Ivy Park at Santa Monica

Allegation investigated: Licensee does not ensure that residents are able to sleep at night Licensee does not ensure facility plumbing is maintained in good repair

***This report supersedes the original report delivered on 11/21/2025. On 4/7/2026, Licensing Program Analyst (LPA) Bernadette Allen arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 11/21/2025. *** On 11/21/2025, at 9:45AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a complaint investigation and deliver findings for the alleged allegations. LPA identified herself and met Clifton Douyon -Administrator who was informed of the purpose of the visit. On 11/21/2025 LPA requested and obtained a staff roster dated 8/27/2025 and resident roster dated 11/19/2025. LPA conducted interviews with staff members 1-5 (S1-S5) and Residents 1-8 (R1-R8) The Investigation consisted of the following: Continued..... Unsubstantiated LPA requested copies of the following documents for Resident 1(R1) admissions agreement dated 6/30/2025, customer agreement dated 7/7/2025, physicians report dated 6/23/2025, plumbing invoice for repairs dated 10/6/2025 and 10/18/2025, and proof of credit/refund for inconvenience for R1 dated 10/16/2025. LPA reviewed email correspondence reviewed between residents and/or responsible parties regarding renovations being conducted with details of changes, projected timeline 7PM- 3AM, and floor order of work dated 9/23/2025,10/24/2025 and a copy of the Notice dated 9/23/2025. LPA also toured the facility and observed renovations had been done throughout the facility painted walls and new carpet/flooring. The investigation revealed the following: Allegation 1: Licensee does not ensure that residents are able to sleep at night On 11/21/2025, LPA interviewed staff members S1–S5. All five staff confirmed that residents and their responsible parties were informed about the renovations both verbally and through written correspondence/email. They also received the Executive Director’s update notice dated 9/23/2025, which outlined the details of the building changes, the projected timeline (7:00 PM–3:00 AM) to minimize disruption and foot traffic), and the work schedule for each floor. Staff acknowledged that there was intermittent noise during the renovation hours of 7:00 PM–3:00 AM, and some residents expressed complaints. However, residents indicated they understood the circumstances and did not report being unable to sleep; staff confirmed that residents were able to rest despite the noise and efforts were made to minimize disruptions during nighttime hours to ensure residents could sleep. The interviews with Resident 1-8 (R1-R8) were as follows, LPA attempted to interview R1 who no longer reside at the facility, R2 stated that they had no problems with sleeping in the evening, R3 was on their way to an appointment and unwilling to talk. Continued Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Clifton Douyon - Administrator at conclusion of the visit with appeal rights. Residents R4, R5, R6, R7, and R8 reported that their sleep was occasionally interrupted due to the renovations. However, they understood the reason for the disturbance and stated that although there was some nighttime noise, they were still able to sleep. They also noted that staff and workers made efforts to minimize disruptions during the night. Allegation 2- Licensee does not ensure facility plumbing is maintained in good repair On 11/21/2025 LPA conducted interviews with staff members 1-5 (S1-S5) and 5 out of 5 staff members stated when plumbing issues occur in the building the plumber is called and scheduled for service. LPA also received documentation of the plumbing service conducted on 9/2/2025, 9/3/2025, 9/13/2025, 9/16/2025, and 10/3/2025 including correspondence confirming relocation of R1 into another room along with refund/credit for concession/ inconvenience dated 10/27/2025. The interviews with Resident 1-8 (R1-R8) were as follows. LPA attempted to interview R1 who no longer reside at the facility, R2 stated that they could not remember having any plumbing problems and R3 was on their way to an appointment and unwilling to talk. The interviews with R4, R5, R6, R7 and R8 stated that they have not had any problems with plumbing in their rooms and if they did have plumbing problems management would be informed and they all expressed confidence that repairs would be made immediately. CONTINUEDthe state’s words, verbatim · CDSS document, Apr 7, 2026 · control 11-AS-20251117102758

Allegation investigated: Licensee does not ensure that residents are able to sleep at night Licensee does not ensure facility plumbing is maintained in good repair

***This report supersedes the original report delivered on 11/21/2025. On 1/07/2026, Licensing Program Analyst (LPA) Bernadette Allen arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 11/21/2025. *** On 11/21/2025, at 9:45AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a complaint investigation and deliver findings for the alleged allegations. LPA identified herself and met Clifton Douyon -Administrator who was informed of the purpose of the visit. On 11/21/2025 LPA requested and obtained a staff roster dated 8/27/2025 and resident roster dated 11/19/2025. LPA conducted interviews with staff members 1-5 (S1-S5) and Residents 1-8 (R1-R8). LPA requested copies of the following documents for Resident 1(R1) admissions agreement dated 6/30/2025, customer agreement dated 7/7/2025, physicians report dated 6/23/2025, plumbing invoice for repairs dated 10/6/2025 and 10/18/2025, and proof of credit/refund for inconvenience for R1 dated 10/16/2025. Unsubstantiated email correspondence between residents and/or responsible parties regarding renovations being conducted with details of changes, projected timeline, and floor order of work dated 9/23/2025,10/24/2025 and a copy of the Notice dated 9/23/2025. LPA also toured the facility and observed renovations had been done throughout the facility painted walls and new carpet/flooring. The investigation consisted of the following: Allegation 1: Licensee does not ensure that residents are able to sleep at night On 11/21/2025 LPA conducted interviews with staff members 1-5 (S1-S5) and 5 out of 5 staff members stated residents and their responsible parties were informed verbally and by correspondence/email and also provided with the executive director update notice dated 9/23/2025 of the renovations being conducted with details of changes, projected timeline, and floor order of work dated 9/23/2025. Staff also acknowledged some residents did have complaints but understood, under the circumstances, and were made aware of the community cosmetic updates being done and the staff /workers made efforts to minimize disruptions during the night to ensure residents could get sleep at night. The interviews with Resident 1-8 (R1-R8) were as follow, LPA attempted to interview R1 and they no longer reside at the facility, R2 stated that they could not remember anything and R3 was on their way to an appointment and was unwilling to talk. Interviews with residents R4, R5, R6, R7 and R8 revealed that they did not initially recall receiving a notice about the renovations. However, when shown the Executive Director’s update dated 09/23/2025, all five (5) residents acknowledged seeing the notice posted throughout the facility. They also recalled being verbally informed on several occasions about the changes taking place. Residents R4, R5, R6, R7and R8 reported that their sleep was occasionally interrupted due to the renovations but understood the reason for the disturbance and stated although there was some nighttime noise they were able to sleep, and staff/workers made efforts to minimize disruptions during the night. Continued Allegation 2- Licensee does not ensure facility plumbing is maintained in good repair On 11/21/2025 LPA conducted interviews with staff members 1-5 (S1-S5) and 5 out of 5 staff members stated when plumbing issues occur in the building the plumber is called and scheduled for service. LPA also observed documentation of the plumbing service conducted on 10/6/2025 and 10/18/2025 including correspondence confirming relocation of R1 into another room along with refund/credit for inconvenience. The interviews with Resident 1-8 (R1-R8) were as followed, LPA attempted to interview R1 who no longer reside at the facility, R2 stated that they could not remember having any plumbing problems and R3 was on their way to an appointment and unwilling to talk. The interviews with R4, R5, R6, R7 and R8 stated that they have not had any problems with plumbing in their rooms and if they did management would be informed and expressed confidence repairs would be made immediately. Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Clifton Douyon - Administrator at conclusion of the visit with appeal rights. Clifton was unavailable to sign the report but Solaange Nkafu was authorized to sign the reportthe state’s words, verbatim · CDSS document, Jan 7, 2026 · control 11-AS-20251117102758

Allegation investigated: Licensee does not ensure that residents are able to sleep at night Licensee does not ensure facility plumbing is maintained in good repair

On 11/21/2025, at 9:45AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a complaint investigation and deliver findings for the alleged allegations. LPA identified herself and met Clifton Douyon -Administrator who was informed of the purpose of the visit. On 11/21/2025 LPA requested and obtained a staff roster dated 8/27/2025 and resident roster dated 11/19/2025. LPA conducted interviews with staff members 1-5 (S1-S5) and Residents 1-8 (R1-R8). LPA requested copies of the following documents for Resident 1(R1) admissions agreement dated 6/30/2025, customer agreement dated 7/7/2025, physicians report dated 6/23/2025, plumbing invoice for repairs dated 10/6/2025 and 10/18/2025, and proof of credit/refund for inconvenience for R1 dated 10/16/2025, email correspondence between residents and/or responsible parties regarding renovations being conducted with details of changes, projected timeline, and floor order of work dated 9/23/2025,10/24/2025 and a copy of the Notice dated 9/23/2025. LPA also toured the facility and observed renovations had been done throughout the facility painted walls and new carpet/flooring. Unsubstantiated The investigation consisted of the following: Allegation 1: Licensee does not ensure that residents are able to sleep at night On 11/21/2025 LPA conducted interviews with staff members 1-5 (S1-S5) and 5 out of 5 staff members stated residents and their responsible parties were informed verbally and by correspondence/email and also provided with the executive director update notice dated 9/23/2025 of the renovations being conducted with details of changes, projected timeline, and floor order of work dated 9/23/2025. Staff also acknowledged some residents did have complaints but understood, under the circumstances, and were made aware of the community cosmetic updates being done. The interviews with Resident 1-8 (R1-R8). LPA attempted to interview R1 and they no longer reside at the facility, R2 stated that they could not remember anything and R3 was on their way to an appointment and was unwilling to talk. The interviews with R4, R5, R6, R7 and R8 stated that they couldn’t remember getting a notice informing them of the renovations but when they were shown the executive director update notice dated 9/23/2025 and 5 out of 5 residents acknowledged seeing it throughout the facility and they did recall being informed verbally on several occasions about changes being made inside the facility. R4-R8 also acknowledged their sleep had been interrupted at times but understood it was because of the updates being done inside the facility. Allegation 2- Licensee does not ensure facility plumbing is maintained in good repair On 11/21/2025 LPA conducted interviews with staff members 1-5 (S1-S5) and 5 out of 5 staff members stated when plumbing issues occur in the building the plumber is called and scheduled for service. LPA also observed documentation of the plumbing service conducted on 10/6/2025 and 10/18/2025 including correspondence confirming relocation of R1 into another room along with refund/credit for inconvenience. The interviews with Resident 1-8 (R1-R8). LPA attempted to interview R1 and they no longer reside at the facility, R2 stated that they could not remember anything and R3 was on their way to an appointment and unwilling to talk. The interviews with R4, R5, R6, R7 and R8 stated that they have not had any problems with plumbing in their rooms. Continued ..... Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Clifton Douyon - Administrator at conclusion of the visit with appeal rights. Clifton was unavailable to sign the report but Solaange Nkafu was authorized to sign the reportthe state’s words, verbatim · CDSS document, Nov 21, 2025 · control 11-AS-20251117102758

Type of visit: Required - 1 Year

On 9/17/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct an annual required inspection visit. LPA Allen met with Clifton Douyon Administrator who was informed of the purpose of the visit. The facility is licensed to serve (100) elderly adults ages 60 and above, of which (80) can be non-ambulatory and (20) Bedridden. The facility has an approved hospice waiver for (10). The facility is a three story building located in a residential neighborhood and consist of the following: Seventy (70) apartment units with attached bathrooms, open patio area in front of the facility, and three patio areas in the back of facility, two of which are on the second and third floor balconies, salon, two living rooms, restaurant style dining room, two bistro areas, 3 activity rooms and several staff offices on first and second floor. LPA Allen and Clifton toured the physical plant which included the inspection of (6) rooms and (6) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed and the bathrooms were in good condition and operational. LPA Allen reviewed seven (7) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings which all appeared to be current. LPA Allen reviewed seven (7) resident files for admission agreements, updated physician reports, and needs and services plans which all appeared to be current. Continued LPA Allen conducted a random audit for four (4) residents’ Medication Administration Records (MARs) which appeared that residents medications are being dispensed as prescribed by their physician, centrally stored and properly locked. During the tour LPA Allen observed the facility to be free of obstruction, sanitary, and appropriately furnished. Storage areas for personal hygiene items were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. Smoke and carbon monoxide detectors were in operable condition, and the fire extinguishers were fully charged, and the last fire drill was conducted on 9/15/2025. The water temperature ranged from 105°F to 120°F, and the temperature ranged from 72°F to 78°F throughout the facility. The kitchen was inspected, and there was a five (5) day supply of perishable and seven (7) day supply of non-perishable food available, which was adequately maintained. There was a menu and activity schedule available for review. All mandated inspection control posters were displayed throughout the facility. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Allen did not observe deficiencies; therefore, no citations were issued at this time. An exit interview was conducted where this report was discussed and provided to Clifton Douyon Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 17, 2025

Allegation investigated: Staff are mismanaging residents medication. Staff did not have resident re-evaluated before placement into memory care Staff are not providing activities for memory care residents Staff did not provide adequate transportation for resident Staff did not ensure residents room was clean Staff did not ensure resident had bedding Staff are not allowing resident to participate in activties with husband

On 8/27/2025, at 10:30 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a complaint investigation and deliver findings for the alleged allegations. LPA identified herself and met Clifton Douyon -Administrator who was informed of the purpose of the visit. On 6/23/2025 LPA conducted an interview with Clifton Douyon-Administrator and requested copies of the following documents: Resident 1-Resident 2 (R1-R2) Client File: Physician report not dated(R1) R2 dated 4/4/2025,Pre-placement dated 4/11/2025, Admission Agreement 4/16/2025,assessment needs and service plan summery dated 4/14/2025,incident reports, Case Notes, Medication Logs, and ID/Emergency information. The investigation consisted of the following: Continued Unsubstantiated On 8/27/2025, Licensing Program Analyst (LPA) conducted interviews with five staff members (S1–S5). LPA attempted to interview Residents R1 and R2; however, they were not present at the facility at the time of the investigation. Interviews were successfully conducted with Residents R3, R4, and R5. In addition to the interviews, the LPA reviewed relevant documentation, including email correspondence, assessments and re-assessments for R2, and the exit ledger following the termination of the admission agreement initiated and signed by R1. The investigation revealed the following: #1 Allegation: Staff are mismanaging residents’ medication. On 8/27/2025, LPA conducted interviews with five (5) staff members (S1-S5) 5 out of 5 staff members stated that all residents receive their medications as prescribed by their physicians. LPA attempted to interview R1 and R2 however they were not at the facility at the time of the investigation and the interviews conducted with R3, R4 and R5 stated they have received their medications as prescribed by their physicians. #2 Allegation: Staff did not have resident re-evaluated before placement into memory care. On August 27, 2025, Licensing Program Analyst (LPA) conducted interviews with five (5) staff members (S1–S5). During the interviews, S1-S2 staff members stated that Resident 2 (R2) had been re-evaluated on 5/16/2025 and it was determined that R2 required a higher level of care. S3,S4 and S5 could not confirm or deny that R2 was re-evaluated prior to moving to memory care. LPA reviewed a Resident Change Form dated May 27, 2025, which documented that R2 was being transferred to the memory care unit with an effective date of May 19, 2025. The form was signed by R1 prior to R2’s relocation. LPA attempted to interview Resident 1 (R1) and Resident 2 (R2); however, both were not present at the facility at the time of the investigation. Continued #3 Allegation: Staff are not providing activities for memory care residents LPA conducted interviews with staff members S1- S5, and 5 out of 5 stated residents, including those in the memory care unit, are provided with activities such as exercises, karaoke and wheel of fortune. LPA attempted to interview Residents R1 and R2; however, they were not present at the facility during the investigation. Interviews conducted with Residents R3, R4, and R5 stated they are provided with activities such as Bingo, fitness, and movies. LPA also observed an activity schedule posted for both the assisted living and memory care unit. #4 Allegation: Staff did not provide adequate transportation for resident. LPA conducted interviews with staff members S1-S5, and 5 out of 5 stated that residents are provided with transportation for appointments with doctors. However, the transportation van has not been available for a while, but alternate transportation is provided for those by utilizing Uber, or Lyft. LPA attempted to interview Residents R1 and R2; however, they were not present at the facility during the investigation. Interviews conducted with Residents R3, R4, and R5 indicated that there has not been anyone to transport residents but if transportation is needed the staff will utilize Uber or Lyft. #5 Allegation: Staff did not ensure residents room was clean LPA conducted interviews with staff members S1-S5, and 5 out of 5 stated that residents’ rooms are cleaned daily or as needed but a deep cleaning is done once a week. LPA attempted to interview Residents R1 and R2; however, they were not present at the facility during the investigation. Interviews conducted with Residents R3, R4, and R5 stated staff cleans their room daily. LPA toured the facility, room 313-B and 217 which appeared to be clean and free of odors. Continued #6 Allegation: Staff did not ensure resident had bedding. LPA conducted interviews with staff members S1-S5, and 5 out of 5 stated that when residents are admitted into the facility, they are responsible for providing their own bedding unless residents indicate assistance is needed upon admission. Licensing Program Analyst (LPA) attempted to interview Residents R1 and R2; however, both were not present at the facility during the investigation. Interviews were conducted with Residents R3, R4, and R5. All three residents stated that they were not provided with bedding upon admission and were informed that they were responsible for supplying their own bedding. #7 Allegation: Staff are not allowing residents to participate in activities with their husband. The Licensing Program Analyst (LPA) conducted interviews with staff members S1-S5. 5 out of 5 stated that all residents are allowed to participate in activities, either individually or in groups. When specifically asked about Residents R1 and R2, staff members S1-S5 confirmed that the two residents always participated in activities together, even after R2 was relocated to the memory care unit. The LPA attempted to interview Residents R1 and R2; however, both were not present at the facility during the time of the investigation. Interviews conducted with Residents R3, R4, and R5 stated they are allowed to participate in activities if they choose to do so. Additionally, they reported that they did not know Residents R1 or R2. Based on interviews conducted, documents reviewed and observations the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Clifton Douyon Administrator at conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 11-AS-20250618125738

Type of visit: Case Management - Other

On 8/27/2025, at 11:56 PM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced case management health and safety visit because of resident-on-resident physical altercation. LPA Allen was greeted by the Administrator Clifton Douyon, who was informed of the purpose of the visit. At the time of the visit LPA Allen requested and received the following documents for resident 1(R1). The assessment summary dated 3/20/2025 which is the original assessment upon R1's arrival to the facility. Resident 2 (R2) Assessment Summary dated 2/5/2025 and the reassessment dated 4/1/2025 and LIC624 with a statement of their adjusted care plan. Clifton has stated R1 and R2 have been separated into different rooms, the residents’ responsible parties were notified of the incident and changes to avoid any future altercations. Staff members have and will continue to observe R2 behaviors and will make note of any changes of conditions. LPA also observed residents separate rooms and observed both residents and there were no health or safety concerns. An exit interview was conducted, and this report was provided to Administrator Clifton Douyon at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 27, 2025

Allegation investigated: Staff do not ensure facility fire alarm is in good repair.

** This report supersedes the report dared 03/20/2025 and is being used to clarify the findings. It does not change the findings. On 04/10/2025 Licensing Program Analyst (LPA) Troy Watson conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at the facility and was greeted by the Executive Director Clifton Douyon. LPA explained the purpose of the visit was to investigate and deliver findings and was granted entry. CONTINUED ON LIC9099-C Substantiated The investigation consisted of the following: On 12/04/2024 Licensing Program Analyst (LPA) Troy Watson reviewed / obtained Resident Roster (dated 12/2024), Staff Roster (dated 12/2024), and Emergency Disaster Plan. Interviews were conducted, with Staff #1 – Staff #8 (S1-S8) and Residents #1- Residents#7 (R1-R7). The facility grounds were toured. Investigation revealed the following: Allegation: Staff do not ensure facility fire alarm is in good repair. It is alleged that the smoke detector is broken and randomly goes off unexpectedly in the facility disturbing its residents. On 12/04/24 LPA Watson interviewed Staff#1 – Staff#8 (S1-S8) regarding the allegation. Of those interviewed 8 out of 8 staff agreed to the allegation. On 12/04/24 LPA Watson interviewed Residents #1- Residents #7 (R1-R7); 7 out of 7 residents interviewed agreed with the above allegation. On 12/04/24 LPA Watson interviewed Executive Director Clifton Douyon. During the interview, Douyon stated that the smoke detectors located in room 118 and 221 were dysfunctional and needed repair. The director explained that they sounded off intermittently because of construction work being performed on the facility ceiling. During the interview it was also revealed that the triggering of the second smoke alarm was due to rainwater from the roof top of the ceiling. On 12/05/24 LPA Troy Watson interviewed and toured the facility grounds with the Maintenance Director Glen Olano, During the tour LPA observed and confirmed that the smoke detectors in rooms 118 and 221 were disconnected, and not functioning. During the interview Olan stated that an order for replacement or repair of the smoke detectors had been placed with Johnson Controls. LPA Watson requested records and called Johnson Controls to confirm the estimated time of repair or replacement of the smoke detectors multiple times. No confirmation of parts ordered or an estimated time of arrival for repairs could be confirmed. Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Therefore, the allegation according to the California Code of Regulations (Title 22, Division 6, Chapter 8) has been Substantiated. The following deficiencies have been observed and a citation issued (ref. LIC 9099-D) An exit interview was conducted with the Executive Director, Clifton Douyon and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 11-AS-20241127150712

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Apr 10, 2025

Maintenance and Operation.The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement has not been met as evidenced by:On 12/04/2024 and 12/05/2024 LPA observed etc. that the fire alarm had been in disrepair and improperly malfunctioning for residents since (11/27/24). This is a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Administrator will repair fire alarm system at the facility and will provide copies of receipts showing repairs have been made and fire alarm system is in good repair. The facility will email/fax by POC due dates. Administrator provided proof of repairs to LPA on 03/20/25 at time of visit.

Allegation investigated: Staff are not meeting resident's dietary needs. Staff isolated resident.

On 03/26/25 10am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Executive Director (ED) Clifton Douyon as the purpose of today’s visit was explained. The investigation consisted of the following: On 03/26/25 LPA Villegas obtained copies of the staff and resident roster, menus for February 2025-March 2025, alternative menus, list of residents with modified diets/dietary restrictions, Dietary report, Serv safe training certificate for staff #1-2 (S1-S2), and list of residents placed on isolation in the last 30 days. On 03/26/25 LPA requested the following documents for resident #1 (R1); facesheet, admission agreement dated:01/31/2018, physicians report dated:04/26/2022, needs and service plan dated:01/25/25, preplacement appraisal dated: 01/31/2018, diet clarification form dated: 2/28/25, and power of attorney documents dated 06/13/2013. On 03/26/25 from 10:20am- 12:15pm LPA conducted Interviews with resident # 1-6 (R1-6), and between 12:15pm-1:30 pm LPA conducted interviews with ED and staff #1-5 (S1-S5). On 03/26/25 LPA toured the facility kitchen and observed the dinning room during lunch time. Unsubstantiated The investigation revealed the following: allegation: Staff are not meeting resident's dietary needs. It is being alleged that staff stopped grinding food for resident in care. On 03/26/25 from 10:20am- 12:15pm LPA conducted Interviews with resident # 1-6 (R1-6), 5 of 6 residents interviewed denied the allegation above, and reported having no issues with the meals being served. 1 of 6 residents interviewed confirmed the allegation above and stated the dinner provided is not being grinded. On 03/26/25 12:15pm-1:30 pm LPA conducted interviews with ED and staff #1-5 (S1-S5), 6 of 6 staff interviewed denied the allegation above and reported meals are provided as indicated by Doctors orders. 6 of 6 staff interviewed reported there is a board in the kitchen that list what diet is needed per resident. On 03/26/25 LPA toured the facility kitchen, LPA observed a large board next to kitchen line that has residents picture along with dietary restrictions and/or modified diets. LPA also observed alternative menus placed in the dinning room that residents can choose from if they want a different meal then what is being served. On 03/26/25 LPA conducted a file review and observed R1 to have a diet clarification form dated: 2/28/25, which indicates a mechanical soft, finely chopped diet. LPA observed there was an order for a swallowing evaluation to assess for any potential concerns related to diet, however it is documented that the resident and responsible party refused. Allegation: Staff isolated resident. It is being alleged that facility staff placed a resident on isolation without informing the resident why. On 03/26/25 from 10:20am- 12:15pm LPA conducted Interviews with resident # 1-6 (R1-6), 5 of 6 residents interviewed denied the allegation above. 1 of 6 residents interviewed confirmed the allegation above and reported being on isolation for 3 weeks without reason. On 03/26/25 12:15pm-1:30 pm LPA conducted interviews with ED and staff #1-5 (S1-S5), 6 of 6 staff interviewed denied the allegation above and reported isolation occurs when it is order by a Doctor. On 03/26/25 LPA conducted a file review and observed documented communication dated 2/28/25 that resident would be placed on isolation for medical condition from 02/28/25-03/04/25 per MD, documentation also indicated responsible party was notified of the isolation order. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 26, 2025 · control 11-AS-20250317151337

Allegation investigated: Staff do not ensure facility fire alarm is in good repair.

On 03/20/2025 Licensing Program Analyst (LPA) Troy Watson conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at the facility and was greeted by the Executive Director Clifton Douyon. LPA explained the purpose of the visit was to investigate and deliver findings and was granted entry. The investigation consisted of the following: On 12/04/2024 Licensing Program Analyst (LPA) Troy Watson reviewed / obtained Resident Roster (dated 12/2024), Staff Roster (dated 12/2024), and Emergency Disaster Plan. Interviews were conducted, with the staff with staff S1-S8 (#1-#8) and residents R1-R7 (#1-#7). The facility ground was toured, and reports were reviewed. CONTINUED ON LIC9099-C Substantiated Investigation revealed the following: Allegation: Staff do not ensure facility fire alarm is in good repair. It is alleged that the fire alarm is broken and randomly goes off unexpectedly in the facility disturbing its residents. On 12/04/24 LPA Watson interviewed staff#1 – Staff#8 (S1-S8) regarding the allegation; Of those interviewed 8 out of 8 staff agreed to the allegation. On 12/04/24 LPA Watson interviewed residents #1-residents#8 (R1-R8); 8 out of 8 staff interviewed agreed with the above allegation. On 12/04/25 an Interview with the Executive Director Clifton Douyon revealed that the smoke detectors located in room 118 and 221 were dysfunctional and did not properly work and needed repair. The director explained that they sounded off intermittently because of construction work being performed on the facility ceiling. During the interview it was also revealed that the triggering of the second smoke alarm was due to rainwater from the roof top of the ceiling. On 12/05/04 LPA Troy Watson interviewed and toured the facility grounds with the Maintenance Director Glen Olano, LPA observed and confirmed that the smoke alarms needed repair and were not functional at the time of visit. LPA Watson also called and contacted Johnson Controls multiple times to verify the estimated time of arrival of the replacement parts and installation of the smoke alarms, but no confirmation of parts ordered or an estimated time of arrival for repairs could be verified. Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Therefore, the allegation according to the California Code of Regulations (Title 22, Division 6, Chapter 8) has been Substantiated. The following deficiencies have been observed and a citation issued (ref. LIC 9099) An exit interview was conducted with the Executive Director, Clifton Douyon and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 11-AS-20241127150712

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Mar 27, 2025

Maintenance and Operation.The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement has not been met as evidenced by:On 12/04/2024 and 12/05/2024 LPA observed etc. that the fire alarm had been in disrepair and improperly malfunctioning for residents since (11/27/24). This is a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Mar 20, 2025

Plan of correction: Administrator will repair fire alarm system at the facility and will provide copies of receipts showing repairs have been made and that the fire alarm system is no longer malfunctioning and is in good repair. The facility will email/fax by POC due dates. Administrator provided proof of repairs to LPA on 03/20/25 at time of visit.

Allegation investigated: Staff did not provide adequate supervision, resulting in a resident slipping in the shower. Staff did not meet a resident's hygiene needs. Staff did not maintain the facility in a clean and sanitary condition. Facility is in disrepair. Facility has mold. Staff yelled at a resident. Facility does not provide a safe environment for a resident.

On 10/19/24, the Community Care Licensing (CCL) associate made an unannounced visit to the facility and was greeted by Sales & Marketing Director (S10: Cyr Mongo). The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations. An initial investigation visit was conducted by (CCL) associates on 03/04/24 who was met by Administrator (S1: Matthew Ryan, Executive Director). (CCL) associates toured the facility’s physical plant for health and safety purposes of residents in care. (CCL) associates obtained copies of the following documents: Facility Resident Roster, Personnel Report LIC 500, Facility Order Review Report, Facility Rent Roll Detail Report, Facility Work Order Reports, Facility Average Daily Occupancy and Census Report, Facility Staff Training Records, Resident #1 (R1’s) care plan, email correspondences and other records pertinent to the allegations mentioned in this complaint. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not provide adequate supervision, resulting in a resident slipping in the shower. Allegation #2: Staff did not meet resident’s hygiene needs. The details of the complaint alleged due to inadequate supervision resident #1 (R1) slipped in the shower. It is reported that due to ineffective staffing (R1’s) hygiene needs are not met caused by delay and refusal from staff. On 03/04/24, between 09:46 am – 10:30 am, the Department interviewed staff #1 (S1) who stated these allegations are false. (S1) claimed (R1's) needs have special requirements. (R1) when using the shower water gets everywhere. (R1) requested for a non-slip in the bathroom but wanted the chemical applied to the whole bathroom and the facility complied to (R1’s) request. (R1) felt hygiene needs were not being met and requested for new toilet did not like the toilet that is provided, and it had nothing to do with facility staff not being able to provide basic services timely. (R1) fell in the shower on 01/15/24, with the assistance and supervision of (R1’s) private care provider present. (S1) indicated that (R1) maintains independence and required no assistance with personal grooming and hygiene needs. (R1) requires assistance with set up of showering material assisted by (R1’s) private care provider. (R1) has been evaluated did not require status checks all according to (R1’s) Facility’s Evaluation Report (dated: 01/15/24). On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (3) out (6) staff #4, #5 and #8 (S4-S5 and S8) were able to confirm of (R1’s) fall and that (R1) received immediate assistance. (S8) indicated that (R1) had the tendency to take showers 3 or 4 times daily and during the fall, (R1’s) private care giver was present when the incident occurred. (S5) reported that (R1) at time refused assistance in the shower twice on 01/15/24 which probably contributed to (R1’s) fall. According to (S4), an incident report was created, and that staff responded to (R1’s) fall right away. Five (5) out of six (6) staff #5-#9 (S5-S9) were interviewed who stated to have had direct care with (R1) and assisted with (R1’s) hygiene needs. As described by (S6), (R1) is challenging when it comes to hygiene assistance. Nevertheless, when requested by (R1), the proper care will be provided. On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (4) out (6) residents #3- #6 (R3-R6) affirmed they are independent and did not need staff assistance nor have experienced a fall. (Evaluation Report continues LIC 9099-C) (R2) who is dependent on assistance from the care staff was complimentary of services received from the caregivers and claimed to have never experienced a fall. (R1) was interviewed and claimed to have worked in an aviation and familiar with walking on slicks surfaces. (R1) said rather than non-slip strips or bath mats, (R1) requested a water based liquid that can be applied to the floor to prevent slipping. (R1) claimed that management did not take the suggestion seriously. (R1) confirmed that (R1) fell while in the shower and assistance was provided by care staff. But did not want to expand further on the incident. (R1) claimed have dispatched for help by pulling the pendant and emergency cord several time and that care staff refused to help (R1). (R1) said the staff are selective on who they want to assist and did not want to help with putting on shoes and did not have orders to help with this sort of service. As a result of reviewing (R1’s) Facility Evaluation Report (dated: 01/15/24), Facility Care/Shift Notes (dated: 01/15/24-01/20/24), Care Plan (dated: 12/18/23) Preplacement Appraisal Information (dated: 11/22/23), Physician Report (dated: 11/22/2023), revealed (R1) is in independent and can self-care, (R1) refused bathing support and (R1) repeatedly pressed for call pendant and that care staff helped, (R1) experience a fall and 911 was dispatched but refused hospital services. The Department reviewed Facility Staff Training Records (dated: 03/2023 – 03/2024) Resident Rights in Assisted Living, Assisting with Personal Care, Essential of Resident Rights, Providing Customer Services, revealed evidence of adherence to regulatory requirements. Based on the gathered information, there is no evidence to support the allegations mentioned above. Allegation #3: Staff do not maintain in a clean and sanitary condition. Allegation #4: Facility is in disrepair. Allegation #5: Facility has mold. The details of the complaint alleged resident #1 (R1’s) room is unclean, unsanitary and in disrepair. It is reported that blood stains on carpet, water leaks, toilet not flushing, lighting in bathroom is non-operable and the shower has mold. It is noted that nothing is being done to address these issues by the facility. On 03/04/24, between 09:46 am – 10:30 am, the Department interviewed (3) out (3) staff #1- #3 (S1-S3) all denied these allegations. (S1-S3) stated every maintenance request from (R1) are fasted tracked. (Evaluation Report continues LIC 9099-C) (R1’s) carpet have been cleaned, but still not to (R1’s) satisfaction. The lighting has to do with light plug outside, with a lock on it. (S1) had a staff unlock that for (R1) to use a grill. There is no evidence of mold in (R1’s) room. (S1) reported an incident with the water overflow into (R1’s) living/kitchenette lead from (R1’s) shower caused water and carpet bubbled but no mold. (S1) indicated Suttles Plumbing arrived on 02/23/24 and noted in their service report no mold. (S1) stated (R1) would see (S2) in the hallway and requests plentiful time for me to have (R1’s) carpet cleaned. (R1’s) carpet was cleaned every week. (S2) indicated there were a slew of maintenance requests in dealing with (R1’s) room. All were followed through by maintenance right away. On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (6) out (6) staff #4-#9 (S4-S9) were not able to corroborate these allegations. Two (2) out of the six (6) staff had heard of some mold issues in (R1’s) room, but it was discredited when professional plumbing services assessed the repairs. (S4-S9) stated if maintenance issues occur, it is resolved by the maintenance team instantly. On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (5) out (6) residents #2- #6 (R2-R6) who indicated no repairs with leaks, toilets, carpet, or lighting issues. Five (5) out of six (6) reported to have had no mold issues. (R1) was interviewed and claimed the water leak came from poor installed shower. The carpet is black from mold left from walls. (R1) claimed to have observed a bucket with plumbing parts in it had mold all over and did not feel safe. On 03/04/24 between 12:52 pm – 1:30 pm, the Department inspected (R1’s) room did not observed stains on carpet, no water leaks, no issues with toilet or lighting. The Department did not observe any evidence of mold. The Department observed (R1’s) room clean, safe, sanitary and in good repair. The Department observed housekeepers were on site conducting housekeeping duties. As a result of reviewing the facility’s Work Orders (dated: 01/01/24 – 03/03/24), it revealed service repair requests by (R1) have been accelerated in priority status and were addressed. There is no evidence that facility failed to act with reasonable care or duty. The Facility Evaluation Report (dated: 01/15/24), it is noted (R1’s) room is not free of clutter and obstacles. (R1) is also provided additional housekeeping 1x/ day (bed making, empty trash, straighten room) beyond standard services. Based on the gathered information, there is no evidence to support the allegations mentioned above. Allegation #6: Staff yelled at a resident. Allegation #7: Facility does not provide a safe environment for a resident. (Evaluation Report continues LIC 9099-C) The details of the complaint alleged that resident #1 (R1) is verbally mistreated by staff. It is reported that with the verbal mistreatment it is considered a harassment and that (R1) is not provided a safe environment. It reported that (R1) was being harassed by staff and management with office calls. On 03/04/24, between 09:46 am – 10:30 am, the Department interviewed (3) out (3) staff #1- #3 (S1-S3) all refuted these allegations. (S1) reported there have been no verbal altercation between staff and (R1) and there has been no harassment from staff or management. (S2-S3) claimed when responding or interacting with (R1), they have always acted in a professional manner. (S2-S3) described (R1) with high standards and is determined that all work orders are addressed promptly. (S1-S3) asserted the residents are provided a safe environment. On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (6) out (6) staff #4-#9 (S4-S9) were not able to validate these allegations. (S4-S9) all indicated that they have not observed or experienced any staff verbal mistreatment or altercations with residents. (S7) claimed to have a good relationship with (R1) and communication is cordial. (S4-S9) reported residents are assisted to ensure their safety and are provided a safe and healthful environment. On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (5) out (6) residents #2- #6 (R2-R6) declared they have never experience or witness any verbal mistreatment of staff on residents. (R4-R5) stated they heard some staff voices raised, residents that have hearing loss, one must raise voices to be heard. Nevertheless, they have not heard anything negative coming from staff. (R2-R6) expressed the facility provided a safe environment for residents in care. (R2-R6) claimed to have never felt unsafe or at risk living at this facility. (R1) was interviewed and claimed staff have verbally mistreated (R1) and (R1) has seen other victims subjected to the same abuse. However, (R1) was unable to provide names of individuals involved nor did not want to further elaborate on the matter. According to (R1), (R1) felt unsafe at the facility as staff makes everyone do their physically therapy up and down the hallway. A contradiction to what was reported about (R1) who felt unsafe due to staff mistreatment or harassment with office calls. As a result of reviewing (R1’s) Facility Evaluation Report (dated: 01/15/24), it revealed (R1) is in independent and can self-care and did not require status check. (Evaluation Report continues LIC 9099-C) The report noted (R1) is severely hearing impaired and that requires additional staff time and assistance with routine communication. Facility Progress Notes (dated: 01/15/24), (R1) can independently provide self-care, however, it is noted a change in behavior repeated inquiry for assistance with activity with use of call pendant/pull cord (R1) needing to be heard for attention, comfort, and reassurance. Based on the gathered information, there is no evidence to support the allegations mentioned above. Based on information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Cyr Mongo (Sales & Marketing Director), and copies of the reports were provided.the state’s words, verbatim · CDSS document, Oct 19, 2024 · control 11-AS-20240226091417

Type of visit: Required - 1 Year

On 9/14/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Clifton Douyon /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (100) elderly adults ages 60 and above, of which (80) can be non-ambulatory and (20) Bedridden. The facility has an approved hospice waiver for (10). The facility is a three-story building located on a residential neighborhood it consist of the following: Seventy (70) apartment units with attached bathrooms, open patio area in front of the facility, and three patio areas in the back of facility, two of which are on second and third floor balconies, two living rooms, restaurant style dining room, two bistro areas, 3 activity rooms and several staff offices on first and second floor. LPA Iniguez and the executive director toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (6) bedrooms and (6) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113.5°F to 115.2°F, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 6/6/24. A review of (5) residents' service files and (5) staff personnel files was maintained in order. LPA reviewed (5) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Clifton Douyon /Executive Director.the state’s words, verbatim · CDSS document, Sep 14, 2024

Allegation investigated: Facility staff did not administer medication as prescribed.

On 07/01/24, at 1:23pm, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Hugo Lemus, Health Services Director, and Richard Alvarenga, Memory Care Director. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegation mentioned above. The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R6). Resident Roster (Dated: 06/13/2024) Staff Roster (Dated: No Date), ID/Emergency Information (Dated: 03/27/2024), Physicians Report (Dated: 01/31/2024 & 07/02/2024), Medication Administration Record (Dated: 06/01/24-06/30/2024) were obtained from the facility for R1. The investigation revealed the following: Allegation #1- Facility staff did not administer medication as prescribed. Report continued on LIC9099-C Unsubstantiated The details of the complaint alleged that R1 was admitted to the hospital after the facility was unable to provide R1 with R1’s insulin medication for at least 5 days. On 07/17/24, from 11:00am-2:00pm, LPA interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. 4 of 4 staff denied the allegation that the Facility staff did not administer medication as prescribed. 4 of 4 staff interviewed stated that R1 did receive all medications as prescribed by R1’s doctor. Staff further stated that R1 received R1’s insulin injections the five prior days before the resident went to the hospital. R1 stated that R1 had self-administered R1’s insulin injection but that there may have been a problem with the Pen-Injector giving the proper amount of the medication. R1 stated that R1 did not blame the staff, it might have been a faulty Pen-Injector. R1 further stated that when the insulin was injected it looked as if the proper dose was being administered. LPA reviewed the Medication Administration Record (Dated: 06/01/24-06/30/24) for R1 and found that the resident self-administered R1’s insulin and it was witnesses by staff. LPA interviewed R1-R6 about the allegation and 6 of 6 residents that were interviewed denied the allegation that Facility staff did not administer medication as prescribed. All residents interviewed stated that the staff does administer their medication as prescribed by their physician and have not missed any doses of their medication. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff did not administer medication as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with Richard Alvarenga, Memory Care Director, and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 17, 2024 · control 11-AS-20240628130119

Allegation investigated: Staff did not safeguard resident’s personal belongings

** This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 06/13/2024.** On 06/13/2024 at 08:00 am the department conducted an initial complaint investigation for the allegation listed above. Upon arriving at the facility, LPA met with Henry Reyes, Business Office Director and Patricia Murphy, Executive Director who assisted with the visit. The purpose of today’s visit was discussed. LPA was granted access and allowed to enter the facility to conduct inspections. The investigation consisted of the following: On 06/13/2024 the department requested a review of current staff/resident roster, admissions agreement, house rules, pre-placement appraisal, and resident personal property and valuables. On 06/13/2024 the deparmtent interviewed Staff 1- Staff 6 (S1-S6) and Resident 1- Resident 6 (R1-R6). Continued on 9099-C Continued on LIC 9099C. Unsubstantiated The investigation revealed the following: Allegation: Staff did not safeguard resident’s personal belongings. On 06/13/2024 the department interviewed Patricia Murphy, Executive Director who denied the allegation. On 6/13/2024 the department interviewed Staff 1-Staff 6 (S1-S6). Of those interviewed, 6 out of 6 staff denied the allegation. On 6/13/2024 the department interviewed resident 1 to resident 6 ( R1-R6). Of those interviewed, 6 out of 6 denied the allegations. On 06/13/2024 the department toured rooms #209, #204, #219, and #221, observing that residents' belongings were secured. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit Interview conducted and a copy of this report was provided to the facility representative. This page intentionally left blankthe state’s words, verbatim · CDSS document, Jun 13, 2024 · control 11-AS-20240603080145

Allegation investigated: Staff is overcharging resident for services. Staff did not provide resident with itemized list of fees.

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 4/8/24. On 4/8/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced subsequent visit to the address listed above. LPA arrived and spoke to Business Office Manager, Henry Reyes and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 03/06/24 LPA Shirley conducted interviews with both staff and residents, a review of Staff roster, Resident roster, Resident files, Admission Agreements, Summary of Fees and conducted a tour of the facility for a health and safety check. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Staff is overcharging resident for services It is being alleged that staff is overcharging resident for services. During document review, LPA first observed the resident roster and did not find the resident listed. LPA did not observe R1 at the facility. LPA learned that R1 is no longer residing at Ivy Park At Santa Monica, as there was no record, file nor bills for this resident. This facility has undergone new ownership and facility did not have records for this resident who resided under the former owner Sunrise Assisted Living of Santa Monica. LPA learned that R1 was placed in hospice and is now residing at a board and care called Beverly Wood. On 3/06/24, LPA Shirley interviewed staff 1 through staff 6(S1-S6). LPA asked staff, does this facility overcharge residents for services previously agreed upon during the admission process. Of those interviewed, 3 out of 6 stated no. LPA Shirley interviewed resident 1 – resident 6 (R1-R6). LPA ask residents if they had been overcharged for services other than what was agreed upon. Of those interviewed, 4 out of 5 answered no. R1 was not available for interview. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not provide resident with itemized list of fees It is being reported that this facility does not provide residents with an itemized list of charges. On 3/06/24, LPA Shirley toured the facility and found no present or imminent threat to the health and/or safety of the residents in care. LPA Shirley reviewed resident files and billing. During file review and interviews, LPA found that prospective residents are provided itemized list of charges that facility anticipates will be charged for services rendered. If it is determined that the resident needs a higher level of care, there is an assessment and staff will discuss the needs of the resident with the families or responsible parties before the resident is charged the additional fees. LPA Shirley reviewed resident’s Admission Agreements and observed the Summary of Fees for services and programs offered. On 3/06/24, LPA Shirley interviewed staff 1 through staff 6(S1-S6). LPA asked staff, when an admission agreement is signed, is there an itemized list of charges provided to families for services that will be rendered. Of those interviewed, 3 out of 6 answered yes. LPA Shirley interviewed resident 1 – resident 6 (R1-R6). LPA ask, when you were admitted to Sunrise Assisted Living, were you provided an itemized list of charges for services that will be rendered during your stay. Of those interviewed, 2 out of 5 answered yes. R1 was not available for interview. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099 was provided to Business Office Manager, Henry Reyes.the state’s words, verbatim · CDSS document, Apr 8, 2024 · control 11-AS-20221109093215

Allegation investigated: Staff did not manage resident's illness while in quarantine Staff did not meet resident's toileting needs while in quarantine Staff do not ensure that hallways are free from hazards Staff did not address inappropriate interaction between residents

On 01/29/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Judith Uy-Villaruz (S1), Executive Director, and the purpose of the visit was explained. S1 and LPA toured the facility. The investigation consisted of the following: On 01/29/24 LPA requested and reviewed facility documents and toured the facility. LPA interviewed seven (7) out of seventy-one (71) residents and four (4) out of seventy-two (72) staff, one staff denied the interview. Report continues, see LIC9099C Unsubstantiated The investigation revealed the following: Regarding the allegation: "Staff did not manage resident's illness while in quarantine". It has been alleged that staff did not assist resident one during their quarantine period.Three (3) staff have denied the allegation, while one staff denied the interview. LPA interviewed seven (7) residents (R1-R7). Five (5) out of seven (7) residents have disagreed with the allegation and feel their needs are being met, while one resident denied the interview. Record reviews revealed that staff members have conducted routine checkups on resident one through the resident's illness quarantine from 12/14/24 - 12/19/24. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation: "Staff did not meet resident's toileting needs while in quarantine." It has been alleged that one resident has Irritable Bowel Syndrome (IBS) that hasn't flared up in the past few years. During resident one's (R1) illness, IBS flared up once more and resident one had terrible diarrhea. LPA interviewed four (4) staff (S1-S4). Three (3) staff have denied the allegation, while one staff denied the interview. Five (5) out of seven (7) residents have disagreed with the allegation and feel their needs are being met, while one resident denied the interview. Record reviews revealed that R1's physician's report and the above-mentioned facilities' care plan both note as the same resident having no assistance needed with toileting. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Report continues, see LIC9099C Regarding the allegation: "Staff do not ensure that hallways are free from hazards" It has been alleged that one resident rides and parks their scooter in the hallway, which obstructs other residents' path of transportation. LPA interviewed four (4) staff (S1-S4). Three (3) staff have denied the allegation, while one staff denied the interview. LPA interviewed seven (7) residents (R1-R7). Four (4) out of seven (7) residents have disagreed with the allegation and one resident denied the interview. Based on observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation "Staff did not address inappropriate interaction between residents". It has been alleged that one resident rides and parks their scooter in the hallway, which obstructs other residents' path of transportation. Another resident went to the subject's room, when they were answered, inappropriately, by the driver of the scooter. LPA interviewed four (4) staff (S1-S4). Three (3) staff have denied the allegation, while one staff denied the interview. One staff have had a conversation with the subject regarding this allegation. LPA interviewed seven (7) residents (R1-R7). Five (5) out of seven (7) residents have not physically observed the allegation, while one resident denied the interview. Based on observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. An exit interview was conducted with Judith Uy-Villaruz, Exective Director (S1), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 11-AS-20240123102547

Allegation investigated: Licensee did not provide notice of rate change to resident. Licensee is overcharging resident for services. Licensee did not provide resident with itemized list of fees.

On 12/27/2023 at 8:45 am Licensing Program Analyst (LPA) David España conducted a subsequent complaint investigation at the above facility to address the following allegations due to needs further investigation of control number 11-AS-20231220152313. LPA España met with Executive Director Judith Uy-Villaruz and explained the purpose of this visit was to deliver findings to control number 11-AS-20231220152313 complaint. Upon arrival at the facility, LPA España conducted a risk assessment at the facility entrance. Based on the assessment, the facility is not clear of Covid-19 infection. The investigation consisted of the following: during today's visit, LPA with Executive Director Judith Uy-Villaruz confirmed positive cases at the facility as of 12/27/2023. It has been determined that there are a total Seven (7) out of Seventy (70) residents still positive with COVID-19. LPA reviewed and received from the Administrator the COVID 19 community tracker as of 12/27/2023 at 9:00 am. EVALUATION REPORT CONTINUES ON LIC 9099-C Unsubstantiated LPA interviewed Seven (7) out of Seventy (70) residents in person. LPA interviewed Seven (7) out of Seventy-One (71) staff in person. LPA interviewed Seven (7) out of Seventy (70) residents in person who could not confirm the date when they were advised of COVID-19 present at the facility. LPA confirmed with the Administrator that the facility reported COVID-19 cases on 12/22/2023 to CCLD. Per interview with the Administrator, there was no need to report cases to CCLD due to no outbreak. LPA confirmed with the Administrator that as of 12/21/2023 there has been only Seven (7) total positive cases active out of the Nineteenth (19) residents that were positive at the facility. LPA confirmed with the Administrator that as of 12/27/23 there were Seven (7) quarantine. Per the Administrator the precaution or quarantine guidelines are that the 6th day if a person does not show fever (symptoms) they, the person who was positive may come outside of quarantine, however, must be masked for Ten (10) days per guidelines. LPA confirmed with the Administrator that there are Twenty-Two (22) out of Seventy-One (71) staff member currently working at the time of visit. The investigation revealed the following: Licensee did not provide notice of rate change to resident. Details provided indicated the facility did not provide notice of rate change to resident. LPA interviewed Seven (7) out of Seventy (70) residents in person. LPA interviewed Seven (7) out of Seventy-One (71) staff in person. LPA interviewed the Administrator who stated that on 11/01/2023, 48 letter were sent out about the rate change (i.e., only). LPA confirmed that 04/27/2023 a letter was sent out about change of ownership from Sunrise to Ivy Park at Santa Monica. LPA interviewed Seven (7) out of Seventy (70) residents in person who confirmed a letter was received, the monthly basic rate would increase by 10% (i.e., monthly fee increases of 10%) as of “January 1, 2024.” Per interview with the Administrator and letter it is due to “normal operating expenses,” “retaining high-performing team members,” and “increases in operational expenses.” Additionally, the letter stated that the reasoning for increasing was “higher utility and transportation costs, and increases in employees' wages and benefit expense.” LPA confirmed with the Administrator there was an advance or written notice provided to all residents in care as of 12/27/2023 relating to monthly rate. LPA also confirmed with the Administrator “Sunrise Increases in Fees and Charges. The Community shall increase the Base Fee in Exhibit 2 on January 1 of each year. Notice of any increase in the fees listed in Exhibit 1, will be provided to the Resident in writing sixty (60) days prior to the effective date of the increase and will state the reason for the increase and a general description of the additional costs.” LPA interviewed Seven (7) out of Seventy (70) residents in person confirmed that they knew the facility was under new ownership. REPORT CONTINUES ON LIC 9099-C LPA noted with the Administrator “The Resident will pay all applicable new or increased fees and charges, unless the Resident terminates this Agreement in accordance with Section V” under Sunrise resident agreement. LPA with the Administrator also confirmed that “A change in the level of service (for example, a change from Basic Assisted Living Services to Assisted Living Plus) is not considered a change of fees or charges” which was written by the Sunrise resident agreement. Based on the evidence; documents reviewed, and interviews conducted the finding is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation of, did or did not occur; therefore, the complaint investigation of the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 Exit Interview Conducted. A copy of this report was discussed and left with the Administrator Judith Uy-Villaruz whose signature on this form confirm receipt of these documents. The investigation revealed the following: Licensee is overcharging resident for services. Details provided indicated the facility does overcharge resident for services. LPA interviewed Seven (7) out of Seventy (70) residents in person. LPA interviewed Seven (7) out of Seventy-One (71) staff in person. LPA interviewed the Administrator who stated that letters were sent out to residents. Per the “Ivy Park at Santa Monica” it revealed that “Each year, we anticipate increases in our normal operating expenses due to the cost of retaining high-performing team members and increases in operational expenses. Due to the increase in year-over-year costs, we are implementing a monthly fee increase of 10%.” LPA noted that the resident agreement does show service fees. LPA noted that all resident agreements are signed by residents or responsible parties. LPA interviewed Seven (7) out of Seventy (70) residents in person who stated they did receive a letter from Ivy Park at Santa Monica. LPA interviewed Seven (7) out of Seventy-One (71) staff in person who stated the facility did send out letters to residents. Based on the evidence; documents reviewed, and interviews conducted the finding is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation of, did or did not occur; therefore, the complaint investigation of the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 Exit Interview Conducted. A copy of this report was discussed and left with the Administrator Judith Uy-Villaruz whose signature on this form confirm receipt of these documents. REPORT CONTINUES ON LIC 9099-C The investigation revealed the following: Licensee did not provide resident with itemized list of fees. Details provided indicated the facility does not provide itemized list of fees to resident for services. The complainant claims resident #5 (R5) does not have an itemized list of fees. An interview with Seven (7) out of Seventy (70) residents in person revealed that they signed a Residency Agreement. The Residency Agreement details what is covered under basic services. Any care services are written in Ivy Park at Santa Monica resident agreement and signed by resident. A review of Seven (7) out of Seventy (70) residents Physician’s Report LIC 602A list their capacity for self-care and it is aligned with what is on the Ivy Park at Santa Monica resident agreement. Seven (7) out of Seventy (70) residents are aware of the extra charges listed if any per the Ivy Park at Santa Monica resident agreement and that the facility did not do anything underhanded. An interview with Seven (7) out of Seventy (70) residents all supported the statement and included they do not know any residents being overcharged for unnecessary services. An interview with Seven (7) out of Seventy-One (71) staff in person all verified that each resident goes through an extensive admission process which includes a personal assessment. At the time of agreement signing the resident or the designated representative will review a list of attachments and acknowledgments before the Residency Agreement is signed. LPA interviewed Seven (7) out of Seventy-One (71) staff in person all confirmed there are no residents in this facility that is being charged for superfluous services. LPA interviewed Seven (7) out of Seventy-One (71) staff in person explained the care services at this facility is not in a set package; rather, it is offered in a separate item(s) based on the resident’s service assessment and these services are listed on the Ivy Park at Santa Monica resident agreement with monthly prices. Based on the evidence; documents reviewed, and interviews conducted the finding is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation of, did or did not occur; therefore, the complaint investigation of the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 Exit Interview Conducted. A copy of this report was discussed and left with the Administrator Judith Uy-Villaruz whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, Dec 27, 2023 · control 11-AS-20231220152313

Allegation investigated: Facility is not reporting a COVID-19 outbreak as required.

This is an amendment of the investigation report delivered on 12/27/2023, the purpose of this amendment is to provide additional information and it does not change the investigation findings. On 12/27/2023 at 8:45 am Licensing Program Analyst (LPA) David España conducted a subsequent complaint investigation at the above facility to address the following allegations due to needs further investigation of control number 11-AS-20231220105042. LPA España met with Executive Director Judith Uy-Villaruz and explained the purpose of this visit was to deliver findings on control number 11-AS-20231220105042 complaint. Upon arrival at the facility, LPA España conducted a risk assessment at the facility entrance. Based on the assessment, the facility is not clear of Covid-19 infection. The investigation consisted of the following: during today's visit, LPA with Executive Director Judith Uy-Villaruz confirmed positive cases at the facility as of 12/27/2023. It has been determined that there are a total Seven (7) out of Seventy (70) residents still positive with COVID-19. LPA reviewed and received from the Administrator the COVID 19 community tracker as of 12/27/2023 at 9:00 am. REPORT EVALUATION REPORT CONTINUES ON LIC 9099-C Substantiated LPA interviewed Seven (7) out of Seventy (70) residents in person. LPA interviewed Seven (7) out of Seventy-One (71) staff in person. LPA interviewed Seven (7) out of Seventy (70) residents in person that could not confirm the date when they were advised of COVID-19 present at the facility. LPA confirmed with the Administrator that the facility reported COVID-19 cases on 12/22/2023 to CCLD. Per interview with the Administrator, there was no need to report cases to CCLD due to no outbreak. LPA confirmed with the Administrator that as of 12/21/2023 there has been only Seven (7) total positive cases active out of the Nineteenth (19) residents that were positive at the facility. LPA confirmed with the Administrator that as of 12/27/23 there were Seven (7) quarantine. Per the Administrator the precaution or quarantine guidelines are that after the 6th day if a person does not show fever (symptoms) they, the person who was positive may come outside of quarantine, however, must be masked for Ten (10) days per guidelines. LPA confirmed with the Administrator that there are Twenty-Two (22) out of Seventy-One (71) staff member currently working at the time of visit. The investigation revealed the following: Facility is not reporting a COVID-19 outbreak as required. Based on observation, interview, and record review, the licensee did not comply with the section cited above. At 10:00 AM LPA observed the facility did not report COVID-19 outbreak as required, which poses/posed a potential health, safety or personal rights risk to persons in care. LPA attempted to interview on 12/22/2023 all positive residents and LPA was provided three (3) out of the total positive cases to interview from the Administrator, however, due to safety concerns LPA felt he could not maintain a suitable conversation (illness). LPA interviewed Seven (7) out of Seventy (70) residents and all Seven (7) residents stated they were notified. LPA and interviewed Seven (7) out of Seventy-One (71) staff members who stated they informed the Administrator of any positive cases. LPA requested by phone and in person Mitigation Plan Report from the Administrator, for purpose of record. LPA has also observed the facility tracking system (excel sheet) and entryway COVID-19 surveillance testing for every person entering the facility. LPA observed staff members provide N95s to be used when entering the facility. LPA reviewed the Administrator tracking system dated with results of “Symptom Start Date: 11/18/2023; 11/23/2023; 12/17/2023; 12/17/2023; 12/17/2023; 12/17/2023; 12/18/2023; 12/19/2023; 12/19/2023; 12/19/2023; 12/19/2023 and 12/22/2023.” LPA has observed and discussed PIN 20-48-ASC Coronavirus Disease 2019 (COVID-19) Mitigation Plan Report and Training with the Administrator. EVALUATION REPORT CONTINUES ON LIC 9099-C Additionally, LPA is citing the following regulation: Title 22, Division 6, Chapter 8, Article 04., Operating Requirements, 87211 Reporting Requirements which states “Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours…” “…to the licensing agency and to the local health officer when appropriate.” Regarding the allegation: “Facility is not reporting a COVID-19 outbreak as required.” Based on LPA’s observations, interviews and record reviews, the preponderance of evidence standard has been met therefore the above allegation is found to be substantiated. California Code of Regulations, Tittle 22 are being cited were assessed please see LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with the Administrator Judith Uy-Villaruz whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, Dec 27, 2023 · control 11-AS-20231220105042

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Jan 5, 2024

87211(a)(2) Reporting Requirements: (2) Occurrences, such as epidemic outbreaks... residents... shall be reported within 24 hours... licensing agency... when appropriate.This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee failed to ensure that COVID-19 cases were reported to the license agency within 24 hours for positive cases between 11/18/2023-12/22/2023 . Which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 27, 2023

Plan of correction: Administrator will review Title 22, Division 6, Chapter 8, Article 04., Operating Requirements, 87211 Reporting Requirements, and submit a written plan detailing how the Administrator will ensure that incidents/deaths are reported to CCL office as required according to the regulation. The plan is due to the CCL office by POC date David.espana@dss.ca.gov.