Greenleaf Court Senior Living

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff do not provide adequate food service to residents Staff do not ensure residents have an easily accessible, working elevator

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced initial visit to investigate the above allegations: LPA met with Activity Director Casey M. Fischer and Wellness Director Denise Bartley arrived a short time later and assisted with the visit. The investigation consisted of LPA taking tour of facility, testing the working elevator, obtaining and reviewing work order dated 08/3/2026 for elevator repair, obtaining and reviewing staff and resident rosters, interviewing six (6) staff, seven (7) residents, obtaining food menu, pizza order from 08/29/2026, and other pertinent documents regarding Elevator. The investigation revealed regarding allegation: Staff do not provide adequate food service to residents. It is alleged that on 08/29/2026 residents were provided with pizza for dinner but there was not enough for all residents to have a full meal. (continued on 9099C) Unsubstantiated (continued from 9099) On 08/29/2026 around dinner preparation time, the cook was injured and had to leave for the day. The facility provided residents with an alternative meal which according to staff consisted of 10 large pizzas, 8 slices each pizza, bread sticks, salad and Ice cream. LPA interviewed six 6) staff, and all six (6) staff denied the allegation. Some staff stated there was enough pizza left over for staff to eat some pizza as well. LPA interviewed seven (7) residents and five (5) of seven (7) residents could not corroborate the allegation. Two (2) residents stated that they were not given more that one slice. Five (5) residents stated that they had plenty of pizza and some even had second servings of pizza. According to staff and residents, this was a one-time occurrence. Based on record review and interviews, there is not enough evidence to substantiate this allegation. Allegation: Staff do not ensure residents have an easily accessible, working elevator. It is alleged that one (1) of two (2) elevators is in disrepair for over one (1) year and facility has not taken action to fix it. LPA interviewed six (6) staff and all six (6) staff denied that it has been in disrepair for over a year. LPA interviewed seven (7) residents and all seven (7) stated the elevator was in disrepair. Some residents stated it has been over a year, and several residents did not recall how long. Administrator stated that on May 28, 2026, the elevator on the west side of the facility was flagged and that Administrator called the Otis elevator repair company that same day. The facility was under Brookdale ownership at this time and Administrator stated that she contacted Brookdale as well. Administrator stated she has lost access to those emails since the purchase of the facility by another corporation. LPA was provided with email chain from 06/02/2026 – 06/22/2026 addressing the elevator repair after it was tagged on 05/28/2026. LPA was provided with an email between Administrator and Otis elevator company discussing the installation of relays that were purchased by Administrator dated 06/30/2026. Administrator stated she did not have access to the order confirmation or receipt for those relays. Administrator stated that Otis sent route mechanic to facility on 7/01/2026 to install the relays and what happen is undocumented at this time. According to Administrator, one relay was the wrong one and has been impossible to find. So, the facility is going to take action to modify and modernize the elevator. Facility is going to pay for the modernization and bill Brookdale. (continued on 9099C) (continued from 9099C) It appears that facility has taken action to get the elevator in operating condition, however due to transition of new ownership, documentation of Elevator Service has not been provided since the elevator was tagged on May 28, 2026. Documentation of recent service calls was provided; however, all the service calls were prior to the elevator being tag out of order on 05/28/2026. According to Administrator, the elevator having issues before the total breakdown and those are the ten (10) service calls from 04/22/2026 to 05/04/2026 that were made during that time. There are twenty-one (21) residents with wheelchairs on the second floor, and the elevator can only handle one wheelchair at a time. There are also nineteen (19) residents with walkers that reside on the second floor. The elevator can accommodate 2 or 3 residents with walkers at same time. The inconvenience to the residents is waiting to access the elevator during mealtimes. Some staff stated that it is an inconvenience to get all the residents down safely and in timely manner since the facility only has one elevator working. Since the facility has at least one elevator that is operating properly, the department cannot substantiate this allegation. Based on interviews and record review, the finding indicates that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted with Wellness Director Denise Bartley. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 22, 2026 · control 28-AS-20260918101724

Type of visit: Case Management - Other

LPA observed west side elevator in disrepair while taking tour of facility during visit. Technical Violation issued. 87303 Maintenance and Operation (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. Elevator on west side is in disrepairthe state’s words, verbatim · CDSS document, Sep 22, 2026

Allegation investigated: Residents are not free to individually contract with their own hospice or home healh providers.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegation. The purpose of the visit was discussed with Executive Director Chanel Sanchez. The investigation consisted of: Resident files and roster was reviewed. Executive Director was interviewed. The complaint alleges the facility informed a resident’s family that their hospice agency provider would have to be discontinued so the resident could switch to the facility hospice agency choice. Based on record review and interview with Executive Director, the findings indicate the resident addressed in this complaint does not reside at this facility. This facility was formerly called Brookdale Central Whittier. There is another facility with a similar name nearby called Brookdale Uptown Whittier. LPA called the facility and confirmed the resident addressed in this complaint lives there. Therefore, the allegation is unfounded. An exit interview was conducted with Chanel Sanchez. A copy of the report was issued. Unfoundedthe state’s words, verbatim · CDSS document, Sep 3, 2026 · control 28-AS-20260901194510

Allegation investigated: Facility staff are interfering with resident's sleep.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegation. The purpose of the visit was discussed with Executive Director Chanel Sanchez. The investigation consisted of: The physical plant was toured. Relevant records were reviewed and obtained, and interviews were conducted with staff (S1-S6) and residents (R1- R10). *Report continues on LIC9099C. Unsubstantiated Allegation: Facility staff are interfering with resident's sleep. It is alleged that on July 19, 2026 at 2:20 AM a care staff knocked on the door, woke up the resident, and entered the room to take out the trash. The complaint alleges staff are not properly trained because they do not know the difference between an independent resident and one that requires supportive care. A total of six (6) staff were interviewed. All staff denied the allegation. According to staff interviews, staff are not supposed to check on independent residents, unless there are any condition changes. Staff interviews revealed that resident room trash is picked up at least once a shift or more often, such as when incontinence briefs are changed. Staff start their shift by conducting resident checks, and resident that are more independent are not typically disturbed in the middle of the night. Staff acknowledged 2:20 AM is an unreasonable time for night shift staff to enter a resident's room to take out the trash. A total of 10 residents were interviewed. Four (4) out of 10 residents stated night shift staff has occasionally interrupted their sleep between the hours of 2 AM - 3 AM by entering their rooms to take out the trash. However, residents stated they were isolated incidents. Interviews revealed that there have been issues in the past about staff entering rooms at night and disrupting the sleep of independent residents. The issue was last addressed during the June 2026 Resident Council meeting. It was reported that sometimes staff pick-up the trash late or postpone trash pick-up because of an emergency during the shift. Based on interviews and record review, the finding indicate that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Executive Director Chanel Sanchez. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 28-AS-20260722123223

Allegation investigated: The facility did not address resident council concerns.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegation. The purpose of the visit was discussed with Executive Director Chanel Sanchez. The investigation consisted of: On 6/4/2026, a physical plant inspection and record review was completed. Copies of resident (R1's) file documents,acivities calendars, and staff and resident rosters were obtained. Three staff were interviewed. A total of seven staff and eight residents were interviewed today. Kitchen diet order were reviewed and additional records were reviewed. *Narrative continues on LIC 9099C. Substantiated Allegation: The facility did not address resident council concerns. It is alleged that the resident council did not obtain a response in writing regarding the May 20, 2026 Resident Council Meeting Minutes. During the first facility visit (June 4, 2026), resident council documents were obtained. The May 20, 2026, Resident Council Meeting Minutes did not have an attached "Concern Form" indicating management provided a response to the resident council within 14 calendar days. During today's visit, a copy of the written response was obtained. The response is not dated and the date it was provided to the resident council cannot be confirmed. June 3, 2026 was the 14 calendar day from the May 20, 2026 resident council meeting. Based on record review, on June 4, 2026 no documentation was provided to LPA showing a written response had been provided to the resident council. Therefore, there is sufficient evidence to support the allegation. Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiency was cited. An exit interview conducted, copy of the report and appeal rights was provided to Executive Director Chanel Sanchez. Allegation: Staff did not meet resident's diabetic needs. It is alleged that on May 19, 2026, resident (R1) asked night shift staff for orange juice in order to adjust diabetic blood sugar levels, but the resident was told that care staff did not have any orange juice. A total of seven staff were interviewed. All staff denied the allegation. According to staff interviews, night shift staff stated they did not refuse to provide orange juice to R1. Staff said that the facility always has sufficient supply of orange juice that is accessible to all care staff 24 hours a day. The 1st floor storage room has a supply of juice that is accessible to all staff. Staff stated that the medication room carts and medication cart have small orange juice containers. Multiple attempts to interview resident (R1) were made. However, R1 did not respond. A total of eight residents were interviewed. Two (2) out of eight (8) resident said that they have asked staff for orange juice and they were not provided any. The kitchen, medication room, and medication carts were inspected. They all have ample juice supply. The kitchen has a binder with diet orders and a bulletin board. The bulleting board needs to be updated, but the binder has physician orders. There is insufficient information to support the allegation. Allegation: Staff did not treat residents with respect. The complaint alleges that staff do not treat residents with respect. It was reported that on one occasion a resident called staff for incontinence assistance and the care partner told the resident to "just go" in their diaper because they could not attend the resident at that moment. Additionally, it is alleged that staff are dismissive and disrespectful when addressing resident's concerns at resident council and town hall meetings. All staff denied the allegation. They stated all residents are treated with respect and have no knowledge of any staff mistreating residents. Staff said that there have several occasions where residents have been disrespectful and aggressive towards staff. A total of eight residents were interviewed. One (1) out of eight (8) residents said they are are not treated with dignity and respect. There is insufficient information to support the allegation. See LIC 9099C Allegation: Facility does not provide activities to residents as advertised. It is alleged that on June 2, 2026 an "Activities Chat" was scheduled at 10:30 AM, and the Resident Engagement Coordinator did not show up to the meeting/activity. According to information obtained, seven residents waited 30 minutes for staff. They notified management, and were then told that the Resident Engagement Coordinator called off. The majority of residents stated they have no issues with activities and confirmed activities are posted and followed, with some exceptions. Staff interviews revealed that the receptionist or business office manager assist with activities if needed. However, on June 2, 2026 no staff attended the scheduled activity. The receptionist stated they start their shift at 10:30 AM, and on the day of the incident they were not informed the Resident Engagement Coordinator had called off. Residents informed front office staff that the activity did not occur because no staff attended. A posted activity calendar was observed. LPA reviewed Community Connections June 2026 Calendar. The "Activities Chat" is listed/scheduled for 10:30 AM. Due to unforeseen circumstances, on June 2, 2026, the staff responsible for the scheduled activity did not work that day. The following day a sign was posted with the rescheduled Activities Chat information. The facility provides an activity calendar and overall adheres to the scheduled activities. There is insufficient evidence to support the allegation. Based on interviews and record review, the finding indicate that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Executive Director Chanel Sanchez. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 3, 2026 · control 28-AS-20260603103725

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.157(c) · Plan of correction due date: Jul 24, 2026

Resident-oriented facility council. If a resident council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response to those concerns or recommendations within 14 calendar days. This requirement was not met evidenced by: Based on record review, the resident council had a meeting on May 20, 2026. On June 4, 2026 LPA obtained copies of the Resident Council Meeting Minutes. No proof of a written response was provided to LPA on that day. The response obtained today is not dated. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 3, 2026

Plan of correction: Executive Director agreed to submit a written plan of correction addressing resident council written responses.

Allegation investigated: Resident sustained pressure injuries due to staff neglect Staff are not meeting residents bathing needs Staff not meeting residents needs

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 06/08/2026 to deliver findings related to the above allegation. LPA met with Administrator Channel Rodriguez and explained the purpose of the visit. Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 06/08/2026 to deliver findings related to the above allegation. LPA met with Administrator Chanel Sanchez and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, R1's face sheet, R1's Admissions Agreement, Pre-Admission Appraisal, records from SCAN Health Plan (including wound care documentation), caregiver notes, bathing schedule, the facility's wound care procedures, R1's Facility Care Assessment, MAR's records and any available medical records related to the reported pressure injuries. LPA conducted interviews with five residents (R1–R5), six staff members (S1–S7), and one witness (W1). Additionally, LPA toured the facility and observed R1's bedroom, as well as the bedrooms of residents R2 through R5. (Continued on LIC 9099C) Unsubstantiated Allegation: Resident sustained pressure injuries due to staff neglect It is alleged that R1 sustained pressure injuries due to staff neglect. During R1's interview, R1 reported noticing sores on their back approximately one week prior to the interview after experiencing itching and scratching the affected areas. R1 stated that staff later bandaged the wounds and that a physician from SCAN Embrace prescribed a topical cream to be applied twice daily. R1 reported that the cream had not consistently been applied as ordered. During resident interviews, Residents R2 through R5 reported having no concerns regarding the care and supervision provided by facility staff. The residents stated that staff are responsive to their requests for assistance and regularly check on residents with higher care needs. The residents acknowledged that staff response times may occasionally be delayed due to staff being busy; however, they reported that staff ultimately provide the requested assistance. During staff interviews, staff consistently reported that R1 requires extensive assistance with mobility, incontinence care, and other activities of daily living. Staff stated that R1 is repositioned every two hours to prevent skin breakdown; however, some staff reported that R1 frequently declined repositioning despite encouragement and education regarding the importance of changing positions. Staff indicated that the facility became aware of the reported sores approximately one week prior to the interviews. Staff further reported that R1's bed had recently been changed from a regular bed to a hospital bed to improve repositioning efforts and facilitate the provision of care. Additionally, staff reported that medical consultation was obtained and treatment measures were implemented. Several staff members expressed the belief that the affected areas were irritation associated with scratching rather than pressure sores. During witness interviews, W1, a physician familiar with R1 who last evaluated R1 on 06/08/2026, reported that the facility promptly notified the medical team regarding skin redness and possible pressure sores on 06/01/2026. W1 stated that a nurse practitioner assessed R1 and determined that the areas represented erythema rather than pressure injuries. W1 further reported having no concerns of neglect related to skin care or pressure injury prevention. Allegation: Staff are not meeting residents bathing needs It is alleged that staff are not meeting R1's bathing needs. During R1's interview, R1 reported that they are scheduled to receive bathing assistance on Tuesdays and Saturdays. However, R1 stated that for approximately four to five weeks, they did not receive one of their scheduled Tuesday baths. R1 denied refusing bathing assistance and reported that staff informed her that a caregiver had forgotten to provide the bath. R1 further stated that staff did not begin cleaning their back until they reported concerns regarding sores. During resident interviews, Residents R2 through R5 reported having no concerns regarding the facility meeting their bathing and personal hygiene needs. The residents stated that they are routinely offered bathing assistance and denied going extended periods without being offered hygiene services. Although the residents noted that staff responses may occasionally be delayed due to staff being busy, they reported that staff ultimately provide the requested care. (continued on 9099C) During staff interviews, staff reported that R1 is scheduled to receive bathing assistance twice weekly. While some staff reported that R1 had refused bathing assistance on occasion, other staff stated that R1 had not refused baths while under their care. Staff further reported that bathing refusals are communicated to medtechs and documented. During witness interviews, W1, a physician familiar with R1's care, reported having no concerns regarding the facility's provision of hygiene services. W1 stated that the facility has maintained ongoing communication with the medical team regarding R1's care needs and had sought assistance in addressing R1's hygiene practices. W1 further reported that no concerns of neglect related to bathing or personal care had been reported to or observed by the medical team. Allegation: Staff not meeting residents needs. It is alleged that staff are not meeting R1's needs by failing to maintain R1's room in an organized manner, resulting in R1 not having access to necessary personal items. During R1's interview, R1 reported that after their regular bed was replaced with a hospital bed, many of their personal belongings were moved and left disorganized throughout the room. R1 stated that tjhey have difficulty accessing items they need and reported that while some caregivers assist them in locating belongings, others decline to help. During resident interviews, Residents R2 through R5 reported having no concerns regarding their ability to access personal belongings and indicated that staff assist them with their needs when requested. The residents noted that staff may occasionally take longer to respond due to being busy; however, they ultimately provide assistance. During staff interviews, staff reported that caregivers assist residents with organizing their rooms and personal belongings when needed. S1 reported that R1 has accumulated a significant number of personal belongings in her room and frequently orders additional items, making organization more difficult. S1 further stated that the facility had been planning to work with R1 to create additional space and improve the organization of her belongings. S6 reported that although their duties include cleaning residents' rooms, caregivers are responsible for assisting residents with organizing personal belongings when necessary. Staff further reported that R1 had not expressed concerns regarding the organization of their room or requested assistance with organizing their belongings. During the tour of the facility, LPA observed that R1's room required some organization; however, the room was not observed to be dirty or unsanitary. The bedrooms of residents R2 through R5 were observed to be clean and well-organized. Based on the investigation conducted, which included interviews with staff, witnesses, and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 9, 2026 · control 28-AS-20260605085519

Allegation investigated: Resident sustained pressure injuries due to staff neglect Staff are not meeting residents bathing needs Staff not meeting residents needs

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 06/08/2026 to deliver findings related to the above allegation. LPA met with Administrator Channel Rodriguez and explained the purpose of the visit. Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 06/08/2026 to deliver findings related to the above allegation. LPA met with Administrator Chanel Sanchez and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, R1's face sheet, R1's Admissions Agreement, Pre-Admission Appraisal, records from SCAN Health Plan (including wound care documentation), caregiver notes, bathing schedule, the facility's wound care procedures, R1's Facility Care Assessment, MAR's records and any available medical records related to the reported pressure injuries. LPA conducted interviews with five residents (R1–R5), six staff members (S1–S7), and one witness (W1). Additionally, LPA toured the facility and observed R1's bedroom, as well as the bedrooms of residents R2 through R5. (Continued on LIC 9099C) Unsubstantiated Allegation: Resident sustained pressure injuries due to staff neglect It is alleged that R1 sustained pressure injuries due to staff neglect. During R1's interview, R1 reported noticing sores on their back approximately one week prior to the interview after experiencing itching and scratching the affected areas. R1 stated that staff later bandaged the wounds and that a physician from SCAN Embrace prescribed a topical cream to be applied twice daily. R1 reported that the cream had not consistently been applied as ordered. During resident interviews, Residents R2 through R5 reported having no concerns regarding the care and supervision provided by facility staff. The residents stated that staff are responsive to their requests for assistance and regularly check on residents with higher care needs. The residents acknowledged that staff response times may occasionally be delayed due to staff being busy; however, they reported that staff ultimately provide the requested assistance. During staff interviews, staff consistently reported that R1 requires extensive assistance with mobility, incontinence care, and other activities of daily living. Staff stated that R1 is repositioned every two hours to prevent skin breakdown; however, some staff reported that R1 frequently declined repositioning despite encouragement and education regarding the importance of changing positions. Staff indicated that the facility became aware of the reported sores approximately one week prior to the interviews. Staff further reported that R1's bed had recently been changed from a regular bed to a hospital bed to improve repositioning efforts and facilitate the provision of care. Additionally, staff reported that medical consultation was obtained and treatment measures were implemented. Several staff members expressed the belief that the affected areas were irritation associated with scratching rather than pressure sores. During witness interviews, W1, a physician familiar with R1 who last evaluated R1 on 06/08/2026, reported that the facility promptly notified the medical team regarding skin redness and possible pressure sores on 06/01/2026. W1 stated that a nurse practitioner assessed R1 and determined that the areas represented erythema rather than pressure injuries. W1 further reported having no concerns of neglect related to skin care or pressure injury prevention. Allegation: Staff are not meeting residents bathing needs It is alleged that staff are not meeting R1's bathing needs. During R1's interview, R1 reported that they are scheduled to receive bathing assistance on Tuesdays and Saturdays. However, R1 stated that for approximately four to five weeks, they did not receive one of their scheduled Tuesday baths. R1 denied refusing bathing assistance and reported that staff informed her that a caregiver had forgotten to provide the bath. R1 further stated that staff did not begin cleaning their back until they reported concerns regarding sores. During resident interviews, Residents R2 through R5 reported having no concerns regarding the facility meeting their bathing and personal hygiene needs. The residents stated that they are routinely offered bathing assistance and denied going extended periods without being offered hygiene services. Although the residents noted that staff responses may occasionally be delayed due to staff being busy, they reported that staff ultimately provide the requested care. (continued on 9099C) During staff interviews, staff reported that R1 is scheduled to receive bathing assistance twice weekly. While some staff reported that R1 had refused bathing assistance on occasion, other staff stated that R1 had not refused baths while under their care. Staff further reported that bathing refusals are communicated to medtechs and documented. During witness interviews, W1, a physician familiar with R1's care, reported having no concerns regarding the facility's provision of hygiene services. W1 stated that the facility has maintained ongoing communication with the medical team regarding R1's care needs and had sought assistance in addressing R1's hygiene practices. W1 further reported that no concerns of neglect related to bathing or personal care had been reported to or observed by the medical team. Allegation: Staff not meeting residents needs. It is alleged that staff are not meeting R1's needs by failing to maintain R1's room in an organized manner, resulting in R1 not having access to necessary personal items. During R1's interview, R1 reported that after their regular bed was replaced with a hospital bed, many of their personal belongings were moved and left disorganized throughout the room. R1 stated that tjhey have difficulty accessing items they need and reported that while some caregivers assist them in locating belongings, others decline to help. During resident interviews, Residents R2 through R5 reported having no concerns regarding their ability to access personal belongings and indicated that staff assist them with their needs when requested. The residents noted that staff may occasionally take longer to respond due to being busy; however, they ultimately provide assistance. During staff interviews, staff reported that caregivers assist residents with organizing their rooms and personal belongings when needed. S1 reported that R1 has accumulated a significant number of personal belongings in her room and frequently orders additional items, making organization more difficult. S1 further stated that the facility had been planning to work with R1 to create additional space and improve the organization of her belongings. S6 reported that although their duties include cleaning residents' rooms, caregivers are responsible for assisting residents with organizing personal belongings when necessary. Staff further reported that R1 had not expressed concerns regarding the organization of their room or requested assistance with organizing their belongings. During the tour of the facility, LPA observed that R1's room required some organization; however, the room was not observed to be dirty or unsanitary. The bedrooms of residents R2 through R5 were observed to be clean and well-organized. Based on the investigation conducted, which included interviews with staff, witnesses, and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 9, 2026 · control 28-AS-20260605085519

Allegation investigated: Staff did not notice a change in a resident's condition, resulting in death Staff did not seek timely medical attention for resident Staff humiliated resident

Licensing Program Analyst (LPA) Herrera conducted a subsequent complaint visit to investigate the above allegations. LPA met with Executive Director Chanel Sanchez and the purpose of the visit was discussed. The investigation consisted of: On 4/1/26 LPA conducted initial visit and obtained copies of Staff/Resident Rosters, copies of the following documents within Resident #1 (R1’s) file: Death Report, Facility Nurse Charting Notes, Face Sheet, Hospice Collaborative Notes, Medication List, Physician’s Report; and conducted 2 staff (S2-S3) interviews. On 4/7/26 LPA conducted 6 Staff interviews via phone call. On 4/14/26 LPA was provided with a copy of R1's death certificate via email. During todays visit 4/23/26 LPA interviewed 6 Residents (R2-R7) and delivered findings on the reported allegations. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff did not notice a change in a resident's condition, resulting in death. It is alleged that R1 was observed in the dining area with blue hands, did not appear well enough to sit at the dining room table to eat and emergency personnel was not called. LPA reviewed R1’s files and facility records, there were observations a caretaker made in the dining on 3/27/26 at approximately 4:38pm that detailed R1 had unsteady gait, was leaning forward, trembling and did not seem able to feed himself, documented on charting note. There were no other drastic changes documented. Other notes indicated that on 3/27/26 at 5:34am R1 needed assistance with reinserting their catheter, at 8am a hospice nurse arrived to assist and reinserted the catheter, there were no notes stating a decline in condition. LPA reviewed R1’s Death Certificate it did not list a suspicious cause of death, additionally there are no other agencies that are further investigating R1’s death. LPA interviewed 8 staff and each denied the allegation, S4-S8 stated that they had been assigned to R1 the week leading up to R1’s passing and R1 appeared to be well, responsive, and able to eat. Interview with S1 revealed that they noticed the decline while R1 was in the dining at approximately 4:30pm on 3/27/26 and they called the MedTech to assess the resident, resident was still able to respond at this time, however, R1 did appear to have unsteady gait, was leaning forward, trembling, and did not appear to be able to feed themselves, therefore, hospice was called and a nurse arrived by 5:57pm to assess R1. LPA interviewed 6 Residents and each denied the allegation and stated they are checked on at least 4-6 times daily and if they are looking ill or not hungry staff will ask them questions to make sure they are fine. Allegation: Staff did not seek timely medical attention for resident. It is alleged that staff did not assess R1 after observations of R1 appearing unwell and instead waited for Hospice to arrive rather than calling 911 for assistance. LPA reviewed R1’s files and facility records, the sign in sheet indicated that hospice nurse arrived at 8am to check on R1 3/27/26, the communication log documented the purpose for the visit was to reinsert the R1's catheter and order urine bags, there were no observations of resident needing immediate medical attention noted. At approximately 4:38pm R1 was observed to have unsteady gait, leaning forward and trembling, Hospice was contacted and arrived by 6:40pm that evening, R1 was then placed on Continuous Care Treatment where a Hospice Nurse was scheduled to be by R1’s side at all times. R1 passed on 3/28/26 at 8:16pm and the assigned Continuous Care Nurse and R1’s POA were that the bedside at time of passing. LPA interviewed 7 staff and each stated that when it comes to residents on hospice the hospice agency is called first, the residents symptoms are explained and the Hospice Nurse will advise if 911 is to be called or to wait for the nurse to arrive. Staff stated that if it appears the resident needs immediate attention 911 will can be called immediately. Interview with S1 revealed that 911 was not called as during the observation of R1s change of condition as R1 was still responsive and it did not appear to be an immediate emergency, therefore, hospice was called. LPA interviewed 6 Residents and each denied the allegation, R2 and R3 stated that sometimes the staff may delay on responding in a timely manner to their call button but that is because staff may be busy attending to other residents. (Continued on LIC9099-C) Allegation: Staff humiliated resident. It is alleged that staff humiliated R1 by taking them to the dining for a meal with fellow residents even though R1 was unable to lift their head, speak, or respond to (no/yes) questions posed by staff. LPA interviewed 7 staff and each denied the allegation and stated they have never humiliated a resident, and stated that if a resident was experiencing these symptoms they would contact the MedTech to assess the resident immediately and try to keep the resident in their room for comfort and safety until the symptoms subside or they are provided with the appropriate care. S1 stated that the observations of R1 leaning forward and unable to feed themselves happened in the dining, they immediately called a MedTech to assess the resident and then called hospice, S1 stated they did not take R1 to the dining with any intention to humiliate them as R1 had said they were fine and wanted to go to dinner in the dining room. LPA interviewed 6 Residents and each denied the allegation and stated that they have never felt humiliated by staff and have not seen other residents humiliated by any of the staff. Based on statements and interviews conducted with staff/residents, and review of R1's files, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 28-AS-20260330101803

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. LPA met with Executive Director Chanel Sanchez. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. The following were observed/inspected: Infection Control: The Infection Control Plan includes Environmental cleaning and disinfection activities. Operational Requirements: The facility has a hospice waiver for 8 residents. A fire clearance for 85 non-ambulatory residents; of which 7 may be bedridden is in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 12/31/2026. The facility does not handle residents' monies. Physical Plant/Environment Safety: The facility is comprised of a 2-story building consisting of 73 resident rooms, 2 activity rooms, beauty salon, dining room, laundry room, and a courtyard patio area. The interior and exterior physical plant was inspected. The interior and exterior physical plant was inspected. A total of 22 randomly selected resident rooms were inspected. The signal system was tested and is operational. Residents use a pendant alert system and bathrooms are equipped with emergency pull cord alert system. Beds have required bedding, linens, and mattress pads. The signal system was tested and is operational. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. Cleaning supplies and toxic substances are inaccessible to residents. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Exit doors are free of any obstruction. There are surveillance cameras in common areas. The last fire inspection was conducted on 2/25/2026 by the County of Los Angeles Fire Department. *Five rooms had beds that did not have mattress pads. Staffing: A total of 33 staff members provide care and supervision of residents. Personnel Records/Staff Training: Administrator certificate expires 7/6/2027. Staff have criminal background clearance. Eight staff files were reviewed. They contained 1st Aid/CPR training, criminal background clearance, health/TB screenings, 1st Aid/CPR training, and training records. Resident Records/Incident Reports: Six (6) resident files were reviewed. They contained Admission Agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and centrally stored medication records. Resident (R5's) file did not have an updated LIC602. Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed. RCFE & Ombudsman complaint posters are posted. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have physician orders for modified diets. A diet list was observed in the kitchen. Kitchen personnel have current food handling certificates. The refrigerator tray had blood from a ground beef bag. A citation was issued. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or facility van. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 3/4/2026. Residents with Special Health Needs: There are currently 4 residents receiving hospice services, 6 residents receive home health services, and no residents have prohibited health conditions. Individual Service Plans, Appraisals, and postural support physician orders are on file. Pursuant to Title 22, deficiencies were observed and are cited. Exit interview was conducted with Executive Director Chanel Sanchez. A copy of report and appeal rights were issued.the state’s words, verbatim · CDSS document, Apr 21, 2026

Allegation investigated: Staff do not provide accommodation for residents’ needs.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegation. The purpose of the visit was discussed with Executive Director Chanel Sanchez. The investigation consisted of: A physical plant inspection of bathroom toilets in resident rooms and public restrooms was conducted. Five (5) staff and 11 residents were interviewed. A copy of LIC 500 Personnel Report and resident roster was obtained. Pictures were taken of observations. *Report continues next page. Substantiated Allegation: Staff do not provide accommodation for residents’ needs. It is alleged that the residents’ bathroom toilets are too small and too low and residents are struggling because it is hard for them to stand up and sit because their legs are weak. It was further alleged that when residents wipe and attempt to remove their hand out of the toilet bowl their hands get stuck and get scraped. A total of 11 residents were interviewed. Six (6) out of 11 residents stated the toilets are too low, and that there is no toilet grab bar. Per staff interviews, they have not heard residents complain about toilet size, but during the physical plant inspection staff observed there are different toilet sizes ranging from 15 inches to 17 inches, and for some residents a 15 inch toilet is too low to get up from. Staff said the residents are evaluated to determine functional capabilities prior to getting a toilet riser. The facility does not provide specialized equipment like shower chairs, toilet risers or elevated plastic toilet risers for residents needing assistance. Staff stated that if a resident cannot buy the specialized equipment, then they may provide a sanitized extra toilet riser that is stored in the facility. During the visit, LPA checked 36 resident room toilets and the public restroom toilet. The majority of the resident rooms toured did not have toilet grab bars. Observations revealed that toilet grab bars for sit-to-stand transfers are not installed in resident bathrooms. Picture were taken. The allegation is supported. Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiency was cited. An exit interview conducted, copy of the report and appeal rights was provided to Executive Director Chanel Sanchez.the state’s words, verbatim · CDSS document, Apr 2, 2026 · control 28-AS-20260330094422

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(4) · Plan of correction due date: Apr 30, 2026

Maintenance and Operation. Grab bars shall be in each toilet, bathtub and shower used by residents. This requirement was not met evidenced by: This deficiency was evidenced by the following: A total of 36 resident rooms and public restroom were toured. There were no grab bars near the toilets. There is a non-ambulatory and bedridden fire clearance. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Apr 2, 2026

Plan of correction: Facility shall ensure all toilets used by residents have grab bars installed. Submit proof of correction.

Allegation investigated: Staff embarrassed and humiliated a resident.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegations. The purpose of the visit was discussed with Executive Director Chanel Sanchez. The investigation consisted of: LPA reviewed documents and interviewed 7 staff and 10 residents. Two (2) resident records [Admission Agreement, Preplacement Appraisal, Assessment Summary], Resident Council Meeting (2/18/26), Care Partner job description, LIC 500 Personnel Report, resident roster, and Resident's Policy and Care Plan Description were obtained. *Narrative continues next page. Substantiated Allegation: Staff embarrassed and humiliated a resident. It is alleged that on February 25, 2026, during the Town Hall meeting the Health & Wellness Director embarrassed and humiliated resident (R1) in front of residents and staff in attendance by responding inappropriately to the resident's concern regarding staff not putting away incontinence wipes in the closet. Resident (R1) stated the staff member's response was humiliating and dismissive. Based on staff and resident interviews, during the town hall meeting R1 addressed to Administration staff concerns brought up during the previous week's resident council meeting. For instance, R1 informed Administration staff that staff had been leaving incontinence wipe packs on the floor, and expressed that staff should put them away in the closet to afford residents dignity. The findings indicate that the Wellness Director's response was inappropriate because they told R1 that family should assist with that, and that care staff are not obligated to do things for residents that they are not paying for. Interviews revealed, that R1 felt humiliated and began to cry in front of all in attendance. Therefore, the allegation is supported. Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiency was cited. An exit interview conducted, copy of the report and appeal rights was provided to Executive Director Chanel Sanchez. Allegation: Staff did not afford a resident privacy. It is alleged that overnight staff did not afford R1 privacy because they entered the room to take out the bathroom trash in the middle of the night, but the resident is independent and does not require night checks. A total of 11 residents were interviewed. Resident (R1) stated the overnight staff person entered the room without permission, did not check on the resident, and collected the bathroom trash and left, which caused sleep disturbance. A total of 10 residents were interviewed, of which 3 residents stated that staff enter the rooms at night to empty out the trash, and it disturbs their sleep. All staff denied the allegation. They stated that there was a recent incident in which a medication technician staff covered an overnight shift, and they checked in on all residents, and took the trash out of the rooms. Staff stated night shift are responsible for checking in on residents that require night checks due to incontinence care and/or other needs, and respond to call lights, and clean. All staff stated the aforementioned incident was an isolated incident, and staff always knock prior to entering a resident's room and always respect resident's privacy. There is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Executive Director Chanel Sanchez. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 28-AS-20260302104128

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

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met evidenced by: During the 2/25/2026 Town Hall meeting, resident (R1) was humiliated by a staff person when they brought up incontinence wipes packs being left out and not put away by staff. This poses a potential health, safety, and personal risk to persons in care.the state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: Executive Director agreed to provide Personal Rights and Price Schedule training to Administration and caregiver staff. Submit proof of training.

Allegation investigated: Staff are inappropriately charging residents for basic services.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegation. The purpose of the visit was discussed with Executive Director Chanel Sanchez. The investigation consisted of: File/record review, physical plant inspection of the facility, and interviews. Seven (7) staff and 11 resident interviews. Copies of Price Schedule, Escort Policy, Wheelchair Assist Policy, Service Plan Process Policy, LIC 500 Personnel Report, resident roster, and two resident's assessment summaries and service plans were obtained. *Report continues next page. Unsubstantiated Allegation: Staff are inappropriately charging residents for basic services. The complaint alleges that facility staff does not assist in pushing residents in a wheelchair as needed to ambulate within the facility, unless the resident(s) pay an extra fee. A total of 7 staff were interviewed. Staff stated that wheelchair bound residents are charged for escort & mobility assistance to the dining room and/or to participate in community activities, if their Personal Service Plan indicates they require assistance. However, not all wheelchair bound residents pay for escort services, but staff assist with escort assistance if they are not feeling good and staff are available during dining meal services. All staff denied the allegation. A total of 11 residents were interviewed. One (1) out of 11 stated they are overcharged for wheelchair assistance and they believe it should be part of the basic services offered. Per record review, Brookdale Price Schedule is determined by the service needs of residents; and personal services are a-la-carte charges. Two resident records were reviewed, no discrepancies in their Assessment Summary and Personal Service Plan was noted. Therefore, the allegation cannot be supported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Executive Director Chanel Sanchez. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 28-AS-20260312093456

Allegation investigated: Staff do not ensure that facility is maintained at a comfortable temperature for residents. Staff do not ensure the facility is free of tripping hazards.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Interim Executive Director Mario Preston and new Executive Director Chanel Sanchez. The investigation consisted of: On 5/23/25, a physical plant inspection of common areas and 7 resident rooms was conducted. Staff (S1- S4) and resident (R1) were interviewed. LPA reviewed documents. Relevant complaint copies were obtained. During today's visit, staff (S5- S6) and residents (R2-R8) were interviewed. During today's visit, a total of 13 2nd floor rooms were inspected. Copies of an incident report pertaining to a fall in the dining room was obtained. *Report continues next page. Substantiated Allegation: Staff do not ensure that facility is maintained at a comfortable temperature for residents. The complaint alleges the air conditioning in residents rooms on the second floor and in the dining room is set too cold and residents complain about being uncomfortably cold. A total of eight residents were interviewed. The majority of the residents interviewed live in the 2nd floor. Three (3) out of eight (8) residents stated the air conditioning in their room was set too low and as a result they were uncomfortably cold. Maintenance staff closed the vents in the room. Per staff interviews, typically the facility temperature is set between 72-74 DF. On 5/23/2025, a physical plant inspection was conducted with Administrator Logan Harrison's assistance. The common areas and dining room were comfortable in temperature. However, 4 out of 7 rooms inspected on the 2nd floor were cold, below 72 DF. Room #207's room temperature measured 62 DF, and rooms 209, 211, and 215 were cold below 72 DF. The findings indicate that room temperature in some of the 2nd floor rooms is controlled by the thermostat in room 207. During today's visit, LPA checked a total of 13 rooms. The temperature in the rooms was within required temperature range. However, there is sufficient evidence to support the allegation. Allegation: Staff do not ensure the facility is free of tripping hazards. It is alleged that a resident fell in the dining room because of uneven flooring. Three (3) out of eight (8) residents confirmed R2 fell in the dining room. Staff interviews confirmed that on April 29, 2025, at approximately 12:30 PM, resident (R2) fell while dancing and walking in the dining room. The incident resulted in a femur fracture and surgery. Staff confirmed some areas in the dining room have peeling laminate flooring. Based on physical plant observations on 5/23/25 and today, the findings indicate the center left flooring in the dining room has a section of raised laminate flooring of approximately 7 inches that poses a tripping hazard. Pictures were taken during the visits. As of today, the flooring has not been repaired. Interim Administrator stated contractors will be coming to the facility in the next couple of weeks to evaluate the flooring issue and determine a repair plan. There is sufficient evidence to support the allegation. Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiency was cited. An exit interview conducted, copy of the report and appeal rights was provided to Interim Executive Director Mario Preston. Allegation: Staff speaks inappropriately to residents. It is alleged that there is a caregiver that talks down to people and argues with residents. According to information obtained, residents are afraid and intimidated with caregiver/staff (S1). A total of 8 residents were interviewed. One out of eight residents stated S1 said to them to mind their own business and shut up, when the resident asked S1 to bring another resident their sweater because the dining room was too cold. Staff (S1) denied the allegation, and stated that on the contrary, a Sunday in May 2025 a resident yelled at S1 called them derogatory names in front of residents in the hallway by the dining room. All staff denied the allegation. The majority of the residents interviewed stated staff (S1) is respectful, treats residents well, and the staff person has never spoken to them inappropriately. Allegation: Staff interacts with residents in an inappropriate manner. The complaint alleges that caregiver/staff (S1) rubbed resident (R1's) back and shoulders when they were standing near the front desk. According to information obtained, the physical touch was unwelcome. One (1) out of eight (8) residents stated that in April 2025, they were at the front desk and S1 came from behind and rubbed their shoulders, which made them feel uncomfortable and shocked, but it was not reported to Administration staff. The majority of residents interviewed stated they have not been inappropriately touched by S1 or any other staff. All staff interviewed denied the allegation. Staff (S1) stated that R1 does not receive any assistance with activities of daily living and is independent, and there has been no physical contact with R1's shoulders. Administration staff looked into the allegation, and determined that S1 may have in the past pat R1's back in passing, but nothing more than that. Per staff interviews, Brookdale policy allows staff to pat residents in the back and hug them if the resident welcomes it. Staff also stated that some residents ask staff for a hug and/or like a pat in their back. All staff stated that if and when a resident is touched it is appropriate. Allegation: Staff do not ensure elevators are in good repair. It was reported that one of the facility elevators has not worked since late 2024, early 2025, and the licensee has decided not to fix the elevator because the parts are obsolete. All residents interviewed confirmed the allegation. One (1) out of 8 residents stated that although there is another operable elevator, it is an inconvenience to walk to the working elevator. Staff interviews revealed that the rear elevator has had issues since January 2025, and stopped working completely in March 2025. A work order was put in March 24, 2025. The elevator was evaluated and it was determined the mother board and two cylinders are not working. According to staff, the facility has 2 elevators, and the other elevator closest to the dining room continues to be operable. As of today, the elevator remains inoperable because the parts needed are still at the manufacture level. However, since the facility has one elevator that works, the allegation cannot be supported. Allegation: Staff do ensure resident's room is clean and sanitary. It is alleged that rooms were cleaned once a week, but a new housekeeper staff was hired and they cleaned resident (R1's) room every 2 weeks, and did not wash bed sheets weekly. One (1) out of 8 residents agreed with the allegation. Another resident stated that their room is cleaned once a week, but their sheets are not washed weekly. Staff interviews revealed that light housekeeping is done once a week, and personal belongings and bed linens are laundered once a week. The rooms are cleaned in rotation. According to interviews, a housekeeper/staff (S4), called out a couple of Saturdays, which was R1's room cleaning day. Administrator stated that when a staff person calls off it is communicated to other housekeepers and overtime is offered. During both visits, LPA inspected resident rooms to determine cleanliness and to check the condition of the bed sheets. The rooms were observed clean and bed sheets were not observed dirty. On 5/23/25, S4 was observed cleaning resident rooms, and during today's visit S6 was observed cleaning and washing clothes and bed linens. There is insufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted with Interim Executive Director Mario Preston. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 28-AS-20250520101953

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(2) · Plan of correction due date: Oct 14, 2025

Maintenance and Operation. A comfortable temperature for residents shall be maintained at all times. The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement was not met evidenced by room inspections of 2nd floor rooms conducted on 5/23/25 and today. Room 207's thermostat read 62DF, and the room controls many rooms located in the 2nd floor. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Executive Director stated and agreed to submit proof of completed air conditioning service request.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 14, 2025

Maintenance and Operation. 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 evidenced by: Based on observation, the dining room laminate flooring is raised and in disrepair. This poses a potential health, safety, and personal risk to persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Executive Director stated and agreed to submit picture proof evidence and a copy of the completed work order.

Allegation investigated: Licensee did not follow resident's admission agreement.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit to investigate the allegation above. LPA discussed the purpose of the visit with Business Office Manager Christina Schoech. Interim Executive Director Mario Preston arrived later. The investigation consisted of: On 7/18/2025, six residents and one staff were interviewed. Common areas were inspected. Copies of resident (R1's) file documents were obtained. During today's visit, record review of admission agreement and account history reports, and interviews with three (3) additional staff was completed. *See next page for narrative report. Unsubstantiated Allegation: Licensee did not follow resident's admission agreement. The complaint alleges resident (R1) lived at the facility for a short time and was billed for services not rendered. According to information obtained, upon move-in (Nov. 28, 2023) a $5,500.00 deposit was made, and later in the month of December 2023 an additional $9,962 was invoiced. In February 2024, the resident's shared bank account was billed $27,724.00, and on March 1, 2023 an automatic withdrawal of $9,962.00 was debited from R1's shared bank account. A total of six (6) residents were interviewed. Residents stated they have not had issues with their admission agreement conditions, payment terms, or services provided. Staff interviews revealed that resident (R1) moved in on November 28, 2023 and moved out on March 2, 2024. According to staff, a deposit in the amount of $5,500.00 was placed on December 4, 2023, and a community fee in the amount of $2,500.00 was paid at the end of November 2023. The resident's monthly charges were $9,962.00. According to record review, R1's responsible party directed the facility to do automatic withdrawal for payment of rent and services. Records indicate R1 shared a bank account with another family member, not the responsible party. The facility has listed the responsible party as the Power of Attorney. On March 7, 2024, R1's responsible party was given a credit refund in the amount of $16,499.02. The licensee issued a check to the responsible party on record and followed refund procedures and admission agreement. Therefore, there is insufficient 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 violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Resident Engagement Coordinator Marina Verdugo. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 28-AS-20250711164055

Allegation investigated: Staff did not ensure resident’s room was adequately cleaned. Staff did not ensure resident’s room was free from odors. Staff did not ensure resident’s room was free from pests.

*This report supersedes report created on 5/16/2025. It was created to add additional details. Revision does not change complaint findings. Operations Specialist/Interim Executive Director Mario Preston was explained the purpose of the visit. On 5/16/25, Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with receptionist. Executive Director Logan Harrison arrived later. The investigation consisted of: On 5/16/25, a physical plant inspection of common areas and 17 resident rooms was conducted. Staff (S1- S5) and residents (R1- R11) were interviewed. Copies of R1's Admission Record, Physician's Report, Personal Service Plan, resident roster, and LIC 500 Personnel Report were obtained. LPA took photographs during room inspections. Substantiated Allegation: Staff did not ensure resident’s room was adequately cleaned. It is alleged resident (R1's) room is dirty and cluttered due to hoarding. According to information obtained, entrance into the room is blocked. A total of 17 rooms were inspected during today's visit. Two (2) out of the 17 rooms were dirty and cluttered with furniture and personal belongings. On 5/16/25, Licensing Program Analyst (LPA) inspected R1's room and observed many dead cockroaches, several alive cockroaches, old discarded food on the floor, pet hair, dirty floors, trash throughout the room, and bathroom bathtub full of clothing. According to staff interviewed, staff attempt to clean the resident's room but the resident refuses. Staff stated that housekeeping staff clean resident rooms once a week, and caregivers take out the trash daily every shift. A total of 11 residents were interviewed, of which one (1) stated staff do not clean their room. None of the other residents had concerns. Resident (R1) stated they do not know why staff do not clean their room, but then acknowledged they refuse to allow staff to clean. Per Personal Service Plan dated 5/13/2025, facility staff have not assisted R1 with cleaning, picking up trash, putting clothes away, or dusting floor to remove dog hair. There is sufficient evidence to corroborate the allegation. Allegation: Staff did not ensure resident’s room was free from odors. It is alleged that resident (R1) has a dog in the room that defecates and urinates in the room and there is a "stench" that is smelled from the hallway when the door is opened. Housekeeping and caregiver staff stated R1's pet dog urinates and defecates in the room and confirmed bad odors. According to staff interviews, when the resident moved in pet services were in place, but R1 was able to take the dog out to potty. Therefore, pet services were stopped. Per facility's pet policy when pet services are in place caregivers walk the pet and clean up after the pet(s). Resident (R1) stated their room does not smell like dog feces or urine. None of the 11 residents interviewed stated their rooms have a strong odor. Based on R1's observations of R1's room, a strong odor of urine and feces was smelled. Based on document review, R1's Personal Service Plan "Pet Care" Resident has a dog and needs pet care assistance. Staff are to take dog for walks daily around 8AM, 12 noon, 4 PM, and 8 PM. Staff will monitor pet to see that they are provided adequate food and water. Although, pet services were stopped, in the updated Personal Service Plan dated 5/13/25 it was noted that staff will assist with pet care. Therefore, there is sufficient evidence to support the allegation. Allegation: Staff did not ensure resident’s room was free from pests. It is alleged resident (R1's) is infested with cockroaches and the facility has not addressed the issue. Four (4) out of the 11 residents interviewed stated they have seen cockroaches in their rooms. Resident (R1) stated there are cockroaches "everywhere in my room", but did not report it to Administration staff. A total of 5 staff were interviewed, of which all stated that they did not have knowledge of the cockroach infestation until this week. According to staff interviews, on Tuesday, May 13, 2025, staff went in to R1's room to remove the bed an observed the infestation of cockroaches under the bed. On Wednesday, May 14, 2025, Administration staff called Dewey Pest Control for services. During today's visit, Dewey Pest Control was observed addressing the problem in R1's room. LPA reviewed pest control service contract. They are scheduled to provide services twice a month and/or as needed. Record review revealed that the facility has on-going pest control services in place that focus on common areas, kitchen/dining room, and resident rooms identified in need of pest control mitigation. However, R1's room was not being treated by pest control despite housekeeping staff insight of room uncleanliness i.e. pet food waste. The first pest control room treatment was conducted on 5/16/25. Based on observation, photo evidence, and interviews, there is sufficient evidence to corroborate the allegation. Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. An exit interview was conducted with Interim Executive Director/Operation Specialist Mario Preston. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jun 26, 2025 · control 28-AS-20250512091819

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 26, 2025

Maintenance and Operation. 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 evidenced by: Based on observation, resident (R1's) room is infested with cockroaches. During 5/16/25 visit the room had dead and alive cockroaches, maggots, unswept floors, food on the floor/tables, clutter, and excessive amounts of personal belongings on the floor. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 26, 2025

Plan of correction: Executive Director Harrison agreed to submit a written plan of correction, proof of staff in-service training, pest control service plan for R1's room., and picture proof evidence that R1's room was cleaned. Proof of completed plan of correction was submitted. *Citation is cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(f) · Plan of correction due date: Jun 26, 2025

Maintenance and Operation. All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement was not met evidenced by: Based on physical plant observation and interviews conducted on 5/16/25, R1's room had a strong odor of pet feces and urine. Pet feces was observed in the patio area and pet urine was on R1's room and temporary room. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 26, 2025

Plan of correction: Executive Director Harrison agreed to conduct staff training in regulation 87303, and pet services job responsibilities for applicable staff. Proof of completed plan of correction was submitted. *Citation is cleared.

Allegation investigated: Facility staff do not ensure facility showers are clean and orderly.

Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial visit to investigate the above allegation. LPA met with Valerie Mendez (S-1) and discussed the purpose of today’s visit. Logan Harrison (Executive Director) arrived at approximately 9:20 A.M.. During this visit, LPA obtained a copy of the staff and resident rosters, a list of residents that receive showers in the common shower room (second floor), interviewed Staff #1 (S-1) through Staff # 4 (S-4), interviewed Resident #1 (R-1) through Resident #5 (R-5) and conducted a tour of the second floor common area shower room (with Logan Harrison-Executive Director). Refer to LIC 9099C for the continuation of this report. Substantiated Allegation: Facility staff do not ensure facility showers are clean and orderly. It has been alleged that the second floor common shower needs cleaning, has mildew, fans do not work properly and the vanity is too large. Staff interviews revealed that the second floor common shower is cleaned after every shower provided and that mildew has not been observed. Interviewed staff indicated that residents enjoy the new sink as it has a vanity which provides more space for residents to store their toiletries while using the shower room. (1) out of (4) staff interviews revealed that the fan inside the shower is non-operational. Resident interviews revealed that there are no issues with the second floor common shower other than needing a deep cleaning on the tile grout. LPA also conducted a tour of the second floor common shower. During this tour, LPA observed a new sink with cabinet storage (below the sink). LPA observed the fan above of the sink to be operational, however, it had lint on the lid. LPA observed the tile in the shower needing a deep cleaning (half bottom of shower grout is darker). LPA observed the fan inside the shower to be non-operational. Interviews and tour conducted corroborates this allegation. Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 05. An exit interview conducted, copy of this report and appeal rights was provided to Logan Harrison.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 28-AS-20250530100910

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 13, 2025

Maintenance and Operation (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 standard is not met as evidence by: LPA conducted a tour of the second floor common bathroom and observed the fan above the sink had lint on the lid, the fan inside the shower was non-operational and the tile in the shower needs a deep cleaning (half bottom of shower grout is darker).the state’s words, verbatim · CDSS document, Jun 6, 2025

Plan of correction: Administrator to provide proof of the shower fan repairs and cleaning, the cleaning of the shower tile grout and a written statement as to how this facility will remain in compliance with this regulation to LPA Irra by POC due date.

Allegation investigated: Staff did not ensure resident’s room was adequately cleaned. Staff did not ensure resident’s room was free from odors. Staff did not ensure resident’s room was free from pests.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with receptionist. Executive Director Logan Harrison arrived later. The investigation consisted of: A physical plant inspection of common areas and 17 resident rooms was conducted. Staff (S1- S5) and residents (R1- R11) were interviewed. Copies of R1's Admission Record, Physician's Report, Personal Service Plan, resident roster, and LIC 500 Personnel Report were obtained. LPA took photographs during room inspections. *Next page. Substantiated Allegation: Staff did not ensure resident’s room was adequately cleaned. It is alleged resident (R1's) room is dirty and cluttered due to hoarding. According to information obtained, entrance into the room is blocked. A total of 17 rooms were inspected during today's visit. Two (2) out of the 17 rooms were dirty and cluttered with furniture and personal belongings. LPA inspected R1's room and observed many dead cockroaches, several alive cockroaches, old discarded food on the floor, pet hair, dirty floors, trash throughout the room, and bathroom bathtub full of clothing. According to staff interviewed, staff attempt to clean the resident's room but the resident refuses. Staff stated that housekeeping staff clean resident rooms once a week, and caregivers take out the trash daily every shift. A total of 11 residents were interviewed, of which one (1) stated staff do not clean their room. None of the other residents had concerns. Resident (R1) stated they do not know why staff do not clean their room, but then acknowledged they refuse to allow staff to clean. There is sufficient evidence to corroborate the allegation. Allegation: Staff did not ensure resident’s room was free from odors. It is alleged that resident (R1) has a dog in the room that defecates and urinates in the room and there is a "stench" that is smelled from the hallway when the door is opened. Housekeeping and caregiver staff stated R1's pet dog urinates and defecates in the room and confirmed bad odors. According to staff interviews, when the resident moved in pet services were in place, but R1 was able to take the dog out to potty and staff pet services were stopped. When pet services are in place caregivers walk the pet and clean up after the pet(s). Resident (R1) stated their room does not smell like dog feces or urine. None of the 11 residents interviewed stated their rooms have a strong odor. However, based on R1's room inspection today, strong odor of urine and feces was confirmed. Therefore, there is sufficient evidence to support the allegation. Allegation: Staff did not ensure resident’s room was free from pests. It is alleged resident (R1's) is infested with cockroaches and the facility has not addressed the issue. Four (4) out of the 11 residents interviewed stated they have seen cockroaches. Resident (R1) stated there are cockroaches "everywhere in my room", but did not report it to Administration staff. A total of 5 staff were interviewed, of which all stated that they did not have knowledge of the cockroach infestation until this week. According to staff interviews, on Tuesday, May 13, 2025, staff went in to R1's room to remove the bed an observed the infestation of cockroaches under the bed. On Wednesday, May 14, 2025, Administration staff called Dewey Pest Control for services. During today's visit, Dewey Pest Control was observed addressing the problem in R1's room. LPA reviewed pest control service contract. They are scheduled to provide services twice a month and/or as needed. Based on observation, photo evidence, and interviews, there is sufficient evidence to corroborate the allegation. Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. An exit interview was conducted with Interim Executive Director Logan . A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, May 16, 2025 · control 28-AS-20250512091819

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: May 27, 2025

Personal Accommodations and Services. The following space and safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met evidenced by: Based on observation and tour of physical plant, LPA observed unswept floors, food on the floor/tables, clutter, and exessive amounts of personal belongings on the floor/ This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: Executive Director agrees to: 1. Conduct an in-service training with all housekeeping and caregiver staff that outlines policies and procedures to maintain clean and sanitary conditions in the facility. 2. Provide a photograph of R1's room.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(f) · Plan of correction due date: May 27, 2025

Maintenance and Operation. All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement was not met evidenced by: Based on physical plant observation and interviews, R1's room had a strong odor of pet feces and urine. Pet feces was observed in the patio area and pet urine was on R1's room and temporary room. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: Executive Director agrees to conduct staff training in regulation 87303, and pet services job responsibilities for applicable staff. Submit proof of staff training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 27, 2025

Maintenance and Operation. 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 evidenced by: Based on observation, resident (R1's) is infested with cockroaches. During today's visit, the room had dead and alive cockroaches, as well as maggots. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: Executive Director agrees to submit a written plan of correction, proof of staff in-service training, and pest control service plan for R1's room.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Galarza conducted a Case Management- Incident visit to follow up on a 3rd party SOC 341 Report of Suspected Dependent Elder Abuse incident report dated 5/6/2025. LPA met with Executive Director Logan Harrison. The purpose of today's visit is to check on the health & safety of resident(s) in care. According to SOC 341, resident (R1) is a victim of financial abuse perpetrated by social media "friends". Resident (R1) and staff were interviewed. The findings indicate R1 has willfully gifted money to persons they met via Facebook. According to staff, they first became aware of suspected financial abuse on March 9, 2025. Staff followed up with resident and cross reported to Ombudsman and family, but not CCLD. This week the facility learned that the resident was a victim of additional financial abuse by social media friends. Record review was completed. The facility failed to submit an SOC 341 to CCLD when knowledge of financial abuse was discovered. Citation was issued. Exit interview conducted and a copy of the report was given to Executive Director Logan Harrison.the state’s words, verbatim · CDSS document, May 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 27, 2025

Reporting Requirements: Each licensee shall furnish to the licensing agency ... A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below..... This requirement was not met evidenced by: Based on record review, on 3/9/25 staff were informed that R1 was being financially abused by social media "friends", but the facility did not submit an SOC 341 or incident report to CCL. This week staff were informed of another financial abuse incident. This poses a potential health and safety risk.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: Executive Director agreed to provide a written plan of correction that includes: 1. In-service training in reg. 87211 2. Copy of facility reporting procedures, and staff protocol re: SOC 341 reporting. 3. Submit to CCL a copy of SOC 341 about most recent financial abuse incident.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Galarza and Gabriela Castro conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Executive Director Logan Harrison. The Residential Care For Elderly (RCFE) facility serves residents ages 60 and over. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs). Operational Requirements: The facility has a hospice waiver for 8 residents. A fire clearance for 85 non-ambulatory residents; of which 7 may be bedridden is in place. Facility does not handle resident monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 12/31/2025. The facility does not have a Dementia waiver. Physical Plant/Environment Safety: Facility is a 2-story building consisting of 73 resident rooms, 2 activity rooms, beauty salon, dining room, laundry room, and a courtyard patio area. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. Beds had required bedding, linens, and mattress pads with the exception of (4 rooms). The signal system was tested and is operational. Water temperature readings did not measure within tthe required 105 - 120 degrees Fahrenheit. Cleaning supplies and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has charged fire extinguishers. The last fire inspection was conducted on 4/11//2025 by Cintas Fire Protection. NOTE: One of the facility elevators is non-operational. Staffing: A total of 38 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 11/19/2025. Staff have criminal background clearance. Seven (7) staff files were reviewed. They contained 1st Aid/CPR training, criminal background clearance, health/TB screenings, 1st Aid/CPR training, and training records. Resident Records/Incident Reports: Seven (7) resident files were reviewed. They contained admission agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records were reviewed. RCFE & Ombudsman complaint posters are posted near the main entrance. Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed. The facility has a Resident Council. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. 18 residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. However, uncovered desserts were observed in the refrigerator. Dining Services Manager's Food Handling Certificate is current. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or 3rd party transportation companies, and facility van. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 3/18/2025. Residents with Special Health Needs: There are currently 3 residents receiving hospice services, 15 receive home health services, and no residents have prohibited health conditions. Individual Service Plans and Appraisals are on file. Postural support physician orders are on file. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview, copy of report/appeal rights was conducted with Executive Director Logan Harrison.the state’s words, verbatim · CDSS document, May 6, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Noemi Galarza made unannounced case management visit regarding a self reported incident on the relocation of 22 residents from Brookdale Santa Monica Gardens # 197606682, 851 2ND St. Santa Monica, CA 90403 to Brookdale Central Whittier due to mandatory evacuation orders from Fire Advisory. LPA met with Executive Director Logan Harrison and explained the purpose of the visit. A physical plant tour of the facility was conducted to check the health and safety of the 22 evacuee residents. The following observations were made: All relocated residents have designated rooms that include bathrooms and beds with bedding/linen, hygiene supplies. Medical equipment i.e., wheelchairs, hospital beds, walkers were observed. A Hoyer lift for one resident will be delivered by tomorrow. One (1) out of 22 residents is bedridden. Some residents are ambulatory and some are non-ambulatory. Incontinence care is being provided by Brookdale Santa Monica Gardens caregivers. Medication Administration Records (MARs) and medication cart was transferred from Brookdale Santa Monica Gardens to the facility. Brookdale Santa Monica Gardens staff are handling/administering the medications of the relocated residents. Two (2) caregivers, 1 med-tech, 1 dining server, 2 housekeepers, and 1 cook from Brookdale Santa Monica Gardens were temporarily assigned to work at this facility. Medical records and other relevant documents are accessible via Point Click Care software. Residents were transferred basic identification/medical insurance information. Review of staff rosters indicate there is sufficient staffing available to provide care for residents of both facilities. The facility has sufficient 2-day perishable and 7-day non perishable food supplies. The facility dining room is able to accommodate all residents. The last routine fire inspection was conducted 7/15/24. The last fire drill was conducted on 12/19/24. Executive Director stated that all resident's responsible parties and families were notified of relocation via phone calls, email, and texts. Exit interview was conducted with Executive Director Logan Harrison and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 10, 2025

Allegation investigated: The facility did not respond in writing regarding any action taken in response to the resident council concerns within 14 calendar days "Rights of Resident Councils" is not posted in a prominent place at the facility accessible to residents, family members, and resident representatives Facility is in disrepair Staff did not ensure housekeeping services were provided to residents in care

Licensing Program Analyst (LPA) Glenn Trueman conducted an initial 10-day complaint investigation visit in regards to the allegations listed above. LPA discussed the purpose of the visit with Staff S1. Shortly thereafter Executive Director Logan Harrison arrived. The investigation consisted of: A physical plant inspection of the common areas and resident (R1's) room was completed. Executive Director, Staff (S1- S3) and residents (R2-R6) were interviewed. Documentation was submitted regarding Resident Council Meeting Minutes and Corrective Action Consent Forms. In regards to the allegation The facility did not respond in writing regarding any action taken in response to the resident council concerns within 14 calendar days, based on interviews conducted and information gathered it was revealed that resident council meeting was conducted on 11/20/24 and on 11/27/24 Concern Form was completed specifying what the corrective plan would be done by the facility. Interview with Resident's R2-R6 who all stated that there is a residents meeting once a month and then a Unsubstantiated town hall meeting where the staff addresses all the issues brought up at the council meeting. Resident's R2-R6 stated that facility writes down how to rectify their concerns and it can be viewed by residents. Interview with staff who stated that there is a town hall to verbally communicate how they will rectify resident concerns from the council meetings. Stated it is 1 week later and also that the written concern form with corrections to be done are available in the activity director's office and can be viewed at anytime. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. In regards to the allegation "Rights of Resident Councils" is not posted in a prominent place at the facility accessible to residents, family members, and resident representatives, based on interviews conducted and information gathered it was revealed on tour of the facility that Rights of Residents is posted in the main hallway of the facility. Interview with Resident's R2-R6 who all stated that they have seen resident rights posted and that it is also in their file when they are admitted. Interview with staff who stated that resident rights are posted in the main hallway. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. In regards to the allegation Facility is in disrepair, based on interviews conducted, information gathered and tour of the facility it was observed during tour of the facility that there were no leaks and the physical plant was in good condition. Tour of Room 137 revealed that there were no leaks and observed everything to be in good working condition. Also temperature in the facility met Title 22 Regulations and elevator was operable. Doors by bird cage were observed to be operable and there were no bad spots observed by the pillars. Interview with Resident's 2-6 who stated the elevator is in working condition and maintenance will jump on it right away if anything needs fixing. Staff interview stated that there are no issues by Room 137 of leakage and also stated that any leaks were 2 years ago by Room 137. Stated that maintenance is on site and will fix things right away. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. In regards to the allegation Staff did not ensure housekeeping services were provided to residents in care, based on interviews conducted and information gathered it was revealed by Resident's 2-6 that their rooms are cleaned 1x a week and the housekeeper does a really good job. Also said she has a schedule and does all the rooms and does not miss any. Interviews with staff who all stated that resident's rooms are cleaned 1x a week and there is a schedule that is followed and every room is completed. Stated that no residents rooms are missed and there have been no complaints. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 28-AS-20241126123740

Allegation investigated: Staff do not ensure that resident is provided transportation as agreed to in the Admission Agreement.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit in regards to the allegation listed above. LPA discussed the purpose of the visit with Wellness Director Denise Bartley. Interim Administrator Logan Harrison arrived shortly after. The investigation consisted of: Record review, physical plant inspection of common areas and parking lot, and interviews with staff (S1-S3) and residents (R1- R7). Copies of R1's Residency Agreement, Admission Record, Physician's Report, Personal Service Plan, DMV Vehicle Registration Renewal Notice, State of CA CHP Safety Compliance Report, resident roster, and staff roster were obtained. Substantiated Allegation: Staff do not ensure that resident is provided transportation as agreed to in the Admission Agreement. It is alleged that the facility has caused resident (R1) to miss a minimum of six (6) necessary medical appointments in the last 6 months because the facility does not have a staff driver for the facility bus. According to information obtained, facility staff have made transportation arrangements with other Brookdale facilities i.e., Brookdale Uptown Whittier and Brookdale Brea to transport R1 to medical appointments. However, in the past week R1 missed 2 necessary pre-surgery medical appointments. It was reported that due to missed or cancelled appointments due to lack of transportation, R1 has almost lost medical referrals. Non-ambulatory resident (R1) uses a motorized scooter and manual wheelchair, and cannot leave the facility unassisted. It was reported that facility staff told R1 they need to hire somebody to push their wheelchair when they go to doctor appointments. A total of 7 residents were interviewed, of which all stated the facility has a bus but no driver, and transportation has not been offered to residents. The majority of the residents interviewed stated they have had to cancel doctor appointments due to lack of transportation. A total of three (3) Administration staff were interviewed. They acknowledged the facility has not had a staff person/bus driver to drive the facility bus in over six (6) months. Interim Administrator stated three (3) other sister communities have assisted with R1's transportation in the past. However, due to unavailability and scheduling conflict R1 was not able to be transported by the other sister communities the last week. Staff stated that R1 has been accommodated with transport to most doctor appointments. Due to recent transportation issues, home care agencies that provide transportation and escort assistance have been contacted, but there is no contract is in place yet. Dial-A-Ride is not able to accommodate resident (R1) because the resident uses a large motorized scooter and if the resident uses a manual wheelchair they require staff assistance to push the resident to desired location. According to staff interviews, there are currently five (5) residents that require facility transportation. Based on record review, the Residency Agreement states "We will make available scheduled transportation services as forth in the Addendum of the Residency Agreement." The Addendum To The Residency Agreement Basic Services states "The Community will provide scheduled transportation for shopping and for other errands and planned social events in and around the local area. The Resident Handbook provides additional transportation guidelines." Per Resident Handbook, "Most Communities offer scheduled transportation to stores and doctor appointments within a designated service area." Per observation and record review, this facility has current DMV registration and Safety Compliance Report that indicates all maintenance records are current. The information obtained sufficiently supports the allegation. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. An exit interview was conducted with Interim Executive Director Logan . A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 28-AS-20241113102148

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(6) · Plan of correction due date: Dec 13, 2024

Basic Services. Basic services shall at a minimum include: Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met evidenced by: Based on interviews conducted and record review, the findings indicate that resident (R1) missed 2 required pre-surgery appointments during the past week, because the facility did not ensure R1 was transported to appointments via facility bus, sister community transport, Dial-A-Ride, or other alternate arrangement. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: Licensee shall ensure the Residency Agreement is adhered to, makes available transportation to medical appointments, and a contingency plan is in place when 3rd party transportation services are not able to transport residents. Submit a written plan of correction.

Allegation investigated: Facility staff are not maintaining laundry equipment in good repair.

Licensing Program Analysts (LPAs) Galarza and Mayra Cota conducted an initial 10-day complaint investigation visit in regards to the allegation listed above. LPA discussed the purpose of the visit with Interim Administrator Logan Harrison. The investigation consisted of: A tour of the common areas, with special focus on laundry rooms was completed. Staff (S1- S5) and residents (R1-R7) were interviewed. Resident (R1's) file documents were reviewed. The following documents were obtained: Residency Agreement, staff roster, and resident roster. *Narrative continues next page. Substantiated Allegation: Facility staff are not maintaining laundry equipment in good repair. It is alleged that the 2nd floor "Resident Laundry Room" dryer is in disrepair and makes a loud thumping noise, that is keeping resident's awake at night when NOC shift staff use the dryer. As a result, some residents are not able to dry their clothes in a timely manner because it is in use by staff or other residents. It was reported that management staff, maintenance staff, and caregivers have received reports from residents of the aforementioned issue, and noise nuisance. In addition, during the last resident council meeting the dryer disrepair was also addressed. A total of 5 staff and 7 residents were interviewed. All staff interviewed confirmed the dryer in the 2nd floor has been in disrepair for approximately 2 - 4 weeks. They stated that the dryer was not working, and maintenance staff installed another dryer over 1 1/2 weeks ago, but the dryer that was installed was observed to be damaged and makes a loud thumping noise. Six (6) out of 7 residents interviewed stated the 2nd floor dryer has been in disrepair for over 1 month; and the replacement dryer also is in disrepair because the dryer drum makes a loud thumping noise. Several residents stated that the dryer disrepair has caused delays in their laundry routine. Based on observation, LPA's observed dents on the 2nd floor dryer, heard the loud thumping noise, and noticed the dryer knob control turns on in "off" mode. In addition, the basement staff laundry room has one (1) washer in disrepair. Staff reported that the washer had a water leak, and was replaced with a new dryer. However, the new dryer did not have a gas line. Therefore, the 2nd floor dryer and basement washer are in disrepair. A new washer and dryer have been ordered and should be arriving by the end of this week or early next week. The findings corroborate the allegation. Exit interview was conducted with Interim Administrator Logan Harrison. A copy of the report and appeal rights will be emailed due to printing issues. A hard copy of the report will be mailed.the state’s words, verbatim · CDSS document, Oct 8, 2024 · control 28-AS-20241002102332

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(g)(1) · Plan of correction due date: Oct 21, 2024

Maintenance and Operation .Facilities which have machines and do their own laundry shall: Have adequate supplies available and equipment maintained in good repair. This requirement was not met evidenced by: Based on interviews and observation, the 2nd floor Resident Laundry Room has a dryer that is in disrepair. During the inspection, LPAs also observed the basement washer in disrepair. Both have been in disrepair for approximately 4 weeks. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Interim Administrator stated he approved the order for a new dryer and washer that should be delivered by early next week. Please submit a copy of the invoice and a picture of the installed new dryer and washer.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Resident Engagement Coordinator Valerie Mendez. Health and Wellness Director Denise Bartley arrived shortly after. Executive Director Sanjay Kabadi arrived later. There are currently 43 elderly residents 60 years and older residing in the facility. The following 12 (CARE) tool domains were utilized during the inspection. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirements: An Infection Control Plan has been added to the Plan of Operation. The facility has a Dementia Waiver in place and an approved Hospice Waiver for 12 residents. A fire clearance for 74 non-ambulatory residents; of which 10 may be bedridden is in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 12/31/2024. No Surety bond is in place. Facility does not handle resident monies. *Narrative continues next page. Physical Plant/Environment Safety: The facility does not have Dementia residents. A hospice waiver for 8 residents is in place. Facility is a 2-story building consisting of 73 resident rooms, 2 activity rooms, beauty salon, dining room, laundry room, and a courtyard patio area. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. Beds had required bedding, linens, and mattress pads. On 1/8/2024, Cintas Fire Protection conducted an inspection. Items of correction were identified, corrections are pending. The sprinkler system, alarms, fire connections, and kitchen hood system were inspected. The facility has fully charged fire extinguishers. Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit, room #261 was [131.6DF], rm # 253 [127.7 DF], rm #241 [120.3 DF], rm# 236 [122.8 DF], rm #235 [123.5 DF], rm # 233 [ 124.4 DF], rm # 210 [124.4 DF]. A citation was issued. Seventeen (17) rooms were inspected. Call light system and resident pendants were tested. Staffing: A total of 37 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 8/16/2024. Administrator provided proof that recertification training documents were submitted to CCL Recertification unit. Recertification process is pending. Staff have criminal background clearance and training. Seven (7) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was observed. Resident Records/Incident Reports: A total of seven (7) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, Individual Service Plans, and medication records. RCFE complaint poster and Personal rights were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in the 1st floor hallway. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Records of physician's orders was reviewed in the kitchen. At 12:12 PM LPA observed an open large size package of hot dogs being thawed in the kitchen sink where dirty dishes are rinsed, and uncovered plates of pie desserts were observed in the refrigerator. Incident Medical and Dental: Seven (7) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Two (2) residents are receiving hospice services. Ten (10) residents receive home health services. Postural support physician orders are on file. Half bed rails for mobility assistance were observed in some resident rooms. No residents have prohibited health conditions. Individual Service Plans and Appraisals are on file. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Sanjay Kabadi. A copy of the report and appeal rights was issued.the state’s words, verbatim · CDSS document, Apr 19, 2024

The state marks this report as 12 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff placed a resident on hospice against their wishes. Staff are not following a resident's legal documentation.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit in regards to the allegation listed above. LPA discussed the purpose of the visit with Executive Director Sanjay Kabadi. The investigation consisted of: A physical plant tour of facility common areas, record review, and interviews of staff (S1- S4), hospice residents (R1-R2). An interview with Power of Attorney (POA) was attempted, but only (F1) was interviewed. The following documents were reviewed/obtained: Resident (R1's) file documents were reviewed. The following documents were obtained: Identification and Emergency Information/Face Sheet, Admission Record, Preplacement Appraisal Information, Personal Service Plan, Physician's Reports, Advance Health Care Directive, Physician's Certification of Incapacity to Make Informed Decision (10/26/23),POLST (8/18/23 & 2/18/24), Home Health Notes, Hospice Admit Notes initiated 2/19/24, incident reports, MARs, LIC 500 Personnel Report, and resident roster. ***See narrative summary on next page.*** Unsubstantiated Allegation: Staff placed a resident on hospice against their wishes. According to information obtained, resident (R1) was "fraudulently" placed in hospice care and had fluids removed against their will. It is alleged that R1 had a recent stroke, but was still able to communicate with hand gestures i.e., hand squeezes and in writing, but no one asked the resident what they wanted. Resident (R1's) advocates asked the facility to restore fluids but the request was not addressed. Per record review, R1 was sent out to the hospital on February 2, 2024 for a urinary tract infection (UTI). The resident was then transferred to a skilled nursing facility, where R1 had another stroke. A total of four (4) staff were interviewed, of which all stated that R1 has a Power of Attorney (POA), who made the decision to enroll the resident in hospice care while the resident was at a higher level of care facility, and prior to returning to the facility on February 19, 2024. Resident (R1) was enrolled in hospice care the same day he returned to the facility. The resident's diet was "NPO", nothing by mouth, "mouth moistening swabs only". The facility presently has 2 other residents enrolled in hospice and both had cognitive impairment and were unable to respond to the questions. Based on record review of the most recent Physician's Report dated 2/19/24, the MD noted hospice care was needed due to permanent CVA and dysphagia. In addition, R1 has an Advance Health Care Directive effective 1/17/2009, appointing their Power of Attorney (POA), "Not to prolong life" and a POLST dated 8/18/2023, that states "no artificial means of nutrition, including feeding tubes". A 2nd POLST was updated on 2/18/24 by POA and signed by MD on 2/21/2024, to "Comfort-Focused Treatment". Therefore, the findings indicate that the POA placed R1 in hospice care. Therefore, the facility followed the POLST, Advance Directive, and POA's decision to initiate hospice service. NOTE: The facility received a phone call from hospice agency reporting that R1 passed away today. Allegation: Staff are not following a resident's legal documentation. It is alleged that the facility is violating the resident's rights by following resident (R1's) family member's decisions without having Power of Attorney. Based on record review, the resident moved in on 11/30/2023 and an a copy of an Advance Healthcare Directive dated 1/17/2009 was provided, along with a POLST signed by R1's legally recognized decision maker. All staff interviewed denied the allegation and stated that the facility obtained legal documents appointing R1's sister as the Power of Attorney for healthcare decisions. The findings indicate, there is no merit to the allegation, because R1's file has all legal documents pertaining to healthcare decisions, and the facility is adhering to the stipulations noted on the documents. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted with Executive Director Sanjay Kabadi. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 27, 2024 · control 28-AS-20240221091238

Allegation investigated: Staff do not ensure that resident's incontinence care needs are met. Staff do not assist resident with grooming. Staff do not provide resident with clean linen. Staff did not ensure that a hazardous item was made inaccessible to resident.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the allegations listed above. LPA discussed the purpose of the visit with Executive Director Sanjay Kabadi. The investigation consisted of: On 12/19/2023, LPA conducted a physical plant inspection of common areas and resident (R1's) room; photographs of R1's room were taken. Staff (S1- S7) and residents (R1-R3) were interviewed. The following documents were reviewed/obtained: Identification and Emergency Information/Face Sheet, Admission Record, Preplacement Appraisal Information, Physician's Report (11/23/2022), Personal Service Plan [12/1/22, 1/25/23, 7/14/23, & 8/7/23], Hospice Care records, Hospice Collaboration Notes, and resident and staff rosters. During today's visit, LPA conducted a physical plant inspection and interviewed resident (R4- R7), and Health and Wellness Director for an update on resident (R1). NOTE: Resident (R1) moved out on 12/21/2023. ****Narrative continues next page.****** Substantiated Allegation: Staff do not ensure that resident's incontinence care needs are met. It is alleged that staff did not meet the incontinence needs of bed bound resident (R1). According to reporting party, facility staff were not changing R1's incontinence diaper, resulting in the resident lying in urine and feces. On 11/20/2023 and 12/8/2023 R1 requested incontinence care assistance via call light system. Staff checked on the resident, but stated they would be back to change R1's diaper and never did. On 12/8/23, an attempt was made to communicate R1's needs/staff neglect to staff (S2), but staff stated "I can't talk right now". Resident (R1) was interviewed and stated that staff allege that the resident refuses to be changed, but that is not the case. The resident stated that sometimes staff came in to the room to change the diaper, while the resident was in the middle of a bowel movement. Therefore, R1 often asked staff to come back in a short while once they are done with their bowel movement, but staff failed to return in a timely manner. Resident (R1) stated that staff "seem to come in to check on me every 3 hours or so", and feels staff are neglectful in meeting incontinence needs. Third party providers have found R1 with dirty diapers. Photographs were obtained. A total of 7 residents were interviewed; none reported issues with incontinence care. A total of seven (7) staff were interviewed. Staff stated that R1 requires a 2-3 person assist when Hoyer lift is used because the resident is heavy. According to staff, R1 can only rotate themselves to the left side, but is distrustful of staff when repositioning during incontinence diaper changes. Staff stated that R1 gets anxious and is afraid staff will drop the resident when using the Hoyer lift. All caregiver staff interviewed stated that R1 sometimes refused to be changed or rotated, and they did not know if the resident had feces or was wet. According to caregiver staff, they have been instructed to change the resident only when there is a bowel movement, since the resident urinates on a urinal. Staff acknowledged that they have observed urine spilled on the floor and feces on chux pads. According to Administration staff interviews, staff are to report when a resident refuses incontinence care. However, facility was not able to provide documentation (Personal Continence Log) of R1's incontinence care refusal. In addition, staff confirmed that Hoyer lift in R1's room has broken down several times. Third party provider photographs were obtained. On 12/19/23, LPA smelled urine upon entering R1's room, and observed urine on the floor next to the urinal container. There is sufficient evidence to prove the allegation. See next page. Allegation: Staff do not assist resident with grooming. It is alleged that resident (R1's) grooming needs have been neglected since approximately May 2023, when the resident's condition change to bed-bound. Tooth brushing is only done when the toothbrush is brought to the resident. In addition, R1 has not had a haircut since approximately April 2023, and staff have not offered R1 escort assistance to the facility's beauty salon. According to staff interviews, the cosmetologist is at the facility every Tuesday and residents set up appointments. Staff can ask for special circumstance i.e., haircut in resident's bed. However, staff did not set up a special circumstance haircut appointment, nor did they offer transport to the beauty salon. Staff stated that grooming is supposed to be done in the mornings, which includes hair brushing, cleaning of face with warm washcloth, electronic shaving, and provide tooth brushing assistance. Resident (R1) stated that staff have neglected their grooming needs, and would like to have better grooming. Staff acknowledged that grooming needs of the resident have been neglected. LPA looked at R1's Admission Record picture. The photograph depicts R1 with short hair and good grooming. On 12/19/23, LPA observed R1's hair tangled and unbrushed. The brush was observed next to the television, inaccessible to bed-bound resident. Pictures were taken of R1's face and hair. Allegation: Staff do not provide resident with clean linen. It was reported that resident (R1's) bed linens are not being changed as required. It is alleged that R1's bed linens were always dirty when third party providers visited the resident. Sheets were often found with feces, blood, and food crumbs. Resident (R1) stated that bed linens are changed by staff when they get "dirty enough", and staff were only changing the disposable under-bed pads as needed. Staff stated that bed linens are changed every week and/or as needed. Families provide linens and most residents have an extra set of sheets. Two (2) out of the seven (7) staff acknowledged seeing dirty sheets, but stated they always change the sheets. However, based on photographs obtained the findings indicate that R1's bed linens are not being changed per facility protocol. On 12/19/2023, LPA did observe bed sheets stained with urine and food. See next page. Allegation: Staff did not ensure that a hazardous item was made inaccessible to resident. It is alleged that toothpicks and plastic knifes have been observed underneath R1's body, which pose a safety hazard because a wound may develop, could become infected or could result in sepsis. Resident (R1) stated that they have plastic wear by the bedside because staff sometimes forget to bring plastic wear with meals, and does drop toothpicks and knives on the bed. Staff interviews revealed that plastic forks, plastic spoons, food, and toothpicks have been found in the bed during incontinence care, and staff are instructed to check/remove hazardous items found in residents' beds. On 12/19/2023, LPA observed a toothpick next to the resident's right hand, and plastic fork on the floor. The findings indicate that staff need to be more cognizant of what is considered hazardous, which may cause skin tears. It is the responsibility of facility staff to ensure all residents are safe, and facility protocols are followed. Based on interviews conducted, document review, and photographs obtained, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D. An exit interview was conducted with Executive Sanjay Vaid. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 28-AS-20231213095036

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jan 25, 2024

Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. Based on record review and interviews conducted resident (R1) required bowel incontinence care since May 2023, due to change in condition to bed-bound. R1 has been left lying in feces and urine and was not provided incontinence care as indicated in care plans. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: Executive Director agreed to re-assess all bed-bound and residents receiving incontinence care, and update their care plans. Submit proof of staff training, staff signature logs, and a written plan that addresses Hoyer lift issues. In addition, facility shall review all resident records to ensure Care Plans have been updated. NOTE: R1 moved out on 12/21/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87101(c)(3)(A) · Plan of correction due date: Jan 25, 2024

Definitions. "Care and Supervision" means those activities which if provided shall require the facility to be licensed... "Care and Supervision" shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: (A) Assistance in dressing, grooming, bathing and other personal hygiene; This requirement was not met evidenced by: Per record review & photographs, caregiver staff failed to provide grooming assistance as indicated in care plans, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: Executive Director agreed to submit a written plan plan that addresses care responsibilities/protocols for residents with declining/change in health conditions, and grooming responsibilties. NOTE: R1 moved out on 12/21/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 25, 2024

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, furnishings and equipment. This requirement was not met evidenced by: Based on photograph evidence and observations made on 12/19/23, R1's bed sheets/linens were observed to be dirty with urine, feces, and food; which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: Executive Director shall ensure all resident's are accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet their needs. Submit a written plan and proof of staff training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(3)(B) · Plan of correction due date: Jan 25, 2024

Personal Accommodations and Services.The following space and safety provisions shall apply.... All persons shall be protected against hazards within the facility through provision of the following:(B) Information and instruction regarding life protection and other appropriate subjects. Based on photographs and observations made the findings indicate that staff failed to remove hazardous items i.e. toothpicks, plastic knives from R1's bed, which can cause skin tears. This posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: Executive Director shall ensure all staff follow care and supervision protocols. Submit a written plan and proof of staff training.

Allegation investigated: Resident sustained a fracture while in care.

***This report supersedes the previous complaint report dated 01/13/23. The reason it’s being superseded is to clarify the investigation findings and include additional information. The finding remains the same. *** Licensing Program Analyst (LPA) Christine Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation and for the purpose of rendering the finding. LPA met with Receptionist Carlina Gomez who allowed entry into the facility and explained the reason for the visit. The administrator, Barbara Tyler, arrived later and assisted with the visit. The investigation consisted of the following: On 12/20/2021, LPA conducted a health and safety check. LPA toured the facility with Denise Bartley and observed that the facility is clean and in good repair. (See LIC 9099C for continuation) Unsubstantiated LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Restrooms, hand washing basins, toilets and bathtub/showers are operable. There are no immediate health and safety concerns. LPA also gathered information from Resident#1 (R1) file and reviewed two other residents' files. The following documents were collected which included: staff and resident roster, R1's resident information/emergency contact sheet, physician report dated on 10/12/21, preplacement appraisal information, physician/healthcare provider order sheet and care profile. The complaint was referred to the CCL IB investigation Unit and assigned to IB Investigator Garcia for full investigation. IB investigator Garcia conducted and completed the investigation which included interviews with the facility administrator, resident’s relatives, facility residents, six facility staff, resident’s physical therapist. IB Investigator Garcia also obtained Hospital Record, police report and facility progress notes. The investigation revealed of the following: Regarding the allegation of “Resident sustained a fracture while in care.” It’s alleged that R1 was rough handled by a facility caregiver. After interviews with administrator and the facility staff, based on interviews and statements provided, there is insufficient evidence to determine if facility caregiver caused the fracture to R1’s right rib. Additionally, per the medical records no evidence of suspected abuse or neglect was deemed at the time of the medical evaluation. Therefore, based on the interviews and statements provided, there’s no sufficient evidence to support the allegation of resident sustained an unexplained fracture while in care. Therefore, LPA finds the allegation to be UNSUBSTANTIATED. 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 allegation is UNSUBSTANTIATED. An Exit Interview Conducted and a copy of the report and appeal right was provided to Administrator Sanjay Kabadithe state’s words, verbatim · CDSS document, Dec 7, 2023 · control 28-AS-20211217150248