West Pico Terrace Assisted Living Center

Allegation investigated: Illegal Eviction.

On 09/18/26 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Administrator Azucena Reyes (staff #1/S1) as the purpose of today’s visit was explained. The investigation consisted of the following: On 09/18/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Facesheet, pre-appraisal, admission agreement, Physicians report dated:05/07/26, resident appraisal dated:01/28/25, Service plan report, SOC 341 report dated: 08/31/26, and medication list. On 09/18/26 from 9:30 am- 10:50 am LPA conducted Interviews with (S1), and (R1). On 09/18/26 LPA Villegas conducted a file review of docuemtns obtained. The allegation revealed the following: Allegation: Illegal Eviction Substantiated It is alleged that Resident in care is being illegally evicted as retaliation. On 09/18/26 LPA conducted interview with R1 regarding the allegation above. R1 confirmed the allegation above and stated that the eviction notice was issued in retaliation for an incident that occurred between R1 and a peer. Furthermore, R1 stated that the facility staff is one-sided and is making R1 look like the perpetrator rather then the victim. On 09/18/26 LPA conducted interview with S1 regarding the allegation above. S1 denied the allegation above and reported that resident in care was issued an eviction notice due to on going aggressive and physical behaviors towards female residents and towards staff. Additionally, S1 reports that S1 sent a copy of the eviction notice to CCLD for review but never heard back. On 09/18/26 LPA conducted review of the eviction notice issued to R1, CCLD obtained a copy of the eviction notice on 09/03/26. Upon review of the eviction notice it was determined that the eviction notice issued to R1 did not meet Title 22 regulations. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights provided and explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 18, 2026 · control 11-AS-20260911164431

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(2)(B-E) · Plan of correction due date: Sep 25, 2026

87224 Eviction Procedures The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)...Provide each resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction. The notice shall include all of the following: (B)A copy of the resident’s current service plan. (C)The relocation evaluation. (D) A list of referral agencies. (E)The right of the resident or resident’s legal representative to contact the department to investigate the reasons given for the eviction pursuant to Section 1569.35. This requirement was not met as eviction did not meet title 22 regs... eviction notice did not have an issue date or move out date, did not list CCLD contact info, no service paln attached, no referral agencies listed, or relocation eval which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2026

Plan of correction: Licensee/Administrator to dismiss the eviction in writing and provide a copy to resident and CCLD by POC due date. Administrator to review title 22 eviction procedures and self certify in written documents that the regulation (87224) was reviewed and it understood. Document to be sent to LPA Villegas at Lizeth.villegas@dss.ca.gov

Allegation investigated: Staff are not meeting a resident's dental needs. Staff do not provide adequate food service. Staff do not keep the facility free from pests. Staff do not properly assist the residents while in care. Staff do not provide transportation service for the residents.

On 09/17/2026 LPA Watson conducted a subsequent complaint visit to the facility listed above. LPA Watson was greeted by the Resident Care Coordinator Heard Melanie Heard and explained the purpose of the visit. LPA Watson was granted entry into the facility. Investigation consisted of the following: On 09/16/2026 the department requested and obtained the following documents: Resident Roster, Staff Roster, Rockport Competency Dietary Tests dated 04/08/26, Meal Alternatives Menu for Breakfast, Lunch & Dinner, Sysco Food Invoices dated 08/18/26 – 09/11/26, Daily Weekly Cleaning Schedule 2026, Rainbow Produce Sales Invoice dated 09/02/26, Dairy King Invoice dated 03/07/27 – 09/08/26, Sysco Food Invoices dated 08/18/26-09/11/26, Assisted Living Resident Agreement, Excel Pest Management Invoices dated 04/15/26 – 04/23/26, CONTINUED ON LICE9099-C Unsubstantiated Care Staff Assignment dated 09/01/26 – 09/14/2026, Monthly ADL Charting Documents for Residents dated 09/2026, Service Plan Reports for R2, R9, R10 dated 08/20/25, 08/21/26 and 08/28/24, Physicians Reports for R10,R2, Medical Assessment for R9. Elite Mobile Dental for R1 dated 06/17/26, Transportation Log Calendar dated 09/2026. The department conducted interviews with Staff #1-#5 and Residents #1-#8. An attempt to interview R9 and R10 was made but both residents refused to be interviewed. Investigation revealed the following: Allegation: Staff are not meeting a resident's dental needs It is alleged that staff are not meeting residents’ dental needs, by failing to repair dentures or arrange timely dental care. On 09/16/2026 between 09:40AM and 04:45PM the department conducted an interview with Staff #1 (S1) Administrator Azucena Reyes. During the interview the department asked S1, how does the facility ensure residents’ dental needs (dentures, repairs, appointments, follow ups) are identified, scheduled, and completed? S1 said that we have our in-house dental services, they serve all our residents, and they will do a check up on everyone. They come here on a monthly or biweekly basis to address complaints, such as tooth aches, root canals etc. and they schedule their appointments for all their dental needs such as denture repairs or replacement. They also do follow-ups on residents who are having progressive or ongoing dental work until it is completed. On 09/16/2026 between 08:00AM and 02:30PM the department conducted interviews with Staff #1-#5 and Residents #1-#8. Out of those interviewed 5 out of 5 Staff denied the above allegation. Out of 8 residents interviewed, 5 out of 8 residents denied the above allegation. On 09/17/26 the department reviewed Elite Mobile Dental logs for R1, dated 06/17/26 and it showed a dental evaluation and assessment was performed for teeth impressions in order to construct a new pair of dentures that according to Elite Mobile Dental will take at least three weeks for delivery. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: Staff do not provide adequate food service It is alleged that staff do not provide adequate food resulting in poor food quality and resident dissatisfaction. On 09/16/2026 between 09:40AM and 04:45PM the department conducted an interview with Staff #1 (S1) Administrator Azucena Reyes. During the interview the department asked S1, what is the facility’s process for preparing meals, addressing food quality complaints, and ensuring residents receive adequate nutrition? S1 explained that the facility serves meals in the dining room and that they have a menu and meal substitutions available. If residents don’t want what is being served S1 said our server will adjust meals to accommodate the residents upon request. S1 also said that our meals are served to the residents by our dietician who ensures that they follow the resident’s meal plans that have been prescribed by their doctors. The dietician makes sure that all meals served are nutritious for all the residents. On 09/16/2026 between 08:00AM and 02:30PM the department conducted interviews with Staff #1-#5 and Residents #1-#8. Out of those interviewed 5 out of 5 Staff denied the above allegation. Out of 8 residents interviewed, 6 out of 8 residents denied the above allegation. On 09/17/26 the department reviewed the facilities breakfast, lunch and dinner Menus, Meal Alternative Menu, Rainbow Produce Sales Invoice dated 09/02/26, Dairy King Invoice dated 03/07/27 – 09/08/26, and Sysco Food Invoices dated 08/18/26-09/11/26, and it showed that a large variety of foods including seafood were being served the residents at the facility. It also showed that an adequate amount of fresh vegetables, fruit and protein was ordered and served on a daily, weekly, and monthly basis at the facility. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff do not keep the facility free from pests It is alleged that staff do not respond with corrective action when residents report that the facility has pests. On 09/16/2026 between 09:40AM and 04:45PM the department conducted an interview with Staff #1 (S1) Administrator Azucena Reyes. During the interview the department asked S1, CONTINUED ON LIC9099-C when were pest control services last performed, and what steps do staff take when residents report bugs or other pests? S1 reported that pest control services were performed the morning of 09/16/2026. The pest control service uses chemical treatments and a canine detection dog specifically for bed bugs. S1 also said that the facility sprays for roaches on a regular basis as well. S1 also stated that staff respond to residents reports of pests by contacting pest control and addressing issues immediately. S1 also said that they have a fumigation service that fumigates on a regular basis. On 09/16/2026 between 08:00AM and 02:30PM the department conducted interviews with Staff #1-#5 and Residents #1-#8. Out of those interviewed 5 out of 5 Staff denied the above allegation. Out of 8 residents interviewed, 5 out of 8 residents denied the above allegation. On 09/17/26 the department reviewed pest control invoices from Excel Pest Management Invoices dated 04/15/26 – 04/23/26 and it showed services administered to the facility for bed bugs and pest fumigation. On 09/17/2026 the department observed heat treatment for bed bugs and pest fumigation services being performed in the facility in various rooms. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff do not properly assist the residents while in care It is alleged that staff do not properly assist residents in care, including failure to provide help with ADLs and requested support. On 09/16/2026 between 09:40AM and 04:45PM the department conducted an interview with Staff #1 (S1) Administrator Azucena Reyes. During the interview the department asked S1, how do staff assist residents with ADLs (bathing, dressing, grooming, toileting, mobility), and how is this assistance documented? S1 stated that caregivers and med techs provide assistance with ADLs, including bathing, dressing, grooming, toileting, and mobility. Each resident is assigned a med tech and a caregiver for every shift. S1 reported that assistance is documented by the staff assigned to each resident. CONTINUED ON LIC9099-C On 09/16/2026 between 08:00AM and 02:30PM the department conducted interviews with Staff #1-#5 and Residents #1-#8. Out of those interviewed 5 out of 5 Staff denied the above allegation. Out of 8 residents interviewed, 7 out of 8 residents denied the above allegation. On 09/17/26 the department reviewed ADL Charting logs and Service Plans for R2, R9, R10 dated 08/20/25, 08/21/26 and 08/28/24 obtained from the facility and it showed that bathing, dressing, grooming, toileting, and mobility is a part of their daily care and is documented on ADL Charting Log on a monthly basis. The department also reviewed the residents Care Staff Assignment documents, and it showed that there were an adequate amount of care givers assigned to all of the residents on each floor. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff do not provide transportation services for the residents It is alleged that staff do not provide transportation for residents, leaving them without safe or reliable access to medical and community resources. On 09/16/2026 between 09:40AM and 04:45PM the department conducted an interview with Staff #1 (S1) Administrator Azucena Reyes. During the interview the department asked S1, what is the facility’s procedure for helping residents obtain transportation services, including Access, medical appointments, or other outings? S1 explained that the facility has a social worker that helps the residents schedule their transportation ahead of time for their appointments. S1 also said that we have a van and driver who will take them to their appointments and our in-house social worker will assist them in getting set-up to use Access, which helps them get around to their personal outings and to their medical appointments on time as well. On 09/16/2026 between 08:00AM and 02:30PM the department conducted interviews with Staff #1-#5 and Residents #1-#8. Out of those interviewed 5 out of 5 Staff denied the above allegation. Out of 8 residents interviewed, 7 out of 8 denied the above allegation. On 09/17/26 the department reviewed an email that was scheduled for R2 to be transported for dialysis treatment by the facility’s social worker. The department also reviewed and transportation logs obtained from the facility, that showed scheduled transportation for R3 and various residents for scheduled medical appointments by the facilities social worker. CONTINUED ON LIC9099-C Based on the information gathered, interviews conducted, and an analysis of records reviewed, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Administrator Azucena Reyes, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 17, 2026 · control 11-AS-20260908083514

Allegation investigated: Staff did not ensure that the resident's catheter care needs were properly met at the facility Staff did not seek timely medical care for residents in care

On 08/06/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced Complaint Visit to the facility listed above. LPA met with Azucena Reyes, Administrator, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA interviewed Staff S1, and S3 -S7, interviewed Residents R2-R10, interviewed W1, and received and reviewed additional documents. The following documents were received and reviewed Preplacement Appraisal Information (dated 02/12/2025), an Assessment Tool conducted by JFS (dated 02/25/2026), and Unusual Incident/Injury Reports (various dates). During the initial visit conducted on 06/15/2026LPA inspected the facility, interviewed Staff S2, interviewed and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Admission Agreement, Identification & Emergency Information Form (Face Sheet), Physician’s Report, Needs and Service Plan, Physician’s Orders, Home Health Documents, Hospital Discharge Documents, and Staffing Notes. The investigation revealed the following: Unsubstantiated Allegation: Staff did not ensure that the resident’s catheter care needs were properly met at the facility. The allegation alleges staff do not empty the resident’s catheter bag as trained to do and there was an extended period of time where the bag was not emptied. During Record Review, LPA received and reviewed Arba Home Healthcare, INC. Clinical Notes, indicating R1’s catheter was checked by the Home Health Nurse regularly. LPA received Clinical Notes for the following dates: 06/01/2026, 05/29/2026, 05/21/2026, 05/14/2026, 05/07/2026, 04/30/2026. LPA received and reviewed the Individual Service Plan, dated 01/25/2026, that indicates R1 requires catheter maintenance and ensures regular monthly catheter replacement. Additionally, LPA received and reviewed an Assessment Tool conducted by the organization JFS on 02/25/2026, that in the Notes on page 24, indicates R1 has an indwelling Foley catheter maintained by facility staff and changed by the home health nurse. During interviews with Staff S1-S7, were asked how often Resident R1’s catheter bag was emptied, seven (7) out of seven (7) stated whenever you saw urine in the bag we emptied it. Additionally, Staff S1- S7 were asked if they had observed the bag full of urine, as if it had not been emptied, seven (7) out of seven (7) stated no, they had not seen the bag full at any time. During interviews with Residents R2-R10, were asked if staff ensure their care needs are properly met, nine (9) out of nine stated yes, staff ensure their care needs are properly met. During an interview with Witness W1, was asked if they had observed Resident R1’s catheter bag full, as if it had not been changed, W1 stated no, that was not observed. LPA asked W1 if they had concerns regarding the assistance R1 was receiving for their catheter at the facility, W1 stated they had no concerns. Additionally, Witness W1 was asked if the care staff at the facility received training regarding emptying the catheter back, W1 stated yes, they received training. Allegation: Staff did not seek timely medical care for residents in care The allegation alleges that care staff had reported a change in condition and the resident was not assessed until the condition worsened and they were blamed for not reporting a change in condition. During Record Review, LPA received and reviewed Arba Home Healthcare, INC. Doctor’s Order Notes dated 05/29/2026, that indicates the home health was at the facility due to staff reporting a leak in the catheter. Per the notes R1’s catheter was secured, no leakage or breakdown observed, and resident R1 had no complaints of pain or discomfort. Additionally, LPA received and reviewed Arba Home Healthcare Clinal Notes dated 06/01/2026, which indicates R1 had complaints of pain in the groin area and the catheter was cloudy and had an odor. After attempting to change the catheter, the facility received orders from the Physician to call 911 for R1’s catheter to be changed in a hospital setting. LPA received and reviewed an Unusual Incident/Injury Report (LIC624) dated 06/01/2026, reporting that Resident R1 was transferred to Cedars- Sinai Emergency Department due to a possible UTI. Additionally, LPA received and reviewed After Visit Summary documents for R1’s from Cedars Sinai dated 06/02/2026 to 06/11/2026. LPA received and reviewed Doctor’ Orders Admission Supplemental Plan and Treatment for Arba Home Healthcare dated 04/20/2026, that indicates on page 3, lists the following teaching, 13. Teach infection prevention/care/management of Foley Catheter. During interviews with Staff S1-S7, were asked if Resident R1 received medical treatment in a timely manner, seven (7) out of seven (7) stated yes, they informed the Physician, Home Health Nurse, and Responsible Party right away, and called 911 per the Physician’s request. During interviews with Residents R2-R10, were asked if staff ensure they receive medial treatment/care in a timely manner, nine (9) out of nine (9) stated yes, they receive medical treatment/care in a timely manner. During an interview with Witness W1, was asked if R1 received medical treatment in a timely manner, W1 stated yes, R1 received medical treatment in a timely manner. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. LPA did not observe or cite any deficiencies during today’s visit. An exit interview was conducted with Azucena Reyes, Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 11-AS-20260612094329

Allegation investigated: Staff did not allow the resident to leave the facility Staff did not ensure that the resident's dental care needs were met Staff did not provide proper food service to resident in care

On 07/30/2026 around 9:00AM, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced complaint visit. LPA met with the Administrator Azucena Reyes. The investigation consisted of the following: The Department interviewed 10 Residents (R1–R10) and four staff members (S1-S5). The following records were collected: Resident roster dated 07/30/2026, staff roster, two complete resident files and two face sheets. The investigation revealed the following: Regarding the allegation “Staff did not allow the resident to leave the facility” It is being alleged that R1 wanted to go home and was not allowed or provided transportation or escorting to go home. Interviews revealed the following: Nine out of ten residents (R1–R7, R9–R10) disagreed with the allegation. Please see (LIC9099-C) for report continuation. Unsubstantiated Based on the evidence gathered, interviews conducted, observations, and records reviewed, although the allegation “Staff did not provide proper food service to resident in care” may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this Complaint Report was given to the Administrator. 5 out of 5 staff disagreed with the allegation (S1-S5). Staff (S5) stated that the facility arranged transportation for R1 to return home, as well as at least three additional trips. S5 further stated that on one occasion, R1 declined an arranged trip. Records review revealed the following: Physician’s Report dated 07/24/2025 indicates (R1) is unable to leave the facility unassisted due to mental and physical condition. Preplacement Appraisal dated 09/24/2025 states R1 is not functionally capable of using a walker or leaving/entering the facility unassisted. Facility Acknowledgement record dated 07/29/26 at 12:45 PM documents that R1 voluntarily left the facility against recommendation, accepted responsibility while away, and agreed to arrange their own transportation unless otherwise coordinated. Based on the evidence gathered, interviews conducted and records reviewed, although the allegation “Staff did not allow the resident to leave the facility may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. Regarding the allegation “Staff did not ensure that the resident's dental care needs were met”. Interviews conducted revealed the following: 9 out of 10 residents disagreed with the allegation (R2-R10), while 1 out of 10 agreed with the allegation (R1). (R1) admitted to being seen by dentist provided by the facility and not agreeing with their assessment. 5 out of 5 staff (S1-S5) disagreed with the allegation. (S5) stated that (R1) was seen for an annual dental exam on 11/10/2025 additionally refused dental services on 05/28/2026. Records review revealed the following: Facilities Dental visit summary record dated 05/28/2026 indicates (R1) refusing services recommended by dentist. Based on the evidence gathered, interviews conducted, observations, and records reviewed, although the allegation “Staff did not ensure that the resident's dental care needs were met” may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. Regarding the allegation Staff did not provide proper food service to residents in care: It is being alleged that staff is not providing the quality diet resident needs due to medical condition. Interviews conducted revealed the following: 1 out of 10 residents disagreed with the allegation (R1). While 9 out of 10 disagreed (R2-R10). (S1) indicated that they have been following physicians’ orders for (R1) regarding diet. Records review revealed the following: Pre-Placement Appraisal dated 09/24/2025 notes (R1) require a RENAL DIET (“RENAL” under Special Diet), which is a kidney friendly plan limiting sodium, potassium, and phosphorus (and sometimes protein or fluids). Ref: Institute of Health. Please see (LIC9099-C) for report continuation.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 11-AS-20260723083501

Allegation investigated: Resident sustained multiple bruises,due to staff neglect

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 4/8/26. On 7/2/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Azucena Reyes and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 4/8/26 LPA Shirley reviewed copies of the following records: Staff and Resident roster, Physicians Reports, service plan, incident reports, conducted a tour of the facility. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff- 6(S1 – S6), and Resident -1 – Resident - 6(R1-R6). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Resident sustained multiple bruises, due to staff neglect It is alleged that R1 fell down the stairwell in her wheelchair, resulting in R1 sustaining multiple bruises due to staff neglect. R1 was admitted to this facility on 10/11/23 based on chart’s face sheet. Per review of R1’s chart on 7/2/26, and interview with S1 and S4, R1 was not considered a fall risk. On 7/2/26, LPA Shirley called R1’s prior facility, Primrose Post Acute and noted that R1’s 2023 Fall Risk Assessment considered her a high risk for falls. LPA Shirley reviewed R1’s Physician Report dated 3/11/26, R1 has no auditory impairment, no motor impairment/paralysis and R1 uses a wheelchair and able to self-propel. LPA Shirley observed Physician’s report dated 3/11/26, R1 also has no history of unsafe wandering nor elopement. A review of consultation dated 10/18/24 R1 denies suicidal or homicidal ideation. Per interview with S4 on 4/8/26, R1 is able to access all areas of the facility independently. LPA Felisa Shirley requested and reviewed all incident reports from 7/2025 to current and noted that there was one report of R1 falling. On 4/8/26, LPA Shirley reviewed an incident report dated 3/29/26 reporting R1 being sent to the hospital due to an unwitnessed fall. During interviews on 4/8/26, both R2 and R3 observed R1 in her wheelchair near the stairwell of the main floor rolling back and forth. Residents were located on the main floor of this facility, which includes the Activity room, TV, snacks and the smoking patio. R3 yelled and told R1 to watch out you’re going to fall. Both R2 and R3 observed R1 proceed backwards down the stairs. R2 stated that no one pushed R1 she just rolled back on her on. Per incident report dated 3/29/26, R1 was given medical treatment, taken to the hospital and R1’s primary care physician and family were informed of the incident. LPA Shirley called and spoke to W1 and was told that R1 had no fractures, scans cleared, bruising on the left side of her face, eye, neck and forehead. LPA interviewed staff 1 – staff 6(S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 6(R1 – R6). Of those who interviewed 3 out of 6 denied the allegation, 1 resident confirmed the allegation and 2 were not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Resident sustained multiple bruises, due to staff neglect,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Azucena Reyes.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 11-AS-20260330144401

Type of visit: Required - 1 Year

On June 1, 2026, Licensing Program Analyst (LPA) Ernand Dabuet and (RA) Retired Annuitant Nicol Wesley conducted an unannounced annual inspection at the facility using the CARE tool. Upon arrival, they were greeted by Azucena Reyes, the Administrator, and Melanie Heard, the Resident Care Director, andexplained the purpose of the visit. The facility is licensed to serve 136 adults aged 60 and over, with a capacity specifically for 136 non-ambulatory residents. Additionally, the facility holds a hospice waiver for 30 residents. Currently, 90 residents live in the facility. The facility is a three-story commercial building. The first floor includes a parking structure, a laundry room, a maintenance office, an administrative office, and a kitchen. Residents occupy the second and third floors. On the second floor, there are two activity rooms and two shaded outdoor patios. The third floor features a dining/activity room and a medication room. The Department, along with Azucena Reyes, conducted a thorough tour of the physical plant, both inside and outside. There were no bodies of water or obstructions present on the premises. The Department and Azucena Reyes inspected rooms #201, #221 and #231 on the second floor, as well as bedrooms #307, and #318 and #324 on the third floor. All the bedrooms had the necessary furniture in good condition, along with bed linens and adequate closet and drawer space to comfortably accommodate each resident. The walls and floors within the facility were observed to be well maintained. Each inspected bedroom featured its own bathroom, which the Department found to be clean, operational, and compliant with Title 22 regulations. The water temperature was properly measured between 113.0°F and 115.2°F. The Department noted that the facility was clean, appropriately furnished, and had clear passageways both inside and outside. Additionally, a comfortable temperature was maintained throughout the facility. Continued on LIC809-C The commercial kitchen was inspected and found to have a sufficient supply of both perishable and non-perishable food, which was maintained in adequate condition. Sharps, toxins, cleaning solutions, and hazardous materials were securely locked away and inaccessible to residents. Medications were also kept locked in the Medication Room on the third floor, ensuring they were out of reach of residents. Medication Administration Records were audited and found to be maintained in order and complete. An audit of Resident #1-#6 (R1-R6) service files and Staff #1 - #6 personnel files. The facility has a current liability insurance coverage policy #AES1206745 The facility has a current administrator's certificate on for Azucena Reyes Serrano #6074172740 valid 02/14/2025 through 02/13/2027. All exits and walkways throughout the facility were clear of debris and hazards. The hardwired smoke detectors and carbon monoxide detectors were functioning properly, and all fire extinguishers in the facility were fully charged. Additionally, the facility is equipped with a landline telephone located in both the office and hallway. Evacuation chairs were available in the stairwells. The last Fire Drill was conducted on 06/19/26. During the visit, the Department observed the facility's infection control practices, which included screening protocols for visitors, staff, and clients. There were sanitizing stations in common areas and restrooms, and all mandated infection control posters were displayed. The Department observed the following deficiencies: Room #230, #307 and #324 with hazardous, toxic chemical items accessible to residents in care. An exit interview was conducted with Azucena Reyes, the Administrator, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 1, 2026

Allegation investigated: Facility staff are not properly supervising resident who is a fall risk.

* This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 04/22/26. * On 06/03/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to deliver an amended report. LPA met with Administrator, Azucena Reyes, and explained the purpose of this visit is to provide an amended copy of the LIC9099 report. On 04/22/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint investigation visit to deliver findings on the above-mentioned allegation. LPA met with Administrator Azucena Reyes, explained the purpose of the visit, and was granted entry into the facility. CONTINUED ON LIC9099-C Substantiated The investigation consisted of the following: On 10/08/25, LPA Gonzalez requested and obtained the staff roster and resident roster. LPA Gonzalez reviewed service records for resident #1 (R1) and requested copies of the following documents: Admission Record, Physician’s Report, Service Plan Report, Unusual Incident/Injury Reports, Medication Administration Record (MAR) for September 2025, Senior Living Assessment, medical records from Cedars-Sinai (dated 09/17/26), and the In-Service/Staff Meeting Training Log. LPA Gonzalez conducted interviews with staff #1–#4 (S1–S4) and residents #2–#8 (R2–R8) and attempted to interview R1. On 01/06/26, LPA Gonzalez received additional documentation from Administrator Azucena Reyes, including R1's Service Plan Report and medical records from East Los Angeles Doctors Hospital (dated 10/08/25). On 02/10/26, LPA Gonzalez attempted to conduct an interview with R1, and obtained a copy of R1’s Death Report. On 06/03/26, LPA Gonzalez conducted a second interview with S2. The investigation revealed the following: For the allegation: Facility staff are not properly supervising a resident who is a fall risk. It is alleged that the resident experienced multiple unwitnessed falls, resulting in injuries. On 10/08/25, LPA Gonzalez interviewed S1–S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said they have been trained in fall risk management. During the interview, S1 stated that R1 has resided at the facility for an extended period of time and is familiar with the layout of the facility. S1 reported that R1 frequently wanders throughout the facility and the adjacent Skilled Nursing Facility (SNF). S1 stated that caregivers are available 24 hours a day, 7 days a week, but no resident at the facility are assigned a one-on-one caregiver. S1 reported that R1 was at the SNF for one of the two mentioned falls, and that the SNF charge nurse saw R1 when they fell, and alerted staff about the fall and called 911. On 10/08/25, LPA Gonzalez conducted interviews with residents R2–R8. On 02/10/26, LPA Gonzalez attempted to conduct an interview with resident R1 but was unable to as LPA was informed that R1 had passed away on 10/31/25. Of those interviewed, 7 out of 7 residents stated that staff check on them frequently. 7 out of 7 residents stated that staff provide the necessary care and supervision required. CONTINUED ON LIC9099-C On 10/08/25, LPA Gonzalez conducted a review of records. Records reviewed included R1’s Physician’s Report dated 05/23/25, which documents that R1 is non-ambulatory, uses a wheelchair, and is unable to leave the facility unassisted. A review of R1’s Service Plan Report dated 07/12/24 indicates that R1 is not to be left unattended in the community, and staff are required to monitor R1’s whereabouts every two to three hours due to wandering behaviors. The LPA also observed a Fall Care Plan within R1’s Service Plan that outlines fall prevention interventions, including the use of bed rails, frequent rounds every two to three hours, access to a call light, ensuring a caregiver is within reach, and providing cueing and gentle reminders. Under the Mobility section of the Service Plan Report, it states that R1 is chairfast, utilizes a wheelchair for mobility, and is able to move about the community with assistance. Additionally, under the Elopement Risk section of the Service Plan Report, it states that R1 is not to leave the community unattended, and that staff will monitor R1’s whereabouts throughout the facility every 2-3 hours or more. A review of an Unusual Incident/Injury Report dated 09/17/25 documents that R1 sustained an unwitnessed fall on 09/17/25. The report indicates that 911 was called and R1 was transported to Cedars-Sinai Hospital. A review of medical records from Cedars Sinai dated 09/17/25 documents that R1 was seen due to a fall, and head injury. Records indicate that R1 was diagnosed with a closed head injury, initial encounter, laceration of scalp, initial encounter, and a fall, initial encounter, and was instructed to follow-up with their primary doctor to have the wound rechecked and sutures removed in 7 days. A review of an Unusual Incident/Injury Report dated 10/01/25 documented that R1 sustained an unwitnessed fall on 09/29/25. According to the report, emergency medical services did not respond on 09/30/25. The Incident Report further indicated that R1 was transported to East Los Angeles Hospital on 10/01/25. An interview with S2 conducted on 06/03/26, revealed that R1 sustained an unwitnessed fall on 09/29/25 between approximately 08:00 p.m. and 09:00 p.m. S2 stated that on 09/30/25, upon R1’s return from a dialysis appointment, staff decided to contact emergency medical services and have R1 transported to the hospital for further evaluation; however, emergency personnel did not arrive to transport R1. S2 further stated that on 10/01/25, S1 made a complaint regarding emergency services’ failure to respond, after which emergency personnel arrived and transported R1 to East Los Angeles Hospital for evaluation. CONTINUED ON LIC9099-C A review of medical records from East Los Angeles Hospital dated 10/08/25 documents that R1 was admitted on 10/01/25 for generalized weakness and an unwitnessed fall. Records indicate that R1 has a previous fall three weeks prior which resulted in a laceration to the top of their head for which they were taken to Cedar-Sinai Medical Center and the laceration was repaired. The records further indicate that R1 was discharged on 10/08/25 with orders to continue medications, monitoring, and placement in a Skilled Nursing Facility (SNF) to continue physical therapy treatments, including balance training, basic training, basic activities of daily living, equipment training, gait training, neuromuscular re-education, patient education, posture/body mechanics training, stair training, therapeutic exercise, and transfer training. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 is being cited on the attached LIC9099-D. An exit interview was conducted, and a copy of the report, along with appeal rights was provided to Azucena Reyes.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 11-AS-20251002104817

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Jun 10, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all...(2) To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by: Based on records reviewed, and interviews conducted, the Licensee failed to adequately supervise (R1) on 09/17/25, and 09/29/25, allowing them to wander the community unaccompanied by staff, which resulted in R1 suffering two unwitnessed falls and sustaining a head injury and a laceration of scalp that led to hospitalization. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 3, 2026

Plan of correction: Licensee/Administrator shall ensure that all staff are trained on fall prevention and resident-specific care plans. Documentation of staff training will be submitted to the Department by 06/10/26 to Elvira.Gonzalez@DSS.CA.GOV

Allegation investigated: Staff are not responding to residents call button.

* This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 3/17/26. On 3/17/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Wellness Director, Sheila Sikula and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 3/17/26, LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Medical Administration Records for Feb/26 and Mar/26, handwritten records of medication from R1. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff- 6 (S1 – S6), and Resident -1 – Resident -8 (R1-R8). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff are not responding to residents call button. It is being reported that it takes staff up to 2 hours to respond to the resident’s call button. Per LPA Felisa Shirley’s observation, the resident call system is stationed in 2 locations within the facility, one place is in the med tech room and the second is in the 3rd floor dining room. LPA Shirley interviewed S1 on 3/17/26, S1 stated that when call button alerts are received, receiving staff uses the walkie to dispatch the caregiver assigned for residents in that specific area on the walkie and the responding caregiver is immediately notified of the resident’s location. LPA Shirley toured the facility and pushed the call button in R1’s assigned room at 10:01am and noted that it took receiving staff 3 minutes to respond and arrived at R1’s room at 10:04am. Per interview with S1, if there is a shortage of staff when an alert comes in from a resident, she sometimes identify who the resident is on the alert panel and responds to the alert herself to help out. Per interviews with S1-S6, there is no tracking system in place to verify response times for call button alerts from residents. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 8 (R1 – R8). Of those who interviewed 2 out of 8 denied the allegation. Two residents confirmed the allegation, and 4 residents neither denied nor confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not responding to residents call button,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to, Azucena Reyes, Administrator. Allegation: Staff did not administer medication to residents in care. It is being reported that R1 stated that medication administration is timely, but the total daily dose is inconsistent. Per review of March 2026 Medical Administration Record, the (MAR) on 3/17/26, LPA Felisa Shirley observed that as of 3/17/26, R1 has 28 active medications and 10 PRN’s. On 3/17/2026, LPA Shirley reviewed the MAR for R1 and noted that for the date of 3/16/2026, MAR had no initials for pantoprazole, however, the medication was not in bubble pack. For 3/17/2026, MAR had no initials for pantoprazole AM dose and medication was still in the bubble pack. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 8(R1 – R8). Of those who interviewed 7 out of 8 denied the allegation. One resident confirmed the allegation. According to the information gathered there is sufficient evidence to support the allegation “Staff did not administer medication to residents in care”. Based on interview and record review the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies are issued and an exit interview is conducted with Azucena Reyes, Administrator . A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 4, 2026 · control 11-AS-20260310162603

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 31, 2026

87465 Incidental Medical and Dental Care (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. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on records reviewed on 3/17/2026, LPA Shirley reviewed facility medication administration records (MAR) for R1 and noted that for the date of 3/16/2026, MAR had no initials for pantoprazole, but medication was not in bubble pack. For 3/17/2026, MAR had no initials for pantoprazole AM dose and medication was still in the bubble pack. This action poses as a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: The Administrator shall submit plan informing the department medication training has been performed with all staff. A written proof of correction must included along with date, time and participants names. Correction must be submitted by due date: 3/31/26 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016.

Allegation investigated: Facility staff are not properly supervising resident who is a fall risk.

** This report serves as an amendment to amend findings. This report supersedes the complaint investigation findings reflected on report created 03/16/26. ** On 04/22/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint investigation visit for the allegation listed above. LPA met with Administrator, Azucena Reyes, and explained the purpose of this visit is to provide an amended copy of the LIC9099 report. On 02/10/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint investigation visit to investigate the above-mentioned allegation and deliver findings. LPA met with Administrator Azucena Reyes, explained the purpose of the visit, and was granted entry into the facility. Continued on LIC9099-C Substantiated The investigation consisted of the following: On 10/08/25, LPA Gonzalez requested and obtained the staff roster and resident roster. LPA Gonzalez reviewed service records for resident #1 (R1) and requested copies of the following documents: Admission Record, Physician’s Report, Service Plan Report, Unusual Incident/Injury Reports, Medication Administration Record (MAR) for September 2025, Senior Living Assessment, medical records from Cedars-Sinai, and the In-Service/Staff Meeting Training Log. LPA Gonzalez conducted interviews with staff #1–#4 (S1–S4) and residents #2–#8 (R2–R8) and attempted to interview R1. On 01/06/26, LPA Gonzalez received additional documentation from Administrator Azucena Reyes, including the Service Plan Report and medical records from East Los Angeles Doctors Hospital for R1 (dated 10/08/25). On 02/10/26, LPA Gonzalez attempted to conduct an interview with R1. Additionally, LPA Gonzalez obtained a copy of R1’s Death Report. The investigation revealed the following: For the allegation: Facility staff are not properly supervising a resident who is a fall risk. It is alleged that the resident experienced multiple unwitnessed falls, resulting in injuries. On 10/08/25, LPA Gonzalez interviewed S1–S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said they have been trained in fall risk management. All staff stated that R1 does not have a one-on-one caregiver assigned, and that residents are checked every 2–3 hours and as needed. During the interview, S1 stated that R1 has resided at the facility for an extended period of time and is familiar with the layout of the facility. S1 reported that R1 frequently wanders throughout the facility and the adjacent Skilled Nursing Facility (SNF). S1 stated that caregivers are available 24 hours a day, 7 days a week, but no residents at the facility are assigned a one-on-one caregiver. On 10/08/25, LPA Gonzalez conducted interviews with residents R2–R8. On 02/10/26, LPA Gonzalez attempted to conduct an interview with resident R1 but was unable to as LPA was informed that R1 had passed away on 10/31/26. Of those interviewed, 7 out of 7 residents stated that staff check on them frequently. 7 out of 7 residents stated that staff provide the necessary care and supervision required. On 10/08/25, LPA Gonzalez conducted a review of records. Records reviewed included R1’s Physician’s Report dated 05/23/25, which documents that R1 is non-ambulatory, uses a wheelchair, and is unable to leave the facility unassisted. Continued on LIC9099-C A review of R1’s Service Plan Report dated 07/12/24 indicates that R1 is not to be left unattended in the community, and staff are required to monitor R1’s whereabouts every two to three hours due to wandering behaviors. The LPA also observed a Fall Care Plan within R1’s Service Plan that outlines fall prevention interventions, including the use of bed rails, frequent rounds every two to three hours, access to a call light, ensuring a caregiver is within reach, and providing cueing and gentle reminders. Additionally, under the Mobility section of the Service Plan Report, it states that R1 is chairfast, utilizes a wheelchair for mobility, and is able to move about the community with assistance. A review of an Unusual Incident/Injury Report dated 09/17/25 documents that R1 sustained an unwitnessed fall on 09/17/25. The report indicates that 911 was called and R1 was transported to Cedars-Sinai Hospital. A review of an Unusual Incident/Injury Report dated 10/01/25 documents that R1 sustained an unwitnessed fall on 09/29/25. According to the report, paramedics did not respond on 09/30/25. On 10/01/25, R1 was transported to East Los Angeles Hospital. A review of medical records from East Los Angeles Hospital dated 10/08/25 documents that R1 was admitted on 10/01/25 for generalized weakness and an unwitnessed fall. The records further indicate that R1 was discharged on 10/08/25 with orders to continue medications, monitoring, and placement in a skilled nursing facility (SNF). On 02/10/26, LPA Gonzalez conducted a review of R1’s Death Report dated 11/07/25, which indicates that R1 passed away on 10/31/25. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 is being cited on the attached LIC9099-D. An exit interview was conducted, and a copy of the report, along with appeal rights was provided to Azucena Reyes.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 11-AS-20251002104817

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Apr 29, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all...(2) To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by: Based on records reviewed, and interviews conducted, the Licensee failed to adequately supervise (R1) on 09/17/25, and 09/29/25, resulting in unwitnessed falls and sustaining injuries. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Licensee/Administrator shall ensure that all staff are trained on fall prevention and resident-specific care plans. Documentation of staff training will be submitted to the Department by 04/29/26 to Elvira.Gonzalez@DSS.CA.GOV

Allegation investigated: Resident sustained multiple bruises,due to staff neglect

On 4/8/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Azucena Reyes and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 4/8/26 LPA Shirley reviewed copies of the following records: Staff and Resident roster, Physicians Reports, service plan, incident reports, conducted a tour of the facility. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff- 6(S1 – S6), and Resident -1 – Resident - 6(R1-R6). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Resident sustained multiple bruises, due to staff neglect It is being reported that R1 fell down the stairwell in her wheelchair, resulting in R1 sustaining multiple bruises due to staff neglect. Based on review of R1’s Physician Report dated 3/13/25, R1 has no auditory impairment, no motor impairment/paralysis and R1 uses a wheelchair. Per interview with S4 on 4/8/25, R1 is able to access all areas of the facility independently. On 4/8/26, LPA Shirley reviewed an incident report dated 3/29/26 reporting R1 being sent to the hospital due to an unwitnessed fall. During interviews on 4/8/26, both R2 and R3 observed R1 in her wheelchair near the stairwell rolling back and forth. R3 yelled and told R1 to watch out you’re going to fall. Both R2 and R3 observed R1 proceed backwards down the stairs. R2 stated that no one pushed R1 she just rolled back on her on. Per incident report, R1 was given medical treatment, taken to the hospital and R1’s primary care physician and family were informed of the incident. LPA Shirley called and spoke to W1 and was told that R1 had no fractures, scans cleared, bruising on the left side of her face, eye, neck and forehead. LPA interviewed staff 1 – staff 6(S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 6(R1 – R6). Of those who interviewed 3 out of 6 denied the allegation, 1 resident confirmed the allegation and 2 were not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Resident sustained multiple bruises, due to staff neglect,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Azucena Reyes.the state’s words, verbatim · CDSS document, Apr 8, 2026 · control 11-AS-20260330144401

Allegation investigated: Staff do not distribute residents' medications as prescribed

On 03/18/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. LPA was met by Azucena Reyes, Administrator (S1) and the purpose of the visit was explained. S1 and LPA toured the facility. The investigation consisted of the following: On 03/18/26 LPA requested and reviewed facility documents and toured the facility. Between 10:00AM and 1:00PM, LPA interviewed six (6) out of eighty-nine (89) residents and three (3) out of thirty-eight (38) staff. The investigation revealed the following: Regarding the allegation, “Staff do not distribute residents' medications as prescribed", it is being alleged that a resident did not receive a specific medication for five (5) days. Record reviews revealed that a resident was provided all of their medication during the month of January-2026, however interviews revealed that four (4) out of six (6) residents and three (3) out of three (3) staff have agreed the allegation has taken place due to a pharmacy not delivering medication on time. Report continues, please see LIC9099-C. Substantiated Based on interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. An exit interview was conducted with Azucena Reyes, Administrator, and a copy of facilities’ appeal rights and this report has been provided.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 11-AS-20260310155911

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 27, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical...care shall be developed by each facility. The plan shall encourage routine medical...care...by compliance with the following: (4) The licensee shall assist...medications as needed. This requirement is not met as evidenced by: Based on interviews conducted, the licensee did not comply with the section cited above in not providing Resident 1 (R1), R2, R3, R5 with medications as prescribed, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: The facility shall retrain staff on ordering refill medications in a timely manner and ensuring that a pharmacy will deliver medication in a timely manner on, or prior to, POC due date which is 03/27/26.

Allegation investigated: Staff are not responding to residents call button.

On 3/17/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Wellness Director, Sheila Sikula and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 3/17/26, LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Medical Administration Records for Feb/26 and Mar/26, handwritten records of medication from R1. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff- 6 (S1 – S6), and Resident -1 – Resident -8 (R1-R8). The investigation revealed the following: Cond on 9099-C Unsubstantiated Allegation: Staff are not responding to residents call button. It is being reported that it takes staff up to 2 hours to respond to the resident’s call button. LPA Felisa Shirley interviewed S1 on 3/17/26, S1 stated that when call button alerts are received, responding staff calls the caregiver assigned for residents in that specific area on the walkie in which the alert was received. Per interview with S1, if there is a shortage of staff, if there is an alert from a resident, she sometimes identify the resident on the alert panel and responds to the alert herself to help out. Per interviews with S1-S6, there is no tracking system in place to verify response times for call button alerts from residents. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 8 (R1 – R8). Of those who interviewed 2 out of 8 denied the allegation. Two residents confirmed the allegation, and 4 residents neither denied nor confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not responding to residents call button,” therefore, the allegation is unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Wellness Director, Sheila Sikula. Allegation: Staff did not administer medication to residents in care. It is being reported that R1 stated that medication administration is timely, but the total daily dose is inconsistent. Per review of March 2026 Medical Administration Record, the (MAR), LPA Shirley observed that as of 3/17/26, R1 has 28 active medications and 10 PRN’s. Records revealed that the medication, Pantoprazole does not have initials on 3/16/26 for the a.m. dose and the pill is missing from the bubble pack. LPA Shirley also observed on 3/17/26 there is no initial for the a.m. dose and the pill is still in the bubble pack. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 8(R1 – R8). Of those who interviewed 7 out of 8 denied the allegation. One resident confirmed the allegation. According to the information gathered there is sufficient evidence to support the allegation “Staff did not administer medication to residents in care”. Based on interview and record review the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies are issued and an exit interview is conducted with the Wellness Director, Sheila Sikula. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 11-AS-20260310162603

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 31, 2026

87465 Incidental Medical and Dental Care (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. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and records reviewed, records revealed that the medication Pantoprazole, with the date of 3/16/26 had no initials for a.m. dose but pill was dispensed, the date 3/17/26 had no initial for a.m. dose and pill is still in the bubble pack. This action poses as an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: The Administrator shall submit plan informing the department medication training has been performed with all staff. A written proof of correction must included along with date, time and participants names. Correction must be submitted by due date: 3/31/26 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016.

Allegation investigated: Facility staff are not properly supervising resident who is a fall risk.

** This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 02/10/26. ** On 03/16/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint investigation visit for the allegation listed above. LPA met with Administrator, Azucena Reyes, and explained the purpose of this visit is to provide an amended copy of the LIC9099 report. On 02/10/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint investigation visit to investigate the above-mentioned allegation and deliver findings. LPA met with Administrator Azucena Reyes, explained the purpose of the visit, and was granted entry into the facility. Continued on LIC9099-C Unsubstantiated The investigation consisted of the following: On 10/08/25, LPA Gonzalez requested and obtained the staff roster and resident roster. LPA Gonzalez reviewed service records for resident #1 (R1) and requested copies of the following documents: Admission Record, Physician’s Report, Service Plan Report, Unusual Incident/Injury Reports, Medication Administration Record (MAR) for September 2025, Senior Living Assessment, medical records from Cedars-Sinai, and the In-Service/Staff Meeting Training Log. LPA Gonzalez conducted interviews with staff #1–#4 (S1–S4) and residents #2–#8 (R2–R8) and attempted to interview R1. On 01/06/26, LPA Gonzalez received additional documentation from Administrator Azucena Reyes, including the Service Plan Report and medical records from East Los Angeles Doctors Hospital for R1 (dated 10/08/25). On 02/10/26, LPA Gonzalez attempted to conduct an interview with R1. Additionally, LPA Gonzalez obtained a copy of R1’s Death Report. The investigation revealed the following: For the allegation: Facility staff are not properly supervising a resident who is a fall risk. It is alleged that the resident experienced multiple unwitnessed falls, resulting in injuries. On 10/08/25, LPA Gonzalez interviewed S1–S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said they have been trained in fall risk management. All staff stated that R1 does not have a one-on-one caregiver assigned, and that residents are checked every 2–3 hours and as needed. During the interview, S1 stated that R1 has resided at the facility for an extended period of time and is familiar with the layout of the facility. S1 reported that R1 frequently wanders throughout the facility and the adjacent Skilled Nursing Facility (SNF). S1 stated that caregivers are available 24 hours a day, 7 days a week, but no residents at the facility are assigned a one-on-one caregiver. On 10/08/25, LPA Gonzalez conducted interviews with residents R2–R8. On 02/10/26, LPA Gonzalez attempted to conduct an interview with resident R1 but was unable to as LPA was informed that R1 had passed away on 10/31/26. Of those interviewed, 7 out of 7 residents stated that staff check on them frequently. 7 out of 7 residents stated that staff provide the necessary care and supervision required. Continued on LIC9099-C On 10/08/25, LPA Gonzalez conducted a review of records. Records reviewed included R1’s Physician’s Report dated 05/23/25, which documents that R1 is non-ambulatory, uses a wheelchair, and is unable to leave the facility unassisted. A review of R1’s Service Plan Report dated 07/12/24 indicates that R1 is not to leave the community unattended and that staff are to monitor R1’s whereabouts every two to three hours due to wandering behaviors. A review of an Unusual Incident/Injury Report dated 09/17/25 documents that R1 sustained an unwitnessed fall on 09/17/25. The report indicates that 911 was called and R1 was transported to Cedars-Sinai Hospital. A review of an Unusual Incident/Injury Report dated 10/01/25 documents that R1 sustained an unwitnessed fall on 09/29/25. According to the report, paramedics did not respond on 09/30/25. On 10/01/25, R1 was transported to East Los Angeles Hospital. A review of medical records from East Los Angeles Hospital dated 10/08/25 documents that R1 was admitted on 10/01/25 for generalized weakness and an unwitnessed fall. The records further indicate that R1 was discharged on 10/08/25 with orders to continue medications, monitoring, and placement in a skilled nursing facility (SNF). On 02/10/26, LPA Gonzalez conducted a review of R1’s Death Report dated 11/07/25, which indicates that R1 passed away on 10/31/25. During record reviews conducted on 10/08/25 and 02/10/26, LPA Gonzalez did not observe documentation indicating that a Fall Care Plan had been developed for R1. Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of the report was provided to Azucena Reyes.the state’s words, verbatim · CDSS document, Mar 16, 2026 · control 11-AS-20251002104817

Allegation investigated: Staff did not administer medication to a resident in care. Staff did not prevent a resident from interrupting another resident's sleep. Staff are not following resident's care plan.

On 02/10/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint investigation visit to further investigate the above-mentioned allegations and deliver findings. LPA met with Administrator Azucena Reyes, explained the purpose of the visit, and was granted entry into the facility. The investigation consisted of the following: On 01/08/26, LPA Gonzalez requested the following documents: staff roster, resident roster, Admission Record for R1-R2, Physician's Report for R1-R2, Individual Service Plan for R1, Preplacement Appraisal Information for R2, and Medication Administration Record (MAR) for the months of December-January 2025 for R1. LPA Gonzalez conducted interviews with staff #1-#7 (S1-S7), and residents #1-#7 (R1-R7). Additionally, LPA Gonzalez toured the facility. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: For the allegation: Staff did not administer medication to a resident in care. It is being alleged that staff frequently run out of the resident’s prescribed medication, resulting in the resident not receiving the medication. On 01/08/26, LPA Gonzalez interviewed S1–S7. Of those interviewed, 4 out of 4 staff denied the allegation. On 01/08/26, LPA Gonzalez conducted interviews with residents R1–R7. Of those interviewed, 6 out of 7 residents could not corroborate with the allegation. 6 out of 7 residents said they are receiving their medication(s) on time and as prescribed by their physician. An interview with R1 revealed that they missed their medication one day, but that they understood it was out of the facility’s hands, and the pharmacy was behind. R1 said that she is overall satisfied with their services at the facility and has no complaints. On 01/08/26, LPA Gonzalez conducted a review of records. LPA reviewed R1’s MAR for the months of December 2025 - January 2026 for R1 and observed them to be in order. Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. For the allegation: Staff did not prevent a resident from interrupting another resident's sleep. It is being alleged that a resident’s roommate frequently disrupts their sleep by making noise and arguing with caregivers, and that staff do not intervene. On 01/08/26, LPA Gonzalez interviewed S1–S7. Of those interviewed, 4 out of 4 staff denied the allegation. On 01/08/26, LPA Gonzalez conducted interviews with residents R1–R7. Of those interviewed, 8 out of 8 residents could not corroborate with the allegation. An interview with R1 revealed that there were a few occasions when R1 was awakened by their roommate and staff. R1 stated they understand that staff were assisting the roommate with activities of daily living. R1 reported that they have since spoken with both their roommate and staff regarding the issue, have reached an understanding, and stated that the situation has improved and is currently going well. Continued on LIC9099-C Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. For the allegation: Staff are not following resident's care plan. It is alleged that staff are required per the resident’s care plan to brush the resident’s hair and have not done so since December 26, 2025. On 01/08/26, LPA Gonzalez interviewed S1–S7. Of those interviewed, 4 out of 4 staff denied the allegation. On 01/08/26, LPA Gonzalez conducted interviews with residents R1–R7. Of those interviewed, 7 out of 7 residents could not corroborate with the allegation. An interview with R1 revealed that staff had just brushed their hair earlier that day, and that they are satisfied with the services provided to them by staff at the facility. On 01/08/26, LPA Gonzalez reviewed R1’s Individual Service Plan and did not observe a requirement for staff to brush R1’s hair daily is a part of the service plan. Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of the report was provided to Azucena Reyes.the state’s words, verbatim · CDSS document, Feb 10, 2026 · control 11-AS-20251229094748

Allegation investigated: Facility staff are not properly supervising resident who is a fall risk.

On 02/10/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint investigation visit to investigate the above-mentioned allegation and deliver findings. LPA met with Administrator Azucena Reyes, explained the purpose of the visit, and was granted entry into the facility. The investigation consisted of the following: On 10/08/25, LPA Gonzalez requested and obtained the staff roster and resident roster. LPA Gonzalez reviewed service records for resident #1 (R1) and requested copies of the following documents: Admission Record, Physician’s Report, Service Plan Report, Unusual Incident/Injury Reports, Medication Administration Record (MAR) for September 2025, Senior Living Assessment, medical records from Cedars-Sinai, and the In-Service/Staff Meeting Training Log. LPA Gonzalez conducted interviews with staff #1–#4 (S1–S4) and residents #2–#8 (R2–R8) and attempted to interview R1. Continued on LIC9099-C Unsubstantiated On 01/06/26, LPA Gonzalez received additional documentation from Administrator Azucena Reyes, including the Service Plan Report and medical records from East Los Angeles Doctors Hospital for R1 (dated 10/08/25). On 02/10/26, LPA Gonzalez attempted to conduct an interview with R1. Additionally, LPA Gonzalez obtained a copy of R1’s Death Report. The investigation revealed the following: For the allegation: Facility staff are not properly supervising a resident who is a fall risk. It is alleged that the resident experienced multiple un-witnessed falls, resulting in injuries. On 10/08/25, LPA Gonzalez interviewed S1–S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said they have been trained in fall risk management. All staff stated that R1 does not have a one-on-one caregiver assigned, and that residents are checked every 2–3 hours and as needed. During the interview, S1 stated that R1 has resided at the facility for an extended period of time and is familiar with the layout of the facility. S1 reported that R1 frequently wanders throughout the facility and the adjacent Skilled Nursing Facility (SNF). S1 stated that caregivers are available 24 hours a day, 7 days a week, but no residents at the facility are assigned a one-on-one caregiver. On 10/08/25, LPA Gonzalez conducted interviews with residents R2–R8. On 02/10/26, LPA Gonzalez attempted to conduct an interview with resident R1 but was unable to as LPA was informed that R1 had passed away on 10/31/26. Of those interviewed, 7 out of 7 residents stated that staff check on them frequently. 7 out of 7 residents stated that staff provide the necessary care and supervision required. On 10/08/25, LPA Gonzalez conducted a review of records. The records reviewed included R1’s Physician’s Report dated 05/23/25, which documents that R1 is non-ambulatory and unable to leave the facility unassisted. A review of R1’s Service Plan Report dated 07/12/24 documents that R1 is not to leave the community unattended and that staff are to monitor R1’s whereabouts every two to three hours due to wandering behaviors. A review of an Unusual Incident/Injury Report dated 09/17/25 documents that R1 sustained an un-witnessed fall on 09/17/25. The report indicates that 911 was called and R1 was transported to Cedars-Sinai Hospital. Unusual Incident/Injury Report dated 10/01/25 documents that R1 sustained an un-witnessed fall on 09/29/25. Continued on LIC9099-C According to the report, paramedics did not respond on 09/30/25. On 10/01/25, R1 was transported to East Los Angeles Hospital. A review of medical records from East Los Angeles Hospital dated 10/08/25 documents that R1 was admitted on 10/01/25 for generalized weakness and an un-witnessed fall. The records further indicate that R1 was discharged on 10/08/25 with orders to continue medications, monitoring, and placement in a skilled nursing facility (SNF). On 02/10/26, LPA Gonzalez conducted a review of R1’s Death Report (dated: 11/07/25), and it revealed that R1 passed away on 10/31/25. Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of the report was provided to Azucena Reyes.the state’s words, verbatim · CDSS document, Feb 10, 2026 · control 11-AS-20251002104817

Allegation investigated: Staff did not administer medication to a resident in care. Staff did not prevent a resident from interrupting another resident's sleep. Staff are not following resident's care plan.

On 02/10/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint investigation visit to further investigate the above-mentioned allegations and deliver findings. LPA met with Administrator Azucena Reyes, explained the purpose of the visit, and was granted entry into the facility. The investigation consisted of the following: On 01/08/26, LPA Gonzalez requested the following documents: staff roster, resident roster, Admission Record for R1-R2, Physician's Report for R1-R2, Individual Service Plan for R1, Preplacement Appraisal Information for R2, and Medication Administration Record (MAR) for the months of December-January 2025 for R1. LPA Gonzalez conducted interviews with staff #1-#7 (S1-S7), and residents #1-#7 (R1-R7). Additionally, LPA Gonzalez toured the facility. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: For the allegation: Staff did not administer medication to a resident in care. It is being alleged that staff frequently run out of the resident’s prescribed medication, resulting in the resident not receiving the medication. On 01/08/26, LPA Gonzalez interviewed S1–S7. Of those interviewed, 4 out of 4 staff denied the allegation. On 01/08/26, LPA Gonzalez conducted interviews with residents R1–R7. Of those interviewed, 6 out of 7 residents could not corroborate with the allegation. 6 out of 7 residents said they are receiving their medication(s) on time and as prescribed by their physician. An interview with R1 revealed that they missed their medication one day, but that they understood it was out of the facility’s hands, and the pharmacy was behind. R1 said that she is overall satisfied with their services at the facility and has no complaints. On 01/08/26, LPA Gonzalez conducted a review of records. LPA reviewed R1’s MAR for the months of December 2025 - January 2026 for R1 and observed them to be in order. Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. For the allegation: Staff did not prevent a resident from interrupting another resident's sleep. It is being alleged that a resident’s roommate frequently disrupts their sleep by making noise and arguing with caregivers, and that staff do not intervene. On 01/08/26, LPA Gonzalez interviewed S1–S7. Of those interviewed, 4 out of 4 staff denied the allegation. On 01/08/26, LPA Gonzalez conducted interviews with residents R1–R7. Of those interviewed, 8 out of 8 residents could not corroborate with the allegation. An interview with R1 revealed that there were a few occasions when R1 was awakened by their roommate and staff. R1 stated they understand that staff were assisting the roommate with activities of daily living. R1 reported that they have since spoken with both their roommate and staff regarding the issue, have reached an understanding, and stated that the situation has improved and is currently going well. Continued on LIC9099-C Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. For the allegation: Staff are not following resident's care plan. It is alleged that staff are required per the resident’s care plan to brush the resident’s hair and have not done so since December 26, 2025. On 01/08/26, LPA Gonzalez interviewed S1–S7. Of those interviewed, 4 out of 4 staff denied the allegation. On 01/08/26, LPA Gonzalez conducted interviews with residents R1–R7. Of those interviewed, 7 out of 7 residents could not corroborate with the allegation. An interview with R1 revealed that staff had just brushed their hair earlier that day, and that they are satisfied with the services provided to them by staff at the facility. On 01/08/26, LPA Gonzalez reviewed R1’s Individual Service Plan and did not observe a requirement for staff to brush R1’s hair daily is a part of the service plan. Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of the report was provided to Azucena Reyes.the state’s words, verbatim · CDSS document, Feb 10, 2026 · control 11-AS-20251229094748

Allegation investigated: Staff threatened resident.

On 11/20/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above mentioned allegation. LPA met with Administrator, Azucena Reyes, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On 11/20/25, the following documents were reviewed and obtained as part of the investigation: staff roster, resident roster. LPA reviewed resident #1's service records and obtained copies of the follwing documents: Physician's Report, Admission Agreement, Admission Record, House Rules, and Personal Rights. Additionally, LPA Gonzalez interviewed staff #1-#4 (S1-S4), and residents #1-#8 (R1-R8). Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff threatened a resident. It is being alleged that a staff member told a resident “We gotta get you out of here”. It is also being alleged that in the past, a staff member told a resident that they’re on their radar”. On 11/20/25, LPA Gonzalez conducted interviews with S1–S4. Of those interviewed, 4 out of 4 staff could not corroborate with the allegation. 4 out of 4 staff said they treat all residents with dignity and respect. During the interview, Administrator, Azucena Reyes told LPA Gonzalez that she did have a conversation with R1 regarding their behavior and an incident with R2. On 11/19/25, LPA Gonzalez interviewed R1–R8. Of those interviewed, 8 out of 8 residents could not corroborate with the allegation. 7 out of 8 residents said that staff treat them with dignity and respect, and 1 out of 8 residents said staff does not treat them with dignity and respect. Based on interviews conducted, and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of the report was provided to Azucena Reyes.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 11-AS-20251113111817

Allegation investigated: Staff does not ensure facility is maintained in good repair for residents.

On 10/01/25, LPA Gonzalez conducted an unannounced complaint visit to investigate the allegation listed above. LPA met with Administrator, Azucena Reyes, and explained the purpose of the visit. LPA was granted access to the facility. The investigation consisted of the following: on 10/01/25, LPA Gonzalez requested the following documents: staff roster, resident roster, maintenance service records dated 08/11/25 from E.Z. Roth Plumbing Inc, and Facility Service Logs dated 08/10/25-10/01/25. LPA conducted interviews with staff #1-#3 (S1-S), witness #1 (W1), residents #2-#7 (R2-R7), and attempted to interview resident #1 (R1). Additionally, LPA and Azucena Reyes conducted a tour of the facility and inspected rooms #229, #230, #231, and #232. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff does not ensure facility is maintained in good repair for residents. It is being alleged that a resident is having water leaks in their room, in the closet ceiling. It is also alleged that this has been going on for the past three years and that the facility has not repaired the issue. On 10/01/25, between 10:30 AM and 11:40 AM, LPA Gonzalez conducted interviews with S1-S3. Of those interviewed, 3 out of 3 staff denied the allegation. S2 said that it was reported to them that there was a water leak in room #231 in August 2025. S2 said that staff immediately went to inspect the room and take care of any repairs needed. S2 said that they decided to open up the closet’s ceiling to see if they found any type of water leaking but had to stop as the residents family member told them to stop with the repair. S2 said that they then had a plumber come and assess the room and the closet, to see if they found any plumbing issues, that might be causing a water leak in this room, but the plumber did not find any issues, or any water leaking at the time of the visit. S2 said that since then, they have been monitoring the room daily to see if there is any signs of water leaking but have not observed any water leaking, damage, or mold. On 10/01/25, between 11:50 AM and 12:00 PM, LPA Gonzalez conducted an interview with a plumber from E.Z. Roth Plumbing Inc. (W1). W1 told LPA that on 08/11/25 they came to this facility and conducted an inspection and ran tests to see if there was any water leak in room #231 but found no leak. W1 said they went upstairs to the room above room #231 and ran the water in the bathroom for about 15 minutes and still had found no leak. W1 stated that they were very thorough during this inspection and ran all the tests possible. W1 said they also ran the AC to see if there was any water leakage coming from there but found no leak. On 10/01/25, between 01:00 PM and 2:25 PM, LPA Gonzalez conducted interviews with R2-R7, and attempted to interview R1, but was unable to due to R1’s diagnosis. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. 6 out of 6 residents said they do not have any problems with water leaking in their rooms. 6 out of 6 residents said they feel that this facility is in good repair. 6 out of 6 residents said they are satisfied with their rooms, and this facility. Continued on LIC9099-C On 10/01/25, LPA Gonzalez conducted a tour of the facility and inspected rooms #229, #230, #231, and #232. LPA did not observe any water leaking from any of the rooms inspected. LPA did observe that the closet in room #231 was empty, and all the residents clothing was hanging in the restroom. LPA did not observe any major water damage, and/or mold in the closet in room #231. Overall, LPA observed the facility to be clean, sanitary, and in good condition. On 10/01/25, LPA Gonzalez conducted a review of records. Of those records reviewed was a service invoice from E.Z Roth Plumbing Inc. dated: 08/11/25, and it revealed that they were following up on a call for a water leak, and that there was no traces of a leak. Additionally, LPA reviewed facility service logs for the following dates: 08/10/25-10/01/25 and revealed that staff has been checking room #231 daily for any water leaks and have not observed any leaks in the room. Based on observation, record review, and interviews conducted, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of this report was provided to Administrator, Azucena Reyes.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 11-AS-20250926105329

Allegation investigated: Staff mismanage residents' medications. Staff do not have appropriate interactions with residents. Staff do not ensure that the facility is free of pests.

On 09/25/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to further investigate the above-mentioned allegations. LPA met with Azucena Reyes, Administrator, and the purpose of the visit was explained. LPA was granted access to the facility. The investigation consisted of the following: On 09/24/25, LPA Gonzalez conducted interviews with staff #1-#5 (S1-S5), and residents #1-#8 (R1-R8). LPA requested and reviewed the staff roster, resident roster, and pest control receipts from Excel Pest Management for the months of August and September 2025. LPA reviewed resident service files for R1-R3, and requested the following documents: Face Sheet, Physician's Report, Needs and Services Plan, and Medication Administration Record (MAR) for the months of August and September 2025. On 09/25/25, LPA Gonzalez conducted an interview with staff #6 (S6). Additionally, LPA Gonzalez conducted a tour of the facility with Azucena Reyes, and inspected the medication room, common areas, and rooms #231, #203, #307, and #312. Unsubstantiated The investigation revealed the following: Allegation: Staff mismanage residents medications. It is being alleged that staff rush the residents when administering their medications, and that residents have gone days without their medications. It is also being alleged that staff does not administer pain medication in a timely manner. On 09/24/25, LPA Gonzalez interviewed S1-S5, and on 09/25/25, LPA Gonzalez interviewed S6. Of those interviewed, 4 out of 6 staff denied the allegation, and 2 out of 6 staff said they did not know if staff mismanage residents medication. 4 out of 6 staff stated that staff are administering the residents medication on time and as prescribed by their physician, and 2 out of 6 staff said they did not know if staff are administering the residents medication on time and as prescribed by their physician. On 09/24/25, LPA Gonzalez interviewed R1-R9. Of those interviewed, 6 out of 8 residents could not corroborate with the allegation, and 2 out of 8 residents said that staff has mismanaged their medication. 6 out of 8 residents said that staff administer their medication on time and as prescribed, and 2 out of 8 residents said that staff does not administer their medication on time and as prescribed. 7 out of 8 residents said they have not gone days without their medication, and 1 out of 8 residents said they have not received several of their medications in over a month. On 09/25/25, LPA Gonzalez conducted a review of the MAR’s for the months of August, and September 2025 for R1-R3 and observed them to be in order and did not observe any discrepancies. Based on LPA observations, a review of records, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. Allegation: Staff do not have appropriate interactions with residents. It is being alleged that facility staff are rude to the residents. On 09/24/25, LPA Gonzalez interviewed S1-S5, and on 09/25/25, LPA Gonzalez interviewed S6. Of those interviewed, 6 out of 6 staff denied the allegation. 6 out of 6 staff said they treat all residents with dignity and respect. On 09/24/25, LPA Gonzalez interviewed R1-R8. Of those interviewed, 8 out of 8 residents denied the allegation. 8 out of 8 residents said staff treat them with dignity and respect. Based on LPA observation, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. Allegation: Staff do not ensure that the facility is free of pests. It is being alleged that the facility has roaches. On 09/24/25, LPA Gonzalez interviewed S1-S5, and on 09/25/25, LPA Gonzalez interviewed S6. Of those interviewed, 6 out of 6 staff denied the allegation. S1 stated that they ensure the facility is free of pests by addressing it immediately, and that they have a pest control company come to treat and spray the facility twice a month. On 09/24/25, LPA Gonzalez interviewed R1-R8. Of those interviewed, 8 out of 8 residents denied the allegation. 8 out of 8 residents said they have not encountered any roaches in the facility. 8 out of 8 residents said that staff has pest control treat the facility regularly. 8 out of 8 residents stated that the facility is kept clean and sanitary. On 09/25/25, LPA Gonzalez toured the facility and inspected rooms #231, and #203 on the second floor, and rooms #307, and #312 on the third floor. LPA observed the facility and the rooms to be clean, sanitary, and free of roaches. Additionally, LPA Gonzalez reviewed pest control service invoices for the months of August and September 2025 from Excel Pest Management and observed that the company has come to the facility twice per month for general pest control services, to target ants, cockroaches, crickets, earwigs, general pests, silverfish, and spiders. Based on LPA observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of this report was provided to Azucena Reyes, Administrator.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 11-AS-20250916161714

Allegation investigated: Staff did not safeguard a resident's personal belongings. Staff did not prevent a resident from biting another resident. Staff did not respond timely to a resident's alerts.

On 08/28/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint report to investigate the allegations listed above. LPA met with Administrator, Azucena Reyes, and the purpose of the visit was explained. LPA was granted access to the facility. The investigation consisted of the following: On 08/27/25, LPA conducted interviews with staff #1-#4 (S1-S4), residents #1-#10 (R1-R10) and attempted to interview resident #11 (R11). LPA received the following documents: staff roster, and resident roster. Additional documents received via email, which included an Unusual Incident/Injury Report (dated: 05/19/25), client progress notes (dated: 05/19/25, and 06/23/25). Furthermore, LPA and Azucena Reyes toured the facility, and inspected resident rooms, and common areas. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not safeguard a resident's personal belongings. It is being alleged that there have been various incidents regarding theft. On 08/27/25, between 11:00 AM and 12:00 PM, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff could not corroborate with the allegation. 3 out 4 staff stated that there hasn’t been any complaints or concerns regarding any residents missing any items. S1 stated that residents have raised concerns involving a certain resident taking other residents personal belongings. S1 stated that they have talked to that resident and are investigating the matter. S1 also stated that in the event that a resident was to have a complaint regarding a missing item, the facility has a theft and loss that the resident will fill out. S1 stated that facility staff will conduct a thorough search for the item, and if the item isn’t found, the facility will then replace that item or provide a reimbursement. On 08/27/25, between 1:10 PM and 3:20 PM, LPA Gonzalez conducted interviews with R1-R10 and attempted to interview R11, but was unable to as R11 was out in the community. Of those interviewed, 9 out of 10 residents could not corroborate with the allegation. 9 out of 10 residents stated that they have no complaints regarding any missing or stolen personal items. 10 out of 10 residents said they are satisfied with the services provided to them at the facility. Based on record review, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is unsubstantiated. Continued on LIC9099-C Allegation: Staff did not prevent a resident from biting another resident. It is being alleged that a resident was bitten by another resident. On 08/27/25, between 11:00 AM and 12:00 PM, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said they maintain a safe and healthy environment for the residents within the facility. S1 stated that there was a resident who first reported that they had smashed their finger with the door but then said another resident bit them the next day. S1 stated staffed assessed the resident’s finger and they did not observe the wound to appear like a bite mark but rather a small tear. On 08/27/25, between 1:10 PM and 3:20 PM, LPA Gonzalez conducted interviews with R1-R10 and attempted to interview R11, but was unable to as R11 was out in the community. Of those interviewed, 10 out of 10 residents did not know of an incident involving a resident biting another resident. 10 out of 10 residents said they feel safe in this facility. 10 out of 10 residents said staff maintain a safe and healthy environment for them within the facility. On 08/28/25, LPA Gonzalez conducted a record review of an Unusual Incident/Injury Report (dated: 05/19/25) which revealed that on 05/17/25, R11 reported that they hurt their finger when opening the room door and noticed a scratch on finger. Then on 05/18/25, R11 told the med-tech that their roommate bit the same finger while he was sleeping and requested a band aid. Client progress notes (dated: 05/19/25, 09:09) revealed that R11 told the facility’s Wellness Director that their roommate bit their finger while they were sleeping. The Wellness Director called Resident Care Coordinator (RCC) to ask what had happened, and RCC stated that on 05/17/25, R11 told them that they had hurt their finger when opening the room door and that they had observed a scratch on R11’s finger. Client progress notes (dated: 05/19/25 10:11) revealed that staff assessed R11’s finger to clean and put a bandage, and observed that R11 has a small skin tear, on their third finger. Staff then spoke with R11’s roommate and they denied doing anything to R11. Based on record review, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is unsubstantiated. Continued on LIC9099-C Allegation: Staff did not respond timely to a resident's alerts. It is being alleged that a resident fell and had to call for support after waiting 45 minutes. On 08/27/25, between 11:00 AM and 12:00 PM, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegations. 4 out of 4 staff stated that they respond to a residents call light requests for between 5-10 minutes. 4 out of 4 staff interviewed said that they are not aware of a resident falling and having to call for support on their own after activating the call light and having to wait 45 minutes. On 08/27/25, between 01:10 PM and 03:20 PM, LPA Gonzalez conducted interviews with R1-R10 and attempted to interview R11, but was unable to as R11 was out in the community. Of those interviewed, 7 out of 10 residents said staff responds to a resident’s call light in a timely manner, 2 out of 10 residents said that staff does not respond to their call light in a timely manner, and 1 out of 10 residents said they did not know because they have never used the call light in their room. On 08/28/25, LPA Gonzalez reviewed the Personnel Roster (Dated: 07/01/2025) and observed that there is sufficient staff to meet the needs of the residents. Additionally, on 08/27/25, LPA Gonzalez inspected resident bedrooms #321 and #301 and observed call buttons to be in operable condition. LPA Gonzalez observed Azucena Reyes activate the call light and found that the facility staff responded to both calls within five minutes. Based on record review, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted with Administrator, Azucena Reyes, and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 11-AS-20250820101821

Type of visit: Required - 1 Year

On 07/07/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced Annual inspection visit to the above facility using the CARE tool. LPA was met by Azucena Reyes, Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve one hundred thirty-six (136) adults aged 60 and over. The requested capacity is for one hundred thirty-six (136) non-ambulatory residents. Facility has a hospice waiver for thirty (30). Currently there are eighty nine (89) residents in this facility. The facility is a three story commercial building. The first floor consists of the parking structure, laundry room, maintenance office, administrative office, and the kitchen. Floors level two (2) and three (3) are occupied by residents. There are two activity rooms, and two outside shaded patios on the second floor. On the third floor there is a dining/activity room, and a medication room. LPA Gonzalez and Azucena Reyes toured the physical plant inside and out. There were no bodies of water or obstructions on the premises. LPA and Azucena Reyes inspected bedrooms #224, #212, on the second floor, and bedrooms #331, #328, #318, on the third floor. All bedrooms had the required furniture and in good condition, bed linens and closet/drawer space to accommodate each resident comfortably. The walls and floors within the facility were observed to be in good repair. Each bedroom inspected had their own bathrooms. LPA inspected the bathrooms and observed them to be clean and operational and found to be within Title 22 regulations. The water temperature properly measured between 105.0 F and 120.0 F. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. A comfortable temperature was maintained in the facility. Continued on LIC809-C The kitchen was inspected and there is sufficient perishable and non-perishable food supply and maintained adequately. Sharps, toxins, cleaning solutions, and hazardous items were securely locked and inaccessible to residents. Medications are kept locked and inaccessible to residents on the third (3rd) floor in the Medication room. Exits/ Walkways around the facility were free of debris and hazards. Hard wired smoke detectors and carbon monoxide are working properly. All fire extinguishers throughout the facility were fully charged. A stocked First Aid kit along with manual was available. The facility has a landline telephone located in the office and hallway. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients. There are sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. LPA did not observe any deficiencies during this inspection, therefore no citations were issued at this time. An exit interview was conducted with Azucena Reyes, Administrator, and a copy of the report and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Jul 7, 2025

Allegation investigated: Staff did not ensure resident’s personal information remained confidential. Administrator is not responsive to resident’s request for communication.

**This report supersedes the report created and delivered on 05/07/25. This report is to clarify findings. On 05/07/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above-mentioned allegations. LPA met with Administrator, Azucena Reyes, and the purpose of the visit was explained. LPA was granted access to the facility. The investigation consisted of the following: On 05/07/25, LPA requested the staff and resident rosters. LPA reviewed resident files, and requested copies of: Admission Agreement, Admission Record, Needs and Services Plan, and Personal Rights for resident #1 (R1). Additionally, LPA conducted interviews with staff #1-#5 (S1-S5) and residents #1-#8 (R1-R8). Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure resident’s personal information remained confidential. It is being alleged that a staff member asked a resident for confidential information such as bank information and Social Security Number (SSN). Now the resident is receiving multiple calls regarding a loan, and/or the callers attempting to get additional personal information from the resident. On 05/07/25, between 12:30 PM and 1:40 PM, LPA interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that the facility ensures that all residents personal information remains confidential. 5 out of 5 staff interviewed stated that they don’t know of a staff member that used a resident’s personal information for personal use and or fraud. 5 out of 5 staff interviewed stated that all residents are treated with dignity and respect. On 05/07/25, between 1:45 PM and 3:05 PM, LPA interviewed R1-R8. Based on interviews conducted, 7 out of 8 residents interviewed stated that staff does ensure that resident’s personal information remains confidential. 7 out of 8 residents interviewed stated that they don’t know of a staff member that used a resident’s personal information for personal use and or fraudulent purposes. 7 out of 8 residents interviewed stated that staff treat them with dignity and respect. 7 out of 8 residents interviewed stated that they are satisfied with the services being provided to them. Based on interviews, file review and observation during the investigation, the above allegation is found to be Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Allegation: Administrator is not responsive to resident’s request for communication. It is being alleged that staff is always busy and never wants to talk to a resident. On 05/07/25, between 12:30 PM and 1:40 PM, LPA interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that staff responds to resident’s requests for communication. Continued on LIC9099-C 2 out of 5 staff interviewed stated that they have not ignored a resident’s request for communication, and 3 out of 5 staff interviewed stated they did not know of staff ignoring a resident’s request for communication. 5 out of 5 staff interviewed stated that all residents are treated with dignity and respect. An interview conducted with S1 revealed that they have an open-door policy, and that the residents can come talk with them whenever they want. S1 stated that if they are busy when the resident requests to speak with them, they will let the resident know they are busy, and to either come back at a later time, or they will go to the resident when they are done and available. On 05/07/25, between 1:45 PM and 3:05 PM, LPA interviewed R1-R8. Based on interviews conducted, 7 out of 8 residents interviewed denied the allegation. 7 out of 8 residents interviewed stated that staff responds to resident’s requests for communication. 7 out of 8 residents interviewed stated that they did not know of staff ignoring a resident’s request for communication. 7 out of 8 residents interviewed stated that they are treated with dignity and respect. 7 out of 8 residents interviewed stated that they are satisfied with the services being provided to them. Based on interviews, file review and observation during the investigation, the above allegation is found to be Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited during this investigation. An exit interview was conducted with Administrator, Azucena Reyes, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 21, 2025 · control 11-AS-20250501092104

Allegation investigated: Staff did not ensure resident’s personal information remained confidential. Administrator is not responsive to resident’s request for communication.

On 05/07/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above-mentioned allegations. LPA met with Administrator, Azucena Reyes, and the purpose of the visit was explained. LPA was granted access to the facility. The investigation consisted of the following: On 05/07/25, LPA requested the staff and resident rosters. LPA reviewed resident files, and requested copies of: Admission Agreement, Admission Record, Needs and Services Plan, and Personal Rights for resident #1 (R1). Additionally, LPA conducted interviews with staff #1-#5 (S1-S5) and residents #1-#8 (R1-R8). Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure resident’s personal information remained confidential. It is being alleged that a staff member asked a resident for confidential information such as bank information and Social Security Number (SSN). Now the resident is receiving multiple calls regarding a loan, and/or the callers attempting to get additional personal information from the resident. On 05/07/25, between 12:30 PM and 1:40 PM, LPA interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that the facility ensures that all residents personal information remains confidential. 5 out of 5 staff interviewed stated that they don’t know of a staff member that used a resident’s personal information for personal use and or fraud. 5 out of 5 staff interviewed stated that all residents are treated with dignity and respect. On 05/07/25, between 1:45 PM and 3:05 PM, LPA interviewed R1-R8. Based on interviews conducted, 7 out of 8 residents interviewed stated that staff does not ensure that resident’s personal information remains confidential. 7 out of 8 residents interviewed stated that they don’t know of a staff member that used a resident’s personal information for personal use and or fraudulent purposes. 7 out of 8 residents interviewed stated that staff treat them with dignity and respect. 7 out of 8 residents interviewed stated that they are satisfied with the services being provided to them. Based on interviews, file review and observation during the investigation, the above allegation is found to be Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Allegation: Administrator is not responsive to resident’s request for communication. It is being alleged that staff is always busy and never wants to talk to a resident. On 05/07/25, between 12:30 PM and 1:40 PM, LPA interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that staff responds to resident’s requests for communication. Continued on LIC9099-C 2 out of 5 staff interviewed stated that they have not ignored a resident’s request for communication, and 3 out of 5 staff interviewed stated they did not know of staff ignoring a resident’s request for communication. 5 out of 5 staff interviewed stated that all residents are treated with dignity and respect. An interview conducted with S1 revealed that they have an open-door policy, and that the residents can come talk with them whenever they want. S1 stated that if they are busy when the resident requests to speak with them, they will let the resident know they are busy, and to either come back at a later time, or they will go to the resident when they are done and available. On 05/07/25, between 1:45 PM and 3:05 PM, LPA interviewed R1-R8. Based on interviews conducted, 7 out of 8 residents interviewed denied the allegation. 7 out of 8 residents interviewed stated that staff responds to resident’s requests for communication. 7 out of 8 residents interviewed stated that they did not know of staff ignoring a resident’s request for communication. 7 out of 8 residents interviewed stated that they are treated with dignity and respect. 7 out of 8 residents interviewed stated that they are satisfied with the services being provided to them. Based on interviews, file review and observation during the investigation, the above allegation is found to be Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited during this investigation. An exit interview was conducted with Administrator, Azucena Reyes, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 7, 2025 · control 11-AS-20250501092104

Type of visit: Case Management - Incident

On 04/24/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced Case Management visit to this facility to follow up on the Unusual Incident/Injury Report (SIR) submitted to the department on 03/20/25. LPA met with Administrator, Azucena Reyes, and the purpose of the visit was discussed. LPA was granted access into the facility. During this visit LPA reviewed resident #1-#2 (R1-R2) files and requested and received the following documents: staff roster, resident roster, copies of Report of Suspected Dependent Adult/Elder Abuse (SOC 341) dated: 02/20/25, and 03/20/25, Admission Agreement, Physician’s Report, Appraisal, and Admission Records for R1-R2. Additionally, LPA conducted interviews with staff #1-#4 (S1-S4), and residents #1-#2 (R1-R2), and conducted an inspection of room #220. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of the Report and Appeal Rights were provided to Azucena Reyes, Administrator.the state’s words, verbatim · CDSS document, Apr 24, 2025

Allegation investigated: Staff do not ensure resident is provided a safe environment.

On 12/19/2024 Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced subsequent complaint visit to deliver complaint investigation findings. LPA Sparkle Day met with Azucena Reyes, Asst Administrator and explained the purpose of today’s visit. The investigation consisted of the following: On 12/10/2024 between 2:30pm and 4:20 pm , LPA Sparkle Day met with Michael Weiss, Administrator of the Skilled facility and spoke with Clarizze Punit, Administrator via phone. LPA requested and received resident roster, staff roster,R#1's Admission Agreement , Medical Assessment, ID and Info sheet, Appraisal and a list of medications. LPA attempted to speak with R#1 and R#2 but they did not answer the door. LPA Day interviewed Staff #1- Staff #5 During todays visit 12/19/24 between 11:15 am and 12:00 pm LPA requested and received the following documents: R#2's Admission Agreement , Medical Assessment, ID and Info sheet, Appraisal and a list of medications and LPA Day interviewed Staff #6. The investigation revealed the following: Substantiated Allegation: Staff do not ensure residents are provided a safe environment It is alleged that staff do not ensure residents are provided a safe environment. During this investigation Licensing Program Analyst Sparkle Day interviewed (6) staff. 6 of 6 staff were consistent in their statements that R#1 has been in the facility for 5 years. R#1 and R# 2 have been in an relationship for about 1 1/2 years and share a room. R#1 does not engage with staff anymore without R#2 since the relationship began. When staff attempt to speak with R#1, R#2 states she will not speak without me present even if you call her on the phone. Staff indicate when R#1 is given a bath R#2 has to be present and never leaves her side. Staff also state that they can hear R#2 yelling at R#1 often and when staff go to knock on the door of R#1 and R#2 they are not allowed in. Staff state they can not talk to R#1 without R#2 and when R#2 is around R#1 will not speak. On 12/10/24 Licensing Program Analyst Sparkle Day attempted to interview R#1 and R#2, however they would not answer the door for interview. On 12/10/24 The facility called the LAPD regarding the personal rights of the matter. The police were able to separate R#1 and R#2 for interview, however R#1 would still not speak. R#2 indicated to the police that he does not trust the staff and will not let R#1 speak with anyone. Licensing Program Analyst Sparkle Day finds that Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the Report and Appeal Rights were provided to Azucena Reyes, Asst Administrator..the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 11-AS-20241210132236

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(b) · Plan of correction due date: Dec 20, 2024

Personal Rights To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, This requirement was not met as evidence by: Staff did not ensure a safe and healthful accommodations for resident in care. Which poses a potential health and safety risk to clients in carethe state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Administrator agrees to Develop a plan that ensures that Resident #1 rights are not violated and All staff shall attend a training on Personal Rights of the residents in care by the POC date. 12/20/2024 A copy of the training logs and development plan will be sent to LPA :Sparkle Day Sparkle.day@dss.ca.gov

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sparkle Day conducted a unannounced Case Management site visit to the facility to ascertain information pertaining to the Licensee-initiated Unusual Incident/Injury Report submitted to CCLD on 11/22/2024 .LPA Day met with Administrator Michael Weiss and Wellness Coordinator Robin Owens and the purpose of the visit was discussed. LPA spoke with Clarizze Punit , Administrator via phone. During this visit LPA requested and received the following documents: Staff and resident roster, file for Resident #1, including but not limited to Identification and information sheet, Admisision Agreement, Medical Assessment , Appraisal and Medications list. LPA interviewed Staff #1 - Staff #5, LPA attempted to interview R#1-R#2, however they would not open the door. Based on the information gathered and the interviews conducted by the LPA. The LPA finds that According to the California Code of Regulations (Title 22, Division 6, Chapter 8),the following deficiencies were issued and a citation was cited. See 809-D An exit interview was conducted and a copy of the Report and Appeal Rights were provided to Robin Owens, Wellness Coordinator..the state’s words, verbatim · CDSS document, Dec 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(b) · Plan of correction due date: Dec 17, 2024

Personal Rights To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, This requirement was not met as evidence by: Staff did not ensure a safe and healthful accommodations for resident in care. Which poses a potential health and safety risk to clients in carethe state’s words, verbatim · CDSS document, Dec 10, 2024

Plan of correction: Administrator agrees to Develop a plan that ensures that Resident #1 rights are not violated and All staff shall attend a training on Personal Rights of the residents in care by the POC date. 12/20/2024 A copy of the training logs and development plan will be sent to LPA : Sparkle Day @ Sparkle.day@dss.ca.gov

Allegation investigated: Staff does not ensure resident is administered medications. Staff wrongfully evicted resident in care.

This is an amendment of the investigation report delivered on 09/04/24. The purpose of this amendment is to provide additional evidence obtained from record reviews. The findings remain Unsubstantiated. On 09/04/24 the Department of Social Services, Community Care Licensing Division (CCLD), conducted an initial, unannounced, complaint visit at the above-mentioned facility. CCLD staff was met by Maria Clarizze Punit, Administrator (S1) and the purpose of the visit was explained. S1 and CCLD staff toured the facility. The investigation consisted of the following: On 09/04/24 CCLD staff requested and reviewed facility documents, including resident one's (R1's) Medication Administration Record (MAR), R1's Physician's report (LIC602A) and toured the facility. Between 09:00AM and 3:30PM. CCLD staff interviewed seven (7) out of seventy-eight (78) clients and three (3) out of forty-one (41) staff. Report continues, see LIC-9099C. Unsubstantiated The investigation revealed the following: Regarding the allegation, “Staff does not ensure resident is administered medications.”, it has been alleged that night staff do not provide residents’ their pain medication (M1) at night. Interviews revealed that five (5) out of seven (7) residents and two (2) out of four (4) staff have denied the allegation has taken place, in addition two (2) out of four (4) staff and resident one (R1) have indicated that R1 does receive M1 per physician's order. Record reviews revealed the following: R1's Medication Administration Records (MAR) indicate that M1 was ordered on 04/15/24 and that it is to be provided as needed(PRN) only, not on a nightly basis. R1's LIC602A, dated 12/29/22, indicates: R1 can "manage own treatment, medication, and equipment", is "able to follow instructions" and is "able to communicate needs". Furthermore, CCLD staff researched M1 via webmd.com. Research revealed that M1 "may sometimes cause addiction. This risk may be higher if you have a substance use disorder." Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation that "Staff wrongfully evicted resident in care." it has been alleged that the facility does not provide thirty (30) days to residents during eviction. Interviews revealed that seven (7) out of seven (7) residents and all four (4) staff have denied the allegation has taken place. During this investigation, CCLD staff observed R1 is present at the facility. Record reviews indicates that there have been requests to collect missed payments from R1, but that no eviction notice has been issued. Based on the department’s record reviews, CCLD staff’s observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been no deficiencies cited during today's visit. An exit interview was held with Maria Clarizze Punit, Administrator (S1) and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 11-AS-20240827084632

Type of visit: Required - 1 Year

On 05/09/24 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced Annual inspection visit to the above facility using the CARE tool. LPA was met by Azucena Reyes, Assistant Administrator, and the purpose of today’s visit was explained.The facility is licensed to serve one hundred thirty-six (136) adults aged 60 and over. The requested capacity is for one hundred thirty-six (136) non-ambulatory residents. Facility has a hospice waiver for thirty (30). Currently there are eighty three (83) residents in this facility. The facility is a three story commercial building. The first floor consists of the parking structure, laundry room, maintenance office, administrative office, and a kitchen. Floors level two (2) and three (3) are occupied by residents. There are two activity rooms, and two outside shaded patios on the second floor. On the third floor there is a dining/activity room, and a medication room. LPA Gonzalez and Azucena Reyes toured the physical plant inside and out. There were no bodies of water or obstructions on the premises. LPA and Administrator inspected bedrooms #201, #203, #207, #209 on the second floor, and bedrooms #307, #309, #314, #316 on the third floor. All bedrooms had the required furniture and in good condition, bed linens and closet/drawer space to accommodate each resident comfortably. The walls and floors within the facility were observed to be in good repair. Each bedroom inspected had their own bathrooms. LPA inspected the bathrooms and observed them to be clean and operational and found to be within Title 22 regulations. The water temperature properly measured between 105.0 F and 120.0 F. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. A comfortable temperature was maintained in the facility. Continued on LIC809-C The kitchen was inspected and there is sufficient perishable and non-perishable food supply and maintained adequately. Sharps, toxins, cleaning solutions, and hazardous items were securely locked and inaccessible to residents. Medications are kept on the third (3rd) floor in the Medication room. Exits/ Walkways around the facility were free of debris and hazards. Hard wired smoke detectors and carbon monoxide are working properly. All fire extinguishers throughout the facility were fully charged. A stocked First Aid kit along with manual was available. The facility has a landline telephone located in the office and hallway. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients. There are sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. During this inspection LPA did not observe any deficiencies, therefore no citations were issued at this time. An exit interview was conducted, and a copy of the report and Appeal Rights was provided to Administrator, Clarizze Punit.the state’s words, verbatim · CDSS document, May 9, 2024

Allegation investigated: Staff relocated resident from facility without consent.

On 04/24/2024 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to West Pico Assisted Living Center facility and was greeted by Administrator Charizze Punit (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. The investigation consisted of the following: LPA Calderon interviewed Administrator A1, Staff S1-S2, Resident R1-R10, Witness W1. These interviews were conducted on 04/22/2024 and 04/24/2024. LPA Calderon obtained and reviewed the following: Veterans Administration VA/Physician Report (dated 12/12/2023), Needs and Service plan (dated 12/12/2023), Admission Agreement (Dated 12/18/2023), Public Guardian (PG) records (date 3/22/2024), email from VA (date 04/24/2024) The investigation revealed the following: Unsubstantiated Regarding Allegation: Staff relocated resident from facility without consent. This complaint alleged that staff relocated R1 from facility without consent. A1 states that A1 received an email from prior administrator Aaron Mayes date 03/21/2024 regarding moving R1 to the new facility. A1 states that A1 started to communicate with the VA on 03/21/2024 and received authorization from the VA on 3/21/2024 and from the PG on 3/25/2024. A1 states that the decision to move the resident was made with the authorization from the VA, PG, and the resident. A1 states that the resident was moved to a smaller facility so that a one-to-one care plan could be given. 2 out of 2 staff state that any change to a resident care consent is requested prior to the change. R1 states that R1 did not know and did not give consent to the change in facilities. 9 out of 10 resident states that any change to care written consent is requested. W1 states that W1 was aware of the change in facilities and gave authorization on 03/25/2024. Reviewed the admission agreement for R1 (date 12/18/2023). The conservator is W1 who is also the PG for resident’s care. Reviewed the Physician report (date 12/12/2023), R1 has health issues and is conserved. Reviewed email from the VA and Four Seasons Assisted Living facility (date 03/22/2024). Appears there is communication between the VA, PG and the facility and authorization granted prior to the resident being moved to the new facility. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of “staff relocated resident from facility without consent” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report were provided to the Administrator Clarizze Punit (A1).the state’s words, verbatim · CDSS document, Apr 24, 2024 · control 11-AS-20240416133420

Allegation investigated: Facility staff failed to properly address bed bugs in the facilitty. Facility is failing to provide a safe means of evacuating resident.

Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to this facility to deliver the complaint findings. LPA met with Azucena Reyes, Social Worker and explained the purpose of today's visit. The investigation consisted of the following: During the initial visit conducted on 04/04/24, LPA Gonzalez requested, and received the following documents: Staff and Resident Rosters, Pest Control Work orders dated 09/09/23, 09/22/23, 11/11/23 and 03/29/24, and Fire Drill Reports dated 01/17/24, 02/22/24, and 03/24/24. LPA Gonzalez along with Social Worker Azucena Reyes, toured the facilities emergency exits, and inspected rooms 203, 204, 207 on the 2nd floor, and rooms 312, 314, and 334 on the 3rd floor. LPA Gonzalez interviewed residents R1-R9 and staff S1-S7. Continued on LIC9099-C Substantiated The Investigation revealed the following: Regarding the allegation: Facility staff failed to properly address bed bugs in the facility. It is alleged that the facility has a bed bug infestation in rooms #321, #312 and #314 and some other rooms on the third floor. On 04/04/24 LPA Gonzalez and Social Worker Azucena Reyes toured the facility and inspected rooms #203, #204, #207 on the 2nd floor and rooms #312, #314, #334 on the 3rd floor. LPA Gonzalez found all rooms to be clean and free of any bed bugs. On 04/04/24 LPA Gonzalez assessed the Pest Control Work Order dated 03/29/24. Per interview with Social Worker Azucena Reyes, the resident in room #312 reported bed bugs in their room. Per pest control work orders, pest control was contacted on 03/22/24 and came by to treat the facility on 03/29/24. Per pest control work order, the following rooms were inspected: on the second floor rooms #201 - #212, #214 - #230, and #232 - #234. On the third floor rooms #301 - #305, #307 - #312, #314 - #331, #333 - #335, break room, kitchen, and the laundry room. Inspection revealed a heavy live bed bug infestation found in rooms #225 and #312. Terminix Commercial came in to the facility on 04/12/24 for a follow up service appointment. On 04/12/24 LPA Gonzalez interviewed two Terminix Commercial (pest control company) employees (W1-W2). W1 stated that Terminix came out to treat the facility on 03/29/24 for general pest control services. W1 stated that the facility has a 12-month bi-weekly agreement with Terminix. The treatment plan that they have with the facility is for general pest control treatment only, which does include treatment for bed bugs. W2 alos stated that Terminix came out to treat facility on 03/29/24 for general pest control services. W2 reported that live bed bugs were found in rooms #225 and #312 and treated by Terminix technician on 03/29/24. W2 also confirmed that the treatment plan with the facility does not include treatment for bed bugs. On 04/04/24 LPA Gonzalez interviewed 7 staff members. When LPA Gonzalez asked staff if there was currently a bed bug infestation in this facility, 6 out of 7 staff stated that there is not a bed bug infestation in this facility. When LPA asked staff if a pest control company would come out to treat the facility, 7 out of 7 staff stated that a pest control company had come to treat the facility on 03/29/24. On 04/04/24 LPA Gonzalez interviewed 9 residents. LPA Gonzalez asked residents if there’s been any issues with a bed bug infestation in this facility. 3 out of 9 residents interviewed stated there is a bed bug infestation in this facility. When LPA Gonzalez asked residents if they like living in this facility 7 out 9 residents interviewed stated they are very comfortable and like living in this facility. When LPA asked residents how they felt about the overall cleanliness of the facility, 7 out of 9 residents interviewed stated that it’s ok, and they like it. Continued on LIC9099-C Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. Regarding the allegation: Facility is failing to provide a safe means of evacuating resident. It is alleged that there are non-ambulatory residents in room(s) on the 3rd floor of the facility. There is a concern that in case of an emergency it would be hard for residents to evacuate the facility. On 04/04/24 LPA Gonzalez interviewed 7 (S1-S7). LPA Gonzalez asked if they (staff) feel that they are trained on the emergency evacuation plan, 6 out of 7 staff interviewed stated that they feel they are trained in the facilities emergency evacuation plan. On 04/04/24 LPA Gonzalez interviewed 9 residents (R1-R9). LPA Gonzalez asked if they feel that this facility is prepared and ready to assist residents to evacuate safely if an emergency were to occur. 5 out of 9 residents interviewed stated that they feel the facility is prepared and ready to assist residents to evacuate safely if an emergency were to occur. When LPA Gonzalez asked residents if the facility conducts emergency evacuation drills, 6 out of 9 residents interviewed said that the facility does not conduct emergency evacuation drills. On 04/04/24 records reviewed revealed the facility has a fire clearance (dated: 03/21/23) for a capacity of 136 non-ambulatory residents. LPA Elvira Gonzalez assessed the Disaster Drill Reports received, which states that an emergency evacuation drill was practiced on the following dates: 01/17/24, 02/22/24, and on 03/24/24. Furthermore, on 04/04/24 LPA Gonzalez toured the facility focusing on the facilities emergency stairwell exits. LPA Gonzalez did not observe an evacuation chair at each stairwell. Each floor has 2 stairwell emergency exits, 2 on the 2nd floor and 2 on the 3rd floor. LPA Gonzalez observed the 3rd floor stairwells had emergency evacuation chairs on both stairwells, and the 2nd floor did not have emergency evacuation chairs at either of the 2 stairwell exits. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. Continued on LIC9099-C Deficiencies are being cited based on LPA interviews, observations, and records review in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, plans of corrections were reviewed and developed. A copy of this report and appeal rights left with Azucena Reyes, Social Worker.the state’s words, verbatim · CDSS document, Apr 12, 2024 · control 11-AS-20240328112304

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 26, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The licensee did not comply with the section cited above in staff stating that bed bugs were reported in room #312, and were treated by Terminix Commercial on 03/29/24. Although they were treated, it did not give proper treatment for bed bugs as there should be continuous treatment for bed bugs, not just one spray. This poses a potential Health, Safety or Personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2024

Plan of correction: Licensee will ensure that bed bug activity in the facility is eradicated. Licensee will provide LPA with a copy of Pest Elimination Service Plan for bed bugs, along with invoice via email to Elvira.Gonzalez@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: HSC 159.695(f)(1) · Plan of correction due date: May 3, 2024

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. Based on observation, the licensee did not comply with the section cited above in not having an evacuation chair in each stairwell. Which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 12, 2024

Plan of correction: Licensee will place an evacuation chair at each stairwell and email proof of corrections to Elvira.Gonzalez@dss.ca.gov

Allegation investigated: Facility does not have an Administrator. Licensee does not follow proper admission procedures with residents in care. Licensee is not ensuring that there are enough staff to meet the needs of residents in care.

On 05/30/24 Licensing Program Analyst (LPA) Mario Leon conducted a follow-up, unanounced, visit to the above-mentioned facility to deliver this amended document. LPA was met by Robin Owens, Wellness Director (S1) and later by Azucena Reyes, Social Worker (S8) and Meshulem "Michael" Weiss (S9). The investigation consisted of the following: On 05/30/24 Licensing Program Analyst (LPA) Mario Leon was provided an additional LIC308 and LIC501 for Meshulem "Michael" Weiss (S9). On 04/03/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Robin Owens, Wellness Director (S1) and the purpose of the visit was explained. S1 and LPA toured the facility. LPA was later met by Maria Clarizze B. Punit, Interim Administrator (S2). LPA interviewed seven (7) out of ninety-five (95) residents and 7 out of forty (40) staff. Report Continues, see LIC9099C. Unsubstantiated The investigation revealed the following: Regarding the allegation: "Facility does not have an Administrator.". It has been alleged that there is no licensed administrator at the facility. Interviews revealed that six (6) out of 7 staff and four (4) out of 7 residents have denied the allegation. Record reviews revealed that the facility manager, Meshulem "Michael" Weiss (S9), was indicated on the LIC308 - Designation of Facility Responsibility as a designated substitute, who has the qualifications adequate to be responsible and accountable for management and administration of the facility as specified in regulation 87405. On 04/03/24, S2 was present at the above-mentioned facility and had been placed on the LIC308 - Designation of Facility Responsibility and that the facility. S2 will be informing the state licensing agency regarding the change of authorization on or before Friday 04/05/24, which is within the ten-day reporting requirement period of the change in authorization. LPA reviewed S2’s staff records. Record Reviews indicate S2’s application for Administrator certificate as pending. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation: "Licensee does not follow proper admission procedures with residents in care.". It has been alleged that there has been fifty (50) new residents within the past two months. Interviews revealed that 6 out of 7 staff and five (5) out of 7 residents have denied the allegation. Record reviews revealed that there were twenty-eight (28) residents admitted between the months of February and March. LPA also reviewed each individual’s recent medical assessment from each residents’ Physician. The facility was also able to provide pre-admission appraisal forms for the previously mentioned residents, which verifies the status of resident admissions are appropriately followed. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation: "Licensee is not ensuring that there are enough staff to meet the needs of residents in care.". It has been alleged that the facility has not kept up on proper staffing with all of these new (50) residents. Report continues, see LIC9099C. Interviews revealed that 5 out of 7 staff and all 7 residents have denied the allegation. Through interviews conducted, there are between 4 and 5 caretakers during each shift. LPA requested staffing updates and LPA was provided a staff roster of February and March. Record reviews revealed that there are 40 staff, twenty (20) of which are caretakers and 7 of which are med-techs. After reviewing these numbers, it has been calculated that the ratio of staff to residents has been sufficient to provide care to the residents during the months of February and March. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. An exit interview was conducted with Meshulem "Michael" Weiss (S9), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Apr 3, 2024 · control 11-AS-20240328161608

Allegation investigated: Staff do not ensure that resident has access to clean clothing. Staff do not ensure that resident's incontinence needs are being met. Staff do not ensure that resident's hygiene needs are being met. Staff do not ensure that resident is provided with an adequate amount of food and water. Staff are not adequately supervising resident.

The purpose of the amendment is to provide additional information and it does not change the investigation findings. On 03/21/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Health and Wellness Director Robin Owens and explained the purpose of the visit. Administrator Aaron Mayes joined us shortly after. The investigation consisted of the following: During today’s investigation, LPA interviewed 8 out of 96 residents, 7 staff which included the Administrator, Health and Wellness Director, (2) MedTech, Laundry and (2) Caregivers, and outside Case Worker. LPA also reviewed the resident records. Continue to LIC 9099-C. Unsubstantiated Allegation(s): Staff do not ensure that resident has access to clean clothing. The investigation revealed the following: Regarding the allegation " Staff do not ensure that resident has access to clean clothing,” it is being alleged that R1 is wearing the same soiled clothes. Interviews conducted indicate the following: laundry services are provided once per week and residents have the right to refuse services. Residents can also request for the additional clothes donated to the facility. LPA Cloyd observed R1’s clothing to be very stained with food. LPA toured R1's room and saw three shirts, one long jean jacket and hoodie, and four folded clothing items in R1's closet. R1 stated that R1 does receive laundry services. Administrator stated that R1 gets angry when prompted to wash clothing and refuses weekly services but will allow biweekly laundry services. Record review indicates that R1 is able to dress/groom self. Based on the interviews, observation, and record reviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation(s): Staff do not ensure that resident's incontinence needs are being met. The investigation revealed the following: Regarding the allegation "Staff do not ensure that resident's incontinence needs are being met,” it is being alleged that R1 has frequent incontinence issues, does not appear to be having regular support with urinary incontinence, and arrives with no adult diapers. Interviews conducted indicate the following: staff conduct rounds and complete incontinence changes, residents have access to a call button to request incontinence changes, residents may refuse services, and supplies are ordered through insurance. LPA Cloyd did not observed R1 to have incontinence needs. R1 stated that R1 can help self. Record review indicates that R1 does not have incontinence issues. Based on the interviews, observation, and record reviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Continue to LIC809-C Allegation(s): Staff do not ensure that resident's hygiene needs are being met. The investigation revealed the following: Regarding the allegation "Staff do not ensure that resident's hygiene needs are being met,” it is being alleged that R1 does not appear to be bathing regularly. Interviews conducted indicate the following: staff conduct rounds and completes shower schedules and residents may refuse shower assistance. R1 stated that R1 can shower self. Record review indicates that R1 does not need showering assistance. Based on the interviews, observation, and record reviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation(s): Staff do not ensure that resident is provided with an adequate amount of food and water. The investigation revealed the following: Regarding the allegation " Staff do not ensure that resident is provided with an adequate amount of food and water,” it is being alleged that R1 frequently asking for coffee/water upon first arriving. Interviews conducted indicate the following: three meals and snacks are offered to the residents, meals can be delivered upon request, and residents may refuse food. R1 stated that R1 does not eat much, does not have to take the food, and will just have coffee. Record review indicates that R1 does not have a special diet and is able to follow directions. Based on the interviews, observation, and record reviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Continue to LIC809-C Allegation(s): Staff are not adequately supervising resident. The investigation revealed the following: Regarding the allegation "Staff are not adequately supervising resident,” it is being alleged that R1 walks into the place of business without being escorted/dropped off. Interviews conducted indicate the following: staff and office communicates when a resident leaves the facility and residents are responsible for signing in and out of the facility. R1 stated that the facility said R1 could not leave but R1 leaves anyways. Record review indicates that R1 can leave the facility without assistance. Based on the interviews, and record reviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted and a copy of this report was left with Health and Wellness Director Robin Owens.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 11-AS-20240313150846

Type of visit: Case Management - Deficiencies

On 03/21/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unaccounced visit to conduct a case management visit and met with Administrator Aaron Mayes. During record review, LPA observed Staff #2 to be working at the facility but not cleared in Guardian nor associated to the facility. Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, Plans of Corrections were developed and reviewed. A copy of this report and appeal rights were discussed and left with Administrator Aaron Mayes.the state’s words, verbatim · CDSS document, Mar 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Mar 22, 2024

All individuals subject to a criminal record review...shall prior to working...in a licensed facility: obtain a California clearance or a criminal record exemption as required... This requirement was not met as evidenced by: LPA observed Staff #2 to be working at the facility but not cleared in Guardian nor associated to the facility.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: The Administrator immediately added Staff #2 (S2) into Guardian and provided Staff #2 with the CDSS Live Scan Form. S2 will not return to work until S2 is cleared. Administrator will ensure that all staff members listed on LIC 500 are cleared and associated. Proof of evidence to be emailed to regina.cloyd@dss.ca.gov by POC due date.

Allegation investigated: Facility doors in disrepair.

On 02/09/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Health and Wellness Director Robin Owens and explained the purpose of the visit. Administrator Aaron Mayes arrived 20 minutes later. The investigation consisted of the following: During today’s investigation, LPA toured the perimeters of the facility which included the front entrance, front emergency exit, outdoor patio, and garage area. LPA also interviewed 8 out of 84 residents and 8 staff which included the Administrator, Health and Wellness Director, MedTech, Payroll Representative, Maintenance and (3) caregivers. LPA also reviewed the resident records. Continue to LIC 9099-C. Substantiated The investigation revealed the following: Regarding the allegation "Facility doors in disrepair," interviews conducted indicated the following: three out of eight residents interviewed agreed with the allegations and five out of eight residents were unaware of a damaged door. During the facility tour, LPA noticed three doors that were in disrepair and one open garage gate. The first door is down the stairs near the second-floor lobby. The second door is down the stairs near the skilled nursing area. The third door is outside near the smoking patio. LPA also observed two residents reaching through the outside fence screening to open the door from the inside. Regarding the allegation “Facility doors in disrepair," based on interviews and observation, the preponderance of evidence has been met therefore the allegation is Substantiated. Deficiencies were issued. An exit interview was conducted and plans of correction developed. A copy of this report and appeals rights was reviewed and left with Administrator Aaron Mayes. The investigation revealed the following: Regarding the allegation “Staff are not safeguarding residents' belongings," interviews conducted indicated the following: seven out of eight residents interviewed had not heard about residents’ belongings being stolen. Eight out of eight staff members have not heard about residents’ belongings being stolen. Record reviews indicate that eight out of eight residents have theft and loss policy on file. Based on the interviews and record reviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted and technical assistance provided. A copy of this report was reviewed and left with Administrator Aaron Mayesthe state’s words, verbatim · CDSS document, Feb 9, 2024 · control 11-AS-20240207092001

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 26, 2024

The facility shall be...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interviews and observations, the facility has three damaged doors and one damaged garage gate which poses a safety risk to the residents in care.the state’s words, verbatim · CDSS document, Feb 9, 2024

Plan of correction: The administrator will provide evidence that the damaged doors and garage gate were repaired. The administrator will also provide a written plan for ensuring the safety of the residents in care. Evidence and plan should be emailed to regina.cloyd@dss.ca.gov by the POC due date.

Allegation investigated: Staff do not answer residents' call buttons in a timely manner

On 1/6/2024 at 9:30 AM Licensing Program Analyst (LPA) Alfonso Iniguez conducted a subsequent complaint visit to deliver the complaint findings. Upon arrival, LPA Montoya met with Administrator Aaron Mayes and LPA explained the purpose of this visit. The investigation consisted of the following: On 11/8/2023, LPA Lourdes Montoya toured the facility with Health and Wellness Director Robin Owens. LPA Montoya interviewed 5 out of 14 on-duty staff and 6 out of 68 residents. LPA attempted to interview two other residents who refused the interview. LPA requested and obtained copies of Staff roster, Resident roster, and one resident's (R1) service records (Admission Agreement, Physician's Reports and Appraisals/Needs and Services Plans). LPA also requested other pertinent records. Report continued in LIC 9099-C Substantiated Investigation revealed the following: Allegation: Staff do not answer residents' call buttons in a timely manner. It was alleged that staff do not answer residents' call buttons in a timely manner. On 11/8/2023 between 11:55 am – 2:05 pm, LPA Montoya interviewed 5 out of 14 on-duty staff and 6 out of 68 residents. Based on interviews conducted, 3 out of 5 staff (S1, S2, S4) stated the resident’s call button should be answered between 5-10 minutes for a timely response. S1 and S2 stated beyond 10 minutes is unacceptable. S5 stated the usual wait for a resident’s call is between 5-15 minutes while S3 revealed residents usually wait for 5-30 minutes. Based on interviews conducted, 4 out of 6 residents (R2, R3, R4, and R6) admitted they use the call button for help, and they wait between 5-45 minutes, 1 out of 6 (R1) residents stated the wait is up to an hour and 20 minutes. One resident (R5) has not used the call button to call for help. LPA did not obtain any records pertaining to call button incidents. Based on LPA’s observation on 11/8/2023 at around 1:03 PM while testing the call button in room #229B with S2, staff did not respond to the call button within 10 minutes. S2 aborted the test immediately after 10 minutes and called staff by using a walkie talkie. Per LPA’s observations, staff do not always answer residents’ call buttons in a timely manner. Based on information gathered, there is sufficient evidence to corroborate the above allegation. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of “Staff do not answer residents' call buttons in a timely manner” is found to be SUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to Melanie Heard/RCC Investigation revealed the following: Allegation: Staff do not provide adequate food service to residents. It was alleged that staff do not provide adequate food service to residents. On 11/8/2023 between 11:55 am – 2:05 pm, LPA Montoya interviewed 5 out of 14 on-duty staff and 6 out of 68 residents. Based on interviews conducted, 5 out of 5 staff and 5 out of 6 residents denied that staff do not provide adequate food service to residents. They revealed that meals are always served timely. S2 stated every meal has a set schedule both in the dining hall and in room service. Breakfast is ready between 8:00 am – 8:15 am, lunch (12:00 pm – 12:15 pm), and dinner (5:00 pm – 5:15 pm). R1 claimed food is sometimes delivered to the room late. Based on LPA’s record review and observation during the visit, the meals serving time posted in the dining hall is consistent with S2’s statements. LPA observed residents eating in the dining hall at 12:00 pm. LPA also observed a staff delivering a tray of a resident’s meal to bedroom # 229A at 12:11 pm which is within the facility’s meals serving time schedule. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff falsified resident documents. It was alleged that staff falsified resident documents. On 11/8/2023 between 11:55 am – 2:05 pm, LPA Montoya interviewed 5 out of 14 on-duty staff and 6 out of 68 residents. Based on interviews conducted, 5 out of 5 staff and 5 out of 6 residents denied that staff falsified resident documents. R1 claimed R1’s contract has been changed many times and it is not signed by the facility administrator. S1 stated R1 owes the facility in back rent, and it was necessary to amend the contract with the agreement to pay the back rent until the account is current. Based on record review, R1’s lease addendum dated 11/1/2023 pertains to the payment for the back rent and it was signed by a facility representative and R1. During the investigation, LPA did not observe unusual activities by the facility falsifying resident documents. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations, “Staff do not provide adequate food service to residents”, and “Staff falsified resident documents” are found to be UNSUBSTANTIATED. Exit interview was conducted and a copy of the report was provided to Melanie Heard/CCRthe state’s words, verbatim · CDSS document, Jan 6, 2024 · control 11-AS-20231101092846

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 22, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This was not met as evidenced by: Based on LPA’s observations and interviews, four residents admitted they use the call button for help, and they wait between 5-45 minutes, while one resident stated the wait is up to an hour and 20 minutes. Two staff admitted the call button should be answered within 5-10 minutes, beyond that is unacceptable. Based on LPA’s observation on 11/8/2023 at around 1:03 PM while testing the call button in room #229B with S2, staff did not respond to the call button within 10 minutes. S2 aborted the test immediately after 10 minutes and called staff by using a walkie talkie. Per LPA’s observations, staff do not answer residents’ call buttons in a timely manner. This poses a potential risk to residents’ health, safety and/or personal rights to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2024

Plan of correction: POC: Administrator shall review the cited section and shall self-certify understanding and compliance with the regulation. Administrator shall conduct an in-service training to staff on this regulation. POC shall be submitted to CCLD by faxing to 424-544-1016 by the POC due date.