The Village at Sherman Oaks

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 02:37 PM to conduct an unannounced Case Management - Incident visit at the facility today. LPA met with facility Interim-Executive Director (ED-I) Justine Ortiz entrance interview conducted and the reason for the visit was explained. The purpose of today’s visit was to follow-up on a self-reported incident that occurred on 08/03/2026. During today’s visit, the LPA conducted a brief physical plant tour, collected copies of pertinent documentation and interviewed the ED-I, one (1) resident, and one (1) staff member between approximately 02:40 PM and 03:10 PM. On 08/10/2026 at 11:00 AM Community Care Licensing Division (CCLD) received a self-reported incident report regarding an incident that occurred on 08/03/2026 in which a resident’s personal property valued at greater than $100 went missing from the facility. LPA observed that the facility had appropriately documented the missing property and had attempted to notify law enforcement within the required timeframe. No immediate concerns were observed. LPA may return at a later date to conduct additional investigation into this incident if it is determined that further investigation is required. No deficiencies were observed during today’s inspection. Exit interview was conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 19, 2026

Allegation investigated: Staff charges resident for services not rendered Staff don't respond to resident in a timely manner

Licensing Program Analyst (LPA) Trevor Byrne conducted a follow-up complaint visit for the above allegations. LPA arrived to the facility at 01:44 PM. LPA met with Interim Executive Director Justine Ortiz (ED-I). Entrance interview conducted and the reason for the visit was explained. During today’s visit, the LPA interviewed the ED-I and delivered findings between approximately 01:46 PM and 03:45 PM. CONTINUED ON LIC 9099C. Substantiated The allegation of “Staff are not practicing proper hand hygiene techniques” alleges that facility staff are not following proper hand hygiene and infection control practices when assisting facility residents. LPA interviewed R1 who stated that facility staff who were assisting them in their apartment would either not change their gloves between taking out the trash, making the bed, and assisting R1 or would not wear gloves at all when performing these tasks. LPA interviewed facility residents who stated that they always observe facility staff wearing gloves when providing assistance. LPA interviewed facility staff members who were able to appropriately identify the facility’s hand hygiene techniques and standard operating procedures. Staff members interviewed were able to appropriately identify the requirements of washing hands prior to assisting residents, changing gloves between assisting residents or performing other tasks in the apartments, and washing hands after finishing with assistance. LPA reviewed the facility’s infection control plan and observed adequate hand hygiene procedures outlined in the plan. LPA interviewed the ED-I who stated that trainings regarding infection control and hand hygiene procedures are performed every other month and the expectations are reviewed with each employee during shift crossovers. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff are not practicing proper hand hygiene techniques.” Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of the report was issued. The allegation of “Staff charges resident for services not rendered.” Alleges that the facility had charged Resident #1 (R1) for services including standby shower assistance and tray delivery service when the services had not been provided. LPA interviewed R1 who stated that they had signed up for standby shower assistance however, when receiving assistance, the staff member who was supposed to be standing by to provide assistance was often performing other tasks around the apartment such as making the bed, taking out the trash, or utilizing their phone. Additionally, R1 stated that when receiving tray delivery service, they would often have to send food back due to the food arriving cold or not cooked to their liking. R1 stated that they would be charged for a second tray delivery when this occurred. LPA reviewed R1’s “Resident Detail Ledger” which outlined the charges R1 accrued at the facility. LPA observed multiple dates where R1 was charged more than three (3) times per day for tray delivery service. LPA interviewed Witness #1 (W1), who stated that R1 was compensated by the Executive Director (ED) when food was sent back to the kitchen and a new meal had to be delivered. LPA reviewed R1’s resident file and observed that on 01/09/2025 R1 was assessed by the facility as needing standby shower assistance seven (7) days per week. LPA observed that as a result of this assessment R1 was identified as requiring level two (2) assistance. LPA observed that R1 ceased standby shower assistance on 03/14/2025. LPA interviewed facility staff and ED who confirmed that when performing standby shower assistance staff are expected to be next to the shower and not performing other tasks around the apartment. LPA requested monthly task logs for shower assistance provided to R1 between January - March of 2025. LPA reviewed the logs that the facility had submitted and observed that between 01/15/2025 and 03/14/2025 only one (1) day was marked as completed, one (1) day was marked as a refusal, and on six (6) days the service was paused. The remainder of the days showed the standby assistance as “Task Not Completed” (TNC). LPA interviewed ED-I who informed LPA that the facility had swapped to a different record keeping system around that time and any logs prior to the implementation of that system would show as “TNC”. The ED-I informed LPA that they were unable to pull any previous records for standby shower assistance as those records are only retained for one (1) year. LPA reviewed evidence submitted and observed notes which indicated that R1 did not receive standby shower assistance on fifteen (15) days between 02/08/2025 and 03/03/2025. Based on the information obtained during interviews and record review there is sufficient evidence to support the allegation of “Staff charges resident for services not rendered.” Therefore, the allegation is deemed Substantiated at this time. CONTINUED ON LIC 9099C. The allegation of “Staff don't respond to resident in a timely manner.” Alleges that facility staff did not clean R1’s room, do R1’s laundry, or take R1’s food orders in a timely manner. LPA interviewed R1 who stated that due to their health conditions they required food to be delivered at specific times during the day. R1 stated that when they originally began tray service they would place their food orders for the kitchen by writing down their requests on the daily menu which a caregiver would deliver to the kitchen to prepare. R1 stated that this led to delays in receiving their food in a timely manner so they were instructed to call in their order to the front desk. R1 stated that on multiple occasions food was not delivered or was left outside of their door without any notification that the food had arrived. LPA interviewed the Director of Dining (DD) who confirmed that the facility had requested R1 to call the front desk to place orders for delivery. DD stated that they expect R1’s call at certain times during the day and if they did not hear from R1 they would personally call to take R1’s order. Regarding the laundry service at the facility LPA interviewed R1 who stated that they were supposed to receive laundry assistance once per week but laundry was often completed late or missed by staff. LPA requested monthly task logs for laundry assistance provided to R1 between January - March of 2025. LPA reviewed the logs that the facility had submitted and observed that between 01/15/2025 and 03/14/2025 all Fridays showed laundry assistance as “Task Not Completed” (TNC). LPA interviewed ED-I who informed LPA that the facility had swapped to a different record keeping system around that time and any logs prior to the implementation of that system would show as “TNC”. The ED-I informed LPA that they were unable to pull any previous records for laundry assistance as those records are only retained for one (1) year. Regarding R1’s room not being cleaned in a timely manner, LPA interviewed R1 who stated that facility staff often did not make their bed or take out the trash from their room in a timely manner. LPA observed R1’s room on 02/09/2026 and observed two (2) trash cans which were full, multiple used towels on the floor of the bathroom, and trash on the sink counter. LPA reviewed evidence submitted and observed notes which indicated that R1 did not receive assistance with taking out the trash or making the bed on 02/08/2026, 02/02/2026, 01/29/2026, 01/22/2026, 01/17/2026, and 01/15/2026. Ten (10) additional dates were observed between 12/16/2026 - 02/08/2026 where assistance with either taking out the trash or making the bed was not provided. Based on the information obtained during observation, record review, and interviews there is sufficient evidence to support the allegation of “Staff don't respond to resident in a timely manner.” Therefore, the allegation is deemed Substantiated at this time. The following deficiencies were cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 29-AS-20260204150834

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Aug 6, 2026

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above as R1 was charged for tray delivery service and standby shower assistance when the services were not provided to R1 which posed a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: ED-I agreed to conduct an in-service training with all facility staff who provide shower assistance to assisted living residents to discuss the expectations of the facility when providing this service. Additionally, ED-I agreed to submit a statement of... understanding confirming that the facility will comply with all agreed upon services laid out in the admission agreement and resident appraisal. ED-I agreed to submit proof of the completed training and the statement to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 6, 2026

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on observation, interview, and record review the licensee did not comply with the section cited above as R1's room was not cleaned, laundry was not done, and food was not delivered on time which posed a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: ED-I agreed to conduct an in-service training with caregivers, servers, and housekeeping staff on the importance of ensuring that resident's needs are met in a timely manner and on the importance of accurately logging resident's refusals of services. ED-I agreed to submit proof of the completed training to... CCLD no later than POC due date.

Allegation investigated: Facility has inadequate food service Facility has inadequate physical activities

Licensing Program Analyst (LPA) Trevor Byrne conducted a follow-up complaint visit for the above allegations. LPA arrived to the facility at 10:43 AM. LPA met with Interim Executive Director Justine Ortiz (ED-I). Entrance interview conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a brief physical plant tour, conducted a file review for one (1) resident, collected copies of pertinent documentation, interviewed the ED-I, the Director of Assisted Living (DOAL) Yamilette Capilla, three (3) staff members, and three (3) residents between approximately 10:45 AM and 03:00 PM. CONTINUED ON LIC 9099C. Unsubstantiated The allegation of “Facility has inadequate food service” alleges that the facility takes an unacceptable amount of time to bring food trays to resident’s rooms and that the food provided to residents is not of good quality. LPA interviewed Resident #1 (R1) who stated that the facility provided them with a tray service and delivered food to their room. R1 stated that they had received many inadequate meals that were burnt, raw, or over salted and that meals delivered arrived cold. LPA Byrne conducted a physical plant tour of the facility and observed the facility to have a sufficient supply of two (2) days perishable and seven (7) days non-perishable foods. LPA interviewed facility staff including the Director of Dining, caregivers, a sous chef, and a server. Staff interviewed stated that R1 received all meals via tray service delivered to their room. Staff #1 (S1) stated that originally, R1 would write their food order for a meal on a menu and the caregiver assisting R1 would take the order down to kitchen staff. S1 stated that ordering this way led to delays in R1 receiving food at the times they requested it so R1 was instructed to call in food orders directly to the dining room. The Director of Dining confirmed that R1 was requested to call in their food orders. The Director of Dining stated that they expected R1’s food orders at certain times during the day and if they had not heard from R1 they would personally call to R1’s room to take their order. Interviews with staff and residents revealed that there have been times where the food that is ordered takes longer than normal to be served to the residents and due to this delay residents were served cold meals. Residents interviewed stated that if notified staff will take the meal back to warm it up or will remake the meal. Staff interviewed confirmed that at resident’s request meals are reheated and denied ever refusing to reheat or remake a resident’s meal. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Facility has inadequate food service.” Therefore, the allegation is deemed Unsubstantiated at this time. CONTINUED ON LIC 9099C. The allegation of “Facility has inadequate physical activities” alleges that the facility had inadequate physical activities for facility residents to participate in. LPA interviewed R1 who stated that they have not participated in physical activities due to their condition. LPA interviewed Witness #1 (W1) who stated that they heard from other residents of the facility that exercise classes were not being offered at the facility anymore. LPA interviewed Executive Director (ED) Grace Hartnett who informed LPA that the facility had let go of their previous fitness director in November of 2025 but the facility was in the process of interviewing individuals to fill the role. LPA interviewed ED-I who informed LPA that a new Fitness Director was hired on 02/11/2026. ED-I denied any resident complaints about the new Fitness Director. Resident’s interviewed denied having concerns about the amount of activities offered at the facility. LPA observed the facility’s activity calendar across multiple days of inspection and observed an average of four (4) exercise (body) activities, four (4) mind activities, one (1) music (Comfort) activity, five (5) social (Connection) activities, and four (4) creative activities offered on a daily basis. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Facility has inadequate physical activities.” Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 29-AS-20260204150834

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure residents signal alert system was implemented as part of their care plan Staff do not ensure care and supervision is being provided to resident. Staff does not ensure residents hydration needs are being met

Licensing Program Analyst (LPA) Trevor Byrne conducted a follow-up complaint visit for the above allegations. LPA arrived to the facility at 09:56 AM. LPA met with Interim Executive Director Justine Ortiz (ED-I). Entrance interview conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a brief physical plant tour, conducted a file review for one (1) resident, collected copies of pertinent documentation, interviewed the ED-I, interim Director of Assisted Living (MC) Yasmin Hernandez, two (2) staff members, and one (1) resident between approximately 10:00 AM and 03:30 PM. CONTINUED ON LIC 9099C. Unsubstantiated The allegation of “Staff did not ensure residents signal alert system was implemented as part of their care plan.” alleges that facility staff did not implement appropriate fall prevention measures including a fall detection mat as part of Resident #1 (R1)’s care plan. LPA conducted a file review for R1 and observed that R1 was identified as a level three (3) fall risk which indicated that R1 had the potential for falls to occur. LPA did not observe a fall detection mat listed in R1’s plan of care. LPA interviewed Witness #1 (W1) who stated that R1 suffered three (3) falls at the facility in a short amount of time between late December 2025 – January 2026. W1 stated that a fall detection mat was purchased for R1 but was not utilized by the facility. LPA interviewed the Executive Director Grace Hartnett (ED), who stated that they had a meeting with R1’s family to discourage the use of the fall detection pad. ED stated that some other memory care residents had similar mats in the past, but all have since been removed. ED stated that the mat is a commercial device that was provided and since the device is not an approved by the facility the responsible party of R1 was responsible for the maintenance of the device. ED stated that they spoke with R1’s responsible party and they agreed to remove the mat. ED stated that they have since implemented a lower bed and a soft mat which is placed at the side of the bed while R1 is sleeping to assist in mitigating R1’s fall risk. ED stated that the facility monitors the apartment for clutter and removes any fall risks throughout the day. ED stated that the resident is on frequent checks each hour and staff are notified via set alarms on their phones. LPA interviewed two (2) staff members who assisted in providing care to R1. The staff members interviewed confirmed that R1 had been placed on frequent 30-minute checks and that additional fall prevention measures including a lower bed and soft mat had been implemented to mitigate R1’s falls. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not ensure residents signal alert system was implemented as part of their care plan.” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Staff do not ensure care and supervision is being provided to resident.” alleges that facility staff do not ensure adequate supervision because R1 suffered three (3) falls in a short timeframe, staff do not check on R1 regularly, and that facility staff do not assist R1 with utilizing the bathroom. LPA observed R1’s resident file and observed that R1 was receiving assistance with incontinence care. LPA observed that R1 was assessed as requiring frequent checks due to R1 residing in the memory care unit of the facility. Additionally, LPA observed that R1 was identified as a level three (3) fall risk which indicated that R1 had the potential for falls to occur. CONTINUED ON LIC 9099C. W1 stated that on 01/21/2026 at approximately 09:00 PM they observed R1 on the floor near their couch via a camera in R1’s room. W1 stated that they had to contact facility staff to assist R1 from the floor. LPA interviewed R1 who stated that they do not have a problem with the facility staff and they do what they can. R1 stated that staff consistently come into their room throughout the day to check on them. R1 denied staff providing inadequate care to them. LPA interviewed eleven (11) additional residents throughout the facility. Ten (10) of the residents interviewed did not express concerns with the quality of care that was provided to them by facility staff. LPA interviewed two (2) staff members who assisted in providing care to R1. One (1) staff member stated that prior to R1’s falls R1 was identified as needing standby assistance only but due to their recent falls R1 has been placed on frequent 30-minute monitoring. The staff member stated that prior to R1’s falls R1 was monitored by memory care staff throughout the day and checks were performed on a regular basis. LPA confirmed that R1 does not have a 1:1 caregiver assigned to them. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff do not ensure care and supervision is being provided to resident.” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Staff does not ensure residents hydration needs are being met.” alleges that on 01/13/2026 R1 was admitted to the hospital as a result of a fall and was found to be dehydrated. W1 provided LPA with photos taken around R1’s 01/13/2026 hospitalization. The photos showed R1’s lips which appeared to be somewhat dehydrated. LPA reviewed R1’s resident file and observed that R1 was identified as being independent regarding meal setup/consumption. LPA observed that R1 did not require reminders/cues, encouragement to consume food/drinks, or assistance with eating/drinking. LPA interviewed R1 who stated that they had no issues/concerns with the food and drink service at the facility. LPA interviewed two (2) staff members who assisted in providing care to R1. One (1) staff member interviewed stated that R1 does not require assistance with eating/drinking. Additionally, the staff member stated that R1 contracted the Flu around their 01/13/2026 hospitalization which contributed to R1’s dehydration as R1 had lowered their fluid intake as a result of the illness. LPA observed that memory care residents were provided with fluids during mealtimes and residents were provided with fluids if they requested them from staff throughout the day. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff does not ensure residents hydration needs are being met.” Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, May 6, 2026 · control 29-AS-20260116102430

Allegation investigated: Staff did not respond to residents’ requests for assistance in a timely manner. Staff did not provide residents with adequate food service. Facility does not have adequate activities for residents.

Licensing Program Analyst (LPA) Trevor Byrne conducted a follow-up complaint visit for the above allegations. LPA arrived to the facility at 09:56 AM. LPA met with Interim Executive Director Justine Ortiz (ED-I). Entrance interview conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a brief physical plant tour, conducted a file review for one (1) resident, collected copies of pertinent documentation, interviewed the ED-I, interim Director of Assisted Living (MC) Yasmin Hernandez, two (2) staff members, and one (1) resident between approximately 10:00 AM and 03:30 PM. CONTINUED ON LIC 9099C. Unsubstantiated The allegation of “Staff did not respond to residents’ requests for assistance in a timely manner.” alleges that facility residents who press their call button have to wait an unacceptable amount of time for facility staff to respond to their requests for assistance. Throughout the investigation of this complaint LPAs Byrne and Cortez interviewed twelve (12) randomly selected residents of the facility. Eleven (11) residents interviewed did not express concerns with the amount of time it takes facility staff to respond to resident’s requests. Residents reported that staff have responded to a pendant press within as little as five (5) minutes but often within 10-15 minutes. LPA Byrne conducted unannounced tests of the signal alert system in four (4) resident units across multiple days of inspection. LPA received responses from the pendant presses that ranged from no less than four (4) minutes to no more than twenty-two (22) minutes. LPA interviewed ED-I who stated that the facility aims for a response time of no more than twenty (20) minutes. LPA observed the facility’s call button response logs from January 2026 - February 2026 and observed an average response time of approximately five (5) minutes. Of two hundred and fifty six (256) call responses in January and two hundred forty seven (247) call responses in February only sixteen (16) exceeded the facility's expected response time of twenty (20) minutes (Excluding outliers where the system was turned into the front desk for battery replacement and the call was not cleared on the system). Of those sixteen (16) only nine (9) response times exceeded twenty five (25) minutes. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not respond to residents’ requests for assistance in a timely manner.” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Staff did not provide residents with adequate food service.” alleges that the food served to residents is not good quality and the facility runs out of some meals to provide residents. LPA Byrne conducted a physical plant tour of the facility and observed the facility to have a sufficient supply of two (2) days perishable and seven (7) days non-perishable foods. LPA interviewed facility staff including the Director of Dining, a Sous Chef, and a Server. Staff interviewed stated that the facility offers an “Everyday menu” and a “Specials menu” for each meal service. Staff explained that the facility stocks approximately 200 portions of the items listed on the specials menu for each dining service as not every resident orders meals off of the specials menu. Staff stated that specials are changed daily and are offered on a first come first serve basis. Staff stated that once they run out of portions no additional special items are offered for the meal service. Staff reported that items on the everyday menu are always available for residents to order if the special items run out. Interviews with staff and residents revealed that there have been times where the food that is ordered takes longer than normal to be served to the residents and due to this delay residents were served cold meals. CONTINUED ON LIC 9099C. Residents interviewed stated that if notified staff will take the meal back to warm it up or will remake the meal. Staff interviewed confirmed that at resident’s request meals are reheated and denied ever refusing to reheat or remake a resident’s meal. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not provide residents with adequate food service.” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Facility does not have adequate activities for residents.” alleges that the facility has inadequate activities on the weekends, inadequate exercise activities, and activities that are not challenging/stimulating for residents. Throughout the investigation LPA interviewed twelve (12) residents. Residents interviewed who participated in activities did not have concerns about the amount of activities offered or the quality of the activities. Residents informed LPA that the facility offers a wide variety of activities and residents lead some of the activity groups offered. LPA interviewed staff members who participated in facilitating resident activities. Staff stated that the facility offers a wide variety of activities for residents to participate in. Staff provided examples of activities including: creative writing, improve classes, poetry, grief and loss support, painting, gardening, a men’s club, elders alliance, live music, bingo, charades, misc. games, etc. LPA observed the facility’s activity calendar across multiple days of inspection and observed an average of four (4) exercise (body) activities, four (4) mind activities, one (1) music (Comfort) activity, five (5) social (Connection) activities, and four (4) creative activities offered on a daily basis. LPA interviewed Executive Director (ED) Grace Hartnett who informed LPA that the facility had let go of their previous fitness director in November of 2025 but the facility was in the process of interviewing individuals to fill the role. LPA interviewed ED-I who informed LPA that a new Fitness Director was hired on 02/11/2026. ED-I denied any resident complaints about the new Fitness Director. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Facility does not have adequate activities for residents.” Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, May 6, 2026 · control 29-AS-20260115163431

Allegation investigated: Staff touched resident inappropriately Staff do not safeguard resident's belongings

Licensing Program Analyst (LPA) Trevor Byrne conducted an initial complaint visit for the above allegations. LPA arrived to the facility at 09:56 AM. LPA met with Interim Executive Director Justine Ortiz (ED-I). Entrance interview conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a brief physical plant tour, conducted a file review for one (1) resident, collected copies of pertinent documentation, interviewed the ED-I, Enliven Director (MC) Yasmin Hernandez, two (2) staff members, and one (1) resident between approximately 10:00 AM and 03:30 PM. CONTINUED ON LIC 9099C. Unsubstantiated The allegation of “Staff touched resident inappropriately” alleges that facility staff inappropriately touched Resident #1 (R1) when applying Medication #1 (M1) to R1’s groin area. LPA reviewed R1’s resident file and observed that R1 resides in the memory care wing of the facility and had a diagnosis of Dementia. LPA observed a previously valid prescription of M1 that was ordered on 12/30/2025. Additionally, LPA observed an order from R1’s physician dated 04/21/2026 ordering the discontinuation of M1 per R1’s Power of Attorney’s (POA)’s request. LPA interviewed MC who stated that they were aware of the allegation that staff had touched R1 inappropriately when administering M1 to R1’s groin. MC stated that the facility had conducted an internal investigation and found no evidence of wrongdoing by facility staff that were involved in providing care to R1. MC stated that M1 was ordered by R1’s physician to be applied but R1 refused application of M1 on each occasion that it was attempted. MC stated that they received an order from R1’s physician to discontinue the application of M1 and M1 was subsequently disposed of. LPA interviewed Staff #1 (S1) who was the staff member responsible for the application of M1 to R1. S1 stated that when M1 was originally ordered R1 was compliant with the daily application of M1. S1 stated that each time before the application of M1 they explained what the medication was and the procedure they were going to use to apply the medication. S1 stated that R1 began refusing the application of M1 after a change in the frequency of administration. S1 denied ever forcing R1 to have M1 applied. St denied ever touching R1 inappropriately during the administration of M1 and stated that M1 was applied as prescribed by R1's physician. LPA interviewed R1 who reported that they did not have any issues with the quality of care staff provide them. R1 stated that staff respect their personal space and boundaries. R1 stated that they were unaware if a staff member had ever touched them inappropriately, but they don’t believe it had happened. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff touched resident inappropriately.” Therefore, the allegation is deemed Unsubstantiated at this time. CONTINUED ON LIC 9099C. The allegation of “Staff do not safeguard resident's belongings” alleges that staff had stolen items from R1’s room including a TV remote and liquids including shampoos and lotions. LPA reviewed R1’s file and observed that R1 resided in the memory care wing of the facility and had a diagnosis of dementia. LPA interviewed R1 who stated that they had observed personal care items missing from their room. R1 stated that items such as shampoos, lotions, nail polish/clippers, and cosmetics were taken by facility staff and had gone missing. During the tour of R1’s room LPA observed the remote for R1’s television located on the arm of their lounge chair. LPA interviewed the MC who stated that because R1 resides in memory care all personal hygiene items and grooming supplies are stored in a secured storage due to the habits of the residents who reside in memory care. MC stated that R1’s personal grooming items including nail supplies, shampoos, and lotions are stored in a secure storage under the sink in R1’s bathroom and the items can be accessed by facility staff. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff do not safeguard resident's belongings.” Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, May 6, 2026 · control 29-AS-20260429143522

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Quoc Huynh and Trevor Byrne arrived at the facility unannounced to conduct the required annual visit beginning at 11:18 AM. LPAs met with facility Executive Director (ED) Grace Hartnett. Entrance interview conducted and the reason for the visit was explained. The facility has three (3) floors divided into separate areas of memory care, assisted living, and independent living occupants. The facility is licensed in Building A on the 1st, 2nd and 3rd floor and In Building B, only on the 2nd floor as an RCFE. Beginning at approximately 12:30 PM, the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: There are One-Hundred sixty-three (163) bedrooms in the facility, one-hundred and forty one (141) are assisted living bedrooms and twenty two (22) are memory care bedrooms. LPA and the facility Administrator toured sixteen (16) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA tested the emergency pull cords in two (2) resident rooms. The staff's response time did not exceed six (6) minutes. BATHROOMS: All resident bedrooms in the facility have attached private bathrooms and shared bathrooms are located throughout the common areas of the facility. All bathrooms LPA inspected were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 106.0 and 113.7 degrees Fahrenheit, which is in compliance with regulation. Continued on LIC 809C. KITCHEN/DINING ROOM: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed the kitchen to contain adequate emergency food supplies. LPA observed the kitchen entrance to be under staff observation. LPA observed the dining room to be clean and properly furnished at the time of the visit. The dining room contained adequate seating and tables for resident use. COMMON AREAS: LPA observed cameras to be located throughout the facility’s hallways. LPA observed the facility’s activities room, libraries, theater, salon, art gallery, and gym. All common area rooms were observed to be clean and in good repair. All furniture observed was in adequate condition and was free from rips and tears. LPA observed locked janitorial closets and laundry rooms throughout the facility’s hallways. The facility had adequate indoor space to accommodate resident’s activities. LPA observed the entryway of the facility to contain two (2) properly screened fireplaces. LPA observed fire extinguishers located throughout the facility to be last serviced on 08/18/2025. LPA observed the facility’s fire alarms, fire doors, emergency power generator, elevators, and sprinkler system to be certified through 10/31/2027 and 05/31/2028. LPA observed the stairwells of the facility to be clear and all stairwells were observed to contain evacuation chairs. OUTDOOR SPACE: LPA observed the outdoor spaces of the facility. LPA observed two (2) terraces and one (1) outdoor yard. LPA observed the outdoor yard to contain an appropriately fenced off pool, a greenhouse, and planter boxes utilized for resident activities. LPA observed clear passageways for emergency exit use. MEDICATION REVIEW: Medication review began at 03:56 PM. Medications are stored centrally and securely in two (2) medication rooms located in each wing of the facility. LPAs observed medications for five (5) residents. All medications were observed to be documented appropriately on their respective centrally stored medication and destruction record sheets. INTERVIEWS: LPAs interviewed five (5) residents and six (6) staff members. All residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. All staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. Continued on LIC 809C. RECORD REVIEW: Record review began at 12:47 PM. Staff and resident records were reviewed for documents including, but not limited to: TB test, physician's report, needs and service appraisal, consent forms, admission agreements, and personal rights. Ten (10) resident files were reviewed. All resident files contained all required documentation and signatures. Ten (10) staff files were reviewed. All staff files contained all required documentation and trainings. No deficiencies were observed during record review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. The facility’s emergency disaster plan is up to date and is adequate. Disaster drills are conducted quarterly and the facility's last emergency disaster drill was conducted on 02/13/2026. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. During today’s visit LPAs obtained a copy of the facility’s emergency disaster plan, resident roster, LIC 500. Administrator agreed to email LPA a copy of the liability insurance no later than end of day 03/06/2026. No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 5, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Quoc Huynh and Trevor Byrne arrived to the facility begining at 11:18 AM to conduct an unannounced Case Management - Deficiencies visit at the facility today. LPA met with facility Executive Director (ED) Grace Hartnett entrance interview conducted and the reason for the visit was explained. The purpose of today’s visit was to follow-up on two (2) self-reported incidents that occurred on 01/26/2026 and 02/14/2026 and one (1) self-reported death report that occurred on 01/29/2026. During today’s visit, the LPA conducted a physical plant tour and an interview with the Executive Director (ED) between approximately 11:25 AM and 04:30 PM. On 02/11/2026 at 06:59 PM Community Care Licensing Division (CCLD) received a self-reported incident report regarding an incident that occurred on 01/26/2026. On 02/27/2026 at 09:56 PM CCLD received a self-reported incident report regarding an incident that occurred on 02/14/2026. On 02/11/2026 at 05:27 PM CCLD received a self-reported Death report regarding an death that occurred on 01/29/2026. LPA interviewed the ED and asked why the reports were not submitted to CCLD in a timely manner. ED explained that they were investigating whether a previous fall was reported but otherwise did not have a justification as to why the incidents and death was reported to CCLD outside of the required timeframe. LPA informed ED that a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence any incident which threatens the welfare, safety or health of any resident or the death of any resident from any cause regardless of where the death occurred. ED confirmed that they are aware of the reporting requirement and agreed to submit the list of individuals from the facility who will be responsible for submitting reports to CCLD in a timely manner for all future reports. Pursuant to Title 22, California Code of Regulations, the following deficiency was cited (refer to LIC 809-D.) Exit interview conducted and copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Mar 5, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Mar 19, 2026

87211 Reporting Requirements (a) Each licensee shall furnish...: (1) A written report shall be submitted to... licensing... within seven days of the occurrence of any of the events specified in (A) through (D) below… This requirement is not met as evidenced by: Based on record review and interview the licensee did not comply with the section cited above as two incident reports and one death report were not submitted to licensing within the required timeframe which posed a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Mar 5, 2026

Plan of correction: ED agreed to submit the list of individuals from the facility who will be responsible for submitting reports to CCLD in a timely manner. Additionally, ED agreed to submit a statement of understanding which confirms that they will adhere to the 7-day reporting requirements for all future incidents. ED agreed to submit the documents to CCLD no later than POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 10:14 AM to conduct an unannounced Case Management - Deficiencies visit at the facility today. LPA met with facility Executive Director (ED) Grace Hartnett and the Director of Assisted Living (DOAL) Yamilette Capilla entrance interview conducted and the reason for the visit was explained. The purpose of today’s visit was to follow-up on a self-reported incident that occurred on 10/04/2025. During today’s visit, the LPA conducted interviews with the Executive Director (ED) and the Director of Assisted Living (DOAL), reviewed Resident #1’s (R1) medication administration record (MAR), and collected copies of pertinent documentation between approximately 10:20 AM and 11:48 AM. Continued on LIC 809C. The 10/04/2025 self-reported incident report stated that R1 had missed administration of Medication #1 (M1) between 09/30/2025-10/03/2025. DOAL conducted a review of R1’s medications on 10/04/2025 and observed that M1 had not been given as prescribed since 09/29/2025. On the 11/06/2025 visit to the facility the DOAL stated that there was verbal communication between facility staff and R1's prescribing physician to hold the administration of M1 pending lab results. During today’s visit the facility was unable to provide documentation of the physician’s orders to hold administration of M1. LPA observed R1’s MAR to contain entries of administered M1 between 10/05/2025 to 10/16/2025. LPA did not observe MAR entries for R1’s M1 administration between 09/30-10/03. LPA observed a physicians order to hold M1 administration dated 10/09/2025, LPA did not observe any further orders to resume M1 administration. DOAL informed LPA that the entries were not cleared at the time of the administration and were cleared at a later date by a different med tech. DOAL stated that because of this, notes were unable to be added noting that the medication was not administered on those dates. DOAL provided LPA with signed statements from the Med tech on duty and the med tech that cleared the entries stating that M1 was not given to R1 on 10/16, 10/15, 10/10, or 10/09. LPA informed the ED and DOAL that they were recently cited for a violation of CCR 87465(a)(4) on 10/01/2025. LPA informed ED and DOAL that a civil penalty in the amount of $250 is being assessed on today’s date (11/19/2025) for a repeat violation of the same licensing regulation within a twelve (12) month period. DOAL stated that med techs and nurses had been given mandatory training on 11/13/2025 which included a review of title 22 regulations regarding medication management and the importance of adhering to policies and procedures regarding medication administration/tracking. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency and civil penalty were cited (refer to LIC 809-D): Exit interview conducted with DOAL and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 19, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and interview the licensee did not comply with the section cited above as R1 missed administration of their prescribed Torsemide between 09/30/2025-10/03/2025 which posed a potential health risk to clients in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: The facility had conducted in-service training with the team responsible for administering R1's medications. POC cleared at the time of the visit.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:49 AM to conduct an unannounced Case Management - Deficiencies visit at the facility today. LPA met with facility Executive Director (ED) Grace Hartnett entrance interview conducted and the reason for the visit was explained. The purpose of today’s visit was to follow-up on two (2) self-reported incidents that occurred on 10/04/2025 and 10/12/2025. During today’s visit, the LPA conducted interviews with the Executive Director (ED) and the Director of Assisted Living (DOAL), conducted a file review for one (1) resident, and conducted a medication review for one (1) resident between approximately 09:52 AM and 01:50 PM. On 11/04/2025 at 6:37 PM and on 11/05/2025 at 1:32 PM Community Care Licensing Division (CCLD) received two (2) self-reported incident reports pertaining to Resident #1 (R1). The two incidents occurred at the facility on 10/04/2025 at 11:00 AM and on 10/12/2025 at 10:00 AM. LPA interviewed the ED and DOAL and asked why the reports were not submitted to CCLD in a timely manner. ED and DOAL explained that a combination of confusion between R1's hospice company not receiving a medication order and the DOAL being out sick from the facility during the times the incidents occurred both contributed to the incident reports being submitted outside of the required time frame. LPA informed ED and DOAL that a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence any incident which threatens the welfare, safety or health of any resident. ED and DOAL confirmed that they are aware of the reporting requirement and agreed to submit all future reports to CCLD in a timely manner and ensure someone in leadership is available to review/approve reports for submission to CCLD in the event of an absence of the ED or DOAL. Continued on LIC 809C. The 10/04/2025 self-reported incident report stated that R1 had missed administration of Medication #1 (M1) between 09/30/2025-10/03/2025. DOAL conducted a review of R1’s medications on 10/04/2025 and observed that M1 had not been given as prescribed since 09/29/2025. DOAL stated that there was verbal communication between facility staff and R1's prescribing physician to hold the administration of M1 pending lab results. LPA determined that further investigation into the missed medication administration is needed prior to determining if a citation is warranted. LPA informed ED that CCLD may return at a later date if it is determined that the issuance of a citation or assessment of a civil penalty is deemed warranted for this incident. ED expressed understanding and agreed to submit any relevant documentation to LPA for review. Pursuant to Title 22, California Code of Regulations, the following deficiency was cited (refer to LIC 809-D.) Exit interview conducted and copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Nov 6, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 20, 2025

87211 Reporting Requirements (a) Each licensee shall furnish...: (1) A written report shall be submitted to... licensing...within seven days of... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on record review and interview the licensee did not comply with the section cited above as two incident reports pertaining to incidents involving R1 were not submitted to licensing within the required timeframe which posed a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: ED and DOAL agreed to submit a written statement confirming that all future reports will be submitted to CCLD within the required timeframe and will ensure someone in leadership is available to review/approve reports for submission to CCLD in the event of an absence of the ED or DOAL. ED and DOAL agreed to submit their plan on how they will ensure adequate coverage to review/submit reports along with the signed statement mentioned above to CCLD no later than POC due date.

Allegation investigated: Staff did not conduct a proper medical assessment of resident. Staff did not provide resident with a copy of admissions agreement. Staff overcharged resident. Staff coerced resident to sign documents.

Licensing Program Analyst (LPA) Trevor Byrne conducted an initial complaint visit for the above allegations. LPA arrived to the facility at 10:03 AM. LPA met with Executive Director Grace Hartnett. Entrance interview conducted and the reason for the visit was explained. On September 09, 2025, the Department received a complaint alleging that facility staff did not conduct a proper medical assessment of resident #1 (R1), staff did not provide R1 with a copy of admissions agreement, staff overcharged R1, and staff coerced R1 to sign documents. During today’s visit, the LPA conducted a file review for R1, collected copies of pertinent documents, and conducted interviews with the Executive Director (ED), the Director of Assisted Living (DOAL), and the Business Office Manager (BOM) between 10:05 AM and 11:53 AM. Continued on LIC 9099C. Unfounded Interviews with ED and BOM revealed that Resident #1 (R1) resided in the building but was an “Independent Living” resident residing in an independent living apartment which is not part of the facility license. The resident did not receive services from the Residential Care Facility for the Elderly (RCFE) component of the facility. A review of R1’s Residency and Service Agreement dated 07/08/2025 specified in the contract that the agreement did not entitle the resident to receive services in the RCFE component of The Village at Sherman Oaks and that the contract was not a Continuing Care or RCFE Contract. A review of the facility roster also did not reflect R1 as a resident of the licensed portion of the facility. Based on the information obtained, R1 did not reside in the licensed portion of the facility and did not receive any elements of care or supervision from the licensee. Therefore, the allegations of facility staff did not conduct a proper medical assessment of R1, staff did not provide R1 with a copy of admissions agreement, staff overcharged R1, and staff coerced R1 to sign documents are deemed UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 29-AS-20250925224237

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 10:03 AM to conduct an unannounced Case Management visit at the facility today. LPA met with facility Executive Director (ED) Grace Hartnett entrance interview conducted and the reason for the visit was explained. The purpose of today’s visit was to follow-up on a self-reported incident that occurred on 09/17/2025. During today’s visit, the LPA conducted interviews with the Executive Director (ED), the Director of Assisted Living (DOAL), and the Business Office Manager (BOM) between 10:05 AM and 11:53 AM. The self-reported incident report stated that Resident #1 (R1) had missed administration of Medication #1 (M1) on 09/17/2025. DOAL and facility staff conducted a review of the resident’s medications and observed that M1 had not been on hand at the facility since 08/04/2025. DOAL made contact with R1’s hospice company on 09/17/2025 and obtained a refill of M1 that same day. R1’s family was notified of the incident at the time of its occurrence. R1 was medically evaluated by a hospice nurse at the time of the incident and no adverse reactions to the missed medications were noted. The facility has since conducted in-service training with the employees involved and has coordinated with the hospice company, veterans affairs, and R1’s family to ensure there is no further delays in obtaining R1’s medications. During today’s visit ED provided LPA with a copy of the facility’s in-service training sign-in sheet that was conducted in response to this incident. Pursuant to Title 22, California Code of Regulations, the following deficiency was cited (refer to LIC 9099-D.) Exit interview conducted and copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Oct 1, 2025

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

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and interview the licensee did not comply with the section cited above as R1 missed administration of their prescribed Olanzapine between 08/04/2025-09/16/2025 which posed a potential health risk to clients in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: The facility had written up the involved employees, conducted in-service training with the involved employees, and contacted hospice, the VA, and R1's family to ensure no further confusion occurs with obtaining R1's medications. POC cleared at the time of the visit.

Allegation investigated: Facility staff did not ensure residents responsible parties received written notice of rate increase.

Licensing Program Analyst (LPA) Erica Mosley conducted an initial 10-day complaint visit to investigate the above allegation. Upon arrival approx at 9:50 a.m., LPA Mosley was greeted by front desk staff who informed LPA that the Executive Director (ED) will not be in until 11 a.m. and stated they would called the ED to inform them of the visit. At 10:10 a.m. LPA met with Director of Assisted Living, Yamilette Caprilla and the reason for the visit was explained. Entrance interview conducted. On 08/20/2025, the Department received a complaint regarding the following allegation, Facility staff did not ensure residents responsible parties received written notice of rate increase. During today's visit at 10:12 a.m. LPA and staff briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. Starting at 10:28 a.m. conducted a file review for Resident #1 (R1), At 10:50 a.m. and 11:00 a.m. conducted two (2) in-person interviews, with the Business Manager and Executive Director (ED), and obtained copies of pertinent documents relevant to the investigation.Report continued on LIC 9099-C PAGE 2... Substantiated (PAGE 2) Report continued from LIC 9099...On the allegation Facility staff did not ensure Residents Responsible Parties (RRP) received written notice of rate increase, it is the concern of the Reporting Party (RP) that R1’s RRP received a bill dated 07/23/2025 with a $500 rent increase without proper notice. To investigate this complaint, LPA Byrne contacted R1's RRP on 08/22/2025 at 10:25 a.m., on 08/25/2025 starting at 10:28 a.m. LPA Mosley conducted a file review for Resident #1 (R1) starting at 10:50 a.m. conducted two (2) in-person interviews, with the Business Manager and at 11:00 a.m. with the ED, and obtained copies of pertinent documents relevant to the investigation. Interview with R1's RRP revealed that they were out of the country and got a bill via email with an invoice reflecting an increase of $500 however never received a notice. R1's RRP stated once they got back from vacation they went in person to ask why there was an increase in August and was told by the finance manager that it was a yearly increase. R1's RRP informed the finance manager that they never got a notice. Interview with Business Manager revealed that an official notice was sent on 06/13/2025 via mail reflecting the rate change to $9,255 effective 08/12/2025 giving a 90-day notice as stated in the admission agreement. It was later noted that there was a mistake and the date was auto populated with a 60 day vs 90 day notice. Interview with the ED revealed that the rent increase notice was sent on 06/13/2025 however there must have been a glitch as they adhere to the 90 day notice per regulation. LPA reviewed facility’s Admission Agreement. Per the admission agreement, under section PART B. 6 Fees, subsection d adjustments to fees: Generally we give sixty (60) days' written notice of any change in the Monthly fee... During today’s visit, LPA clarified that, pursuant to updated Health and Safety regulation effective January 2025, on and after January 1, 2025, a licensee must provide no less than 90 days written notice for rate increases. The written notice must include the amount of the increase, the reason or reasons for the increase, and a description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident (PIN 24-08-ASC page 4-5). LPA requested a revised version of facility’s admission agreement under PART B. 6 Fees, subsection d adjustments to fees: to reflect new changes. It was noted that a 60 day notice was given however a 90 notice is required per regulation. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that “Facility staff did not ensure residents responsible parties received written notice of rate increase” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 25, 2025 · control 29-AS-20250820110652

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655 · Plan of correction due date: Sep 8, 2025

1569.655 (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents...the licensee shall provide no less than 90 days' prior written notice...the amount of the increase...This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when they issued a general rate increase with less than 90 days’ notice, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 25, 2025

Plan of correction: Executive Director will rescind letter issue to RRP and issue a new one with correct effective date and submit proof that the admission agreement section Fees has been updated to reflect 90 days instead of 60 days. (POC cleared on site)

Allegation investigated: Staff are not properly addressing pest infestation in the facility

Licensing Program Analyst (LPA) Trevor Byrne conducted an initial complaint visit for the above allegation. LPA arrived to the facility at 10:03 AM. LPA met with Executive Director Grace Hartnett (ED). Entrance interview conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a physical plant tour to ensure there are no health and safety hazards, conducted a facility file review, obtained copies of pertinent documentation, interviewed two (2) staff and the ED between 10:05 AM and 11:30 AM. Continued on LIC 9099C. Unsubstantiated The allegation of “Staff are not properly addressing pest infestation in the facility” alleges that the facility was experiencing an active cockroach infestation in the dry food storage room of the kitchen area and facility staff were not taking appropriate measures to address the problem. Interviews with ED, staff #1 (S1), and staff #2 (S2) revealed that the facility had an inspection by a County of Los Angeles Department of Public Health, Health Inspector (W1) on 07/08/2025. LPA reviewed the inspection report from 07/08/2025 and observed the following. The inspection began at 02:18 PM and was concluded at 03:24 PM. During this inspection W1 observed approximately ten (10) live adult and nymph German cockroaches on inside the dry storage room, under the ice making machine. Additionally, W1 observed five (5) cockroach eggs and dead cockroaches on the floor, inside the dry storage room. Interviews with ED, S1, and S2 revealed that after learning of the infestation in the dry storage room facility staff took measures to immediately address the infestation. An interview with ED and a review of the facility’s pest control records revealed that the facility contacted a pest control specialist from Orkin and treatment was performed on 07/09/2025 between 03:58 AM and 04:50 AM. A review of the treatment record revealed that treatments for a cockroach infestation were applied to the kitchen and storage areas. The service invoice stated that Orkin will be providing a follow-up service to monitor the status of the treatment on the week following the initial treatment (07/14/2025-07/18/2025). Additionally, LPA observed the yearly pest control record for the facility. The facility’s last pest control service was conducted on 04/23/2025 and included treatments and preventions for cockroaches in the kitchen and dry food storage area. The interview with S1 revealed that in addition to the pest control treatment, facility staff removed all items from the dry storage room and performed a deep cleaning from floor to ceiling. Facility staff additionally removed all food from cardboard boxes and secured food items into plastic storage bins with tight fitting lids. S1 stated that facility staff sealed off two (2) of the three (3) drains in the floor and replaced the ice maker drainage tube to ensure proper function. Additionally, after all repairs, treatment, and cleaning were completed facility staff repainted the room. All staff interviewed stated that they have not observed cockroaches since the initial treatment and repairs. During the physical plant tour LPA observed the dry storage room, the kitchen, and the dining area. LPA did not observe any signs of a cockroach infestation during the tour of these areas. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff are not properly addressing pest infestation in the facility.” Therefore, the allegation is deemed Unsubstantiated at this time. A copy of the report was printed and exit interview was conducted.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 29-AS-20250709122724

Allegation investigated: Resident fell sustaining injuries due to lack of supervision Resident did not receive timely medical treatment

Licensing Program Analyst (LPA) Trevor Byrne conducted an initial complaint visit for the above allegations. LPA arrived to the facility at 11:47 AM. LPA met with Executive Director Grace Hartnett. Entrance interview conducted and the reason for the visit was explained. On June 2, 2025, the Department received a complaint alleging Resident fell and sustained injuries due to lack of supervision and Resident did not receive timely medical treatment. During today’s visit, the LPA conducted a file review for Resident #1 (R1), collected copies of pertinent documents, and conducted an interview with the Executive Director and one (1) independent resident between 12:00 PM and 01:50 PM. Continued on LIC 9099C. Unfounded The interview with the Executive Director revealed that Resident #1 (R1) resided in the building but is an “Independent Living” resident residing in an independent living apartment which is not part of the facility license, and the resident does not receive services from the Residential Care Facility for the Elderly (RCFE) component of the facility. A review of R1’s Residency and Service Agreement dated 11/29/2016 specified in the contract that the agreement did not entitle the resident to receive services in the RCFE component of The Village at Sherman Oaks and that the contract was not a Continuing Care or RCFE Contract. A review of the facility roster also did not reflect R1 as a resident of the licensed facility. The interview with Independent resident #1 (I1) who was a family member of R1 and who also lives in an independent apartment in the building also confirmed that R1 was an independent resident and was not receiving services from the RCFE component of the facility. Based on the information obtained, R1 did not reside in the licensed facility and did not receive any elements of care or supervision from the licensee. Therefore, the allegations of Resident fell and sustained injuries due to lack of supervision and Resident did not receive timely medical treatment are deemed UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 29-AS-20250602101948

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 10:28 AM. LPA met with facility Administrator Grace Hartnett. Entrance interview conducted and the reason for the visit was explained. RECORD REVIEW: Record review began at 10:40 AM. Staff records were reviewed for documents including, but not limited to: TB test, physician's report, criminal record clearance, and first aid training. five (5) staff files were reviewed. All staff files contained all required documentation and trainings. No deficiencies were observed during record review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. The facility’s emergency disaster plan is up to date and is adequate. Disaster drills are conducted quarterly and the facility's last emergency disaster drill was conducted on 03/17/2025. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. During today’s visit LPA obtained a copy of the facility’s liability insurance. No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 3, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 02:17 PM. LPA met with facility staff who contacted the Assistant Manager and the Administrator Grace Hartnett. Entrance interview conducted and the reason for the visit was explained. INTERVIEWS: LPA interviewed five (5) staff members. All staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. RECORD REVIEW: Record review began at 02:40 PM. Resident records were reviewed for documents including, but not limited to: TB test, physician's report, needs and service appraisal, consent forms, admission agreements, and personal rights. Ten (10) resident files were reviewed. All resident files contained all required documentation and signatures. No deficiencies were observed during record review. During today’s visit LPA obtained a copy of the facility’s updated LIC 500. Due to time constraints LPA will return at a later date to conduct staff file review and to review the facility’s emergency disaster plan and infection control plan. No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 26, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Quoc Huynh and Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:57 AM. LPAs met with facility Administrator Grace Hartnett. Entrance interview conducted and the reason for the visit was explained. The facility has several floors divided into separate areas of memory care, assisted living, and independent living occupants. The facility is licensed in Building A on the 1st, 2nd and 3rd floor and In Building B, only on the 2nd floor. There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature at approximately 72 degrees. Beginning at 10:46 AM, the LPAs, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: There are One-Hundred sixty-three (163) bedrooms in the facility. LPAs and facilityAdministrator toured seventeen (17) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPAs observed one (1) resident room to contain a ripped balcony screen door. LPAs tested the emergency pull cords in two (2) resident rooms. The staff's response time did not exceed 10 minutes. BATHROOMS: All resident bedrooms in the facility have attached private bathrooms and shared bathrooms are located throughout the common areas of the facility. All bathrooms LPAs inspected were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 107.8 and 114.6 degrees Fahrenheit, which is in compliance with regulation. Continued on LIC 809C. COMMON AREAS: LPAs observed cameras to be located throughout the facility’s hallways. LPAs observed the facility’s activities room, libraries, theater, salon, art gallery, and gym. All common area rooms were observed to be clean and in good repair. All furniture observed was in adequate condition and was free from rips and tears. LPAs observed locked janitorial closets and laundry rooms throughout the facility’s hallways. The facility has adequate indoor space to accommodate resident’s activities. LPAs observed the entryway of the facility to contain an fireplace. It is appropriately screened and contains no tools. LPAs observed a fire extinguishers located throughout the facility to be last serviced on 08/28/2024. LPAs tested the facility’s fire alarm system at 01:50 PM. All alarms and fire doors observed functioned properly at the time of the test. OUTDOOR SPACE: LPAs observed the outdoor spaces of the facility. LPAs observed two (2) terraces and one (1) outdoor yard. LPAs observed the outdoor yard to contain an appropriately fenced off pool, a greenhouse, and planter boxes utilized for resident activities. LPAs observed one (1) of the terraces to have two (2) window screen frames that were observed to be in disrepair. KITCHEN/DINING ROOM: The LPAs observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPAs observed the kitchen to contain adequate emergency food supplies. LPAs observed the kitchen entrance to be under staff observation. LPAs observed the dining room to be clean and properly furnished at the time of the visit. The dining room contains adequate seating and tables for resident use. MEDICATION REVIEW: Medication review began at 02:00 PM. Medications are stored centrally and securely in two (2) medication rooms located in each wing of the facility. LPAs observed medications for seven (7) residents. One (1) resident’s medications were observed to be documented incorrectly on their centrally stored medication and destruction record sheets. INTERVIEWS: LPAs interviewed five (5) residents. All residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. Continued on LIC 809C. During today’s visit LPAs obtained a copy of the facility’s resident roster. Due to time constraints LPAs will return at a later date to conduct employee interviews, conduct resident and staff file review, review the facility’s emergency disaster plan and infection control plan, and to obtain copies of the facility’s LIC 500 and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 17, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:37 AM to conduct an unannounced Case Management visit at the facility today. LPA met with facility Executive Director (ED) Grace Hartnett entrance interview conducted and the reason for the visit was explained. The purpose of today’s visit was to follow-up on a self-reported incident that occurred on 02/02/2025. During today’s visit between 09:45 AM and 10:45 AM LPA conducted a brief physical plant tour, interviewed the Executive Director and The Director of Assisted Living Yamilette Capilla. Additionally, LPA conducted a file review and obtained copies of pertinent documentation. The self-reported incident report stated that Resident #1 (R1) had self-administered opioid medications and suffered a medical emergency. ED stated that R1 had snuck medications into the facility without staff’s knowledge. ED stated that R1 is enrolled with the facility’s medication management program and is not permitted to store their own medications. ED stated that the facility has implemented room sweeps, pauses on deliveries to R1’s room, and additional care checks for R1 to prevent this behavior. Additionally, ED has had conversations with the responsible party (RP) for R1 in an effort to mitigate this behavior in the future. LPA was unable to interview R1 at the time of the inspection as they were out of the facility. Further investigation is needed prior to determining if citations are warranted. LPA will return at a later date to inform ED of the outcome of the investigation. No deficiencies were cited during today’s inspection. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 7, 2025

Allegation investigated: Neglect/Lack of Care and Supervision: Staff failed to provide adequate supervision to Resident #1 (R1) resulting in a fall and head injuries. Staff falsified incident report regarding resident in care.

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met with Grace Hartnett and explained the reason for the visit. On 03/19/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding neglect/ lack of care and supervision. The complaint alleged that staff did not provide adequate supervision to Resident #1 (R1) who was a fall risk by leaving R1 alone in the bathroom, resulting in R1 sustaining a fall causing injuries to head and face. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Laura Garcia. On 03/20/2024, from 12:30 p.m. to 3:30 p.m., LPA Balisi conducted an unannounced complaint visit. At approximately 1:00 p.m., the LPA conducted a physical plant tour, interviewed staff, and reviewed and obtained copies of pertinent documents relevant to the investigation. Unsubstantiated continued from 9099 On 05/14/2024, at approximately 11:20 a.m., Investigator Garcia conducted interviews with R1’s resident representative; on 05/25/2024, from approximately 11:00 a.m. to 1:30 p.m., with Memory Care Director, Med Tech, and staff; on 07/23/2024, from approximately 3:00 p.m. to 3:30 p.m., with facility physical therapist, Affinity Healthcare Resource Center Director of Nurses, and Resident #2’s (R2’s) resident representative. Investigator Garcia attempted to conduct interviews with the reporting party and facility nurse practitioner on several dates from 03/26/2024 to 07/23/2024, left voice mails, but no contact was made possible. In addition, the investigator reviewed Kaiser medical records and facility file documents related to R1. According to R1’s Physician Report, dated 12/20/2022, R1’s diagnosis was listed as dementia with behavioral disturbance. Other conditions included confused, disoriented, sundowning, and a fall risk. The report indicated R1 needed assistance with bathing, dressing, grooming and toileting. The review of the incident report submitted by the facility, indicated on the morning of 09/29/2023, 9:30 a.m., R1 was restless during breakfast, constantly trying to stand up. R1 then requested to go to the bathroom and Staff #1 (S1) assisted R1 to the bathroom. While R1 was sitting on the toilet, S1 turned away from R1 to reach for the wipes, when R1 stood up and fell off the toilet. S1 did not see R1 hit their head but heard a loud thud. Med Tech was notified to assess the injury. R1 sustained discoloration on right side of face and sustained a bump on the back of head. The report further stated R1 was alert and talkative. The Paramedics were called via 911 and R1 was taken to Kaiser Panorama City. R1’s resident representative was notified via phone call. R1’s Primary Care Physician (PCP) was notified via fax, and Kaiser Registered Nurse (RN) from the Geriatrics Department was notified via phone call. The report documented R1 sustained an abrasion to head. R1 returned to the facility the same day with a diagnosis of Urinary Tract Infection (UTI), prescribed antibiotics, and placed on frequent checks continued from 9099-C The review of the Kaiser medical records revealed R1 arrived at the Emergency Room (ER) on 09/29/2023 at 10:11 a.m., with the chief complaint listed as fall with a cause of injury listed as accidental fall, other diagnosis included bone lesion, left lower leg; UTI; and major vascular neurocognitive disorder, unspecified severity, without behavioral disturbance. The records indicated past medical history of lacunar stroke c/b vascular dementia. The records also noted information provided by R1’s resident representative indicated R1 “has a history of multiple falls, is typically in a wheelchair but likes to get up and walk but has unsteady gait so falls often”. X-rays revealed no acute fracture or malalignment identified, no significant joint disease in the hips. R1 was discharged 09/29/2023 with a diagnosis of UTI. The information obtained through the Department’s interviews was consistent with the information documented in the incident report and the medical records. The Memory Care Director explained that preventive measures were implemented for R1 due to R1’s “high risks for falls” such as providing R1 with a low-rise bed, security mats, alarms when R1 attempts to get out of bed, constant supervisions, frequent checks, and staff adaptations such as encouraging R1 or transferring R1 to the common areas to maintain direct supervision. In addition, R1’s resident representative confirmed that on the day of the incident 09/29/2023, R1 was in the bathroom being assisted by a caregiver. R1’s resident representative was not able to recall details of the incident, however, advised that the caregivers acted accordingly and immediately rendered first aid while contacting paramedics. R1’s resident representative deemed it accidental and reiterated that they did not have any issues regarding the level of care provided. R1’s resident representative denied ever witnessing any lack of supervision or neglect and denied previously having any complaints or issues that were never addressed by the facility staff members. Based on the statements and documentation provided, the Department found insufficient evidence to determine if there was negligence or lack of supervision on behalf of the facility. Continued from 9099-C Therefore, the allegation of “Neglect/Lack of Care and Supervision: Staff failed to provide adequate supervision to Resident #1 (R1) resulting in a fall and head injuries” is deemed to be Unsubstantiated at this time. It was reported that "Staff falsified incident report regarding resident in care" as it was alleged that Staff #2 (S2) did not notate that S1 left R1 unsupervised , when R1 fell. Interviews and record reviews revealed that when a fall or any incident affecting a resident’s health and safety occurs, the staff member who witnessed the incident writes a report and gives it to the med tech for review. The report is then reviewed internally by corporate and sent to the Executive Director, who forwards it to the Regional Office and any other agencies that need to be notified about unusual incidents. Interviews with six staff members indicated that they all recalled the same details of the incident that occurred on the morning of September 29, 2023, at 9:30 a.m., which were consistent with what was sent to the Regional Office. All six staff members expressed no concerns about any staff falsifying incident reports at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff falsified incident report regarding resident in care” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Sep 20, 2024 · control 29-AS-20240319161408

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240319161408). LPA met with Executive Director Grace Hartnett and explained the reason for the visit. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. At approximately 9:45 a.m., the LPA reviewed Resident #1 (R1)'s records and found that R1's physician's report (LIC 602) was dated December 20, 2022. The needs and services plan was last updated on June 12, 2024. According to Executive Director Grace Hartnett, staff have made multiple attempts to obtain the LIC 602 from Kaiser but have been unsuccessful. Staff contacted Kaiser again today, September 20, 2024, to request an updated LIC 602 and will inform the LPA once it is received. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed and copy of reports issued.the state’s words, verbatim · CDSS document, Sep 20, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Oct 4, 2024

Each resident with dementia shall have an annual medical assessment as specified in section 87458, medical assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident' dementia care needs. This requirement is not met as evidenced by: Based on record review, the licensee did not comply witht he section cited above as R1 Physician's report (LIC602) is dated 12/20/2022 which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 20, 2024

Plan of correction: Licensee agreed to obtain an updated LIC 602 and send to LPA via email by 10/04/2024 COB.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Trevor Byrne and Erica Mosley conducted an unannounced case management visit in regard to a self-reported incident that occurred on 08/06/2024. On that date Resident # 1 (R1) was administered the incorrect medication by Staff #1 (S1). S1 then informed the Enlivin Director (S2) of the error. R1 experienced a vomiting episode and was placed on monitoring by the resident’s physician. Between 01:14pm – 02:30pm, LPAs conducted a brief physical plant tour, interviewed staff and reviewed pertinent documentation relevant to the incident. Interviews conducted and records review revealed that community staff followed the appropriate reporting procedures and complied with the resident’s physician’s recommendations for monitoring. An in-service training was conducted on six (6) resident rights and avoiding medication errors. Three (3) staff including S2 attended the in-service. S1 at the time of the visit had terminated their employment with the facility. Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.the state’s words, verbatim · CDSS document, Aug 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 13, 2024

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.the state’s words, verbatim · CDSS document, Aug 13, 2024

Plan of correction: Facility has conducted an in service training on 6 resident rights and avoiding medication errors. S2 attended and S1 has terminated their employment at the facility. POC cleared.

Allegation investigated: Staff leaves resident soiled for an extended period of time. Staff speak inappropriately about residents to other staff. Staff do not properly dispose resident's diapers. Staff do not clean soiled furniture. Staff leaves residents unsupervised for an extended period of time. Staff do not include resident(s) in outside activities. Staff do not follow proper hand washing practices. Staff do not wear protective masks when sick.

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with Executive Director Grace Hartnett and explained the reason for the visit. On 11/03/2023, from 10:00 a.m. – 3:00 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, interviewed private caregivers, interviewed staff, and reviewed and obtained pertinent documents relevant to the investigation. On 04/29/2024, from 10:00 a.m. – 3:00 p.m. LPA conducted a subsequent visit and conducted physical plant and interviewed family members of residents in care. On 05/28/2024, at approx. 01:15 p.m. LPA interviewed Resident #1 (R1)’s case worker (CW). It was reported that “Staff leaves resident soiled for an extended period of time, as it was alleged that R1 is not provided incontinent services in a timely manner. Unsubstantiated Continued from 9099 Interviews conducted with six (6) private caregivers and six (6) staff, reflected that residents who require incontinent services are provided upon request and resident diapers are checked at least three (3) times per shift, once before a caregivers shift starts, again after meals and commonly before a caregiver’s shift ends. All twelve (12) parties interviewed above never observed any resident left in soiled diapers for an extended period. LPA’s interview with seven (7) family members / responsible parties of residents in care revealed they did not express any immediate or potential concerns for residents not provided incontinent services in a timely manner. LPA’s interview with R1’s Case worker further revealed they have never been informed of R1 being left in soiled clothing or diapers for an extended period. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff leaves resident soiled for an extended period of time” is deemed Unsubstantiated at this time. It was reported that “Staff speak inappropriately about residents to other staff” as it was alleged that staff are making inappropriate comments to resident’s private caregivers. Interviews conducted with six (6) private caregivers, six (6) staff, seven (7) family members / responsible parties of residents in care and R1’s case worker revealed that the twenty (20) parties interviewed above have not witnessed any staff speak inappropriately about residents. Each party interviewed also did not express any potential or immediate concerns that staff speak inappropriately about residents in care. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff speak inappropriately about residents to other staff” is deemed Unsubstantiated at this time. It was reported that “Staff do not properly dispose resident’s diapers”, as it was alleged that soiled diapers are not thrown away and are left around R1’s bedroom. Interviews conducted with six (6) private caregivers and six (6) staff revealed that all twelve (12) parties interviewed have not observed any soiled diapers laying around any resident’s room. In addition, the (12) parties interviewed revealed, that when a resident is provided incontinent care, staff bring a plastic bag with them so they can dispose of the soiled diaper in the plastic bag. Continued from 9099-C Once the service is complete the staff dispose the plastic bag in a trash container outside of resident's room. LPA’s interview with R1’s case manager and seven (7) family members / responsible parties of residents in care revealed they did not express any potential or immediate concerns for staff not disposing soiled diapers properly. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff do not properly dispose resident’s diapers,” is deemed Unsubstantiated at this time. It was reported that “Staff do not clean soiled furniture” , as it was alleged that a chair in R1’s room is often soiled and staff do not clean it in a timely manner. Interviews conducted with six (6) private caregivers, six (6) staff, and seven (7) family members / responsible parties of residents in care revealed that the nineteen (19) parties interviewed have never observed any piece of furniture soiled for an extended amount of time in resident bedrooms. Each party interviewed also did not express any potential or immediate concerns for any piece of furniture not being cleaned in a timely manner. In addition, LPA interview conducted with Staff #1 (S1) and R1’s case worker, revealed when a resident soils a piece of furniture it is cleaned right away by housekeeping staff. During the physical plant on 11/03/2023 and 04/29/2024, LPA observed chair in R1’s room to be clean and there was no evidence of the chair being severely soiled. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not clean soiled furniture” is deemed Unsubstantiated at this time. It was reported that “Staff leaves residents unsupervised for an extended period of time”, as it was alleged that residents in wheelchairs are left unsupervised for extended periods of times after activities. Interviews conducted with six (6) private caregivers, six (6) staff, R1’s case worker and seven (7) family members / responsible parties of residents in care revealed that the twenty (20) parties interviewed above, have never observed any resident left unsupervised. Each party interviewed also did not express any potential or immediate concerns for any resident being left unsupervised for an extended period. During physical plant on 11/03/2023 and 04/29/2024, LPA observed residents participating in an activity and upon completion LPA did not observe any resident left unsupervised for an extended period. Continued from 9099-C Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff leaves residents unsupervised for an extended period of time” is deemed Unsubstantiated at this time. It was reported that Staff do not include R1 in outside activities, as it was alleged that staff never ask R1 if they want to participate in any activities. Interviews conducted with six (6) private caregivers and seven (7) family members / responsible parties of residents in care revealed that all thirteen (13) parties did not express any potential or immediate concerns that residents were not asked to participate in activities. Interviews conducted with six (6) staff revealed that in the morning residents are presented with the activities for the day and they are asked if they want to participate. In addition, staff, R1’s case worker and the private caregiver of R1 continued to state that R1 rarely chooses to participate in any activities as they prefer not to be around loud noise or bright lights. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff leaves residents unsupervised for an extended period of time” is deemed Unsubstantiated at this time. It was reported that “staff do not follow proper hand washing practices”, as it was alleged staff are sitting down with residents in the dining room, eating their own meals and feeding the residents without washing their hands. Interviews conducted with six (6) private caregivers, six (6) staff , and six (6) dining room staff revealed that all eighteen (18) have not observed any staff eating their own meal while assisting residents with their food. In addition, the (12) staff interviewed revealed they are required to wash their hands before and after handling food. Interviews conducted with R1’s case worker and seven (7) family members / responsible parties of residents in care revealed they did not express any potential or immediate concerns for staff not following proper hand washing practices. Continued from 9099-C During physical plants on 11/03/2023 and 04/29/2024, LPA did not observe any staff eating their own meal while assisting residents with their food. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not follow proper hand washing practices” is deemed Unsubstantiated at this time. It was reported that “Staff do not wear protective masks when sick,” as it was alleged that multiple staff members do not wear masks when showing cold like symptoms. Interviews conducted with six (6) private caregivers, six (6) staff revealed that all twelve (12) parties interviewed have not observed any staff provide service to residents while showing cold symptoms. In addition, interviews with six (6) staff revealed that when any staff shows any cold or flu like symptoms they are typically sent home for the day. Interviews conducted with R1’s case worker and seven (7) family members / responsible parties of residents in care revealed that each family member / responsible party did not express any immediate or potential concerns for staff not following proper infection control protocols. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not wear protective masks when sick” is deemed Unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, May 28, 2024 · control 29-AS-20231101085510

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management visit in regard to a self reported incident that occurred on 04/01/2024. On that date Resident # 1 (R1) was observed outside of the community by Staff #1 (S1) while driving outside of the community. S1 then informed staff at the community who then confirmed R1 was not in the community. R1 was brought back to the facility by S1 without any injuries or health concerns. Between 01:00pm – 03:30pm, LPA conducted a physical plant, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the incident. Interviews conducted and records review revealed that R1 walks around the community often with their private caregiver or staff, however during that time frame that R1 eloped from the facility R1's private caregiver was not with R1. In addition, Record review revealed that R1 is unable to leave the facility unassisted, is diagnosed with dementia, and is ambulatory. Following the 04/01/2024 elopement, staff had completed a new needs and service assessment for R1 identifying the need for use of wearing a wander guard. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.the state’s words, verbatim · CDSS document, Apr 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1)(c) · Plan of correction due date: Apr 18, 2024

87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for...ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by: Based on interviews and records review, R1 is not permitted to leave the facility unassisted, and was found outside of the facility without supervision, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 17, 2024

Plan of correction: Licensee agreed to conduct an in-service training with staff to review section cited. In addition Licensee agreed to submit a letter of understanding to LPA via email by 04/18/2024 EOD.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Valeria Conway and Teresa Camara arrived at the facility to conduct a One (1) year Required inspection. LPAs met with Executive Director (ED), Grace Hartnett at 10:05 a.m. and at 10:30 a.m. Mariana Pelayo (Regional Nurse) arrived at the facility and joined the visit. LPAs explained the reason for the visit. At 11:45 a.m. LPAs, ED and RN conducted a physical plan tour of the facility to ensure there are no health and safety hazards. The building has several floors divided into separate areas of licensed and independent living occupants. The facility is licensed in Building A on the 1st, 2nd and 3rd floor. There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature at 72 degrees. In Building B, only the 2nd floor is licensed. Fire extinguishers were observed throughout the facility and appeared to be fully charged and last serviced in October 2023. The facility’s fire suppression system was last checked by Johnson Controls North America on 2/22/2024 and passed. The elevators and emergency power generator was last checked on 9/2/2023 by Absolute Fire Protection, Inc. and passed. Smog detector and carbon monoxide detectors were checked in all resident’s room on 12/27/2023 and passed. Resident Rooms: From 12:12 p.m. until approximately 2:08 p.m., LPAs inspected (10) randomly selected apartments. The resident rooms were properly furnished with, at minimum, a bed, nightstand, chairs, and sufficient lighting for each resident. The rooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPAs observed all bathrooms in each resident room were clean, properly supplied and had functional fixtures. LPAs observed all resident bathrooms to have grab bars, and non-slip materials in showers. The hot water was measured in each bathroom between 106.2 – 120 degrees Fahrenheit. Continued on 809-C Continued from LIC 809 Common Areas: Between 11:55 a.m.- 2:07 p.m., LPAs inspected the common areas throughout the facility. These included two (2) dining areas, activity rooms, (2) libraries, sitting area, theater, fitness areas, café, patios, and inner courtyard. The common areas were observed to be properly furnished and relatively clean at this time. At approximately 1:45 p.m., LPAs observed multiple residents playing cards in the 1st floor activity area. LPA observed appropriate posters and information about resident’s rights. Kitchen: The kitchen was observed to be only accessible to staff. The kitchen appeared to be clean, and the appliances and fixtures appeared to be in operable condition during the time of visit. LPAs observed enough perishable and non-perishable food at the facility; properly stored. LPAs observed emergency food supply to be sufficient at this time. Dining furniture in dining room area appeared to be clean and sufficient at this time. Staff lounge located off the rear hallway near the kitchen. Memory Care: LPAs inspected (3) randomly chosen rooms during the physical plant tour. The resident rooms were observed to be properly furnished with a bed, nightstand, and sufficient lighting for each resident. The rooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Each room had a private bathroom. LPAs observed each bathroom to be clean, properly supplied and had functional fixtures. LPAs observed all resident bathrooms to have grab bars, non-slip material in showers and locked cabinets. LPAs observed an alarm sound off upon opening the exit door and staff responded immediately. Outdoor Area: There were shaded areas throughout the exterior of the facility with sufficient room for activities. LPAs observed sufficient furniture designated for outdoor use. There is a pool located on the facility located on the independent living side of the facility. LPAs observed gate to the pool to be closed and locked at this time. Parking Garage was accessible from the exterior. Cleaning supplies were located in a storage closet on the far wall near the exit of the garage. There was a fountain located in the courtyard entrance. Interviews: LPAs conducted interviews with seven (7) residents; no concerns noted. LPAs conducted interviews with six (6) staff; no concerns noted. LPAs will return at a later date to conclude the annual inspection. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Mar 13, 2024