Fairwinds - West Hills

Allegation investigated: Staff are not ensuring appropriate assistance is provided when observation reveals unmet needs of residents Staff are not meeting residents' incontinence care needs Unqualified staff are providing diabetic care to residents Unqualified staff are providing catheter care to residents

At approximately 10:00 a.m. on 09/03/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 05/20/26 and interviewed staff and witnesses between 10:00 a.m. and 3:30 p.m., toured the facility inside and out at 10:30 a.m., and conducted a record review of pertinent records, including but not limited to an admission agreements, medical assessments, care plans, and staff and client rosters at 12:00 p.m. LPA conducted a subsequent visit on 07/21/26 and toured the facility at 10:10 a.m., interviewed staff and residents between 10:15 a.m. and 3:45 p.m. Today, LPA interviewed staff and residents between 10:15 a.m. and 2:30 p.m. and toured the facility at 10:15 a.m. Unsubstantiated Regarding the allegations "Staff are not ensuring appropriate assistance is provided when observation reveals unmet needs of residents" and “Staff are not meeting residents' incontinence care needs" it was alleged Resident #1 (R1) and Resident #2 (R2) were left in wet undergarments overnight by Staff #1 (S1) and Staff #2 (S2). Interview with R1 at 2:00 p.m. on 07/21/26 revealed staff have not left them soiled overnight and their incontinence needs have been met. Interview with R2 and their private caregiver at 12:55 p.m. today revealed facility staff sufficiently assist with their incontinence needs. R2’s private caregiver also verified that they have never been found in wet undergarments. Telephonic interview with R2’s representative at 1:00 p.m. on 07/08/26 revealed they were allowed to place a camera in R2’s room. From their video review, R2’s representative confirmed staff provided adequate incontinence care for R2. Telephonic interview with S1 at 12:30 p.m. on 07/08/26 revealed they and S2 changed R1 and R2 twice every shift. S1 confirmed R1 and R2 were not left in wet undergarments. S2 was unavailable for interview. Interviews with Staff #3 (S3) at 1:30 p.m. today and Staff #4 (S4) at approximately 2:00 p.m. on 07/21/26 confirmed staff changed R1 and R2 at least twice every shift, or twice every eight (08) hours. S3 and S4 never found R1 or R2 in wet undergarments. Record review of care plans revealed the facility agreed to support R1’s and R2’s incontinence needs. No other pertinent information was found during record review. Based on interviews and record review, it was concluded that although the allegation may have occurred, there is no measurable and verifiable information to confirm validity of the complaint. Hence the allegation is UNSUBSTANTIATED at this time. Regarding the allegation "Unqualified staff are providing diabetic care to residents" it was alleged staff provide Resident #3 (R3) with insulin injections. Interview with R3 at 3:00 p.m. today revealed they perform their insulin injections with staff supervision. Interview with R3’s roommate at 2:00 p.m. today confirmed staff supervise R3’s insulin injections but do not perform the injections. Interviews with the Health and Wellness Director (HWD) at 10:45 a.m. on 07/21/26, S3, and Staff #5 (S5) at 2:10 p.m. today confirmed R3 performs their own injections with staff supervision. Record review of R3’s medical assessment revealed they are able to administer their own injections. Record review of R3’s care plan revealed staff were not required to assist R3 with diabetes management. Based on interviews and record review, it was concluded that although the allegation may have occurred, there is no measurable and verifiable information to confirm validity of the complaint. Hence the allegation is UNSUBSTANTIATED at this time. Regarding the allegation "Unqualified staff are providing catheter care to residents" it was alleged unqualified staff performed catheter care for R3 and Resident #4 (R4). Interview with R3 revealed staff empty their catheter bag, but home health perform all other aspects of catheter care. Interview with R3’s roommate confirmed staff only empty the catheter bag. R4 was unavailable for interview. Interview with the HWD revealed staff empty R3’s catheter bag when it is full, as instructed by physician orders. Home health performs all other catheter-related tasks for R3. R4 does not have an indwelling catheter but rather an external catheter. R4 and their private caregiver are the only ones to use the device. Interviews with S1, S3, and S4 confirmed staff do not provide assistance for R3 and R4 beyond emptying a catheter bag. Record review of R3’s care plan revealed R3 “will need catheter care done by… home health”. Record review of R3’s home health care plan revealed home health changes the catheter bag monthly, and R3 and staff are responsible for monitoring the catheter for complications. Record review of R4’s care plan revealed R4’s “Private caregiver assists with pure wick” and “staff… ensure it is nearby”. Based on interviews and record review, it was concluded that although the allegation may have occurred, there is no measurable and verifiable information to confirm validity of the complaint. Hence the allegation is UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 3, 2026 · control 31-AS-20260202093652

Type of visit: Annual/Random

At approximately 10:00 a.m. on 09/03/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with the administrator and disclosed the reason for the visit. The facility was last visited on 07/21/26 for a complaint visit. It is a two story building with private apartments, living rooms, shared and private dining rooms, activity rooms, card room, beauty salon, two (02) gyms, four (04) laundry rooms, medication room, business offices, courtyards, and outdoor areas. It has an approved fire clearance for 130 nonambulatory residents. Approved hospice waivers for 7. LPA reviewed staff and resident files at 10:10 a.m. All files were complete, current, and available for audit. Additionally, LPA reviewed REG4 fire testing which was completed on 07/30/26 with all systems passing, the certificate of liability insurance which is valid until 04/30/26, and a recent dietitian report from 02/04/26. Around 11:00 a.m., LPA observed residents sitting in the front shaded area. The facility displayed postings for confidential complaint contacts, facility sketch, facility license, emergency disaster plan, rights of resident councils, weekly menu, and activity schedule. The reception area contained a sign-in sheet for visitors and residents and a fully-stocked first aid kit. In the kitchen, LPA observed an adequate supply of perishable and non-perishable food. Around 11:15 a.m. LPA observed temperature logs for the refrigerator, freezer, and hot water for washing dishes. At 11:25 a.m. LPA measured the refrigerator and freezer temperatures to be 38 degrees Fahrenheit and 0 degrees Fahrenheit, respectively. Hoods were clean and free of debris. Appliances were functional. All surfaces were sanitary. Dietary cards and preferences with resident photos, sanitation logs, and weekly, daily, and alternative menus were posted. The dining room had adequate seating. Furniture was clean and in good repair. Pastries, fruit, water, and beverages were available near the dining areas. Resident mailboxes were located near the dining area as well. A card room and lounge area contained reading materials, board games, video games, television, and puzzles. The medication room was locked and contained medication carts and medication refrigerators. At approximately 12:15 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. The facility has 115 apartments. Apartments range from studios to two-bedroom apartments. All bedrooms contained a chair, nightstand, lamp, storage, emergency call systems, and bed with adequate bedding. All furnishings were clean and in good condition. The Administrator and LPA inspected Room #141 and Room #243. Call system tests were conducted at 12:45 p.m. and 12:55 p.m. A caregiver responded to each request within four (04) minutes. Hot water temperatures in the room were measured at 12:50 p.m. and 1:00 p.m. to be 119.1 degrees Fahrenheit and 117.1 degrees Fahrenheit. Bathrooms contained liquid soap, paper towels, trash cans, grab bars near the toilet and shower, and emergency call systems. Four (04) laundry rooms were available for resident use. Each room has two (02) washers and two (02) dryers. All appliances were operational. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. Two (02) out of two (02) elevators were operational with permits valid until 10/08/26. Six (06) out of six (06) emergency exit paths were free from obstructions. Between 11:30 a.m. and 1:30 p.m. LPA observed fully charged fire extinguishers near the lobby, in upstairs and downstairs hallways, and the kitchen. They were last inspected on 06/17/25 with tags attached. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 3, 2026

Allegation investigated: Staff yell at residents Staff do not safeguard resident's cash resources Residents records are incomplete Staff do not ensure staff are properly trained

At approximately 9:00 a.m. on 07/08/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with Staff #3 (S3) and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 05/20/26 and interviewed staff and witnesses between 10:00 a.m. and 3:30 p.m., toured the facility inside and out at 10:30 a.m. Today, LPA interviewed staff, witnesses, and at least ten percent (10%) of residents, or nine (09) out of eighty five (85) residents, between 9:10 a.m. and 4:00 p.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, staff training records and resident records, and staff and client rosters at 10:00 a.m., and toured the facility inside and out at 10:30 a.m. Regarding the allegation “Staff yell at residents” it was alleged Staff #1 (S1) and Staff #2 (S2) yelled at residents. Interviews with nine (09) out of nine (09) residents interviewed revealed they have not heard S1 Unsubstantiated or S2 yell at residents. Interview with S1 at 10:00 a.m. on 05/20/26 revealed they have not yelled at residents. S1 increases the volume of their speech for residents who are hard of hearing. Interview with S2 at 3:15 p.m. today revealed they do not yell at residents. Interviews with S3 and Staff #4 (S4) at 9:10 a.m. and 9:20 a.m. today and telephonic interview with Staff #5 (S5) at 1:00 p.m. today revealed they have not heard S1 or S2 yell at residents. During the facility tour today, LPA observed staff treating residents respectfully. Based on interviews and observations, there is not enough evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff do not safeguard resident's cash resources” it was alleged S1 stole the petty cash fund. Interview with S1 revealed they only handle the petty cash fund for resident expenses. All purchases are logged and receipts are obtained. Interview with S3 revealed the facility does not handle resident money. They facility receives $200 at a time from the licensee for resident expenditures. Interviews with S3 and S4 confirmed S1 has not stolen petty cash. Resident interviews revealed no pertinent information to the investigation. Record review of the facility petty cash log for 2026 revealed all funds were accounted for by the log and associated receipts. LPA and S3 counted the petty cash fund at 3:45 p.m. today and confirmed all money was accounted for. Based on interviews, record review, and observations, there is not enough evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Residents records are incomplete” it was alleged the facility did not maintain forms required by the Department in resident files. Interviews with S1, S3 and S4 revealed the facility does maintain all required forms in resident files. S4 indicated that they reviewed all resident files and the required forms are maintained. Interviews with residents revealed nothing pertinent to the investigation. LPA reviewed at least ten percent (10%) of the resident files, or nine (09) out of eighty five (85) files, at 3:30 p.m. today. Record review revealed all required forms were maintained in resident files. All care plans, appraisals, and medical assessments were updated. Based on interviews and record review, all resident files reviewed today were complete. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff do not ensure staff are properly trained” it was alleged staff are not sufficiently trained to meet resident needs, and staff training records are not maintained. Interviews with S1 and S3 revealed all staff receive annual training. Interview with S4 revealed staff are issued monthly online training to meet requirements. Interviews with Staff #5 (S5) at 2:45 p.m. and Staff #6 (S6) at 3:00 p.m. today confirmed they complete monthly and annual training. Interviews with eight (08) out of nine (09) residents revealed staff meet their needs. Record review of staff records revealed staff completed all initial and annual training. All first aid and CPR certifications were current. Proof of completion was maintained in their files. All staff had training in general assistance with Activities of Daily Living (ADLs), and staff had specific training for their designated roles, such as medication training or food service. Based on interviews, record review, and observations, there is not enough evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 31-AS-20260515105133

Allegation investigated: Staff does not isolate resident with symptoms of contagious illness

At approximately 9:00 a.m. on 07/08/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the Director of Regional Operations (DRO) and disclosed the reason for the visit. To investigate the allegation above, LPA interviewed staff, witnesses, and at least ten percent (10%) of residents, or nine (09) out of eighty five (85) residents, between 9:10 a.m. and 4:00 p.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 10:00 a.m., and toured the facility inside and out at 10:30 a.m. Regarding the allegation "Staff does not isolate resident with symptoms of contagious illness" it was alleged Resident #1 (R1) coughs in the dining room and may have an infectious disease. Staff do not protect other Unsubstantiated residents from R1’s disease. Interview with Staff #1 (S1) at 9:25 a.m. today revealed R1’s physician verified that R1 does not have a contagious illness. S1 does not disclose R1’s health status to residents to protect R1’s right to privacy. Interview with R1 at 10:00 a.m. today confirmed they do not have a contagious illness. Interview with Witness #1 (W1) at 10:50 a.m. and Witness #2 (W2) at 11:20 a.m. today confirmed R1 does not have a contagious illness, and R1’s physician encourages coughing to prevent further illness. Interviews with eight (08) out of nine (09) residents interviewed revealed they do not know if R1 has a contagious illness. Record review of R1’s medical assessment and appointments confirmed that they do not have an infectious disease. At 10:35 a.m. today, LPA observed staff supervising R1 during their breakfast in the dining room. Based on observations, interviews, and record review, R1 does not have an infectious disease. Staff protect R1’s right to dignity and freedom of choices, and staff protect all residents’ rights to a healthy and safe environment. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 31-AS-20260701132647

Allegation investigated: Uncleared adults in the facility

At approximately 10:00 a.m. on 05/20/26 Licensing Program Analysts (LPA) Nicholas Reed and Tihesha Smith conducted an unannounced complaint visit. LPA met with the Health and Wellness Director (HWD) and disclosed the reason for the visit. To investigate the allegation above, LPA interviewed staff and witnesses between 10:00 a.m. and 3:30 p.m. today, and toured the facility inside and out at 10:30 a.m., and conducted a record review of pertinent records, including but not limited to resident, staff and facility files at 12:00 p.m. Regarding the allegation “Uncleared adults in the facility”, it was alleged corporate staff filled in vacant positions without obtaining criminal background clearances before entering the facility. Interview with the HWD at 10:30 a.m. revealed corporate staff did temporarily support the facility after multiple staff positions were vacated in April 2026. Telephonic interview with the Vice President of Operations (VPO) at 11:50 p.m. today revealed that Staff #1 (S1) filled in the chef position for three (03) days and the VPO attended Substantiated residents for one (01) day. Record review of the facility’s associated staff at 12:00 p.m. today revealed neither S1 or the VPO were associated to the facility. Interview with the VPO revealed they were associated to a sister facility belonging to the same company, but not this facility. Based on interviews and record review, uncleared adults were present in the facility. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is issued on the corresponding LIC 9099-D page. Civil penalties are issued in the amount of $100 per day of each uncleared adults’ presence in the facility on the corresponding LIC 421BG form. Exit interview conducted. Appeal rights discussed. Copy of report provided. Record review confirmed the HWD has an active and valid administrator certificate as well as a signed LIC 308 form indicating she is the administrator designee. Telephonic interview with the Vice President of Operations (VPO) at 11:50 a.m. today confirmed they supported the HWD for one (01) day, and the HWD has served as the administrator since the previous administrator left. Based on interviews and record review, the facility has operated with a qualified administrator. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 31-AS-20260515105133

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: May 21, 2026

87355 Criminal Record Clearance (e) All individuals... shall prior to working... (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) Based on record review and interview, the licensee did not comply with the section cited above in two (02) corporate staff who worked temporarily in the facility without first transferring criminal background checks to be associated to the facility which posed an immediate risk to the Health, Safety, or Personal Rights of residents in care.the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: The VPO successfully transferred their criminal background clearance to the facility during the visit. The VPO also scheduled a training for 06/03/26 regarding the cited section. Deficiency cleared.

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: Staff do not reat residents with dignity.

At 10:10 am, Thursday, 2/12/26, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced, initial complaint visit to invesitgate the above allegation. LPA met with Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:20 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received Facility resident roster, and staff roster. LPA conducted interviews with Administrator, Nine (9) Residents, and five (5) Staff. Allegation: Staff do not treat residents with dignity. It was alleged the Administrator is undignified and confrontational with residents, and is rude with residents and their families. [LIC9099] Unsubstantiated To investigate this allegation, From 10:40am to 12:15pm, LPA conducted interviews with nine (9) residents. Between 12:35pm and 1:40pm, LPA conducted interviews with five (5) staff. All residents and staff interviewed stated to LPA that Administrator and staff treat residents with dignity and respect. During the physical plant inspection, LPA observed multiple on-duty caregivers, food services, and house keeping staff; LPA did not observe any personal rights violations while present at the facility. Based on the information obtained, it could not be proven that Administrator, nor staff, neglect the dignity of residents while in care. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 31-AS-20260202093652

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: Staff did not ensure that the facility had a working water source. Resident did not receive medication as prescribed.

On 10/30/2025, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at the facility to conduct an unannounced initial 10-day complaint visit. Upon arrival, LPA met with the General Manager Drinkhouse Marissa, introduced herself by showing her badge and explained the reason for the visit. Entrance interview conducted. At 11:00am, LPA requested residents and staff rosters. At approximately 11:45am, LPA requested copies of pertinent information which include but are not limited to Residents’ files: Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, copy of (CSMDR) Centrally Stored Medication and Destruction Record, Medication Administration Records (MAR), copies of Incident Reports, copies of Staff training, Facility Program Design, Maintenance/service invoices, and potential documents relevant to the investigation. At approximately 12:55pm LPA conducted a physical plant tour to ensure health and safety of the residents are protected and the facility is in compliance with Title 22 Regulations. No health and safety hazards noted during the visit. Continue on LIC9099-C Unsubstantiated During today’s visit, from 1:00pm to 2:35pm, LPA interviewed eleven (11) residents residing in the facility, one (1) Health and Wellness Director (LVN), five (5) Caregivers/Staff, and the General Manager. From 1:50pm-3:20pm, LPA conducted a records review of residents’ files, as well as other relevant documents. Allegation: Staff did not ensure that the facility had a working water source. It was reported that the facility was without water for over 24 hours and during this period, residents were unable to flush toilets or use the sink. To investigate this allegation, LPA conducted records review of facility’s maintenance/service invoices and incident reports. Made observations to the facility’s water system, kitchen, common bathrooms, and resident rooms. Conducted interviews with Staff and residents residing in the facility. During the visit, LPA observed that the facility had running water in the kitchen, resident restrooms, and staff areas. Interviews with residents and staff confirmed that there was a temporary water disruption on October 6th, 2025. The community discovered a water leak which was due to a city pipe and the community had no control over that. Documentation reviewed showed that the staff promptly notified the water company and the issue was resolved within few hours. A letter was immediately served to residents and responsible parties notifying them regarding the issue with community’s water system. Interviews with staff and residents confirmed that although there was an issue with water system, all residents continued to have access to toilets, food, and water. Residents also confirmed that they were provided with gallons of water in their rooms and that the facility took appropriate action and their needs were met during the water outage issue. Residents also added that dining room was open as well and the kitchen did not get affected by the water outage. Based on the information obtained through interviews, records review and observation, there is insufficient evidence to support the allegation. Therefore, the allegation listed above is deemed Unsubstantiated at this time. Continue on LIC9099-C Allegation: Resident did not receive medication as prescribed. It was reported that the facility was without water for over 24 hours and during this period, residents did not take their medications, and residents did not receive the care agreed upon (RP did not state exact care). To investigate this allegation, LPA reviewed the medication administration records (MAR) and compared with the Physicians orders records indicated that residents’ medication was administered as prescribed. Interviews with residents, staff responsible for medication administration, and the facility General Manager confirmed no missed or incorrect medications observed and all medications were provided timely. Additionally, all interviewees stated that they are very pleased and happy with the care and supervision they receive in the facility and denied ever being mistreated or ignored by the staff especially during the water outage. Interviews with residents who are independent and administer their own medications stated although they are responsible for their own medications, the Health and Wellness staff do assess them every six (6) months or as needed, and if there is a change in their medications it gets reported and documented. Interviews with Residents who require medical care and do not administer their own medications, stated that Med-techs and LVNs never miss their medications, and they never had any issues of not receiving their meds or receiving them late. Based on the information obtained through interviews, records review and observation, there is insufficient evidence to support the allegation. Therefore, the allegation listed above is deemed Unsubstantiated at this time. No deficiency cited during today’s visit. Exit interview conducted, copy of the report delivered.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 31-AS-20251020163145

Allegation investigated: Facility is unable to provide power during a power outage to residents Facility staff do not keep facility at a comfortable temperature

On 09/29/2025, Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced 10-day complaint visit to the facility to investigate the above allegations. LPA was greeted and granted access to the facility by staff. LPA met with new Administrator Marissa Drinkhouse and explained the reason for the visit. Entrance interview conducted. At approximately 11:30 am, LPA requested copies of resident and staff rosters. LPA also requested copies of Emergency Disaster Plan, copy of facility internal investigation/maintenance reports, and any documents relevant to the investigation. At 12:15 pm, LPA conducted a physical plant tour to ensure the health and safety of the residents are protected. At approximately 12:45 pm LPA conducted a file review of documents provided. Between 1:00 pm and 03:00 pm, LPA conducted interviews with Administrator, five (5) staff, and eleven (11) out of eighty-eight (88) residents residing at the facility. Continued LIC9099-C Unsubstantiated Allegation: Facility is unable to provide power during a power outage to residents. It is reported that facility is unable to provide power during a power outage to residents. Regarding this allegation, it is reported that during a recent power outage the facility did not have an emergency plan to provide power due to not having a back up generator. It is further reported that residents had to resort to taking the stairs to other floors instead of the elevator due to the facility failing to provide power. LPA interviewed Administrator who stated that the power outage only lasted about an hour or so and that facility staff were on alert going room to room to check on residents. During this time Administrator states that there were no reports of residents being in distress or having any major concerns with the power being out. Furthermore, Administrator states that there are backup generators that automatically turn on when the power goes out, allowing for necessary appliances to have power such as refrigerators and computers. Administrator explained that during this time essential equipment was backed up but that when power was restored about an hour later, everything requiring power was fully functional. Administrator also explained that residents with oxygen needs were also provided assistance with portable oxygen tanks, and/or individual power banks for providing electricity to oxygen tanks. It was also stated by Administrator that the activities room was provided with additional power in case residents needed to charge cellphones or additional items. Administrator states that residents on the second floor who wished to go to the first floor were transported via the evacuation chair and vice versa. LPA interviewed Plant Operations Manager (POM) who confirmed that power was only out for an hour or so due to Spectrum Internet company cutting a power cable causing an outage to the surrounding area, something beyond the facilities control. However, POM stated that the back up generators are fully functioning and provided power to essential appliances. LPA interviewed four (4) additional staff members who stated that they went to all resident rooms to make sure that the residents’ needs were being met. Additionally, staff stated that they gave primary attention to residents on oxygen. During facility tour LPA was shown backup generators and logs of maintenance. LPA interviewed eleven (11) out of eighty-eight (88) residents. All eleven (11) residents reported that they were not significantly affected by the outage and had no major concerns. None of the interviewed residents expressed safety issues or distress related to the temporary power loss. The facility demonstrated that backup systems were in place and functioning, and staff took appropriate measures to ensure resident safety during the outage. Therefore, based on observation, interview and record reviews this allegation is deemed unsubstantiated. Continued LIC9099-C Allegation: Facility staff do not keep facility at a comfortable temperature. It is reported that facility staff do not keep facility at a comfortable temperature. Regarding this allegation it is reported that the facility did not have a backup generator during a power outage causing the residents to be exposed to high temperatures during a heat wave. LPA interviewed Administrator who stated that the power outage only lasted about an hour and that facility staff were on alert going room to room to check on residents. During this time Administrator states that there were no reports of residents in distress or having any major concerns with the power being out, nor was there a heat wave as temperatures that day were in the mid 70’s. Furthermore, Administrator states that there are backup generators that automatically turn on when the power goes out, allowing for necessary appliances to have power such as refrigerators and computers. Administrator explained that during this time essential equipment was backed up but that when power was restored about an hour later, everything requiring power was fully functional. Administrator states that there were no reports from residents experiencing heat exhaustion or discomfort, reiterating that at the time there was no heat wave and that the facility temperature was comfortable for residents and staff. Interview with POM revealed that although the generators did not power the AC units, the power was not out long enough to cause discomfort or expose residents to extreme heat. POM expressed that generators are inspected and tested on a weekly basis and provided maintenance logs. During facility tour, LPA tested various areas of the facility with portable temperature meter that read temperatures ranging from 72˚F to 77˚F, putting facility at comfortable temperatures throughout. LPA interviewed four (4) staff and eleven (11) residents, who stated that the facility maintained comfortable temperature at all times, and no discomfort was expressed. Therefore, based on interviews, record reviews and observations, this allegation is deemed unsubstantiated. No citations were issued. Exit interview conducted and a copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Sep 29, 2025 · control 31-AS-20250924084430

Allegation investigated: Staff did not prevent resident from engaging in verbal altercations with other residents. Staff are not providing a comfortable environment for residents.

On 7/21/2025, Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Leslie Ngo-Castaneda conducted an unannounced 10-day complaint visit to the facility to investigate the above allegation. Upon arrival, LPAs introduced themselves by showing their department badges, met with the Facility General Manager Gutierrez Elvis and explained the reason for the visit. Entrance interview conducted. At 9:20am, LPAs requested copies of resident and staff rosters. LPA also requested copies of Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, Medication list, copy of Incident Reports, copy of facility internal investigation report, and potential documents relevant to the investigation. At approximately 9:45am, LPAs conducted a physical plant tour to ensure the health and safety of the residents are protected. No immediate health and safety hazards were noted during the visit. Between 10:00am – 12:40pm, LPA conducted interviews with the facility General Manager, four (4) staff/caregivers, and nine (9) out of ninety-six (96) residents residing at the facility. Continue on LIC9099-C Unsubstantiated Allegation: Staff did not prevent resident from engaging in verbal altercations with other residents. It was reported by Resident #1 - R1 that there was an incident back on January 3rd 2025, where R1 got involved in verbal altercation with R2. To investigate the allegation, during today’s visit, LPAs interviewed the General Manager, four (4) staff/caregivers, and nine (9) out of ninety-six (96) residents residing at the facility. LPAs also reviewed R1 and R2 files, incident reports, and facility internal investigation reports. Interviews with staff members confirmed that a verbal interaction occurred between two residents (R1 and R2) on February 3rd 2025, and they described the situation as a brief verbal disagreement near the elevator area. Staff were immediately alerted to the situation and responded promptly. They separated the residents, de-escalated the interaction, and ensured that both parties were safe and calm. The management followed the internal procedures by documenting the incident, notifying appropriate parties, and facility driver transported R1 to UCLA West Valley Medical Center - ER for evaluation, as R1 mentioned that during the verbal altercation R2 swung the empty canvas bag, did not hit R1, however, R1 wrenched the right side of the body and was in pain. Staff continually monitored both residents R1 and R2 for any signs of distress or further conflict. Interviews with residents confirmed that the staff presence and intervention are always timely and appropriate. No evidence of negligence or lack of supervision observed during today’s visit on the part of the facility staff. Residents also denied of witnessing or observing any ongoing issues between residents residing in the community and stated that they feel safe and supervised at all times. Although, the verbal altercation did occur between R1 and R2, staff responded immediately and intervened appropriately to manage the situation. Therefore, based on interviews, records review and observation, the allegation that staff did not prevent a resident from engaging in verbal altercation with other resident is Unsubstantiated at this time. Continue on LIC9099-C Allegation: Staff are not providing a comfortable environment for residents. It was reported by R1 that there was an incident back on January 3rd, where R1 got involved in verbal altercation with R2. R1 also reported that about four to six (4-6) weeks ago R1 had scabies and that R1 was told by the facility’s attorney that R1 brought the scabies in through his/her parakeet. To investigate the complaint, LPAs interviewed the General Manager, four (4) staff/caregivers, and nine (9) out of ninety-six (96) residents residing at the facility. LPAs also reviewed R1 and R2 files, incident reports, and facility internal investigation reports. In course of the investigation, interviews and review of medical records confirmed that Resident #1 (R1) had reported skin condition in March 2024, described a rash on their body. R1 was assessed by dermatologist, who confirmed that the rash was diagnosed as scabies. Upon receiving the diagnosis, the facility staff took immediate and appropriate action in line with infection control protocols. R1 and R1’s spouse who also resides in the same room were temporarily isolated to prevent the possible spread. Both residents received prescribed medication treatment as ordered by the physician. There were no additional reports of skin rash or scabies symptoms among other residents or staff members before or after the incident. Staff members also confirmed that enhanced cleaning and sanitizing procedures were conducted. Interviews with multiple residents indicated they feel safe and comfortable in the facility. Residents reported satisfaction with the living conditions and the attentiveness of the staff. All residents interviewed denied of ever having skin rash or scabies while residing in the facility. Observations made during the facility visit showed a clean, well maintained, and welcoming environment. No evidence was found to support the claim that the environment is not conducive to resident comfort. Based on the information obtained through interviews, documentation review, and on-site observations, there is insufficient evidence to support the allegation of staff failing to provide safe environment for residents. Therefore, the allegation listed above is deemed Unsubstantiated at this time. No deficiency cited during today’s visit. Exit interview conducted, copy of the report delivered.the state’s words, verbatim · CDSS document, Jul 21, 2025 · control 31-AS-20250714092054

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Perchui Khurshudyan conducted an Annual Required visit and inspection of the facility. LPAs met with the manager, Elvis Gutierrez and advised him of the visit. At approximately 10:00 AM, with the assistance of the manager, LPAs took a tour of the physical plant. The facility is a two story building. There are five stairwells and two elevators. Kitchen: LPAs observed an adequate supply of perishable and non-perishable food. The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPAs found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. There is a temperature log for refrigerator temperatures. All surfaces were sanitary. Food storage and preparation areas are clean and inaccessible to pests. Bedrooms: The facility has 115 apartments. Apartments range from studios to two bedroom apartments. All bedrooms contained a chair, night stand, lamp, storage, emergency call systems, and bed with adequate bedding. All furnishings were clean and in good condition. At 10:30 AM smoke detectors and emergency call systems in random units were tested, and are functional. Continue to LIC 809-C Bathrooms: Bathrooms were checked for proper fixtures, grab bars, appropriate hygiene items and emergency call systems. LPAs measured the water temperature in the public bathrooms and the bathrooms in resident rooms to be at an average of 109.5 degrees Fahrenheit. Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. The facility common areas have television/monitors, variety of seating, tables and chairs. LPAs toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished and tidy. There is a private dining room on the first floor, located by the elevator. LPAs observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance. Resident mailboxes are located near the front lobby. Appliances in the laundry room were operational and sanitary. Surrounding Grounds: All emergency exit paths were free from obstructions. LPAs observed fully charged fire extinguishers all throughout the facility. They were last charged on 6.27.2025. Outdoor areas: There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. There is no garage just a big parking lot for residents and staff to park. Resident Files: LPAs conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPAs also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is beside the entrance of the facility. Records were checked for expired or missing certificates and clearances: LPAs conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training. Medications: Medication room is locked when no staff are present. All medications were locked inside the medication room. Medication and Medication Records were reviewed for proper storage and documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of this Report Issued.the state’s words, verbatim · CDSS document, Jul 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted an Annual Required visit and inspection of the facility. LPAs met with the administrator, Elvis Gutierrez and advised him of the visit. At approximately 9:30am, with the assistance of the administrator, LPAs took a tour of the physical plant. The facility is a two story building. There are five stairwells. An evacuation chair is stationed at each stairwell. Kitchen: LPAs observed an adequate supply of perishable and non-perishable food. There is a monthly temperature log for refrigerator temperatures. Kitchen appliances were clean, free of debris and functional. All surfaces were sanitary. Bedrooms: The facility has 115 apartments. Apartments range from studios to two bedroom apartments. All bedrooms contained a chair, night stand, lamp, storage, emergency call systems, and bed with adequate bedding. All furnishings were clean and in good condition. Smoke detectors and emergency call systems in random units were tested, and are functional. Communication within staff throughout the building is made through walkie talkie. Bathrooms: Bathrooms were checked for proper fixtures, grab bars, appropriate hygiene items and emergency call systems. LPAs measured the water temperature in the public bathrooms and the bathrooms in resident rooms to be 120 degrees Fahrenheit. Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. The facility common areas have television/monitors, variety of seating, tables and chairs. There is a private dining room on the first floor, located by the elevator. Dinning area has multiple tables enough to seat the capacity of 130. Resident mailboxes are located near the front lobby. Near the mailboxes hung postings for resident rights, rights of resident councils, personal property procedures, ombudsman contacts, and a suggestion box. Surrounding Grounds: All emergency exit paths were free from obstructions. LPAs observed fully charged fire extinguishers all throughout the facility. They were last charged on 07/25/24. The most recent fire inspection was made by LAFD on 08/13/24 and 08/14/24. Fire doors, sprinklers and alarms were found with no defects. The report showed all systems passed inspection. The last fire drill was conducted by the facility on 08/29/24. Outdoor areas: LPAs observed the southern courtyard to be free of debris and tripping hazards. There was furniture appropriate for outdoor use. Laundry area: Appliances in the laundry room were operational. The laundry room was sanitary. All detergents were locked. The laundry room was locked with a numeric keypad. Resident Files: LPAs conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPAs also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: Medication room is locked when no staff are present. All medications were locked inside the medication room. Medication and Medication Records were reviewed for proper storage and documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of this Report Issued.the state’s words, verbatim · CDSS document, Sep 14, 2024

Allegation investigated: Admission Agreement was inappropraitly completed.

On 8.14.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Elvis Gutierrez who is the Executive Director (ED) of the facility. An entrance interview was conducted. At 10 AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care. Allegation: Admission Agreement was inappropriately completed. It was alleged that the facility’s Admission Agreement was inappropriately completed. Continue to LIC 9099-C Substantiated R1 is getting all the additional care that is needed to be provided by the facility when assess by the wellness director yearly. Regarding the increased costs of service, ED has been trying to negotiate a price increase with the reporting party since November of 2023 and the family refuses to accept the increased amount regarding board and care. According to the facility program and record review, ED has been following the 60-day advance notice for a fee increase. Interview sixteen (16) residents out of one hundred seven (107) residents at the facility regarding the above statement are untrue, ten (10) out of sixteen (16) residents expressed no concern regarding this allegation. Based on the information received and record review this allegation is unsubstantiated this time. Allegation #3: The staff did not follow the physician's instructions for prescribed medications. It was alleged that staff did not follow the physician's instructions for prescribed medications. To investigate this investigation, LPA reviewed the Centrally Store Medication Destruction Record (CSMDR) and Medication Administration Record (MAR) of R1. All staff (S1, S2, S3 and, S4) stated that R1 always received their medication as prescribed but resident has a history of refusing their medication and they can’t force the resident to take it. LPA reviewed the Medication Administration Record (MAR) and observed that from February 2023 to July 2023 and from April 2024 to May 2024 the resident medication was given in a timely manner and R1 refused to take their medication occasionally. LPA interviewed sixteen (16) residents about the allegation, and ten (10) out of sixteen (16) residents revealed that it was untrue. Residents stated that they always get their medication as prescribed by their physician and that the staff gives it to them at the correct times. Based on the information received and reviewed this allegation is Unsubstantiated this time. Allegation #4: Staff interfered with the resident's sleeping/bedtime. It was alleged that staff interfered with the resident's sleeping/bedtime. It was alleged that medication was given at an inappropriate time causing R1 circadian rhythm to be interfered. To investigate this allegation, LPA interviewed five (5) out of sixty-five (65) staff and sixteen (16) out of one hundred seven (107) residents. Continue to LIC 9099-C LPA did a record review, and R1 has no medical note from a Primary Care Physician (PCP), sleep specialist, or neurologist to state that medications given at a different time from July of 2023 would cause R1 to have a circadian rhythm. According to interviews with staff, they will only help residents to sleep at night or wake them up at a certain time in the morning when requested to go out with family or doctor appointment. According to interviews with residents, they have no issues with sleeping/ bedtime, residents go to sleep and wake up when they want. Based on the information received this allegation is Unsubstantiated at this time. Allegation #5: Staff isolated resident It was alleged that staff isolated the resident. Staff would leave R1 on their sofa instead of their recliner in bedroom #118. When sitting on the sofa, R1 has a hard time getting up, compared to sitting on the recliner, where R1 can just maneuver from the recliner to their walker to roam the facility independently. To investigate this allegation, LPA reviewed incident reports and interviewed five (5) out of sixty-five (65) staff and sixteen (16) out of one hundred seven (107) residents. LPA found out that R1 needs assistance while walking with their walker and transferring. R1 is at high risk of falling by themselves when transferring and roaming the facility, there are four (4) incident reports: 10.8.2023, 10.21.2023, 11.15.2023, and 2.10.2024 where R1 had fallen. R1 has been advised repeatedly to use the call button for staff assistance for transfer. During the interview ten (10) out of sixteen (16) residents revealed that staff would not isolate them, they have all the freedom to do activities and roam around the facility. Based on the information received this allegation is Unsubstantiated at this time. An exit interview was conducted with Elvis Gutierrez, executive director (ED), and a hard copy of this report was provided. It was alleged that resident #1 (R1) admission agreement addendum M was incomplete and added by the facility. To investigate the allegations above, LPA conducted an initial visit on 5.15.2024. LPA toured the facility and requested and reviewed the physician's report, staff roster, resident roster, admissions agreement of R1, appraisals, and incident reports. LPA interviewed staff and residents, five (5) out of sixty-five (65) staff and sixteen (16) out of one hundred seven (107) residents. The interview with the executive director (ED) and residents regarding the above statement is untrue, and all residents expressed no concern regarding this allegation. Upon reviewing admission agreement records obtained from the reporting party (RP) and records from the facility. According to the ED, no residents can be admitted to the facility without signing all necessary documents. LPA reviewed sixteen (16) other residents' records and all their admission agreements were signed but incomplete on addendum A that has the total cost of monthly fee. All the residents admissions agreement was not filled in appropriately, according to page 13 (addendum A Monthly fee), total costs indicate only the monthly payment, which was incomplete. ED did not indicate additional ‘Monthly Service Agreement Summary Charges (addendum M) as requested on page 13 under ‘additional services’. Therefore, aside from the monthly charges indicated on page 13, ED is then requesting another fee for monthly service fee from addendum M from addendum M. Based on the information and record review received this allegation is substantiated this time. Deficiency will be cited on LIC 9099-D. Exit interview conducted, a copy of this report was given to ED.the state’s words, verbatim · CDSS document, Aug 14, 2024 · control 31-AS-20240506163316

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(a)(1) · Plan of correction due date: Aug 28, 2024

87507(g)(a)Admission agreements shall specify the following: (1) A comprehensive description of any items and services provided under a single fee, such as monthly fee for room, board, and other items and services shall be listed. This requirement was not met as evidenced by: Based on interviews and document review facility did not indicate the correct total amount for monthly fee on their admission agreement paperwork which poses an potential health and safety risk or personal rights to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

Plan of correction: The ED will submit in writing to RO by 8/28/24, how they will ensure that all residents in care have a proper signed admission agreement.

Allegation investigated: Staff did not treat resident with respect. Staff yelled at resident.

Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPAs met with the administrator, Elvis Gutierrez, and advised him of the complaint. Today's investigation consisted of interviews with the administrator, staff, and residents. LPAs also conducted a physical plant inspection of the facility to insure the health and safety of the residents, and a review of records. In regards to the allegations, it was alleged that on or around April 23, 2024, facility administrator yelled at Resident 1 (R1) and accused R1, or R1's pet of bringing scabies into the facility. There were no witnesses identified to confirm these allegations. Interviews with administrator and staff deny the allegations. Interviews with seven (7) of seven residents also deny the allegations, with several residents stating staff and administrator treat them with respect. Based on the information, there was insufficient evidence to corroborate the allegations of staff not treating residents with respect, or staff yelling at residents. Therefore, the allegation is deemed Unsubstantiated at this time. Administrator advised and a copy of this report issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 12, 2024 · control 31-AS-20240610145500

Allegation investigated: Resident sexually abused another resident

Licensing Program Analyst Melissa Spaeth (LPA) conducted an unannounced subsequent complaint investigation for the allegation(s) listed above. LPA was greeted by Busines Office Manager. On 4/10/2023, a complaint was received by the Woodland Hills Adult & Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s Investigation Branch as an assignment to investigate the complaint on 4/13/2023. The investigation consisted of the following: On 04/11/2023, LPA Spaeth conducted a 10-day visit, toured the physical plant and requested residents’ documentation, the resident roster, and the staff roster. During LPA’s visit, LPA received the requested documentation. On 8/01/2023, LPA Spaeth conducted a subsequent visit and interviewed six staff members and interviewed a resident. Continued- 9099C Unsubstantiated A complete investigation was conducted by IB Investigator, Laura Garcia. During the course of the investigation, Investigator Garcia interviewed the Facility Manager, staff members, resident(s), resident’s relatives and a LAPD Detective. Regarding the allegation: Resident sexually abused another resident - It’s being alleged that a resident (R1) was raped by another resident (R2) within the facility. In October 2022, it is alleged that R2 entered R1’s room uninvited and raped R1. R1 stated they woke up and R2 was on top of R1. It is also alleged that R2 could have put something in R1’s drink which made R1 sleepy so that the incident could occur. R2 seemed confused about the incident and denied it happened and stated it was consensual. The investigation revealed that a medical test was not able to be completed on R1 due to their inability to identify the specific time and date of the incident. The LAPD Detective advised the sexual assault allegation was rejected by the District Attorney’s Office due to insufficient evidence and cognitive impairments from both R1 and R2. IB Investigator Garcia’s interview of R1 revealed R1 was unable to provide a date and time of the incident and was unable to provide specific details regarding the incident. A second investigation was conducted by Laura Garcia. Investigator Garcia interviewed R1 on 4/13/2023. The interview revealed R1 was unable to remember what happened and only remembers waking up to pain. Investigator Garcia requested additional police reports from the LAPD Detective but the Detective informed Garcia no additional incident reports were available. Based upon interviews with residents, staff members, and the LAPD Detective, the complaint is unsubstantiated. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Jun 7, 2024 · control 31-AS-20230410124655

Allegation investigated: Facility failed to follow regulations adopted by the State Fire Marshal for the protection of life and property against fire. Facility did not follow Covid-19 protocol.

On 02/07/24, at 8:50am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Administrator Elvis Gutierrez. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 9:45am, LPA toured the physical plant, conducted staff and resident interviews, and received documentation regarding the above allegation(s). 9099C-continued Unsubstantiated Regarding the allegation: Facility failed to follow regulations adopted by the State Fire Marshal for the protection of life and property against fire. It’s being alleged that RP states facility is not following brush clearance requirements and not enough is being done by the facility to clear potential fire hazards from hill side. During, LPA's physical plant tour, LPA did not observe any bushes to be overgrown. There are pictures to prove that the bushes and pine trees are being kept to Fire Marshal code which is not to exceed three (3) inches in height. There is also an email from Linsay Pellegrini Inspector I, Valley Public Safety Unit and an interview that the LPA conducted clearing the above facility of any fire hazard violation. The interview states that the Pine Trees are alive and that causes no fire hazard violation and that there was a removal of a fallen branch between the intersection of Woodlake and Roscoe that was picked up. Also, there is a fire clearance dated 02/02/24 for the above facility that was obtained by the LPA from the City of Los Angeles. Eight (8) out of ten (10) residents were interviewed regarding the above allegation(s) and there was no concerns. In addition, there was also seven (7) staff that were interviewed regarding the above allegation(s) and there were no concerns. The staff also received a recent, simulated fire drill on 12/12/23 so they can be aware about fire procedures. Furthermore, there is a red binder in the front entrance of the facility that is titled Emergency Procedure Manual and Exposure Control Plan (ECP) which has a facility sketch, evacuation routes and infection control procedures for both the staff and residents to view and obtain information that was reviewed by the LPA. Therefore, based on the LPA's interviews, observations, and record reviews the above allegation(s) above is unsubstantiated at this time. Regarding the allegation: Facility did not follow Covid-19 protocol. It’s being alleged that RP states there were three cases of Covid on December 28, 2023 and Fairwinds protocol was not that prescribed by government...also at the facility there were very concerned when "medical" cleared husbands of those in Quarantine to roam, including dining-room...they said it's was ok for occupant to "get mail", etc.. Another person, in quarantine was also free to roam anywhere. LPA was able to obtain the Unusual Incident/Injury Report sent to Community Care Licensing Division (CCLD) regarding the residents that recently had Covid-19 and the reporting email to the Public Health with covid guidance. A town hall agenda and meeting were also held on 01/31/24 with residents that wanted to attend listing the Emergency Procedure Binder as one of the topics which has the infection control procedure included. LIC 9099C-continued Eight (8) out of ten (10) residents were interviewed in regards to the above allegation(s) and there was no concerns. Eight (8) out of ten (10) residents stated similar protocol that residents are not allowed out of there room if they test positive for Covid-19. The residents also stated that they get room service where food is delivered to their room and they not allowed to enter the dining hall to eat. There was also seven (7) staff that were interviewed regarding the above allegation(s). Two of the Health and Wellness staff were interviewed and described the Covid-19 procedures. They both stated that once the resident has Covid-19 symptoms or has been exposed to someone that had Covid-19 they shall be tested. Once they are tested and the result is positive the resident immediately is isolated in their room for about five (5) days. There are then two signs displayed outside of the their room alerting anyone entering the room or close by the room and there is one sign in the room to remind the resident that they are Covid-19 positive. There is a bin then kept outside of the room with gloves, hand sanitizer, mask, wipes for resident to use if needed. Another bin is kept in the room which is red for laundry that is to be washed separately. The resident is then retested until a negative test is shown and the resident can go on to route procedures. The administrator was interviewed and described the Covid-19 procedure is to report to CCLD, public health and then follow precautions regarding the Covid-19 and its procedures for not only residents infected but to prevent further spread. Therefore, based on the LPA's interviews, observations, and record reviews the above allegation(s) above is unsubstantiated at this time. An exit interview was conducted, no citations were issued for the two (2) above allegations, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 31-AS-20240202120520

Allegation investigated: Emergency disaster plan is not sufficient to meet the needs of residents in an emergency.

On 12/18/2023 at 10:00 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conducted a complaint visit to investigate the above mentioned allegation. LPA was greeted by the General Manager (GM) Elvis Gutierrez. LPA explained the purpose of the visit. LPA interviewed the GM at 10:12 a.m. and obtained copies of the facility's Emergency and Disaster Plan (LIC610E), Building Emergencies - Electrical Outages plan pulled from the Emergency Procedure Manual, a list of the residents in the facility which reflect provisions for appropriate support in the event of an emergency, maintenance log of facility's generator, and a facility calendar displaying a Town Hall Meeting May 31, 2023. At 10:52 a.m. LPA along with the GM conducted a physical plant inspection to assure the health a safety of the residents. Allegation: Emergency disaster plan is not sufficient to meet the needs of residents in an emergency. It was alleged if the facility experiences a power outage lasting longer then 8 hours the one generator the facility has is insufficient. (CONT. on LIC 9099-C) Unsubstantiated (CONT. from LIC 9099-C) To investigate the allegation LPA reviewed the facility's Emergency and Disaster plan along with the supplemental and the electrical outages plan. Interview with GM confirms the facility experienced a power outage on two occasions. One on 11/18/2023 lasting approximately an hour and a second one on 11/20/2023 lasting approximately 10 hours. The documents revealed the facility is equipped with one generator that will support emergency lighting communication and the building fire system. Facility also listed maintaining a list or residents dependent on electrical power usage for health maintenance and would have at least one flashlight or portable lighting devise in designated areas. Furthermore documents revealed staff would be required to check on residents every two hours and provide assistance and support to residents dependent on electrical power usage for health maintenance as needed. Interviews with staff and residents revealed facility made available to every resident a flashlight. LPA interview with residents dependent on oxygen and those not dependent reported the staff came into their rooms and checked on them while facility had the power outages. Facility records revealed at the time of the incident three residents were dependent on oxygen and 1 resident uses a wheelchair on the second floor. According to the GM the facility utilized the generator to charge batteries for the oxygen tanks and residents where able to switch out batteries to continue charging them. GM also stated residents could be assisted down the stairs to plug into a line that was directly plugged into the generator to continuously use oxygen devise. LPA observed one of two emergency chairs to assists residents down stairs during an emergency. According to residents and staff facility was able to obtain oxygen cylinders. LPA discussed with GM that facility should consider supplementing Emergency and Disaster Plan to include a procedure addressing residents dependent on oxygen in a disaster lasting longer then 72 hours and have residents input on such procedure. Based on record review and interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 18, 2023 · control 31-AS-20231208140029

Allegation investigated: Staff do not ensure food served is of good quality for residents in care

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with Executive Director, Elvis Gutierrez, and explained the reason for the visit. --- Staff do not ensure food served is of good quality for residents in care It was alleged that the facility served food that caused resident to be sick and food is left on the counter for an extended time. To investigate the allegation, on 12/07/2023, LPA conducted a physical plant tour at around at 11:00 AM, requested the resident roster at 12:00 PM, interviewed three (03) staff from 12:15 PM – 1:30 PM and interviewed ten (10) residents from around 1:30 PM – 3:30 PM. During the physical plant tour, LPA observed fresh food being prepared and served immediately. (CONT. on LIC 9099-C) Unsubstantiated A review of the resident roster revealed that resident mentioned in the allegation is not a resident at the facility and is unknown to staff. During interviews with staff, all staff stated that food is served fresh and that they are not aware of any complaints as it pertains to food. All residents stated they are satisfied with the quality of the food, that it is always served fresh and have no digestive issues caused by the food served. Based on interviews, there is enough not information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 7, 2023 · control 31-AS-20231204104907