-12:30PM, and discussed allegation with ED at 12:35PM. REPORT CONTINUED ON LIC 9099-C. Unsubstantiated During today’s visit at 11:55AM, LPA observed the double doors leading to the staff area by the corner of the common area. LPA observed a surveillance camera installed facing the door and a hole drilled in above the door for the camera’s cables. There were no signs on the community-facing side of the door, but LPA observed two (2) framed signs on the staff-side door that state “ATTENTION: PLEASE OPEN DOOR WITH CAUTION.” LPA also observed a staff member opening the door with relative caution at 11:57AM. ED stated that the facility is installing a surveillance camera to monitor the double door. The camera does not contain an audio component and is direct feed, no video surveillance will be stored or saved. A monitor screen will be installed next to the staff-side of the door for staff to check if residents are in the door path prior to opening. LPA reviewed proof of purchase and receipts for the camera installation. During a previous complaint visit for complaint control #29-AS-20250305161155, it was alleged that the facility door poses a safety concern for residents as there are no windows or cameras to alert staff if residents are in the way of the door. LPA visited the facility on 03/11/2025 and observed caution signs on the door on both the staff and community sides. LPA interviewed five (5) staff members on 03/11/2025 and confirmed that staff had been advised to open the door cautiously and to redirect residents when they are observed to be near door paths. LPA unsubstantiated the allegation due to there being no regulations in the California Code of Regulations, Title 22 and/or California Health and Safety Code that require facility doors to have windows, cameras, or other equipment for staff to observe if residents are behind a door, and there being no evidence of lack of supervision. On 03/11/2025, LPA had a conversation with ED about minimizing the potential risk of the facility door and ED informed the maintenance director who stated they will inquire about having a window placed on the door or some other feature that could allow staff to check for residents in the way. Information obtained through interview, record review, and observation for this investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation “Staff do not ensure a facility door is safe for the residents while in care” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 16, 2025 · control 29-AS-20250709121859

Allegation investigated: Licensee did not obtain documentation of a medical assessment prior to a person's acceptance as a resident

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation at 10:45AM. Upon arrival, LPA met with staff and Executive Director (ED) Susan Weisbarth at 10:11AM. Entrance interview conducted. During today’s visit, LPA Barutyan conducted a brief physical plant tour between 10:12AM-10:20AM, interviewed three (3) staff between 10:18AM-11:15AM, and reviewed and obtained copies of pertinent documents between 10:23AM-12:55PM. During the initial visit on 05/20/2025, LPA interviewed three (3) staff, reviewed and obtained copies of pertinent documents, conducted a brief physical plant tour with ED, and discussed the allegation with ED Report Continued on LIC 9099-C. Unsubstantiated It was alleged that the facility admitted Resident #1 (R1) on 05/13/2025 and Resident #2 (R2) two to three months ago without medical assessments. During the initial visit on 05/20/2025, LPA conducted a record review and observed that R1 had a preplacement appraisal dated 05/11/2025, a signed medical assessment dated 05/11/2025, a chest x-ray TB screening dated 05/12/2025, and a signed admission agreement dated 05/13/2025. LPA also reviewed records for two (2) residents admitted on 05/15/2025 and 05/19/2025. During today’s visit, LPA conducted a record review and observed that R2 was admitted on 02/23/2025 and had a preplacement appraisal dated 12/22/2024, a signed medical assessment dated 11/25/2024, a TB test dated 12/07/2024, and a signed admission agreement dated 02/23/2025. LPA also reviewed records for one (1) resident admitted on 05/28/2025. Five (5) out of five (5) resident files reviewed contained medical assessments, preplacement appraisals, and admission agreements. Staff interviews confirmed that staff are knowledgeable in admission procedures and Title 22 requirements. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Licensee did not obtain documentation of a medical assessment prior to a person's acceptance as a resident” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 9, 2025 · control 29-AS-20250515140552

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 12:24PM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 04/17/2025 Upon arrival, LPA met with Executive Director (ED) Susan Weisbarth and Health and Services Director (HSD) Antonio “Tony” Nunez. Entrance interview conducted. On 04/17/2025, the Department received a verbal and written incident report stating that on 04/17/2025, Resident #1 (R1)’s PRN Benzonatate 200mg was left unattended by Staff #1 (S1) and Resident #2 (R2) self-administered the medication mistaking the medication for their own. The error was observed after R2 asked S1 to take R1’s medication to them since R2 took it instead. R2’s primary care physician was notified and R2 was placed under direct supervision for delayed effects. R2 was monitored for changes in condition, no significant changes were noted, and vitals were stable within normal limits. HSD Nunez conducted one-on-one trainings with S1 on proper medication storage and administration protocols. Staff were also reminded to never leave medications unattended. All staff attended a training session vendored by Guardian Pharmacy on 04/07/2025. HSD stated that a corrective action form was issued to S1 and that each medication technician will be shadowed for a full day and tested on proper protocols and regulations. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Civil penalty was assessed in the amount of $250. Administrator was informed that failure to correct deficiency may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided. This report has been amended to include a civil penalty of $250 due to repeat violation of Section 87465(h)(4) as it has been cited one other time within 12 months on 03/11/2025.the state’s words, verbatim · CDSS document, Apr 24, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(4) · Plan of correction due date: May 1, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws... This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above as Resident #1 (R1)'s Benzonatate medication was left unattended by Staff #1 (S1) which Resident #2 (R2) self-administered. This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: S1 received one-on-one training from HSD Nunez and attended a training session vendored by Guardian Pharmacy on 04/07/2025. A corrective action form was issued to S1 and HSD stated that each medication technician will be shadowed for a full day. HSD will submit a training plan for each medication technician to CCLD by 05/01/2025.

Allegation investigated: Staff handled resident in a rough manner Staff yells at residents in care

Licensing Program Analysts (LPAs) Angela Barutyan and Quoc Huynh arrived at the facility unannounced to conduct an initial complaint investigation for the allegations listed above at 10:35AM. Upon arrival, LPAs met with staff and Executive Director (ED) Susan Weisbarth. Entrance interview conducted. During today's visit, LPAs conducted a physical plant tour between 10:40AM-11:10AM, interviewed seven (7) residents and attempted interview with one (1) resident between 10:42AM-11:22AM, reviewed and obtained copies of pertinent documents relevant to the investigation between 11:33AM-12:25PM, interviewed five (5) staff members between 12:26PM-01:35PM, and discussed allegations with ED and Health and Services Director (HSD) Tony Nunez at 03:40PM. CONTINUED ON LIC 9099-C. Unsubstantiated It was alleged that Staff #1 (S1) yells at residents and handles them in a rough manner and that on 04/04/2025, S1 restrained and pushed Resident #1 (R1) and on 04/05/2025, S1 yelled at Resident #2 (R2) to leave. LPAs attempted an interview with R1, and interviewed R2 and six (6) other residents. No concerns were noted and no information supporting the allegations were found. Residents interviewed stated that staff treat them fairly and do not yell at them or handle them roughly. LPAs interviewed five (5) staff of which four (4) were on shift between 04/04/2025-04/05/2025. One (1) out of five (5) staff interviewed stated that S1 yells at residents and handles residents in a rough manner. Four (4) out of five (5) staff interviews had no evidence supporting the allegations and stated that staff have not been observed to yell at residents or handle them roughly. All staff and four (4) out of seven (7) resident interviews confirmed that R1 is combative, and staff physically redirect R1 from hitting staff or other residents as has happened in the past. LPAs observed R2 to be hard of hearing and staff interviews confirmed that R2 requires louder volume to hear. LPAs reviewed S1’s training transcript and observed all training up to date, including dementia care, ethics, and knowing the rights of residents. LPAs reviewed R1’s physician’s report dated 01/18/2023 documenting R1 with “inappropriate behavior” and R2’s physician’s report dated 04/17/2024 documenting R2 with “auditory impairment.” Based on interviews, record review, and LPAs’ observation, the information obtained during the investigation does not have sufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations “Staff handled resident in a rough manner” and “Staff yells at residents in care” are deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 29-AS-20250407142736

Allegation investigated: Staff negligence caused injury to resident Facility door poses a safety concern for residents

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above 10:40AM. Upon arrival, LPA met with Executive Director (ED) Susan Weisbarth and staff. Entrance interview conducted. During today's visit, LPA interviewed five (5) staff members between 10:43AM-1:01PM, reviewed and obtained copies of pertinent documents relevant to the investigation between 11:40AM-12:36PM, conducted a brief physical plant tour at 12:40PM, attempted interviews with two (2) residents between 03:04PM-03:06PM, and discussed allegations with ED and Health and Services Director (HSD) Tony Nunez at 01:05PM. REPORT CONTINUED ON LIC 9099-C. Unsubstantiated It was alleged that on 02/22/2025, Resident #1 (R1) was hit with a facility door by Staff #1 (S1). S1 opened the double doors leading to the staff area at 08:01AM and was unaware that R1 was behind the doors. R1 fell and hit their head, resulting in bruising and a laceration on the right side of their face. Paramedics were called and family was notified by the facility immediately. R1 did not sustain serious injuries. During today’s visit at 10:50AM, LPA observed caution signs taped to the doors on the staff side that state “ATTENTION: PLEASE OPEN DOOR WITH CAUTION.” Per interviews, staff have been advised to open the door cautiously and to redirect R1 when R1 is observed to be near door paths. Record review and observation of R1 indicate that R1 has dementia and wandering behaviors. Staff are knowledgeable in redirecting R1. At 12:49PM, LPA observed R1 with a small pale green bruise under their right eye by their nose, slight redness above the right eyebrow, and no swelling or significant bruising. Lack of supervision, malicious intent, and concerns of negligence were not noted. It was further alleged that the facility door poses a safety concern for residents as there are no windows or cameras to alert staff if residents are in the way of the door. At this time, there are no regulations in the California Code of Regulations, Title 22 and/or California Health and Safety Code that require facility doors to have windows, cameras, or other equipment for staff to observe if residents are behind a door. LPA had a conversation with ED about minimizing the risk of reoccurrence as the door is heavy and requires force to open which could be problematic if a resident was in its path. ED informed the maintenance director and stated they will inquire about having a window placed on the door or some other feature that could allow staff to check for residents in the way. During the visit, ED placed additional signs on the community side of the door stating, “CAUTION WHEN OPENING DOOR PLEASE OPEN CAREFULLY PLEASE DO NOT STAND IN FRONT OF THE DOOR.” ED also stated that they will have staff redirect R1 if R1 gets close to the door and ED and HSD will have weekly reminders for staff to open the door cautiously. LPA observed a daily meeting agenda on 02/24/2025 with the goal of informing staff to monitor R1 and open doors cautiously. LPA observed ED reminding staff to open the door carefully at 03:07PM. Information obtained through interview, record review, and observation for this investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations “Staff negligence caused injury to resident” and “Facility door poses a safety concern for residents” are deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 29-AS-20250305161155

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 10:40AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 02/26/2025. Upon arrival, LPA met with Executive Director (ED) Susan Weisbarth and staff. Entrance interview conducted. During today's visit, LPA interviewed five (5) staff members between 10:43AM-1:01PM, reviewed and obtained copies of pertinent documents relevant to the investigation between 11:40AM-12:36PM, conducted a brief physical plant tour at 12:40PM, and attempted interviews with two (2) residents between 03:04PM-03:06PM. On 02/27/2025, the Department received a verbal incident report stating that on 02/26/2025, Resident #1 (R1)’s morning Lorazepam medication dose was not administered by Staff #1 (S1). The discrepancy of the missing dose was observed around 02:30PM, same day. R1’s hospice agency and responsible party were notified. R1 was monitored for changes in condition, no significant changes were noted. Health and Services Director (HSD) Tony Nunez conducted one-on-one trainings with S1 on 02/27/2025 and 03/04/2025. As of 03/06/2025, S1 no longer works at the facility. HSD stated that the facility will be auditing medications and plans to have a vendored medication training in the near future. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(4) · Plan of correction due date: Apr 1, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws... This requirement is not met as evidenced by: Based on medication review and interview, the licensee did not comply with the section cited above as Resident #1 (R1)'s Lorazepam medication was not administered by Staff #1 (S1) as prescribed, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: S1 no longer works at the facility. HSD stated they will schedule a vendored training soon and will submit proof to CCL of the scheduled date by 04/01/2025.

Allegation investigated: Staff retained resident without proper admission procedures

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above 01:05PM. Upon arrival, LPA met with Executive Director (ED) Susan Weisbarth. Entrance interview conducted. During today's visit, LPA delivered final finding for the above allegation. During the initial visit on 02/11/2025, LPA conducted a brief physical plant tour, conducted interviews with five (5) staff members and four (4) residents, reviewed and obtained copies of pertinent documents relevant to the investigation, and discussed allegation with ED and Health and Services Director (HSD) Tony Nunez. It was alleged that on 07/20/2024, the previous ED Michael Owens retained Resident #1 (R1) without proper admission procedures. ED Owens was in communication with responsible party(ies) of R1 and informally agreed to move R1 to the facility, as evidenced by text messages between ED Owens and responsible party dated 07/19/2024 – 07/26/2024. Continued on LIC 9099-C. Substantiated Information obtained confirms that required documents were provided to the facility, such as the resident’s physician’s report and medication list, and that ED Owens spoke with R1’s doctor to create a plan of care. LPA reviewed R1’s file retained at the facility and observed R1’s physician’s report dated 01/17/2024, TB test dated 07/20/2024, COVID/influenza A + B/multiplex NAA nasal test from 07/18/2024, hospital discharge paperwork from 07/18/2024 – 07/20/2024, R1’s medication list dated 07/20/2024, and interim service plans from the facility dated 07/20/2024 and 07/23/2024. R1 moved into the facility on 07/20/2024, however, no admission agreement was provided for review or signature even after prompting from responsible party. No admission agreement, pre-placement appraisal, or care plan/needs and services appraisal was observed in R1’s file. R1 resided at the facility for five (5) days without a contract between 07/20/2024 – 07/25/2024. ED Owens resigned without proper notice end of day on 07/22/2024. R1’s responsible party was informed by corporate management on 07/25/2024 that R1 needs to leave the facility as there is no written contract for R1’s admission. LPA interviewed Staff #1 (S1) and Staff #2 (S2) who were employed during the ED abandonment and confirmed that a resident was improperly admitted to the facility by ED Owens during that time. LPA interviewed current ED Weisbarth, HSD Nunez, and Resident Care Coordinator (RCC) Angelica Caton who were not employed at the facility during the time of the alleged incident. No concerns of the facility’s current admission procedures were noted. Interviews revealed that residents admitted during previous management were not properly assessed, however, the facility has been assessing residents and updating care plans quarterly and organizing resident files to be in compliance. Residents interviewed did not have evidence relevant to the investigation. LPA conducted previous visits regarding ED Owens and absence of management which were assessed during that time. Based on the facility’s history, interviews, and record review, the allegation “staff retained resident without proper admission procedures” is deemed SUBSTANTIATED at this time. Plan of Correction has been met as current administration is knowledgeable in admission procedures and is properly documenting admissions and assessing residents. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. Appeal rights and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 29-AS-20250207095420

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87456(a) · Plan of correction due date: Feb 27, 2025

87456 Evaluation of Suitability for Admission (a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8 This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as Resident #1 (R1) was admitted without an admission agreement and appraisal which posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 20, 2025

Plan of correction: Current administration is knowledgeable on proper admission procedures per regulation and provided proof to LPA during the visit of admission procedures. POC has been met.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Emily Peraldi made unannounced case management visit regarding a self-reported incident on the relocation of 20 residents from Bentley Suites- License # 198320302 to PRESERVE AT WOODLAND HILLS, THE - License #195850091 due to mandatory evacuation orders from Fire Advisory. The LPA met with Administrator Susan Weisbarth and Administrator from Bentley Suites, Belen Taico and explained the purpose of the visit. During the visit, LPA Peraldi conducted a health and safety check and no concerns were observed. LPA reviewed and obtained resident and staff rosters for both facilities. Per interview with the Administrators, 20 residents have been relocated to The Preserve at Woodland Hills. The facility has sufficient beds, hygiene supplies, beddings, linens, and everyone has a designated room. All rooms have an ensuite bathroom. The dining room is large enough to accommodate all residents with staggered dining schedules. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. Medications and files of the Bentley Suites residents have been transferred and stored in a locked room. There is sufficient staffing available to provide care for resident of both facilities. The Administrator Belen Taico confirmed all families and responsible parties from Bentley Suites have been notified of the relocation. Current Preserve at Woodland Hills residents will not be affected by this relocation. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 10, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 02:12PM. The purpose of this visit is to conduct an investigation regarding two self-reported incidents that occurred on 12/05/2024 and 12/22/2024. Upon arrival, the LPA met with staff and Executive Director (ED) Susan Weisbarth. Entrance interview conducted. During today’s visit, LPA Barutyan conducted a brief physical plant tour to ensure there are no health and safety hazards and conducted interviews with five (5) staff members and attempted interviews with two (2) residents. On 12/10/2024, the Department received an incident report stating that on 12/05/2024 around 10PM, Resident 1 (R1) eloped and left the facility unassisted through the back Egress door and had a fall on the sidewalk. Staff heard the alarm ring and noticed that R1’s room was empty. Staff checked inside and outside the facility and found R1 outside being assisted by the Fire Department, which a neighbor called in. R1 was transported to the hospital and was diagnosed with a urinary tract infection (UTI) contributing to R1’s confusion and wandering. Facility management held a meeting with R1’s responsible party to discuss changes in care such as a 1:1 caregiver for nighttime, bed/floor alarms, or relocating R1 to a room in the front of the facility. On 12/27/2024, the Department received an incident report stating that on 12/22/2024 around 2PM, Resident #2 (R2) was spotted by Staff #1 (S1) outside of the community as R2 had eloped unnoticed. S1 recognized R2 and assisted R2 back to the facility. No injuries were noted. Report Continued on LIC 809-C LPA interviewed ED Weisbarth and Health and Services Director (HSD) Tony Nunez on 01/02/2025 who stated that R1 and R2 eloped from the same back Egress door. According to ED and HSD, staff reported that the alarm sounded when R1 eloped on 12/05/2024, which is why staff were able to act quickly and call a code yellow, but did not sound when R2 eloped on 12/22/2024, which is why staff were unaware that R2 had eloped. ED and HSD reviewed the alarm logs and checked the system which showed that the alarm did ring on 12/22/2024. Per HSD, the alarm rings very loud and it is unlikely that staff did not hear the alarm. ED stated they are currently in the process of installing perimeter cameras and a potential gate to secure the grounds. ED also stated that they are looking into changing the delayed egress from 15 seconds to 45 seconds. LPA requested copies of pertinent documents relevant to the investigation on 12/10/2024 and 12/31/2024, documents were received via email on 01/03/2025. On 01/03/2025, LPA reviewed preplacement appraisals and physician’s reports for R1 and R2. R1’s physician’s report dated 11/26/2024 documents that R1 has dementia, mental condition is confused/disoriented, has wandering and sundowning behavior, and is not able to leave the facility unassisted. R2’s physician’s report dated 03/27/2024 documents that R2 has dementia, requires continuous bed care, mental condition is confused/disoriented, has sundowning behavior, is not able to communicate needs or follow instructions, and is not able to leave the facility unassisted. During the visit, LPA interviewed staff who stated that R1 was away from the facility for a period of about 10 minutes. Staff heard the alarm and noticed R1’s empty room, code yellow was immediately called and all staff searched for the resident. For R2’s elopement, staff stated that two (2) door alarms sounded. When staff went to check the doors, they observed Resident #3 (R3) who has a habit of attempting to open the Egress doors and sounding the alarms. Staff assumed that the alarm was sounded by R3 and did not check if other residents were missing. During the visit, LPA observed R3 wandering in the hallways. LPA was unable to interview the residents as R1 moved out of the facility, R2 did not wish to speak to the LPA, and R3 was disoriented and unable to communicate with LPA. During the physical plant tour, LPA asked the maintenance director to demonstrate that the delayed egress door worked. Door was tested twice at 02:34PM and was functioning properly during the visit. The alarm was triggered when the bar was pushed, and each door has three (3) alarms. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1596.312(a) · Plan of correction due date: Jan 8, 2025

Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews conducted, evidence submitted and file review, the licensee did not comply with the section cited above. Facility staff failed to provide the necessary care and supervision to R1 and R2 which allowed the residents to elope from the facility unassisted, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: ED stated they will increase the delayed egress. ED will submit a written plan of action outlining the actionable changes the facility will take to prevent R2's elopement behavior by 01/08/2024 to CCL.

Allegation investigated: Staff do not ensure that resident is provided their medication(s) according to physician’s instructions.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility at 10:00 a.m. At 10:10 a.m., the LPA met with the Executive Director (ED), Susan Weisbarth and explained the reason for the visit. During the initial visit conducted on 08/31/2023 between 9:00 a.m. and 12:30 p.m., LPA Peraldi conducted an interview with the Administrator at the time, Trevin Willis, five (5) residents, and four (4) staff. During the initial visit, the LPA also conducted a physical plant tour and obtained copies of pertinent documents. During today’s visit, between 10:10 a.m. and 2:30 p.m., the LPA conducted interviews with the ED, four (4) residents, and two (2) staff. The LPA also conducted a physical plant tour and obtained copies of pertinent documents during the time of the visit. During today’s visit, between 10:28 a.m. and 11:15 a.m., the LPA conducted a review of medication and medication documentation with staff for four (4) residents. Continued on LIC 9099-C. Substantiated Regarding the allegation: Staff do not ensure that resident is provided their medication(s) according to physician’s instructions. During today’s visit, between 10:28 a.m. and 11:15 a.m., the LPA conducted a review of medication and medication documentation with staff for four (4) residents and observed the following: Resident #1 (R1’s) Evening medications, Carbidopa-Levodopa 25-100 Tab, Acetaminophen 500 MG Cap, Quetiapine Fumarate 25 MG, and Memantine 10 MG Tab were not self-administered or given to the resident for 12/18/2024. Per record review and staff interview, notes or documentation from 12/18/2024 indicating that R1 refused the medication was entered on 12/19/2024. The ED stated that an in-service training will be conducted to remind staff to properly document medication refusals. Based on observation and record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided. Regarding the allegation: Staff do not ensure that residents have an operable call button (pendant). Resident interviews conducted on 08/31/2023 and 12/19/2024 revealed that there are no issues with their call buttons. On 12/19/2024, the ED explained that the resident rooms now have a movement censor and the majority of residents have a pendant. The ED explained that staff periodically check if the pendants are functional. During the visit on 08/31/2023 and 12/19/2024, the LPA tested a random sample of residents’ pendants and observed them functioning properly. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff do not respond to requests for assistance in a timely manner. It was alleged that it takes up to two (2) hours for staff to respond to request for assistance. Resident interviews conducted on 08/31/2023 and 12/19/2024 revealed that staff respond to their request for assistance within 5-10 minutes. Resident interviews did not reveal any concerns regarding the staff response time. Interview with the ED conducted on 12/19/2024, revealed that staff aim to respond to request for assistance within 5 minutes. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff do not ensure that resident’s medication(s) are ordered in a timely manner. Resident interviews conducted on 08/31/2023 and 12/19/2024 revealed no concerns regarding staff ordering their medications. Staff interviews conducted 08/31/2023 and 12/19/2024 revealed that medications get ordered 7-10 days prior to the current medication cycle ending. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 29-AS-20230823123714

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 20, 2024

87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and observations, the licensee did not comply with the section cited above, as the facility staff did not properly assist with R1’s self-administered medications per physician’s order which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Within 24 hours, the ED will notify the LPA when medication training will be completed. Administrator stated that training for all medication staff will be completed and submit documentation to CCL by 12/31/2024.

Allegation investigated: . Staff did not follow the care plan established by the resident's physician 2. Staff did not inform resident's authorized person of a change to resident's care plan 3. Staff do not meet resident's toileting needs; 4. Staff do not keep the facility clean & sanitary 5. Staff did not meet the resident's hygiene needs; 6. Staff did not maintain residents laundry 7. Staff did not safeguard resident's personal items; 8. Staff do not ensure that resident is adequately fed 9. Facility window is in disrepair; 10. Staff did not keep the facility free of spiders 11. Staff did not keep the facility free of ants; 12. Staff do not prevent residents from entering another resident's room; 13. Resident's shower rod is in disrepair

Licensing Program Analyst (LPA) Christine Yee conducted another unannounced subsequent complaint visit to investigate the above allegations and met with Lorrain Walters, Business Office Manager. The reason for today's visit was provided. On 12/11/23 Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit regarding the above noted allegations. LPA met with administrator Trevin Willis and explained the reason for the visit. At 11:03 a.m. LPA discussed the complaint with the administrator. Based on the allegations the administrator was aware of the resident this complaint was regarding. While LPA was conducting a quick tour of the facility at 11:40 a.m. LPA observed housekeeping cleaning the room of resident 1 (R1). At 11:45 a.m. LPA observed R1 in the dining room. R1 appeared well groomed but anxious. At 12:30 p.m. R1 had an aggressive outburst and threw a plate of food at resident 2 (R2). Staff redirected R1 who then started yelling and wandering the halls. R1 stated they were in pain and wanted to see a doctor. Administrator Continued on LIC9099-C Unsubstantiated Page 2 called 911. At 1:15 p.m. LPA obtained pertinent documents. This complaint requires further investigation. An LPA will return at a later date to continue this investigation. No deficiencies observed at this time. Copy of report was provided to the administrator. On 12/17/24, Licensing Program Analyst (LPA) Christine Yee conducted a subsequent unannounced complaint visit to conduct additional investigation for the above allegations and met with Susan Weisbarth, Executive Director. The reason for today's visit was explained. On today's visit LPA Yee conducted an interview with Staff #1 at 11:28am, Staff #2 at 12:38p, Staff #3 at 1:05pm, Staff #4 at 1:33pm, Staff #5 at 2:22pm, Staff #6 at 3:20pm and toured Bedroom #102, #126 and #127 at 2:57pm. LPA Yee also obtained copies of facility documents during the visit. Per information received during the visit, it was again determined that additional investigation is needed to make findings for the above allegations. An exit interview was conducted and a copy of this report was provided. Another unannounced subsequent complaint visit was conducted today to continue investigation of the above allegations. LPA Yee met with Lorrain Walters and Iveth Barron and the reason for today's visit was provided. LPA Yee conducted an interview with Resident #2 at 11:07am, Resident #3 at 1:33pm, Resident #4 at 12:24pm, Resident #5 at 12:35pm and Staff #6 at 1:47pm. Per information received through interviews conducted for all the above allegations, Resident #1 was admitted to the facility with dementia. Resident #1 would refuse medications and would easily be agitated and turns very aggressive. Resident #1 would be given breakfast, lunch and dinner and would eat only about half the meal. Resident#1 is able to feed themselves but was very picky with their food and would request pancakes with syrup, ice cream with whip cream, sprinkles and syrup and used syrup on all the facility meals. Resident loves ice cream and noodles and orange chicken from Panda Express. The facility staff will order food just so that the resident will not get agitated but resident would not eat the ordered food. Resident #1 demands to be served their meal first and gets what they request so that they don't get agitated. Resident #1 would get very upset and agitated when there was no syrup or did not get what they wanted. Resident would yell and scream loudly at the staff and that they were being mean and trying to kill them. Resident would also throw cups, plates and other things, rip the shower rod down and destroy their bedroom when it was cleaned, within minutes of returning to the room. Resident #1 got so agitated that Page 3 at the bedroom window. Staff would attempt to re-direct the resident and would call the responsible family member for assistance via telephone or in person. As a result of this behavior, the facility asked the family to speak with the resident's doctor and obtain medications to assist with controlling the agitation. An order for CBD /THC gummies 1mg was prescribed by the physician. Resident #1 refused the CBD gummies and other medications. Multiple attempts would be made to get the resident to take the prescribed gummies and was unsuccessful. Resident #1 would be constantly agitated and confused. Resident would blame the staff for not cleaning the bedroom, refused to be assisted with changing their briefs when it was soiled or it was sopping wet or let staff wash their hands when it was observed with feces from the resident putting their hands inside their briefs or when they did not wipe themselves after having a bowel movement. Resident #1 would transfer the feces on to door handles and bedding and would often not let staff into the room to clean the mess. The wet briefs would be sopping wet and dripping urine on the floor. Resident #1 would refused to be changed and also refused to be bathed. The room would smell. They would have to bribe the resident with ice cream or a trip to San Francisco. Sometimes it worked and sometimes it didn't. Resident #1 is also particular about who gives them a bath. Resident #1 will not usually allow the 2 African American staff to bath them and prefers a male staff if they agree to a shower. Staff could clean Resident #1's room and change the bedding when the resident was out of the room. The resident's belonging would be put in order and minutes after the resident returned, Resident #1 would turn it upset down again. Resident would yell at the staff and tell staff that they do not want their room cleaned and say that someone stole their stuff when things are put away or taken to be laundered. The resident Resident #1 was also a very messy eater. Resident #1 would throw food all over the room and get it all over their clothes. Resident #1 loved to eat their food in the bathroom. Resident #1 loved sweets and their food was always mixed with syrup and had sprinkles. Food was also all over the bathroom including the dirty plate. Per Staff, the food would be cleaned up once they were allowed into the room but until they could clean up, the syrup could attract ants and other pests. Per staff, they have not seen any ants, spiders or roaches in Resident #1's room. Per staff, they have to clean the resident's room everyday. Per information obtained from interviews, Resident #1 was away from the facility for about 3 months. Staff were not sure where the resident went before returning to the facility. Resident #1 was observed to have lost weight upon return. Upon return, Resident #1 was still agitated and the facility staff advised the family to Page 4 speak with the resident's physician and obtain medications to assist with the resident's agitation. The doctor prescribed Quetiapine Fumara 25mgs, PRN, 1 tablet, every 12 hours, 2 doses in 24 hours and Quetiapine Fumara 12.50mgs at bedtime. However, for unknown reasons, the family had the doctor discontinue the medication. Resident #1 continued to de-escalate. Resident #1 believed that people were doing things to them. Resident would also not sleep at night. Per information obtained from family, they wanted to try to reduce the number of naps taken by the resident first before using prescribe medications to aide Resident #1 with sleeping during the night. However, the doctor had submitted a prescription for the sleep medication and it was filled. Once the facility received the medications, there was no reason not to dispense the medication contrary to the family's instructions. The facility is required to dispense the medication as prescribed by the doctor unless the facility or family member obtains a discontinue order from the doctor regardless of what the family wanted. Per information provided, Resident #1 likes to leave their bedroom door unlocked. Dementia residents who wander around would enter the Resident #1's room. Resident #1 would say that they are after them or doing things to them and blame them for messing up their room. Resident #1 would imagine things. Per information received from interviews, there is not sufficient evidence to support the allegations noted above. It may have happened or may not have happened, but there is not a preponderance of evidence to support the above the allegations, therefore the allegations are unsubstantiated at this time.the state’s words, verbatim · CDSS document, Dec 18, 2024 · control 29-AS-20231208120748

Allegation investigated: Facility does not have enough staff to meet the needs of residents in care.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a second subsequent complaint investigation for the allegation listed above at 02:45PM. LPA met with Health and Services Director (HSD) Antonio “Tony” Nunez and Executive Director (ED) Susan Weisbarth and explained the reason for the visit. During today's visit, LPA delivered final finding for the above allegation. During the subsequent visit which took place on 10/17/2024, LPA interviewed ED and HSD, reviewed and obtained copies of pertinent documents, conducted a brief physical plant tour, and interviewed two (2) residents and one (1) visitor. During the initial complaint visit which took place on 09/04/2024, LPAs Barutyan and K. Dulek reviewed records, conducted interviews, conducted a brief physical plant tour, conducted a medication review, and obtained copies of pertinent documents. Continued on LIC 9099-C. Unsubstantiated It was alleged that the facility has insufficient staffing. On 08/29/2024, LPA Barutyan conducted a visit for an unrelated complaint and observed one (1) caregiver, Staff #1 (S1) attending to around twenty-five (25) residents in the dining room. At 11:28AM during LPA’s physical plant tour on 08/29/2024, Resident #1 (R1) needed incontinence assistance and S1 left to assist R1 to the bathroom. LPA observed the remaining residents in the dining room left unassisted with no care staff. Staff #2, a kitchen staff member accompanying LPA on the tour, stated that it is like this “50% of the time” and that “residents get left alone, but it's never for too long.” S2 stated that he/she tries to stay in the dining room and watch the residents when he/she does not have to be in the kitchen, in order to help lighten the work load on care staff. S2 also stated that "the facility is very short-staffed, but the staff on shift are able to handle the load." S2 stayed behind to supervise staff until S1 returned around 20 minutes later. The complainant alleged that on 08/28/2024, only one (1) care staff was on shift after 7PM and on 08/24/2024, two (2) care staff were on shift from 2PM-10PM. LPA reviewed shift timestamp records which document four (4) staff on shift on 08/28/2024 after 7PM and three (3) staff on shift on 08/24/2024 between 2PM-10PM. There are two (2) residents who require two (2) person assists. Interviews conducted between 08/21/2024 – 09/04/2024 revealed nine (9) concerns of staffing numbers. One (1) caregiver on 08/21/2024, one (1) family member on 08/26/2024, one (1) staff member and four (4) family/responsible parties of residents on 08/29/2024, and two (2) family members on 09/04/2024 had concerns of the number of staff on shift. Although there were concerns of staffing, shift timestamp records from 08/11/2024 – 08/31/2024 document more than three (3) staff on shift at all times. Per regulation, there are no staffing ratios for residential care facilities for the elderly. California Code of Regulations, Title 22 Section 87415 Night Supervision states that “In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes.” Furthermore, the facility has hired and onboarded one Health and Services Director, one Lifestyle Director, one Executive Director, one Business Operations Manager, one Resident Care Coordinator, six (6) caregivers, two (2) medication technicians, one Sous Chef, and one kitchen staff between 08/16/2024 – 11/13/2024. Record review of the current staff schedule reveals 3-4 care staff for the AM (6AM – 2PM) shift, 3-4 staff for the PM (2PM – 10PM) shift, and three (3) for the NOC (10PM – 6AM) shift. Based on record review, observation, and interviews, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation, therefore, the allegation “Facility does not have enough staff to meet the needs of residents in care” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. Copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 29-AS-20240830143412

Allegation investigated: Resident was physically abused while in care.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegation listed above at 02:45PM. LPA met with Health and Services Director (HSD) Antonio “Tony” Nunez and Executive Director (ED) Susan Weisbarth and explained the reason for the visit. During today's visit, LPA met with the HSD and ED to deliver final findings for the above allegation. During the initial complaint visit which took place on 10/17/2024, LPA interviewed ED and HSD, reviewed and obtained copies of pertinent documents, conducted a brief physical plant tour with ED at 04:47PM, and interviewed two (2) residents and one (1) visitor between 04:49PM - 05:05PM. Continued on LIC 9099-C. Unsubstantiated It was alleged that a resident was physically abused while in care. The complainant alleged that on 10/08/2024, Resident #1 (R1) was observed to be in distress and crying while pointing to their bathroom and saying, “they beat me.” The LPA interviewed the complainant who stated that the allegation was “more a hunch than proof that was the case, [R1] simply may have been a little tired from exercising” and stated that R1 has difficulty expressing words due to history of Aphasia. The complainant also stated that no markings were observed on R1. LPA interviewed R1’s responsible party (RP) who stated they were told that R1 was screaming and saying they were beating R1 up, but RP did not observe any bruises on R1’s arms except for a small bruise on the wrist that was from a week prior. RP also stated that R1 did not used to be aggressive, but lately that has changed. According to RP, R1 gets agitated very easily, tries to exit, cries, does not like to leave the room, and thinks everyone is mean to R1. RP stated they do not see the staff being mean to R1. RP stated that R1 gets aggressive during showers and there was a particular day on 10/08/2024 where R1 had to have two (2) showers which left R1 agitated. LPA interviewed HSD Nunez and ED Weisbarth who both stated that R1 gets aggressive during showers and pinches staff and self. HSD stated that staff are trained on redirecting and de-escalating aggressive episodes and that R1’s family is aware. HSD also stated that R1 had to be removed from their second shower on 10/08/2024 for their’s the staff’s safety as R1 was having an aggressive episode and scratched staff. HSD provided LPA with a date-stamped picture taken on 10/10/2024 of the small bruise on R1’s forearm. RP confirmed that they were aware of the bruise. During the LPA’s visit on 10/17/2024, the police independently conducted a wellness check on R1 and determined that R1 has severe dementia, and the resident is safe. The LPA reviewed Resident #1’s (R1) records which confirm R1’s dementia diagnosis. Based on interviews and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Resident was physically abused while in care” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 29-AS-20241015125318

Allegation investigated: Staff overmedicate resident(s) in care.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegation listed above at 04:00PM. LPA met with Health and Services Director (HSD) Antonio Nunez and Executive Director (ED) Susan Weisbarth and explained the reason for the visit. During today's visit, LPA interviewed ED and HSD between 04:02PM - 6:00PM, reviewed and obtained copies of pertinent documents, conducted a brief physical plant tour with ED at 04:47PM, and interviewed two (2) residents and one (1) visitor between 04:49PM - 05:05PM. During the initial complaint visit which took place on 09/04/2024, LPAs Barutyan and K. Dulek reviewed records, conducted interviews, conducted a brief physical plant tour, conducted a medication review, and reviewed and obtained copies of pertinent documents. Continued on LIC 9099-C. Unsubstantiated It was alleged that staff overmedicated a resident in care. LPAs Barutyan and Dulek conducted a medication review of five (5) residents on 09/04/2024 and observed all medications being given as prescribed. Medications are stored, documented, and administered in accordance with California Code of Regulations, Title 22 and state and federal law. Interviews with the reporting party (RP) indicated concerns of medication dosages that were being administered to Resident #1 (R1) and medication-technicians administering painkillers that were “too strong.” Interviews with staff and ED Willis revealed that the painkillers were prescribed by R1’s physician and that the med-techs were administering the prescribed medications per the medication instructions on the Rx label, which is consistent with LPA observation during the medication audit. The RP also stated that R1 was “numbed and dazed” from the strength of the painkillers and that the med-techs should not have administered that strong of a dosage. Per regulation, med-techs do not need to be licensed medical professionals and therefore, cannot alter or prescribe medications. Medication review indicated that family of R1 provide over-the-counter nutrients, supplements, and medications like “fear spray” and “calming essential oils” which med-techs stated they do not know how to use as R1 cannot verbally or physically express if they are scared. ED Willis stated that they are worried that assuming how R1 is feeling and administering something that R1 cannot consent to is a violation of personal rights. LPAs Barutyan and Dulek did not observe any medication errors for five (5) residents reviewed on 09/04/2024 and for four (4) residents reviewed on 08/13/2024 by LPAs Barutyan and Emily Peraldi. LPA telephonically interviewed the co-complainant on 10/14/2024 who stated that the allegation was “inaccurate” and that they do not believe the staff are over-medicating. Co-complainant did not have any information to support the allegation. Based on interviews, medication review, and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff overmedicate resident(s) in care” is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Oct 17, 2024 · control 29-AS-20240830143412

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced case management visit at 9:50 a.m. Upon arrival, the LPA met with Executive Director (ED) Susan Weisbarth and explained the reason for the visit. The reason for today's inspection is to follow up on a self-reported incident report received on 09/10/2024. The report pertains to Staff #1 (S1) placing a cloth over Resident #1’s (R1’s) mouth after R1 attempted to bite S1. Starting at 9:54 a.m., the LPA conducted interviews with the ED and one (1) staff member. At 10:07 a.m., the LPA conducted a file review and obtained copies of pertinent documents. Additional report may follow if warranted. Exit Interview conducted and report was issued.the state’s words, verbatim · CDSS document, Sep 13, 2024

Allegation investigated: Staff violated resident’s personal rights.

Licensing Program Analysts (LPAs) Angela Barutyan and Kelly Dulek arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegation listed above at 09:38AM. LPAs met with staff and Executive Director (ED) Trevin Willis and explained the reason for the visit. During today's visit, LPAs reviewed records, conducted interviews, conducted a brief physical plant tour at 10:56AM, conducted a medication review at 12:15PM, and obtained copies of pertinent documents. During the initial complaint visit which took place on 08/29/2024, LPA Barutyan spoke with ED, reviewed and obtained copies of pertinent documents, reviewed staff personnel and resident files, conducted a brief physical plant tour, and interviewed two (2) staff and four (4) responsible parties of residents. On 08/21/2024, LPA Barutyan conducted a Case Management – Incident visit to investigate two (2) incidents, of which one (1) relates to the complaint, that were self-reported to the Department. During the Case Management visit, LPA Barutyan conducted interviews with the ED and three (3) staff members, reviewed files, and obtained copies of pertinent documents relevant to the investigation. Continued on LIC 9099-C. Substantiated It was reported that staff violated a resident’s personal rights by taking a photograph of a resident in the bathroom. The Department received a self-reported incident report on 08/20/2024 stating that on an unknown date, Staff 1 (S1) and Staff 2 (S2) took a selfie in front of Resident 1 (R1) who was on the toilet in their personal bathroom and exposed in the picture. Staff members then shared the picture among their personal circles. Staff 3 (S3) reported the incident to ED Willis on 08/20/2024. Interviews conducted on 08/21/2024, 08/29/2024, and 09/04/2024 revealed that staff members S1, S2, and S3 involved in the incident have been suspended and are in the process of termination for involvement. Photo evidence from a credible witness was received. LPA Barutyan spoke with management company representative, Wendy Souders, at 10:48AM on 08/29/2024 who did not authorize to release requested documents pertinent to the investigation. LPAs spoke with Wendy Souders over the phone today, 09/04/2024, at 10AM who again did not authorize the release of requested documents. During the time of the visit around 12:30PM, the management company called ED Willis to inform him to release the requested documents to the LPAs. Based on photo evidence received from a credible witness, interviews conducted, and pertinent documents obtained, the allegation “staff violated resident’s personal rights” is deemed SUBSTANTIATED at this time. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. Appeal rights and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 29-AS-20240823102422

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 5, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews, record review, and evidence from a credible witness, the Licensee did not comply with the section cited above in that three (3) staff members did not respect a resident's dignity which poses an immediate personal rights risk for persons in care.the state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: All staff members involved have been suspended and are in the process of termination. The facility has been actively hiring new staff and training on personal rights is being provided and will continue to be provided on an ongoing basis. POC is cleared.

Allegation investigated: Licensee does not ensure that staff are adequately trained.

Licensing Program Analysts (LPAs) Angela Barutyan and Kelly Dulek arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above at 09:38AM. LPAs met with staff and Executive Director (ED) Trevin Willis and explained the reason for the visit. During today's visit, LPAs reviewed records, conducted interviews, conducted a brief physical plant tour at 10:56AM, conducted a medication review at 12:15PM, and obtained copies of pertinent documents. Report continued on LIC 9099-C Substantiated It was alleged that the licensee does not ensure that staff are adequately trained. LPA Barutyan conducted an unannounced required annual visit on 08/07/2024 in which the facility received two (2) citations for incomplete 40 hours of initial training and 20 hours of annual continuation training. The plans of correction for the deficiencies cited on 08/07/2024 are still pending and have a due date of 09/06/2024. Based on record review and interviews, the allegation “licensee does not ensure that staff are adequately trained” is deemed SUBSTANTIATED at this time. While the allegation is substantiated, a deficiency will not be cited as the facility have open and pending plans of correction addressing personnel training. ED Willis has provided evidence of in-service training that has been conducted since 08/07/2024, and personnel are getting time allotted to complete online training at the facility. Exit interview conducted, a copy of the report provided.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 29-AS-20240830143412

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Resident was locked in room while in care Staff did not provide resident with meals in a timely manner Staff did not meet resident's care needs.

Licensing Program Analysts (LPAs) Angela Barutyan and Kelly Dulek arrived at the facility unannounced to conduct an initial complaint investigation for the allegations listed above at 09:38AM. LPAs met with staff and Executive Director (ED) Trevin Willis and explained the reason for the visit. Entrance interview conducted. During today's visit, LPAs spoke with Administrator/ED at 09:40AM, spoke with Management company representative telephonically at 10:00AM, reviewed and obtained copies of pertinent documents, conducted a brief physical plant tour with ED at 10:55AM, observed lunch service at 12:11PM, observed medications for 5 (five) residents at 12:17PM, spoke with 3 (three) resident family members, and observed 5 (five) resident rooms/door locks beginning at 03:21PM. Previously, during unrelated visits at the facility, LPA Barutyan had conducted staff and family member interviews related to these complaint allegations. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: "resident was locked in room while in care:" The complaint alleges that Resident #1 (R1) was left alone in their room while residing at the facility. LPAs reviewed R1's admission agreement as well as R1's needs and service appraisal. Upon admission, and up until R1 had a change of condition on 08/12/2024, R1 was able to ambulate and did not require assistance with mobility. During today's visit, LPA observed the door lock/closing mechanism on 5 different resident rooms, including that of R1. All door locks observed do have the option to remain unlocked at all times or a switch can be engaged which allows the door to remain locked from the outside, but the door will open when the handle is turned from the inside. There is also the option for a resident to engage a lock from the inside, which will not allow entry to the room, but again, the resident can turn the handle which disengages the lock, and a resident can exit the room. LPA confirmed that residents can exit their individual rooms at all times, without unlocking the door or requesting staff assistance. Interview revealed that residents can choose whether they remain in their room during the day, however, staff encourage all residents to leave their rooms and engage in facility activities. Based on interview and observation, although the allegation may be valid, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "resident was locked in room while in care" is deemed UNSUBSTANTIATED at this time. Allegation: "Staff did not provide resident with meals in a timely manner:" The complaint alleges that residents are waiting up to 2 hours for meals, which resulted in R1 losing a significant amount of weight. During today's visit and during a prior visit, LPAs observed meal service to residents. Additionally, interviews were conducted related to meals and meal service. Interview revealed that kitchen staff prepare the meals in the kitchen area, then deliver prepared food to the dining room. Lunch is served beginning at 12:00PM. Salad or soup is delivered first, then meals that are to be delivered to resident rooms are set up for care staff to deliver. One care staff is able to deliver the few meals to resident rooms, while the other care staff assist residents with their meals in the dining room. Kitchen staff then bring out the main course for care staff to serve. During today's visit, LPAs observed lunch at 12:07PM. All residents had been served the salad and about half had been served the main course at that time. Dining room staff were observed returning to the kitchen to deliver additional meals for the other residents. R1, who was named in the complaint, was able to ambulate to the dining room for all meals prior to a change in condition. R1 also had a log book in their room indicating their food and beverages eaten. On 09/03/2024, R1's doctor ordered NPO (nothing by mouth) as R1 is on hospice care, so R1's food could not be observed during today's visit. Additionally, R1 had been hospitalized as of 08/12/2024 following a medical incident. When R1 returned to the facility, R1 was placed on hospice care. As R1 had a change in condition, it is unclear whether the Continued on LIC 9099-C weight loss was a result of the change in condition or whether there was insufficient food service. Based on interview, record review, and observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "Staff did not provide resident with meals in a timely manner" is deemed UNSUBSTANTIATED at this time. Allegation: "Staff did not meet resident's care needs:" The complaint alleges that staff did not check on R1 timely while residing at the facility. Although interview with R1's family member revealed there was a verbal agreement indicating R1 would be checked every 30 minutes, review of R1's admission agreement revealed that there was no documented number of times staff would be checking on R1. During today's visit, LPA observed on the wall in R1's room a log indicating hourly checks for R1, which was completed in full for the September 2024 log. Staff interviewed indicate that all residents are encouraged to leave their rooms and engage in activities during the day and are therefore observed regularly. Staff indicated that residents who prefer to remain in their rooms are checked on based on their needs and service appraisal. Based on interview, record review, and observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation "staff did not meet resident's care needs" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 29-AS-20240903124736

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management visit at 02:20PM. The purpose of this visit is to conduct an investigation regarding two self-reported incidents and SOC 341s that occurred on unknown dates. Upon arrival, the LPA met with Executive Director (ED) Trevin Willis and explained the reason for the visit. Entrance Interview conducted. On 08/17/2024, the Department received an incident report stating that on an unknown date, two (2) staff members, Staff 1 (S1) and Staff 2 (S2), were witnessed by Staff 3 (S3) slapping Resident 1 (R1) across the face in R1’s bedroom. According to the report, the incident occurred weeks ago and was reported to the previous ED Michael Owens and Health and Services Director Gloria Barron, but no action was taken at the time. S3 reported the incident to Staff 5 (S5) who reported to ED Willis on 08/16/2024. S1 and S2 have been placed on leave until a formal investigation can be completed by company HR. Families have been notified. The Department received another incident report on 08/20/2024 stating that on an unknown date, S1, S3, and Staff 4 (S4) took a selfie in front of Resident 2 (R2) in the bathroom who was exposed in the picture. Staff members then shared the picture among their personal circles. Staff 6 (S6) reported the incident to ED on 08/20/2024. S1, S2, S3, and S4 have been placed on leave until a formal investigation can be completed by company HR. Families were notified to call ED. During today’s visit, LPA Barutyan conducted interviews with the ED and three (3) staff members between 02:25PM-03:53PM, conducted a file review at 03:00PM, and obtained copies of pertinent documents relevant to the investigation. Prior to issuing final licensing report, it has been determined that further investigation is needed at this time. Exit Interview Conducted and Report was Issued.the state’s words, verbatim · CDSS document, Aug 21, 2024

Allegation investigated: Staff handle residents in a rough manner.

Licensing Program Analysts (LPAs) Angela Barutyan and Emily Peraldi arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegation listed above at 09:46AM. LPAs met with staff and Executive Director (ED) Trevin Willis and explained the reason for the visit. During today's visit, LPAs reviewed resident records and conducted a medication review. During the initial complaint visit which took place on 08/07/2024 beginning at 09:47AM, LPAs spoke with Administrator/ED, reviewed and obtained copies of pertinent documents, reviewed staff personnel records, interviewed 4 (four) staff and 5 (five) residents, and toured the facility with facility staff at 12:48PM. Report Continued on LIC 9099-C Unsubstantiated It was reported that staff handled resident in a rough manner, and that specifically Staff 1 (S1) and Staff 2 (S2) have been observed to handle residents roughly. The complainant alleged that either S1 or S2 grabbed a resident roughly, resulting in a skin tear. The complainant did not provide specific resident names. Interviews conducted with four (4) staff revealed that staff have not observed or heard of other staff rough-handling residents, but that there are certain staff members, Staff 3 (S3), Staff 4 (S4), and Staff 5 (S5), who are neglectful and not properly trained. Staff members have reported S3, S4, and S5 before to the previous administration, but concerns were ignored. LPAs’ interview with five (5) residents and responsible parties of residents in care revealed that no one expressed any potential or immediate concerns for staff servicing the residents at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff handled resident in a rough manner” is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Aug 13, 2024 · control 29-AS-20240731164044

Allegation investigated: Facility staff admitted a resident beyond their level of care. Facility staff not ensuring resident's diabetic needs are met.

Licensing Program Analysts (LPAs) Emily Peraldi and Angela Barutyan conducted an unannounced subsequent visit to this facility to deliver findings. At 9:45 a.m., the LPAs met with staff and explained the reason for the visit. At 10:03 a.m., Executive Director (ED) Trevin Willis arrived at the facility. During the initial visit conducted on 07/24/2024, between 1:00 p.m. and 4:05 p.m., LPA Peraldi met with Resident Care Coordinator (RCC) Ana Gutierrez and conducted a physical plant tour and requested pertinent documents. The LPA also conducted interviews with seven (7) staff and two (2) residents. During today’s visit, the LPAs conducted a brief physical plant tour and reviewed resident records. Continued on LIC 9099-C. Substantiated Regarding the allegations: 1.) Facility staff admitted a resident beyond their level of care. 2.) Facility staff not ensuring resident's diabetic needs are met. On 07/23/2024, the Department received a complaint alleging that Resident #1 (R1) who is diabetic and requires finger prick testing twice a day to test blood sugar was admitted to the facility. The complainant is alleging that R1 does not have the capacity to perform a self-finger prick test and the facility does not have an appropriate skilled professional to perform the test, hence not meeting R1’s diabetic needs. Per record review, R1 was discharged from Kaiser Permanente Hospital and admitted to the facility on 06/08/2024. Per R1’s hospital records and discharge medication list dated 06/08/2024, R1 was to continue performing OneTouch Verio test strips with the following instructions “Check your blood sugar 2 times a day every morning before breakfast and every evening before dinner.” Per R1’s physician report dated 06/07/2024, R1’s primary diagnosis is noted as Dementia and secondary diagnosis as Diabetes. R1’s physician report also indicated that R1 is not “Able to perform own glucose testing.” During R1’s stay at the facility, R1’s blood sugar was not being tested daily. On 07/23/2024, the previous management team quit and did not leave clear instructions regarding R1’s diabetic needs to remaining staff. Interviews with staff revealed that R1 was not getting their blood sugar tested and instead, previous management was attempting to contact R1’s physician to get the blood sugar test discontinued. Additionally, the facility does not have a skilled professional to perform R1’s blood sugar test. The facility’s current ED, Trevin Willis, worked with R1’s family to find an appropriate licensed facility that can perform R1’s blood sugar test. On 08/08/2024, R1 was moved out of the facility. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations of “Facility staff admitted a resident beyond their level of care” and “Facility staff not ensuring resident's diabetic needs are met” are deemed Substantiated. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 13, 2024 · control 29-AS-20240723133024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 14, 2024

87464(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section, as facility accepted R1, who could not perform own glucose testing and facility did not have skilled professional to perform the glucose test which posed an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2024

Plan of correction: On 08/08/2024, R1 was moved out of the facility due to the facility not being able to meet R1 diabetic needs. The Administrator will submit a statement of understanding regarding the above regulation by due date. Additionally, Administrator stated that he will submit a plan on how the facility will ensure residents' basic services will be met by due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Aug 14, 2024

87628(a) Diabetes (a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing…, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as R1 could not perform own glucose testing and facility did not have skilled professional to perform the glucose test which posed an immediate health risk to resident in care.the state’s words, verbatim · CDSS document, Aug 13, 2024

Plan of correction: On 08/08/2024, R1 was moved out of the facility due to the facility not being able to meet R1 diabetic needs. The Administrator will a statement of understanding regarding the above regulation by due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Angela Barutyan and Emily Peraldi arrived at the facility unannounced to conduct a Case Management - Annual Continuation visit at 9:46AM, continuing the inspection that began on 08/07/2024. LPAs met with staff and Executive Director (ED) Trevin Willis and explained the reason for the visit. RECORD REVIEW: LPAs began record review at 10:10AM. LPAs reviewed 5 (five) resident files for documents including, but not limited to: health screening, TB test, physician’s report, needs and service appraisal, and personal rights. All resident files reviewed were complete. MEDICATION REVIEW: Medications are locked and centrally stored in the medication office. At 11:35AM, medications for 4 (four) residents were reviewed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. During today's visit, LPAs obtained a copy of the facility's liability insurance. No deficiencies were observed during the inspection. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2024

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Angela Barutyan and Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 09:47AM. LPAs met with staff and Executive Director (ED) Trevin Willis and explained the reason for the visit. Beginning at 12:48PM, the LPAs, along with the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: Upon entry to the facility, there is a central entry point for check in with staff. There are no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which are fully charged and last serviced 04/19/2024. Activities are offered and all activity rooms and common spaces appeared clean and in good repair. Fire alarm and sprinkler systems are tested annually and were last tested on 11/20/2023. KITCHEN: LPAs inspected the kitchen at 01:09PM. The facility has a sufficient supply of 2 (two) days perishable and 7 (seven) days non-perishable food and an emergency water supply. Food was stored at appropriate temperatures. Appropriate hand washing signs were posted throughout the kitchen. Facility has a set menu and offers an alternate menu for residents. Food is prepared based on the resident’s diets. Snacks and beverages are available for residents throughout the day. BEDROOMS: The LPAs observed 10 (ten) random resident bedrooms throughout the facility. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report Continued on LIC 809-C BATHROOMS: Restrooms were observed to contain nonskid mats and grab bars by the showers and toilets. LPAs measured water temperatures in 5 (five) resident bathrooms and were between 107.8 and 113.2 degrees Fahrenheit, which is within the required range. OUTDOOR SPACE: The LPAs toured the outside area of the facility and observed appropriate outdoor furniture in the courtyard, with a covered shaded area for residents. Parking is available. Area is maintained clean. RECORD REVIEW: LPAs began record review at 10:10AM. LPAs reviewed 5 (five) staff files for documents including, but not limited to: health screening, TB test, training records, fingerprint clearance, and CPR/First-Aid certification. LPAs observed all 5 (five) staff files to have insufficient training with 3 (three) out of 5 (five) staff files missing 40 hours initial training and 2 (two) out of 5 (five) staff files missing 20 hours annual training. Resident files will be reviewed during annual continuation. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. MEDICATION REVIEW: Will be reviewed during annual continuation. INTERVIEWS: During today's visit, LPAs interviewed 4 (four) staff and 5 (five) residents. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 7, 2024

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Administrator abandoned facility.

Licensing Program Analysts (LPAs) Emily Peraldi and Angela Barutyan conducted an unannounced initial complaint visit to this facility. At 9:30 a.m., the LPAs met with staff and explained the reason for the visit. At 9:40 a.m., the LPAs met with Trevin Willis. Between 9:41 a.m. and 10:38 a.m., the LPAs conducted interviews with Trevin W., four (4) staff and three (3) residents. At 9:55 a.m., the LPAs reviewed records and obtained copies of pertinent documents. At 10:26 a.m., the LPA along with Trevin W. conducted a physical plant tour. Continued on LIC 9099-C. Substantiated Regarding the allegation: 1.) Administrator abandoned facility. On 07/25/2024, the Department received a complaint alleging that the Executive Director (ED) / Administrator Michael Owens quit without proper notice, abandoning the facility. Per record review and interviews, ED Michael Owens left a resignation letter dated 07/22/2024 on a desk on Monday July 22, 2024. The letter was found by staff on Tuesday, July 23, 2024. The remaining management team Resident Care Coordinator (RCC), Chef and Maintenance were the only management team left to manage the facility. Staff interviews from 07/24/2024 and 07/31/2024, revealed that RCC and other staff attempted to reach out to ED Michael Owens after finding resignation letter, however ED Michael Owens did not respond to RCC and staff. The Preserve at Woodland Hills’s management company was notified and sent out personnel to help manage the facility on Wednesday July 24, 2024. The Preserve at Woodland Hills is currently working on filling all management vacancies including the Administrator position. Based on observation and interviews, the preponderance of evidence standard has been met, therefore the above allegation of “Administrator abandoned facility” is deemed Substantiated. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 31, 2024 · control 29-AS-20240725095157

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Aug 1, 2024

87405(a) Administrator Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section…This requirement was not met as evidenced by: The Licensee did not comply with the regulation cited above as the Administrator/ ED quit without proper notice, abandoning the facility which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 31, 2024

Plan of correction: Licensee will provide a plan and documents to CCL to update the Certified Administrator on record assigned to manage and oversee this facility by 08/01/2024.

Type of visit: POC

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Plan of Correction (POC) visit to this facility to issue a civil penalty for a POC that has not been corrected within the required time frame. LPA arrived at the facility at 09:40AM and met with Business Office Manager (BOM) Edie Cano. Executive Director Michael Owens arrived during the visit. Entrance interview conducted. LPA Dulek had previously conducted a complaint visit on 05/08/2024 and issued a POC to the facility for not issuing a refund, per the resident's Admission Agreement. During today's visit, LPA spoke with Business Office Manager at 09:43AM, and LPA conducted a brief physical plant tour. BOM reviewed the facility records and indicated there is a check # associated with the refund related to the POC issued and the check was cut on 05/20/2024, however the POC was due on 05/15/2024. Additionally, the check that was cut on 05/20/2024 is in the incorrect amount and there is an additional $561.25 owed. A civil penalty in the amount of $900 was issued during today's visit. (See LIC 421 dated 05/24/2024, located under the LIC 9099 dated 05/08/2024). Exit interview was conducted with Business Office Manager and Executive Director. Appeal rights were discussed. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 24, 2024

Allegation investigated: Facility is not adhering to resident's Admission Agreement

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint visit to address the allegation listed above. LPA arrived at 09:26AM and was greeted by front desk staff. Shortly after arrival, LPA met with Executive Director Michael Owens. Entrance interview conducted. During today’s visit, LPA interviewed Executive Director (ED) at 09:30AM, toured the facility with ED at 10:38AM, and LPA reviewed and obtained copies of pertinent documents. The following was then determined: The complaint alleges that following Resident #1 (R1)'s death and personal belongings were removed from the facility, no refund was issued to R1's family/estate, per the Admission Agreement. Based on interview and record review, R1 passed away on 12/19/2023. Interview revealed that R1's personal items were removed as of 12/30/2023. Payment for R1's December fees had been paid in full, including both Report Continued on LIC 9099-C Substantiated care fees and base rent. Per R1's Admission Agreement, related to resident death, indicates "within 15 days after your personal property is removed, your estate...will receive a refund of any fees paid in advance covering the period after your personal property has been removed." All parties interviewed were in agreement that R1's personal belongings were removed as of 12/30/2023. Additionally, interview with Executive Director revealed that R1 should not have accrued care fees, as of the date of their death. Instead, only the base rate should have been charged following R1's death to the date their items were removed from the R1's room. Review of R1's Admission Agreement and all attachments, as well as their ledger did show R1 had a carried over credit on their account. Interview revealed that this credit was due to a July 2023 rent concession, which should have been utilized for that month only and not carried over. However, the ledger indicates a credit labeled as "aging 8/2023" and is shown carried over each month R1 resided at the facility. Review of R1's Admission Agreement does not explicitly state this credit does not carry over, and as it does show carried over on R1's ledger, therefore, this amount is also owed to R1's estate. Documents reviewed revealed that Administrator Trevin Willis did request to their corporate office a refund in the amount of $2289.00 most recently on 02/01/2024, however as of today's visit the refund has not been issued. Therefore, based on interview and record review, the allegation that "Facility is not adhering to resident's Admission Agreement" is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC 9099-D.) Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 8, 2024 · control 29-AS-20240429101753

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: May 15, 2024

§1569.652 (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued...resident’s estate, within 15 days after the personal property is removed. This requirement is not met as evidenced by: Based on interview and record review, the Licensee did not comply with the above cited section, as R1 passed away and all belongings were removed as of 12/30/2023 and refund has yet to be issued, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Executive Director sent a new refund request to the Licensee's accounting department during today's visit to request the refund be issued as soon as possible. Executive Director will provide proof to CCL by POC due date of refund issued.

Allegation investigated: Staff failed to report incident

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit regarding above noted allegation. Reason for the visit is to deliver the investigation finding. Upon arrival LPA met with staff who then contacted designated staff in charge. Executive Director Trevin Willis was not available during todays visit. Reason for visit was discussed with Michael Owen, Acting Executive Director. Following is a summary of the investigation: On 8/11/2023, the Department received information that facility manager/administrator did not follow reporting requirements upon haveing knowledge of an alleged sexual assault happening sometime around 7/2022. It was alleged that, although the former Administrator Eileen Esquivel was informed about two staff allegedly sexually assaulting resident #1 (R1), the former Administrator did not follow through to report to Community Care Licensing as mandate through with reporting requirements by submitting a Special Incident Report (SIR) to the Licensing Office as required; nor did they submit a SOC341 for suspected abuse. (Cont.) Substantiated Records reviewed and interview conducted with staff on 08/14/2023 from approximately 10:05am-11:45am, confirmed that above alleged incident was not reported. Therefore, based on the information obtained during this investigation, there is sufficient evidence to support the claim that staff failed to follow through with alleged investigation in timely manner. This allegation is Substantiated at this time. Pursuant to Title 22, California Code of Regulation, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted. Appeal rights provided. Copy of report provided. On 08/16/2023, from approximately 1:55 p.m.-2:45 p.m., IB Investigator Douglas Real interviewed facility Administrator and the two (2) staff. On 08/17/2023 at approximately 2:20 p.m., IB Investigator Douglas Real interviewed R1’s responsible party. R1 passed away on 06/24/2023 and was not interviewed. Staff interview revealed that sometime in November 2022 the facility was notified by R1’s family that R1 had reported being sexually assaulted by two (2) male facility employees while being showered. The facility director at the time was Ilene Owens and she investigated the matter and interviewed the staff. The staff denied the allegation, and nothing was uncovered suggesting there was any merit to the allegation. Staff reported that R1 had dementia, was combative on occasion, and did not like to bathe or shower. R1 frequently needed two-person assistance, especially with showers. Staff reported that R1 dementia was bad, and R1 was often confused. Staff denied the allegation. Interview with the R1 responsible person (RP) revealed that R1 had dementia and was frequently confused. R1 did not like showering or bathing but needed to be cleaned. It took two (2) caregivers to shower R1 and it was very difficult getting R1 to shower. Sometime in November 2022, R1 was showered by two (2) staff, and R1 claimed staff raped R1. RP stated that they had known the two staff as they had worked with the R1 at another facility, and they had always provided a good level of care. R1 had never made an allegation like that before. After the allegation, they took R1 to be checked by a doctor at an urgent care and the doctor found no evidence of a sexual assault. According to RP, the facility Administrator at the time was notified of the allegation and investigated the allegation. Staff were questioned and the staff denied the allegation. RP saw nothing at the time to suggest the R1 had been assaulted and RP does not believe that R1 was raped. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Resident was sexually assaulted by staff” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 29, 2024 · control 29-AS-20230811115447

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211 · Plan of correction due date: Apr 4, 2024

(a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency within 7 days of the occurrence... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on interviews and record review, facility's former Administrator was aware of the alleged sexual assault R1 made and failed to notify CCLD and follow mandated reporting requirements. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Former Administrator was terminated. The current Administrator shall do the following: 1.Administrator to review Regulation 87211 and Mandated Reporting requirements and submit Statement of Understanding. 2. Provide in-service to all staff on Mandated reporting requirements.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 3:43 p.m., the LPA met with Administrator, Trevin Wills and explained the reason for the visit. The reason for today's inspection is to follow up on two (2) self-reported Report of Suspected Dependent Adult/Elder Abuse (SOC 341), one submitted on 12/18/2023 and the other submitted on 12/20/2023. At 3:45 p.m., the LPA conducted an interview with the Administrator. At 4:03 p.m., the LPA obtained copies of pertinent documents. At 4:42 p.m., the LPA along with the Administrator conducted a physical plant tour. No immediate health and safety concerns were observed during today's inspection. Further investigation is required at this time. An additional reports may follow if warranted. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 20, 2023

Allegation investigated: Facility failed to conform with fire safety regulations

Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit regarding the above noted allegations. LPA met with administrator Trevin Willis and explained the reason for the visit. At 11:30 LPA discussed the issue with a glass door separating the residents' dining room from the main entry lobby. At 11:47 a.m. LPA observed the door was locked and required a code to open or for the lock to be electronically released by the receptionist. It has a magnet that is connected to the fire system which will release the door in the event there is a fire. There is no delayed egress on this door. The Los Angeles Fire Department (LAFD) Inspector informed the facility on 12/8/2023 that this door is not in compliance with fire regulations. (continued on 9099-C) Substantiated (continued from 9099) LPA conducted a brief tour of the facility starting at 11:35 a.m. Administrator demonstrated the LAFD approved delayed egress doors at the rear of the facility and the audible alarms attached to the doors. There is a 15 second delay on all three doors and when the alarm was triggered other staff responded quickly. There is a section in the facility that is for staff only; it houses the entry to the commercial kitchen, utility closet, laundry, storage and administrative offices. The door to reach this area remains locked at all times for the safety of the residents. LPA and administrator discussed the newer glass door in the front which is installed in a glass partition wall that was added approximately 18 months ago. While this administrator was not working as the administrator of the facility at that time, it was his understanding permits were pulled and the addition of the wall and locked door was approved by LAFD and Community Care Licensing (CCL). However, during a recent annual inspection by the LAFD Inspector, the fire regulatory compliance of the door was questioned. The facility has been put on notice by LAFD that the door must have delayed egress and cannot remained locked while waiting for the repairs or replacement of the door. The administrator stated today, 12/11/2023, he called their fire protection company, GFP (Guard Fire Protection System, Inc. GFP installed the magnetic lock on the door which is part of their fire system. He will have them come to the facility on an emergency basis to release the magnet so the door can remain unlocked until the delayed egress system can be installed. During the time this door is unlocked, the reception desk will remain staffed 24 hours a day to ensure residents do not exit the building unassisted by staff or a responsible party. Based on the observations and interviews, the door in the lobby/reception area to exit the residents' dining room, was locked and did not have delayed egress. Therefore, the allegation the facility failed to conform with fire safety regulations is deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the CA Code of Regulations (CCR), the following deficiencies were cited (please refer to LIC 9099-D). Exit interview was conducted with the Administrator and report and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Dec 11, 2023 · control 29-AS-20231208151409

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Dec 12, 2023

87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on the investigation, observations and interviews, the licensee did not comply with the section cited above, as the door to exit the dining room to the lobby was locked and does not have delayed egress, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2023

Plan of correction: Administrator has contacted their fire protection system company to release the magnetic lock on the door by 12/12/2023. He will staff the reception area 24 hours/day until they can make the door delayed egress and LAFD inspects the door for compliance.