Hollywood Hills Senior Living

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

Type of visit: Case Management - Annual Continuation

On 9/21/26, Licensing Program Analyst, (LPA) Ray Comer, made an unannounced site visit to this facility as a continuation of the required annual Inspection initially conducted on 09/10/2026. LPA met with Administrator, and the purpose of visit was disclosed. The following remaining inspection domains were observed, reviewed and inspected: Commons: Activity rooms, movie theater, dining rooms, pool hall, exercise room, and library observed to be clean with adequate seating for residents. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed by LPA. *Note: During a tour of the physical plant, LPA observed that the facility's second floor was furnished with portable A/C units. Apparently, the facility's central air system was experiencing some operation issues; per the Administrator, staff had provided proper cooling for residents on the second floor. However staff had failed to report the issue to CCL. Deficiency for failing to report to be issued on LIC809D. Medications: Medication room is located on first floor. LPA observed room as locked and inaccessible to residents. Inside the room, medications are properly labeled and stored in secured cabinets. Resident medication documentation and distribution records appear to be accurate and complete. [continued on LIC809-C] Laundry: LPA observed the laundry room located on the sub-floor, and forth floor, across from salon. Residents have access to the fourth floor laundry area to do their own laundry. Sub floor laundry area is serviced by staff-only and inaccessible to residents. All laundry areas are clean and clear from obstruction. Cleaning supplies and other toxins are stored in separate locked storage area and inaccessible to residents. Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Random resident rooms (#1005, #2012, #2006, #3003, #3010, #4004, #4011, #5002, #5010, #6008, #6004) were inspected and observed to maintain required furnishing and sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction. Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured between 115°F and 118.0°F.; within the required range. Outdoor: Courtyard area observed to have shaded patio(s), with tables with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. Resident records: A total of seven (7) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, centrally stored medication logs, and resident identification. Resident records appeared to be complete and current. Staff records: A total of six (6) staff files are stored in Administrator's office; secured and inaccessible to residents. Staff files were reviewed for criminal record clearances, Health Screening, staff associated to this facility, and all required documentation. Staff records appear to be complete and current. Deficiency was issued during today’s visit. Exit interview conducted, appeal Rights explained. and copy of this report provided. [continued on LIC809-C]the state’s words, verbatim · CDSS document, Sep 21, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(d) · Plan of correction due date: Sep 30, 2026

87211 Reporting Requirements (a) Each licensee shall furnish..such reports as the Department may require, including, but not limited to, the following: (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on interviews, the licensee failed to report Air Conditioning operations issues which poses a potential health and safety risk to Residents in care.the state’s words, verbatim · CDSS document, Sep 21, 2026

Plan of correction: The administrator shall submit an written incident report (LIC 624) regarding the incident and the actions the administrator is taking to resovle this incident and mitigation efforts to maintain comfortable room temps. POC shall be submitted by 9/30/26.

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

Type of visit: Annual/Random

On 09/10/26, Licensing Program Analyst, (LPA) Raymond Comer, arrived unannounced to conduct an annual inspection of the Facility. LPA met with Executive Director, and reason for the visit was disclosed. Facility is licensed as a six (6) floor complex and top floor penthouse. Fire clearance approved for (110) non-ambulatory residents, and ten (10) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, two (02) residents are receiving hospice care services, and one (1) resident is bedridden. At 2:30 pm, LPA conducted a tour of the physical plant and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main doors are the primary entry/exit access. Screening area is located immediately upon entrance. As the Facility provides dementia care, LPA observed the delayed egress system working properly. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 75.0°F., within the required range. The facility maintains an approved Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. [Continued on LIC 809C] Fire Detection/Protection system is present in the facility. Multiple smoke and carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. LPA observed all fire suppression and signaling systems to be tested and "passed" inspection; report certified by the Los Angeles Fire Department on 01/15/2026. Fire drill last conducted August 05, 2026. Fire extinguishers were observed throughout the facility. All extinguishers were last serviced by July 13, 2026. Evacuation chairs were observed in each stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Kitchen: LPA observed kitchen as clean, refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons were observed near any food areas. Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report was provided. [continued on LIC809-C]the state’s words, verbatim · CDSS document, Sep 10, 2026

Type of visit: Case Management - Incident

On 09/10/26, Licensing Program Analyst (LPA) Ray Comer followed up on a Unusual Incident/Injury Report and SOC 341 that the Community Care Licensing Department on 8/28/26. According to the incident report, a Responsible Family Member (F1) of Resident #1 (R1) reported to facility staff#1 (S1) that that Resident#2 (R2) was allegedly sexually assaulted by staff#2 (S2) while providing R2 shower assistance. Proper measures and protocol were taken by the facility. R2 was assessed by medical staff; no bodily injury was identified at the time of assessment. S2 was placed on work suspension pending completion of an internal investigation by facility management. F1 was notified. Staff contacted both the Ombudsman, and the Police were informed; they arrived to the facility to investigate; police declined to complete a report. S1 and S3 interviewed R1 and R2, with F1 present. During the interview, R2 could not recall the date when the alleged incident occured. R2 would only say that S2 provided shower assistance to them in an "unprofessional manner". Per R2, they did not experience any pain, nor body discomfort from their interactions with S2. Let it be noted, this is R2's second occasion when they have accused a staff of sexual assault while staff assistance was provided at the same facility. LPA interviewed F1, who revealed the following: Both R1 and R2 experience visual hallucinations and have a a history of making specious claims without merit. Per F1, such claims are "the nature of their mental state." [LIC809] Continued- Per F1, they are "very satisfied" with the communication, reports and quality of staff care provided to both R1 and R2. Exit interview was conducted, no citation(s) were issued, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2026

Allegation investigated: Staff retaliated against complainant Administrator is not able to provide adequate attention to the management and administration of the facility

At approximately 9:45 a.m. on 08/13/26, Licensing Program Analyst (LPA) Nicholas Reed conducted unannounced subsequent visit to deliver final findings for the above noted allegations. LPA met with the administrator and explained the purpose of this visit. The complaint was initiated on 12/16/25 by LPA Antonia Alvizar Ettima. During the visit at 1:20pm, LPA requested and received residents and staff rosters, and facility file for staff #1 (S1). In addition, LPA requested and received staff contact information. At 1:30 p.m., LPA, the Executive Director (ED), and the Resident Services Director (RSD) conducted a physical plant walk-through and LPA spoke with administrative personnel. Prior to this visit, LPA Comer reviewed licensing records of similar allegations. During previous licensing visits, LPA Comer also spoke with various facility personnel regarding above noted allegations. Due to nature of the allegations, there was no need to interview facility residents. At the time of this visit LPA Reed requested and reviewed facility file of the former ED. Unsubstantiated ALLEGATION: Staff retaliated against complainant It was alleged that that staff was wrongfully terminated in retaliation for their complaints filed against facility. Interviews of administrative personnel, including the ED revealed that S1 did not follow specific instructions to perform their job duties. ED and S1’s immediate supervisor spoke with S1 many times. Over time, S1’s insubordination led to disciplinary actions taken against S1 and subsequently S1 was terminated. A review of S1’s file verified the information revealed by administrative personnel. Based on interviews and record review there is insufficient information to verify the allegations. Therefore, the allegation is UNSUBSTANTIATED at this time. ALLEGATION: Administrator is not able to provide adequate attention to the management and administration of the facility. It was alleged that the facility’s ongoing issues are directly related to the leadership of former ED, who has exhibited a pattern of dishonesty and unprofessional behavior, which has contributed significantly to the facility operation. Critical staff positions remain unfilled, including payroll, Wellness, nursing, memory care, and maintenance. These vacancies contributed to the facility's overall dysfunction. LPA's interviews with administrative personnel, including the current ED, RSD, Concierge, & Business Office Manager (BOM) revealed that facility is going through some changes. The Former ED is no longer in charge. However, the facility operation was not reflected as they always have other leads relieving ED. During the investigation, LPA Alvizar-Ettima and LPA Comer were unable to obtain the information regarding former ED's separation from the company. A review of former ED's file did not reveal any information to support the allegation. Overall investigation did not reveal any sufficient information to support the allegation. Based on interviews and record review, it was concluded that although the allegation may have occurred, there is no measurable and verifiable information to confirm validity of the complaint. Hence the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues were noted at the time of this visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 31-AS-20251209125100

Allegation investigated: Questionable Death(s). Unqualifed staff are providing care and supervison to residents in care. Staff are providing false information to residents in care.

On 5/16/26, Licensing Program Analyst, (LPA) Ray Comer conducted unannounced subsequent visit to the facility to complete the investigation of the above allegation(s). The initial visit was conducted on 11/20/25, at which time at 9:25am, the department gathered residents and staff roster and other facility records included but not limited to Staff Training records, residents’ records, employee Handbook and other documents relevant to investigation. At approximately 9:30am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. During previous visit on 10/30/25 between 9:50am-12:00pm, and on 11/20/25 between 9:30-12:00pm LPAs interviewed the Administrator, Residents Care Director, med tech and five (05) other staff. In addition, LPA spoke with one (1) witness and ten (10) out of sixty-eight (68) residents. During this visit at 1:00 pm, LPA Comer requested and review facility files for the resident #1 (R1) and Resident #2 (R2). Their medication records and internal incident log also were requested and reviewed. [LIC9099C]Continued- Unsubstantiated Allegation: Questionable Deaths- It was alleged that multiple facility residents passed away due to neglect in care and supervision, including medication mismanagement. The Administrator, RCD and other staff indicated that no residents passed away within the month of November 2025. Between September 2025 and December 2025, there were total of 2 residents that passed away; Resident#1 (R1) and Resident#2 (R2) were in hospice. R1 passed in April 2024, and R2 passed in July 2025. A review of facility records, including copies of death reports verified the information received from staff. No documents were available to verify that staff mismanaged residents’ medication. Based on interviews and record reviews, there is insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Unqualified staff are providing care and supervision to residents in care. It was alleged that staff #1 (S1), a former med tech working on NOC shift, was neglecting care of the residents residing in memory care. Resident #3 (R3) was calling for help for several hours and no one responded. Finally, S3 responded and put R3 back to bed without proper assessment. Staff verified that S3 no longer works for the facility. However, they had no knowledge of R3 being neglected by S3. Residents interviewed during investigation did not address any concerns regarding their care and supervision provided at the facility. A review of facility records, including incident reports and internal incident records, did not reveal any information to verify the allegation. Based on interviews and record reviews it was concluded that although the allegation may have happened, there is not enough pertinent information to confirm validity of the complaint. Hence, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff are providing false information to residents in care. Concerns were addressed that facility Administrator, residents care director and other staff were mis-representing themselves as Registered Nurses. However, they were Licensed Vocational Nurses (LVNs). The Administrator and residents care directors denied misrepresenting themselves. Although they have few LVNs in the facility, they do not practice medical care in the facility. They indicated that everyone in the facility had knowledge that there are few LVNs working in the facility including the Administrator. [LIC9099C] Continued- Other staff interviewed during investigation had no knowledge that staff misrepresented themselves. Residents had no knowledge about medical titles of facility staff. A review of staff records did not support the allegation. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety hazard was nod during this visit. Exit interview was conducted and copy of the report was provided.the state’s words, verbatim · CDSS document, May 16, 2026 · control 31-AS-20251030124720

Allegation investigated: Staff do not permit resident to have visitors.

On 5/16/26, Licensing Program Analyst, (LPA) Ray Comer conducted an unannounced subsequent facility visit to complete the investigation of the above allegation. An initial visit was conducted on 07/24/2025, at 10:00am by LPA Evelin Rios, at which time LPA Rios requested and reviewed Resident#1's (R1’s) facility file included, but not limited to, Physician report, pre-appraisal, and other records pertaining to the investigation. At 11:15am, LPA Rios spoke to the Residents Service Director (RSD) and five (5) staff present at the facility. At the time of this visit, LPA Comer requested a copy of the R1’s Power of Attorney, and spoke with Memory Care (MC) Director to discuss R1’s personal rights. Allegation: Staff do not permit resident to have visitors. [LIC9099C]Continued- Substantiated It was alleged that on 07/13/25. Resident #1 (R1’s) family member arrived to visit R1 and staff informed him that R1’s POA does not allow the family member to visit R1. R1 is competent and is able to make their own decisions. Staff revealed that R1 was competent enough to let their needs be known. Staff verified that on 07/13/2025 there was a phone argument between R1’s family members. One of the siblings (R1’s POA) did not allow another sibling to visit R1. The staff followed POA's request documented in the facility records and did not allow R1’s family member to see R1. Staff admitted not informing R1 about a family member visiting the facility. A review of facility records verified that R1 was able to make their own decision to accept or deny visitation. Based on interviews and records review, there is sufficient information to support the allegation. Therefore, the allegation is substantiated at this time. Note: LPA Comer spoke with ED and informed them that POA does not extend to residents’ personal rights and Resident should be able to have visitation with a family member at their own will. Under Title 22 Division 6, Chapter 7, the following citation was issue and recorded on LIC9099D. Exit interview was conducted, appeal rights were discussed and a copy of report was issued.the state’s words, verbatim · CDSS document, May 16, 2026 · control 31-AS-20250714151853

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: May 16, 2026

87468.1 Personal Rights of Residents...(a) Residents...shall have all of the following personal rights: (11)To have their visitors…permitted to visit privately during reasonable hours and without prior notice… This requirement is not met as evidence by: Based on LPA interviews, and records review, Staff did not permit R1’s family member to visit R1, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2026

Plan of correction: A written statement shall be sent to LPA in which Administrator agrees staff shall not infrige on visitation rights of residents, and provide proof of completed in-service staff training regarding resident visitation rights specifically and resident personal rights in general.

Allegation investigated: Staff did not follow physician's orders, resulting in hospitalization. Staff did not adequately monitor resident for change of health condition. Staff did not seek timely medical attention.

On Tuesday, 4/28/26, Licensing Program Analyst (LPA) Raymond Comer conducted unannounced subsequent visit to complete an investigation of the above noted allegation(s). To investigate the allegation, on 4/14/26, LPA conducted an initial complaint visit. During initial visit, between 9:45 am and 11:30 am, LPA received and reviewed copies of R1's Identification\emergency contact info, physician's report (LIC 602), appraisal, and other relevant documents. At 11:45 am, LPA interviewed two (2) staff. At 1:20 pm, LPA spoke with the Administrator. During today’s visit, between 9:10 am and 10:40 am, LPA interviewed three (3) additional staff and between 10:50 am, and 12:15pm, LPA interviewed six (6) out of sixty-two (62) total residents. [LIC9099C] Continued- Unsubstantiated Allegation: Staff did not follow physician's orders, resulting in hospitalization. It was alleged that staff did not follow physician order to provide adequate hydration assistance to the resident #1 (R1). Staff did not provide R1 access to beverages and Pedialyte liquid nutrition, as per physician's orders. LPA Interviews with staff revealed the following: Staff were aware of R1's needs and service plans and provided R1 access to water, juices, milk, and Pedialyte drinks. Staff revealed that R1 was encouraged to stay hydrated and beverage refills were provided throughout the day. Observation of R1's liquid consumption/refusals were reported to the Memory Care (MC) director. Interviews with residents revealed that physician orders were followed in timely manner and required assistance is provided to residents on a daily basis; residents did not report any issues. Based on LPA interviews with Administrator, Staff, and Residents, there is not sufficient information to support this allegation. Thus, this allegation is deemed UNSUBSTANTIATED at this time. Allegation: Staff did not adequately monitor resident for change of health condition. Allegation: Staff did not seek timely medical attention. It was alleged that staff failed to observe R1 showing signs of dehydration. Subsequently on 04/07/26 that resident #1 (R1) was hospitalized due to severe dehydration. In addition, it was reported that due to inadequate hydration assistance, R1’s health conditions were changed and staff did not act in a timely manner to seek medical attention to address noted changes. LPA interviews with Administrator and staff revealed the following: On 4/2/26, R1 was observed by the Memory Care (MC) Director as refusing to drink liquids and Pedialyte beverage and appeared lethargic. Staff contacted R1's Primary Care Physician (PCP) and R1 was transferred, via ambulance, to the hospital for medical evaluation and treatment. Interviews with staff reveal that changes in R1's health/behavior were monitored and responded to in a timely manner. Review of submitted Incident reports (LIC 624's) verify that staff are documenting, observing changes in R1’s health condition, and provided timely reporting to appropriate medical providers and other parties. Other residents interviewed during investigation did not address any concerns regarding timely attention to their medical care. Based on LPA interviews, record reviews, and interviews, these allegation(s) are deemed Unsubstantiated at this time. Exit interview conducted, and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 31-AS-20260407161012

Allegation investigated: Licensee does not ensure that facility administrator is on the premises a sufficient number of hours. Facility staff do not answer communications from resident’s representatives appropriately. Facility staff do not properly report unusual incidents.

On 3/28/26, Licensing Program Analyst (LPA) Raymond Comer, conducted an unannounced subsequent complaint visit to the facility. LPA met the Memory Care Director and explained that the purpose of this visit is to conduct additional investigation of the above noted allegations and deliver final report. To investigate the allegations LPA Comer conduced the initial complaint visit on 05/16/25. At which time, LPA spoke with ED and discussed allegations. Between 2:15 pm and 3:00 pm, LPA recieved staff and residents’ rosters and interviewed facility staff. On 09/24/25, LPA Comer conducted subsequent visit. During this visit, at 12:30 pm LPA Comer conducted interviews with residents and responsible family members. Between 2:20 and 3pm, LPA requested and reviewed facility records, included but not limited to, facility schedule, internal incident reports, call log for emergency services, and other pertinent documents. [LIC 9099]-Continued Unsubstantiated Allegation: License does not ensure that facility administrator is on the premises a sufficient number of hours. It was alleged that the facility does not have an Administrator/ ED on property. The Administrator is present less than 20 hours per week with no after-hours qualified Designee. EDs lack of presence in Memory Care demonstrates a disregard for accountability." Interviews with ED, other staff and facility residents revealed that ED is present in the facility sufficient number of hours. There are designated staff responsible for Assisted Living (AL) and Memory Care (MC) units. A review of facility staff schedule verified that there are specific personnel responsible to oversee the operations in AL and MC. There is no information to verify that ED is not precent in the facility as it is required. Therefore, based on interviews and record review, there is an insufficient information to verify the allegation, Hence the allegation is unsubstantiated at this time. Allegation: Facility staff do not answer communications from residents’ representatives appropriately. Allegation: Facility staff do not properly report unusual incidents. It was alleged that family and resident requests are ignored by ED. Incident reports with falls and hospitalization aren’t submitted because ED is too busy and she can’t approve “minor” issues. ED revealed that any incidents reflecting residents’ health and safety are being reported to residents’ responsible parties, medical providers, and appropriate agencies. Staff indicated that upon knowledge of the incidents involving residents, they immediately report to their supervisor or lead. Residents interviewed during investigation addressed no concerns about incidents reported to their responsible parties. During subsequent visit LPA Comer spoke with residents’ responsible parties and they verified that ED or designees are in communication with them if needed. A review of facility records, including internal incident log and Incidents reports did not provide any measurable and verifiable information to verify the allegation. Therefore, based on interviews and record review, the above noted allegations are unsubstantiated at this time. No immediate health and safety issues were noted during investigation. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Mar 28, 2026 · control 31-AS-20250506100750

Allegation investigated: Staff did not ensure residents records were safely secured

At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina and Perchui Milena Khurshudyan conducted an unannounced subsequent visit to deliver final findings. LPAs met with the Executive Director, and explained the reason for the visit. An initial complaint visit was conducted on 10/30/25 at 9:25am by LPA and Licensing Program Manager (LPM) Nichelle Gillyard. During that visit LPA and LPM requested resident and staff roster. At 09:35am, LPA and LPM requested copies of pertinent information which include, but not limited to Maintenance Log and annual Fire Inspection. Between 09:50am – 12:00pm, LPA and LPM conducted an interview with the Administrator and one (1) resident. Five (5) out of nine (9) allegations were resolved. Continue on LIC9099-C Unsubstantiated On 11/20/2025 at 9:20am, LPA conducted a subsequent visit and requested additional copies of pertinent information which include, but not limited to Staff Training, Employee Handbook (Workplace Violence, Prohibited Conduct and Procedures for Reporting a Threat) relevant to the investigation. Between 9:35am - 12:00pm, LPA conducted an interview with the (former) Administrator, Concierge, one (1) MedTech and five (5) staff, one (1) witness and ten (10) residents. During the subsequent visit, LPA resolved three (3) out of four (4) “remaining” allegations. Allegation: Staff did not ensure residents’ records were safely secured It was alleged that the facility Director shared resident (R1’s) records with hospice staff who are not the attending nurses for the resident(s). To investigate this allegation, LPA conducted an interview with the Director, during the initial visit, who denied the above allegation and informed LPA that hospice resident files must be accessible to assigned hospice employees only, upon request. If the resident’s attending nurse is on vacation or off, another/substitute nurse (from the same hospice agency) may conduct the visit and review the file. LPA was also informed that based on the Health Insurance Portability and Accountability Act (HIPPA) no resident information can be disclosed to other agencies without resident’s consent. Thus, no HIPPA rights were violated by the facility staff. Ten (10) residents interviewed expressed no concern regarding this allegation. Additionally, interview with R1 revealed that he/she is currently receiving hospice services (from the same agency) since October 2025 and had no issues or concerns that his/her information was ever shared with 3rd party company without his/her consent. R1 stated: “This place is very organized.” Lastly, LPA reviewed R1’s hospice file and confirmed that the agency remained the same and no changes have been made since October 2025. Therefore, based on interviews and record reviews this allegation is deemed Unsubstantiated, at this time. No deficiency issued during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 31-AS-20251024095352

Allegation investigated: Staff did not ensure residents received their medication in a timely manner

On 1/29/26 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an initial 10-day complaint visit to investigate the above allegation. Upon arrival, LPA introduced herself at concierge – Pattie Reyes, then met with the Business Office Manager (BOM) Dannisha Beavers and explained the reason for the visit. Entrance interview conducted. At 10:00am, LPA requested residents and staff rosters. LPA also requested copies of pertinent information which include but are not limited to R1’s Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, copy of facility staff shift schedules. Facility Program design: Medication Policy, and additional documents relevant to the investigation. At approximately 1:25pm, LPA conducted a physical plant tour of the entire facility including the Medication room to ensure health and safety of the residents are protected. LPA did not observe any immediate health and safety issues. Continue on LIC9099-C Substantiated Allegation: Staff did not ensure residents received their medication in a timely manner. It was alleged that facility staff failed to ensure residents received their medications in a timely manner. The Reporting Party (RP) stated that on 1/25/26, the facility had no Medication Technicians (Med-techs) on duty throughout the day, resulting in medications being administered at approximately 5:52 p.m. RP further reported that residents did not receive their scheduled morning and afternoon medications and that staff were overworked and working double shifts. To investigate the allegation, the Licensing Program Analyst (LPA) conducted a review of facility records and interviewed the Executive Director (ED), Business Office Manager (BOM), two Med-techs, and eight (8) residents. During the interview, the ED confirmed that on 1/25/26, there was a staffing conflict and a staff call-out for the Assisted Living (AL) unit’s morning Medication Technician (MT) shift. This resulted in a delay in administering morning medications. The ED also stated that Resident 1 (R1) did not receive their morning medication because the delayed administration time was too close to the scheduled afternoon medication pass, making it unsafe to administer both. Interviews with the Med-techs confirmed that no MT had been scheduled to cover the AL unit for the morning shift on 1/25/26. Med-techs reported that an MT from the Memory Care Unit (MCU) was eventually called to assist with AL medication administration; however, by the time coverage was arranged, there was insufficient time to administer medications to one resident due to the proximity of the afternoon medication schedule. LPA interviewed eight (8) out of sixty-seven (67) residents regarding their medication experience on 1/25/26. Two (2) out of eight (8) residents, including R1, confirmed they did not receive their morning medications on 1/25/26. The remaining six out of eight residents reported having no issues with their medications and stated they had never missed a dose. LPA reviewed the staff schedule for 1/25/26 and verified that MT had been assigned to the AL morning shift, however the call out resulted in a lack of timely medication coverage. LPA also reviewed residents’ Medication Administration Records (MARs) for that date and confirmed that R1’s morning medications were not initialed or documented as administered. Additionally, LPA reviewed the unusual incident report submitted to CCLD on 1/29/26, which documented the missed medication. Continue on LIC9099-C Throughout the investigation, LPA evaluated the facility’s medication procedures, staffing practices, and documentation protocols. LPA also discussed medication administration expectations with facility staff. Based on interviews and record review, it was determined that the facility did not ensure R1 received their medication in a timely manner on 1/25/26 due to inadequate staffing coverage and delayed medication administration. Therefore, the allegation is SUBSTANTIATED. A deficiency issued during today's visit, see LIC9099-D Exit interview conducted, appeal rights explained, and a copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 31-AS-20260126093805

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jan 29, 2026

87465- Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on interviews and medication records review, licensee did not comply with the section above by not assuring that R1 and R2 prescribed medications were administered in a timely manner as prescribed. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: LPA reviewed the staff roster and confirmed that the facility has coverage for all three shifts, seven days a week. LPA was also informed that the facility is in the process of hiring additional staff and will submit an updated roster once the new employees are onboarded. During today's visit LPA cleared the deficiency.

Allegation investigated: Medication mismanagement contributed to residents death. Staff are not dispensing medication as prescribed.

On 12/13/2025 at approximately 10:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the staff members and stated the reason for their visit was to deliver the findings of the complaint. The Regional Director of Operations, Vanessa Jewell, arrived shortly after to assist with today’s visit. To investigate the allegation(s), on 07/31/2025 at approximately 10:00 AM, LPA conducted a physical plant tour. By 11:00 AM, LPA requested relevant documentation. From 11:30 AM to 2:00 PM, LPA conducted record review. On 10/16/2025 LPA conducted a subsequent visit to the facility to conduct interviews and additional record review. LPA attempted to interview five (5) staff members (S1-S5). (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Medication mismanagement contributed to residents death. It is being alleged that staff members S2 and S5 are purposely providing false information to hospice pertaining to residents’ medication which resulted in the death of two (2) residents (R1-R2). To investigate the allegation, LPA conducted record review of both R1’s and R2’s files. Record review revealed that R1 was admitted to Gentle Touch Hospice on 9/26/2023 due to a decline in their condition as a result of their medical diagnosis. On 9/02/2025, LPA requested R1’s medical records from hospice. Record review revealed that R1 was placed on various medications due to their diagnosis. The medication in question (per the Reporting Party) was allegedly discontinued by S5 which caused R1’s death on 4/17/2024. However, LPA’s record review of R1’s Interdisciplinary Group Review (IDG) showcased that R1’s attending physician had placed the order to discontinue said medication on 4/14/2024. The order to discontinue the medication was documented to be due to R1 being, “…susceptible to bruising while on anticoagulant” (page 2). Additional record review confirmed R1 was observed during hospice visits to have had a change of condition resulting in their Plan of Care being updated to meet R1’s needs until their time of death. LPA’s review of R1’s Certificate of Death documented their death to have been contributed by both cardiac arrest and cognitive decline. LPA’s record review of R2’s file revealed that R2 was admitted to Easy Care Hospice on 9/13/2024 due to a decline in their condition related to their medical diagnosis. On 9/02/2025, LPA requested R2’s medical file from Hospice. Record review revealed that R2 was placed on various medications due to their diagnosis. The medication in question (per the Reporting Party) was allegedly requested to be discontinued by S5 which caused R2’s death on 7/17/2025. However, LPA’s record review showcased that R2 had been sent to the hospital on 9/06/2024, where an order to discontinue the medication in question was placed by the attending physician on 9/11/2024. Additional record review of R2’s Physician’s Orders (6/02/2025 to 7/15/2025) showed no record of said medication listed. LPA’s record review of R2’s Certificate of Death documented their death to have been contributed to both cardiac arrest and cognitive decline. It was also alleged staff are receiving compensation for hospice enrollment. LPA’s interview with S2 regarding whether they are receiving any compensation through monetary gains for residents being admitted into Hospice were denied. LPA’s interview with S1 revealed that they would “fire” any staff that would partake in any financial gain through residents being admitted into hospice. LPA attempted to interview S5 but S5 no longer works at the facility and could not be contacted. Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Staff are not dispensing medication as prescribed. It is being alleged that staff are not administrating medication as prescribed. To investigate the allegation LPA conducted interviews with four (4) staff members. All four (4) staff members confirmed that resident’s medications are administered as prescribed. During LPA’s physical plant tour, LPA observed the medication rooms located in both the Assisted Living Unit and the Memory Care Unit. LPA observed, at random, a total of ten (10) residents’ medications. LPA observed all ten (10) residents' medications to be labeled correctly, assigned to the correct person and administered on the correct date. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to The Regional Director of Operations.the state’s words, verbatim · CDSS document, Dec 13, 2025 · control 31-AS-20250730105811

Allegation investigated: Licensee does not ensure that staff provide adequate care and supervision to residents in care. Staff left residents unattended for extended periods of time while in care. Staff member under the influence of a substance while providing care and supervision to residents in care.

At approximately 09:15am, Licensing Program Analyst (LPA) Raymond Comer, and Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced 10-Day complaint visit in response to the above-mentioned allegation(s). LPAs met with the Administrator and explained the reason for the visit. At 09:20am, LPAs requested resident and staff roster. At 09:25am, LPAs requested copies of pertinent information which include, but not limited to Staff Training, Employee Handbook (Workplace Violence, Prohibited Conduct and Procedures for Reporting a Threat) relevant to the investigation. At approximately 9:30am, LPAs conducted a physical plant tour; no resident health and safety issues were observed. Between 9:35am - 12:00pm, LPA conducted an interview with the Administrator, Concierge, one (1) MedTech, five (5) staff, one (1) witness, and ten (10) residents. (Continue on LIC9099-C) Unsubstantiated Allegation: Licensee does not ensure that staff provide adequate care and supervision to residents in care. The reporting party alleges that staff do not provide adequate care and supervision to residents, that residents are neglected and minimal activities provided to residents. To investigate this allegation, LPAs interview with the Administrator revealed the following: The Administrator refutes this allegation, and stated that staff are well trained and provide adequate care and supervision to all residents. LPAs observed eighteen (18) memory care residents in the activities rooms; residents appeared clean, free of odor, and engaged with staff. LPAs interview with residents revealed the following: Ten (10) out of ten (10) residents stated they are treated well, feel respected by staff, and are provided with adequate care and supervision. LPAs interview with staff revealed the following: Six (6) out of seven (7) staff stated that licensee ensures adequate staff coverage at the facility, that work assignments are manageable and do not feel overwhelmed with resident assistance tasks. Staff stated checking on residents a minimum of every two hours, or as needed. Based on the LPAs observations, and interviews with Administrator, residents and staff, this allegation was found to be "unsubstantiated" at this time. Allegation: Staff left residents unattended for extended periods of time while in care. The reporting party alleges that staff neglect causes residents to wait extended periods of time before toileting\changing assistance is provided. To investigate this allegation, LPAs interview with the Administrator revealed the following: The Administrator refutes this allegation, and stated that adequate staff coverage is available during all work shifts, that resident calls are responded to a timely manner, and that all residents are checked at a minimum of every two hours, or as needed. LPAs interview with residents revealed the following: Ten (10) out of ten (10) residents (five Memory Care and five Assisted Living) stated that staff provide adequate care and supervision. Residents with incontinence issues stated that staff provide timely toileting and changing assistance on a consistent basis. [Continued LIC9099-C] LPAs interview with staff revealed the following: Seven (7) out of seven (7) staff stated that residents are provided adequate care and supervision, that staff respond to resident assistance calls on a timely basis, (average response within 7-to-10 mins) and that resident room checks occur a minimum of every two hours, or as needed. Based on the LPAs observations, and interviews with Administrator, residents and staff, this allegation was found to be "unsubstantiated" at this time. Allegation: Staff member was under the influence of a substance while providing care and supervision to residents in care. The reporting party alleges that a former Staff#1 (S1) was under the influence of a substance while providing care and supervision to residents. To investigate this allegation, LPAs interview with the Administrator revealed the following: The Administrator refutes this allegation, and stated that it is S1's personal decision to quit their position at the facility and was not terminated due to any violations of work policies, specifically substance abuse issues while employed as facility staff. LPAs interview with residents revealed the following: Ten (10) out of ten (10) residents refute the allegation and stated never having witnessed, nor heard of any staff exhibiting behavior suggesting substance usage. LPAs interview with staff revealed the following: Seven (7) out of seven (7) staff refute the allegation, and stated never having witnessed S1, nor any facility staff exhibiting behavior suggesting subtance Based on the LPAs observations, and interviews with Administrator, residents and staff, this allegation was found to be "unsubstantiated" at this time.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 31-AS-20251030124720

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

Allegation investigated: Staff does not ensure residents are spoken to in a respectful manner Staff engage in inappropriate interactions while in the presence of residents Staff do not have the ability to communicate with residents

At approximately 09:15am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit in response to the above-mentioned allegations. LPA met with the Administrator and explained the reason for the visit. At 09:20am, LPA requested resident and staff roster. At 09:25am, LPA requested copies of pertinent information which include, but not limited to Staff Training, Employee Handbook (Workplace Violence, Prohibited Conduct and Procedures for Reporting a Threat) relevant to the investigation. At approximately 9:30am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 9:35am - 12:00pm, LPA conducted an interview with the Administrator, Concierge, one (1) MedTech and five (5) staff, one (1) witness and ten (10) residents. Continue on LIC9099-C Unsubstantiated Allegation: Staff does not ensure residents are spoken to in a respectful manner It was alleged that the Administrator is disrespectful to staff and residents. To investigated this allegation, LPA conducted an interview with the Administrator and was informed that all staff and residents are afforded dignity and respectful relationship. All staff interviewed denied the above allegation and informed LPA that they haven't witness the Administrator acting or speaking with staff and or residents in a disrespectful manner. Additionally, ten (10) residents interviewed expressed no concern regarding this allegation. LPA was informed that all staff members are very professional and all residents personal rights are being respected. Therefore, based on interviews this allegation is deemed Unsubstantiated at this time. Staff engage in inappropriate interactions while in the presence of residents It was alleged that staff who are in relationships demonstrate inappropriate behaviors with each other while at the facility in the memory care wing. To investigate this allegation, LPA conducted an interview with the Administrator who confirmed that the facility has a couple working at the Memory Care Unit, however, both parties always show professionalism during their work duties and never demonstrate inappropriate behavior with each other whilst at work. LPA conducted interviews with one (1) MedTech and five (5) staff members who denied ever witnessing an inappropriate relationship between the staff members during their work duties. Ten (10) residents and one (1) witness interviewed also expressed no concern regarding this allegation. Lastly, LPA conducted review of the facility Employee Handbook and observed a section under “Prohibited Conduct” as follows: Threats or any acts made toward or by any company employee will not be tolerated… Copies of all employee training were also obtained. Therefore, based on interviews and record reviews this allegation is deemed Unsubstantiated at this time. Staff do not have the ability to communicate with residents It was alleged that the maintenance staff don't speak or understand English and can't communicate with residents when they request repairs to be done. To investigate this allegation, LPA conducted an interview with the Maintenance Director (MD), during today's visit, and observed that MD is fluent in English and is able to freely communicate and understand the conversation. Ten (10) residents interviewed expressed no concern regarding this allegation. Therefore, based on interviews this allegation is deemed Unsubstantiated at this time. No deficiency issued during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 31-AS-20251024095352

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff do not ensure facility is kept clean, safe, sanitary and in good repair at all times Staff does not ensure facility furniture is in good repair

At approximately 09:25am, Licensing Program Analyst (LPA) Angela Panushkina and Licensing Program Manager (LPM) Nichelle Gillyard conducted an unannounced complaint visit in response to the above-mentioned allegations. LPA and LPM met with the Administrator and explained the reason for the visit. At 09:30am, LPA and LPM requested resident and staff roster. At 09:35am, LPA and LPM requested copies of pertinent information which include, but not limited to Maintenance Log and annual Fire Inspection. Between 09:50am – 12:00pm, LPA and LPM conducted an interview with the Administrator and one (1) resident. Continue on LIC9099-C Substantiated Allegation: Staff do not ensure facility is kept clean, safe, sanitary and in good repair at all times It was alleged that the facility floors are dirty and the facility is kept in an unsanitary condition. To investigate this allegation, LPA and LPM conducted a physical plant tour at 10:09am and visited random resident rooms on the 2nd, 3rd and 4th floors. At 10:16am, LPA and LPM observed a smear in the bathroom wall. At 10:23am, upon entry to the room #2011 LPA observed scrape on the wall, the room smelled like urine, and one (1) outlet cover was broken and needed to be replaced. At 10:33am, LPA and LPM observed room #2008 had a crack on the stucco that needed to be fixed. At 10:40am, during the physical plant tour LPA and LPM observed room #3016 (1-2) carpets were dirty and had stains. At 10:50, LPA and LPM observed a strong smell of urine in room #3007. At 10:45am, room #3014 dresser's two (2) handles were observed broken and required to be replaced. At 10:51am, LPA and LPM observed the top portion of the dresser (in room #3007) was missing. Lastly, all trash cans, in nine (9) bathrooms, were missing fitted lids. Administrator was informed that all trash cans must have a fitted lid to protect them from cross contamination. Therefore, based on LPA and LPM observation, this allegation is Substantiated. Allegation: Staff does not ensure facility furniture is in good repair It was alleged that the dinning room furniture is wobbly and the chairs are in bad condition and need to be replaced. To investigate this allegation, LPA and LPM conducted a physical plant tour at the Memory Care Unit (on a 2nd floor) dining room area. LPA and LPM inspected fifteen (15) out of fifteen (15) chairs and didn’t observe any issues. However, two (2) out of ten (10) tables were confirmed to be unsteady and wobbly which is a potential hazard for falling apart while being used. Both tables were immediately removed during today’s visit. Based on LPA and LPM observation this allegation is Substantiated. Deficiency issued on LIC9099-D Exit interview conducted, appeal rights explained and copy of this report signed and delivered. Allegation: Staff does not ensure facility floors are maintained in good repair It was alleged that the facility carpets are loose which is a tripping hazard. To investigate this allegation, LPA and LPM conducted an interview with the Administrator and were informed that the facility has carpets on the 3rd, 4th and 5th floors. At some places, LPA and LPM observed the carpets were slightly loose. However, it’s not a tripping hazard. The carpets are not frayed, not torn and you are able to walk over without catching your shoe, walker or the wheelchair. The Administrator was already aware of this situation and informed LPA and LPM that an order had been placed to fix the carpets. Proof of document was obtained during today ‘s visit. Therefore, based on interview, document review, LPA and LPM observation this allegation is deemed Unsubstantiated, at this time. Allegation: Staff does not ensure facility is kept free of hazardous obstructions It was alleged that the parking garage has a water leak and there are hazards due to being over filled with equipment. LPA and LPA along with the Administrator toured the garage area and observed a large storage area that contained various large items. The maintenance room was not accessible to residents in care. LPA observed random furniture out of the way, placed by residents' family for disposal when they left. Furniture is not stored in an obstructive hazard. Therefore, based on LPA and LPM observation and information gathered during today's visit this allegation is Unsubstantiated, at this time. Allegation: Staff do not ensure restricted area of facility is safely secured It was alleged that the staff do not ensure the door to the roof top of the building is kept locked to prevent residents from having access. To investigate this allegation, LPA and LPM along with the Administrator conducted a physical plant tour of the facility. At 11:35am, LPA and LPM observed that the roof access had no lock. Room #7709, which is independent and not part of the licensed facility, is located across from the roof top door and is the only room that has access to outside. At 1:02pm, LPA contacted the Fire Inspector and confirmed that the fire door and access to the roof should not be locked. Therefore, based on LPA and LPM observation and information gathered during today’s visit, this allegation is deemed Unsubstantiated at this time. No deficiency cited Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 31-AS-20251024095352

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 7, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPAs observation, the licensee did not comply with the section cited above by having a dirty carpet in multiple resident rooms and in hallways, including chipped walls/doors, and missing paint on the walls/doors (throughout the facility).Which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: During today's visit, two (2) wobbly dining table were removed from the Memory Care Unit. Licensee/Administrator agreed to have faclitity carpet cleaned, replace all broken/damaged dressers and paint chipped/molded walls/doors. Pictures will be submitted to LPA by POC date.

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

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst, (LPA) Ray Comer, made an unannounced site visit to this facility as a continuation of the required annual Inspection initially conducted on 09/12/2025. LPA met with Administrator and the purpose of visit was disclosed. The following remaining inspection domains were observed, reviewed and inspected: Fire Detection/Protection system is present in the facility. Multiple smoke and carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. LPA observed all fire suppression and signaling systems to be tested and "passed" inspection by contracted vendor, Fire Alliance Inc. Inspection report submitted to Los Angeles Fire Department on 01/22/2025. Fire drill last conducted September 10, 2025. Fire extinguishers were observed throughout the facility on all floors. All extinguishers were last serviced by July 2, 2025. Evacuation chairs were observed in each stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Kitchen: LPA observed kitchen as clean, refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons were observed near any food areas. However, LPA observed two (2) staff working in kitchen area without required hair net coverings. Deficiency will be issued in LIC 809-D. [continued on LIC809-C] Commons: Activity rooms, movie theater, dining rooms, pool hall, exercise room, and library observed to be clean with adequate seating for residents. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed by LPA. Medications: Medication room is located on first floor. LPA observed room as locked and inaccessible to residents. Inside the room, medications are properly labeled and stored in secured cabinets. Resident medication documentation and distribution records appear to be accurate and complete. However, an adjacent door to room where refrigerated medications are stored was observed as unlocked and accessible. Deficiency will be issued in LIC 809-D. Laundry: LPA observed the laundry room located on the sub-floor, and forth floor, across from salon. Residents have access to the fourth floor laundry area to do their own laundry. Sub floor laundry area is serviced by staff-only and inaccessible to residents. All laundry areas are clean and clear from obstruction. Cleaning supplies and other toxins are stored in separate locked storage area and inaccessible to residents. Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Random resident rooms on all floors (#1003, #2010, #2006, #3003, #3010, #4004, #4006, #5008, #5016, #6016, #6010) were inspected and observed to maintain required furnishing and sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction. Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured between 111.0°F and 113.0°F.; within the required range. Outdoor: Courtyard area observed to have shaded patio(s), with tables with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. [continued on LIC809-C] Staff records: Staff files are stored in Administrator's office; secured and inaccessible to residents. Staff files were reviewed for criminal record clearances, Health Screening, staff associated to this facility, and all required documentation. Staff records appear to be complete and current. Deficiencies issued during today’s visit. Exit interview conducted, appeal Rights explained. and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 18, 2025

Type of visit: Required - 1 Year

On Friday, 09/12/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived unannounced to conduct an annual inspection of the Facility. LPA met with Administrator, and reason for the visit was disclosed. Facility is licensed as a six (6) floor complex and top floor penthouse. Fire clearance approved for (110) non-ambulatory residents, and ten (10) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, fifteen (15) residents are receiving hospice care services, and two (2) residents are bedridden. At 8:40 am, LPA conducted a tour of the physical plant and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main doors are the primary entry/exit access. Screening area is located immediately upon entrance. As the Facility provides dementia care, LPA observed the delayed egress system working properly. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 74.0°F., within the required range. The facility maintains an approved Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. [Continued on LIC 809C] Resident records: A total of seven (7) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, centrally stored medication logs, and resident identification. Resident records appeared to be complete and current. Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report was provided.the state’s words, verbatim · CDSS document, Sep 12, 2025

Allegation investigated: Staff are not following proper medication training-

Today, Friday, 7/11/25, at 8:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned, initial10- day visit to investigate the above allegation. LPA met with Resident Services Director, Keith Bernanbe, presented official CDSS badge identification, and reason for the visit was disclosed. At 8:15 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate this allegation, LPA received facility resident roster, and staff roster. From 8:35 am to 9:30 am, LPA conducted a tour of facily medication rooms. From 9:45 am, to 11:30 am, LPA conducted interviews with Administrator, and Staff. [LIC9099C]-Continued Unsubstantiated Allegation: Staff are not following proper medication training- The Reporting Party (RP) states that facility Medication Technicians are instructed by Staff#1 (S1) to reuse cups used to distribute medications to residents. RP states that Med Techs buy medication cups with their own personal funds in order to remain in compliance with facility's medication services policy. LPA interview with Administrator revealed the following: Administrator denies the claim that staff do not comply with the facility medication services policy, stating that all Med Tech staff are provided in-service training requiring all medication cups to be disposed of after use. Per Admin, staff managers are well aware of the medication services policy, and have not instructed staff to retain used medication cups for any reason. Per Admin, facility keeps ample supplies of medication cups in stock, and that the facility has not experienced critical shortages of any supplies to service residents. LPA conducted interviews with five (5) staff, which revealed the following: All staff interviewed by LPA deny claim of non-compliance with facility medication services policy, stating that staff have taken medication training and are well aware of the proper handling of resident medications, that medication cups used for resident meds distribution are promptly disposed after use. All staff interviewed by LPA state they have not purchased medication cups using personal funds, and that supplies of medication cups are consistently stocked at the facility. LPA conducted a tour of the facility, which revealed the following: Medication Rooms, located in the Assisted Living Unit, and Memory Care Unit, were observed and found to contain adequate supplies of packaged medication cups to service residents. Staff informed LPA that medications are transferred directly from medication containers and into resident cups, and that their hands do not touch the distributed medication pill/liquid. Moreover, LPA requested S4 and S5 to demonstrate how medications are dispensed and observed that staff are properly following medications procedures. Based on LPA observations, and interviews with Administrator, and Staff, LPA was unable to find evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 31-AS-20250702160429

Allegation investigated: Staff yells at residents-

Today, Tuesday, 6/03/25, at 10:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned, initial10- day visit to investigate the above allegation. LPA met with Administrator, Vanessa Jewell, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:15 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate this allegation, LPA received facility resident roster, and staff roster. From 10:20 am to 1:00 pm, LPA conducted interviews with Administrator and Staff. From 1:10 am to 2:25 pm, LPA conducted interviews with residents. [LIC9099C]-Continued Unsubstantiated Allegation: Staff (S1) yells at residents- The RP alleges Staff (S1) "constantly yells and screams" at residents. LPA interview with Administrator and Staff revealed the following: Administrator refutes this allegation, stating that S1 maintains a professional demeanor and has not heard, nor witnessed S1, nor any other staff, yelling at any residents in care. LPA conducted interviews with eight (8) staff which revealed the following: Eight (8) out of eight (8) staff state they have not witnessed, nor heard of S1, nor any other staff, yelling, nor neglecting to respect the rights of residents in care. LPA conducted interviews with eight (8) residents which revealed the following: Eight (8) out of eight (8) residents state they have not witnessed, nor heard of S1, nor any other staff, yelling nor neglecting to respect the rights of residents in care. Based on interviews with the Administrator, staff, residents, LPA was unable to find evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 31-AS-20250527130048

Allegation investigated: Food Service Personnel are performing duties in an unsanitary manner-

Today, Friday, 5/16/25, at 7:50 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned, initial10- day visit to investigate the above allegation(s). LPA met with Administrator, Vanessa Jewell, presented official CDSS badge identification, and reason for the visit was disclosed. At 8:10 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate this allegation, LPA received facility resident roster, and staff roster. From 8:45 am to 10:45 am, LPA recieved and reviewed documents relevant to the investigation. From 10:50 am to 1:45 pm, LPA conducted a tour of the facility kitchen, interviews with Administrator and Staff. [LIC9099C] Continued--- Substantiated Allegation: Food Service Personnel are performing duties in an unsanitary manner- The reporting party (RP) alleges that kitchen staff do not practice proper food handling standards, do not wash dishes thoroughly, and do not wear hair nets while performing their duties as food service staff. LPA conducted a tour of the facility kitchen which revealed the following: Kitchen equipment- Commercial refrigerators, and freezers and food warmer, were observed as working properly, daily logs show refrigerators kept at minimum internal temperature of 40 degrees Fahrenheit, freezers kept at minimum internal temperature of 0 degrees Fahrenheit. Food Warmer was observed at minimum internal temperature of 160 degrees Fahrenheit. However, commercial dishwasher temperature gauge was unreadable, and daily dishwashing temperatures are not logged by staff. Work area sanitation- Serving dishes, glasses, eating utensils, etc... were observed as thoroughly cleaned and free of food debris. Kitchen floors, Food storage areas, internal compartments of refrigerators, freezers, and food warmers were observed as clean, free of dirt, grime, spillage, rodents, vermin, or insects. Food service staff hygiene- All food service staff were observed wearing hairnets. However, two (2) of a total three (3) food service staff working in the kitchen were observed as not wearing gloves. Cross Contamination Prevention- All meats and vegetables observed as properly stored, food prep surfaces were observed as clean; food storage containers were securely closed. Based on LPA observations and interviews, staff failed to provide required food service service sanitation practices. Therefore, the allegation is deemed SUBSTANTIATED at this time. Exit interview conducted, and report provided. Deficiencies cited on LIC9099D.the state’s words, verbatim · CDSS document, May 16, 2025 · control 31-AS-20250506094816

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(29) · Plan of correction due date: May 16, 2025

GENERAL FOOD SERVICE REQUIRMENTS-All equipment...and dishes,shall be kept clean and maintained in good repair and free of breaks, open seams, cracks and chips. This requirement is not met as evidenced by: Based on LPA observation. Kitchen dishwasher temperature guage is unreadable, and staff were unable to provide a recorded dishwasher temperature log as required in facility's dining services guidelines. This poses an potential risk to the health and safety of clients in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: On, or before 5/30/25, Adminstrator states that repairs will be completed to restore functionality of dishwasher temperature guage and that staff will log dishwasher temperatures on a daily basis.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(15) · Plan of correction due date: May 16, 2025

GENERAL FOOD SERVICE REQUIRMENTS- All persons engaged in food preperation and service shall observe personal hygiene and food service sanitation pratices which protect the food from contamination. This requirement is not met as evidenced by: Based on LPA observation. Two (2) out of three (3) total food services staff were found working in the facility kitchen without required gloves.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: On, or before 5/30/25, Adminstrator states that all food service staff complete in-service trainings regarding personal hygiene and food services sanitation practices.

Type of visit: Case Management - Deficiencies

Today, Friday, 5/16/25, at 2:00 pm, Licensing Program Analyst, (LPA) Raymond Comer, met with Administrator Vanessa Jewell for a case management visit. The purpose of the case management visit is to address deficiencies observed during the course of investigation for complaint # 31-AS-20250506094816. The deficiencies were not alleged but are related to the complaint. It has come to the attention of LPA Comer that the Administrator did not have a fingerprint clearance on file associated to the facility since their date of hire (08/10/20) LPA explained to Administrator that this is an immediate civil penalty. Citations issued. Please see LIC809-D and LIC421-BG Appeals rights discussed and provided. Exit interview conducted and a copy of this report given to Administrator.the state’s words, verbatim · CDSS document, May 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80019(e)(2) · Plan of correction due date: May 16, 2025

Criminal Record Clearance (e)All individuals subject to a criminal record review pursuant to …shall prior to working... in a licensed facility: (2)Obtain a California clearance or a criminal record exemption...This requirement is not met as evidenced by: Based on records review, the Administrator does not have a criminal record cleareance associated with this faciliy. Administrator has been employed with the facility since 8/10/20the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: As of today, the Administrator is associated with the faciliy.

Allegation investigated: Staff did not prevent outbreak of virus- Facility food warmer is in disrepair-

Today, Tuesday, 5/06/25, at 10:15 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned, initial10- day visit to investigate the above allegation(s). LPA met with Administrator, Vanessa Jewell, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:25 am, LPA conducted a physical plant tour; "Frequent Hand Washing" postings promentently displays throughout the facility. Common area dining room, coffee lounge, and bristro, (located in the front lobby) are closed until GI Outbreak has been determined as resolved. To investigate this allegation, LPA received facility resident roster, and staff roster. From 11:00 am to 2:15 pm, LPA reviewed records, conducted observations, and interviewed staff. [LIC9099C] Continued--- Unsubstantiated Allegation: Staff did not prevent outbreak of virus- The Reporting Party (RP) alleges that multiple residents are sick from viral outbreak which occurred at the facility approximately "a week and a half ago", or around 4/22/25, and that staff have neglected to prevent viral spread. LPA review of staff records revealed the following: On Tuesday, 4/22/25, Staff#1 (S1) reported to Los Angeles County Department of Public Health (LACDPH) and Community Care Licensing. (CCL) that five (5) Memory Care Residents were experiencing GI symptoms of loose bowel, diarrhea, and vomiting. Staff correspondence included listing of residents/staff affected by the GI Outbreak. On Wednesday, 4/23/25, LACDPH Community Outbreak Team Representative confirmed notification of GI Outbreak reported by staff, and that a district public health nurse was assigned for outbreak management. On Wednesday, 4/30/25, LPA spoke with S1,via telephone, who stated twenty-eight (28) residents and four (4) staff are affected by the GI Outbreak. Per LACDPH Community Health representative, (N1) facility staff have provided updates regarding any change in circumstances. LPA spoke with S1, during today's on-site observation, who stated the following: A total of thirty-two (32) residents [comprised of fourteen (14) Assisted Living (AL) residents, eighteen (18) Memory Care (MC) residents] and eight (8) staff are affected by the GI Outbreak. Facility observations conducted by LPA revealed the following: "Notice of Gastrointestinal Exposure", dated 4/22/25 is posted prominently on main doors of facility's entrance. Masks are available upon request. Housekeeping staff were observed cleaning exposed surfaces. (i.e., counter tops, handrails tables, floors, etc...) Staff were observed wearing the proper Personal Protective Equipment. (PPE) Therefore, based on LPA observations, records review, and interviews with staff, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided. [LIC9099C] Continued--- Allegation: Facility food warmer is in disrepair- RP states facility food warmer is in disrepair, yet is still in use to serve resident meals. LPA observation of facility kitchen revealed the following: Facility food warmer was tested and found to be working properly; device reached temperature of 164 degrees Fahrenheit at the time of testing. LPA interviews with staff revealed the following: Staff#2 (S2) states that resident meals are initially temperature checked when placed in the food warmer, and again on a second occasion when meals are transported and delivered to residents. Both Staff#2 and Staff#3 state that the food warmer has been working consistently at the appropriate temperature (140 f. to 165 f) in order to prevent bacterial growth. Therefore, based on LPA observations, records review, and interviews with staff, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, May 6, 2025 · control 31-AS-20250429132801

Type of visit: Office

On this day at 11 am, a meeting was conducted by Assistant Program Administrator (APA) Stacy Barlow to verify Chapter 7 Bankruptcy Report filed by the Pacifica Senior Living as reported by the media. Present during the meeting are: Shelley Grace - Assistant Branch Chief, CCLD Craig Lundgren - Legal Counsel, CCLD Carl Knepler - Chief Executive Officer Marlene Nelson - Director, Quality Assurance and Risk Management APA Barlow verified with Knepler information received by CCL from the media as follows: $25M lawsuit against the community located in Bakersfield Photography lawsuit against one of the properties lawsuit against a Skilled Nursing Facility (SNF) in the Healdsburg location Knepler states that despite the lawsuits, there is no financial impact to any of the properties, residents or staff of the company. Knepler added there are no vendor issues as well. continuation on LIC 809-C Knepler also states that management communicates with the staff and residents to make them aware of the changes. Signages have been changed. Knepler added that the bankruptcy did not affect any of the communities because Pacifica Senior Living Management was no longer the management company for any of the Pacifica Communities, that the communities had given notice to the department and residents back in October or November of last year of the changes in management companies. He said that the judgment in Bakersfield did not involve the operating entity, only the management company. He said there were no other suits pending against any of the Pacifica entities. APA requested the following documents be provided to CCL by today: Spread sheet of all facilities whose management company was/is Pacifica Senior Living Management Company management companies for each location letter provided to the residents notifying them of the changes At the conclusion of the meeting, APA emphasized to Knepler the importance of communicating with CCL any lawsuits that the company may have in the future. Knepler agreed with APA. A copy of this report was provided to Knepler.the state’s words, verbatim · CDSS document, Apr 4, 2025

Allegation investigated: Staff are not able to provide care services to resident in care-

Today, Thursday, 4/03/25, at 9:50 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned initial10- day visit to investigate the above allegation. LPA met with Administrator, Vanessa Jewell, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:10 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate this allegation, LPA received facility resident roster, and staff roster. From 10:20 am to 11:45 am, LPA conducted interviews with staff, reporting party (RP), and responsible family member (F1). LPA reviewed resident records and interviewed residents from 12:15 pm to 2:20 pm. LPA received copies of the Admissions Agreement, Physician Communications, Hospital "After-Visit" Summaries, Staff "Narritive Charting", Physician’s Report (LIC 602), and Needs/Service Plans. [LIC9099C] Continued--- Unsubstantiated Allegation: Staff are not able to provide care services to residents- The RP alleges that Resident#1 (R1) is not provided care by staff. LPA contacted the RP, via phone, who stated the following: Staff called 911 on several occasions to send R1 to the hospital. RP states that R1 had no medical issues which required emergency services and said to LPA that facility staff are simply "wasting public resources". LPA review of R1's file revealed the following: Physician's report identifies R1 as diagnosed with dementia and altered mental status. R1 was assessed and admitted to the facility as a Memory Care (MC) resident in October of 2024; R1's daughter is acting Power of Attorney (POA). Unusual Incident Reports, with occurrences dated 3/23/25, and 3/35/25, describe R1 as sustaining fall injuries and exhibiting aggressive behavior which necessitated staff to call for 911 emergency services. Incident reports indicate that R1's Primary Care Physician (PCP), Neurologist, and POA were informed by facility staff. LPA interview with Staff and Administrator revealed the following: Both Administrator, S1 and S2 refute this allegation, stating that R1 is provided adequate staff care and supervision, and that 911 emergency service calls made by staff on R1's behalf were necessary to provide R1 proper health assessment and timely medical treatment. LPA interview with R1's Responsible Family Member (F1) revealed the following: F1 states that facility staff provide them timely communications regarding all incidents involving R1. F1 states she is confident that facility staff are providing R1 proper care and supervision. LPA interviews with seven (7) residents revealed the following: Seven (7) out of seven (7) residents state that staff provide satisfactory care and supervision. Therefore, based on LPA interviews with staff, residents, responsible family member, and documents review, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 31-AS-20250324110641

Allegation investigated: Staff did not prevent a resident from eloping while in care-

On Tuesday, 03/11/25, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced subsequent complaint visit at the facility investigating the above allegation. LPA met with the Administrator and reason for the visit was disclosed. The Initial investigation to the above allegation was conducted on 1/21/25, and subsequent visit conducted on 2/18/25. Based on the information received, the complaint pertaining to the above allegation was deemed as "Substantiated." On today's subsequent visit, LPA conducted a review of documents and interview of staff which revealed the following: [LIC 9099C]- Continued Substantiated Allegation: Staff did not prevent a resident from eloping while in care- Reporting Party (RP) alleges that on 1/11/25,Resident#1 (R1) was identified as wandering around the Griffith Park area unattended. To investigate this allegation, LPA conducted a interviews with staff, which revealed the following: Both Administrator and Staff Director (S1) state that, is spite of R1's dementia diagnosis, the facility's initial pre-placement assessment indicated R1 was on a the "high functioning" end of the dementia spectrum. This resulted in the facility placing R1 as an Assisted Living (AL) resident, with frequent observation and reassessment to determine if AL is the optimal placement. (Per 6/7/24 Needs and Services Plan documentation) Per the Administrator, from R1's initial placement, R1 was placed on a list of AL residents, "who cannot leave the facility unassisted". The aforementioned list is given to staff during shift meetings and are instructed to provide enhanced vigilance regarding the supervision and frequent well checks of these residents. Per the Administrator, the facility currently does not have surveillance cameras to visually monitor common areas and perimeter entry/exit points. However, after R1's elopement, the installation of such cameras and the use of fobs tracking resident's distance from the facility's perimeter is being considered in the licensee's strategy to mitigate the occurrence of resident elopement. LPA review of R1's file and other relevant documents reveals the following: Regarding R1's mental condition, pre-placement appraisal documentation simply states "withdrawn"; omitting PCP's diagnosis. Additionally, staff assessment identifies R1 as "Independent". Thus, needed no redirection, interventions, or room visits. Therefore:Based on information obtained through documents review and interviews, sufficient evidence was found to sustain the above allegation as Substantiated.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 31-AS-20250116121515

Allegation investigated: Faciity failed to report suspected abuse/neglect of residents in care-

Today, Monday, 3/10/25, at 8:45 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned, subsequent complaint visit to continue investigating the above allegation. LPA met with Administrator designee, Keith Bernanbe, presented official CDSS badge identification, and reason for the visit was disclosed. An initial10- day visit was completed on 2/14/25. At 9:00 am, LPA conducted a physical plant tour; no health and safety issues were observed. Allegation: Reporting Party (RP) alleges, on 11/16/24, a staff (S1), held and pushed a pillow over the face of Resident#1 (R1). RP alleges this incident was reported to Staff Supervisor(s) (S2), and (S3). However, RP alleges that both supervisors ignored the reported incident. [LIC9099C] Continued--- Unsubstantiated Additionally, RP alleges that Resident#2 (R2) was observed as "covered in urine and feces" lying on the floor in their facility bedroom. RP alleges the facility's night shift staff are responsible for neglect of R2. To investigate this allegation, LPA received facility resident roster, and staff roster. LPA conducted a review of resident files for R1 and R2, and interviewed facility residents and staff. Regarding the alleged incident involving R1, LPA interviews with Staff revealed the following: Staff Supervisors (S2 and S3) refute the claim, stating that the alleged incident was never reported to them. Furthermore, both S2 and S3 deny the occurrence of the alleged incident, stating that staff respect R1's personal rights, and provide R1, and all other residents, professional care and supervision. LPA interviews with five (5) Memory Care Unit (MCU) Staff revealed the following: Five (5) out of five (5) staff could not corroborate the allegation, stating they have not witnessed, nor heard of any neglect/abuse committed upon residents by staff. LPA's interview with R1's Responsible Family Member (F1) revealed the following: F1 states, "Our family visits R1 "a minimum of once, or twice per week", and asserts "facility staff respect R1's personal rights, and overall, we are happy staff treatment of R1". F1 states having no facility health or safety concerns. Regarding the alleged incident involving R2, Staff Supervisors (S2 and S3) refute the allegation, stating that R2 was "well cared for" by staff throughout their residency at the facility. Responsible Family Members were informed, and an incident report was submitted to Community Care Licensing (CCL) regarding R2's fall injury and subsequent ambulance transport to Kaiser for medical evaluation. However, S2 and S3 deny that R2 was "covered in urine and feces" as alleged. LPA interviews with five (5) Memory Care Unit (MCU) Staffers revealed the following: Five (5) out of five (5) staff could not corroborate the allegation, stating they did not witness, nor hear of any neglect\abuse committed upon R2 by staff. LPA interview with seven residents revealed the following: Seven (7) out of seven (7) residents state that staff provide adequate levels of care and assistance. All residents interviewed expressed having no concerns regarding neglect, nor abuse of residents by staff. Based on the information obtained, there was insufficient evidence to prove that staff failed to report suspected abuse/neglect of residents in care. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of this report delivered.the state’s words, verbatim · CDSS document, Mar 10, 2025 · control 31-AS-20250210120851

Allegation investigated: Staff do not respond timely to a resident's alerts- Staff did not provide adequate care and supervision-

On Friday, 02/28/25, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced subsequent complaint visit at the facility investigating the above allegation(s). LPA met with the Administrator Designee, Keith Bernanbe, and the reason for the visit was disclosed. The Initial investigation to the above allegations was conducted on 11/05/24. At that time, based on the information received, the complaint pertaining to the above allegations was deemed "Unsubstantiated." On today's subsequent visit, LPA conducted additional interviews with residents which revealed the following: [LIC 9099C]- Continued Unsubstantiated Allegation: Staff do not respond timely to a resident's alerts- It was reported that R1 pressed the service call button and staff did not respond to provide assistance. LPA Interviews with seven residents (7) revealed the following: six (6) out of seven (7) residents state staff response times to service calls is both timely and acceptable. LPA entered R1's room and activated the service call button; caregiver staff arrived within six minutes of the call button's activation. Based on the information obtained through LPA observation, and interviews, it cannot be proven that staff fails to respond to resident service calls. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff dose not provide adequate care and supervision- It was reported that staff do not know how to change resident diapers. RP states that staff "do not know what they are doing". LPA's Interviews with seven (7) residents revealed the following: seven (7) out of seven (7) residents state staff are professional and provide satisfactory levels of caregiver assistance. Based on the information obtained through LPA interviews, it cannot be proven that staff fails to provide adequate service to residents in care. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Feb 28, 2025 · control 31-AS-20241030125453

Allegation investigated: Staff physically abused resident-

Today,Friday, 2/21/25, at 8:30 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned,subsequent complaint visit to continue investigation of the above allegation. LPA met with Administrator designee, Keith Bernanbe, presented official CDSS badge identification, and reason for the visit was disclosed. prior subsequent visit completed on 2/20/25, and initial10- day visit was completed on 2/13/25. At 8:40 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate this allegation, LPA received facility resident roster, and staff roster. From 9:00 am to 10:30 am, LPA conducted interviews with staff, and residents [LIC9099C] Continued--- Unsubstantiated Allegation: Staff physically abused resident- The reporting party (RP) alleges that sometime in the month of Jan, 2025, Resident#1 (R1) suffered physical abuse by caregiver staff (S5). Per the RP, when caregiver staff were providing Resident#1 (R1) a diaper change, S5 was alleged to have "strangled and slapped" R1. LPA interview with the RP revealed the following: RP says she heard about the alleged abuse incident from staff med tech (S1). Per RP, S1 also reported the alleged abuse incident to their immediate supervisor (S4). LPA interviews with S1 and S4 revealed the following: S1 refutes the RP's claim, stating that she did not witness, nor hear of any abuse inflicted upon R1, nor any other facility resident. S4 also refutes the claim that an abuse of R1 was reported by S1, or any other facility staff. LPA interviewed five (5) staff who provided to care and assistance to R1. Five (5) out of five (5) staff state not witnessing, nor hearing off any abuse by committed upon R1, nor any other facility resident. LPA interviewed four (4) memory care residents, and three (3) assisted living residents: All residents interviewed by LPA state that staff respect their personal rights and have never witnessed, nor heard of any abuse committed at the facility. LPA could not interview R1 because resident passed away on 1/19/25. LPA interviewed responsible family member (F1) of R1 which revealed the following: Per F1, Facility staff treated R1 professionally and with respect to their personal rights. From the time of R1's admission as a resident, until R1's passing in Jan 2025, F1 states that R1 never displayed anxiety with staff and was comfortable interacting with facility staff until R1's passing. . Based on the information obtained, there is insufficient evidence to corroborate the allegation that resident (R1) was physically abused by staff. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 31-AS-20250212131914

Allegation investigated: Staff spoke inappropriately to resident-

Today,Thursday, 2/20/25, at 10:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned,subsequent complaint visit to continue investigation of the above allegation. LPA met with Administrator designee, Keith Bernanbe, presented official CDSS badge identification, and reason for the visit was disclosed. An initial10- day visit was completed by LPA on 2/13/25. At 10:10 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate this allegation, LPA received facility resident roster, and staff roster. From 11:00 am to 1:30 pm, LPA conducted interviews with staff, and Resident#2 (R2) . [LIC9099C] Continued--- Substantiated Allegation: Staff spoke inappropriately to resident- The reporting party (RP) alleges that staff-caregiver (S7) yelled at resident#2 (R2). Per RP, R2 was stated to say they no longer want S7 providing them direct care and assistance. LPA interview with staff-Resident Services Director (S6) revealed the following: R2 spoke to S6, stating that caregiver, S7 acted "unprofessionally", spoke rudely, and handled R2 "roughly" when assisting them with diaper changes. Per S6, S7 was spoken to by their supervisor regarding R2's concerns. S7 received a written warning citing unsatisfactory job performance. Per S6, to honor R2's request, S7 no longer provides R2 direct assistance with bathing/grooming/diaper changes. LPA interview with staff-caregiver (S7) revealed the following: S7 refutes the claim of "yelling" at R2. However, S7 corroborates that she "could have communicated better" with R2 and states apologizing to R2 regarding the "rough" handling of the resident when assisting with their diaper changes. LPA interview with resident#2 (R2) revealed the following: R2 stated that S7 did speak inappropriately, communicating rudely, and speaking in a condescending manner. R2 stated to LPA that facility management's response to this concern demonstrates proper respect to their personal rights; Per R2, the issue has been addressed to their satisfaction. Based on interviews with staff and resident, staff did speak inappropriately to resident. Therefore, the allegation is deemed SUBSTANTIATED at this time. Exit interview conducted, and report provided. Deficiencies cited on LIC9099D.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 31-AS-20250212131914

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 20, 2025

Personal Rights of Residents in All Facilities-(a) Residents in all residential care facilities...shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff...This requirement is not met as evdenced by: Based on interviews, facility caregiver spoke inappropriately to Resident#2 (R2), violating their personal rights, which poses a immediate Health, Safety, or Personal Rights risk to clients in care.the state’s words, verbatim · CDSS document, Feb 20, 2025

Plan of correction: Corrected before visit. Licensee has spoken with caregiver, issued disciplinary action to caregiver, and removed caregiver from providing further assistance to resident.

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

Allegation investigated: Staff did not prevent a resident from eloping while in care-

Today,Tuesday, 2/18/25, at 9:35 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned,subsequent complaint visit to continue investigating the above allegation. LPA met with Administrator designee, Keith Bernanbe, presented official CDSS badge identification, and reason for the visit was disclosed. An initial10- day visit was completed by LPA on 1/21/25. At 9:45 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate this allegation, LPA received facility resident roster, and staff roster. At 10:15 am, LPA conducted a review of Resident 1's (R1's) file, From 11:05 am to 1:00 pm, LPA conducted interviews with facility staff, and R1's responsible family member (F1). [LIC9099C] Continued--- Substantiated Allegation: Staff did not prevent a resident from eloping while in care- The Reporting Party (RP) alleges that on 1/11/25, approx. time of 7:49 pm, Resident#1 (R1) was identified as wandering around the Griffith Park area unattended. To investigate this allegation, LPA conducted a records review, which revealed the following: Physician's report lists R1 as having a diagnosis of dementia. Incident reports show that, on Saturday, 1/11/25, R1 was last seen at the facility around 5:30 pm. Incident report states that R1 was later found wondering around the Griffith Park area by Los Angeles Police Department Officers who then transport R1 to Kaiser Hospital-Los Angeles for medical evaluation. Records review also revealed that, the following week, a subsequent elopement incident involving R1 occurred on Friday, 1/17/25. On both occasions, R1 was returned to the facility, and responsible family member (F1) was notified. Both incident reports state that R1 did not sustain any injuries, nor discomfort during these elopement events. LPA conducted interviews with staff which revealed the following: Staff-Resident Services Director, (S1) and Staff-Memory Care Director, (S2) both confirm that R1 eloped from the facility unsupervised, stating that R1 eluded facility's supervision. LPA interviewed R1's responsible family member (F1) which revealed the following: F1 states that the facility's community is good, and that staff workers "do a good job" of caring for R1. F1 confirms that facility staff provided them immediate notice when R1 eloped from the facility. Upon R1's return to the facility, F1 states the Administrator informed them that staff would be re-trained regarding resident supervision. Based on LPA records review, and interviews, the allegation that resident wandered away due to lack of supervision, is deemed Substantiated. Exit interview, copy of report, appeal rights, and citation provided.the state’s words, verbatim · CDSS document, Feb 18, 2025 · control 31-AS-20250116121515

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(c) · Plan of correction due date: Feb 18, 2025

87464(f)(c)- "Care and supervision" means facility assumes responsibility for...assistance with activities of daily living without which the resident’s...safety, or welfare would be endangered. This requirement is not met as evidenced by: Staff interviews and record review by LPA finds R1, a resident diagnosed as having dementia, and documented instances of wandering from the faciltiy, was able to elope from the facility unsupervised. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Administrator shall review regulations regarding supervision and dementia care. Administrator shall provide trainings to staff and submit plans to ensure residents do not elope by POC date of 2/28/25. Plan will be submitted either via fax or email to LPA.

Allegation investigated: Night Shift Staff not meeting incontinance needs of residents in care-

On Friday, 2/14/25, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced, initial10-day complaint visit to investigate the above allegation(s). LPA met with Memory Care Director, Esmeralda Guevara,and presented official CDSS identification. At 9:00am, the Administrator arrived to the facility and LPA disclosed reason for the visit. To investigate this allegation, LPA received Facility resident roster, and staff roster. Between 6:15 am, and 8:30 am, LPA conducted random observations of resident bedrooms, and interviewed seven (7) residents. Between 8:45 am, and 12:35 pm, LPA interviewed the Administrator, and seven (7) staff. Allegation: Night Shift staff not meeting incontinence needs of residents in care- Reporting Party (RP) alleges that night shift staff neglected to provide incontinence service assistance to memory care residents. [LIC 9099C]- Continued Unsubstantiated To investigate the allegation, LPA conducted observations of random bedrooms in the memory care unit: (Memory Care Bedrooms #2009, #2011A/B, #2010, #2004A, #2003, #3003, #3004, #3007, #3016) LPA observations revealed the following: All observed bedrooms appeared as clean and organized; no foul odors detected. Residents in observed bedrooms appeared to be clean and dry, blankets and bedsheets appears as clean, and residents observed wearing clean diapers, and showing no trace of urine or feces. LPA conducted interviews with the Memory Care Director which revealed the following: Current Memory Care Unit (MCU) census is twenty nine (29). During morning (6:00 am-2:30 pm) and afternoon (2:30 pm-10:00pm) shifts, the MCU comprises four (4) caregiver staff, and one (1) Med Tech. During the night shift, (10:00 pm-6:00 am), the facility comprises three (3) caregiver staff, and one (1) Med Tech. The Memory Care Director states that all incontinent residents are changed a minimum of three (3) times per shift, and as needed. Six (6) staff members interviewed by LPA corroborated statement provided by the MCD. LPA conducted interviews with three (3) residents from the memory care unit, and four (4) residents from the assisted living unit. All, a total of seven (7) out of seven (7) residents, interviewed stated that staff provide satisfactory incontinence assistance and expressed no concerns regarding this allegation. Therefore, based on LPA interviews with staff, residents and observations, this allegation is deemed Unsubstantiated, at this time.the state’s words, verbatim · CDSS document, Feb 14, 2025 · control 31-AS-20250210120851

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff did not prevent resident from sustaining a fracture while in care- Staff did not seek medical attention in a timely manner-

On 9/06/24, Licensing Program Analyst, (LPA) Raymond Comer conducted a subsequent visit to conclude investigation of the above allegation(s). LPA met with the administrator, Vanessa Jewell, advising of the complaint. Initial visit was made on 6/06/24. The complaint was also referred to Investigations Branch (IB) and accepted by Investigator, Veronica Padilla, as a full investigation. IB Padilla’s investigation consisted of interviews with facility, staff, family members of Resident#1 (R1), and review of facility records. IB Padilla also searched text messages submitted by relevant staff, conducted investigations, and reviewed documents received from outside agency/services. The following is a summary of IB’s investigation: On 06/10/24, IB conducted interviews with family member of R1. Family member believes that R1 sustained an unwitnessed fall from their bed on 10/31/23, between the hours of 1200 and 0600. States that R1 was found on the ground in their room several hours later and that staff failed to report. Staff called saying R1 was in a lot of pain. The Family member asked staff if R1 had fallen, and staff stated, “no”. [continued on LIC9099C] Substantiated On 06/12/24, IB obtained the following documents gathered from LPA, Raymond Comer, during the course of his initial investigation: R1’s Plan of Care, Resident Assessment, Physician Report, Release of Resident Medical Information, Staff Narrative Charting, Admissions Agreement and other relevant documents. On 6/14/24, IB conducted an interview with Hospice personnel Witness#1 (W1) provider of hospice care for R1. W1 submitted an email to IB investigator stating R1 requires maximum assistance with transfers and is a fall risk. W1’s email response contains a statement from R1’s doctor showing that R1 is 100% dependent for all care needs. Communications log submitted by W1 shows, that on 10/31/23, facility staff were aware that R1 was in extreme pain and not physically able to stand, nor move their leg without experiencing a lot of pain, and that Hospice agency was not notified of R1’s fall injury. On 08/15/24, IB conducted an interview with staff 1 (S1), who confirmed that R1 had sustained a fall from their bed on 10/30/23 around 01:00am. S1 states that on 11/01/23, they inquired to the responsible caregivers about the falling incident. The caregivers responded that they, “…didn’t think it was necessary to report it”. S1 states that disciplinary actions were taken against the responsible caregiver staff for failing to report at the time of the incident’s occurrence. On 8/19/24, IB conducted a subsequent interview with W1 who spoke with IB investigator, via phone, and stated the following: W1 contacted facility staff and Administrator asking if R1 had fallen; Staff and Administrator, “kept saying no”. W1 stated to IB investigator that protocol requires, “…when a patient falls, the expectation of the facility is to contact hospice immediately. We have to be notified immediately…”. On 08/20/24, IB conducted an interview with staff 2 (S2), who assisted R1 at the time of the reported incident. S2 confirms that they did not conduct a physical check of R1 for any injuries, stating, “I messed up on that aspect”. On 8/28/24, IB conducted a records review of relevant documents submitted by Kaiser records department. IB’s review of records reveals, on 11/03/23, R1 was admitted for a left hip fracture due to a fall injury which occurred at the facility. Noted comments indicate R1 sustained a fall on 10/31/23, and was put back to bed with no concerns, and that family was not informed of the injury until the following day. [continued on LIC9099C] On 08/30/24, IB conducted an interview with staff 3 (S3), who stated that, if an injury is suspected, staff are trained to check residents for any bruises, report the incident to their supervisor, and call 911 if there is any pain or bleeding. S3 states that staff did not report the incident, in spite of R1’s constant complaints of pain, saying that R1 always complained of pain, “which was normal behavior for R1”. On 9/04/24, IB conducted an interview with facility staff 4. (S4) who stated they were not at the facility and the time of the incident involving R1. However, S4 stated concerns of the facility not having enough staff to keep the residents safe. On 09/09/24, IB conducted an interview with resident 2 (R2), who was present at the time of the incident involving R1. R2 stated they were awakened from the sound of screams coming from R1’s room. R2 went looking for staff to assist R1 because it appeared R1 was in a great deal of pain. Based on interviews with staff, residents, and review of relevant documents, it appears that facility staff failed to report R1’s suspected falling incident to supervisory staff, nor provide required medical assessment and treatment in a timely manner. Therefore, pursuant to Title 22, Division 6, Chapter 1, the above allegation(s) are Substantiated. An immediate Civil Penalty of $500.00 is being issued today; Refer to LIC 421M. An additional Civil Penalty determination may be assessed at a later date. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Feb 13, 2025 · control 31-AS-20240604154507

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 28, 2025

(87466) Observation of the Resident- Licensee shall ensure residents are regularly observed for changes in physical... functioning...appropriate assistance is provided when such observation reveals unmet needs...This requirement is not met as evidenced by: Based on records reviewed and interviews conducted by (IB) investigator, facility staff failed to provide required medical assessment and treatment in a timely manner, which posed an immediate heatlh and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2025

Plan of correction: Liencee shall submit evidence of vendored trainings to be provided to staff regarding the observation and medical assessment of residents, in order to prevent injuries while in care. Licensee shall submit afformentioned evidence to CCL no later than 2.28.2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Feb 28, 2025

87465(g) Incidental Medical and Dental Care: Licensee shall immediately telephone 9-1-1 if an injury...has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted by (IB) investigator, facility staff failed to provide timely reporting of R1’s falling incident, which poses an immediate heatlh and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2025

Plan of correction: Liencee shall submit evidence of vendored trainings to be provided to staff regarding timely reporting of resident injuries/accidents while in care. Licensee shall submit afformentioned evidence to CCL no later than 2.28.2025

Allegation investigated: Unqualified staff is providing care and supervision-

On Thursday, 2/06/25, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced, initial10-day complaint visit to investigate the above allegation. LPA met with the Administrator, Keith Bernanbe, presented official CDSS identification, and reason for the visit was disclosed. At 10:10 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate this allegation, LPA received Facility resident roster, and staff roster. At 10:10 am, LPA conducted a review of Staff1 (S1's) employee file. Between 11:15 am and 12:30 pm, LPA interviewed the Administrator, staff, and three (3) residents. [LIC 9099C]- Continued Substantiated Allegation: Unqualified staff is providing care and supervision- The Reporting Party (RP) Alleges that Staff#1 (S1) provides caregiver services to residents in the facilities memory care unit, but is not qualified. LPA interview with Administrator revealed the following: S1 was initially hired to work as a facility caregiver, but currently functions as a memory care unit activities assistant "programmer". (i.e. creating the resident activities calendar, scheduling/coordination of "senior scenic walks", arts and crafts, stimulation activities, trivia game activities, etc.) LPA interview with Staff#2 (S2) and Staff#3 (S3) revealed the following: S1's primary role is that of a activities "programmer". In addition, S1 does, at times, help caregiver staff as a "floater" assisting residents, and other caregiver staff when necessary. LPA interviews which three (3) memory care residents reveals the following: three (3) out of three (3) residents state being familiar with S1 and confirm that S1 has provided satisfactory staff care and assistance. However, upon review of S1's employee file, and corroborative statements from S2, It was found that S1's previous supervisor (no longer associated with the facility) failed to provide documented proof that S1 completed all "in-service" staff trainings. Thus, this allegation has been substantiated. Exit interview conducted, and report provided. Deficiencies cited on LIC9099D.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 31-AS-20250204161800

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(6) · Plan of correction due date: Feb 14, 2025

Licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). ...Documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. This requirement is not met as evidenced by: Based on records review and interviews conducted by LPA, the facility did not provide supervisory verification that all facility "in-service" trainings were completed by S1, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 6, 2025

Plan of correction: Licensee shall submit proof that S1 has re-taken and completed all facility staff "in service" trainings. Additionally, S1's supervisor will verifiy "in-service" re-trainings as completed. Licensee shall submit to CCL no later than 2.14.2025

Allegation investigated: . Staff do not provide a planned activities program for residents 2. Staff do not provide hydration to residents between meals 3. Staff do not ensure residents' right to wear their own clothes is met

Licensing Program Analyst (LPA) Tuesday Cabiness and Licensing Program Manager (LPM) Troy Agard conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegations. LPA and LPM met with Administrator, Vanessa Jewell and informed her the reason of the visit. An initial visit was conducted on 10/05/2023. During today's visit, from 945am to 230pm, LPA and LPM, conducted interviews, reviewed facility and resident documents, and conducted a physical plant inspection. The following was determined: Regarding the allegation #1: Staff do not provide a planned activities program for residents. It’s being alleged that residents are neglected all day and sit there with no type of activities throughout the day. During interviews with residents and staff it was confirm that residents are provided with activities such as yoga, bingo, walking groups, a book club and drama club, etc for residents in assisted living and memory care. Activities are tailored based on residents’ cognitive abilities. Based on interviews and documents reviewed this allegation is Unsubstantiated at this time. Unsubstantiated Regarding the allegation #2: Staff do not provide hydration to residents between meals. It’s being alleged residents are not offered hydration in between meals. During interviews with residents and staff it was determined that residents have access to pitchers of water and water stations with infused fruits. During facility tour LPA & LPM observed water stations throughout the facility, including the Bistro. Furthermore, it was determined residents are provided with hydration during breakfast, lunch, dinner, and at snack times. Residents can also request for coffee, juice, and tea at any time. Based on interviews and observations this allegation is Unsubstantiated this time. Regarding the allegation #3: Staff do not ensure residents' right to wear their own clothes is met. It’s being alleged residents do not have clean clothes and caregivers have to borrow from other residents. During interviews with residents and staff it was determined that residents clothing are washed on a weekly basis. Residents in the memory care unit are provided with free (included in their monthly rent) laundry services performed by the evening and night shift staff. Residents in the assisted living are responsible for their own laundry needs. Based on interviews, this allegation is Unsubstantiated at this time. Exit interview and copy of report provided. the allegation is Substantiated at this time. Exit interview, citation, appeal rights and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 31-AS-20230928100059

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Jan 2, 2025

Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety... This requirement was not met, evidenced by, based on interviews and documentation, during the night shift there are inconsistencies with coverage in staffing. This poses as a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: Executive Director will in-service with managment regarding staff coverage. And moving forward, the staff schedule will reflect additional names, with staff or manager who are working and covering shifts that are vacant.

Allegation investigated: Staff do not ensure that resident's incontinence needs are met- Staff do not provide resident with laundry service- Staff do not distribute resident's medication as prescribed-

On Friday, 12/06/24, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation(s) listed above. LPA conducted the initial complaint visit on 10/03/24. LPA met with facility Administrator, Vanessa Jewell, and the purpose of the visit was disclosed. At 9:35 am, A physical plant tour of the facility was conducted by LPA; No health and safety issues were observed. Allegation: Staff do not ensure that resident's incontinence needs are met- It was alleged that staff are inconsistant reguarding provision of incontinence service/diaper changes for Resident#1. (R1) [LIC 809-C Continued] Unsubstantiated To investigate the allegation, LPA conducted records review from 9:35 am to 10:15 am, interview with staff from 10:40 am to 11:25 am, and interview with Residents from 12:00pm to 1:30 pm. LPA review of resident records revealed that Resident#1 (R1) is identified with having incontinence issues as stated in the Physician's Report. Resident assessment documents show R1 requested staff to provide status checks at least twice per shift. Additionally, resident records indicate that R1 was provided incontinence supplies by the facility at no charge. LPA interviews with R1 revealed the following: R1 confirmed to LPA that staff do provide diaper changes regularly, and as needed. However, expressed frustration that staff's response time was unreasonable when call button is activated. Interviewed Residents (R2 through R5) revealed that staff do provide incontinence services regularly, and as needed in a timely manner. Staff state that R1 is provided incontinence services regularly, and as needed. Staff state R1 often becomes impatient and angry if staff do not show up immediately to answer R1's call button. Based on LPA records review, interviews with Staff and Residents, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not provide resident with laundry service- It was alleged that staff are not laundering Resident#1 (R1's) clothing and and linens due to R1's refusal to pay an extra $100.00 per month for laundry service. To investigate the allegation, LPA conducted records review from 9:35 am to 10:15 am, interview with staff from 10:40 am to 11:25 am, and interview with Residents from 12:00pm to 1:30 pm. LPA review of resident records revealed that Resident#1 (R1) was not charged for laundry service. Interview with Administrator revealed the following: Administrator confirms that charges for laundry services were waived on behalf of R1, and that laundry service was consistently provided to R1 once per week, and at times, twice per week, in response to R1's incontinence service needs. [LIC 809-C Continued] LPA interview with R1 revealed the following: R1 confirmed to LPA that staff do provide them laundry service on a weekly basis. However, expressed frustration that staff, "should clean my things every day", due to them having incontinence issues. Interviewed Residents (R2 through R5) revealed that staff do provide weekly laundry services on a consistent basis. Based on LPA records review, interviews with Staff and Residents, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not distribute resident's medication as prescribed- It was alleged that staff are not providing Resident#1 (R1) their morning medications at 8:00 am, as prescribed. Instead, distributing R1's medications between 8:00am, and 12:00 pm. To investigate the allegation, LPA conducted records review from 9:35 am to 10:15 am, interview with staff from 10:40 am to 11:25 am, and interview with Residents from 12:00pm to 1:30 pm. LPA review of R1's Medication Administration Records (MAR) revealed that Resident#1 (R1) is provided their medications, as prescribed. LPA observed the following: A Staff medical technician attempted to provide R1 their morning medications. However, R1 refused, telling the med tech to leave it in the room for R1 to take at a time of their choosing. The med tech informed R1 that they had to witness R1 take their morning medication, as prescribed. Again, R1 refused to take their morning medication. LPA interview with Residents (R2 through R5) revealing the following: Interviewed Residents state that staff do provide them their medications throughout the day, as prescribed. LPA interviews with Staff revealed the following: Staff state that R1 is often difficult while assisting them with their medications at the times prescribed. Based on LPA records review, observation, interviews with Staff and Residents, the allegation is UNSUBSTANTIATED at this time. An Exit interview was conducted, and report was provided to the Administrator.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 31-AS-20240930160917

Allegation investigated: Staff do not respond timely to a resident's alerts- Staff did not provide adequate care and supervision-

On Tuesday, 11/05/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced initial 10-day complaint visit at the facility investigating the above allegation(s). LPA met with the Administrator, Vanessa Jewell, and the reason for the visit was disclosed. At 09:55 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation(s), LPA received Facility resident roster, and staff roster. At 10:10 am, LPA conducted a review of Resident 1's (R1) file, and other documents relevant to the investigation. Between 10:45 am and 12:30 pm, LPA interviewed the Administrator, three (3) Staff, three (3) Residents, and R1's Responsible Family Member (F1), via cellphone. [LIC 9099C]- Continued Unsubstantiated Allegation: Staff do not respond timely to a resident's alerts- It was reported that during the night of October 29th, 2024, R1 pressed the service call button and staff did not respond to provide assistance. LPA's review of the facility's service call log reveals that R1's activated service call button was indeed responded to, on multiple occasions, by night staff. Interviews with three (3) residents that are wheelchair bound, and require similar levels of caregiver assistance, revealed the following: three (3) out of three (3) residents state staff response times to service calls is both timely and acceptable. Interviews with three (3) staff, and R1's responsible family member (F1) state that R1, at times, refuses assistance from newly hired staff and/or staff which R1 is unfamiliar. LPA entered R1's room and activated the service call button; caregiver staff arrived within three minutes of the call button's activation. Based on the information obtained through LPA observation, records review, and interviews, it cannot be proven that staff fails to respond to resident service calls. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff did not provide adequate care and supervision LPA's Interviews with three (3) residents that are wheelchair bound, and require similar levels of caregiver assistance, revealed the following: three (3) out of three (3) residents state staff are professional and do provide adequate levels of caregiver assistance. Interviews with three (3) staff, and R1's responsible family member (F1) reveal that R1, at times, refuses assistance from newly hired staff and/or staff which R1 is unfamiliar. LPA interview and the Administrator reveals that, although there have been challenges with staff turnover, the facility has added an additional caregiver staff to its memory care unit in order to maintain adequate levels of service coverage. Based on the information obtained through LPA observation, records review, and interviews, it cannot be proven that staff fails to respond to resident service calls. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Nov 5, 2024 · control 31-AS-20241030125453

Allegation investigated: Resident sustained multiple unexplained bruises while in care- Staff did not safeguard resident’s personal belongings-

Today, Tuesday, 10/29/24, at 10:00 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation(s) listed above. LPA conducted the initial complaint visit on 9/20/24, and subsequent visit on 10/01/24. Today, LPA met with facility Administrator, Vanessa Jewell, and purpose of the visit was disclosed. At 10:10 am, LPA conducted a physical plant tour of the facility; No health and safety issues were observed. Allegation: Resident sustained multiple unexplained bruises while in care- It was alleged that Resident#1 (R1) showed bruising on both arms, and staff cannot explain. To investigate the allegation. LPA conducted a records review, and interviews with staff. [LIC 9099C Continued] Unsubstantiated At 10:30 am, LPA conducted a review of R1's resident files which revealed the following: Staff observations identified R1's general skin condition as "thin and fragile" and to be "monitored in order for skin integrity be maintained." Interviews with Staff corroborate documented observations, and that some of R1's prescribed medications can cause bruising with very little pressure applied to the skin. Records show that Officers of the Los Angeles Police Department (LAPD) conducted a health "well check" of R1 at the request of the reporting party. A review of LAPD notes show Officers describing R1's condition as "good" and no suspicious injuries were observed. At 11:00 am, LPA spoke with an outside vendor providing R1 with hospice services. The hospice staffer stated that R1 would sustain bruises from simply being lifted from their bed to the bathroom. Furthermore, staff states that R1 would, at times, exhibit behaviors that could potentially cause bruising. Based on the information obtained through documents review, and interviews, this allegation is deemed UNSUBSTANTIATED at this time. Allegation: Staff did not safeguard resident’s personal belongings- It was reported that R1 always wore their wedding ring, however, it was reporting as missing. The reporting party states not knowing the specific time of the ring's disappearance. To investigate this complaint, LPA conducted a records review, and interviews with administrator. A review of R1's inventory list, signed by R1's Power of Attorney, (POA) notes that the responsible party chose not to fill out the form, and that "all items of value will be left at home." Documents reviewed do not indicate responsible party communicated this issue to Staff. R1 is no longer a resident of the facility, and LPA's attempt to contact the responsible party yielded no response. Based on the information obtained, it could not be proven that Staff did not safeguard resident's personal belongings. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was proved to the Administrator.the state’s words, verbatim · CDSS document, Oct 29, 2024 · control 31-AS-20230822143552

Allegation investigated: Staff did not supervise residents, resulting in residents entering other resident's rooms- Staff did not provide adequate food service to resident-

Today, Tuesday, 10/01/24, at 9:45am, Licensing Program Analyst (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation(s) listed above. LPA conducted the initial complaint visit on 9/20/24. Today, LPA met with facility Business Office Manager, Delaila Betancourt, who put LPA in contact with Administrator, Vanessa Jewell, via cellphone. LPA spoke to the Administrator, and the purpose of the visit was disclosed. At 11:15am, Administrator Designee, Keith Bernanbe arrived to the facility, and assisted LPA with this complaint investigation. At 10:20 am, A physical plant tour of the facility was conducted by LPA; No health and safety issues were observed. Allegation: Staff did not supervise residents, resulting in residents entering other resident's rooms- [LIC 9099C Continued] Unsubstantiated It is alleged that, due to a shortage of facility staffing, residents are wandering, without permission, into other resident bedrooms. To investigate the allegation, LPA conducted a records review of the facility's current monthly work schedule, and work schedules for the months of March, 2023,and September, 2023; dates in which the reporting party (RP) states the alleged incident occurred. Based on LPA's review, the facility work schedules suggests the licensee provides sufficient staff coverage during all shifts to prohibit intrusion of unwanted/unauthorized persons into into resident bedrooms. LPA interviews with residents revealed the following: Seven (7) out of seven (7) residents state that staffing is sufficient; they feel safe living at the facility, and have no concerns regarding the safeguarding of their personal items kept in resident bedrooms. LPA interview with staff revealed the following: Four (4) out of four (4) staff state that facility ensures sufficient staffing during all work shifts to keep residents safe, and prohibit unwanted intrusion into resident bedrooms. Based on LPA's observations, records review, and interviews with residents and staff,the allegation is UNSUBSTANTIATED at this time. Allegation: Staff did not provide adequate food service to residents- It is alleged that as a result, resident#1 (R1) did not have breakfast, due to lack of staffing. To investigate the allegation, LPA conducted a records review of the facility's current monthly work schedule, and the work schedule for the month of March, 2023; dates in which the RP stated the alleged incidents occurred. A review of the facility's work schedule reveals that the facility maintains a sufficient number of staff personnel on all shifts to provide food service for all residents. LPA interviewed seven residents who stated the following: Seven (7) out of seven (7) residents were complimentary of staff, reporting they are well informed of mealtimes and the menu of food items provided. Residents reported that meals were satisfactory and that staff consistently provide alternative meals in the event that a resident misses an opportunity to eat during a specified meal time. Residents reported that meals were satisfactory and that staff consistently provide alternative meals in the event that a resident misses an opportunity to eat during a specified meal time. LPA interviews with staff revealed the following: Four (4) out of four (4) staff states consistency in ensuring all residents are provided food service, and that alternatives are provided when residents miss scheduled mealtimes. Based on LPA's observations, records review, and interviews with residents and staff, the allegation is UNSUBSTANTIATED at this time. An Exit interview was conducted, and report was provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 31-AS-20230822143552

Allegation investigated: Staff mismanaged resident's medication- Staff insufficient to meet resident needs-

On Tuesday, 9/24/24, at 9:15am, Licensing Program Analyst (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation(s) listed above. LPA conducted the initial complaint visit on 9/06/24. LPA met with facility Administrator, Vanessa Jewell, and the purpose of the visit was disclosed. At 9:35 am, A physical plant tour of the facility was conducted by LPA; No health and safety issues were observed. Allegation: Staff mismanaged resident's medication- It was alleged that a dosage error was committed within Resident#1's (R1) medications distribution. [LIC 9099C Continued] Unsubstantiated To investigate the allegation, LPA conducted a records review, interviewed two (2) staff, and eight (08) residents between 11:00 AM to 1:15 PM. A review of R1’s medication administration records reveal R1 was indeed provided their medications as prescribed. Further review shows that a dosage notation error was noticed, and corrected. LPA interviews with Staff indicates that Medical Technicians responsible for the error were counseled, and a discussion regarding due diligence took place to ensure accuracy when notating resident medical information. LPA interviews reveal that eight (8) out of eight (8) residents state having no issues, nor concerns with medication distribution services provided to them by Staff. Based on LPA's records review, and interviews, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff insufficient to meet resident needs- It was alleged that the facility does not have sufficient Staff to provide adequate medication distribution services to residents. To investigate the allegation, LPA conducted a records review, interviewed two (2) staff, and eight (08) residents between 11:00 AM to 1:15 PM. A review of the facility's work schedule reveals that a minimum of two (2) Medical Technicians are staffed on all shifts to provide adequate coverage for residents. LPA interviews with Staff reveal that medical service coverage is adequately provided to residents, and that additional staff are available to provide coverage, when necessary. LPA interviews reveal that seven (7) out of eight (8) residents confirm medical staff consistently provide services, such as medication management/distribution and that residents have no issues, nor concerns with staffing sufficiency. Based on LPA's records review, and interviews, the allegation is UNSUBSTANTIATED at this time. An Exit interview was conducted, and report was provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 24, 2024 · control 31-AS-20240904112453

Allegation investigated: Staff did not assist resident with mobility needs in a timely manner-

On Friday, 9/20/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced initial complaint visit regarding the allegation listed above. At 9:15 AM, LPA met with facility Administrator, Vanessa Jewell, and the purpose of the visit was disclosed. A physical plant tour of the facility was conducted. No health and safety issues were observed. Allegation: Staff did not assist resident with mobility needs in a timely manner- It was alleged that the right side padding on Resident #1, (R1's) wheelchair was loose, causing leg irritation. R1 requested help from staff to resolve. However, staff was stated as not providing assistance. [LIC 9099C] Continued Unsubstantiated To investigate the allegation, LPA conducted interviews with Staff from 10:00am to 11:15am, and interview with R1 from 11:25 to 12:25pm. LPA's interview with the Administrator revealed the following: On Monday, (9/16/24) R1 informed the Administrator that the leg pad on their wheelchair was very loose, causing it to irritate R1's right leg. The Administrator responded to R1 saying, although staff are not permitted to make any modifications to a resident's medical devices, staff would be sent to assess the problem. On the same day, the Administrator and a staff member, went to R1's room, and adjusted two bolts on R1's wheelchair. Once the adjustment was completed, R1 was stated to have thanked staff for resolving the issue. LPA's interview with R1 revealed that staff did indeed resolve the issue with their wheelchair, and that the problem was resolved within the same day of R1's request for staff assistance. During the interview, LPA observed R1's wheelchair, and witnessed that the leg pad was attached, and functioning as required. R1 confirmed to LPA that their mobility needs were addressed by staff in a timely manner. Based on LPA's observations, and interviews,the allegation is UNSUBSTANTIATED at this time. An Exit interview was conducted, and report was provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 20, 2024 · control 31-AS-20240916114553

Type of visit: Case Management - Deficiencies

At 9:00 AM, on 09/20/2024 Licensing Program Analyst, (LPA) Raymond Comer, conducted an subsequent complaint visit for complaint #31-AS-20240724164758. During the course of the investigation, LPA discovered deficiencies in the facility. The deficiencies are addressed on this LIC 809 as part of a case management visit. In the course of the complaint investigation, LPA observed the licensee's policies and procedures regarding documentation retention state that staff communications, Incident reports, end of shift reports and medication staff communication logs are only kept for ninety (90) days and then subsequently destroyed. Due to the Licensee's records retention policy being in conflict with California Title 22 records retention requirements, a deficiency is cited on an LIC 809-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 20, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e)87506(e) · Plan of correction due date: Sep 20, 2024

87506(e) - RESIDENT RECORDS Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This represents a potential health and safety issue to residents in care. This requirement is not met as evidenced by: The Licensee's Documentation Retention Policy only allows retention of documents for a minimun of 90 days and then, records are to be subsequently destroyed.the state’s words, verbatim · CDSS document, Sep 20, 2024

Plan of correction: Administrator says they will work with licensee to amend the facility's documentation retention policy to comply with California Title 22 regulations.

Allegation investigated: Staff did not safeguard resident's personal belongings-

Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced initial complaint visit on 6/04/2024, and subsequent site visit on 7/02/24. Today, 9/05/24, LPA conducted a second subsequent site visit regarding the allegation listed above. At 9:50 AM, LPA met with facility Administrator, Vanessa Jewell, and the purpose of the visit was disclosed. Allegation: Staff did not safeguard residnt's personal belongings- It is alleged that jewelry items belonging to Resident#1 (R1) were stolen while living at the facility due to Staff not providing required safegards as neccessary, according to Title 22 reporting requirments. (87218) [9099 C-Continued] Unsubstantiated LPA observed the posting of the facility's theft and loss policy and procedures, which are prominently displayed for viewing by residents and the public. LPA review of Staff files confirms, that during employee orientation training, facility employees are made aware of the facility theft and loss policy and their role in safeguarding resident belongings within the first 90 days of their employment. LPA review of Resident files confirms that facility staff notify all current and new residents, upon admission, of the facility's theft and loss policy. Seven (7) out of seven (7) resident files reviewed contain a completed Client/Resident Personal Property and Valuablesinventory log with signatories acknowledging they have received, and are acquainted with, facility personal property safeguard procedures. LPA's review of Resident #1's (R1) file confirms personal items were logged as described by the Reporting Party. (RP) Statements made by facility Administrator and facility business officer confirm, upon resident/conservator request, facility provides centralized storage of resident cash or valuables. LPA interviewed Residents#2 thru-#8 about the allegation; seven (7) out of seven (7) residents denied the allegation that Staff do not safeguard resident belongings. Residents interviewed state, while living at the facility, they have not had any personal items stolen and feel confident that Staff adequately safeguard their personal items. Based on the evidence gathered, interviews conducted, and records reviewed by the LPA, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of the Report was provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 31-AS-20240604154507

Type of visit: Case Management - Deficiencies

This case management visit is conducted by Licensing Program Analyst (LPA) Raymond Comer, in conjunction with a complaint investigation visit to this facility. On 9/05/24, LPA conducted an unannounced subsequent visit to this facility in conjunction with complaint control #31-AS-2024064154507. LPA met with the Administrator, Vanessa Jewell, and the reason for the visit was disclosed. LPA conducted a records review of resident#1 (R1) file, and the facility's theft and loss policies and procedures. Upon record review, LPA observed lapses in required reporting of theft of R1's personal belonging. Therefore, based on the record review, and interview with administrator, it was concluded that the facility did not provide reporting of the theft of R1's belongings to law enforcement as required. Under Title 22 Regulations, the following citation is issued and recorded on LIC809D. Deficiency will be cleared during today’s visit since Administrator implemented a Staff in-service training regarding the facility's theft and loss policies and procedures. No immediate health and safety hazard is noted at the time of this visit. Exit interview was conducted. Appeal rights discussed and a copy of report was issued.the state’s words, verbatim · CDSS document, Sep 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(i) · Plan of correction due date: Sep 6, 2024

Theft and Loss (i) Reports to the local law enforcement agency within 36 hours when the administrator of the facility has reason to believe resident property with a then current value of one hundred dollars ($100) or more has been stolen… This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section cited above, as the administrator did not follow the theft and loss procedures as required, which is a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: The Administrator has agreed to do the following: 1. Review the facility's Theft and Loss policy. Submit a Plan of Action as to how the facility will maintain compliance. Submit plan to CCLD by 9/6/2024.

Allegation investigated: Facility is in disrepair-

On Thursday, 8/22/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced initial complaint visit regarding the allegation listed above. At 10:45 AM, LPA met with facility Administrator, Vanessa Jewell, and the purpose of the visit was disclosed. A physical plant tour of the facility was conducted. No health and safety issues were observed. Allegation: Facility is in disrepair- It was alleged that broken pipes, located on the ceiling above the the underground parking garage, are leaking water, and multiple buckets, placed below the leaks, are overflowing onto the floor. To investigate the allegation, At 11:15 AM, LPA conducted a physical plant tour, interviewed the Adminstrator, and a staff (S1) at around 11:45 AM. During the physical plant tour, LPA observed a section of parking lot flooring wetted by a slow, steady drip of water coming from the ceiling. [LIC 9099C Continued] Unsubstantiated LPA did observe efforts by the facility to mitigate potential health and safety issues, such as the taping off of the area directly below the leak to prohibit accessibility, and sinage posted displaying "Caution-Wet Flooring". LPA did not observe open, or broken piping, nor did LPA observe buckets on the floor left to contain leaking water. During the interview with the Administrator, they stated the leak is a result of excessive water condensation dripping from HVAC pipe conduit. Administrator says this specific leak only occurs during the summer months when the cooling system is used at peak capacity. A document review of an email communication between the Administrator and the facility's contracted HVAC vendor (NCWS Mechanical Service) indicates the vendor was called out to the assess and provide recommended repairs to resolve the issue. During LPA interview with staff, (S1) They stated excess water is swept into a drain inlet located near the leak at least twice a day, and as needed. Based on LPA physical inspection, and interviews with Administrator, and Staff, LPA did not observe the facility to be in disrepair. Thus, this allegation is unsubstantiated. During LPA interview with the Administrator, they confirmed that annual First Aid training had not yet been completed for Staff, and that scheduling efforts were in progress. LPA interview with Staff (S2) also confirmed that training had not been completed. S2 provided a list of Staff with status of First Aid training as "pending", and an email communication with Vendor (ON SITE CPR) showing coordination of preliminary scheduling efforts.. Based on the information obtained, this allegation is deemed Substantiated. An Exit interiew was conducted, a copy of the report was provided, and Appeal Rights explained. Deficiency cited on LIC 9099 D.the state’s words, verbatim · CDSS document, Aug 22, 2024 · control 31-AS-20240816104401

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Aug 22, 2024

First aid training not completed for facility staff. 87411(c)(1) Personnel Requirements-General. Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on interviews, facility staff have not completed annual first aid training which poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Licensee says First aid certification training shall be completed by 9/15/24, with documentation submitted to Licensing.

Allegation investigated: Staff is providing false information to residents.

Today, Friday, 8/16/2024, Licensing Program Analyst, (LPA) Raymond Comer conducted a subsequent complaint visit regarding the allegation listed above. LPA conducted the initial10-day complaint visit on 8/02/24. At 9:25 AM, LPA met with facility Administrator, Vanessa Jewell, and the purpose of the visit was disclosed. A physical plant tour of the facility was conducted. No health and safety issues were observed. Allegation: Staff is providing false information to residents- During the subsequest complaint visit, LPA conducted interviews with residents and staff. [LIC 9099C Continued] Unsubstantiated Six (6) out of the seven (7) residents interviewed stated they have neither heard, nor witnessed the Administrator providing false information. Five (5) out of the seven (7) staff interviewed stated they have neither heard, nor witnessed the Administrator providing false information. Thus, Staff and Resident interviews do not corroborate this 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. Based on LPA's observations, interviews, and documents review, the allegation is UNSUBSTANTIATED. An Exit interview was conducted, and report was provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 16, 2024 · control 31-AS-20240724164758

Allegation investigated: Staff did not comply with reporting requirements.

Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced initial complaint visit on 6/04/2024. Today, 7/02/2024, LPA conducted a subsequent site visit regarding the allegation listed above. At 9:30 AM, LPA met with facility Administrator, Vanessa Jewell, and the purpose of the visit was explained. Allegation: Staff did not comply with reporting requirements--- It is alleged that Staff were aware of Resident#1 (R1) having sustained an injury, yet Staff did not submit an incident report as neccessary, according to Title 22 reporting requirments. (87211) [9099 C-Continued] Unsubstantiated To investigate the allegation, LPA obtained and reviewed relevant documents. (Resident Files, Incident Report submissions, Resident roster,and Staff roster.) According to the documents reviewed, on November 3, 2023, Staff informed the Person responsible for R1 of the incident, and filed an incident report to Community Care Licensing, which was sent in a timely manner and according to regulations. Per Interview with Administrator, Staff were aware of the incident on the day of occurrence and required notifications were submitted. Administrator states that the Responsible Party (RP) for R1 wished to consult with additional family members prior to making any emergency medical treatment efforts. However, the Administrator says they continued on with due diligence to assess and monitor R1's health and pain concerns. Therefore, the allegation that Staff failed to follow proper reporting requirements is UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jul 2, 2024 · control 31-AS-20240604154507

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst, (LPA) Raymond Comer, made an unannounced site visit to this facility as a continuation of the Required 1 Year Annual Inspection conducted on 06/06/2024. LPA met with Administrator, Vanessa Jewell and the purpose of visit was disclosed. The following remaining inspection domains were observed, reviewed and inspected: Fire Detection/Protection system is present in the facility. Multiple smoke and carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire system back up and tests are done, in house, on a monthly basis. Fire drill last conducted May 15, 2024. Fire extinguishers were observed throughout the facility on all floors. All extinguishers were last serviced on June 30, 2023. Evacuation chairs were observed in each stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Kitchen: LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons were observed near any food areas. Medications The medications were locked in the medication carts, properly labeled, and stored. Medication documentation and implementation appeared to be complete. First aid kits were observed on each medication cart stored/parked in the medication room located in the second floor. [Continued on LIC 809C] Laundry: LPA observed the laundry room located on the fourth floor, across from salon. Residents have access to the laundry area to do their own laundry. Laundry area is clean and clear from obstruction. Cleaning supplies and other toxins are stored in separate locked storage area and inaccessible to residents. Commons: Activity rooms, movie theater, dining rooms, pool hall, exercise room and library observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Random resident rooms on all floors were inspected and observed to maintain required furnishing and sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction. Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 114.5°F. Within the required range. Outdoor: Courtyard area observed to have a shaded patio, with tables with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. Resident records: Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current. Staff records: Staff files were reviewed. Criminal record clearances, Health Screening, Employee Rights Records were present and Staff are associated to this facility. Staff records appear to be complete and current. There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility Administrator.the state’s words, verbatim · CDSS document, Jun 7, 2024

Type of visit: Required - 1 Year

On 06/06/24, 9:45 AM Licensing Program Analyst (LPA) Raymond Comer conducted an unannounced Annual required visit and inspection of the Facility, met with Administrator, Vanessa Jewell, and reason for the visit was stated. Facility is licensed as a complex occupying six (6) floors and a penthouse. Fire clearance approved for (110) non-ambulatory, and an additional ten (10) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, there are six (6) residents receiving hospice care services, and two (2) bedridden residents. At 10:05AM, LPA conducted a tour of the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main doors is the primary entry/exit access. Screening area is located immediately upon entrance. As the Facility provides dementia care, LPA observed the delayed egress system working properly. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 78.0°F. within the required range. The facility maintains an approved Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 5/15/2024. [Continued on LIC 809-C] Resident records: A total of seven (7) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, centrally stored medication logs, and resident identification. Resident records appeared to be complete and current. Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report given to Administrator, Vanessa Jewell.the state’s words, verbatim · CDSS document, Jun 6, 2024

Allegation investigated: Staff are not assisting resident with incontinence needs Staff did not respond to resident's call button in a timely manner Staff do not allow resident to manage own medication

Licensing Program Analyst (LPAs), Raymond Comer and Micheal Cava conducted an unannounced complaint visit to investigate the above stated allegations. LPA met with the Executive Director Vanessa Jewell and explained the reason for the visit. Allegation: Staff do not allow resident to manage own medications It was alleged that R1is restricted from self administering their medications and storing them in their room. R1 states that, prior to this complaint, they were able to self-administer medications and keep them in their room. Facility Policy states that residents may keep their own medications, if they are kept in a secure enviorment, and that medications are not left sitting out in a resident's room. Unsubstantiated However, LPAs interviewed S1 who states R1 kept their medications exposed in open bins on top of their kitchen counter and often keeps door (room #5013) open, allowing other residents access. LPAs conducted a desk review and observed the following: R1's Physician's report states that they cannot manage their own medications. R1's service plan states the Medication Assistance are to be totally assisted by the Facility's Med Tech. PCP communication, dated 4/5/24, states that R1 "Is unable to utilize arm for safe management of of medication along with a safety concern to keep all meds in a central location locked in a cabinet or have his room door locked" and confirms that "Staff continue to manage meds on hand." Allegation: Staff are not assisting resident with incontinence needs\Staff did not respond to resident's call button in a timely manner. It was alleged that R1was not responded to in a timely manner to address incontinence needs, nor provide timely response to R1's activation of call button for Staff assistance. LPAs conducted an interview with R1 requesting them to activate intercom call button. Response time to R1 service call was nine (9) minutes. LPAs interviewed a total of seven residents (including R1) asking them about the timeliness of service call response by facility staff. All residents interviews stated that Facility Staff responded in a timely manner to service calls. Based on observations, document review, and resident interviews, the above allegation(s) deemed Unsubstantiated at this time. Exit interview conducted and a copy of this report delivered.the state’s words, verbatim · CDSS document, Apr 16, 2024 · control 31-AS-20240409144225

Allegation investigated: Staff are not dispensing medication as prescribed.

Licensing Program Analyst (LPA), Mariana Agban conducted an unannounced complaint visit to investigate the above stated allegation. LPA met with the Executive Director Vanessa Jewell and explained the reason for the visit. At 10:40 AM, LPA requested resident and staff roster. At approximately 11:30 AM, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. Between 12:00 AM – 1:30 PM, LPA conducted an interview with the Administrator, one (1) staff member and eight (8) residents. Allegation: Staff are not dispensing medication as prescribed. It was alleged that staff has not been providing the correct dose of medication. ( Continue on LIC 9099C) Substantiated LPA reviewed medications and medications records and observed that R1 missed a dose of METFORMIN 500 MG on February 18, 2024. Interview with S1 and S2 revealed that R1 has been transferred from out of state facility without having the appropriate amount of medication supplies. R1's insurance refused to refill the medications until R1 sees southern CA doctor and establish residency. S1 enrolled R1 to AAA Care Pharmacy (facility's pharmacy) to get R1 medications. S2 stated that on 2/18/24 R1 missed the medication due to delay of medication delivery. LPA asked if there was an incident report sent to CCLD. S2 admitted that there was no Incident Report sent to CCLD. Based on interviews and record reviews, the allegation is deemed Substantiated at this time. Exit interview conducted, Citation issued and Copy of this report delivered.the state’s words, verbatim · CDSS document, Feb 26, 2024 · control 31-AS-20240220103619

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80061(e) · Plan of correction due date: Mar 5, 2024

Reporting Requirements. Resident authorized representatives, if any shall be sent any required reports. Licensee failed to provide an SIR regarding missed medication dose. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 26, 2024

Plan of correction: Administrator will sent an SIR by the POC date

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87465(a)(4) · Plan of correction due date: Mar 5, 2024

The licensee shall assist residents with self-administered medications as needed.Based on the record review the licensee did not comply with the section cited above. LPA observed missed dose of METFORMIN on 02/18/24. This poses a potential health and safety risk to resdients in care.the state’s words, verbatim · CDSS document, Feb 26, 2024

Plan of correction: Administrator agreed to provide In service training to prevent any future missed medication dosages. Administrator will email LPA proof of training by the POC date

Allegation investigated: Facility cental heating system is not working

At 12:15 p.m. on 01/19/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the Executive Director (ED) and disclosed the reason for the visit. To investigate the allegation above, LPA interviewed the ED at 12:15 p.m. today, Staff #1 (S1) at 2:00 p.m., and seven (07) out of sixty-nine (69) residents, which was at least 10% of residents, between 1:00 p.m. and 2:00 p.m., reviewed records including but not limited to the resident list, staff list, and work orders at 12:30 p.m., and toured the facility at 12:45 p.m. Regarding the allegation “Facility central heating system is not working” it was alleged the central heating is not working. Interview with the ED revealed the facility is an old building with some structural issues. Substantiated The city supplies low voltage to the building and major construction is not allowed due to the historical nature of the building. The facility has had issues with the heating system on the sixth and fourth floors of the assisted living portion since 2022. There are no heating issues in the memory care portion. The ED and the staff have taken steps to mitigate the issues on the sixth and fourth floors such as frequently calling a repair company to fix ongoing issues, placing portable heaters in resident rooms to maintain a comfortable temperature, training staff to resolve electrical issues, and supporting residents when they encounter issues. Record review revealed service reports from an outside vendor to resolve issues on 04/22/2022, 04/29/2022, 05/03/2022, 08/03/2023, 08/09/2023, 08/22/2023, 08/28/2023, and 01/04/2024. Another document showed the facility purchased seven (07) additional tower heaters for surplus on 01/11/2024. LPA toured the fourth and sixth floors with S1 and saw at least one (01) portable heater in each resident room. Interviews with residents revealed six (06) out of seven (07) residents had no issues with heating or temperature. One (01) out of seven (07) residents stated they had an issue but the facility has responded to fix it. Based on interviews, record review, and physical plant tour, the facility central heating is not working on two (02) out of seven (07) floors. The facility is maintained at a comfortable temperature, and the facility has worked to resolve all heating issues in a timely manner. Therefore, the allegation is deemed SUBSTANTIATED without deficiency at this time. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 19, 2024 · control 31-AS-20240117120207

Allegation investigated: Facility did not prevent resident from developing a stage 4 pressure injury while in care. Facility did not seek medical attention in a timely manner.

This report was amended to add additional information received after delivering an initial visit report on 01/03/2024. Executive Director, Venessa Jewell will be signing and accepting the AMENDED report. On 01/03/2024, Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA met with Marketing Director, Jana Mahany, and explained the reason for the visit. LPA spoke with the Executive Director, Venessa Jewell, and designated Mahany to sign and accept this report. --- Due to improper care, resident developed prohibited health condition. It was alleged that while at the hospital, Resident #1 (R1) was observed to have three bed sores located on the left hip (unstageable or stage 4), left ankle and left knee. To investigate this allegation, on 01/03/2024, LPA requested documents at 12:30PM, interviewed three staff from 12:45PM–2:15PM and interviewed other parties at 2:30PM. Staff #1(S1) and Staff #3(S3) verified R1 developed pressure injury on left hip and right lower leg on 12/14/23. They notified R1’s responsible party(RP) and suggested an initiation of hospice services. RP refused and chose Home Health(HH) services for R1's pressure injuries.(cont. on LIC 9099-C) Substantiated HH started to provide wound care as of 12/18/23. However, the conditions of the wounds were not improving. During interviews with medical professionals, on 12/27/23, R1 was admitted to the emergency department (ED) at which time in addition to other health complications, R1 was presented with multiple pressure injuries, including Unstageable pressure injury on left hip. A review of the facility’s documents including the documentation completed by the HH care agency indicates that on 12/14/2023, R1 was noted with a small sore on the left thigh and redness on the right lower leg. The conditions of the injuries were not improving and R1 began receiving HH care assistance for pressure injuries on 12/18/2023. Between 12/18/23 and 12/27/23, R1’s pressure injuries were not getting better. On 12/27/24 due to health complication R1 was sent to the hospital and was presented with Unstageable and stage 3-4 pressure injuries. A review of hospital medical records received on 05/17/24 revealed that at the time of R1’s admission to the ED, R1 presented with multiple pressure injuries. A pressure injury on the left hip was staged as Unstageable and others were staged Stage 3 and 4. Based on interviews and record review, there is a sufficient information to verify that while in care of the facility, R1 developed prohibited health condition. Facility did not seek proper care and supervision and/or required incidental medical services. Therefore, the allegation is SUBSTANTIATED at this time. ---Facility did not seek medical attention in a timely manner. It was alleged that R1’s health was declining, and facility did not seek required medical attention or call 911 immediately. To investigate this allegation, on 01/03/2024, LPA requested documents at around 12:30 PM, interviewed three (03) staff from 12:45 PM – 2:15 PM and interviewed other parties at 2:30 PM. Interviews of facility staff and other medical professionals revealed that since beginning of December 2023, facility staff had noticed significant changes in R1’s physical and mental condition, however, no additional steps were taken by facility staff to seek proper medical attention until 12/27/23. On 12/27/23, R1 was transferred to the hospital after facility staff received a phone call from a medical professional, who was contacted by R1’s family member, and requested to transfer R1 to the hospital due to health decline. A review of facility documents and an incident report submitted to the Department, verified the information revealed from interviews during the investigation. Overall investigation revealed that although facility staff noted significant changes in R1’s health condition, including developing prohibited health condition, they did not seek required medical attention or attempt to seek a higher level of care in timely manner. Therefore, based on interviews and record review, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 31-AS-20240102131717

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Jan 5, 2024

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be ...retained in a residential care facility for the elderly:(1)Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by; Based on record review and interviews, the facility retained in a resident with Stage 4 and unstageable pressure injuries which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 3, 2024

Plan of correction: The Administrator will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to 87615 Prohibited Health Conditions; The Administrator will also submit proof of training for all staff. All proof must be sent to the LPA by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Jan 5, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have the following personal rights (16) To received medical care or other services. This requirement was not met as evidenced by: Based on record review and interviews, the facility did not allow an ambulance to take R1 to the hospital immediately and receive medical care. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 3, 2024

Plan of correction: The Administrator will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to 87468.1 Personal Rights of Residents in All Facilities; The POC must be sent to the LPA by the POC due date.