Sparr Heights Estates Senior Living

Allegation investigated: Staff did not respond timely to the residents alerts Staff are not administering medications as prescribed Staff do not provide adequate food service Staff do not provide activities for the residents

On 08/18/26, at 8:15am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Denise Gotto, Executive Director. LPA explained the purpose of this visit was to gather information, conduct interviews and deliver findings regarding this complaint. On 08/18/26, LPA Saucedo asked for the census, staff, and resident rosters. On 08/18/26, at 8:50am, LPA Saucedo conducted a physical tour, interviewed staff and residents and delivered findings. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not respond timely to the residents’ alerts. It is alleged that residents are waiting thirty (30) minutes for assistance. During LPA’s physical tour, LPA pressed four (4) random alarms in the resident’s room and the staff responded within one (1) to two (2) minute time frame. In addition, the signal alarm transmits a visual and/or auditory signal to a central staffed location at the front of the facility which is then communicated with the caregivers. LPA interviewed seven (7) residents that confirmed they receive immediate assistance if they press their pendant and/or alarm in the room. LPA interviewed three (3) staff that confirmed that their response is as quick as possible and that no resident has complained about their pendant and/or alarm not functioning. Therefore, based on the interviews conducted and the observation of the LPA the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not administering medications as prescribed. It is alleged that residents are not receiving their medications on time. During LPA’s physical tour, LPA observed two (2) Licensed Vocational Nurses passing out medication at 8:35AM which is within the one (1) hour medication time of the 8:00AM medication to be passed out. LPA also observed bubble packs of medication being passed out that were prescribed by a pharmacist/doctor and given out within the one (1) hour time frame. LPA interviewed seven (7) residents that confirmed they receive their medication on time. One (1) out of the seven (7) residents confirmed they manage their own medication. LPA interviewed three (3) staff that confirmed medication is given within the time frame of the prescription provided. Three (3) of the staff also confirmed that medication is given within the one (1) hour time frame of the prescription order. Therefore, based on the interviews conducted and the observation of the LPA the allegation(s) is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff do not provide adequate food service. It is alleged that the food service is not good quality and there are no snacks like ice cream, apples or bananas to eat. During LPA’s physical tour, LPA observed residents eating eggs, toast and bacon. LPA matched what the residents were eating to what the food menu showed and took a picture of the food menu which also showed an alternative menu. LPA interviewed seven (7) residents about the quality of food and about the snacks. One (1) out of the seven (7) residents confirmed that they do not like the food but the food has gotten better since they spoke about it at the Resident Council Meeting. Another resident stated they are on a puree diet and sometimes salt is added to their food. LPA verified that the resident was on a puree diet and that the kitchen had their diet paperwork, which was in a binder, but the puree diet did not limit any salt. LPA interviewed two (2) staff that confirmed the quality of food is provided based on the state, nutritional regulations and that they also provide three (3) meals a day with snacks in between. Therefore, based on the interviews conducted and the observation of the LPA the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not provide activities for the residents. It is alleged that there has been no field trip since January 2026 and that residents are facing the wall and no activities are being done. During LPA’s physical tour, LPA observed residents in the living room area of the facility watching the morning news which was on the activity calendar and another activity named “Thoughtful Tuesday” was also observed. LPA matched the activities being done to the activity calendar and received a copy of the activity calendar. LPA did not observe any residents facing the wall at the time the activities were being performed. LPA interviewed seven (7) residents about the activities, and all seven (7) residents confirmed activities are done every day. One (1) resident said they do not attend because they rather watch television in their room but did say they do have different activities at facility. Another resident confirmed they loved bingo which is played every day. LPA interviewed two (2) staff that confirmed the activities are done every day. One (1) staff confirmed that the residents love bingo and bingo must be on the calendar every day. Therefore, based on the interviews conducted and the observation of the LPA the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issue, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Aug 18, 2026 · control 31-AS-20260812135612

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose Tan initially met with the receptionist Bertha Barbes who called the Executive Director and explained the reason for the visit. Ms. Gotto stated that the files were locked so she would be at the facility. Ms. Gotto arrived at around 11:16 AM. A tour of the physical plant was conducted at around 10:41 AM with the Marketing Director and eventually the Executive Director and the following was noted: The facility is fire cleared for one hundred twenty (120) non-ambulatory of which twenty (20) may be bedridden. The facility is currently occupying a total of seventy-five (75) residents, ten (10) of which are in hospice care. There is only one main entrance being utilized at the facility with sign-in sheets. Each residents' room has a full bathroom. LPA inspected random rooms in Memory Care and Assisted Living both first and second floor. Room 3E of Memory Care has toxins under the sink and Room 7E of Memory Care has no hot water on its sink. All rooms were observed to be adequately furnished with appropriate lighting system and enough clean linen available. Hallways are well lit. Residents have enough personal hygiene products provided by the licensee. The bathroom was checked for cleanliness and proper operation. The hot water temperature was measured at a range of 108.9°F to 118.9°F. Towels and washcloths are not shared. 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. Laundry detergents, cleaning agents and other toxins were observed to be locked in the parking area. (continued on LIC 809-C) (continued from 809) Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The facility has two (2) elevators, both of which are working properly. The facility maintains a comfortable temperature at 75°F. The facility's smoke alarms are hard-wired, interconnected with a pull system. The facility is equipped with sprinkler system but the facility has been currently on fire watch since September 2025, and per the Executive Director, they are in the process of updating their fire alarm and pull system. Fire extinguishers are located all throughout the facility and were last serviced on 02/11/26. Fire Drill was last conducted on 03/26/26. The living, dining and activity rooms are neat and clean. The facility maintains a comfortable temperature at 73°F but each resident has their own thermostat and can control the temperature in their rooms. The smoke alarms are hardwired, interconnected and centralized. Each room has a carbon monoxide detector installed. A signal is dispatched to the Los Angeles Fire Department automatically and the system is tested monthly. Laundry area is located in the basement area and is inaccessible to residents. Emergency drinking waters are also located in the basement/parking area. Medications were observed to be locked in the medication carts and inaccessible to residents. There were two (2) complete first aid kits in the medication room and medication carts. LPA observed medication carts locked and inaccessible to residents. Facility maintains a complete first aid kit. At 2:20 PM, LPA reviewed records of six (6) random residents and six (6) staff. Residents' records are observed to be current and updated. Staff #1 (S1) did not have a First Aid certificate on file. Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 28, 2026

Allegation investigated: Staff do not ensure adequate care and supervision is provided to residents in care. Staff spoke inappropriately while in front of resident.

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 pertaining to the investigation. Continue to LIC9099C Unsubstantiated LPA de la Cerra’s interviews with staff #2 (S2) at 11:55am revealed that R1’s care and supervision was increased due to showing some signs of decline, confusion and bladder retention problems, S1 then instructed staff members to do hourly routine check for R1. Interviews with staff #3 (S3) at 3:05pm and phone interview with staff #4 (S4) on 4/30/25 who both were assigned on night shift (NOC) duty during April 2024 revealed that around the beginning of April, staff members were instructed to increase the routine check on R1 to every hour. Staff S3 and S4 did check in on R1 routinely every hour and the last check in would normally be at 6:00am when their shift would end. LPA de la Cerra’s interviews with staff members, staff #5 (S5) and staff #6 (S6) who were with the AM shift (starts at 6am) during April 2024 revealed that they checked in with R1 usually at 6:30am. and every hour thereafter. Interviews with caregivers, S3, S4, S5 and S6 revealed that although the check in with R1 was hourly but most of these check-ins with R1 would not be documented in the facility’s observation log. Caregivers are instructed that there is no need to document on the observation log if there are no changes observed with the residents or if they are just sleeping.. Interviews with residents reveal that they receive sufficient care and supervision from facility staff. Furthermore, interviews with staff # S2, S3 and S7 on 4/30/25, revealed that R1 did not like wearing incontinence underwear and the incident on 4/09/24 with the broken toilet could be due to R1 attempting to flush their incontinence underwear in the toilet which would cause the toilet to overflow and malfunction. Review of R1’s records reveal that due to R1’s change in health condition, R1’s individual service plan was modified, that facility staff will provide total assistance to R1 to ensure successful toileting. During LPA de la Cerra’s subsequent visit on 4/24/25, R1 was not available for interview, record review by LPA de la Cerra revealed the R1 no longer resides at Sparr Heights Estates Senior Living, R1’s Power of Attorney-POA moved R1 out of the facility on 3/18/2025. Based on inspection, observations, interviews and record reviews, there is insufficient information to support this allegation. Therefore, the allegation remains Unsubstantiated. CONTINUE to LIC9099-C Allegation: Staff spoke inappropriately while in front of resident. It was alleged that while the reporting party was with R1 in R1’s room, and a female staff with hair dyed pink or purple, who is Filipino said to the reporting party that R1 is “coo coo”. 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 pertaining to the investigation. During LPA de la Cerra’s physical plant tour, LPA did not observe any staff member with hair dyed pink or purple, who is Filipino. LPA de la Cerra’s interviews with staff #1 (S1) at 11:00am and staff #2 (S2) at 11:55am on 4/24/25 revealed that the facility did not have a Filipino staff member with hair dyed pink or purple around April 2024. Interviews with residents reveal that they have never been spoken to inappropriately by any staff members. Additionally, residents interview also revealed that no staff member ever spoke inappropriately about them in front of their family member. During LPA de la Cerra’s subsequent visit on 4/24/25, R1 was not available for interview, record review by LPA de la Cerra revealed the R1 no longer resides at Sparr Heights Estates Senior Living, R1’s Power of Attorney-POA moved R1 out of the facility on 3/18/2025. Based on inspection, observations, interviews and record reviews, there is insufficient information to support this allegation. Therefore, the allegation remains Unsubstantiated. No health and safety hazards 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, May 1, 2025 · control 31-AS-20240410154700

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with the Executive Director, Denise Gotto, for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 10:00 AM and the following was noted: The facility is fire cleared for one hundred twenty (120) non-ambulatory of which twenty (20) may be bedridden. The facility is currently occupying sixty-eight (68) residents. There is a main entrance being utilized at the facility with sign-in sheets. Each residents' room has a full bathroom. LPA inspected seven (07) rooms at random and all rooms were observed to be adequately furnished with appropriate lighting system and enough clean linen available. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at an average 109.6°F. Towels and washcloths are not shared. 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. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. (continued on LIC 809-C) The living and dining room are neat and clean. The facility maintains a comfortable temperature at 73°F but each resident has their own thermostat and can control the temperature in their rooms. The smoke and carbon monoxide detectors are hardwired, interconnected and centralized. A signal is dispatched to the Los Angeles Fire Department automatically and the system is tested monthly. Fire extinguishers are located throughout the facility, observed to be fully charged and last inspected 01/17/2025. LPA observed medication carts to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 20, 2025

Allegation investigated: Staff sexually abused resident in care. Staff did not report incident to the proper agencies.

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 Unsubstantiated During todays visit, LPA Panushkina obtained copies of R1's Admission Agreement (dated on 12/22/21), Appraisal Needs and Services Plan (dated on 11/17/21) and Resident Abuse and Neglect Policy (effective date 11/01/2014) related to the complaint. This complaint investigation was conducted by Laarni Santiago, Investigator from Community Care Licensing Division’s Investigations Branch (IB). The investigation consisted of interviews, conducted between 09/07/23 to 10/26/23 with the Executive Director (ED), Health Services Director (HSD), Former Executive Director (FED), six (6) staff and attempt to interview four (4) memory care residents. Allegation: Staff sexually abused resident in care. The investigation findings revealed that R1 had been living at this facility since 12/28/2021 and resided in a Memory Care Unit. Also, during that time, S1 was working at this facility as a MedTech and it was alleged that R1 was routinely molested by S1 for a span of at least 3-6 months in 2022. Investigator conducted interviews with the Executive Director and Health Services Director and both parties could not provide any relevant information since they were not aware of any incidents between R1 and S1. Investigator also conducted an interview with S1, who denied the above allegation and advised that R1 “cried a lot” and S1 would only give a “hug” just to comfort R1. During the interview with S4, Investigator was informed that S4 and S5 witnessed S1 “kiss” R1. However, S5 refuted the claim and denied witnessing S1 commit any sexual conduct towards R1 or other residents. Moreover, S5 informed the Investigator that none of the residents or staff complained about S1. Both staff interviewed revealed inconsistent and conflicting information. Former Executive Director (FED) also informed the Investigator that no complaints from residents nor staff regarding S1’s inappropriate behavior was ever received. In addition, FED expressed that S1 was polite and reliable and voluntarily resigned to focus on school and become a Licensed Vocational Nurse (LVN). Furthermore, the Investigator conducted an interview with S6, who reported that he/she saw S1 inappropriately touched a resident. However, there were no other witnesses to corroborate the incident and S6 could not confirm that it was R1. Interviews with other two (2) staff did not indicate that they witnessed S1 touch or handle residents inappropriately and reported that S1 seemed to be a “genuine” and “caring” staff. Lastly, the Investigator attempted to conduct interviews with four (4) Memory Care residents, but they could not provide pertinent or relevant details. Based on interviews and information gathered during the investigation, there is insufficient evidence to prove the alleged violation occurred. Therefore, it deemed Unsubstantiated, at this time. Continue on LIC9099-C Allegation: Staff did not report incident to the proper agencies. It was alleged that R1 was routinely molested by S1 for a span of at least 3-6 months in 2022 and upon discovering the situation, the Former Executive Director (FED) forced S1 to resign, but didn’t report S1 to the authorities. To investigate this allegation, on 10/12/23 the Investigator conducted an interview with the FED and was informed that this was the first time he/she heard about the sexual abuse allegation. FED also denied that any staff came forward about concerns involving S1 and R1; or that they witnessed S1 conduct any inappropriate behavior. In addition, FED informed the Investigator that R1’s responsible party was highly involved in R1’s care and visited R1 frequently. R1’s responsible party did not bring up any concerns about S1 or any staff. Moreover, FED dined that S1 was forced to resign due to a “very odd” allegation and informed the Investigator that S1 voluntarily left because S1 wanted to focus on school and become a Licensed Vocational Nurse (LVN). Thus, there was no reason for this information to be reported and or to be escalated to the authorities. Lastly, interview conducted on 10/24/23 with S1, confirmed that he/she resigned because the facility required staff to work longer hours, but S1 could not because of school. Therefore, based on interviews and information gathered during the investigation, this allegation is Unsubstantiated. No deficiency cited during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jan 31, 2025 · control 31-AS-20230728111241

Allegation investigated: Staff are not following proper reporting requirement Resident care needs are not being met by facility staff

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. None of the twelve (12) residents interviewed expressed any issue with care or staff at this time. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Regarding the allegation that Staff are not following proper reporting requirement, it was alleged that two (2) residents were in altercation and the former Executive Director (ED) did not take the staff concern seriously and did not report to CCL. The reporting party (RP) did not provide any details of the alleged incident as to who, when and where it happened. The RP also did not provide any contact details, so no contact was made with the RP to get the details of the alleged incident that was not reported. LPA's record review today between at 1:00 PM to 1:38 PM revealed that the ED referred to on RP's report had left the facility sometime in June 2023. LPA's interview with a staff at 12:45 PM however, revealed that the only altercation happened during the time of the former ED between two (2) residents happened sometime in May of 2023. LPA's record review today between 1:00 PM to 1:38 PM revealed that the facility had submitted Unusual Incident/Injury Report (LIC 624) on 05/22/23 regarding an altercation between two (2) residents happened on 05/21/23. The incident was also reported to the local law enforcement. Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, May 23, 2024 · control 31-AS-20230308135842

Allegation investigated: Facility is unsafe for residents in care due to unsecured access ways Residents are not provided proper medication assistance

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 12:30 PM also revealed that there was never an issue with the access and ingress and egress on the Memory Care Unit and never in disrepair for the last one and half year since the maintenance staff was employed. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099-C) Regarding the allegation that residents are not provided proper medication assistance, it was alleged that there were Medication errors and late Medications pass at the facility. LPAs interviewed six (6) random residents or 10% of current census today between 12:30 PM to 2:00 PM revealed that six (6) out of six (6) residents did not experience medication error nor late medication administration. Further interviews also revealed that six (6) out of six (6) residents did not witness or aware of any resident who had medication error or late medication pass. LPAs interview with two (2) Medication staff today between 12:30 PM to 2:00 PM also revealed that there was no medication error or medication late pass and/or reported for the last two (2) years that the medication staff were employed. Based on the information gathered during this visit the allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 31-AS-20230308135842

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: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required 1 year inspection to the facility. LPA met with Helen Kirkorian, Business Office Manager and the purpose of the visit was discussed. LPA conducted a physical plant tour of the facility. There is one main entrance being utilized at the facility. The facility consists of one main building. The Independent Living section of the facility is on the top floor and the Memory Care Unit is located on the bottom floor. The facility has a capacity for 131 residents. Currently 58 rooms are being occupied. Common areas were checked for cleanliness. Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. The residents rooms are adequately furnished with appropriate furniture and lighting system. The facility maintains a comfortable temperature at 78 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There are carbon monoxide detectors in the facility. Fire extinguishers are located throughout the facility and were last serviced in January of 2024. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at 120 degrees F. Medications-LPA observed medication carts in the nursing station to be locked and inaccessible to residents. There is one ( 01) complete first aid kit. Exit interview conducted. A copy of this report was issued and signature obtained. No deficiencies were issued at this timethe state’s words, verbatim · CDSS document, Feb 27, 2024