Los Feliz Gardens

Type of visit: Required - 1 Year

On 08/11/26, at 8:05am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. LPA met with Maria Chengcuenca, Medical Technician and the Administrator, Nonna Sharpiro arrived later. LPA asked for the census, resident, and staff files. Required postings were observed throughout the facility. This is an RCFE with a capacity of 199. The census is currently 88-(Eighty-Eight). The facility consists of a three (3) floor building with a total of 100 resident bedrooms (50 bedrooms on the second level and third level), each having its own bathroom. The first floor consists of the following: a lobby area, administrative offices, function room, dining area, activities room, television room, laundry room, staff lounge, family visiting room, restrooms, storage rooms, kitchen, and a conference room. There are two (2) operable elevators, one designated for residents and the other for staff. The activity room has chairs and an activity menu displayed. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. There is also a parking garage outside. Laundry Room: Located on the first floor and inaccessible to residents. Detergents are kept in the laundry room locked. LIC 809-C-continued Kitchen is sufficiently stocked with at least seven (07) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and are located on the first floor. Knives and sharps are observed to be only accessible to staff. All toxins and cleaning supplies are locked and inaccessible to residents in storage room. The kitchen has a special diet with names against the wall and there is also a food menu at the entrance of the dining hall. The kitchen area also has a water jug for resident use. The common and dining areas are neat and clean. The facility maintains a comfortable temperatures at 72, 74, 75, 76 and 77°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located throughout the facility and observed to be fully charged and last inspected 06/2026. Random resident rooms were observed. There was adequate furniture with appropriate lighting. Random bathrooms were checked for cleanliness and proper operations and had grab bars and non-slip bathrooms. The hot water temperature was measured and varied with temperatures of 111, 112, 115 Fahrenheit. The bathrooms and bedrooms have pull cord alarms for residents. There are also several telephones for residents to use throughout the facility. The facility also has several evacuation chairs in the stairway and cameras in common areas. The medication room /Wellness Room is locked and inaccessible to the residents. The facility uses the MAR-Medication Administrator Record and Centrally Stored forms. Facility maintains a complete first aid kit. Resident records/Staff records: LPA conducted a complete file review of nine (09) resident records. Resident records were complete and updated. Staff records: LPA conducted a complete file review of six (6) staff records. Staff records were complete and updated. LPA reviewed LIC 405 for some residents that have safeguarded cash resources and is kept in the business office. Administrative: The Insurance plan is dated as of 05/2027. The Administrative Certificate expires on 06/2027. There is a board against the wall that displays-Personal Right,Ombudsman, Emergency and Disaster Plan. Fire Drills have been conducted the last fire drill was in July of 2026. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Aug 11, 2026

Allegation investigated: Staff did not prevent a client from hitting another client Resident sustained injuries due to staff neglect or physical abuse

On 03/09/26, at 9:35am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Maria Chengcuenca, Medical Technician. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 03/09/26, LPA Saucedo asked for the census, staff, and resident rosters. On 03/09/26, at 10:15am, LPA Saucedo conducted a physical tour, interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not prevent a client from hitting another client. It is being alleged that resident #1 (R1) was hit by Resident #2 and staff did not prevent it. LPA interviewed two (2) caregivers that were working on the day of 02/28/26 when R1 returned from the hospital and both confirmed that when R1 returned from the hospital, R1 already had bruises. One (1) staff documented it and alerted the administrator. R1 was returned back to the hospital that same day and a police report was filed. LPA obtained the Unusual Incident Report regarding R1 that was sent to Community Care Licensing Department. In addition, LPA interviewed two (2) social workers from the hospital that confirmed R1 is at times confused and disoriented. LPA reviewed R1's resident appraisal and physician's report that also confirms that R1 has confusion, forgetfulness and unspecified dementia. LPA attempted to interview R1 via telephone/face time. LPA asked R1 if they were hit by R2 and R1 replied, "no." LPA asked R1 how did they obtain the bruises to their facial area but R1 did not know. LPA asked R1 again about the bruises but R1 fell asleep. Furthermore, LPA interviewed R2 and R2 stated, "no, I never hit R1 but R1 was in a lot of pain when they returned from the hospital." LPA interviewed eight (8) additional residents that confirm they have never been hit by R2 and they also feel safe at the facility and staff intervene if there are problems amongst each other. Therefore, based on the record review and interviews conducted the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Resident sustained injuries due to staff neglect or physical abuse. It is being alleged that due to staff neglect at the facility, resident #1 (R1) was hit by another resident and R1 sustained injuries to their facial area. LPA interviewed two (2) caregivers that were working on the day of 02/28/26 when R1 returned from the hospital and One (1) of the caregivers reported to the administrator that R1 had returned from the hospital with bruises to their facial area from the hospital. R1 was then returned to the hospital on the same day 02/28/26 so R1’s facial bruising could be treated. LPA obtained the Unusual Incident Report regarding R1 that was sent to Community Care Licensing Department and a police report was filed. LPA interviewed R1 and R1 was asked if they were hit by another person and R1 stated, “no.” LPA asked R1 how the bruises happened but R1 did not answer anymore of LPA’s questions. In addition, LPA interviewed eight (8) additional residents including R1’s roommate to determine if they have ever sustained injuries due to staff neglect and/or if any physical abuse from another resident and/or staff has happened and all eight (8) residents confirmed by saying, "no." Therefore, based on the staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Mar 9, 2026 · control 31-AS-20260303103544

Allegation investigated: Staff did not seek timely medical care for resident

On 2/12/2026 at approximately 9:50 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by staff and stated the reason for their visit. The Administrator, Nonna Shapiro arrived later to assist with today’s visit. To investigate the allegation(s), at approximately 10:00 AM, LPA conducted a physical plant tour. By 10:30 AM, LPA requested relevant documentation. From 10:30 AM to 02:00 PM, LPA attempted interviews with ten (10) resident (R1), three (3) staff members (S1-S3) and conducted record review. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff did not seek timely medical care for resident. It was alleged S1 did not seek timely medical attention for R1. To investigate the allegation, LPA conducted interviews with ten (10) residents and two (2) staff members. LPA’s interview with R1 revealed about two (2) weeks from today’s date (they could not provide a specific timeframe) they became ill where they were vomiting consistently for five (5) days. R1 stated they told staff. When questioned if staff had denied them medical treatment, R1 stated, “No”. When questioned if they were ever seen by a medical professional, R1 stated, “Yea”. LPA’s interview with 9 of the 9 residents confirmed that staff have not denied them medical attention. LPA’s interview with S1 revealed R1 was attended to by their physician where medication was prescribed to help with their symptoms of vomiting. S1 stated once they observed R1 was not becoming better, they sent them to the hospital on 1/30/2026. LPA’s interview with S2 confirmed S1’s interview regarding R1’s hospitalization. LPA’s record review of R1’s Centrally Stored and Destruction Medication Record (CSDMR) and Medication Administration Record (MARS), showed R1 was prescribed Metoclopramide on 1/27/2026 from 1/27/2026 to 2/10/2026. The order of the medication stated, “Take 1 tab by mouth. 3xs daily for Nausea/vomiting”. LPA's record review of R1's discharge paperwork from the hospital confirmed they were attended to. Based on interviews and record review, R1 stated staff attended to their medical needs. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 31-AS-20260202094224

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Case Management Annual Continuation visit to the facility. Upon arrival, LPA met with med-tech who granted access to the facility. Later Licensee/Administrator joined and explained the purpose of the visit. This visit was conducted to complete Required 1 year inspection initiated on 09/26/2025. During this visit at 9:55a.m., LPA and Med-Tech conducted a tour of the facility, including both interior and exterior areas to ensure no health and safety hazards were observed at the time of inspection. At approximately 10:30a.m., LPA recorded ten (10) residents’ interviews previously conducted during initial visit. At about 12:35p.m. LPA reviewed five (5) out of one hundred and two (102) residents records and they were complete at the time of this visit. LPA also reviewed those five (5) residents’ medication and MAR’s records. Medications are in a centrally stored and locked medication room in Wellness room including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation forms. First-aid kits have all proper items and were observed to be stored in the Wellness room. LPA reviewed six (6) staff files, and they had criminal record clearance and Cardiopulmonary Resuscitation (CPR) certificate at the time of this visit. All required documents were appropriately signed and dated. No deficiencies were observed during today’s visit. The facility appears to be operating within Title 22 regulations. All required postings were visible and current, including the facility license, complaint poster, personal rights, and emergency disaster plan. No immediate health or safety hazard were observed. An exit interview was conducted. A copy of this report was issued.the state’s words, verbatim · CDSS document, Oct 15, 2025

Type of visit: Required - 1 Year

At 10:00a.m., Licensing Program Analyst (LPA), Antonia Alvizar-Ettima and Regional Manager (RO), Angela Whittaker conducted a Required One (1) Year Annual visit. LPA and RO met with Manager and granted entry. Staff called the Administrator, and the purpose of visit was stated. Later the Administrator/Licensee joined us. At about 10:35a.m., LPA, RO and manager conducted a tour of the physical plant. Required postings were observed throughout the facility. This is an RCFE with a capacity of 199. The census is currently 103. The facility consists of a three (3) floor building with a total of 100 resident bedrooms (50 bedrooms on the second level and third level), each having its own bathroom. The first floor consists of the following: a lobby area, administrative offices, function room, dining area, activities room, television room, laundry room, staff lounge, family visiting room, guest restrooms, storage rooms, kitchen, and a sitting garden. There are two operable elevators, one designated for residents and the other for staff. The temperature of the facility wall thermostat was set at 72°F and observed to be within required range. The most recent fire and disaster drills were conducted on 09/03/2025. Care and supervision to meet the resident’s needs was observed. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools during the inspection and observed the following: Bedrooms: Bedrooms in the 2nd floor has non-ambulatory residents and the 3rd floor has ambulatory residents. Bedrooms were toured and observed to be clean and properly furnished with appropriate dresser, bedding, and linens with sufficient lighting. Linen storage was also checked and observed to have an ample supply of clean linen and towels. Cont. on LIC 809-C Bathrooms: Bathrooms were observed to be properly supplied and working fixtures, with appropriate grab bars, and non-slip mats were present. Hot water temperature was measured at a range of 109.9°F to 113.1°F which meets Title 22 regulations. Adequate supply of hygiene supplies available stored in supply room. Emergency Phone numbers, exit plan and menu: Posted and readily available for review in the lobby floor hallways. All fire extinguishers are fully charged with service tag date of 06/25/25. Smoke Detectors: Resident rooms and common areas have a manual smoke detector. Carbon monoxide detectors are located in each facility floor hallway. Fire inspection including smoke detectors, bells, door magnets, strobes, mini horns and full fire inspection was last done on 04/16/25. Common Areas: These include a lobby area, function room, dining area, activities room, television room, staff lounge, family visiting room, physical therapy room, guest restroom, and a sitting garden. There are two operable elevators, one designated for residents and the other for staff. The common areas were properly furnished. Furniture in common areas was observed to be in good repair. No obstructions or tripping hazards throughout the facility. Kitchen: Kitchen was observed to be clean and sanitary and free of pets. The kitchen appliances and fixtures were functional. Food: LPA observed at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. All food was properly wrapped, labeled, and stored. Food storage and preparation areas are clean and inaccessible to pests. Knives, cutlery and other sharp kitchen utensils are stored in the kitchen and only accessible for staff. All toxins and cleaning agents are locked in storage rooms. Laundry Room: Located on the 1st floor and inaccessible to residents. Detergent is kept in the laundry room locked. All toxins were stored and locked in the supply room. Surrounding Grounds: Entry and exits were free of obstruction. Outdoor areas were clean, with appropriate furniture and no hazards noted. The facility does not have a swimming pool or other body of water. Due to time constraints, LPA were unable to complete today's annual inspection. LPA will complete the inspection at a later date. There was no immediate health or safety hazard were observed. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 26, 2025

Allegation investigated: Resident developed multiple pressure injuries in care due to staff neglect Facility staff handled resident in a rough manner

On 07/01/2025 at 11:00 am Licensing Program Analyst (LPA), Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegations. Staff greeted and allowed LPA entry. Staff called Administrator Nonna Shapiro who arrived shortly after. LPA explained the reason for the visit and an entrance interview was conducted. At 12:15 PM LPA Casillas conducted a physical plant tour with the Administrator. During the investigation, interviews and record reviews were conducted. LPA requested resident roster, LIC 500, and Liability Insurance. LPA requested copies of pertinent information relevant to the investigation including, but not limited to, resident records and any other information pertaining to resident care. LPA conducted interviews of staff and residents from 12:30 to 2:30 pm. Continued on LIC9099-C Unsubstantiated Allegation: Resident developed multiple pressure injuries in care due to staff neglect It is alleged that a resident developed multiple pressure injuries in care due to staff neglect. Regarding this allegation it is reported that Resident #1 (R1) was not moved for seven (7) months, and they developed pressure injuries rendering R1 wheelchair bound. During interview with R1, R1 was not able to provide, date, time or names of staff involved, at times mentioning different facilities. Interview with Administrator revealed that R1 was a resident but that R1 left in March of 2023. According to Administrator R1 was presenting with lethargy and was sent to the hospital where the provider recommended R1 go to a skilled nursing facility due to R1 needing a higher level of care facility. Per Administrator R1 did not have wounds on them when R1 left the facility in March of 2023. The Administrator also stated that when R1 was admitted to the facility, R1 was already in a wheelchair. LPA was able to interview four (4) additional staff that were present at the time that R1 was present, and they stated that R1 did not have wounds and that R1 was compliant with taking their medication. Staff stated that R1 was sometimes difficult because R1 refused grooming at times but that R1 was in good health for the most part during R1’s stay at the facility. Furthermore, it was revealed by the Administrator that during the working shift at night there is an internal policy to make rounds every two (2) hours so that staff can check on residents and make sure that they are all doing ok, to include assistance with repositioning if needed. LPA interviewed ten (10) residents, and they all revealed that the facility takes good care of them, the staff are nice and that they have no concerns about lack of care being provided. LPA Casillas reviewed R1’s file and there was no indication of any wounds being present during R1’s approximate three (3) year stay. During the record review LPA also found that R1 did in fact already use a wheelchair upon admission to the facility. LPA also reviewed staff files and there were no disciplinary actions taken against staff pertaining to neglect. Therefore, based on LPA observations, record reviews and interviews, this allegation is deemed unsubstantiated. Continued on LIC9099-C Allegation: Facility staff handled resident in a rough manner It is alleged that facility staff handled resident in a rough manner. Regarding this allegation it is reported that facility staff turned R1 in such a manner that “they almost dislocated my hip”. Interview with R1 revealed that R1 does not recall the date, time or names of the staff involved and at times R1 kept referring to other facilities. R1 also stated that they do not have medical records to offer LPA, refusing to provide additional information. Interview with Administrator denied the allegation stating that R1 was difficult at times as far as grooming went, but that R1 was constantly checked on to make sure that R1 was comfortable. Administrator stated that during R1’s stay at the facility, there were no reports made by R1 pertaining to R1 being mistreated or reported by anyone else. Administrator states that concerns about such matter are taken very seriously and had they been made aware, it would have been taken care of immediately. Interview with four (4) staff corroborated Administrators’ statements denying that R1 was mishandled. Staff revealed that they were very much in tune with R1’s needs to the point that when R1 displayed any concerns, they were all made aware and worked as a team to help R1. LPA interviewed ten (10) residents, and they all stated that the staff at the facility are caring and would never hurt them. LPA reviewed records and could not find any documents indicating R1 being mistreated. Therefore, this allegation is deemed unsubstantiated. No citations issued, exit interview conducted. Copy of report given to Administrator.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 31-AS-20250625093354

Allegation investigated: Facility staff interfered with resident's medical care.

This is to amend the report that was delivered on 1/29/2025. Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced subsequent complaint visit on 4/30/25 to this facility to investigate the above allegation. At 11:00am LPA met with Krystie Kim and explained the reason for the visit. Regarding the allegation: Facility staff interfered with resident's medical care. It was alleged that facility staff (S1) coerced resident #1 (R1) by interfering and discouraging R1 and R1's medical case managers (W1 and W2) to stop R1's planned surgery scheduled for 9/05/24. To investigate this allegation on 9/11/2024 LPA de la Cerra requested pertinent documents relevant to the investigation at 11:00AM, conducted and interviewed staff between 11:30PM to 2:30PM, reviewed records from 11:00AM to 12:30AM and conducted physical plant tour at 2:00PM with staff member. On 01/29/25, at 11:00am LPA de la Cerra asked for additional facility records included but not limited to; staff schedule, residents roster, R1’s facility records, medical information and other pertinent documents. From 1:00pm to 2:30pm LPA conducted interviews with twelve (12) residents and a third-party witness present at the facility. Unsubstantiated LPA de la Cerra’s interviews two (2) out of two (2) staff members, S1 and S2 revealed that staff members did not coerce R1 to stop or postpone the scheduled surgery. R1 was only informed of the possible complications of the surgery and R1 showed signs of hesitation in going forward with the surgery. Furthermore, the night before (which was 9/04/24) of the scheduled surgery date of 9/05/2024, R1 informed S2 that they wanted to proceed with their scheduled surgery. S2 provided help and assistance to R1 so all arrangements can be made for R1 to be delivered to the hospital on 9/05/24. On 12/06/24 LPA contacted R1 by phone, R1 verified and confirmed the information revealed from staff S1 and S2. Interviews with residents revealed they never encountered any issues with facility staff interfering with any previous or future medical care, scheduled appointments or medical care needs. A review of records also verified the information revealed from staff and R1. Facility records contain a note handwritten and signed by R1 deciding to hold off on the surgery. Based on the inspection, observations, interviews, and record reviews there is no sufficient information to verify validity of the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No deficiency cited during today's visit. Exit interview conducted and copy of this report was signed and delivered.the state’s words, verbatim · CDSS document, Apr 29, 2025 · control 31-AS-20240904125603

Allegation investigated: Staff mismanaged resident's medication Staff did not safeguard resident's personal belongings Illegal eviction Staff did not treat resident with dignity and respect

This is an addendum to the previous licensing report delivered to the facility on 07/02/2024. On 04/23/25, at 9:35am, Licensing Program Analyst (LPA) Gina Saucedo conducted a subsequent visit to the facility to conduct additional investigation for the above noted allegations. LPA met with Maria Chengcuenca, Medical Technichian and explained the reason for the visit. On 07/02/24, LPA Rosaura conducted an initial visit, interviewed staff and residents and delivered findings. On 04/23/25, LPA Saucedo asked for the census, staff, and resident rosters. On 04/23/25, LPA Saucedo conducted a physical tour and interviewed additonal staff, residents and received relevant documentation. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff mismanaged resident's medication. It is being alleged that staff #1 (S1) was trying to over medicate and poison Resident #1 (R1). LPA received an Unusual Incident/Injury Report that states R1 was sent out to the community due to a 5150 hold on March 04, 2024 due to being a danger to self and others. Additionally, LPA obtained confirmation via the Medication Administration Record that R1 refused four (4) days of a medication that deals with treating schizophrenia prior to the incident on March 04, 2024. Two (2) staff confirmed that R1 was not taking their medication at the time of the incident and as a result their behavior had became worse. Four (4) staff confirmed that R1 would yell and scream from time to time. Eleven (11) residents were interviewed that confirmed they receive their medication and it is not mismanaged by staff. One (1) out of the eleven (11) residents that was R1's friend confirmed that R1 had episodes of yelling and screaming when they would not take their medication. Let it be noted, R1 had a bipolar disorder, anxiety and depression and was supposed to be taking several types of medication for these conditions. LPA obtained R1's Centrally Stored Medication and Destruction Record, Physician's Report, Preplacement Appraisal and Resident Appraisal, Appraisal Needs and Services Plan and the Medication Administration Record. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not safeguard resident's personal belongings. It is being alleged that staff discarded Resident #1 (R1)’s personal belongings. During LPA's interview with R1, R1 stated that their belongings were taken to the Skilled Nursing Facility where they were staying. LPA interviewed two (2) of the staff that confirmed R1's belongings were taken to the Skilled Nursing Facility because R1 did not want to return to the above facility. LPA also interviewed R1's social worker and the social worker confirmed that R1's belongings were brought to the Skilled Nursing Facility and the belongings that were brought were in several boxes and were put in the basement for R1 until their transfer to another facility. LPA also obtained R1's Client/Resident Personal Property and Valuables that confirmed R1 did not entrust any values to the above facility signed by R1. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Illegal eviction. It is being alleged that the facility administrator illegally evicted Resident #1 (R1) and was transferred to a Skilled Nursing Facility. LPA interviewed R1 and R1 confirmed that they were not illegally evicted. R1 chose to not come back to the above facility because they felt they were being mistreated and the administrator had taken their belongings to the Skilled Nursing Facility. Furthermore, R1 confirmed that they asked their social worker not to bring them back to the above facility and instead look for a new place for them to live. Therefore, based on the LPA's resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not treat resident with dignity and respect. It is being alleged that staff #1 (S1) did not treat Resident #1 (R1) with dignity and respect. LPA interviewed eleven (11) residents that confirmed S1 and/or other staff have treated them with dignity and respect. Furthermore, while interviewing residents, one (1) out of the three (3) residents that knew R1 stated that R1 told them they were going to burn the building down. Three (3) out of the eleven (11) residents confirmed that R1 yelled and screamed at them. Two (2) staff confirmed that they saw R1 walking down the hallway without clothes. Therefore, based on the LPA's resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to Maria Chengcuenca, Medical Technichian.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 31-AS-20240628141803

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required-1 year visit to this facility. LPA met with Administrator Nonna Shapiro and explained the purpose of today's visit. This is an RCFE with a capacity of 199. The census is currently 112. This is a 3 story building which consists of 100 resident bedrooms, large living room, large dinning room, activity room, t.v. room, wellness center, office and conference room. The facility consists of a three (3) level floor building with a total of 100 resident bedrooms (50 on the second level and 50 on the third level), each having its own bathroom. The first floor consists of the following: a lobby area, administrative offices, function room, dining area, activities room, T.V. room, laundry room, staff lounge, family visiting room, guest restrooms, storage rooms, kitchen, and a sitting garden. The facility also counts with two operable elevators. The facility fire clearance is maintained in conformity with State Fire Marshall regulations. The facility operates and is within capacity limits. Carbon monoxide and smoke detectors were tested and all were operable. No bodies of water were observed in or around the facility. The facility maintains a comfortable temperature. Hot water temperature was measured in the kitchen and in resident bathrooms and was within the required 105 degrees F and 120 degrees F. LPA observed the resident rooms to be properly furnished. Centrally stored medicines are kept in the medication room and are locked. There is a functioning call system in each residents' room. Outdoor and indoor passageways were observed to be free and clear of obstructions. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored. LPA observed there to be a minimum of one (1) week of nonperishable foods and two (2) days of perishable for the number of residents being served. Total daily diet has quality and quantity to meet resident's needs. Grab bars were available for each toilet, bathtub and shower used by residents. Bathtubs/showers have nonskid mats or strips and surfaces. Licensee provides hygiene supplies such as soap and toilet paper. There is one complete first aid kit. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 9, 2024

Allegation investigated: Staff mismanaged resident's medication Staff did not safeguard resident's personal belongings Illegal eviction Staff did not treat resident with dignity and respect

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Administrator Nonna Shapiro and explained the reason for the visit. It was reported that staff mismanaged resident's medication. Resident #1 (R1) alleged that Staff #1 (S1) was trying to over medicate and poison them. To investigate this allegation on 07/02/2024, between 11:30am and 1:07pm, staff interviews were initiated. Interviews revealed that R1 was medication non-compliant. R1 refused to take medication and as a result their condition has became worse. Between 1:15pm and 1:45pm, facility records (physician's report, administrator notes, incident reports, 5150) were reviewed. Records confirmed what staff told LPA. Based on interviews and records review there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. Continue on 9099-C Unsubstantiated It was alleged that staff did not safeguard resident's personal belongings. R1 alleges that facility staff threw away their belongings and placed them out in the street. To investigate this allegation between 11:30am and 1:07pm, staff interviews were initiated. Interviews revealed that on 03/14/2024, R1 received their personal belongings at the Skilled Nursing Facility (SNF) and they signed the inventory list as acknowledgement of having received them. Furthermore, Staff deny throwing away R1's personal belongings out on the street. Between 1:15pm and 1:45pm, facility records were reviewed. Records confirmed what staff told LPA. Based on interviews and records review, there is not sufficient information to support this allegation. Hence, the allegation is UNSUBSTANTIATED at this time. It was report that R1 was illegally evicted. To investigate this allegation, between 11:30am and 1:07pm, staff interviews were initiated. Interviews revealed that R1 was not evicted from the facility. Due to medication non-compliance, R1's condition became worse and had to be sent out of the community on a 5150 due to being a danger to self and others. R1 was discharged from the psychiatric unit on 03/11/2024 and was sent to a Skilled Nursing Facility (SNF) due to continuing to be medication non-compliant. On 07/01/2024, staff found out that R1 was no longer at the SNF and that they had been discharged to another board and care. Between 1:15pm and 1:45pm, facility records were reviewed. Records confirmed what staff told LPA. Based on interviews and records review, there is not sufficient information to verify this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. It was alleged that staff did not treat resident with dignity and respect. To investigate this allegation, between 11:30pm and 1:07pm, staff interviews were initiated. Interviews revealed that staff treat all residents in care with dignity and respect. R1 was at times rude and disrespectful to staff and residents. R1 was constantly making threats to the community that they were going to burn the building down. Sometimes R1 even physically assaulted residents and staff. Between 1:15pm and 1:45pm, facility records were reviewed. Records confirmed what staff told LPA> Based on interviews and records review, there is not sufficient information to support this allegation. Hence, this allegation is UNSUBSTANTIATED at this time. No health and safety issued noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 2, 2024 · control 31-AS-20240628141803

Allegation investigated: Staff did not give resident's records to resident's responsible party.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with the Executive Director (ED), Nona Shapiro, and explained the reason for the visit. --- Staff did not give resident's records to resident's responsible party. It was alleged that facility did not provide a complete copy of Resident #1’s (R1) records. To investigate this allegation, on 05/23/2024, LPA interviewed the ED from around 1:30 PM – 2:00 PM, and requested all documents that were sent to the responsible party (RP) at around 2:00 PM. During the interview with the ED, they stated documents were requested by R1’s RP on 04/19/2024. After receiving the request from the RP, ED stated they sent partial documents, contacted the RP explaining that remaining documents will take additional time and RP allegedly replied, “take your time”. (CONT. on LIC 9099-C) Substantiated ED stated the additional documents were mailed to the RP on 05/16/2024. A review of the records that facility provided to the RP revealed that Home Health records, hospital discharge documents, medication records, needs and service plans and physician’s reports were partially or entirely missing from the set of documents. Based on interviews and record review, there is enough information to verify the allegation, therefore, 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 health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 23, 2024 · control 31-AS-20240521173105

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(19) · Plan of correction due date: May 30, 2024

87468.2 (19) Additional Personal Rights of Residents in Privately Operated Facilities-To have prompt access to review all of their records and....shall be provided within two (2) business days…This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure all records were provided to the responsible party which poses a potential personal right violation to residents in care.the state’s words, verbatim · CDSS document, May 23, 2024

Plan of correction: The Administrator will review regulation 87468.2 (19) Additional Personal Rights of Residents in Privately Operated Facilities and submit a written statement ensuring that they will adhere them and submit all missing documents to the responsible party by the POC due date.

Allegation investigated: Staff neglected a resident in care leading to resident developing stage 3 pressure injuries. Staff did not feed a resident in care leading to resident becoming malnourished. Staff did not prevent resident from developing an infection while in care. Resident sustained unexplained injuries while in care.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. At around 10:00 AM LPA met with the Administrator, Nonna Shapiro, and explained the reason for the visit. --- Staff neglected a resident in care leading to resident developing stage 3 pressure injuries. It was alleged that Resident #1 (R1) developed stage three injuries while in the facility. To investigate the allegation on 10/23/2023 LPA requested pertinent documents at 12:30 PM and interviewed staff and other parties between 1:00 PM to 03:30 PM. On 04/03/2024, LPA interviewed a third party at 3:00 PM. A review of Physician’s Reports, Home Health records and hospital discharge documents did not indicate that resident had stage three (03) or any other pressure injuries. During interviews with staff, all staff stated that the resident did not have pressure injuries while in the facility. (CONT on LIC 9099-C) Unsubstantiated During interviews with other parties, they stated R1 developed pressure at a different facility after moving out of this facility. During interview with third party, they stated that resident did not develop pressure injuries in the facility. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not feed a resident in care leading to resident becoming malnourished. It was alleged that facility was not feeding the resident which led to malnourishment. To investigate the allegation on 10/23/2023 LPA requested pertinent documents at 12:30 PM and interviewed staff between 1:00 PM – 3:30 PM. On 04/03/2024, LPA interviewed ten (10) residents from 1:00 PM to 3:00 PM and a third party at around 3:00 PM. A review of Physician’s Reports, Home Health records and hospital discharge documents did not indicate that resident was malnourished. A review of the facility’s menu revealed that facility offers well-balanced nutritious meals throughout the day with various options. During interviews with staff, all staff stated they not only fed the resident and provided the same meals as everyone else but purchased additional food according to R1’s preference using staffs’ own money. Staff added, resident had a very healthy appetite while in the facility. During interviews with residents, all residents stated they are served three (03) meals a day and that snacks are available throughout the day. During interview with third party, they stated that R1 loved to eat and did not suspect any malnourishment or inconsistencies in weight while in the facility. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not prevent resident from developing an infection while in care. It was alleged that Resident #1 (R1) developed infection while in the facility. To investigate the allegation on 10/23/2023 LPA requested pertinent documents at 12:30 PM and interviewed staff between 1:00 PM to 03:30 PM. On 04/03/2024, LPA interviewed a third party at around 3:00 PM. (CONT on LIC 9099-C) A review of Physician’s Reports, Home Health records and hospital discharge documents did not indicate that resident had an infection. During interviews with staff, all staff stated that there were no signs of infection upon admittance and that R1 was sent to the hospital when signs were first noticed by physician and that R1 did not return to the facility after hospitalization. During interviews with third party, they stated that R1 was sent to the hospital as soon as the redness around the knee was first discovered and that they are not aware of any injury sustained in the facility that may have caused it and that it may have been cause by hardware in the knee combined with preexisting conditions. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Resident sustained unexplained injuries while in care. It was alleged that R1 had unexplained sores on the palms of their hand. To investigate the allegation on 10/23/2023 LPA requested pertinent documents at 12:30 PM and interviewed staff between 1:00 PM to 03:30 PM. On 04/03/2024, LPA interviewed a third party at around 3:00 PM. A review of Physician’s Reports, Home Health records and hospital discharge documents did not indicate that R1 had sores on their palms. During interviews with staff and third party, they stated that are not aware of any sores during their stay in the facility. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Apr 3, 2024 · control 31-AS-20231019120206

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required-1 year visit to this facility. LPA met with Administrator Nonna Shapiro and explained the purpose of today's visit. This is an RCFE with a capacity of 199. The census is currently 113. This is a 3 story building which consists of 100 resident bedrooms, large living room, large dinning room, activity room, t.v. room, wellness center, office and conference room. The facility consists of a three (3) level floor building with a total of 100 resident bedrooms (50 on the second level and 50 on the third level), each having its own bathroom. The first floor consists of the following: a lobby area, administrative offices, function room, dining area, activities room, T.V. room, laundry room, staff lounge, family visiting room, guest restrooms, storage rooms, kitchen, and a sitting garden. The facility also counts with two operable elevators. The facility fire clearance is maintained in conformity with State Fire Marshall regulations. The facility operates and is within capacity limits. Carbon monoxide and smoke detectors were tested and all were operable. No bodies of water were observed in or around the facility. The facility maintains a comfortable temperature. Hot water temperature was measured in the kitchen and in resident bathrooms and was within the required 105 degrees F and 120 degrees F. LPA observed the resident rooms to be properly furnished. Centrally stored medicines are kept in the medication room and are locked. There is a functioning call system in each residents' room. Outdoor and indoor passageways were observed to be free and clear of obstructions. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored. LPA observed there to be a minimum of one (1) week of nonperishable foods and two (2) days of perishable for the number of residents being served. Total daily diet has quality and quantity to meet resident's needs. Grab bars were available for each toilet, bathtub and shower used by residents. Bathtubs/showers have nonskid mats or strips and surfaces. Licensee provides hygiene supplies such as soap and toilet paper. There is one complete first aid kit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 28, 2023