West Hills Assisted Living

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. UnsubstantiatedRead the full finding— CDSS inspection report, April 24, 2025 · control 31-AS-20250418143609

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 0Read the full finding— CDSS inspection report, December 30, 2024 · control 31-AS-20241101093152

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. UnsubstantiatedRead the full finding— CDSS inspection report, December 19, 2024 · control 31-AS-20241213164110

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 aRead the full finding— CDSS inspection report, August 13, 2024 · control 31-AS-20240809155427

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 PhysicRead the full finding— CDSS inspection report, May 30, 2024 · control 31-AS-20230614111602

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 complaininRead the full finding— CDSS inspection report, April 16, 2024 · control 31-AS-20220706113627

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. UnsubstantiatedRead the full finding— CDSS inspection report, January 17, 2024 · control 31-AS-20240109152040

At 11:00 a.m. on 11/02/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the Administrator and Director and disclosed the reason for the visit. Regarding the allegation “Staff are unlawfully evicting resident”, it was alleged the eviction Resident #1 (R1) was unlawful and R1 did not receive an eviction notice.\ To investigate the allegation above, LPA conducted a file review at 9:45 a.m. today, interviewed staff between 11:00 a.m. and 12:00 p.m., and toured the facility at 11:45 a.m. No immediate health or safety hazards were noted during the time of this visit. UnsubstantiatedRead the full finding— CDSS inspection report, November 2, 2023 · control 31-AS-20231031144549

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Chris Salvador, and care coordinator, Mike Dy, and advised them of the complaint. Today's investigation consisted of interviews with residents and staff, and a physical plant inspection, which were conducted between 9:15am to 11:15am. A record review between 11:15am and 12:30pm was also made. Staff do not maintain facility in good repair: In regards to the allegation, it was reported that Resident 1's (R1) room is really hot. Room temperature is not maintained in a comfortable level. R1 has asked for a change of the air conditioning (AC) unit because the AC in their room is very old and does not work properly. During the course of the investigation, LPA conducted a physical plant inspection. The building is two stories. LPA inspected five (5) of five (5) resident rooms on the first floor, and five (5) of five (5) resident rooms oRead the full finding— CDSS inspection report, July 28, 2023 · control 31-AS-20230721144737

On 06/26/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit for the above allegation. LPA arrived at the facility at 10:05 a.m. and was greeted by staff #1(S1) at reception. S1 called the Director of Operation/Administrator Chris Salvador. LPA explained to Chris the purpose of the visit. Entrance interview conducted. At 10:26 a.m. LPA and Chris conducted a physical plant tour to ensure the health and safety of the residents in care. No issues or concerns were observed. From 10:31 a.m. to 11:30 a.m. LPA interviewed at random six (6) out of fifty-four (54) residents. From 11:31 a.m. to 2:00 p.m. LPA reviewed resident records and obtained documents relevant to this investigation and reviewed the facility Program submitted to Community Care Licensing (CCL). Allegation: Facility does not provide residents transportation to medical appointment. It is alleged a resident has not been provided transportation to their medical appointments and that instead aRead the full finding— CDSS inspection report, June 26, 2023 · control 31-AS-20230621164128

At 9:00 a.m. on 03/23/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with a facility representative and disclosed the reason for the visit. At 9:10 a.m. LPA toured the facility and observed no immediate health or safety concerns. At 10:10 a.m. LPA spoke with the Administrator on the phone. The Administrator stated the facility representative could sign licensing documents in their absence. Staff did not refill resident’s medication on time Regarding the allegation above, it was alleged Resident #1 (R1) did not have their medication refilled before it ran out. LPA conducted a records review on 10/26/22 at 2:30 p.m. Facility documents revealed that R1’s medication arrived on the scheduled day. LPA interviewed facility Director on 08/02/2022 around 10:45 a.m., a facility med tech on 08/02/2022 at 12:43 p.m., and R1’s doctor and pharmacy technician on 10/14/2022 from 3:30 p.m. to 4:30 p.m. UnsubstantiatedRead the full finding— CDSS inspection report, March 23, 2023 · control 31-AS-20220726164145

At 9:00 a.m. on 03/23/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with a facility representative and disclosed the reason for the visit. At 9:10 a.m. LPA toured the facility and observed no immediate health or safety concerns. At 10:10 a.m. LPA spoke with the Administrator on the phone. The Administrator stated the facility representative could sign licensing documents in their absence. Staff did not ensure resident received their mail while in care. Regarding the allegation above, it was alleged Resident #1 (R1) did not receive their mail. LPA interviewed residents and staff on 12/29/2022 from 1:50 p.m. to 3:00 p.m. Staff and Director stated mail gets delivered to the front desk. It is then sorted into individual mailboxes. The mail is either delivered to residents, or residents pick up their mail at the front desk. UnsubstantiatedRead the full finding— CDSS inspection report, March 23, 2023 · control 31-AS-20221227105313

At 9:00 a.m. on 03/23/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with a facility representative and disclosed the reason for the visit. At 9:10 a.m. LPA toured the facility and observed no immediate health or safety concerns. At 10:10 a.m. LPA spoke with the Administrator on the phone. The Administrator stated the facility representative could sign licensing documents in their absence. Regarding the allegation above, it was alleged the fan in the bathroom of Resident #1 (R1) was broken. LPA and R1 inspected the fan on 12/29/2022 at 2:15 p.m. R1 turned the switch on and the fan did not operate. LPA interviewed R1 and the Director on 12/29/2022 from 1:50 p.m. to 3:00 p.m. R1 stated they did not report the issue to the facility. The Director confirmed no reports for maintenance were received. LPA informed the Director about the required maintenance at approximately 2:45 p.m. on 12/29/2022, and the Director immediately sRead the full finding— CDSS inspection report, March 23, 2023 · control 31-AS-20221228083700

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 9:20 am to deliver findings. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator was contacted and arrived later. During initial visit, on 12/22/2022, LPA Smith conducted tour of physical plant at 11:40 am, conducted interviews with administrators and requested documents relevant to the investigation. LPA Smith made a subsequent visit to this facility on 01/31/23. From 12:40 pm-3:00 pm, LPA interviewed six (6) staff, five (5) residents, conducted a physical plant tour and requested pertinent documents at 12:45 PM. LPA was unable to interview Resident #1 (R1) due to time constraints. The following two out of three allegations for Complaint Control #: 31-AS-20221221094559: Facility staff are allowing residents to smoke inside the facility Facility air conditioning is in disrepair was delivered on 01/31/23 and both allegations were UNSUBSTANTIATEDRead the full finding— CDSS inspection report, March 9, 2023 · control 31-AS-20221221094559

***This report was amended to change the findings of the allegation "Facility is in disrepair"**** At approximately 9:15 a.m. on 03/02/2023, 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. --- Facility is in disrepair --- LPA interviewed staff and residents from 9:45 a.m. to 11:30 a.m. LPA conducted a records review at 9:55 a.m. and toured the physical plant at approximately 10:25 a.m. No immediate health or safety concerns were observed. Regarding the allegation above, it was alleged the facility did not have hot water for four days. From record review, the facility notified Community Care Licensing (CCL) of the maintenance via email. UnsubstantiatedRead the full finding— CDSS inspection report, March 2, 2023 · control 31-AS-20230228114452

At approximately 3:15 p.m. on 02/08/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. Regarding the allegation above, it was alleged Resident #1 (R1) is being unlawfully evicted. LPA conducted a file review at 1:45 p.m., interviewed staff at 4:05 p.m., and toured the facility at 3:30 p.m. From file review, the facility notified Community Care Licensing in a timely manner of R1’s eviction on 08/19/2022. R1 was notified of the eviction. The Los Angeles Sherriff’s Department posted R1’s Notice to Vacate on 01/14/2023. Based on file review, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Appeal rights discussed. Copy of report provided. UnsubstantiatedRead the full finding— CDSS inspection report, February 8, 2023 · control 31-AS-20230203152728

Licensing Program Analyst (LPA) Tihesha Smith made a subsequent unannounced complaint visit to this facility and met with administrator and explained the purpose of this visit. During initial visit, on 12/22/2022, LPA Smith conducted tour of physical plant at 11:40 am, conducted interviews with administrators and requested documents relevant to the investigation. Facility staff are allowing residents to smoke inside the facility. At approximately 12:40 pm-3:00 pm LPA interviewed six (6) staff, five (5) residents conducted a physical plant tour and requested pertinent documents at 12:45 PM. LPA unable to interview Resident #1 (R1) due to time contraints. LPA interview with five (5) out of five (5) residents revealed they have not smoked or seen any residents (Cont to 809C) UnsubstantiatedRead the full finding— CDSS inspection report, January 31, 2023 · control 31-AS-20221221094559

At 1:35 p.m. on 01/04/2023 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the Administrator designee and disclosed the reason for the visit. LPA toured the facility and observed no immediate health or safety concerns. LPA interviewed the Administrator designee at 1:45 p.m. and conducted another file review at 1:55 p.m. Regarding the allegation “Facility does not have a certified administrator”, it was alleged the administrator designee served as the facility administrator duties without proper certification. From file review, the administrator designee was not listed in Community Care Licensing’s (CCL) list of pending and active Administrator certificate. The administrator designee did not have an active certificate. The designee explained that the licensees Ginger and Jeffrey Po maintained active administrator certificates. LPA confirmed this to be true from a 1:55 p.m. file review of the CCL website. UnsubstantiatedRead the full finding— CDSS inspection report, January 4, 2023 · control 31-AS-20221230080630