Ivy Park at Woodland Hills

Allegation investigated: Facility staff are not properly addressing bed bugs in the facility Facility staff did not safeguard resident's personal property Facility staff did not ensure that resident was adequately fed Facility staff did not ensure that resident was accorded dignity

Licensing Program Analysts (LPAs) Quoc Huynh and Angela Barutyan conducted a subsequent complaint visit to deliver findings for the above allegations. The LPAs arrived at 12:50PM and met with Business Director (BD) Aurora Israelson and Health Services Director (HSD) Reina Rubi. Entrance interview conducted. On 05/27/2026, LPA Huynh conducted an initial visit. Between 2:43PM and 5:42PM, the LPA conducted a physical plant tour, interviewed two (2) staff and the Executive Director (ED) Lilit Mnatsakanyan, and reviewed and obtained pertinent documents. On 08/19/2029, LPAs Huynh and Barutyan conducted a subsequent visit. Between 10:08AM and 11:25AM, the LPAs conducted a physical plant tour and interviewed one (1) resident. Report Continued on LIC 9099-C Substantiated During today’s visit, the LPAs and HSD conducted a physical plant tour at 1:01PM and no immediate concerns were observed. The following was then determined: Allegations: “Facility staff are not properly addressing bed bugs in the facility,” “Facility staff did not safeguard resident's personal property,” “Facility staff did not ensure that resident was adequately fed,” and “Facility staff did not ensure that resident was accorded dignity” It was reported that the facility did not properly address bed bugs in Resident #1’s (R1) room, did not safeguard or maintain documentation of R1’s personal property, did not provide R1 with lunch, and did not ensure R1 was accorded dignity. Between 05/20/2026 and 05/21/2026, R1 disclosed to Staff #1 (S1) that they were experiencing bug bites on their skin, prompting S1 to inspect R1’s room. The room inspection revealed a bed bug infestation originating from R1’s sofa recliner and found throughout R1’s clothing and the remainder of the room. The ED and S1 consulted with a treatment company and their Regional Manager, who advised the facility to pursue chemical spray treatments, despite the ED and S1 advocating for heat treatments. The treatment company instructed the facility to remove R1 from the room, empty the room of personal belongings as much as possible, and prepare for a second spray treatment to occur twenty-four (24) hours after the first. The ED noted that R1 often refused housekeeping services and described R1 as a “hoarder.” Staff entered R1’s room utilizing personal protective equipment (PPE) and began bagging R1’s belongings per the treatment company’s guidance. S1 reported that belongings were bagged by general category and that items identified as excessively infested–including sandals, clothing, a comforter, and recliner–were discarded. S1 confirmed that no inventory list was completed. During the removal process, Staff #2 (S2) conducted a skin assessment and instructed staff that R1 required a shower. It was reported that staff stripped R1 of their clothes and R1 showered independently with staff supervision. Staff then completed the removal of belongings and S1 stated that restroom contents were not collected because R1 was in the restroom without clothes on and all other belongings had already been bagged. Report Continued on LIC 9099-C S2 later returned to R1’s apartment for a follow up skin assessment and observed R1 unclothed and standing in their hallway between the restroom and front door. R1 reported to S2 that they were not provided lunch. S2 then requested food delivery to R1’s room. It was reported that between approximately 11:30AM and 1:30PM, R1 remained in the infested room without clothing. S2 stated that they notified staff to provide R1 clean clothes and expressed concerns to the ED regarding R1 being left unclothed in an infested room. The facility attempted to contact R1’s Power of Attorney (POA) throughout the day and was unsuccessful. The POA later returned the facility’s call and inquired about available/vacant rooms for relocation. The ED informed the POA that the facility was “at capacity.” It was reported by staff that the ED did not want R1 placed in any available room due to concern about spreading the infestation. The ED stated that R1 was independent and had agreed to be relocated to a hotel. The ED reported that they personally purchased clothing and essential items prior to R1’s hotel check-in. R1 was checked into a nearby hotel between approximately 6PM and 7PM same day on 05/21/2026. On 05/22/2026, S2 visited R1 at the hotel. R1 reported being cold and was observed to only have two (2) pairs of pajamas. S2 purchased R1 additional clothing including a jacket and essential items after observing R1 brushing their hair with a fork. Records showed the first chemical spray treatment occurred on this day. On 05/23/2026, S2 returned to the hotel, provided clean clothing, and collected items to be laundered at the facility. Meals and activity sheets were delivered to R1 throughout their hotel stay. On 05/24/2026, R1’s hotel reservation ended and R1 was at risk of being escorted out. The facility transported R1 to a second hotel and reserved a room for one (1) day. A second chemical spray treatment was completed at approximately 9PM. S1 believed that the previously established twenty-four (24) hour interval was not followed due to the holiday weekend. Staff reported that the technician cleared R1 to return to their room after 3PM the following day (05/25/2026). Report Continued on LIC 9099-C On 05/25/2026, R1 checked out of their hotel. R1 and the POA inspected the room and observed dead bed bugs on the clean linens and noted that no bed sheet was provided. The ED and S1 explained this could occur as bugs crawled out and died, indicating the treatment was effective. R1 and the POA were not comfortable returning under these conditions. The ED stated it was their choice, and R1 returned to the hotel. On 05/26/2026, the POA visited the facility and observed R1’s bed had new linens presumably from the model room. Upon inspection, dead bugs were found on top of and underneath the blanket, similar to the previous day. The POA explained that had R1 returned, the bugs would have crawled onto R1 and died. The POA also reported that R1’s wallet and cash were missing and requested access to R1’s bagged belongings. Staff escorted the POA to the basement parking garage, where several black bags containing R1’s belongings were observed scattered in a corner. On 05/27/2026, S1 reported they had washed and disinfected R1’s belongings and had begun the process the previous day, completing approximately fifteen (15) bags. S1 and the ED stated all belongings were returned to R1’s room. LPA Huynh inquired why R1 was not temporarily placed in another room at the community. The ED stated the facility and sister facilities were at capacity. The LPA pointed out vacant rooms observed during the tour. The ED stated those rooms were reserved for incoming move-ins and that the only available room was the model room in the memory care unit. The ED stated R1 could not be placed in the model room due to risk of spreading infestation and that the room was not suitable for living despite being fully furnished. The LPA noted a bed could be obtained; the ED responded that this would risk introducing more bed bugs and that no extra beds were available in storage or at sister facilities. The ED stated that relocating R1 into another unit would risk infestation to other residents. The LPA clarified that R1’s room was infested, not R1. The ED replied that R1 was in fact infested because “bed bugs lay eggs on the skin.” Report Continued on LIC 9099-C The LPA noted that if this were the case, the facility should not have allowed R1 to return on 05/25/2026 under unacceptable conditions and then state it was R1’s choice to return to the hotel. On 06/03/2026, a temporary room became available and R1 returned to the facility. The date R1 returned to their original room is unknown. Interview with R1 revealed the entire bed bug situation was distressing. R1 confirmed that staff stripped them of their clothing when the infestation was discovered. R1 stated that they felt awkward, uncomfortable, and vulnerable. After showering independently, no clothing was provided because all belongings had been removed. R1 remained unclothed for an extended period and missed a meal. Staff later requested a meal be delivered to R1’s room and provided pajamas purchased from a nearby store. R1 also reported that restroom items were not removed and that upon returning to the facility, they again observed bed bugs on the bed and in the restroom. R1 and the POA declined to return under those conditions and remained at the hotel until later placed in a temporary room. On 08/19/2026, LPA Huynh inspected R1’s room. Despite S1 and the ED stating all belongings had been returned, the closet, dresser, and nightstand were mostly empty. The closet contained three (3) shirts, three (3) pants, a safe box, two (2) pairs of house slippers, one (1) set of bed linens, and several empty hangers. The six (6) drawer dresser contained three (3) pairs of undergarments and socks. R1 reported most of their jewelry was missing and described additional missing items, including shoes, clothing, towels, paperwork, their sofa recliner, and kitchen items. R1 also stated the key to their safe box was stored in a shoe that was not returned, preventing access to the safe box. R1 stated they have been re-wearing the same limited clothing. Photos and videos confirmed that numerous bags of belongings were collected which was inconsistent with the small number of items returned, the ED’s characterization of R1 as a hoarder, and the facility’s assertion that belongings were returned. Record review showed additional chemical treatments and inspections on 05/30/2026 (which recommended the room be taken out of service), 06/01/2026, 06/15/2026, 07/11/2026, and 07/26/2026. Report Continued on LIC 9099-C A recorded call with the treatment technician on 05/29/2026 revealed that the technician instructed the facility to fully clear R1’s room—including restroom contents—and recommended steam cleaning the carpet and removing the mattress and recliner. Because the mattress and restroom contents were not removed, the technician stated the treatment was not completed as required. For safety reasons, the technician reported they did not advise the facility to allow R1 to return to the room on 05/25/2026. Based on interviews, observations, and record review, the facility failed to properly address the bed bug infestation by not following treatment instructions, resulting in incomplete remediation and leaving R1 in an infested room. Staff removed R1’s belongings without creating an inventory and stored the items haphazardly, resulting in numerous missing possessions and failure to safeguard personal property. R1 missed a meal during the incident and was left unclothed for an extended period, placing them in a vulnerable and undignified situation. The preponderance of evidence standard has been met; therefore, the allegations are deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Sep 24, 2026 · control 29-AS-20260526120211

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Sep 25, 2026

(a) In addition to the rights listed in Section 87468.1… (25) To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154. This requirement was not met as evidenced by: Based on interviews and observations, the licensee did not comply with the above section in R1’s personal property were not adequately safeguarded or inventoried which posed an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: The Licensee will provide staff in service training regarding theft and loss. The Licensee will also determine the value of R1's items with R1 and their POA to provide compensation or replacement for lost items. The Licensee will provide CCLD with proof by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 25, 2026

(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 was not met as evidenced by: Based on interviews, the licensee did not comply with the above section in R1 was stripped of their clothes by staff and left in their room unclothed for a long period of time which posed an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: The Licensee will provide staff in service training and provide CCLD proof by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 1, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above section in R1 had bed bugs that the facility did not appropriately address per professional advisement which posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: The Licensee will provide in service training regarding bed bug protocols and provide CCLD with prood by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f) · Plan of correction due date: Oct 1, 2026

(f) Basic services shall at minimum include: This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the above section in R1 was not provided lunch which posed a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: The Licensee will provide staff in service training and provide CCLD proof by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Quoc Huynh and Angela Barutyan conducted an unannounced case management visit in conjunction with complaint #29-AS-20260526120211. The LPAs arrived at 12:50PM and met with Business Director (BD) Aurora Israelson and Health Services Director (HSD) Reina Rubi. Entrance interview conducted. During today’s visit, the LPAs and HSD conducted a physical plant tour at 1:01PM. The LPAs observed the facility’s salon was under renovations and was accessible to residents in care as the door was unlocked. The salon was observed to have exposed wires, paint, and sharp objects. The HSD and BD stated that the door should have been locked and believed that the contractors had taken their break during this time. The salon was locked during the visit. The complaint investigation revealed that the facility did not properly address the bed bug infestation in Resident #1’s (R1) room. Staff failed to follow treatment company instructions, did not fully clear the room of required items, and left R1 in the infested room without clothing for an extended period. The infestation persisted across multiple treatments, and both R1 and the Power of Attorney (POA) observed dead bed bugs and incomplete preparation even after the facility stated the room was ready. The Executive Director (ED) Lilit Mnatsakanyan declined to place R1 in available rooms, provided conflicting explanations about infestation risks, and relied on hotel relocation instead of implementing an adequate on-site solution. Report Continued on LIC 809-C Statements from the treatment technician confirmed the initial treatments were not completed properly and that R1 should not have been cleared to return on 05/25/2026. R1 returned to the community on 06/03/2026. Upon returning to the community in a temporary room, R1 was not provided with adequate furniture, including a lamp, blankets, and bed linens. Staff reportedly laundered R1’s linens and clothing daily; however, linens were not consistently replaced or returned, with some being returned as late as 11PM. Photos provided to the Department showed R1 sleeping on an exposed mattress and on pillows without pillowcases. Due to insufficient lighting, R1 reportedly read their Bible in the restroom each night, as it was the only functional light source in the temporary room. Additional incidents occurred during this period, including a popcorn-related smoke event in the common area that triggered the Los Angeles Fire Department’s (LAFD) response. Interview with additional residents confirmed the incident and described it as a “false alarm.” A medical emergency in approximately July 2026 resulting from R1 experiencing significant bleeding from a bite they scratched. On 08/19/2026, LPA Huynh observed blood splattered on the carpet of R1’s room, which the facility attempted to clean at R1’s expense. Per R1’s admission agreement, the resident is responsible for any damages to their room outside of “normal wear and tear;” however, R1’s incident was an unplanned medical emergency. Interview with the BD revealed that a maintenance request form was completed by staff who subsequently notified R1's Power of Attorney. The BD confirmed that a signed acknowledgement and addendum to the admission agreement for the service charge was not completed. The facility did not provide the Department with incident reports for either occurrence. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). A civil penalty in the amount of $250 was assessed for a repeat violation within a twelve (12) month period (Refer to LIC 421FC). The BD was advised that failure to correct and continued violation may result in additional civil penalties. Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Sep 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 24, 2026

(a) ... the licensee shall ensure that ... tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by: Based on observation and interview, the licensee did not ocmply with the above section in the renovated salon was not secured and contained tools and sharp objects which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: The staff secured the salon during the visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a)(3) · Plan of correction due date: Oct 15, 2026

(a) Living accommodations and grounds shall be related to the facility's function… provide comfortable living accommodations… (3) Equipment and supplies… shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above section in R1 was not provided with required furniture or accommodation which posed a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: The Licensee will obtain a sufficient supply of equipment and supplies and provide CCLD proof by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 1, 2026

(a) Each licensee shall furnish to the licensing agency... including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified in (A) through (D) below… This requirement is not met as evidenced by: Based on interviews and observation, the licensee did not comply with the above section in the facility did not provide written reports to the Department of incidents which posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: The Licensee will provide the leadership team with training regarding reporting requirements and will provide CCLD proof by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.884(c) · Plan of correction due date: Oct 1, 2026

(b) A facility may assess a separate charge for an item or service only if that separate charge is authorized by the admission agreement. If additional services are available… that were not available at the time the admission agreement was signed, a list of these services and charges shall be provided to the resident or… representative. A statement acknowledging the acceptance or refusal to purchase the additional services shall be signed and dated by the resident or the resident’s representative and attached to the admission agreement. This requirement was not met as evidenced by: Based on interviews, observations, and record review, the licensee did not comply with the above section in the facility charged R1 a service that was not established in the admission agreement and did not document acknowledgement or a statement of the additional service which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: The Licensee will confer with R1 and POA regarding the charges and will provide reimbursement if authorization is not granted. The Licensee will provide CCLD proof by POC due date.

Allegation investigated: Staff mismanage residents medications

Licensing Program Analysts (LPAs) Quoc Huynh and Angela Barutyan conducted a subsequent complaint to deliver findings for the above allegation. The LPAs arrived at 9:40AM and met with Executive Director (ED) Lilit Mnatsakanyan. Entrance interview conducted. On 05/27/2026, LPA Huynh conducted an initial complaint visit. Between 2:43PM and 5:42PM, the LPA conducted a physical plant tour and interviewed one (1) staff and reviewed and obtained pertinent documents. During today’s visit, the LPAs conducted a physical plant tour at 10:08AM, and no immediate concerns were observed. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegation: “Staff mismanage residents medications” It was reported that facility staff did not refill four (4) of Resident #1’s (R1) medications, resulting in R1 not receiving these medications for over thirty (30) days. Interview with Staff #1 (S1) confirmed the oversight and revealed that there had also been a miscommunication regarding R1’s primary care physician (PCP). R1’s PCP had changed, and the facility was not notified. After S1’s attempt to resolve the issue, it was discovered that R1’s pharmacy had not been informed of the PCP change, preventing renewal of R1’s medication orders. S1 additionally reported that the facility’s Medication Technicians noted the medication discrepancies on the Medication Administration Record (MAR) but did not conduct any further follow up. The Medication Technicians listed the medications as “not on hand” in the MAR. Record review showed that R1’s medications were documented as “not on hand” from varying start dates to 05/20/2026 when medications were filled and resumed: Citracal+D 600MG starting 03/24/2026, Donepezil 10MG starting 04/17/2026, Memantine 10MG starting 04/11/2026, Mirtazapine 15MG starting 05/01/2026, and Losartan 25MG starting 05/05/2026. On 04/29/2026, the facility requested R1’s PCP to provide a new order for Citracal+D, and on 05/05/2026, requested new orders for the remainder of R1’s medications. The PCP provided the new orders on 05/06/2026. The facility’s MAR documented that R1 resumed receiving the missing medications on 05/20/2026, resulting in discrepancies of up to fifty-seven (57) days. Additionally on 07/06/2026, the Department received an Incident Report stating that on 06/30/2026 Resident #2 (R2) was scheduled to receive a dose of ten (10) units of Tresiba and it was not administered. Based on interview and record review, the preponderance of evidence standard has been met; therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 19, 2026 · control 29-AS-20260521102549

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a) · Plan of correction due date: Aug 20, 2026

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with section cited above as R1’s medications were not refilled and subsequently not administered for over 30 days, and R2 was not administered their prescribed medication which posed an immediate health, safety, and personal rights risk to person in care.the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: The Licensee will submit a statement of understanding of the section cited and provide proof to CCLD by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Quoc Huynh and Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 09:40AM. LPAs met with Executive Director (ED) Lilit Mnatsakanyan and Business Office Director (BOD) Aurora Israelson. Entrance interview conducted. Beginning at 10:08AM, the LPAs, along with ED Mnatsakanyan and BOD Israelson, 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: FACILITY LAYOUT: The facility is a five (5) story building, including an underground parking garage. There are sixty-two (62) private-use units throughout the assisted living (AL) levels and twenty-seven (27) units in the memory care (MC) level which is the entirety of the third floor. KITCHEN: At 10:08AM, LPAs observed the kitchen to have a sufficient supply of perishable and non-perishable food at the time of the visit. Appliances in the kitchen were clean and appeared functional. Snacks and beverages are available for residents. Food is prepared in the main kitchen, which is located on the first floor and is delivered to the common dining areas and MC Unit. Emergency water supply is stored in the locked laundry room in the basement. Report Continued on LIC 809-C BEDROOMS: The LPAs toured a total of twelve (12) randomly selected resident rooms. LPAs observed two (2) resident rooms in the MC Unit. Lighting in the rooms appeared adequate. The rooms were properly furnished and were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. BATHROOMS: LPAs observed the bathrooms to be equipped with grab bars near the toilet and shower/tub, and slip-resistant surfaces and mats in the shower/tub. LPAs tested hot water temperatures in resident bathrooms which were measured to be between 105.4-110.3 degrees Fahrenheit, which is within the required range. COMMON AREAS: LPAs inspected the common areas throughout the facility including the Activity Room, Lobby, reading room, lounge, café, health center, theater, and salon. All rooms were furnished appropriately, and no immediate health and safety concerns were noted. The fire extinguishers are located on every floor in each building and were observed to be fully charged and serviced on 10/24/2025. There is a functioning telephone on the premises. Required postings were posted in the facility entryway and LPAs observed the Ombudsman Poster, DSS Complaint Poster, and emergency exiting plans/sketch posted in the hallways throughout the community. The signal system can be activated in the resident bedrooms and restrooms by a pull cord. At 10:47AM, LPA Barutyan pulled the signal cord in a resident restroom. After ten (10) minutes of waiting for staff response, LPA informed ED to have a staff member come clear the signal. Staff #1 (S1) arrived at 10:59AM, approximately twelve (12) minutes after pulling the pull cord, to clear the signal. Staff members stated that the resident was in the common area; ED explained to staff that signals should still be cleared regardless. LPA observed the signal system to be in working order. Staff provided clarification on signal clearing protocol to S1. Residents also have pendants they can wear to signal staff. All systems go directly to a central tablet and to hand-held devices. Designated staff carry a handheld device, which displays the location of the alarm that has been pulled. Staff also utilize walkie-talkies to communicate accordingly. There are two (2) delayed egress doors in the MC unit. LPAs tested one (1) delayed egress door at 11:05AM which was operational at the time of the visit. Report Continued on LIC 809-C The community’s smoke detectors and carbon monoxide detectors are hard wired and were last tested on 07/16/2026 by American Eagle Fire Protection and approved by the Los Angeles Fire Department. OUTDOOR AREAS: LPAs toured the outdoor perimeter and observed self-latching gates. All exits were observed to be clear and free of hazards. There are several enclosed patios. No health and safety hazards observed. MEDICATION REVIEW: Medications are locked and centrally stored in the medication office on the second floor and the MC unit medication room. Beginning at 4:06PM, medications for two (2) residents were reviewed for compliance. Both residents’ medications were not labeled and maintained on the centrally stored medication and destruction record. RECORD REVIEW: Beginning at 4:05PM, five (5) resident and five (5) staff records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, personal rights, and first aid/CPR training. All resident and staff files reviewed were complete and were observed to be in compliance. During today’s visit, LPAs obtained a copy of the facility’s liability insurance. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: 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. Emergency disaster drills are conducted at least quarterly as required, with the last drill conducted on 07/12/2026. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 19, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Unlawful eviction

Licensing Program Analyst (LPA), Sandra Urena conducted an unannounced subsequent visit to deliver the findings for the for the allegation listed above. LPA Urena met with the Executive Director (ED) Lilit Mnatsakanyan and explained the reason for the visit. On 07/09/2028 Licensing Program Analyst (LPA) Quoc Huynh conducted an initial complaint visit for the above allegation. The LPA arrived at 9:48AM and met with Executive Director (ED) Lilit Mnatsakanyan. The LPA met with Executive Director (ED) Lilit Mnatsakanyan. On 07/08/2026, the ED provided the LPA with pertinent documents, however requested an extension for the remainder of the documents. The ED agreed to provide the LPA with the remainder of the requested documents which include the resident’s care plans conducted while residing at the facility, medication records, and any supporting documentation pertaining to their eviction notice. The documents will be provided to the LPA via email no later than close of business today, 07/09/2026. Continued on LIC 9099C... Substantiated Unlawful eviction. It was alleged that facility issued an unlawful eviction notice to Resident #1 (R1); the concern of the Reporting Party (RP) is that the facility is trying to evict R1 as part of retaliatory measures for the facility being reported to the regulatory agency (Community Care Licensing Department). LPA Huynh conducted an initial visit and requested documents pertinent to the investigation. LPA Urena conducted record review of the copy of the Admission Agreement and House Rules and the eviction notice given to R1. Furthermore, LPA Urena asked the ED and the RP pertinent questions via email. LPA Urena reviewed the Eviction Notice, which states in the opening paragraph: “Over the past weeks we have had numerous discussions... a summary of the incidents that have been observed and documented”. Per the ED, the incidents were discussed in person with R1, however the ED did not provide written documentation to the LPAs about the discussions that took place with R1, other than the Eviction Notice. Furthermore, after LPA Urena reviewed the Admission Agreement (page #14, paragraph #20.) which discusses the Meet and Conference/Mediation process states the following: MEET AND CONFER/MEDIATION: You(resident) and Ivy Park agree that in the event of any dispute arising out of or related to this Residence and Services Agreement including but not limited to contract disputes or personal injury claims, the parties, before taking any legal action, will first meet and confer informally in good faith to try to resolve any such dispute. In the event that the parties are unable to resolve their dispute(s) through such informal meeting, the parties agree that they then will submit the dispute to formal non-binding mediation to be conducted by a qualified, neutral mediator agreed to by the parties. The fees and expenses relating to such mediation shall be borne equally by You and Ivy Park, except that each party shall pay its own attorneys' fees and expenses. LPA Urena asked the ED via email if this mediation process was offered to R1, and the ED, replied, “Yes, a meeting between the Ivy’s (ED and VPO) and R1’s family member, on behalf of R1, was conducted via phone on 7/10/2026. This was informal and without any legal presence.” The LPA record’s review identified R1 as being responsible for themselves. Furthermore, when LPA Urena interviewed the RP via email about R1 being offered a mediation meeting, the RP reported that the mediation meeting was not offered to R1. Based on the information obtained through record review and interviews, the facility staff did not follow their own Admission Agreement rules, consequently the facility did not give R1 to opportunity to resolve the disputes described in the Eviction Notice served to R1 on July 1, 2026 through the mediadtion process. Therefore, the allegation of Unlawful Eviction is deemed Substantiated at this time. Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 9099-D). Exit interview conducted. Citation issued. A copy of the report and Appeal Rights was issuedthe state’s words, verbatim · CDSS document, Jul 28, 2026 · control 29-AS-20260701152144

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(3) · Plan of correction due date: Jul 31, 2026

(a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). (3)Failure …said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as the facility did not follow the facility’s Admission Agreement policy of providing the resident with the opportunity for the mediation process, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: The Executive Director has agreed to read, review the facility's Admission Agreement and submit a statement of understanding on Regulation 87224 Eviction Procedures and submit to CCLD.

Allegation investigated: Staff not preventing construction from disturbing residents sleep.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent unannounced visit to deliver the findings for the allegation listed above. The LPA met with Litit Mnatsakanyan, Executive Director (ED) and explained the reason for the visit. On 06/30/2026, LPA Urena conducted an initial unannounced visit to investigate the allegation listed above. LPA Urena interviewed staff and residents and requested records pertinent to the investigation. Staff not preventing construction from disturbing residents’ sleep. On the allegation that staff are not preventing construction from disturbing residents’ sleep; it is the concern of the Reporting Party (RP) that there has been a lot of construction work being done between the hours of 7:00 p.m. to 3:30 a.m. The RP reported that there is painting, hammering and floors being redone. To investigate the allegation, LPA Urena conducted a tour of the physical plant of the facility along with the ED, and interviewed the residents in care, staff, and the ED. During the tour of physical plant areas inside, specifically on the second floor of the facility, the LPA observed that the common space where residents have art activities, was pending remodeling/renovation work done. Substantiated The room had an odor of fresh paint, and some of the walls were unfinished. A second room, which appeared to be an empty office room, was also being remodeled/renovated (floor carpet was to be removed, walls painted and wood flooring installed). This Office Room and the Wellness room (medication room) share a wall with a residents’ bedroom. The Wellness Room remodeling was completed at the time of the visit, which included removing carpeting, shelf, painting and installing wood floor. Interviews with residents revealed that loud banging was heard in the early hours of the evening, starting at around 7:00 p.m. and the noise would be heard throughout the early hours of the next day till 3:30 a.m. disturbing their sleep, and keeping them awake till the work was completed for the night. Per the resident, a crew of about eight (8) to 10 workers worked on the remodeling project every night. Another resident’s responsible party (RP) was present when some of the banging could be heard in the early evening. The resident’s RP asked a staff member, “what was with all the noise”, and the staff replied, “there is nothing we can do about it”. The LPA interviewed a staff member who reported that the remodeling project of the Wellness room was completed, and explained that the carpet was pulled, new flooring was installed and walls painted. Interview with the ED revealed that the remodeling project was announced to the residents through the “Lilit’s June Newsletter”. LPA Urena reviewed the June’s Newsletter and found the following sentence: “Please note that some renovation work will be conducted between the hours of 7:00pm-3:30am or during regular business hours. Furthermore, the ED stated that the renovation project included the removal of the floor carpets, painting and installing new wood flooring. Per the ED, the renovation crew of at least eight (8) workers worked quietly without making excessive noise. The LPA reviewed the Ivy Park at Woodland Hills House Rules (page #1, first paragraph) which include the following statement: “We request that all residents monitor the volume of their televisions and radios, specifically in the evening and the early morning hours”. It appears that the facility violated their own House Rules policy by engaging in renovation projects that were done during the evening and early morning hours. Although the facility’s staff informed the residents of the upcoming renovation project via a newsletter, the facility not only violated their own House Rules, but most importantly the residents’ rights, by depriving them of a quite environment during the hours (7:00 p.m. to 3:30 a.m.) and length (at least seven (7) days) of the renovation project. Therefore, the allegation that staff did not prevent construction from disturbing residents’ sleep, is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies were cited (refer to LIC809-D). Citations were issued. Exit interview conducted. A copy of the report was issued via email and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 29-AS-20260624155120

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2)(3) · Plan of correction due date: Jul 31, 2026

Personal Rights of Residents in All Facilities- (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... (3)To be free from …interfering with daily living functions such as… sleeping...This requirement is not met as evidenced by: Based on observation: The facility was being renovated during the evening hours between 7:00 p.m. and 3:30 a.m. which causes excessive noise and disrupts the sleep of residents in care, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: The Executive Director agrees to submit to the department Plan of Corretion by self certifying that they reviewed the regulations as they pertain to the personal rghts of the residents.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sandra Urena conducted a Case Management - Deficiencies visit in conjunction with a complaint visits (Complaint Control # 29-AS-20260701152144 and C# 29-AS-20260624155120). The purpose of the visit is to issue a citation for deficiencies observed during the initial complaint investigations unrelated to the complaints. During today’s visit, LPA Urena met with Lilit Mnatsakanyan, Executive Director and the reason for the visit was explained. During the course of the investigations, it was discovered that the facility failed to inform the department of several incidents involving a resident; furthermore, the facility failed to inform the department of renovation work being done at the facility prior to all commencement of such work. Per CCR regulations, all incidents must be reported to the CCLD via the LIC 624 (Report of unusual incidents...) Data search of the incidents involving the resident and the renovation/alterations to the facility were not submitted to the office within the specified time frame of seven(7) days. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Exit interview conducted, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 28, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jul 31, 2026

87211(a)(1)Reporting Requirements-(a)Each licensee shall furnish to the licensing agency ... including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include...This requirement is not met as evidenced by: Based on file review, the facility didnot submit incident reports involving R1 to the department as specified in the regulation, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: The Executive Director agrees to review the reporting requirements regulations and will submit self certication to the department.

Allegation investigated: Staff did not dispense medications as prescribed Staff did not meet resident's hygiene needs

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding regarding above allegations. Upon arrival LPA met with Aurora Israelson, Business Office Director. The reason for the visit was explained. On 11/21/2025, Community Care Licensing Division received the above allegations. On 11/26/2025, LPA Chochian conducted the initial complaint visit and interviewed two (2) staff and three (3) residents from approximately 12:30pm-1:30pm. A subsequent visit was conducted on 1/21/2026, additional interviews were conducted with four (4) staff from approximately 11:45am-12:30pm; and interviewed four residents from approximately 1pm-2pm. LPA also reviewed the facility’s medication policy and procedures with staff. Following is a summary of the allegations and investigation finding: Regarding allegation “Staff did not dispense medications as prescribed”. (Continue to LIC9099c) Unsubstantiated It was reported that sometime on or about 11/20/25, staff gave an unauthorized medication to resident #1. Staff interviewed denied the allegation and stated that they would never give any resident medication that is not prescribed to the resident. LPA asked staff if they ever gave any resident something that might look like medication and staff said no. Staff also reported that residents on medication management would only receive medications from the medtechs and no other staff. Staff interviewed reported that medication policy and procedures are that only medtechs dispense medication and all medications handled by the facility require a doctors order. LPA interview total of eight (8) residents including resident #1 and all residents reported that they have never been offered any type of medication or vitamins from any facility staff. Residents on medication management stated that staff dispense prescribed medications only. Resident #1 manages own medications. All residents interviewed were observed very alert and able to communicate well with LPA. 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 allegation “Staff did not dispense medications as prescribed” is deemed UNSUBSTANTIATED at this time. Regarding allegation “Staff did not meet resident's hygiene needs”: Information was received that resident #2 was observed to have something dark under fingernails, most likely feces and staff was unable to remove it with a wet wipe and did not try washing resident’s hands. Staff interviewed reported that residents requiring assistance with toileting and showers are always assisted with hygiene care. Staff reported that residents are not left unclean or unsanitary. LPA conducted interview with resident #2. Resident #2 is alert and able to communicate needs. Resident #2 did not report any issues with staff. Resident #2 stated that staff assist with daily living activities and medications. Resident #2 was satisfied with the services provided by staff. Random residents interviewed also expressed satisfaction with the care team services. Eight (8) out of eight (8) residents interviewed reported no issues with care services provided by staff. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not meet resident's hygiene needs” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 29-AS-20251121110048

Allegation investigated: Staff does not ensure medications are kept centrally stored and secured at all times Licensee allows unqualified staff to dispense medication to residents in care Staff do not ensure spoiled medication is properly discarded Staff do not ensure sanitary practices are followed while dispensing medications to residents in care

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding regarding above allegations. Upon arrival LPA met with Aurora Israelson, Busines Office Director. The reason for the visit was explained. On 06/02/2025, Community Care Licensing Division received the above allegations. On 06/03/2025, LPA Chochian conducted the initial complaint visit and conducted interviews with seven (7) staff members and seven (7) residents from approximately 11:15am-2:30pm. Also, LPA reviewed medication procedures and policy with staff. During the annual visit on 07/24/2025, staff training records were reviewed. Following is a summary of the allegations and investigation finding: Regarding allegation “Staff does not ensure medications are kept centrally stored and secured at all times”. It was also stated that medications are dropped on the floor and left outside the residents doors. Unsubstantiated It was reported that med-techs leave the residents medications out in the caregiver office with the door open. Staff interviewed reported that if any medication is found on the floor it is picked up and taken to the medication room to report, record and properly disposed. Staff interviewed did not report any issues with missing medications. Two randomly selected residents medication was audited and found to be accurate in remaining quantity during initial visit. Seven (7) out of seven (7) residents interviewed reported that the medication room is kept lock and never unattended. 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 allegations “Staff does not ensure medications are kept centrally stored and secured at all times” is deemed UNSUBSTANTIATED at this time. Regarding allegation “Licensee allows unqualified staff to dispense medication to residents in care”: Information was received that caregivers who are not qualified and trained are asked to dispense medications to the residents. LPA reviewed staff training records and observed that the designated staff handling residents medication have completed the required training to assist residents with medication. Staff interviewed reported that only the med-techs and nurses prepare and assist residents with medication. Medtech staff interviewed denied ever asking caregivers to pass medication to residents. Residents interviewed confirmed that the med-techs provide their medication and not a caregiver. 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 allegations “Licensee allows unqualified staff to dispense medication to residents in care” is deemed UNSUBSTANTIATED at this time. Regarding allegations “Staff do not ensure spoiled medication is properly discarded and Staff do not ensure sanitary practices are followed while dispensing medications to residents in care”. It was reported that medications are not properly discarded and the med-techs have unsafe and careless methods of dispensing residents medications. It was reported that the med-techs will stop and use the restroom and will bring the medication tray into the restroom with them. Staff interviewed reported that medication destruction procedures are followed accordingly. Staff reported that expired medication and discontinued medications are stored in the medication room in a bin and secured in a cabinet until it is picked up by the company. Regarding med-techs practicing unsafe and careless methods of dispensing medication – Staff interviewed denied taking medication trays in the bathroom. Residents interviewed reported that they have not seen med-techs take medication into the restrooms. Residents reported that medtech and caregiver staff have gloves on when providing assistance with care and medications. 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 allegations “Staff do not ensure spoiled medication is properly discarded” and “Staff do not ensure sanitary practices are followed while dispensing medications to residents in care” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 27, 2025 · control 29-AS-20250602091623

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Zabel Chochian conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20250602091623). The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation. During the complaint investigation of complaint #29-AS-20250602091623, the following deficiency was observed: Two out Two residents medications reviewed revealed inaccurate medication record keeping. Resident #1's and Resident #2's medications were not accurately recorded on the centrally stored medication record log (medication not recorded on the centrally stored log). Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit Interview. Citation issued. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Sep 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h) · Plan of correction due date: Sep 30, 2025

(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. Two out Two residents medications reviewed revealed inaccurate medication record keeping. Medications were not recorded on the centrally stored log. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 27, 2025

Plan of correction: Executive Director to provide plan of correction to ensure residents medications are properly record on the centrally store medication record. Provide procedures implemented since 6/2/2025.

Allegation investigated: Staff does not ensure residents are accorded reasonable accommodations Staff are not properly addressing room repairs for residents in care

Licensing Program Analysts (LPA) Valeria Conway conducted an unannounced subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. Executive Director, Lilit Mnatsakanyam, was unavailable during today's visit, however, she was on the phone when report was read. Also, ED authorized Business Office Director, Aurora Israelson. to sign today's reports. Entrance interview conducted. At 11:50 P.M. LPA met with Business Office Director, Aurora Israelson, and explained the purpose of the visit. On 12/23/2024, LPA Chochian, met with staff and with the facility's Business Office Director, Aurora Israelson. The reason for the visit was discussed. A brief physical plant tour was conducted and a copy of the resident and staff roster obtained. On 02/05/2025 and 07/21/2025, LPA Valeria Conway conducted a subsequent complaint visit, toured the physical plant, interviewed staff and residents and obtained copies of pertinent documentation relevant to the investigation. Continued on LIC 9099 Unsubstantiated Continued from LIC 9099 Throughout the course of the investigation, LPA reviewed all documents obtained, conducted telephonic and in-person interviews with additional credible witnesses and other relevant parties. During today's visit, LPA conducted a brief physical plant tour, no health and safety concerns. The following was then determined: Regarding allegation of “Staff does not ensure residents are accorded reasonable accommodations” it was alleged that a resident’s request to move to a vacant, refurbished room, due to recent flooding, outdated room conditions, and high monthly fees, was not considered by the former ED, Terri Seifert. Interview with former ED revealed that room change requests are evaluated on a case-by-case basis at management discretion, based on individual circumstances and unit availability. The current ED Lilit Mnatsakanyam, explained that according to corporate, residents who lived in the community prior to the ownership change from “Sunrise Senior Living of Woodland Hills” (Sunrise) to Ivy Park at Woodland Hills (Ivy Park) were communicated verbally during a meeting held with residents of the option to either keep their original Sunrise agreement with existing perks and discounts or sign a new agreement under Ivy Park. The Reporting Party (RP), who pays a monthly rent and a $42 care fee under a Sunrise agreement, did not recall being offered a new contract and admitted not inquiring about the differences. The RP expressed concern that new residents are paying significantly lower rent than those who moved in under previous ownership. In December 2024, the RP requested to be moved to a vacant, recently refurbished apartment of the same size, and to pay the same monthly rent as new residents moving into the community. According to the RP, this request was submitted verbally to community management. The RP stated that initially, there was no response, but after several weeks, they were approved to move into the refurbished unit, However, the monthly rent amount was not going to be reassessed or reduced. RP declined this offer and reported that later, they requested to remain in their current apartment and have their rent lowered instead, but the former ED indicated that they were never presented with this request. When asked, the RP acknowledged that they eventually stopped inquiring about the matter. Continued on LIC 9099-C Continued from LIC 9099-C Neither Ivy Park management nor the RP were able to provide written documentation to confirm that these conversations took place or that a formal request was submitted. LPA reviewed RP’s Sunrise admission agreement with revision date of 05/2015. LPA was unable to identify any clause specifying the process or terms applicable when a resident wishes to substitute their apartment. Regarding flooding incidents, the RP stated that maintenance staff responded by drying the carpet using a commercial vacuum cleaner. The RP also confirmed that there was no water damage present in their unit. LPA visited multiple random units including the RP’s apartment, no visible stains on the carpet, mold on the walls, or any sign of water damage inside the unit were observed. 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 does not ensure residents are accorded reasonable accommodations” is deemed Unsubstantiated at this time. It was reported that "Staff are not properly addressing room repairs for residents in care”. According to the allegation, a resident left the water running, which resulted in flooding into other units and the saturation of carpets in neighboring rooms. It was further alleged that staff responded by only drying the affected carpets without taking further action. Interviews with the former ED revealed that in December 2024, there were two separate incidents involving flooding. One involved a resident who left water running for an extended period, resulting in overflow and water dripping into units below. The second incident was related to a plumbing issue, in which a resident had flushed excessive amounts of toilet paper, leading to a clogged pipeline. In both cases, maintenance staff were immediately dispatched to the affected areas. The maintenance team cleaned the flooded units and used a plumbing snake from the parking lot to the affected unit’s pipelines to address the clog. A review of Ivy Park’s maintenance work orders showed that both residents and staff submitted requests related to carpet cleaning and clogged plumbing. These work orders were completed in a timely manner by maintenance staff. Additionally, the former ED stated that carpets are cleaned as needed and shampooed on a regular schedule. Residents interviewed stated that when they submit work order requests, the issues are generally addressed promptly. While not every problem is resolved on the first attempt, maintenance staff are reported to follow up and ensure completion. Continued on LIC 9099-C Continued from LI 9099-C Residents also noted that for minor repairs, such as replacing light bulbs, changing broken accessories or fixing broken screens, a formal work order is not always necessary, as these concerns are often resolved on the spot by available staff. With regards to carpet cleaning, residents reported that when requested, carpets are cleaned and shampooed using the community’s own carpet cleaning equipment, and that these requests are generally fulfilled without issue. 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 are not properly addressing room repairs for residents in care” is deemed Unsubstantiated at this time. Exit interview was conducted. No citations issued. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 4, 2025 · control 29-AS-20241217100027

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Zabel Chochian conducted a required annual visit. LPA met with the new Executive Director (ED), Lilit Mnatsakanyan, and explained the reason for the visit. The facility is a (five) 5 story building including an underground garage. At approximately 10A.M., LPA observed the posting of required documents near the entrance of the facility. The common areas were observed to be properly furnished and relatively clean at the of the visit. At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature at the time of visit. A physical plant tour of the inside and outside of the facility with the ED. There are fire sprinklers and fire doors throughout the facility. Emergency/disaster drills are conducted monthly. Last fire drill was conducted on 07/15/2025. LPA inspected the common areas throughout the facility including the Activity room, Lobby, reading room, lounge, café, health center. All the rooms have been appropriately furnished. All exits in Memory care have functioning auditory devices and were operational at the time of the visit. There is an evacuation chair in each stair well on each side of the building. LPA inspected eight (8) randomly selected rooms in all four (4) floors including the memory care unit. resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, and a bedspread. All rooms had a comfortable room temperature of 75 degrees Fahrenheit. Hot water temperature was measured in all eight (8) bathrooms and they were between the temperature range of 105-120 degrees Fahrenheit. Lighting in the rooms appeared adequate. All rooms were free of odors. All window screens were clean and maintained in good repair. The resident bathroom(s) have a shower with non-skid materials. The toilets were in working conditions and the showers observed with grab bars. (Continued on LIC 809-C) The kitchen was observed to be inaccessible to residents in care. Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Dining room furniture were observed to be in good condition and appeared to be relatively clean. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. No flies or other vermin were observed. At approximately 1:06PM - 1:12PM, LPA observed ice cream, sauces, vegetables and other items stored in the freezer uncovered. Also, pies and other deserts observed in the refrigerator that were made a day or two ago according to the Executive Chef, were observed uncovered in the refrigerator. Resident records review began at 2:30 P.M. Eight (8) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Staff records review began at 1:30 P.M, Eight (8) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were observed to be in order at this time. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. the main two (2) first aid kits were observed in the memory care director office and the health service office. Medications are stored in a medication cart which are kept in each floor and inaccessible to residents in care. Medications review began at approximately 12P.M. Medications are documented on a centrally stored log printed by the pharmacy and maintained in a folder in a drawer in the medication room. Random sample review of residents medication completed during visit. Current procedures in place by ED and LVN with regards to record keeping. Centrally Stored records are being moved into binders for easy access. Entry/exits were free of obstructions. The outdoor areas were clean and free of hazards. The patios and balconies observed have proper furnishings. There were no bodies of water noted. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit inter view conducted and copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 24, 2025

Allegation investigated: Staff do not prepare and serve food in a safe and healthful manner.

Licensing Program Analyst (LPA) Zabel Chochian imitated a complaint visit regarding above allegation. Upon arrival LPA was greeted by the concierge staff. LPA met with Aurora Israelson, Business Office Director and Terri Seifer, Executive Director (ED) and informed them of the purpose for this visit. On 04/02/2025, the department received information that the facility staff do not prepare and serve food in a safe and healthful manner; kitchen and dining staff do not wear gloves or hair nets when handling food. At approximately 10am, LPA and ED toured the kitchen and dining area and observed the staff handling food to be wearing gloves and hair nets; LPA was informed that the back house kitchen staff (cooks) wear hair nets and gloves; front-line kitchen staff who place the orders, pick up and serve the residents meals are not required to wear a hair net or gloves unless they are touching/preparing food. From approximately 11am-12:30, LPA conducted interviews with three kitchen/dining staff and six (6) residents; additional four (4) resident interviews were conducted after lunch beginning at approximately 1:15pm. (Continue to Lic9099c) Unsubstantiated Following records reviewed: Facility's March 2025 Dietitian Report did not reveal any food preparation and meal service issues. According to staff interviews the cooks and staff preparing/handling food items are to wear gloves and hair nets. LPA was informed that the servers that do not handle/prepare meals are not required to wear hair nets or gloves. LPA observed supply of gloves and hair nets stationed through out the kitchen in different areas. Staff interviewed confirmed that the cooks and any staff preparing meals is required to wear gloves and hair nets. Interview conducted with ten (10) random residents revealed no issues or concern with the facility food service. Residents interviewed expressed being satisfied with the food service and meals. Ten (10) out of ten (10) residents interviewed were all satisfied with the culinary team. No health and safety issues or concerns reported. Based on the above information gathered, although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff do not prepare and serve food in a safe and healthful manner” is deemed unsubstantiated at this time. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 29-AS-20250402184729

Allegation investigated: Staff verbally abused a resident while in care

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation at 10:13AM. Upon arrival, LPA met with staff and Executive Director (ED) Terri Seifert. Entrance interview conducted. During today’s visit, LPA Barutyan conducted a brief physical plant tour, conducted interviews with two (2) residents and two (2) staff members, and reviewed and obtained copies of pertinent documents. During the initial visit on 01/27/2025, LPA conducted a brief physical plant tour, conducted interviews with three (3) staff members and one (1) resident, reviewed and obtained copies of pertinent documents relevant to the investigation, and discussed allegation with ED Seifert. CONTINUED ON LIC 9099-C. Unsubstantiated It was alleged that Staff #1 (S1) verbally abused Resident #1 (R1). LPA interviewed S1, R1, ED, Resident #2 (R2), and Resident #3 (R3). Interviews conducted did not include evidence supporting the allegation of verbal abuse. No evidence of verbal abuse or threats from S1 to R1 were observed or noted. No immediate health and safety concerns were noted. Furthermore, ED, R1 and S1 held a formal meeting mediated by the Ombudsman soon after the initial visit on 01/27/2025. No concerns were noted from the meeting or reported to the Department. LPA reviewed S1’s training transcript and observed twenty-seven and a half (27.50) hours of training completed between 09/18/2024-09/26/2024 that include courses such as “knowing the rights of residents,” “abuse, neglect, and exploitation in the elder care setting,” and “focus on the individual by listening.” ED and S1 were knowledgeable in de-escalation techniques and types of abuse. LPA had a discussion with the ED and S1 about documenting incidents involving resident-on-resident and resident-on-staff altercations. LPA also discussed with ED about identifying and addressing resident changes of condition and how to address and mitigate high behaviors in residents. The information obtained 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 verbally abused a resident 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, Feb 27, 2025 · control 29-AS-20250123134452

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Valeria Conway and Brian Balisi conducted a pre-licensing visit to this property at 09:45AM. LPAs met with Executive Director (ED), Patrice O’Grady, and explained the reason for the visit. This application is for a Change of Ownership Application (CHOW) currently operating with Facility license #197608478 and the current licensed facility has residents in care. The applicant has obtained fire clearance for One hundred and nineteen (119) non-ambulatory which eight (8) bedridden residents. There is a pending hospice care waiver. The facility is a (five) 5 story building including an underground garage. At approx. 10:30 A.M., a physical plant tour was conducted inside and out. There are fire sprinklers and fire doors throughout the facility. The kitchen was observed to be inaccessible to residents in care. Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Dining room furniture were observed to be in good condition and appeared to be relatively clean. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Trash cans had tight fitting lids. No flies or other vermin were observed. At 10:35 A.M. hot temperature water measured at 113 degrees Fahrenheit. Continued on LIC 809-C Continued from LIC 809 At approximately 10:50 A.M, LPAs inspected eight (8) randomly selected rooms in all four (4) floors including the memory care unit. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. All rooms had a comfortable room temperature of 75 degrees Fahrenheit. Hot water temperature was measured in all eight (8) bathrooms and they were between the temperature range of 105-120 degrees Fahrenheit. Lighting in the rooms appeared adequate. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is a brake room for staff at the facility. For nocturnal (NOC) shift, there will be awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. The resident bathroom(s) have a shower with non-skid materials. The toilets were in working conditions and the showers have grab bars. LPAs inspected the common areas throughout the facility including the Activity room, Lobby, reading room, lounge, café, health and fitness center. All the rooms have been appropriately furnished. There is a dedicated area for the posting of required documents throughout the facility. The common areas were observed to be properly furnished and relatively clean at the of the visit. At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. All exits in Memory care have functioning auditory devices and were operational at the time of the visit.There is an evacuation chair in each stair well on each side of the building. Resident records review began at 11:55 A.M. Six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Staff records review began at 12:30 P.M, Six (6) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Daily vehicle inspection list and California Highway Patrol Inspection report was revieweds. Last emergency disaster drill was conducted 07/09/2024. Continued on LIC 809-C Continued from LIC-809C All records were observed to be in order at this time. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. the main two (2) first aid kits were observed in the memory care director office and the health service office. Medications are stored in a medication cart which are kept in each floor and inaccessible to residents in care. Medications review began at approximately 12:45 P.M. Medications are properly documented on the centrally stored medications and destruction record. Entry/exits were free of obstructions. The outdoor areas were clean and free of hazards. The patios and balconies observed have proper furnishings. There were no bodies of water noted. Component III was conducted in conjunction with the visit. No corrections required on a pre-licensing visit at this time. Exit interview conducted. Report issued and provided to Executive Director. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.the state’s words, verbatim · CDSS document, Jul 19, 2024