Sparr Heights Estates Senior Living

This is an addendum to the Licensing report previously issued on 04/15/2024. Licensing program Analyst (LPA) Leizl DeLaCerra conducted announced subsequent visit to the facility on 05/01/25 to deliver the findings. LPA met the administrator and explained the purpose of the visit Allegation: Staff do not ensure adequate care and supervision is provided to residents in care. It was alleged that due to lack of supervision, resident #1 (R1) spent the night in the flooded room on 4/08/2024 and staff did not check on R1 until next morning”. To investigate this allegation. LPA Rosaura Valenzuela conducted an initial visit and delivered findings on 4/15/2024. During LPA de la Cerra's subsequent visit, 0n 4/24/2025. LPA conducted physical plant tour, conducted record reviews and staff interviews between 10:30am to 12:00pm and 1:30pm to 3:00pm, resident interviews were conducted between 12:30pm to 1:30pm. LPA obtained the staff roster, resident list, and gathered additional documents pertainingRead the full finding— CDSS inspection report, May 1, 2025 · control 31-AS-20240410154700

An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Angela Panushkina to issue the findings of the above listed allegations. Upon arrival, LPA met with the Executive Director, Bill Heady, and explained the reason for the visit. On 07/28/23, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegations, “Staff sexually abused resident in care” and “Staff did not report incident to the proper agencies”. The complaint was referred to Community Care Licensing Division’s Investigations Branch. The complaint was assigned to Investigator, Laarni Santiago. On 07/31/23, LPA Ruiz initiated the complaint. LPA conducted tour of the facility and obtained copies of pertinent information which include but not limited to R1’s Physician’s Report (dated on 11/01/21). Continue on LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, January 31, 2025 · control 31-AS-20230728111241

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Business Office Manager Helen Kirkorian and explained the reason for the visit. LPA conducted physical plant tour at 9:42 AM, requested copies of facility documents relevant to the investigation at 10:18 AM and interviewed staff and residents between 11:00 AM to 1:00 PM. Regarding the allegation that resident care needs are not being met by facility staff, it was alleged that Residents are complaining about quality of care and multiple issues with resident care needs. LPA's interview with six (6) residents on 03/13/24 between 12:30 PM to 2:00 PM and another six (6) residents today between 11:00 AM to 1:00 PM revealed that twelve (12) out of twelve (12) residents or about 20% of current census stated that the staff are respectful and provide all the care that they need and the quality of care are to their satisfaction. NRead the full finding— CDSS inspection report, May 23, 2024 · control 31-AS-20230308135842

Licensing Program Analysts (LPAs) Gary Tan and Ray Comer conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPAs met with interim Administrator Tracy Waite as the current administrator is indisposed and explained the reason for the visit. LPAs conducted physical plant tour at around 9:40 AM, requested copies of facility documents relevant to the investigation at 10:10 AM, reviewed records between 10:30 AM to 11:40 AM and interviewed residents and staff between 12:30 PM to 2:00 PM. Regarding the allegation that Facility is unsafe for residents in care due to unsecured access ways, it was alleged that there is an issue regarding residents' safety and elopement from unsecured access ways in Memory Care Unit. LPAs observation during today's visit revealed that the access ways in the Memory Care units are secured and all the delayed egress and all safety protocol are in place. LPAs' interview with the maintenance staff at 12:30Read the full finding— CDSS inspection report, March 13, 2024 · control 31-AS-20230308135842

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegations. LPA met with Resident Care Coordinator Veronica Sanchez and explained the reason for the visit. LPA conducted physical plant tour at 9:34 AM, requested copies of facility documents relevant to the investigation at 10:02 AM, reviewed records between 10:15 to 12:00 PM and interviewed staff and 12:10 PM to 2:00 PM. Regarding the allegation that residents hygiene needs are not being met, it was alleged that the Resident #1 (R1)'s hair was dirty and R1's teeth were dirty like they had not been washed and brushed for a while. LPA's record review revealed that R1's was showered and body inspected as scheduled unless R1 refused. (continued on LIC 9099-C) UnsubstantiatedRead the full finding— CDSS inspection report, October 9, 2022 · control 31-AS-20210519142527

Licensing Program Analyst (LPA) Rosaura Valenzuela made a unannounced subsequent visit for the above noted allegation. LPA met with Executive Director Ernest Lewis and explained the reason for the visit. It was alleged that on 02/17/2022 Resident #1 (R1) had been injured and sustained a bruise while in care. To investigate this allegation on 03/15/22 at 1:00pm and on 09/11/2022 at 11:00am, LPA inspected the facility and R1’s room. At the time of this visit between 11:15am and 12:00pm, LPA interviewed two current staff. Furthermore, LPA Valenzuela made an attempt to speak with facility staff #1 (S1) and staff #2 (S2) who were assisting R1 in the month of February 2022 and was informed that both staff no longer work at the facility. Staff interviews revealed that Resident # 1 (R1) was observed to be scratching their face all the time. R1’s nails were noted to be long and were recently trimmed by the hospice agency. Staff believe that on 02/17/2022 R1 sustained injuries, due to scratchingRead the full finding— CDSS inspection report, September 15, 2022 · control 31-AS-20220314112215

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Executive Director Ernest Lewis and explained the reason for the visit. LPA conducted physical plant tour at 9:35 AM, requested copies of facility documents relevant to the investigation and reviewed records between 10:00 AM to 12:00 PM. LPA also interviewed staff between 12:15 AM to 1:30 PM. Regarding the allegation that the staff did not follow orders, it was alleged that Resident #1 (R1) resident supposed to have one (1) patch to put on his back daily but was found to have two (2) patches on R1's chest on 05/03/21. LPA's record review today between 10:00 AM to 12:00 PM, revealed that R1 was prescribed one (1) patch for every twenty four (24) hours. Photo evidence provided by the witness revealed that R1 had two (2) patches on R1's chest. (continued on LIC 9099-C) SubstantiatedRead the full finding— CDSS inspection report, September 15, 2022 · control 31-AS-20210519142527

Licensing Program Analyst Rosaura Valenzuela conducted an unannounced subsequent visit for the above noted allegations. LPA met with Veronica Sanchez, Resident Care Coordinator The purpose of the visit was discussed. It was reported that staff did not seek medical attention for resident #1 (R1) when they sustained an injury. On 3/15/2022 at 3:02pm, staff interviews were initiated. Interviews revealed that staff did seek medical attention for R1. Facility informed R1's primary care physician and hospice agency. On 9/11/2022 between 12:30pm and 1:30pm, LPA Valenzuela reviewed R1's records. Records reviewed confirmed what staff had told LPA, On 2/18/2022 the hospice agency staff came to the facility to assess R1. Hospice staff noted that R1 was not in distress or pain at the time. According to hospice staff the injury looked better. Based on interview and record review there is insufficient information to support this allegation, therefore it is deemed UNSUBSTANTIATED at this time. UnsubsRead the full finding— CDSS inspection report, September 11, 2022 · control 31-AS-20220314112215

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with staff Veronica Sanchez and explained the reason for the visit. LPA conducted physical plant tour at 9:35 AM, requested copies of facility documents relevant to the investigation and reviewed records between 10:00 AM to 11:30 AM. LPA also interviewed staff and residents between 11:30 AM to 1:30 PM. Regarding the allegation that Resident's clothes are missing, it was alleged that Resident #1 (R1)'s underwear and clothes are missing, LPA's record review at 10:00 AM, revealed that R1's Power of Attorney (POA) did not declare any personal belongings on the inventory section of R1's Admission Agreement. LPA's observation during physical plant tour at 9:35 AM also revealed that R1 has a walk in closet full of clothes. (continued to LIC 9099-C) UnsubstantiatedRead the full finding— CDSS inspection report, September 11, 2022 · control 31-AS-20210519142527

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with staff Lizette Halili and explained the reason for the visit. LPA conducted physical plant at 9:35 AM, requested copies of facility documents relevant to the investigation at 10:20 AM and interviewed residents and staff between 10:50 AM to 2:00 PM. Regarding the allegation that staff are not cleaning resident(s) rooms, it was alleged that no one is cleaning residents' room as they were dirty and unkempt. LPA's interview with nine (9) residents or more than 14% of current census, today between 10:50 AM to 2:00 PM revealed that nine (9) out of nine (9) residents stated that staff clean their room everyday and do general cleaning once a week. LPA's observation on 08/17/22 at 10:35 AM also revealed that twelve (12) out of twelve (12) room visited were clean and in proper order. (continued on LIC 9099-C) UnsubstantiatedRead the full finding— CDSS inspection report, August 20, 2022 · control 31-AS-20201124081727

Licensing Program Analysts (LPAs) Gary Tan and Rosaura Valenzuela conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPAs met with Executive Director Ernest Lewis and explained the reason for the visit. LPAs conducted physical plant tour at 10:20 AM, requested copies of facility documents relevant to the investigation at 11:00 AM and interviewed Executive Director and staff between 11:15 AM to 1:30 PM. Regarding the allegation the there is insufficient linens to meet resident(s) needs, it was alleged that residents are sleeping on dirty sheets and there are not enough sheets for residents in care. LPAs observation today at around 10:35 AM revealed that there are sufficient linens in stock at the facility's multiple linen storage. LPAs also visited twelve (12) residents' room during physical plant tour and observed that twelve (12) out of twelve (12) rooms visited, linens were clean and in good condition. LPAs interview witRead the full finding— CDSS inspection report, August 17, 2022 · control 31-AS-20201124081727

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit to investigate the above noted allegations. LPA met with Ernest Lewis, Executive Director and explained the purpose of the visit. It was reported that staff is not providing resident's medication as prescribed. To investigate this allegation on 7/07/2022 at 1:00pm, LPA Valenzuela initiated staff interviews. Interviews revealed that Resident #1 (R1) is being given their medication. At 2:15pm, LPA Valenzuela reviewed R1's Medication Administration Record (MAR) for the months of June and July of 2022. LPA did not observe any discrepancies. The M.A.R. for the month of June indicated that R1 did not receive medication from 6/12-6/20/22 due to the fact that they were not in the community. Also, one cream was not administered on 6/24 and 6/25 of 2022 because the facility had not received the medication. Besides the dates mentioned previously, according to the M.A.R. and staff interviews, R1 has been receiving thRead the full finding— CDSS inspection report, July 7, 2022 · control 31-AS-20220701095734