West Hills Assisted Living

Type of visit: Case Management - Deficiencies

In conjunction to the complaint 31-AS-20260924154150, Licensing Program Analyst (LPA) Mariana Agban conducted Case Management Deficiency visit. During investigation, LPA discovered that Administrator did not submit R1's incident report that occurred on 08/12/26. LPA conducted record review and did not observe Incident report submitted to Community Care Licensing (CCL). LPA advised the administrator that a written report shall be submitted to the licensing agency within seven days of the occurrence of any incidents. Administrator had emailed Woodland Hills RO the incident report during today's visit. During the physical plant inspection, LPA observed that the side gate near R1’s room provided direct access to the street. LPA also observed that the auditory alarm associated with the side gate was not functioning. LPA advised the Administrator that leaving the side gate accessible without a functioning auditory alarm could increase the risk of elopement for residents with dementia. Exit interview conducted. Appeal rights given and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Sep 30, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 2, 2026

A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This requirement was not met. Based on record review Administrator did not submit an incident report for R1's elopement on 08/12/26 to CCL. This poses a potential health and safety risk to clients in carethe state’s words, verbatim · CDSS document, Sep 30, 2026

Plan of correction: During today's visit, Administrator had emailed the incident report to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(d) · Plan of correction due date: Oct 14, 2026

(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement was not met. Based on observations, the auditory alarm on the side exit door was not functioning. This poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Sep 30, 2026

Plan of correction: Administrator agreed to set up a new auditory device on the side gate. Proof of working auditory alram will be emailed to LPA by POC.

Allegation investigated: Resident sustained pressure injuries due to staff neglect Staff caused bruises to resident while providing incontinent care Delay in staff assistance resulted resident falls Staff did not provide reasonable living arrangements

At approximately 1:30 p.m. on 08/20/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 01/23/26 and toured the facility inside and out at 9:00 a.m., interviewed the administrator, staff, residents, and a witness between 9:15 a.m. and 12:45 p.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and the resident roster at 11:15 a.m. LPA conducted a subsequent visit on 04/15/26 and toured the facility at 9:45 a.m. and interviewed staff and at least ten (10) percent of residents [seven (07) out of sixty-two (62) residents] between 10:00 a.m. and 4:00 p.m. LPA conducted another visit on 07/16/26 and interviewed staff and residents between approximately 10:00 a.m. and 3:00 p.m. Today, LPA toured the facility at 1:40 p.m. and interiewed Resident #4 (R4) at 2:15 p.m. Unsubstantiated Regarding the allegations "Resident sustained pressure injuries due to staff neglect" and “Staff caused bruises to resident while providing incontinent care” it was alleged Resident #1 (R1) had pressure injuries on their back due to improper care and bruises from rough handling during diaper changes. Interview with R1 at 2:20 p.m. on 07/16/26 revealed they have no pain, bruises, or pressure injuries, and they are well taken care of by staff. Staff are gentle when changing R1. Interview with the administrator at 11:00 a.m. on 01/23/26 confirmed R1 has not had any pressure injuries. Interviews with caregivers Staff #8 (S8), Staff #9 (S9), and Staff #1 (S1) at 1:30 p.m., 1:45 p.m. and 2:15 p.m. on 04/15/26 confirmed R1 has not had any pressure injuries, and R1 is repositioned and changed approximately every three (03) hours. S1 and S8 noted R1 has “spots” on their legs, likely from rolling into their bedrails, but no bruising. LPA observed minor spots on R1’s leg during the interview, but no bruises. Record review of R1’s medical assessment revealed they had a history of poor skin integrity, but no pressure injuries. Based on interviews, observations, and record review, although the allegation may have occurred, there is no measurable and verifiable information to confirm its validity. Hence the allegation is UNSUBSTANTIATED at this time. Regarding the allegation "Delay in staff assistance resulted resident falls" it was alleged Resident #2 (R2) and Resident #3 (R3) have had falls due to long wait times when using their call buttons. Interviews with R2 at 2:45 p.m. on 07/16/26 and R3 at 2:25 p.m. on 04/15/26 revealed they have not had any falls, and staff are responsive when they need them. Telephonic interview with R3’s representative at 12:00 p.m. on 05/21/26 confirmed they have not had any falls in the facility. Interviews with the administrator, S1, S8, and S9 also verified that R2 and R3 have not had any falls. The administrator added that R2 uses their call button frequently, and staff assist R2 promptly. LPA tested R2’s call button at 2:47 p.m. on 07/16/26, and staff arrived within thirty (30) seconds. Based on interviews, observations, and record review, although the allegation may have occurred, there is no measurable and verifiable information to confirm its validity. Hence the allegation is UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not provide reasonable living arrangements" it was alleged R4 is moved to different rooms which causes them distress. Interview with R4 revealed staff have accommodated their requests to change rooms, though they want a private room. Interview with the administrator revealed R4 requested multiple room changes due to incompatibility with their roommates. Per their requests, R4 has had at least four (04) room changes, and the administrator has fulfilled their requests each time. Interviews with caregivers revealed R4 often complains, but staff do their best to accommodate their needs and follow their care plan. Record review of R4’s care plan revealed they have diagnoses which may cause agitation, so staff monitor R4 for mood changes and encourage socialization. Based on interviews, observations, and record review, although the allegation may have occurred, there is no measurable and verifiable information to confirm its validity. Hence the allegation is UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 31-AS-20260116105124

Allegation investigated: Staff is mismanaging resident's medications Staff do not provide adequate food services for resident Staff does not ensure resident's call button is accessible to resident Staff wrongfully evicted resident Staff did not conduct a proper assessment for resident Staff did not assist to help find a different placement for resident

At approximately 9:00 a.m. on 07/16/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 01/23/26 and toured the facility inside and out at 9:00 a.m., interviewed staff, residents, and a witness between 9:15 a.m. and 12:45 p.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, medication list, and client roster at 11:15 a.m. LPA conducted a subsequent visit on 04/15/26 and toured the facility at 9:45 a.m., interviewed staff and at least ten (10) percent of residents [seven (07) out of sixty-two (62) residents] between 10:00 a.m. and 4:30 p.m. and requested additional pertinent records at 1:00 p.m. Today LPA toured the facility at 9:30 a.m. Unsubstantiated Regarding the allegation "Staff is mismanaging resident's medications" it was alleged staff gave sleeping medications to Resident #1 (R1) during the day and night to sedate them. Interviews with seven (07) out of seven (07) residents on 04/15/26 revealed the facility assisted them appropriately with medications. Interview with Staff #1 (S1) at 10:00 a.m. on 01/23/26 and with the administrator at 11:00 a.m. on 01/23/26 revealed the facility followed R1’s physician orders when assisting with medications. S1 and the administrator confirmed R1 was prescribed medications which were not sleeping pills but had side effects that made them drowsy. One (01) medication was prescribed for the morning, and two (02) were prescribed for the evening. Record review of R1’s medication list and physician orders confirmed the medications were designated to be taken in the morning and night. Based on interviews and record review, there is insufficient evidence to confirm staff mismanaged R1’s medications. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff do not provide adequate food services for resident" it was alleged staff did not escort R1 to the dining room or provide sufficient meals. Interviews with six (06) out of seven (07) residents on 04/15/26 revealed they felt the food service was adequate. Interview with Staff #2 (S2) at 9:15 a.m. on 01/23/26 revealed the facility was assisting R1 to the dining room and providing regular meal service. R1 caused disturbances to other residents and did not like the food served to them, so the facility provided an alternate meal service to their room per their liking. Interview with the administrator confirmed the facility provided complimentary tray service to R1’s room and provided meals based on their preferences. Interview with Staff #3 (S3) at 2:15 p.m. on 04/15/26 confirmed R1 was provided adequate food service. Record review of R1’s file did not reveal information pertinent to the investigation. Based on interviews, and record review, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff does not ensure resident's call button is accessible to resident" it was alleged staff put R1’s call button out of reach to ignore their calls for assistance. Interviews with six (06) out of seven (07) residents on 04/15/26 revealed their call buttons have been accessible and operational. Interview with Resident #2 (R2) at 2:25 p.m. on 04/15/26 and Resident #3 at 3:15 p.m. on 04/15/26 confirmed staff respond quickly when residents call. Interview with the administrator revealed R1’s call button was accessible. To further assist R1’s needs, they were moved closer to the offices and medication room for increased staff supervision. During the facility tour on 01/23/26, LPA observed R1’s call button was within reach from their bed. Based on observations and interviews, staff ensured R1’s call button was accessible. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegations "Staff wrongfully evicted resident" and "Staff did not conduct a proper assessment for resident" it was alleged R1 and their representative, Witness #1 (W1) were issued an eviction notice without proper cause, and the facility should have retained R1 based on their preplacement assessment. Interview with the administrator revealed R1 was admitted in November 2025. The facility was able to care for R1’s needs at that time. R1 later developed aggressive behaviors which were not present upon admission. R1’s behaviors were dangerous to both staff and residents. The facility consulted with R1’s family, physician, and psychiatrist about their care. After multiple attempts to retain R1 in the facility, R1 was reassessed and determined to be no longer suitable. The facility submitted R1’s notice of eviction at 2:00 p.m. on 01/05/26. Record review of the eviction at 3:00 p.m. on 01/05/26 revealed it was issued in accordance to Title 22 regulations. The eviction notice also documented the facility’s multiple attempts to address R1’s problem behaviors prior to eviction. Record review of R1’s preplacement appraisal and physician assessments confirmed the facility was no longer suitable for R1. Based on interviews, and record review, the facility adhered to Title 22 regulations and issued an eviction notice to R1 based on their increased behaviors. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not assist to help find a different placement for resident" it was alleged the facility evicted R1 without assisting them in finding another home. It was noted that the facility provided a long list of facilities, but no further assistance. Interview with the administrator confirmed they provided R1 and W1 a list of about one thousand (1000) facilities which were appropriate for R1. The administrator also provided contact information for referral services. Record review of R1’s eviction notice confirmed the facility provided the list to R1 and W1. It also stated the facility met with W1 regarding R1’s care and future placement. LPA also observed the administrator meet with W1 at 11:10 a.m. on 01/23/26 to assist with their placement needs. Based on observations, interviews, and record review, staff assisted R1 and W1 with finding different placement. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 31-AS-20260116124713

Allegation investigated: Staff did not prevent a resident from sustaining fractures while in care

At approximately 11:00 a.m. on 05/21/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. Regarding the allegation "Staff did not prevent a resident from sustaining fractures while in care" it was alleged Resident #1 (R1) suffered seven (07) fractured ribs while under staff supervision. To investigate the allegation above, LPA conducted an initial visit on 05/14/26 and interviewed the administrator at 11:15 a.m., requested pertinent records at 11:30 a.m., and toured the facility at 11:40 a.m. Today, LPA Reed toured the facility inside and out at 11:15 a.m., conducted a review of pertinent records, including but not limited to R1’s admission agreement, medical assessment, care plan, staff and client rosters, resident sign in and sign out logs, and a copy of the Adult Protective Services (APS) report filed by the facility administrator for suspected neglect/abuse of R1 at 11:30 a.m., and interviewed staff between 12:30 p.m. and 2:30 p.m. Record review of staff notes and emails revealed R1 returned to the facility from a vacation at 1:45 a.m. on 05/09/26 with a soiled diaper and high blood sugar. Unsubstantiated Telephonic interview with Staff #1 (S1) today at 1:00 p.m. confirmed R1 expressed pain during their bath hours after they returned to the facility. Interview with Staff #2 (S2) at 1:20 p.m. today also confirmed R1 expressed pain when being repositioned on 05/09/26 and 05/10/26. R1 reported to S2 that they were handled roughly on a bus while travelling. Around 4:45 pm. on 05/09/26, staff noticed bruising on R1’s arms. Photographs taken by facility staff confirmed bruising on both of R1’s arms. During a home health visit at 11:30 a.m. on 05/10/26, R1 noted a pain level of “10 out of 10”. R1 was sent to the hospital for medical attention where their fractures were discovered. The APS report submitted by the administrator for R1’s suspected abuse confirmed the evidence found in the investigation. The overall investigation revealed that although R1 suffered multiple rib fractures, there is insufficient evidence to verify that the fractures resulted at the facility due staff neglect. Therefore, based on interviews and record review the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 31-AS-20260513095333

Allegation investigated: Resident sustained injuries due to staff neglect Staff do not provide comfortable water temperature for resident's baths Staff spoke to resident in an inappropriate manner

On 05/05/26, at 9:15am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Edgardo Galang, Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 01/23/26 Licensing Program Analyst (LPA) Nicholas Reed conducted the initial complaint visit. On 05/05/26, at 9:50am, LPA Saucedo conducted a physical tour, interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Resident sustained injuries due to staff neglect. It is being alleged that resident #1 (R1) had scratches and bruises on their neck and arm elbow. LPA interviewed two (2) of resident #1 (R1)'s daughters and one (1) daughter stated, "No, I did not see any scratches on them and also R1 was not an easy person to take care of." Another daughter stated, "yes, I saw scratches." During LPA's physical tour, LPA did not witness any scratches on any of the five (5) residents that were interviewed. Furthermore, during LPA's file review, R1 was given an eviction notice, for being verbal and/or physical abuse directed towards other residents or staff. LPA interviewed four (4) staff that confirmed that R1 did not have any scratches and/or bruises on them. All four (4) staff confirmed that R1 was aggressive and R1 hit three (3) out of four (4) staff that were interviewed. R1 would threw food and physically hit the staff. LPA interviewed five (5) residents that confirmed they have not sustained any injuries due to staff neglect. All five (5) residents confirmed that staff treat them well and they like living there. Therefore, based on the observations and interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not provide comfortable water temperature for resident's baths. It is being alleged that when resident #1 (R1) is taken to the shower area the water temperature is first very cold then it turns very hot. LPA interviewed two (2) of resident #1 (R1)'s daughters and both daughter's stated, "that R1 would be taken to the shower area where the water was either very cold or/and very hot." During LPA's physical tour, LPA did not observe any shower area. The facility does not have a shower area, every room has their individualized full bathroom with a shower/bathing tub and toilet. LPA tested several showers/bathing tubs and toilet areas including the room R1 was residing in and they were within regulations of 119.1, 118.2 and 119.4. LPA interviewed two (2) staff that would shower R1 and confirmed that R1 would yell and scream for no reason when they were showering. One (1) staff said they would test the water and have R1 test it before they would shower. LPA interviewed five (5) residents that confirmed they do not have an issue with the temperature of their water in their room. Therefore, based on the observations and interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff spoke to resident in an inappropriate manner. It is being alleged that staff cursed at resident #1 (R1). LPA interviewed two (2) of resident #1 (R1)'s daughters and both stated, "they never heard staff speak to R1 in an inappropriate manner." During LPA's physical tour, LPA did not witness any staff speaking to any resident in an inappropriate manner. During LPA's file review, R1 was given an eviction notice, for being verbal and/or physical abuse directed towards other residents or staff. LPA interviewed four (4) staff that confirmed that they never spoke to R1 and/or any other residents in an inappropriate manner. All four (4) staff confirmed that R1 would scream, yell, throw things and curse at them. One (1) staff stated, "R1 would also curse us in Spanish since they knew how to speak Spanish." LPA interviewed five (5) residents that confirmed they have not been spoken to in an inappropriate manner. All five (5) residents confirmed that staff treat them very well and are nice to them. Therefore, based on the observations and interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, No citation(s) were issued and a copy of this report was given to the Administrator. Regarding the allegation: Staff did not safeguard resident's personal belongings. It is being alleged that resident #1’s glasses are missing. LPA interviewed two (2) of resident #1 (R1)'s daughters and both daughter's stated, "that R1 wore glasses and they went missing and were never found." Although, LPA interviewed five (5) residents that confirmed they have never lost anything, during LPA's interview with staff, four (4) staff confirmed that R1 did wear glasses. Four (4) staff confirmed that R1 had lost their glasses but they were found but had lost them again. LPA reviewed R1's file and it was confirmed that R1 did wear vision glasses. LPA received a copy of R1's Medical Assessment, Admission Record, Preplacement Appraisal Information, Functional Capability Assessment and the updated LIC 621-Client/Resident Personal Property and Valuables that were signed and that said that R1 wore glasses and there's a picture of R1 with glasses. Therefore, based on R1's file review and interviews conducted, the allegation is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, an appeals right was provided and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, May 5, 2026 · control 31-AS-20260120125325

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a) · Plan of correction due date: Jun 2, 2026

87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. This requirement was not met by: Based on LPA's file review and interviews, the licensee/administrator did not comply with the section cited above when resident #1 (R1) lost/got stolen their glasses which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: The Administrator/Licensee will pay R1 and/or R1's guardian/POA/Family member $150.00 for recovery of glasses. POC Cleared: 06/02/26

Allegation investigated: Facility is in disrepair Staff are double diapering residents in care Residents’ medications were not ordered in a timely manner Staff did not follow the residents’ modified diet Staff argue in front of residents in care

At approximately 9:30 a.m. on 04/15/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 01/23/26 and toured the facility inside and out at 9:00 a.m., interviewed staff, residents, and a witness between 9:15 a.m. and 12:45 p.m., and conducted a record review of pertinent records at 11:15 a.m. Today LPA toured the facility at 9:45 a.m., interviewed staff and at least ten (10) percent of residents [seven (07) out of sixty-two (62) residents] between 10:00 a.m. and 4:30 p.m. and requested additional pertinent records at 1:00 p.m. Regarding the allegation "Facility is in disrepair" it was alleged the facility roof has a leak, mold in the stairwells, broken washing machines, and the front door has a broken lock. Interview with the Director at 11:00 a.m. on 01/23/26 revealed the roof did have a leak, and the facility requested maintenance from a professional immediately. Unsubstantiated Mold in the staircase was caused by one of the leaks and was cleaned on 01/15/26. The facility has enough washing machines to accommodate resident laundry needs. The front door remains secure and staff supervise the main entrance at all hours of the day. During the facility tour at 9:00 a.m. on 01/23/26, LPA toured two (02) out of two (02) stairwells with the Director. LPA observed no mold in either stairwell. The Director showed one (01) patched and painted section in the rear stairwell where mold was cleaned and disposed of. LPA also observed four (04) out of six (06) washing machines to be operable. At approximately 10:00 a.m. on 03/04/26 during the annual inspection, LPA observed an outside vendor making additional repairs to the roof. At 9:30 a.m. today, LPA observed the front door to be in working order. Record review of work order receipts showed the facility ordered maintenance for the roof immediately. Interviews with seven (07) out of seven (07) residents revealed they had no issues with the facility’s state of repair. Based on observations, interviews, and record review, the facility has taken reasonable and timely steps to remain in good repair. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff are double diapering residents in care" it was alleged staff put two diapers on residents instead of changing them properly. Interview with Staff #1 (S1) at 2:15 p.m. today revealed they and other staff never double diaper residents. Interview with Staff #2 (S2) at 2:00 p.m. today revealed only one (01) staff was double diapering residents, Staff #3 (S3). S2 said S3 did not follow the facility incontinence procedures, so S2 provided proper incontinence care in a timely manner to fix S3’s mistake. Interview with the Director at 11:00 a.m. on 01/23/26 confirmed no staff besides S3 put double diapers on residents. S2 checks residents every morning. S2 told management about S3’s improper care. The Director addressed the issue with S3 and eventually terminated their employment. Interviews with seven (07) out of seven (07) residents revealed none have been double-diapered or received improper incontinence care. Based on interviews, although a staff member provided improper incontinence care, other staff and management corrected the issue with no consequence to residents in care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Residents’ medications were not ordered in a timely manner " it was alleged medications were not ordered on time. Interview with S2 revealed medications are ordered in the afternoon and evening by Staff #4 (S4) and Staff #5 (S5). S2 said they have never run out of medications. No residents have missed routine or pain medications. All physician orders have been followed. Interview with the Director at 11:00 a.m. on 01/23/26 confirmed no residents have run out of medications, all physician orders are followed, and no refills have been delayed. Interview with S4 at 4:30 p.m. today revealed they and the administrator order refills. The facility has not had issues with running out of medications. Interviews with seven (07) out of seven (07) residents revealed they have not had issues with medication errors or running out of medications. LPA conducted a medication review of three (03) residents at 11:30 a.m. today. All resident medications were maintained in sufficient quantities. Based on interviews, observations, and record review, there is insufficient evidence to verify the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not follow the residents’ modified diet”, it was alleged staff did not follow resident modified diets. Interview with S2 revealed staff do follow modified diets, especially diabetic diets. S2 and home health agencies monitor resident blood sugar levels, and they review resident diets. Interviews in the kitchen with Staff #6 (S6) and Staff #7 (S7) at 4:10 p.m. today revealed all modified diets are followed. LPA observed dietary cards, allergy restrictions, and resident preferences posted in the kitchen. Interviews with seven (07) out of seven (07) residents today revealed all of their modified diets and preferences are followed. Based on interviews and observations, staff follow modified diets. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff argue in front of residents in care" it was alleged the administrator and S1 constantly argue in front of residents. Interview with administrator at 9:15 a.m. on 01/23/26 revealed they never argue with S1, especially not in front of residents. Interview with the Director at 11:00 a.m. on 01/23/26 confirmed the administrator has never argued with S1 in front of residents. The Director noted S1 speaks loudly, but they do not argue. Interview with S1 today at 2:15 p.m. revealed they have never argued with the administrator in front of residents. Interviews with seven (07) out of seven (07) residents confirmed they have never heard S1 and the administrator, nor any other staff, argue in front of them. LPA did not observe staff arguing today or during the initial visit. Based on interviews and observations, staff do not argue in front of residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 31-AS-20260116105124

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.

Type of visit: Required - 1 Year

At approximately 9:00 a.m. on 03/04/26, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and later the administrator and disclosed the reason for the visit. The facility is a two-story building with private and shared bedrooms, private and public bathrooms, common areas, activity rooms, living rooms on both floors, dining room, laundry areas on both floors, and outdoor areas. It has an approved fire clearance for thirty (30) ambulatory residents and sixty (60) non-ambulatory residents, of which fifteen (15) may be bedridden. Approved hospice waivers for thirty (30) residents. The administrator noted ongoing renovations including additional laundry appliances upstairs, as well as kitchen and dining room repairs. LPA observed postings near the main entrance and medication room for COVID precautions, visitation policy, emergency disaster plan, Ombudsman contacts, confidential complaint contacts, theft and loss policy, house rules, resident rights, rights of resident councils, facility sketch with evacuation routes, weekly menus, activity schedules, emergency contacts, and nondiscrimination policy. The front yard was maintained. The lobby area was clean and contained appropriate seating, visitor logs, water, a mounted digital thermometer, mailboxes, and a reception area. The activity room near the main entrance contained furniture in good repair, a piano, reading material, and a television. Cameras were observed common areas and exterior areas. The front outdoor area was accessible from the television room. The outdoor area contained patio furniture in good repair and was shaded by umbrellas. At approximately 9:20 a.m. LPA observed fully-charged fire extinguishers near the front lobby, kitchen, and in the upstairs and downstairs hallways. They were last serviced on 02/13/26 and had tags attached. Another activity room near the dining room contained music supplies, art supplies, board games, a new vending machine, a billiards table, and exercise equipment. The upstairs area also had an activity room with pianos, furniture, and reading material. The designated smoking area was adjacent to the upstairs activity room with a newly installed fan to diminish smoke. Public restrooms were clean and fully stocked with liquid soap, paper towels, and trash cans with tight fitting lids. At 9:30 a.m., the temperature of the first-floor public restroom was measured to be 109.6 degrees Fahrenheit. The janitorial closet, storage rooms, and employee lounge were locked and inaccessible. The elevator was operable. A linen closet was also observed in the first floor hallway and contained an adequate supply of fresh sheets and beddings. The first floor laundry area was locked and contained two (02) operable washers, two (02) dryers, and detergents. Another laundry room was located on the second floor and was free of hazards. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. A daily menu and an alternate menu were posted in the dining room. Modified dietary cards were posted according to updated physician orders. Emergency water and food supplies were observed in a separate room and in ample amount. At 10:00 a.m., the walk-in refrigerator temperature was measured to be 38 degrees. The walk-in freezer was inoperable, so additional freezers were provided in the medication room and kitchen. At 11:30 a.m. the freezer temperature was measured to be -10 degrees Fahrenheit. Kitchen staff also maintained temperature logs for cooling and heating appliances. LPA inspected Room 115 and 219. Bedrooms were sanitary and free of hazards. Resident bathrooms and showers contained grab bars, liquid soap, personal towels, trash cans, and non-skid mats and strips. Resident rooms contained chairs, nightstands, lamps, call systems, and beds with furnishings in good condition. “No Smoking – Oxygen in Use” signs were observed in appropriate rooms. Facility call system tests were conducted in Room 219 at 10:18 a.m. and in Room 115 at 10:37 a.m. Staff responded to each call system test within two (02) minutes. LPA also heard the receptionist announce the call lights over the intercom within one (01) minute. At approximately 10:20 a.m. and 10:40 a.m., LPA measured the water temperatures in the resident bathrooms to be 112.5 and 111.7 degrees Fahrenheit. Fire sprinklers, alarms, and extinguishers were located throughout the facility. Two (02) storage sheds outside were inaccessible as well and contained extra supplies. Three (03) out of three (03) emergency exits were unlocked. All emergency exit paths were free of hazards. Emergency chairs were observed in two (02) out of two (02) stairwells. Delayed egresses on both stairwells were tested and operational. The medication room was made inaccessible and contained a complete first aid kit, a medication refrigerator, locked medication carts, disposal bins for sharps, and locked PRN and hospice medications. A refrigerator contained residents snacks. A medication review was conducted around 12:00 p.m. Six (06) out of six (06) resident medications were stored in the correct quantities. At 12:45 p.m. LPA reviewed resident and personnel files. All files and physician orders were complete and available for audit. LPA also reviewed updated liability insurance, in-service trainings, dietitian reports, and annual fire inspection tests from 01/08/26. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 4, 2026

Allegation investigated: Staff touched client inappropriately

At approximately 9:30 a.m. on 07/01/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. Regarding the allegation "Staff touched client inappropriately" it was alleged a female nurse laid in bed with Resident #1 (R1) and stroked their hair. No additional identifying information was provided for the staff member. To investigate the allegation, LPA interviewed staff and residents between approximately 10:00 a.m. and 3:15 p.m. today, conducted a record review of pertinent records at 10:30 a.m., including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters, and toured the facility inside and out at approximately 11:00 a.m. Interview with the administrator at approximately 10:00 a.m. today revealed that there were no reports of staff touching a resident inappropriately. Interview with R1 at approximately 11:15 a.m. revealed a medication technician touched them last Thursday or Friday with R1’s consent. Unsubstantiated R1 did not have an issue with the touching and did not want it reported. Record review of the staffing schedule and interview with the administrator confirmed that there were two (02) female medication technicians on schedule for the past week. Interview with Staff #2 (S2), a medication technician, at approximately 10:45 a.m. today revealed they have never touched or laid in bed with R1. Interview with S1, the other medication technician, at 3:20 p.m. today revealed R1 often hugs them to help with their anxiety. S1 occasionally rubs R1 on their back to calm them down. S1 noted they never laid in bed with R1 or stroked their hair, and R1 never expressed discomfort with S1. Interviews with seven (07) out of seven (07) other residents revealed they have never been inappropriately touched by staff or made to feel uncomfortable. Based on interviews and record review, there was not enough evidence found during the investigation to verify that staff or anyone touched a resident inappropriately. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 31-AS-20250630191701

Allegation investigated: Facility staff are financially abusing resident

At approximately 3:00 p.m. on 04/24/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA interviewed the administrator at 3:15 p.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and financial ledgers at 3:30 p.m., and toured the facility inside and out at 3:45 p.m. Regarding the allegation "Facility staff are financially abusing resident" it was alleged that the facility is the direct Social Security Income (SSI) payee for Resident #1 (R1). Interview with the administrator revealed the facility is not R1’s payee of SSI funds. R1’s previous facility serves as their payee, and that facility sends R1’s full amount of SSI funds each month to West Hills Assisted Living. Unsubstantiated Review of R1’s admission agreement and ledger of cash resources revealed R1 is self-responsible, and R1’s full amount of SSI funds have been transferred each month since admission. The current balance listed in R1’s ledger matched the cash on hand maintained by the facility. Telephonic interview with R1 today at 3:45 p.m. revealed no pertinent information to the investigation. Based on observations, interviews, and record review, the facility assists with R1’s finances, but R1 is not being financially abused. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 31-AS-20250418143609

Type of visit: Required - 1 Year

At 8:50 a.m. on 01/17/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and later the administrator and disclosed the reason for the visit. The facility is a two-story building with private and shared bedrooms, private and public bathrooms, common areas, activity rooms, living rooms on both floors, dining room, laundry areas on both floors, and outdoor areas. It has an approved fire clearance for thirty (30) ambulatory residents and sixty (60) nonambulatory residents, of which fifteen (15) may be bedridden. Approved hospice waivers for thirty (30) residents. At 9:15 a.m. LPA reviewed resident and personnel files. All files and physician orders were complete and available for audit. LPA also reviewed updated liability insurance good through 07/01/25, in-service trainings, and passed quarterly and annual fire inspection tests from 11/19/24. LPA observed signs near the main entrance and throughout the building for COVID precautions, visitation policy, emergency disaster plan, Ombudsman contacts, confidential complaint contacts, theft and loss policy, house rules, resident rights, rights of resident councils, facility sketch with evacuation routes, daily, monthly, and alternate menus, activity schedules, emergency contacts, and nondiscrimination policy. The lobby area was clean and contained appropriate seating, visitor logs, and a reception area. The main activity room near the main entrance contained furniture in good repair, a piano, reading material, and a television. Cameras were observed common areas and exterior areas. The outdoor area was accessible from the television room. The outdoor area contained patio furniture in good repair and was shaded by umbrellas. At approximately 11:45 a.m. LPAs observed a fully charged fire extinguisher near the front lobby. It was last serviced on 02/05/2024. Another activity room near the dining room contained music, art supplies, board games, a new vending machine, and exercise equipment. The upstairs area also had a separate activity room. Public restrooms were clean and fully stocked with liquid soap, paper towels, and trash cans with tight fitting lids. The janitorial closet, storage rooms, and employee lounge were locked and inaccessible. A linen closet was also observed in the first floor hallway and contained an adequate supply of fresh sheets and beddings. The first floor laundry area was locked and contained two (02) operable washers, two (02) dryers, and detergents. Another laundry room was located on the second floor and was free of hazards. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. A daily menu and an alternate menu were posted in the dining room. Modified diet cards were posted according to updated physician orders. Emergency water and food supplies were observed in a separate room and in ample amount. At 12:10 p.m., the walk-in refrigerator and freezer temperatures were measured to be 32 degrees and -5 degrees Fahrenheit. Kitchen staff also maintained temperature logs for cooling and heating appliances. The house telephone was used to call and deemed operational at approximately 12:15 p.m. LPA inspected Room #113, 118, and 226. Bedrooms were sanitary and free of hazards. Resident bathrooms and showers contained grab bars, liquid soap, personal towels, trash cans, and non-skid mats and strips. Resident rooms contained chairs, nightstands, lamps, call systems, and beds with furnishings in good condition. “No Smoking – Oxygen in Use” signs were observed in appropriate rooms. Facility call system tests were conducted in Room #113 at 11:55 a.m. and in Room #226 at 12:37 p.m. Staff responded to each call system test within two (02) minutes. At 12:00 p.m. and 12:30 p.m., LPA measured the water temperatures in the resident bathrooms to be 117.1 and 114.8 degrees Fahrenheit. Fire sprinklers, alarms, and extinguishers were located throughout the facility. LPA also observed a designated smoking area upstairs with appropriate signage, air filters, and plants. Another designated smoking area was observed on the first floor in the rear of the facility near a gardened area. Two (02) storage sheds outside were inaccessible as well. At approximately 12:45 p.m. a carbon monoxide detector was tested and operational. Three (03) out of three (03) emergency exits were unlocked, and all emergency exit paths were free of hazards. Emergency chairs were observed in two (02) out of two (02) stairwells. Delayed egresses on both stairwells were tested and operational. The medication room was made inaccessible and contained a complete first aid kit, a medication refrigerator, a locked medication cart, and disposal bins for sharps. A medication review was conducted around 1:00 p.m. Three (03) out of three (03) resident medication supplies reviewed had correct amounts of medications to today’s date. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 21, 2025

Allegation investigated: Licensee's lack of supervision led to resident's death

At 9:00 a.m. on 12/30/24 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. Regarding the allegations above, the Department received an incident report on 09/26/23 which noted that Resident #1 (R1) and Resident #2 (R2) required medical assistance due to injuries on the morning of 09/20/2023. R1 experienced rib pain and a head laceration, and R2 was found bleeding and unresponsive. The facility later submitted R2's death report. LPA and Licensing Program Manager (LPM) Naira Margaryan conducted a case management on 09/29/23 and interviewed two (02) staff and three (03) residents between 9:00 a.m. and 11:00 a.m., reviewed records at approximately 10:15 a.m. and 11:30 a.m. including but not limited to service plans, medical assessments, incident reports, and an observation log, and toured the facility at approximately 10:40 a.m. The case was referred to the Investigations Branch on 09/29/23. Substantiated Between 10/17/23 and 03/21/24, Investigator Juan Lozano reviewed the hospital medical records of R1 and R2 and reviewed an LAFD report and an LAPD report from the 09/20/23 incident. A County Clerk death report for R2 was obtained and reviewed on 04/12/24. The case was referred to Investigator Phillipe Miles on 04/17/24. Investigator Miles interviewed additional staff between 04/17/24 and 06/05/24. Investigation findings were delivered on 07/24/24 and the facility was issued a deficiency for violating HSC §1569.312(e) Basic Service Requirements and an immediate $500 civil penalty. LPA conducted further investigation on 11/05/24 and toured the facility inside and out at 1:30 p.m., interviewed staff and residents between 1:45 p.m. and 3:30 p.m., and conducted a record review at 2:30 p.m. Today, LPA toured the facility at 9:15 a.m. Regarding the allegation "Licensee's lack of supervision led to resident's death" it was alleged the facility did not provide adequate supervision to R1 and R2 which led to R2's death. As noted on the case management report delivered on 07/24/24, record review of incident reports, service plans, and medical assessments indicated the facility was aware of R1’s and R2’s substance abuse of alcohol. Service plans indicated that facility staff would encourage both residents not to drink. Incident reports indicated the facility attempted to address R1’s substance abuse through therapy, educational physician meetings, and written and verbal warnings. The facility issued an eviction notice to R1 on 06/13/23, but R1 remained at the facility. The incident report from 09/26/23 indicated that R1 and R2 “prior to admission and during stay at [the facility] have had alcohol substance abuse issues” and that Staff #1 (S1) performed a room check on R1 and R2 “around 4 – 5 AM where everything was fine”. Interview with Staff #2 (S2) at 2:30 p.m. on 05/14/24 revealed R1 and R2 were friends, were independent, required minimal supervision, and were known to have “on and off” histories of alcohol abuse. S2 further stated that on the morning of 09/20/23, R1 walked to the medication room where S2 observed blood on R1’s shirt and a laceration on their head. After R1 was transported to the hospital, S2 searched for R2 and discovered R2 in their room with blood around them and breathing heavily. That morning, S2 had called 9-1-1 for both R1 and R2. Interview with Staff #3 (S3) at approximately 11:45 a.m. on 04/17/24 revealed R1 was verbally and physically abusive and had previously kicked S3. S3 never reported the incident to police. However, S3 did report the occasions which the room of R1 and R2 was checked, smelled of alcohol, and bottles of alcohol were discovered. Interview with Staff #4 (S4) at approximately 10:30 a.m. on 06/05/24 revealed R1 and R2 were friends who sometimes fought, drank, and smoked in the facility. S4 also stated that the nighttime staff did not check on R1 or R2 prior to the incident on 09/20/23. Review of an LAPD police report indicated that R2 was admitted to the hospital with a Blood Alcohol Content of .135 and had suffered a subdural hemorrhage. Officer Galvez interviewed R1 at the hospital at approximately 2:00 p.m. on 09/26/23. R1 told Galvez they and R2 had each drank two (02) bottles of vodka prior to the incident, though R1 denied any altercation between the two residents or any knowledge of how their injuries came about. R2 passed away on 09/23/23 after their family chose not to elect for further surgical procedures. R2’s death certificate showed “Sequelae of blunt head trauma” as their cause of death. The facility’s daily monitoring log indicated that on 09/20/23, R1 was last checked on at 6:00 a.m. and R2 was check on at 6:00 a.m. and 8:00 a.m. Based on interviews and record review, the facility did not provide sufficient care and supervision to R1 and R2. The facility was aware of R1 and R2 consuming alcohol against the house rules and of R1’s history of physical and verbal abuse. The facility did not adequately protect R2 from serious injury at the facility. Therefore, the allegation is deemed SUBSTANTIATED at this time without deficiency since a deficiency was cited during the 07/24/24 case management visit along with a $500 immediate civil penalty for a violation resulting in injury to R2. Exit interview conducted. Appeal rights discussed. Copy of report provided. Between 10/17/23 and 03/21/24, Investigator Juan Lozano reviewed the hospital medical records of R1 and R2 and reviewed an LAFD report and an LAPD report from the 09/20/23 incident. A County Clerk death report for R2 was obtained and reviewed on 04/12/24. The case was referred to Investigator Phillipe Miles on 04/17/24. Investigator Miles interviewed additional staff between 04/17/24 and 06/05/24. Investigation findings were delivered on 07/24/24 and the facility was issued a deficiency for violating HSC §1569.312(e) Basic Service Requirements and an immediate $500 civil penalty. LPA conducted futher investigation on 11/05/24 and toured the facility inside and out at 1:30 p.m., interviewed staff and residents between 1:45 p.m. and 3:30 p.m., and conducted a record review at 2:30 p.m. Today, LPA toured the facility at 9:15 a.m. Regarding the allegation "Licensee failed to do a proper assessment on a resident to ensure compatibility with the general population" it was alleged R1 had a history of violence and sexual abuse which the licensee did not properly address. Record review of R1’s Needs and Service Plan update from 11/03/22 revealed they had a history of falls and alcohol use, but there was no indication of physical violence or sexual abuse. Review of R1’s Preplacement Appraisal and Physician’s Report from 08/08/22 indicated R1 did not exhibit aggressive behavior. Interviews with staff and residents on 11/05/24 between 1:45 p.m. and 3:30 p.m. revealed no staff or residents had witnessed or experienced sexual abuse form R1. Interviews with residents revealed no residents experienced or witnessed physical abuse from R1. Interview with S3 revealed they were previously kicked by R1 after R1 had fallen while inebriated. Review of an incident report revealed that on 04/28/23, R1 kicked a door while inebriated which hit Staff #5 (S5). The facility conducted in-service trainings after each incident. Interview with S2 at 2:30 p.m. on 05/14/24 revealed R1 and R2 were “best friends” who required minimal supervision. Interview with Resident #3 (R3) at 10:45 a.m. on 09/29/23 revealed R1 and R2 were like "two peas in a pod". Based on interviews and record reviews, although there were two (02) documented incidents of R1 kicking staff while inebriated, facility and physician assessments of R1 did not indicate incompatibility with the populations of residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 30, 2024 · control 31-AS-20241101093152

Allegation investigated: Resident escaped from the facility due to lack of supervision

At approximately 10:00 a.m. on 12/19/24 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA toured the facility inside and out at 10:00 a.m., interviewed staff, a resident, and a representative between 10:05 a.m. and 10:45 a.m. today, and conducted a record review of pertinent records at 11:00 a.m., including but not limited to medical assessments, a care plan, and hospital discharge paperwork. Regarding the allegation "Resident escaped from the facility due to lack of supervision" it was alleged Resident #1 (R1) had an unsupervised fall on the street out of the facility. Record review of R1’s medical assessment revealed they were ambulatory, capable of leaving the facility unassisted, and had no cognitive impairment. Unsubstantiated Interview with R1 at 10:15 a.m. today revealed they walk outside almost every day without assistance, as they prefer. R1 noted they recently developed balance issues. R1 recalled that they had lost their balance and fallen outside of the facility, but R1 sustained no bruises or injuries from the fall. Interview with the administrator at 10:30 a.m. today confirmed R1 walks outside almost every day and does not require supervision. The administrator further noted that the facility has been working with R1 and their representative to arrange medical care necessary to fix R1’s balance issues. Interview with R1’s representative at 10:50 a.m. today confirmed the facility has sufficiently provided care and supervision in the facility for R1 and has assisted R1 in arranging medical appointments to fix their balance issues. Based on interviews and record review, the resident did not require supervision outside of the facility and was able to leave unassisted. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 31-AS-20241213164110

Allegation investigated: Illegal eviction

At approximately 9:00 a.m. on 08/13/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint inspection. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA interviewed staff at 9:30 a.m. and 9:40 a.m., toured the facility at 10:00 a.m., and conducted a records review of documents pertinent to the investigation, including but not limited to a medical assessment, service plan, and identification form. Regarding the allegation “Illegal eviction” it was alleged Resident #1 (R1) was ready to return to the facility from the hospital, and facility staff did not allow R1 to return. Interview with Staff #1 (S1) revealed they visited R1 at the hospital on 08/07/24 to reassess their needs and ensure they were suitable for readmission to the facility. It was discovered that R1 had contracted a communicable disease which was potentially infectious to other residents. Therefore, the facility did not readmit R1 at that time. Unsubstantiated Interview with the hospital staff at 3:10 p.m. today confirmed that R1 was not ready for discharge when S1 visited and the hospital would provide care for R1 until their infectious period had passed. Interview with S2 confirmed that the facility designated a room for quarantine after R1’s return to ensure the health and safety of all facility residents. Based on interviews and record review, the facility did not evict R1 but instead waited for R1 to become suitable for readmission. Therefore, the allegation is deemed UNSUBSTANTIATED at this time, No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 13, 2024 · control 31-AS-20240809155427

Type of visit: Required - 1 Year

At 9:00 a.m. on 08/07/2024, Licensing Program Analysts (LPA) Nicholas Reed and Abeye Duguma conducted an unannounced annual visit. LPAs met with Staff #1 (S1) and disclosed the reason for the visit. LPAs and S1 toured the facility inside and out. A file review was conducted prior to today’s visit. The facility was last visited on 07/24/2024 for a case management visit. It is a two story building with private and shared bedrooms, private and public bathrooms, common areas, activity room, living rooms on both floors, dining room, laundry areas on both floors, and outdoor areas. It has an approved fire clearance for thirty (30) ambulatory residents and sixty (60) nonambulatory residents, of which fifteen (15) may be bedridden. Approved hospice waivers for thirty (30) residents. Upon entry, LPAs observed signs for COVID precautions, visitation policy, emergency disaster plan, Ombudsman contacts, confidential complaint contacts, theft and loss policy, house rules, resident rights, rights of resident councils, facility sketch with evacuation routes, menus, activity schedules, emergency contacts, and nondiscrimination policy. The lobby area was clean and contained appropriate seating. LPAs observed residents in the television room near the main entrance engaged in the morning activity routine with the Activity Director. The television room contained furniture in good repair, a piano, and a television. The outdoor area was accessible from the television room. The outdoor area contained patio furniture in good repair and was shaded by umbrellas. At approximately 10:05 a.m. LPAs observed a fully charged fire extinguisher near the lobby. It was last serviced on 02/21/2024. The medication room was inaccessible to persons in care. The medication room contained a complete first aid kit, a medication refrigerator, a locked medication cart, a separate refrigerator for snacks and drinks, and disposal bins for sharps. The activity room contained music, art supplies, board games, and exercise equipment. Cameras were observed in hallways and common areas. Public restrooms were clean and fully stocked with liquid soap, paper towels, and trash cans with tight fitting lids. The janitorial closet, storage rooms, and employee lounge were locked and inaccessible. A linen closet was also observed in the hallways and contained an adequate supply of fresh sheets and beddings. Bedrooms were sanitary and free of hazards. Resident bathrooms and showers contained sturdy grab bars, commodes, liquid soap, personal towels, and non-skid mats. Resident rooms contained chairs, nightstands, lamps, call systems, and beds with furnishings in good condition. “No smoking – Oxygen in use” signs were observed in appropriate rooms. LPAs observed an adequate supply of perishable and non-perishable foods in the kitchen. A daily menu and an alternate menu were posted in the dining room. Modified diet cards were posted. Emergency water and food supplies were observed in separate store rooms. The hood was last cleaned and certified on 07/05/24. Sharps and cleaning solutions were locked and stored separately from food supplies. At 10:30 a.m. the walk-in refrigerator temperature was measured to be 32 degrees Fahrenheit. The walk-in freezer temperature was measured to be 10 degrees Fahrenheit at 10:30 a.m. and 0 degrees Fahrenheit at 3:00 p.m. S1 explained that the high volume of use during meal preparation hours attributes to an increased temperature. No food was observed to be spoiled or unsafe. A deficiency is cited on the corresponding LIC 809-D page for the freezer being above the regulatory temperature. The house telephone was tested around 10:45 a.m. and deemed operational. The laundry room was located behind the activity room. It contained 4 operable machines. An additional laundry area was located upstairs for residents to use. Detergents were locked and inaccessible. Fire sprinklers, alarms, and extinguishers were located throughout the facility. LPAs also observed a designated smoking area upstairs with appropriate signage, air filters, and plants. At approximately 11:15 a.m. a carbon monoxide detector was tested and operational. At approximately 11:30 a.m. and 11:40 a.m., pull cords in Rooms 211 and 103 were tested and deemed operational. Water temperatures were measured to be 109.5 and 113.1 degrees Fahrenheit. Outside, LPAs observed a gardening area and a designated smoking area. Around 11:45 a.m. S1 stated a vehicle recently crashed into a perimeter wall, so the facility placed objects around the broken wall area to maintain resident safety. Three (03) out of three (03) emergency exits were unlocked, and all emergency exit paths were free of hazards. Emergency chairs were observed in two (02) out of (02) stairwells. LPAs conducted a record review at approximately 12:00 p.m. of resident and personnel files. All required documents were up to date and readily available for inspection. Recent fire tests and drills and updated liability insurance were also reviewed. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 7, 2024

Type of visit: Case Management - Deficiencies

At approximately 10:15 a.m. on 07/24/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with Co-Administrator Ed Galang and Director Chris Salvador and disclosed the reason for the visit. Today’s case management visit is a subsequent visit to deliver findings from the 09/29/23 case management visit conducted by LPA Reed and Licensing Program Manager (LPM) Naira Margaryan. On 09/26/23 the facility submitted an incident report in which Resident #1 (R1) and Resident #2 (R2) required medical assistance due to injuries on the morning of 09/20/2023. R1 experienced rib pain and a head laceration, and R2 was found bleeding and unresponsive. The facility later submitted R2's death report. LPA and LPM conducted an initial visit on 09/29/23 and interviewed two (02) staff and three (03) residents between 9:00 a.m. and 11:00 a.m., reviewed records at approximately 10:15 a.m. and 11:30 a.m. including but not limited to service plans, medical assessments, incident reports, and an observation log, and toured the facility at approximately 10:40 a.m. The case was referred to the Investigations Branch on 09/29/23. Between 10/17/23 and 03/21/24, Investigator Juan Lozano reviewed the hospital medical records of R1 and R2 and reviewed an LAFD report and an LAPD report from the 09/20/23 incident. A County Clerk death report for R2 was obtained and reviewed on 04/12/24. The case was referred to Investigator Phillipe Miles on 04/17/24. Investigator Miles interviewed additional staff between 04/17/24 and 06/05/24. Record review of incident reports, service plans, and medical assessments indicated the facility was aware of R1’s and R2’s substance abuse of alcohol. Service plans indicated that facility staff would encourage both residents not to drink. Incident reports indicated the facility attempted to address R1’s substance abuse through therapy, educational physician meetings, and written and verbal warnings. The facility issued an eviction notice to R1 on 06/13/23, but R1 remained at the facility. The incident report from 09/26/23 indicated that R1 and R2 “prior to admission and during stay at [the facility] have had alcohol substance abuse issues” and that Staff #1 (S1) performed a room check on R1 and R2 “around 4 – 5 AM where everything was fine”. Interview with Staff #2 (S2) at 2:30 p.m. on 05/14/24 revealed R1 and R2 were friends, were independent, required minimal supervision, and were known to have “on and off” histories of alcohol abuse. S2 further stated that on the morning of 09/20/23, R1 walked to the medication room where S2 observed blood on R1’s shirt and a laceration on their head. After R1 was transported to the hospital, S2 searched for R2 and discovered R2 in their room with blood around them and breathing heavily. That morning, S2 had called 9-1-1 for both R1 and R2. Interview with Staff #3 (S3) at approximately 11:45 a.m. on 04/17/24 revealed R1 was verbally and physically abusive and had previously kicked S3. S3 never reported the incident to police. However, S3 did report the occasions which the room of R1 and R2 was checked, smelled of alcohol, and bottles of alcohol were discovered. Interview with Staff #4 (S4) at approximately 10:30 a.m. on 06/05/24 revealed R1 and R2 were friends who sometimes fought, drank, and smoked in the facility. S4 also stated that the nighttime staff did not check on R1 or R2 prior to the incident on 09/20/23. Review of an LAPD police report indicated that R2 was admitted to the hospital with a Blood Alcohol Content of .135 and had suffered a subdural hemorrhage. Officer Galvez interviewed R1 at the hospital at approximately 2:00 p.m. on 09/26/23. R1 told Galvez they and R2 had each drank two (02) bottles of vodka prior to the incident, though R1 denied any altercation between the two residents or any knowledge of how their injuries came about. R2 passed away on 09/23/23 after their family chose not to elect for further surgical procedures. R2’s death certificate showed “Sequelae of blunt head trauma” as their cause of death. The facility’s daily monitoring log indicated that on 09/20/23, R1 was last checked on at 6:00 a.m. and R2 was check on at 6:00 a.m. and 8:00 a.m. Based on interviews and record review, the facility did not provide sufficient care and supervision to R1 and R2. The facility was aware of R1 and R2 consuming alcohol against the house rules. The facility was also aware of R1’s history of physical and verbal abuse. Therefore, the facility did not adequately protect R2 from serious injury at the facility. A deficiency is cited on the corresponding LIC 809-D page. A $500 immediate civil penalty is assessed today for a violation resulting in injury to R2. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. Appeal rights discussed. Civil penalties issued. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Jul 26, 2024

§1569.312 Basic services requirements Every facility... shall provide... the following basic services: (e) Monitoring the activities of the residents ... to ensure their general health, safety, and well-being. This requirment was not met as evidenced by: The licensee did not comply with the section cited above in one (01) out of approximately fifty-two (52) residents which posed an immediate risk to the Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2024

Plan of correction: Licensee has agreed to provide an in-service training for staff on managing aggrsssive behaviors and submit proof by POC due date.

Allegation investigated: Resident was allowed to leave the facility unassisted resulting in injury

On 5/30/2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator, Chris Salvador. LPA explained the purpose of this visit was to conduct interviews and present findings. LPA conducted a physical tour at 12:45 pm until 1:00 pm. LPA observed the facility was clean and did not observe any safety issues. The investigation consisted of the following: On 06/21/2023, LPA Spaeth initiated a complaint investigation. LPA reviewed resident file and received copies of the documentation. LPA Spaeth also interviewed six residents. LPA Spaeth interviewed four staff members via phone call on 5/29/2024 at 3:00 pm until 4:00 pm. Regarding the allegation, Resident was allowed to leave the facility unassisted resulting in injury, it is alleged that a resident (R1) was allowed to leave the facility unassisted and walked to the store. LPA Spaeth reviewed the Physician’s Report for R1 dated 03/31/2022. The report states R1 can leave the facility unassisted. Unsubstantiated Also it is alleged that R1 fell two times walking to the store as of December, 2023 and sustained injuries. The first fall resulted in R1 having bruises on R1’s face. The second fall resulted in a passer by finding the resident on the ground and an ambulance called. Three out of twenty staff members were interviewed and stated R1 did not leave the facility during December, 2023 and R1 did not have any injuries during that month. The three staff stated if a resident is injured, an Incident Report is completed and the Administrator is notified. All three staff stated there is no incident report regarding R1 falling during December 2023. The three staff members confirmed R1 would occasionally leave the facility to walk a few blocks to a grocery store to purchase a soda. On 2/24/2023, R1 left the facility between 10:30 pm and 10:45 pm. R1 did not sign out and did not inform staff R1 was leaving. S3 and S4 work the night shift and stated they check each residents’ rooms every two hours. At the 9:00 pm check, S3 and S4 observed R1 was asleep in R1’s room. During the 11:00 pm check, S3 and S4 discovered R1 was not in bed. Both staff members checked the entire facility and did not find R1. S3 and S4 also stated they woke R1’s roommate (R2). R2 stated did not see R1 walk out of the room. The Administrator and another staff member (S1) were immediately contacted. S1 immediately drove to the facility and drove throughout the neighborhood searching for R1. Other staff members joined the search but R1 was not found. Staff members searched for R1 from 11:30 pm until 4:00 am. The Administrator confirmed they assisted with the search & confirmed staff followed protocol. The local police department was contacted around 1:00 am and the local hospital was contacted but hospital staff confirmed R1 was not at the hospital. A staff member contacted another hospital and discovered R1 had been found by another source and was admitted to the hospital. LPA interviewed six residents on 6/21/2023 from 12:00 pm until 1:00 pm. The six residents’ rooms are on the second floor and all confirmed they did not witness a resident leaving the facility the evening of 2/24/2023. LPA received copies of the residents’ Physician’s Report and observed the six residents (R2, R3, R4, R5, R6 and R7) are able to leave the facility unassisted. All six residents confirmed when leaving the facility, residents are asked to sign out and inform staff of their destination. R2, R3, R4, R5, R6 and R7 stated there has been no issues when leaving the facility. Based upon LPA’s documentation review and interviews of staff and residents, the above allegation is unsubstantiated. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, May 30, 2024 · control 31-AS-20230614111602

Allegation investigated: Financial abuse

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit and met with Director of Operations Chris Salvador and informed him the reason of the visit. The reason of the visit was to deliver the final findings of the allegation mentioned above. The following was determined. It was alleged that staff financially abused a resident. On 07/07/2022, from 10am to 230pm, LPA conducted the initial visit, obtained documents pertaining to the allegation, and conducted interviews. During today’s visit, LPA obtained additional documents and interviewed staff. From the information obtained, resident # 1 (R1) complained to Administration that (R1) was not receiving (R1’s) money from staff. Upon the facility’s internal investigation, it was revealed to LPA, that (R1) gave staff (R1’) s debit card and pin number to withdraw funds from (R1’s) account. It was alleged staff was not providing receipts of the withdrawals, nor was staff giving the money to (R1). Once (R1) began complaining, and documentation revealed that there was an excessive amount of money being withdrawn, Administration interviewed the staff, who denied keeping the funds. Administration contacted the police and Licensing to report potential financial abuse. The local police Unsubstantiated department also interviewed staff and (R1), but because (R1) gave the consent and pin to staff to withdraw money, there was no further action taken. Administration conducted a room search of (R1), and staff found over $4000 in the drawer of (R1). Staff denied to LPA and Administrators, taking R1's funds. Although, (R1’) money was found and returned to (R1), there is insufficient evidence, due to (R1) providing the personal banking information to staff. Therefore, based on documentation of records, and interviews, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Apr 16, 2024 · control 31-AS-20220706113627

Allegation investigated: Facility staff are refusing to accept resident back after hospitalization Facility staff are not returning resident's responsible parties' phone calls

At 8:30 a.m. on 01/17/2024 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA interviewed Staff #1 (S1) at 8:45 a.m., Staff #2 (S2) at 9:00 a.m., Staff #3 (S3) at 9:15 a.m., Staff #4 (S4) at 9:45 a.m., Resident #1 (R1) at 10:15 a.m., and R1’s responsible party at 12:45 p.m., toured the facility at 10:00 a.m., and reviewed pertinent records including but not limited to physician’s reports, a face sheet, identification form, needs and service plan, and medical notes at 10:30 a.m. today. Regarding the allegation “Facility staff are refusing to accept resident back after hospitalization” it was alleged the facility did not accept R1 back to the facility on 01/04/2024. Interview with S3 revealed R1 experienced a change of condition in the hospital. Unsubstantiated S2 notified the hospital on 01/04/24 and 01/05/24 that in order to remain in compliance with Title 22 regulations, the facility needed to arrange home health for R1 prior to readmitting them. S3 visited the hospital on 01/09/24 to reassess R1 and arrange for proper documentation and home health support. The hospital updated R1’s records, arranged for home health services, and discharged R1 on 01/12/24. Based on interviews and record review, the facility was unable to readmit R1 without updated documentation reflecting R1’s change of condition and home health services. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility staff are not returning resident's responsible parties' phone calls” it was alleged the facility did not inform R1’s responsible party of their change of condition. Interview with R1’s responsible party revealed they told the facility to send R1 to the hospital on 01/02/24. R1 was readmitted to the facility on 01/12/24. S3 spoke with R1’s responsible party on 01/04/24 and 01/05/24. The responsible party sent S3 an email at approximately 6:30 p.m. on 01/06/24. S4 sent the responsible party emails on 01/02/24, 01/03/24, 01/09/24 and 01/10/24. Based on interviews and record review, the facility properly informed R1’s responsible party of their condition via email. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety hazards were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 17, 2024 · control 31-AS-20240109152040