Carson Senior Assisted Living

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff stole money from resident in care Staff do not ensure hazardous items are inaccessible to residents. Staff do not ensure the facility is free of insects. Staff do not provide activities. Staff do not adequately supervise residents.

On 07/09/26 at 2:30 pm Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Administrator Ginger Enriquez (staff #1/S1) as the purpose of today’s visit was explained. The investigation consisted of the following: On 07/08/26 LPA Villegas obtained copies of the staff and resident roster, activity calendar for June 2026-July 2026, pest control reports for April 2026-June 2026, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre-appraisal dated: 05/13/25, Physicians report dated: 04/22/26, needs and service plan dated: 05/16/26, resident appraisal dated: 05/16/26, property sheet dated: 05/13/26 medication administration record (MARs) from June 2026-July 2026, and copies of incident reports dated: 04/10/26, 04/13/26, and 04/30/26. On 07/08/26 from 9:30 am- 11:45 am LPA conducted Interviews Residents # 1-10 (R1-R10), and on 07/08/26 and 07/09/26 LPA conducted interviews with staff #1-7 (S1-S7). On 07/08/26 and 07/09/26 LPA conducted a check of (4) bedrooms on both floors. Unsubstantiated The allegation revealed the following: Allegation: Staff stole money from a resident in care. It Is alleged that facility staff stole money from a resident in care. On 07/08/26 from 9:30 am- 11:45 am LPA conducted Interviews R1-R10 regarding the allegation above. 9 of the 10 residents interviewed denied the above allegation. 1 of the 10 residents interviewed confirmed the allegation above and stated that they believe a facility staff is taking money from their social security check. On 07/08/26 and 07/09/26 LPA conducted interviews with S1-S7 regarding the allegation above. 7 of the 7 staff interviewed denied the allegation above. Furthermore, 6 of the 7 staff stated that if a resident reports missing money, staff would report to management. 1 of the 7 staff interviewed stated that the facility would investigate the concern, search the resident's room and belongings when appropriate, contact family members if applicable, documents findings, and files required reports. 07/08/26 LPA conducted a review of R1’s Physicians report dated: 04/22/26 and resident appraisal dated: 05/16/26. Upon review LPA observed that R1 cannot handle cash resources and has a DPOA who handles finances, facility does not have access to resident’s cash resources. Allegation: Staff do not ensure hazardous items are inaccessible to residents. It is alleged that a resident in care consumed a chemical left behind by staff. On 07/08/26 from 9:30 am- 11:45 am LPA conducted Interviews R1-R10 regarding the allegation above. 9 of the 10 residents interviewed denied the above allegation. 1 of the 10 residents interviewed confirmed the allegation above and reported they consumed pine sol thinking it was mouthwash. On 07/08/26 and 07/09/26 LPA conducted interviews with S1-S7 regarding the allegation above. 6 of the 7 staff interviewed denied the allegation above, 1 of the 7 staff interviewed reported having no knowledge of the allegation above. 4 of the 7 staff interviewed indicated that chemicals and toxins are locked in a storage room, 3 of the 7 staff interviewed stated they are unaware of where chemicals and toxins are stored. On 07/09/26 LPA toured facility with S6, LPA observed 5 locked storage rooms located on the 2nd floor. Allegation: Staff do not ensure the facility is free of insects. It is alleged that a resident’s bedroom is full of roaches. On 07/08/26 from 9:30 am- 11:45 am LPA conducted Interviews R1-R10 regarding the allegation above. 1 of the 10 residents interviewed denied the above allegation. 4 of the 10 residents interviewed confirmed the allegation above and reported notifying it to staff, and the bedroom was treated. 5 of the 10 residents interviewed reported seeing roaches in the past. 10 of 10 residents interviewed confirmed that pest control comes out regularly to service the facility. On 07/08/26 and 07/09/26 LPA conducted interviews with S1-S7 regarding the allegation above. 2 of the 7 staff interviewed reported having no knowledge of the above allegation. 5 of the 7 staff interviewed denied the allegation above, 2 of the 5 staff stated that residents have reported roaches in their bedroom in the past but nothing recent. 7 of 7 staff interviewed reported that the facility has pest control services come out regularly. On 07/08/26 LPA conducted a review of pest control reports dated :04/15/26, 05/06/26, and 06/10/26. Per maintenance service reports no pest activity was found. On 07/08/26 and 07/09/26 LPA conducted a check of (4) bedrooms on both floors, LPA did not observe any pest. Allegation: Staff do not provide activities. It is alleged that facility does not provide activities for the residents in care. On 07/08/26 from 9:30 am- 11:45 am LPA conducted Interviews R1-R10 regarding the allegation above. 9 of the 10 residents interviewed denied the above allegation, although residents reported that for the most part residents do not want to participate in activities. 1 of the 10 residents interviewed confirmed the allegation above and reported no activities are provided by facility staff. On 07/08/26 and 07/09/26 LPA conducted interviews with S1-S7 regarding the allegation above. 7 of the 7 staff interviewed denied the allegation above and reported activities are provided daily. 6 of the 7 staff reported that residents are reminded and encouraged to participate in activities being held. 1 of the 7 staff stated they are unaware of what staff are doing to engage residents in activities. On 07/08/26 LPA conducted a review of activity calendar for June 2026-July 2026. LPA observed that 3-4 activities are scheduled throughout each day. During visit LPA observed residents being notified and encouraged to participate in activities, LPA observed residents to opt out of activities and made their way outdoors. Allegation: Staff do not adequately supervise residents. It is alleged that facility staff are not checking on residents when residents are right outside of the facility. On 07/08/26 from 9:30 am- 11:45 am LPA conducted Interviews R1-R10 regarding the allegation above. 4 of the 10 residents interviewed could not provide information regarding the allegation as they do not leave the facility. 1 of the 10 residents denied the allegation above and reported staff checking in with residents if staff have something urgent for them. 5 of the 10 residents interviewed confirmed the above allegation and report that staff do not check in on them when they are out in the community. Additionally, 6 of 7 residents stated that residents must sign in and out of the facility when going out to the community. On 07/08/26 and 07/09/26 LPA conducted interviews with S1-S7 regarding the allegation above. 3 of the 7 staff interviewed reported having no knowledge of the above allegation. 2 of the 7 staff interviewed confirmed the allegation above and reported that if staff are sitting outside the facility, staff will check in with residents in addition to the cameras outside. 2 of the 7 staff interviewed reported that staff will monitor the sign in/out log to monitor return times. Additionally, 6 of 7 staff interviewed reported that residents have been educated in community safety. On 07/08/26 LPA observed residents coming in and out of the facility throughout the day, LPA observed most residents to stop at the front office to either sign in or sign back out. 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, Jul 9, 2026 · control 11-AS-20260630121105

Type of visit: Office

On July 7, 2026, an office meeting was held to discuss Complaint 11-AS-20250714154313. The attendees included Interim Regional Manager (RM) Janae Hammond, Licensing Program Analyst (LPA) Ernand Dabuet, Executive Director Joe Goldman, and Assistant Administrator Ginger Enriquez. During the meeting, the Interim Regional Manager (RM) reviewed the details of the complaint. On March 17 2026, the Department confirmed allegation of neglect and a lack of care and supervision. The facility staff failed to provide proper care, which resulted in the resident to sustained (3) pressure injuries. When the findings were delivered on March 17 2026, the Department indicated that an enhanced civil penalty determination was pending under Health and Safety Code Section 1569.49(f) for Serious Bodily Injury. The Department is currently reviewing the complaint for an enhanced civil penalty for serious bodily injury as per H&S 1569.49(f). The total civil penalty has been set at $10,000 for serious bodily injury. During the meeting Technical Support Program (TSP) was offered to the Executive Director. At this time the Department will follow up in a later date to see if the facility wants to participate in the program. TechnicalSupportProgram@dss.ca.gov An exit interview was conducted with Joe Goldman, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 7, 2026

Allegation investigated: Staff are not properly addressing bed bug infestation in the facility.

This report supersedes the report created on 05/13/2026 to include additional observations conducted during today’s subsequent complaint investigation visit. The findings remain unchanged. The investigation consisted of the following: On 05/13/2026 The Department interviewed ten (10) staff members (S1-S10) and eleven (11) residents (R1-R11), conducted observations of the facility, including the television room, common areas, memory care unit, and assisted living area, and reviewed pest control receipts, staff and resident rosters, a resident file, the facility food policy, and the food menu for May 2026. On 06/30/2026, the Department returned to the facility and conducted additional observations related to the allegation. Along with Assistant Administrator and staff, six (6) residents’ bedrooms, including beds, mattresses, mattresses, seams, bedframes, furniture seams, and linens, were inspected for visible signs of bed bug activity. The Department also inspected the television room across from the receptionist office and hallway areas. Please see report continuation on (LIC9099-C) Unsubstantiated The investigation revealed the following: Regarding the allegation that staff are not properly addressing a bed bug infestation in the facility: Interviews revealed the following: interviews conducted with ten (10) staff members (S1-S10) denied knowledge of an active bed bug infestation within the facility. Resident interviews conducted with eleven (11) residents (R1-R11) did not corroborate the presence of bed bugs. LPA’s observations revealed the following: On 05/13/2026, LPA did not observe bed bugs within the television room or common areas. On 06/30/2026 LPA did not observe live bed bugs or visible signs of bed bug activity, including insects consistent with bed bugs, fecal spotting, blood spots, shed skins, eggs, or other visible evidence. Records reviewed revealed the following: pest control invoices and treatment records documenting ongoing extermination services conducted on multiple dates, including March 18, March 25, April 1, April 8, April 15, and May 6, 2026. Records documented treatment and monitoring for various pests, including bed bugs, and indicated continued pest control maintenance services were being provided. Based on the evidence gathered, interviews conducted, observations made, and records reviewed, although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. No deficiencies were cited regarding this allegation. An exit interview was conducted, and a copy of this report was provided to the Assistant Administrator.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 11-AS-20260504140021

Allegation investigated: Staff are not properly addressing bed bug infestation in the facility.

On 05/13/2026, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced complaint investigation visit regarding the allegation above. LPA met with Assistant Administrator Ginger Enriquez. The investigation consisted of the following: The department interviewed ten (10) staff members (S1-S10), eleven (11) residents (R1-R11), observations of the facility including the television room and common areas, memory care and assisted living side. Review of pest control receipts, Staff & Resident roster, Resident file, Food policy, food menu for May 2026. The investigation revealed the following: Regarding the allegation that staff are not properly addressing bed bug infestation in the facility, interviews conducted with (10) staff members (S1-S10) denied knowledge of an active bed bug infestation within the facility. Resident interviews conducted with (11) residents (R1-R11) did not corroborate the presence of bed bugs. During the visit, no bed bugs were observed within the television room or common areas. Please see (LIC9099-C) for report continuation. Unsubstantiated Records revealed: Pest control invoices and treatment records documenting ongoing extermination services conducted on multiple dates including March 18, March 25, April 1, April 8, April 15, and May 6, 2026. Records documented treatment and monitoring for various pests, including bed bugs, and indicated continued pest control maintenance services were being provided. Based on the evidence gathered, interviews conducted, observations made, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. No deficiencies were cited on this visit. A copy of this report and exit interview was provided to the Assistant Administrator.the state’s words, verbatim · CDSS document, May 13, 2026 · control 11-AS-20260504140021

Allegation investigated: Staff do not ensure resident is eating Staff are leaving residents in soiled briefs Staff are sleeping in a resident's room while on duty

On 05/13/2026, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced complaint investigation visit regarding the allegations above. LPA met with Assistant Administrator Ginger Enriquez. The investigation consisted of the following: The department interviewed ten (10) staff members (S1-S10), eleven (11) residents (R1-R11), observations of the facility including the television room and common areas, memory care unit and assisted living side, Staff & Resident roster, resident file, Food policy, food menu for May 2026 and Monitoring logs for (AM-PM) and (GY) Graveyard shifts were collected. The investigations revealed the following: Regarding the allegation that staff do not ensure residents are eating, staff interviews conducted with (10) Staff (S1-S10) stated residents are provided meals, snacks, and assistance as needed. Resident interviews conducted with (11) Residents (R1-R11) confirmed residents receive meals daily. Resident (R2) stated receiving meals at the facility. No residents interviewed reported being denied food assistance. Please see report continuation (LIC9099-C) Unsubstantiated Observations revealed: kitchen staff plating and serving food to residents during lunchtime. Food menu for 05/13/2026 confirmed the lunch items that were observed. Based on the evidence gathered, interviews conducted, observations made, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. Regarding the allegation that staff are leaving residents in soiled briefs, staff interviews conducted with (10) Staff (S1-S10) stated incontinent residents are checked and changed routinely approximately every one to two hours or as needed. Interviews with (11) Residents (R1-R11) did not agree with being left in soiled briefs for extended periods. No odors or unattended incontinent residents, or conditions indicating residents were being left in soiled briefs were observed. A review of resident monitoring and incontinence care logs dated 05/08/2026 documented routine resident checks, repositioning, toileting assistance, and monitoring conducted throughout (AM-PM), and graveyard shifts. Based on the evidence gathered, interviews conducted, observations made, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. Regarding the allegation that staff are sleeping in a resident’s room while on duty, interviews conducted with (10) Staff (S1-S10) and (11) Residents (R1-R11) did not agree or report any knowledge of the allegation. Staff members (S8-S9) denied sleeping in resident rooms while on duty. Additional staff interviews indicated (S8-S9) were not assigned to the memory care unit and had not worked in that unit for several months. Based on the evidence gathered, interviews conducted, observations made, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. No deficiencies were cited on this visit. A copy of this report and exit interview were provided to the Assistant Administrator.the state’s words, verbatim · CDSS document, May 13, 2026 · control 11-AS-20260508164855

Type of visit: Required - 1 Year

On May 2, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Ginger Enriquez. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (230) non-ambulatory elderly adults of which (10) may be bedridden ages 60 and above. Currently, the facility has (167) residents and (2) in hospice care. The facility is approved for (10) hospice residents. The facility is a two-story building located in a commercial neighborhood. It consists of the following: (35) resident bedrooms in Arbor Unit and (99) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, an activity room, a dining area, a kitchen, and outside patio area. LPA and administrator toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The residents’ rooms were inspected in Arbor Hall: 16, 20, and #22. Assisted Living: 1, 148, 203, 148, 213, 251, 257, 264, 265, and #276. Bathrooms were operational with water temperature measured at 105.6 – 115.0 degrees F. A comfortable temperature was maintained in the facility at 73- 74 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Evaluation Report continues LIC 809-C Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. The facility has conducted Fire and Disaster Drill March 11, 2026. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. LPA conducted an audit of resident #1-#10 (R1-R10) service files, and staff #1-#10 (S1-S10) personnel files were in order and complete. The facility is current in CCLD annual fees. The facility has a current administrator certificate for Ginger Enriquez # 7007668740 valid through 03/07/2027. Deficiencies: During the facility inspection, LPA identified rooms 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 203, 216, 220, and 221 that had damaged or missing window screens. An exit interview conducted with Jessica Ponce and a copy of the report is provided.the state’s words, verbatim · CDSS document, May 2, 2026

Allegation investigated: Facility staff do not ensure to provide adequate supervision to residents in care.

On 4/14/2026, at approximately 9:00 AM, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met with Ginger Enriquez/Facility Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: the department conducted the following interviews: Administrator interview, (A#1), Residents Interviews (R#1-R#8), and Staff interview (S#1-S#5). The department gathered the following documents: copy of personnel schedule dated 4/14/26, copy of resident roster dated:4/14/26, and copies of facility staff Memorandum of Understanding dated: 3/20/2020. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Facility staff do not ensure to provide adequate supervision to residents in care. The details of the complaint alleged that facility staff are not providing adequate supervision to residents because they are using their cell phones On April 14, 2026, at approximately 10:00 a.m., during the records review, the Department observed a copy of the facility’s Staff Memorandum of Understanding dated March 20, 2020. The Department noted that the memorandum states the following policies are to be followed: no personal calls are permitted while on duty, and all telephones in the facility are for business use only. The memorandum further states that no local or long-distance personal calls are to be made on facility phones at any time. On April 14, 2026, during an interview with the facility administrator (A#1), (A#1) stated that staff are permitted to have their personal cell phones in their pockets while on duty because the facility uses a work-related group chat for communication. In addition, (A#1) noted that staff utilize walkie-talkies for communication within the facility. When asked about measures in place to ensure staff provide adequate supervision to residents, (A#1) explained that the resident care coordinator and (A#1) regularly monitor staff performance. Finally, when questioned about any concerns or past incidents involving staff members using their personal cell phones in a manner that affected resident supervision, (A#1) stated, "Not at all." On April 14, 2026, during interviews with residents in care (R#1 through R#8), (8) out of (8) residents stated that staff check on them regularly and that they feel supervised and supported while in the common areas. All residents interviewed stated they have not noticed staff using their personal cell phones while supervising or assisting residents. Additionally, (8) of (8) residents reported feeling safe and well-supervised in the facility and had no concerns about staff attentiveness. Evaluation Report continues LIC 9099-C On April 14, 2026, during interviews with facility staff (S#1 through S#5), (5) out of (5) facility staff stated that their responsibilities related to resident supervision responsibilities as ensuring residents are clean and dry, assisting with dressing, preparing residents for meals, and escorting them to activities. Staff stated that the facility policy prohibits personal use of cell phones but allows work-related communication via group chat. In addition, (5) out of (5) facility staff denied any instances where personal cell phone use interfered with resident supervision. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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. An exit interview was conducted, and a copy of the Complaint Report was given to Ginger Enriquez/ Facility Administratorthe state’s words, verbatim · CDSS document, Apr 14, 2026 · control 11-AS-20260408164609

Allegation investigated: Resident developed a pressure injury due to neglect by staff. Staff did not seek timely medical attention for resident in care.

***This amended report supersedes the report dated March 14, 2026. This report has been created to include detailed description of the types of pressure injuries for "Resident developed a pressure injury due to neglect by staff". All other aspects of the complaint report remain in effect. *** This unannounced subsequent complaint inspection is being conducted by the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet for the purpose of delivering findings for the investigation into the above identified complaint allegations. Jessica Ponce receptionist greeted the LPA and explained that the purpose of the visit. (Evaluation Report continues LIC 9099-C) Substantiated The investigation included interviews, record reviews, and a tour of the facility. Investigation conducted by Investigator Philippe Ryan Miles of the CDSS Investigation Branch. Interviews with Staff member S#1 - S#6 (S1-S6), Resident #2 - #10 (R2- R11) and Witness #1 (W1). The Department reviewed several documents, including the Facility Resident Roster (dated 07/15/25 & 03/13/26), the Personnel Report LIC 500 (dated 07/15/25 & 03/13/25), (R1's) Physician Report (LIC 602A dated 08/09/24), Facilty's charting notes (07/09/25 and 07/11/25), Medication Administration Record (dated 07/01/25 to 07/31/25), Harbor UCLA Medical Center Records (dated 07/17/25) and other pertinent records associated with this complaint. INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Resident developed a pressure injury due to neglect by staff. It is alleged that Resident #1 (R1) developed a pressure injury due to staff negligence. It was reported that R1 has contracted pressure ulcers and has been scratching the tailbone. No further information is available or provided. Resident #1 (R1) was admitted to Carson Senior Assisted Living on February 17, 2020, according to the Identification and Emergency Information (LIC 601, dated 02/17/25). On July 11, 2025, (R1) was hospitalized at Harbor UCLA Medical Center for septic shock. During the medical assessment, it was discovered that (R1) had a left trochanteric pressure ulcer, classified as Stage II, which had deteriorated, increasing in size and depth. Additionally, there was a left ischial ulcer that remained unchanged at the time, along with a deep tissue pressure injury (DTPI) to the sacrococcygeal area that also deteriorated, presenting a non-blanching wound bed and a boggy texture upon touch. On October 6, 2025, between 11:16 AM and 12:14 PM, the Department interviewed staff members identified as Staff # 1 through Staff #5 (S1-S5). One (1) out of the five (5) staff members was able to verify by observation that (R1) had some skin blister and that staff were applying ointment on the blister for any skin condition. Four out of the five (5) claimed to have never observed any pressure injuries on (R1). All five staff members unanimously confirmed that (R1) was hospitalized on July 11, 2025, due to a significant decline in health, and importantly, were not receiving any home health or hospice care at that time. On September 18, 2025, at 10:19 AM, the Department interview witness identified as Witness #1 (W1). (W1) was informed that (R1) was taken to Harbor UCLA for low blood pressure, dehydration, and bed sores. Later, (R1) was transferred to Kaiser Permanente and passed away on July 20, 2025. (W1) noted that (R1) did not receive home health or hospice care while at the facility. (Evaluation Report continues LIC 9099-C) The Department was unable to interview Resident #1 (R1) due to (R1's) passing on July 20, 2025. The Department reviewed the Physician Report (LIC 602A dated 08/09/24) for Resident #1 (R1), which indicated a history of skin conditions and breakdowns. The facility's charting notes documented a body assessment showing that on 07/09/25, (R1) had a skin tear in the left lower buttocks. On 07/10/25, the evaluation noted blisters and a skin tear on the left hip and continued breakdown in the lower buttocks. By 07/11/25, (R1) was again noted to have skin breakdown. Additionally, a review of the Medication Administration Record (dated 07/01/25 to 07/31/25) showed that (R1) was prescribed (11) medications, with (10) of those having side effects that could lead to skin rashes, itchy blisters, skin reactions, or peeling, which may potentially result in pressure injuries (ref: National Institutes of Health). Medical records from Harbor UCLA Medical Center indicate that (R1) developed three pressure injuries while under the care and supervision of the facility. The details of the injuries are as follows: - Wound #1: Sacrococcygeal area (Deep Tissue Pressure Injury), measuring 13 cm x 8 cm. - Wound #2: Left ischium (Unstageable), measuring 6 cm x 3.5 cm. - Wound #3: Left trochanter (Stage 2), measuring 3.5 cm x 2 cm. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Allegation #3: Staff did not seek timely medical attention for resident in care. It is alleged that the staff failed to seek timely medical attention for Resident #1 (R1). Reports indicate that the facility neglected (R1), who was taken to the Harbor UCLA Medical Center emergency department due to concerns about low blood pressure and poor food intake. Upon assessment, (R1) was found to have low sodium levels, dehydration, and a pressure ulcer above the tailbone. It was reported that (R1) had been eating adequately in March 2025, and that the staff had not been notified about the bedsores. No further information is available or provided. (Evaluation Report continues LIC 9099-C) On October 6, 2025, between 11:16 AM and 12:14 PM, the Department interviewed a staff member, Staff #1 (S1). According to (S1), staff checked (R1)'s vitals, which showed low blood pressure, prompting them to contact 9-1-1. (R1) was transported to Harbor UCLA, where a deteriorating left trochanter Stage II pressure injury was discovered, showing an increase in size and coloration. Additionally, there was an unstageable left ischium injury that remained unchanged at the time, and an evolved Deep Tissue Pressure Injury (DPTPI) to the sacrococcygeal area that had also deteriorated, presenting a non-blanching wound bed that felt boggy to the touch. (R1) was later transferred to Kaiser Permanente and passed away at the hospital on July 20, 2025. According to facility staff, (1) out of (5) staff members observed that (R1) had a skin blister and that staff were applying ointment to address the condition. However, (4) out of (5) staff members reported never having observed any pressure injuries on (R1) and (2) out of the (5) staff members recognized a change in mental and physical change in condition. Nevertheless, the facility's charting notes documented a body assessment showing that on 07/09/25, (R1) had a skin tear in the left lower buttocks. On 07/10/25, the evaluation noted blisters and a skin tear on the left hip and continued breakdown in the lower buttocks. By 07/11/25, R1 was again noted to have skin breakdown. The charting notes indicate that Resident 1 (R1) is exhibiting signs of weakness and requires assistance during mealtimes. Additionally, (R1) had been showing a noticeable decline in appetite, often refusing to eat or showing little interest in food. The Department was unable to interview Resident #1 (R1) due to (R1's) passing on July 20, 2025. The Department reviewed the Physician Report (LIC 602A dated 08/09/24) for Resident #1 (R1), which indicated a history of skin conditions and breakdowns. The facility's charting notes documented a body assessment showing that on 07/09/25, (R1) had a skin tear in the left lower buttocks. On 07/10/25, the evaluation noted blisters and a skin tear on the left hip and continued breakdown in the lower buttocks. By 07/11/25, R1 was again noted to have skin breakdown. Additionally, a review of the Medication Administration Record (dated 07/01/25 to 07/31/25) showed that (R1) was prescribed (11) medications, with (10) of those having side effects that could lead to skin rashes, itchy blisters, skin reactions, or peeling, which may potentially result in pressure injuries (ref: National Institutes of Health). The medical records from Harbor-UCLA Medical Center reveal that (R1) has been experiencing a significant decline in eating habits, raising concerns about malnutrition. Additionally, laboratory tests showed dangerously low sodium levels, which can lead to serious health complications. (R1) was suffering from dehydration, suggesting inadequate fluid intake, and has developed bed sores due to prolonged immobility. These changes in (R1's) condition necessitate prompt medical intervention to address these health issues. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099 D). An exit interview was conducted with Jessica Ponce , and copies of the report and appeal rights were provided. *Immediate Civil Penalty issued* ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000)the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 11-AS-20250714154313

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87631(a)(1) · Plan of correction due date: Mar 18, 2026

87631 Healing Wounds- (a)The licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (1)When care is performed by or under the supervision of an appropriately skilled professional. This requirement was not met as evidenced by: Based interviews and record review, the facility did not ensure that (R1)'s pressure injuries were cared for by an appropriately skilled professional. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: Administrator and staff shall take state approved vendored training on 87631 Healing wounds. Submit vendor name, address, vendor number and phone number with date of training. Plan of correction must be submitted to ernand.dabuet@dss.ca.gov by 03/18/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 18, 2026

87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement was not met as evidenced by: Based on interviews and record review, the administrator did not take appropriate action or assistance timely medical attention for (R1) when noticeable changes were observed in (R1)’s condition. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: Administrator and staff shall take state approved vendored training recognizing resident's change in health condition. Submit vendor name, address, vendor number and phone number with date of training. Plan of correction must be submitted to ernand.dabuet@dss.ca.gov by 03/18/26.

Allegation investigated: Resident developed a pressure injury due to neglect by staff. Staff did not seek timely medical attention for resident in care.

On March 14, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Melissa Serafin Medication Technician greeted the LPA. (LPA) explained that the purpose of the visit is to deliver findings for the allegations mentioned above. The investigation included interviews, record reviews, and a tour of the facility. Investigation conducted by Investigator Philippe Ryan Miles of the CDSS Investigation Branch. Interviews with Staff member S#1 - S#6 (S1-S6), Resident #2 - #10 (R2- R11) and Witness #1 (W1). The Department reviewed several documents, including the Facility Resident Roster (dated 03/13/26), the Personnel Report LIC 500 (dated 03/13/26), (R1's) Physician Report (LIC 602A dated 08/09/24), Facilty's charting notes (07/09/25 and 07/11/25), Medication Administration Record (dated 07/01/25 to 07/31/25), Harbor UCLA Medical Center Records (dated 09/04/25) and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Resident developed a pressure injury due to neglect by staff. It is alleged that Resident #1 (R1) developed a pressure injury due to staff negligence. It was reported that R1 has contracted pressure ulcers and has been scratching the tailbone. No further information is available or provided. Resident #1 (R1) was admitted to Carson Senior Assisted Living on February 17, 2020, according to the Identification and Emergency Information (LIC 601, dated 02/17/25). On July 11, 2025, (R1) was hospitalized at Harbor UCLA Medical Center for septic shock. During the medical assessment, it was discovered that (R1) had a left trochanteric pressure ulcer, classified as Stage II, which had deteriorated, increasing in size and depth. Additionally, there was a left ischial ulcer that remained unchanged at the time, along with a deep tissue pressure injury (DTPI) to the sacrococcygeal area that also deteriorated, presenting a non-blanching wound bed and a boggy texture upon touch. On October 6, 2025, between 11:16 AM and 12:14 PM, the Department interviewed staff members identified as Staff # 1 through Staff #5 (S1-S5). One (1) out of the five (5) staff members was able to verify by observation that (R1) had some skin blister and that staff were applying ointment on the blister for any skin condition. Four out of the five (5) claimed to have never observed any pressure injuries on (R1). All five staff members unanimously confirmed that (R1) was hospitalized on July 11, 2025, due to a significant decline in health, and importantly, were not receiving any home health or hospice care at that time. On September 18, 2025, at 10:19 AM, the Department interview witness identified as Witness #1 (W1). (W1) was informed that (R1) was taken to Harbor UCLA for low blood pressure, dehydration, and bed sores. Later, (R1) was transferred to Kaiser Permanente and passed away on July 20, 2025. (W1) noted that (R1) did not receive home health or hospice care while at the facility. The Department was unable to interview Resident #1 (R1) due to (R1's) passing on July 20, 2025. The Department reviewed the Physician Report (LIC 602A dated 08/09/24) for Resident #1 (R1), which indicated a history of skin conditions and breakdowns. The facility's charting notes documented a body assessment showing that on 07/09/25, (R1) had a skin tear in the left lower buttocks. On 07/10/25, the evaluation noted blisters and a skin tear on the left hip and continued breakdown in the lower buttocks. (Evaluation Report continues LIC 9099-C) By 07/11/25, (R1) was again noted to have skin breakdown. Additionally, a review of the Medication Administration Record (dated 07/01/25 to 07/31/25) showed that (R1) was prescribed (11) medications, with (10) of those having side effects that could lead to skin rashes, itchy blisters, skin reactions, or peeling, which may potentially result in pressure injuries (ref: National Institutes of Health). Records from Harbor UCLA Medical Center indicated that (R1) developed pressure injuries while under the care and supervision of the facility with left trochanter Stage II that deteriorated with noted increase in size and coloration. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Allegation #3: Staff did not seek timely medical attention for resident in care. It is alleged that the staff failed to seek timely medical attention for Resident #1 (R1). Reports indicate that the facility neglected (R1), who was taken to the Harbor UCLA Medical Center emergency department due to concerns about low blood pressure and poor food intake. Upon assessment, (R1) was found to have low sodium levels, dehydration, and a pressure ulcer above the tailbone. It was reported that (R1) had been eating adequately in March 2025, and that the staff had not been notified about the bedsores. No further information is available or provided. On October 6, 2025, between 11:16 AM and 12:14 PM, the Department interviewed a staff member, Staff #1 (S1). According to (S1), staff checked (R1)'s vitals, which showed low blood pressure, prompting them to contact 9-1-1. (R1) was transported to Harbor UCLA, where a deteriorating left trochanter Stage II pressure injury was discovered, showing an increase in size and coloration. Additionally, there was an unstageable left ischium injury that remained unchanged at the time, and an evolved Deep Tissue Pressure Injury (DPTPI) to the sacrococcygeal area that had also deteriorated, presenting a non-blanching wound bed that felt boggy to the touch. (R1) was later transferred to Kaiser Permanente and passed away at the hospital on July 20, 2025. According to facility staff, (1) out of (5) staff members observed that (R1) had a skin blister and that staff were applying ointment to address the condition. However, (4) out of (5) staff members reported never having observed any pressure injuries on (R1) and (2) out of the (5) staff members recognized a change in mental and physical change in condition. Nevertheless, the facility's charting notes documented a body assessment showing that on 07/09/25, (R1) had a skin tear in the left lower buttocks. On 07/10/25, the evaluation noted blisters and a skin tear on the left hip and continued breakdown in the lower buttocks. (Evaluation Report continues LIC 9099--C) By 07/11/25, R1 was again noted to have skin breakdown. The charting notes indicate that Resident 1 (R1) is exhibiting signs of weakness and requires assistance during mealtimes. Additionally, (R1) had been showing a noticeable decline in appetite, often refusing to eat or showing little interest in food. The Department was unable to interview Resident #1 (R1) due to (R1's) passing on July 20, 2025. The Department reviewed the Physician Report (LIC 602A dated 08/09/24) for Resident #1 (R1), which indicated a history of skin conditions and breakdowns. The facility's charting notes documented a body assessment showing that on 07/09/25, (R1) had a skin tear in the left lower buttocks. On 07/10/25, the evaluation noted blisters and a skin tear on the left hip and continued breakdown in the lower buttocks. By 07/11/25, R1 was again noted to have skin breakdown. Additionally, a review of the Medication Administration Record (dated 07/01/25 to 07/31/25) showed that (R1) was prescribed (11) medications, with (10) of those having side effects that could lead to skin rashes, itchy blisters, skin reactions, or peeling, which may potentially result in pressure injuries (ref: National Institutes of Health). Records from Harbor UCLA Medical Center indicated that (R1) had a decline in eating habits, low sodium levels, dehydration, and bed sores. Based on the information gathered, there is sufficient evidence to support the allegations mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099 D). An exit interview was conducted with Melissa Serafin, and copies of the report and appeal rights were provided. *Immediate Civil Penalty issued* ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000) INVESTIGATION REVEALED THE FOLLOWING: Allegation #2: Staff are not meeting resident’s dietary needs. It is alleged that Resident #1 (R1) dietary needs were not met. It was reported that (R1) was brought to Harbor UCLA Medical center for low-blood pressure and sudden changes in eating patterns. It is reported that facility has been providing/attempting to provide liquid nutrition to patient since development of poor food intake. No further information is available or provided. On October 6, 2025, and December 15, 2025, between 11:16 AM and 03:20 PM, the Department interviewed staff member identified as Staff #1 through Staff #6 (S1- S6). Two (2) out of the six (6) staff members were only able to verify that (R1’s) eating habits had changed. According to (S5) (R1) was not eating and verbalized of little pain. While (S6) claimed that (R1) ate but in small amounts and was being assisted. (S1) stated that (R1) was not in need of any special diet and was on regular diet. On October 03, 2025, and October 21, 2025, between 9:35 AM and 03:45 PM, the Department interviewed resident members identified Resident #2 through Resident #11 (R2-R11). Ten (10) out of the eleven (11) resident members could not corroborate this allegation. Ten residents confirmed that they receive adequate nutritional dietary needs. The Department was unable to interview Resident #1 (R1) due to (R1's) passing on July 20, 2025. The Department reviewed the Physician Report (LIC 602A dated 08/09/24) for Resident #1 (R1), indication of no special dietary needs. The facility's charting notes documented on 07/11/25, (R1) were weak and had a lower intake of food. Additionally, a review of the Medication Administration Record (dated 07/01/25 to 07/31/25) showed that (R1) was prescribed (11) medications, of which (10) had side effects that could affect appetite (ref: National Institutes of Health). A further review of the Facility Menu has been approved, as indicated by Nutrition Menu Solutions. (Evaluation Report continues LIC 9099-C) During visit on October 25, 2025, the Department did observe Facility Menu displayed throughout the facility in common areas of Memory Care and Assisted Living units. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with Melissa Serafin, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Mar 14, 2026 · control 11-AS-20250714154313

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87631(a)(1) · Plan of correction due date: Mar 16, 2026

87631 Healing Wounds- (a)The licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (1)When care is performed by or under the supervision of an appropriately skilled professional. This requirement was not met as evidenced by: Based interviews and record review, the facility did not ensure that (R1)s pressure injuries were cared for by an appropriately skilled professional, which caused an immediate health and safety risk to (R1).the state’s words, verbatim · CDSS document, Mar 14, 2026

Plan of correction: Administrator and staff shall take state approved vendored training on 87631 Healing wounds. Submit vendor name, address, vendor number and phone number with date of training. Plan of correction must be submitted to ernand.dabuet@dss.ca.gov by 03/16/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 16, 2026

87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement was not met as evidenced by: Based on interviews and record review, the administrator did not take appropriate action or assistance timely medical attention for R1 when noticeable changes were observed in R1’s condition, which caused an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Mar 14, 2026

Plan of correction: Administrator and staff shall take state approved vendored training on 87631 Healing wounds. Submit vendor name, address, vendor number and phone number with date of training. Plan of correction must be submitted to ernand.dabuet@dss.ca.gov by 03/16/26.

Allegation investigated: Staff did not prevent a resident from sexually abusing another resident

This report supersedes the report created 12/5/25 and the findings will remain unchanged. On 1/21/2026 at approximately 1:30 PM, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Julian Villanueva/Resident Coordinator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Facility Administrator Interview (A#1), Resident Interviews (R#1-R#10) and Witness Interview (W#1). LPA gathered the following documents: Resident Roster dated: 11/21/25, Staff Roster dated:12/11/25, copy of (R#1) Physician’s Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602 dated:6/25/25, copy of (R#1)’s medication list, copy of (R#1)’s Identification and Emergency Information or LIC 601, copy of (R#1)’s Resident Appraisal or LIC 603A date:9/24/25, and copy or (R#1)’s Appraisal/Needs and Services Plan or LIC 625 dated:9/24/25. Evaluation Report continues LIC 9099-C Unsubstantiated This report supersedes the report created 12/5/25 and the findings will remain unchanged. Investigation Revealed the Following: Allegation: Staff did not prevent a resident from sexually abusing another resident The details of the complaint alleged that (R#1) was sexually assaulted by (R#2). On December 11, 2025, at approximately 12:00 p.m., during a review of records, Licensing Program Analyst (LPA) Iniguez observed Resident #1’s (R#1) Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A), dated June 25, 2025. The report indicates that (R#1) has been diagnosed with a mental health condition that may influence their thought processes and belief system. Additionally, the LIC 602A form notes that (R#1) is confused and disoriented. LPA Iniguez also reviewed (R#1)’s current medication list, which includes a prescription for Haloperidol 50 mg to be administered every morning. This medication is associated with the management of (R#1)’s diagnosed mental health condition. Furthermore, LPA Iniguez reviewed (R#1)’s Appraisal/Needs and Services Plan (LIC 625), dated September 24, 2025, which states that the facility is responsible for monitoring R#1 throughout the day for any physical or mental changes. On December 11, 2025, during an interview, the facility administrator (A#1) she stated that upon being notified of (R#1)’s allegation of sexual abuse by their mental health case manager, the facility took immediate action by assessing (R#1) and offering to relocate them to a different room once one becomes available. (A#1) also indicated that the Long-Term Care Ombudsman would be informed of the incident. To ensure (R#1)’s safety, the facility implemented a two-hour wellness check protocol, with staff monitoring (R#1) throughout the day and night for any physical or mental changes. In addition, (A#1) stated that in response to the allegation, the facility followed its internal abuse protocols by interviewing relevant parties, documenting the incident, and notifying Licensing, the Ombudsman, the mental health case manager, and (R#1)’s psychiatrist. The facility does not utilize in-room surveillance cameras due to resident privacy rights, which align with regulatory standards. Evaluation Report continues LIC 9099-C This report supersedes the report created 12/5/25 and the findings will remain unchanged. On December 11, 2025, at approximately 1:00 p.m., (W#1) stated that when a program client reports abuse, the department follows a protocol to ensure the client’s safety. This includes providing immediate access to medical and mental health support, formally reporting the incident to authorities. On January 20, 2026, (W#1) reported via email that after receiving the client’s report, they consulted their supervisor and the on-site clinician to confirm the facility was aware of the incident. That afternoon, (W#1) reported the incident to Adult Protective Services (APS) and was instructed to contact the Long-Term Care Ombudsman hotline. (W#1) then completed a SOC 431 form and emailed it to the Long-Term Care Ombudsman and Community Care Licensing. (W#1) also indicated that, to their knowledge, no investigation was initiated by them. On December 11, 2025, at approximately 11:00 am, during an interview with (R#1), they stated that the alleged incidents occurred approximately 15 times over a period of three months. When asked whether the incidents were reported to facility staff immediately after they occurred, (R#1) stated that they did not report them at the time because they believed the behavior would stop on its own. In addition, (R#1) stated that since the report was made, (R#1) indicated that the facility has “placed a camera in their room” to monitor their safety. When asked if they currently feel safe living at the facility, (R#1) responded affirmatively, stating that they do feel safe now. On December 11, 2025, at approximately 11:20 am, during an interview with (R#2), they stated that they do not engage in conversation with (R#1) and simply share the room for sleeping purposes. Also, (R#2) reported no knowledge of any concerns or complaints made against them by either their roommate (R#1) or facility staff. In addition, in response to the allegation of inappropriate physical contact involving (R#1), (R#2) firmly stated that they have never touched (R#1) in a sexual or harmful way and that they always maintain respectful and appropriate behavior toward them. When asked whether they feel safe living at the facility, the individual responded affirmatively. Evaluation Report continues LIC 9099-C This report supersedes the report created 12/5/25 and the findings will remain unchanged. On December 11, 2025, at approximately 11:30 am, during interviews with residents (R#3-R#10), (8) out of (8) stated that the facility consistently responds in a positive manner when asked about the facility’s response to resident concerns regarding safety, privacy, or personal well-being and, they affirmed that staff respond appropriately to both serious concerns and minor requests for assistance, based on their personal observations. In addition, (8) out of (8) residents stated that they have not observed or heard of any concerning incidents involving (R#1) and their roommate (R#2), and they feel safe living here. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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. An exit interview was conducted, and a copy of the Complaint Report was given to Julian Villanueva/Resident Coordinator.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 11-AS-20251205101712

Allegation investigated: Staff did not prevent a resident from sexually abusing another resident

On 12/11/2025 at approximately 9:30 AM, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Ginger Enriquez/ Facility Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Facility Administrator Interview (A#1), Resident Interviews (R#1-R#10) and Witness Interview (W#1). LPA gathered the following documents: Resident Roster dated: 11/21/25, Staff Roster dated:12/11/25, copy of (R#1) Physician’s Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602 dated:6/25/25, copy of (R#1)’s medication list, copy of (R#1)’s Identification and Emergency Information or LIC 601, copy of (R#1)’s Resident Appraisal or LIC 603A date:9/24/25, and copy or (R#1)’s Appraisal/Needs and Services Plan or LIC 625 dated:9/24/25. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff did not prevent a resident from sexually abusing another resident The details of the complaint alleged that (R#1) was sexually assaulted by (R#2). On December 11, 2025, at approximately 12:00 p.m., during a review of records, Licensing Program Analyst (LPA) Iniguez observed Resident #1’s (R#1) Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A), dated June 25, 2025. The report indicates that (R#1) has been diagnosed with a mental health condition that may influence their thought processes and belief system. Additionally, the LIC 602A form notes that (R#1) is confused and disoriented. LPA Iniguez also reviewed (R#1)’s current medication list, which includes a prescription for Haloperidol 50 mg to be administered every morning. This medication is associated with the management of (R#1)’s diagnosed mental health condition. Furthermore, LPA Iniguez reviewed (R#1)’s Appraisal/Needs and Services Plan (LIC 625), dated September 24, 2025, which states that the facility is responsible for monitoring R#1 throughout the day for any physical or mental changes. On December 11, 2025, during an interview, the facility administrator (A#1) she stated that upon being notified of (R#1)’s allegation of sexual abuse by their mental health case manager, the facility took immediate action by assessing (R#1) and offering to relocate them to a different room once one becomes available. (A#1) also indicated that the Long-Term Care Ombudsman would be informed of the incident. To ensure (R#1)’s safety, the facility implemented a two-hour wellness check protocol, with staff monitoring (R#1) throughout the day and night for any physical or mental changes. In addition, (A#1) stated that in response to the allegation, the facility followed its internal abuse protocols by interviewing relevant parties, documenting the incident, and notifying Licensing, the Ombudsman, the mental health case manager, and (R#1)’s psychiatrist. The facility does not utilize in-room surveillance cameras due to resident privacy rights, which align with regulatory standards. Evaluation Report continues LIC 9099-C On December 11, 2025, at approximately 1:00 pm, during an interview with (W#1), (W#1) explained that when a report of sexual abuse is made by a client participating in the program, the department follows a specific protocol to ensure the client's safety and well-being. This includes offering immediate access to medical care and mental health support services tailored to the client's needs. (W#1) further stated that the department is responsible for formally reporting the incident to the appropriate authorities and initiating a thorough investigation to determine the facts and ensure accountability. These steps are taken to protect the client and uphold the program's integrity. On December 11, 2025, at approximately 11:00 am, during an interview with (R#1), they stated that the alleged incidents occurred approximately 15 times over a period of three months. When asked whether the incidents were reported to facility staff immediately after they occurred, (R#1) stated that they did not report them at the time because they believed the behavior would stop on its own. In addition, (R#1) stated that since the report was made, (R#1) indicated that the facility has “placed a camera in their room” to monitor their safety. When asked if they currently feel safe living at the facility, (R#1) responded affirmatively, stating that they do feel safe now. On December 11, 2025, at approximately 11:20 am, during an interview with (R#2), they stated that they do not engage in conversation with (R#1) and simply share the room for sleeping purposes. Also, (R#2) reported no knowledge of any concerns or complaints made against them by either their roommate (R#1) or facility staff. In addition, in response to the allegation of inappropriate physical contact involving (R#1), (R#2) firmly stated that they have never touched (R#1) in a sexual or harmful way and that they always maintain respectful and appropriate behavior toward them. When asked whether they feel safe living at the facility, the individual responded affirmatively. Evaluation Report continues LIC 9099-C On December 11, 2025, at approximately 11:30 am, during interviews with residents (R#3-R#10), (8) out of (8) stated that the facility consistently responds in a positive manner when asked about the facility’s response to resident concerns regarding safety, privacy, or personal well-being and, they affirmed that staff respond appropriately to both serious concerns and minor requests for assistance, based on their personal observations. In addition, (8) out of (8) residents stated that they have not observed or heard of any concerning incidents involving (R#1) and their roommate (R#2), and they feel safe living here. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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. An exit interview was conducted, and a copy of the Complaint Report was given to Ginger Enriquez/ Facility Administrator.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 11-AS-20251205101712

Allegation investigated: Staff did not seek medical attention for resident in a timely manner.

On October 21, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit at this facility. Ginger Enriquez the administrator greeted LPA. LPA explained that the purpose of this visit was to gather information for the allegation mentioned above. The investigation consisted of the following: An interview with Resident #1 to #10 (R1-R10) and Staff #1 to Staff #4 (S1-S4). A copy of the Facitliy Roster (dated 10/21/25), Register of Facilty Resident LIC 9020, Personnel Report LIC 500, (dated 10/03/25), Resident Face Sheet (dated 10/03/23), Identification and Emergency Information Lic 601 (dated 10/10/23), Admissions Agreement (dated 10/03/23), and Consent for Emergency Medical Treatment LIC 627C (dated10/10/10/23), Physician’s Report LIC 624 (dated 03/27/25), Preplacement Appraisal Information LIC 603 (dated 08/26/23), and Medication Administration Record (dated 10/01/25 to 10/31/25) and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not seek medical attention for resident in a timely manner. The complaint alleges that facility staff failed to promptly seek medical attention for Resident #1 (R1). Reports indicated that (R1) was very sick, yet the staff did not take any action to treat the illness. (R1) is experiencing cold symptoms and, although other residents are also ill, suspects it may be COVID-19, which raises concerns given (R1's) other underlying health issues. No additional information regarding this situation was provided. On October 03, 2025, and October 21, 2025, between 09:50 AM and 03:45 PM, the Department interviewed staff members identified as Staff #1 through Staff #4. Four (4) out of the four (4) staff members could not support the allegation. Each of them confirmed that no COVID-19 cases had been reported among the facility's residents or staff. Staff members (S1-S4) stated that the facility continues to take proactive measures to stay up to date on COVID-19 vaccinations, practice good hygiene, wear masks, maintain distance from individuals who are ill, and isolate those individuals when necessary. According to the information from (S1-S4), (R1) is independent and capable of self-care with no requirement of assistance with activities of daily living, leave the facility every day, and do not have any mental health conditions. (R1) only requires assistance with daily medication administration. (S1-S4) confirmed that (R1) exhibited no symptoms of cold or flu, and no symptoms were ever observed that would require immediate medical attention. (S1-S3) reported the residents are actively monitored for cold or flu symptoms. When symptoms are observed, primary physicians are promptly notified. Should these symptoms persist for multiple days, hospitalization may be necessary, as recommended by the physician. On October 03, 2025, and October 21, 2025, between 9:35 AM and 03:45 PM, the Department interviewed resident members identified Resident #1 through Resident #10 (R1-R10). Nine (9) out of the ten (10) resident members could not corroborate this allegation. Eight (8) out of the ten (10) confirmed that they receive adequate medical attention and that staff are responsive to their medical needs. (R2), who shares a room with (R1), denied claims that (R1) is ill or showing symptoms of a cold or flu. (R2) stated that (R2) would generally be aware of (R1)'s health condition, given our close living quarters, and that (R2) would report to staff immediately if either of them was ill. (Evaluation Report continues LIC 9099-C) (R1) mentioned that (R1) experienced a minor cough a few weeks ago, which did not require medical treatment. Although it persisted for several days, (R1) did not have any COVID-19-related symptoms. (R1) stated that (R1) continues to receive daily assistance with medication administration from the staff and is satisfied with the care services provided. (R1) stated to be independent and have no mental condition and can freely advocate for self. The Department reviewed (R1’s) Resident Face Sheet (dated 10/03/23), Identification and Emergency Information LIC 601 (dated 10/10/23), Admissions Agreement (dated 10/03/23), and Consent for Emergency Medical Treatment LIC 627C (dated 10/10/10/23). Further review of the Physician’s Report LIC 624 (dated 03/27/25), Preplacement Appraisal Information LIC 603 (dated 08/26/23), and Medication Administration Record (dated 10/01/25 to 10/31/25) verified (R1) is capable of self-care with no mental health conditions and requires only assistance with medication. During visits on October 3, 2025, and October 21, 2025, the Department did not observe any residents or staff displaying symptoms of illness. The Department observed the facility's infection control practices with screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. The Department observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated infection control posters were posted. Additionally, the facility had not reported any COVID-related cases to Community Care Licensing. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. No deficiencies issued. An exit interview was conducted with Ginger Enriquez, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 11-AS-20251002090122

Allegation investigated: Staff wrongfully evicted resident.

On 09/25/2025, Licensing Program Analyst (LPA) Pamela Bunker conducted an subsequent visit to gather information regarding the above allegation. LPA met with Ginger Enriquez, Assistant Administrator, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On September 03, 2025, the following documents were reviewed and obtained as part of the investigation: Personnel Report (dated 09/03/2025), Resident Roster (dated 09/03/2025), 30-day Eviction Notice (dated 08/08/2025), Unusual Incident Report (dated 08/20/2025), Admission Agreement (dated 10/24/2023) Identification and Emergency Information (dated 10/24/2023 ), Physician’s Report (dated 03/27/2025), Medical Assessment (dated 03/27/2025), Medication Administration Records (MARs) (dated 08/01/2025-09/01/2025), Appraisal & Needs and Services Plan (dated 11/13/2024), Functional Capability Assessment (dated 11/13/2024), Preplacement Appraisal Information (dated 11/13/2024), Personal Rights (dated 10/24/2023), Consent Forms (dated 10/24/2023), House Rules (dated 10/24/2023), Los Angeles County Sheriff Report (date 08/20/2025), See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 and Unusual Incident Reports (dated 07/18/2025 - 09/02/2025). On 09/25/2025, at 11:40 A.M. - 4:00 p.m., LPA Bunker interviewed Staff members #1-#4 (S1-S4) and residents #1-#8 (S1-S8). The investigation revealed the following: Allegation: Staff wrongfully evicted a resident. It has been alleged that staff wrongfully evicted a resident. On September 3, 2025, and September 25, 2025, LPA Bunker interviewed staff members #1 through #4 (S1–S4). LPA asked whether any resident was being wrongfully evicted. All four staff members interviewed (4 out of 4) answered no. They stated that R1 is still a resident and did not receive a three-day eviction notice. LPA Bunker reviewed R1’s Admission Agreement, which was dated and signed on October 24, 2023. On the same date, R1 also signed the House Rules. LPA Bunker reviewed Unusual Incident Reports dated between July 18, 2025, and September 2, 2025, and observed 14 incidents involving R1’s ongoing aggressive behavior toward staff and residents, including combative actions and harassment. S1-S4 stated that the 30-day eviction notice and the Special Incident Reports were submitted to CCLD in a timely manner. LPA also reviewed the Los Angeles Sheriff’s report dated August 20, 2025, and a 30-day eviction notice dated August 20, 2025. There is no record on file indicating that the facility provided R1 with a three-day eviction notice or that staff wrongfully evicted resident #1. Staff members #1 through #4 (S1–S4) denied the allegation. LPA interviewed residents #1 through #8 (R1–R8). Residents interviewed (7 out of 8) answered no when asked if a resident was being wrongfully evicted. R1 stated that staff provided a 30-day eviction notice dated August 20, 2025, and confirmed that they never received a three eviction notice and no hard copy of a three-day notice was provided. Seven out of eight residents denied the allegation. See Continued LIC9099-C page 3 Continued LIC9099-C page 3 Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099 and LIC9099-C was provided to the facility Med Tech/Resident Coordinator Julie Villanueva. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 11-AS-20250827083449

Allegation investigated: Staff Physically assaulted resident causing injury.

On 07/07/2025, Licensing Program Analyst (LPA), Antonine Richard conducted an initial visit to gather information regarding the above allegation. LPA met with Enriquez Ginger, the assisted living Administrator, and the purpose of the visit was explained. LPA toured the facility. The investigation included the following steps: On July 7, 2025, LPA Richard reviewed and collected various documents, including the Facility Resident Roster (dated July 7, 2025) and the Personnel Report LIC 500 (also dated July 7, 2025). Additionally, LPA obtained and reviewed Resident #1's (R1) Face Sheet for ID and Emergency Information LIC 601 (dated April 21, 2025), the Physician Report LIC 602A (dated December 20, 2024), and the Preplacement Appraisal Information LIC 603 (dated April 21, 2025). Other documents reviewed included the Admissions Agreement LIC604A (dated April 21, 2025) and the Appraisal/Needs and Services Plan (dated April 21, 2025), along with any other relevant records related to this allegation. Interviews were conducted with residents #2-#7 (R2-R7), staff members #1-5 (S1-S5), and the Client Wellness Program Manager (CWPM) from DHS. Unsubstantiated Allegation: Staff physically assaulted resident causing injury. The complaint alleges that the staff " verbally and physically abused the resident, resulting in bruises, scratches, on left knee and left wrist" On July 7, 2025, between 9:20 AM and 10:45 AM, the LPA interviewed five staff members (S1-S5), all of whom denied the allegation and stated that no staff member has ever hit or verbally abused a resident in their care. Later, on the same day, from 11:00 AM to 01:00 PM, LPA Richard interviewed eight residents (R2-R9). Seven out of eight residents denied the allegation, affirming that the staff never verbally abused or physically hit them or witnessed staff hitting any residents. However, they reported having observed residents fighting among themselves, with staff intervening to separate them. At 12:10 PM on July 7, 2025, LPA Richard called and spoke with the Client Wellness Program Manager (CWPM) from DHS. The CWPM denied the allegation and mentioned that they are collaborating with the Medical Case Worker (MCW) from DHS to transfer Resident #1 (R1) to a different facility, as R1 requires a higher level of care. (Evaluation Report continues LIC 9099-C) Additionally, LPA reviewed incident reports and photos of R1, dated July 1, 2025, which showed no bruises or scratches on R1's left wrist or arms. LPA was unable to interview R1 because the resident was in the hospital. Based on the information collected, there is no evidence to support the allegations made. Based on information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the LPA found no evidence to support the allegation mentioned above. 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. A copy of the report was provided to the Assisted Living Administrator Ginger Enriquez.the state’s words, verbatim · CDSS document, Jul 7, 2025 · control 11-AS-20250703114547

Type of visit: Case Management - Annual Continuation

On 04/23/2025 at 1:40pm , LPA Zina Brown conducted an unannounced continuation annual visit using the CARE Inspection Tool. LPA met with the Administrator Ginger Enriquez. and the purpose of today’s visit was explained. During the initial unannounced annual inspection on 4/14/2025, between the hours of 11:30am - 3:15 pm, LPA conducted a records review of (11) resident records. LPA conducted a records review for (2) is on hospice care plan, and out of the eleven (11) residents records reviewed from the initial unannounced annual inspection: (1) is on home health care and (3) residents have Personal & Incidental Today on 04/23/2025, between the hours of 1:45pm - 3:00pm, LPA conducted a records review for: (1) Home health resident record (2) Hospice care plan resident records (3) LIC405: Record of Clients/Residents Safeguarded Cash Resources (Personal & Incidental) Staff training (for the year of 2024 from January - December) All client records were complete & all staff records were incomplete and LPA do not observe any discrepancies at the time of visit.No deficiencies were cited during the time of visit. An exit interview conducted with Ginger Enriquez and a copy of the report is provided.the state’s words, verbatim · CDSS document, Apr 23, 2025

Type of visit: Required - 1 Year

On 04/14/2025 at 9:30am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. At 10:15 am, LPA met with Administrator Ginger Enriquez. LPA Brown explained the purpose of today’s visit. The facility is licensed to operate for (230) non-ambulatory residents ago 60 and above with an approved hospice waive for (10) residents and dementia special program - facility has a delay egress unit for 68 residents. Currently, the facility has a total of 158 residents of which (53) are non-ambulatory residents, (105) are ambulatory residents. Also, the facility has (43) residents on home health, (2) on hospice care, (43) residents diagnosed with dementia, (33) residents are incontinent, (19) of the residents are in assisted living and (14) are in memory care The facility annual need are current. The facility has liability insurance with Notting Hill Risk Retention Grp (NAIC #17052): Policy Number ANH0000205-00 with effective dates 10/16/2024 - 10/16/2025. The facility is a two story structure located in a commercial neighborhood which consists of the following: (27) resident bedrooms in Arbor Unit and (119) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, an activity room, a dining area, a kitchen, and outside patio area. Between the hours 10:23 am - 11:30am of LPA and administrator toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. The resident rooms inspected: in memory care room #4, #9, #10, #13, #24 and in room #36, #148, #163, and #206 in assisted living. All call buttons were in working condition. Bathrooms were operational with water temperature measured at 106.9 – 120 degrees F. Report continues on LIC 809-C. Between the hours of 11:30am - 3:15 pm, LPA conducted a records review of (11) resident records, (11) staff records, (11) Client Medication Administration Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit and did not observed any discrepancies at the time of visit. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. On 11/14/2024, the fire department conducted an inspection for the alarm, smoke detectors and the fire extinguishers were charged and operable in each resident's room. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. Due to time constraints LPA will continue the annual inspection at a later date. No deficiencies were cited during the time of visit, but deficiencies maybe issued at a later date. An exit interview conducted with Ginger Enriquez and a copy of the report is provided.the state’s words, verbatim · CDSS document, Apr 14, 2025

Type of visit: Case Management - Incident

On 11/18/24, Licensing Program Analyst (LPA) Ernand Dabuet initiated an unannounced Case Management visit at this facility. LPA met with Resident Care Coordinator RCC #1 (RCC#1) Gabby Eusebio. LPA explained the purpose of this visit is about an incident on 08/05/24 associated with resident #1 (R1) and staff #1 (S1) in the Arbor Hall Memory Care Unit. El Segundo Regional Office received an LIC 624 Incident Report (dated: 11/11/24). Information revealed on 11/05/24, approximately 01:00 am, (R1) from Arbor Hall was discovered not in the room or any part of the facility. The care staff on duty search for (R1) outside grounds of the facility but did not find (R1). The care staff contacted the Carson Sheriff's Department. On 11/12/24, (LPA) Dabuet followed up with Administrator and was informed not having any notion how (R1) was able to leave the Arbor Hall (memory care unit) when exit doors are controlled egress locking system. The facility is also has surveillance cameras in the common areas to monitor daily activities. The Resident Care Coordinator contact local emergency rooms in search for (R1). Later late afternoon on 11/12/24, (R1) was found by Fullerton Police Department and was taken to Anaheim Global Hospital for observation. Interviews with the Administrator and Resident Care Coordinator verified (R1) eloped from the facility without care supervision. A review of (R1's) Physicians Report LIC 602A (dated: 03/31/23) revealed that (R1) has wandering behavior and is not able to leave the facility unassisted. Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, "NEGLECT and LACK OF CARE AND SUPERVISION". California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. Exit interview was conducted with Gabby Eusebio, Resident Care Coordinator and a hard copy of the report along with appeal rights.the state’s words, verbatim · CDSS document, Nov 18, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Nov 19, 2024

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:.(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement was not met as evidence by: Based on LPA interviews conducted and record reviews, the Licensee failed to ensure to address R1's history of wandering behavior and went missing, while unsupervised by facility staff. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 18, 2024

Plan of correction: Licensee agrees that a Plan of Correction will be submitted to CCLD by 11/19/24, Administrator agreed that Arbor Hall staff will be advised to be on "high alert" meaning being more vigilant in monitoring all access exit door and windows while a Plan of Correction is developed by POC date 11/19/21 to the licensing office.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87466 · Plan of correction due date: Dec 2, 2024

87466 Observation of Resident -The licensee to ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. Based on LPA interviews conducted and record reviews, the Licensee was aware of of R1's history of wandering behavior failed to ensure proper supervision was in in place. This violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 18, 2024

Plan of correction: Licensee shall have a written plan to ensure that in addition to the resident's needs and services plan a specific plan is drafted for each resident's change in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The plan must be submitted by POC date 12/02/24 to the licensing office.

Allegation investigated: Lack of supervision resulting in physical altercations between residents.

On 10/21/24, the Community Care Licensing (CCL) associate made an unannounced visit to this facility and was greeted by Administrator (S1: Ginger Enriquez). The purpose for today’s visit is to gather information pertaining to the above-mentioned allegation. The investigation consisted of the following: A health and safety inspecton, interviews, and collection of records. (CCL) associate reviewed the following documents: Facility Resident's Roster (dated: 10/21/24); Personnel Report LIC 500 (dated: 10/21/24); Resident #1 and #2 (R1-R2) Resident Face Sheet ID and Emergency Information LIC 601 (dated: 10/24/23); Physician Report LIC 602A (dated: 07/14/23 & 06/28/24), Preplacement Appraisal Information LIC 623 (dated: 10/23/23); Admissions Agreement LIC604A (dated: 07/23/24 & 10/24/23); and other pertinent records in association with this allegaitoin. Interviews with residents #1-#10 (R1-R10), staff #1-S3 (S1-S3), and witnesss #1 (W1). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not prevent residents from engaging in physical altercation. The details of this complaint alleged that due to a lack of facility supervision residents engaged in an altercation. It is reported that Resident #1 (R1) is being repeatedly hit on the back of the head by Resident #2 (R2) while both are in the dining room. The administrator has been informed of the incidents and (R1) has been ignored. Further details indicated that there have been no injuries. On 03/21/24 between 09:50 am – 12:20 pm, the Department interviewed (10) out (10) resident #1 - #10 were unable to corroborate the allegation. Eight (8) out (10) residents #2 - #10 (R2-R10) revealed themselves unable to verify these incidents, and no one observed any act of aggression on a resident. (R2-R10) stated that staff are responsive and will not tolerate inappropriate behavior from residents. (R1) was interviewed and was unwilling to provide a statement. (R1) claimed there is no issue with (R2). (R2) was interviewed and stated engagements with (R1) are friendly. (R2) described an incident last week where (R1) inappropriately addressed other residents in the dining hall. (R2) had enough of (R1’s) behavior and confronted (R1) and made (R1) aware of the improper verbal actions. (R2) claimed there was no physical altercation and that the administrator consulted (R1) and (R2) about the incident. (R2) indicated and (R1) are in kind terms. On 03/21/24 between 10:10 am – 11:20 am, the Department interviewed (3) out of (3) staff #1-#3 (S1-S3) who denied an altercation between (R1) and (R2). (S1) claimed last week, (S1) was made aware of verbal exchanges between (R1) and (R2). Both residents were consulted for their actions and given a verbal warning. (S1-S3) have experienced or witnessed (R1) have made offensive comments about other residents. (R1) has been consulted repeatedly and informed that this behavior is unacceptable according to (S1-S3). On 03/21/24 between 11:04 am – 11:22 am, the Department interviewed a family representative of (R1) witness #1 (W1). (W1) claimed to be unaware of any incident involving (R1) and (R2). (W1) described (R1) as being a strong head, and if (R1) did not want to volunteer a statement or stated to disregard it, it is mostly likely that (R1) was at fault. (Evaluation Report continues LIC 9099-C) (W1) claimed that (R1) does not have a pattern of engaging in improper verbal attacks on others, unless (R1) has been provoked. (W1) verified that the administrator has reached out to (W1) for (R1) insensitive comments towards other residents. Based on the gathered information, there is no evidence to support the allegations mentioned above. Based on information collected, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. 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 with Ginger Enriquez, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Oct 21, 2024 · control 11-AS-20241014093112

Type of visit: Case Management - Incident

On 09/06/24, Licensing Program Analyst (LPA) Ernand Dabuet initiated an unannounced Case Management visit at this facility. LPA met with Resident Care Coordinator RCC #1 (RCC#1) Gabby Eusebio and Assistant Administrator #1 (A#1) Ginger Enriquez. LPA explained the purpose of this visit is about an incident on 08/05/24 associated with resident #1 (R1) and staff #1 (S1) in the Arbor Hall Memory Care Unit. El Segundo Regional Office received an LIC 624 Incident Report (dated: 08/12/24). Information revealed on 08/05/24, approximately around noon, (R1) was in the dining room for lunch grabbed a Lorazepam medication from another resident sitting next to (R1), and swallowed it. On the evening of 08/05/24, (R1) had an unwitnessed fall in (R1’s) room and sustained a laceration behind the right ear. On 09/06/24, an interview with Resident Care Coordinator (RCC#1) and Assistant Administrator (A#1) verified the incident and communicated that it was the negligence of (S1) to leave medications unattended. (S1) failed to supervise and allowed for (R1) to have access to medications that were not prescribed to (R1). (RCC#1) and (A1#1) both claimed that (S1) withheld information from management and did not report the incident immediately to them. The hospice team examined (R1) and assessed the laceration after (S1) reported it to (R1's) hospice. Interviews with the CV Hospice nurse and (R1’s) authorized representatives verified the incident with the medication error may have been attributed to the unwitnessed fall with injuries. However, medication records for (R1) revealed (R1) is prescribed Lorazepam as a (PRN). Interviews were not available for (R1) and (S1). (R1) had voluntarily terminated residency on 08/31/24, and (S1) was terminated from employment. (Evaluation Report continues on LIC 809-C) Based on observations, interviews, and record reviews, a preponderance of evidence standard has been met. (S1) failed to carry out the responsibilities and duties of a caregiver who failed to store medications and inaccessible to residents in care. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 809-D. An exit interview was conducted with Ginger Enriquez, Assistant Administrator, and a hard copy of the report along with appeal rights.the state’s words, verbatim · CDSS document, Sep 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Sep 7, 2024

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on interviews and record review, (S1) failed to carry out the duties and responsiblites and left medication unattended and accessible to (R1) with dementia. This violation poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Licensee/Administrator agreed to comply with and review Title 22 Regulation, Section “Care of Persons with Dementia" and will ensure all staff complete Medication Training. A sign-in sheet with all staff who completed the training is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov

Allegation investigated: Resident sustained unexplained bruising while in care. Facility staf did not seek medical attention in a timely manner. Facility staff did not allow resident visitation.

On 08/17/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit at this facility. LPA was greeted by receptionist Jessica Ponce. LPA explained the purpose of this visit was to deliver findings for the allegations mentioned above. The investigation consisted of the following: Investigation visits conducted on 07/19/24, 0813/24 and 08/17/24. A tour of the physical plant, interviews, and collection of records. LPA Dabuet reviewed the following documents: Facility Resident's Roster (dated: 07/19/24 & 08/13/24); Personnel Report LIC 500 (dated: 07/19/24 & 08/13/24); Resident #1 (R1's) ID and Emergency Information LIC 601(dated: 08/20/21); ) Physician Report LIC 602A (dated: 03/27/24), Preplacement Appraisal Information LIC 623 (dated: 08/17/21); Unusual Incident Report LIC 624 (dated: 06/24/24 and 06/30/24); Harbor UCLA Medical Records (dated: 06/08/24); Facility’s Body Assessment Chart (dated: 06/08/24 and 06/29/24): Southern California Hospital Medical Records (dated: 07/03/24), SeniorDoc Medical Notes (dated: 01/31/24 -06/26/24); Medication Administration Record (dated:06/01/24-06/30/24), and other pertinent records associated with this complaint. Interviews with residents #1-#11 (R1-R11), staff #1-S4 (S1-S4), and witnesss #1-#7 (W1-W7). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Resident sustained unexplained bruising while in care. The details of the complaint alleged resident #1 (R1) had sustained unexplained bruising while in care at this facility. (R1) was found with suspicious bruises. The report did not provide any further details. Investigation revealed resident #1 (R1) was admitted at Carson Senior Assisted Living (CSAL) on 08/20/21 according to Identification and Emergency Information (dated: 08/20/21). (R1) voluntarily terminated residency from (CSAL) on 06/30/24. Physician’s Report (dated: 03/27/24) and Preplacement Appraisal Information (date: 08/17/21) identified (R1) can self-care is independent and requires assistance only with dispensing medications. Records indicated (R1) had no history of skin condition or breakdown. On 06/06/24 at 05:30 pm, (R1) was hospitalized at Harbor UCLA Medical Center (HUCLAMC) due to abdominal pain on the left side and general weakness per Incident Report LIC (dated: 06/06/24). (HUCLAMC) medical records (date: 06/08/24) revealed (R1) was treated for UTI/Pyelo with possible colitis. On 08/13/24 between 10:10 am - 02:45 pm, the Department interviewed (4) out of (4) staff #1-#4 (S1-S4) who reported knowing a bruise on (R1’s) left hand/wrist. (S1-S4) explained they were aware of the bruised hand/wrist as it was documented by (S3) on the facility’s Body Assessment Chart (dated: 06/29/24). Written remarks indicated (R1) was showered. No scratches the body is clear and clean. Bruise on left hand indicated by (S3) on 06/29/24. (S1-S4) described (R1) is diagnosed with mental deterioration but is independent and can self-care. (R1) was not on home health or hospice care. (S1-S4) claimed that (R1) is non-ambulatory and requires assistance with assistive devices. (S1-S4) stated that (R1) was not on any required medical restraint while in care. (R1) had no accidents or falls or physical wrangles. As being independent (R1), to have minimal social interactions with other residents or staff. Interactions were defined with family representatives who came to visit or take (R1) out in the community. (S1) was being examined monthly by (R1’s) internal primary physician. SeniorDoc Medical Notes (dated: 06/26/24) verified (R1) was examined and no signs of falls, wounds, bruises, or skin breakdowns in the last six months. (Evaluation Report continues on LIC 9099-C) On 08/13/24 between 10:30 am -01:16 pm, the Department interviewed (10) out of (11) residents #2-#11 (R2-R11) who are unable to corroborate this allegation. (R2-R11) claimed they have never experienced or known a resident who has sustained bodily bruises while in care. As a result of the Department reviewing (R1) Physician Report LIC 602A (dated: 03/27/24), Preplacement Appraisal Information LIC 623 (dated: 08/17/21); Unusual Incident Report LIC 624 (dated: 06/24/24 and 06/30/24); Harbor UCLA Medical Records (dated: 06/08/24); Facility’s Body Assessment Chart (dated: 06/08/24 and 06/29/24); Southern California Hospital Medical Records (dated: 07/03/24), SeniorDoc Medical Notes (dated: 01/31/24 -06/26/24), revealed while hospitalized, (R1) was administered Intravenous (IV) between (06/06/24-06/07/24); (R1) was on medical restraint devices between 06/30/24 – 07/07/24. Medication Administration Record (dated:06/01/24-06/30/24) revealed (R1) is on twenty (20) routine medications. Eleven (11) out of twenty (20) prescribed medications have side effects related to unusual bleeding and bruising according to the National Institute of Health (ref: NIH). Based on the gathered information, there is no evidence to support the allegation mentioned above. Allegation #2: Facility staff did not seek medical attention in a timely manner. The details of the complaint alleged facility staff did not seek medical attention for resident #1 (R1) in a timely manner. It was reported that (R1) required immediate medical attention and the facility staff refused to assist on 06/30/29. The report did not provide any further details. On 08/13/24 between 10:10 am - 02:45 pm, the Department interviewed (4) out of (4) staff #1-#4 (S1-S4) who reported were aware that (R1) was sent out for further medical evaluation at a local hospital on 06/30/24. (S2) indicated family representatives came for a visit on 06/30/24 and felt a concern for (R1’s) requiring immediate 911 (EMS) medical attention. (S2) did not contact Emergency Medical Services (EMS) as (R1) was not having a life-threatening condition. (S2) described that (R1) was not badly hurt, in danger, distressed, fainted, collapsed, persistent chest pain or difficulty breathing was the reason (S2) refused to contact 911 (EMS). Instead, (S2) contacted a regular ambulance to transport (R1) to Southern California Hospital for further medical evaluation on 06/30/24 at 5:35 pm. (Evaluation Report continues LIC 9099-C) (S1-S4) claimed that (R1) was medically evaluated by a monthly internal medical physician. (R1) was observed daily for vital signs and monitored hourly by staff. Assessments were conducted on the body. (S1-S4) claimed that (R1) was medically evaluated by a monthly internal medical physician. (R1) was observed daily for vital signs and monitored hourly by staff. Assessments were conducted on the body. A change of condition was recorded and notified to (R1's) physician. (S1-S4) refuted the allegation the staff did not seek medical attention is untrue. On 08/13/24 between 10:30 am -01:16 pm, the Department interviewed (10) out of (11) residents #2-#11 (R2-R11) who are unable to support this allegation. (R2-R11) claimed they are medically assisted by the facility’s internal medical physicians or their external primary physicians in a timely manner. On 08/13/24 between 09:45 am -03:30 pm, the Department interviewed family representatives (1) out of (4) witnesses #1-#4 (W#1-W#4) who had observed a bruise and concerned for (R1) not feeling well during the visit on 06/30/24. (W1) was one of the individuals who felt that immediate medical attention was necessary. (W1) verified that an ambulance was dispatched to transport (R1) to the hospital. (W2-W4) claimed to have no issues with residents seeking medical attention as medical assistance is provided internally by the medical physicians. (W2-W4) stated they are notified by the facility staff if there’s any change in the resident’s condition. As a result of the Department reviewing (R1) Physician Report LIC 602A (dated: 03/27/24), Preplacement Appraisal Information LIC 623 (dated: 08/17/21); Unusual Incident Report LIC 624 (dated: 06/24/24 and 06/30/24); Facility’s Body Assessment Chart (dated: 06/08/24 and 06/29/24); SeniorDoc Medical Notes (dated: 01/31/24 -06/26/24), Medication Administration Record (dated:06/01/24-06/30/24); Change of Condition Notification Chart (dated: 06/18/24 and 06/23/24); Arbor Hall Resident 1 Hour Monitoring (dated: 06/01/24 – 06/30/24); Hospital List Char 01/01/24 - 06/30/24); Monthly Weight Record (dated: 01/04/24 – 06/05/24), revealed (R1) was monitored daily for any change of condition, and notifications were sent to (R1’s) primary care physician promptly. Based on the gathered information, there is no evidence to support the allegation mentioned above. Allegation #3: Facility staff did not allow resident visitation. The details of the complaint alleged the facility staff did not allow resident #1 (R1) visitors. The report indicated (R1) was denied visitors during 06/16/24 – 06/30/24. (Evaluation Report continues LIC 9099-C) On 08/13/24 between 10:10 am - 02:45 pm, the Department interviewed (4) out of (4) staff #1-#4 (S1-S4) and stated this allegation is untrue. (S1-S4) claimed that (R1) was often seen with visitors at the facility. It was common for family representatives to conduct visits outside or inside the facility. (S1) indicated there were some occasions when (R1) did not want to go outside and family did not want to visit inside and another time when (R1) did not welcome a visit and only wanted a phone conversation with family. . On 08/13/24 between 10:30 am -01:16 pm, the Department interviewed (10) out of (11) residents #2-#11 (R2-R11) who are unable to validate this allegation. (R2-R11) said visitors are welcome, and they have no knowledge of or experience with visitors not receiving access. On 08/13/24 between 09:45 am -03:30 pm, the Department interviewed family representatives (4) out of (4) witnesses #1-#4 (W#1-W#4) claimed they were unable to support this claim. (W1) stated (W1) was never denied visits with (R1). The Department reviewed the facility’s Visitation Records (dated: 06/01/24 – 06/30/24), and records revealed (R1) had routine visits on 06/10/24, 06/11/24, 06/16/24, and 06/30/24. Based on the gathered information, there is no evidence to support the allegation mentioned above. Between 08/05/24 - 08/13/24, the Department made several attempts to interview resident #1 (R1) by telephone who is now recovering at St. Francis Hospital. (R1) was unwilling and unable to communicate in full conversation. Between 08/06/24 – 08/14/24, the Department attempted to interview family representatives of (R1) witnesses #5-#7 (W5-W7) by telephone who were unavailable for statements. 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 Beverly Malacas , and copies of the reports were provided.the state’s words, verbatim · CDSS document, Aug 17, 2024 · control 11-AS-20240717143242

Allegation investigated: Staff withheld residents' medication, which resulted in their hospitalization

On 8/13/2023 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Ginger Enriquez /Administrator. LPA explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Resident’s interviews (R#1-R#9) and Staff Interviews (S#1-S#4). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#5) Identification and Emergency Information, (R#1-R#5) Admissions agreements, (R#1-R#5) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#5) Needs and Services Plan, (R#1-R#5) Medication Administration Record (MAR) from January 2024-June 2024 and (R#1)’s hospital records dated 2/17/24 and 3/13/24. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff withheld residents' medication, which resulted in their hospitalization. The details of the complaint alleged that facility staff withheld resident’s medications, which resulted in their hospitalization. During the records review, LPA Iniguez reviewed (R#1)’s Medication Administration Records-MAR from August 2024; LPA did not find discrepancies on the logs, and the facility documented every time (R#1) got their medications. In addition, LPA reviewed (R#2-R#4)’s Medication Administration Records-MAR from January to August 2024; LPA did not find discrepancies in the logs. Furthermore, LPA reviewed (R#1)’s hospitalization records dated 2/17/24 and 3/13/24; the medical records did not state that hospitalization was due to medication management but instead was another physical illness that (R#1) was diagnosed. During an interview with the Administrator (A#1), she stated that residents are getting their medications as prescribed by their physician and that the facility has never withheld residents’ medications. Also, (A#1) stated that no resident missed their medicines due to staff negligence. During interviews with residents (R#1-R#10), (10) out of (10) residents stated that they took prescribed medications and that they have never missed a dose due to staff negligence. Also, (10) out of (10) residents stated that the facility has never withheld their medications. Evaluation Report continues LIC 9099-C During interviews with staff (S#1-S#3), (3) out (3) facility staff stated that residents are getting their medications as prescribed by their physician and that the facility has never withheld residents’ medications. Also, (3) out of (3) facility staff stated that no resident has ever missed their medicines due to staff negligence. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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. An exit interview was conducted, and a copy of the Complaint Report was given to Ginger Enriquez /Administrator.the state’s words, verbatim · CDSS document, Aug 13, 2024 · control 11-AS-20240805102936

Allegation investigated: Staff do not allow resident to manage own funds Staff did not safeguard resident's finances

On 8/13/2023 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Ginger Enriquez /Administrator. LPA explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Resident’s interviews (R#1-R#10) and Staff Interviews (S#1-S#4). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#5) Identification and Emergency Information, (R#1-R#5) Admissions agreements, (R#1-R#5) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#5) Needs and Services Plan, (R#1-R#5) Medication Administration Record (MAR) from August 2024 copy of Social Security Administration Retirement, Survivor and Disability Insurance dated 8/4/2024. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff do not allow resident to manage own funds. The details of the complaint alleged that facility staff did not allow resident to manage their own funds. During the records review, LPA Iniguez reviewed (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A. It is written that (R#1) is not confused or disoriented, but the physician completing the form marked “A084” as an extra notation in this field. Also, (R#1) can manage its cash resources. In addition, LPA reviewed (R#1)’s Preplacement Appraisal Information or LIC 603, and it is written that (R#1) is confused. Furthermore, LPA reviewed a copy of the Social Security Administration Retirement, Survivor and Disability Insurance dated 8/4/2024; it is written that Social Security Has chosen the facility Carson Retirement Center as the representative payee for (R#1)’s monthly check. Also, the letter states that as the payee for (R#1), the facility needs to keep track of how they will use the money they send for (R#1); each year, they will ask to report on how they used it. Furthermore, LPA reviewed (R#1)’s admissions agreement. (R#1) was admitted to the facility on 2/19/2020. However, during the interview with LPA Iniguez, (R#1) stated that all these allegations happened eight years ago, back in 2016, and (R#1) was not living at that time at this facility. During an Interview with the Administrator (A#1), she stated that (R#1) used to manage their funds until Social Security deemed that the facility would manage (R#1) 's funds starting 8/4/23. The facility became (R#1) 's payee from Social Security Administration Retirement, Survivors, and Disability Insurance Services, and since the facility manages some residents' finances, they do have a Surety Bond. Also, (A#1) stated that she has not known of heard about (R#1)’s wallet being stolen or (R#1) getting physically attacked while living at the facility. Evaluation Report continues LIC 9099-C This report serves as an amendment to clarify finding. It does not supersedes the complaint investigation findings reflected on report created 8/13/24 During an interview with resident 1 (R#1), they stated that they had been here for eight years; the facility administrator manages their finances, but the administrator is taking their money from their bank account. LPA asked (R#1) how they knew the administrator was taking money from them; they said the bank told them the administrator had taken their money. LPA asked (R#1) if they had something in writing about that. (R#1) said no, all my money is under the administrators. During interviews with residents (R#2-R#10), (5) out of (10) residents stated that the facility manages their finances and P&I; those funds are from Social Security. Also, (3) out of (10) residents indicated that their families and conservator manage their finances, and (2) out of (10) residents manage their finances. In addition, (9) out of (10) residents stated that they fee safe living here. During interviews with staff (S#1-S#3), (3) out (3) facility staff stated that they do not know if (A#1) has taken money from (R#1)’s bank account and they don’t think (A#1) is not allowing (R#1) to manage their finances, they said Social Security made the facility the payee for (R#1)’s monthly check. Also, (3) out of (3) facility staff stated that they had not heard about (R#1)’s wallet being stolen or (R#1) getting physically attacked while living at the facility. Allegation: Staff did not safeguard resident's finances. The details of the complaint alleged that facility staff did not safeguard resident’s finances. During the records review, LPA Iniguez reviewed (R#1)’s Record of the Client’s/Resident’s Safeguarded Cash Resources or LIC 405 from August 2023 until August 2024; the ledger shows the amount (R#1) gets from Social Security to pay for their rent. In addition, the facility keeps a record of the leftover money as P&I for (R#1) every time they give some (R#1) signs for it. Furthermore, LPA reviewed (R#1)’s admissions agreement. (R#1) was admitted to the facility on 2/19/2020. However, during the interview with LPA Iniguez, (R#1) stated that all these allegations happened eight years ago, back in 2016, and (R#1) was not living at that time at this facility. Evaluation Report continues LIC 9099-C During an Interview with the Administrator (A#1), she stated that the facility safeguards (R#1) 's finances and the other residents; the facility uses the Record of the Client's/Resident's Safeguarded Cash Resources or LIC 405 to record the resident's finances. In addition, (A#1) stated that she has not taken money from (R#1) 's bank account, and (R#1) has not had their wallet stolen or been physically attacked while living here. During an interview with resident 1 (R#1), they stated that they had been here for eight years; the facility administrator manages their finances, but the administrator is taking their money from their bank account. LPA asked (R#1) how they knew the administrator was taking money from them; they said the bank told them the administrator had taken their money. LPA asked (R#1) if they had something in writing about that. (R#1) said no, all my money is under the administrators. LPA asked (R#1) if they felt safe living here, and they stated that no, I got hit five times in the face. Also, (R#1) stated that someone stole their wallet eight years ago. During interviews with residents (R#2-R#10), (5) out of (10) residents stated that the facility manages their finances and P&I; they feel the facility does a good job. Also, (3) out of (10) residents indicated that their families and conservator manage their finances, and (2) out of (10) residents manage their finances. During interviews with staff (S#1-S#3), (3) out (3) facility staff stated that the facility keeps a ledger or a Record of the Client’s/Resident’s Safeguarded Cash Resources or LIC 405 for the residents that received Social Security benefits. Evaluation Report continues LIC 9099-C During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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. An exit interview was conducted, and a copy of the Complaint Report was given to Ginger Enriquez /Administrator.the state’s words, verbatim · CDSS document, Aug 13, 2024 · control 11-AS-20240718111100

Allegation investigated: Staff did not ensure residents dentures were clean. Staff did not ensure residents clothes were clean. Due to staff neglect resident sustained pressure injuries. Staff did not safeguard residents' personal property. Staff did not contact authorized representative when resident became unresponsive. Staff did not notice residents change in condition.

Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Administrator (A1: Ginger Enriquez). The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: A complaint visit for health and safety check of residents in care was on 08/10/23, 04/04/24, and 06/20/24. LPA requested pertinent documents related to the allegations mentioned above: Residents’ Roster (dated: 08/10/23), Register of Facility Residents LIC 902 (dated: 06/21/21), Staff Roster & Work Schedules (date: 08/10/23), Admissions Agreement (dated 03/11/21), Physician’s Report (dated 12/13/22), Preplacement Appraisal Information LIC 603 (dated 03/11/22), Appraisal/Needs Services Plan LIC 625 (dated: 08/11/21), Identification and Emergency Information LIC 601 (dated: 03/11/21), Personal Care Log (dated 05/24/23 - 0710/23), Caregiver Notes (dated: 04/4/23 -07/10/23), One Hour Monitoring Log (dated: 04/01/23 -07/10/23) (Evaluation Report continues LIC 9099-C) Unsubstantiated Two-Hour Incontinent Check Log (dated: 05/01/23-07/10/23), Daily Body Check Log (dated: 02/02/22 - 07/10/23), and Medication Administration Records (dated 05/01/23 - 07/31/23) for Resident #1. A review of Harbor UCLA Medical Center (HUCLAMC) hospital records (dated 07/14/23) and Providence Hospice, Inc. Communication Log (dated: 12/11/22 – 07/19/23), Dental Records, Home Health Records. Interviews of family representatives (W2-W9), home health agency administrator (W1) facility staff (A1, S1-S3), and residents (R2-R10). INVESTIGATION REVEALED THE FOLLOWING: According to Identification and Emergency Information LIC 601 (dated: 03/11/21) and Admission Agreement (dated: 03/11/21) Resident #1 (R1) was a former Driftwood Nursing Center resident who was admitted to Carson Senior Assisted Living on 03/11/21. (R1) was in the care of Concise Home Health Service from (03/03/21 through 12/10/22) and Providence Hospice, Inc. from (12/11/22 through 07/19/23). The Certificate of Death (dated: 04/10/24) indicated the cause of death was Cardiorespiratory Arrest on 07/25/23. Allegation #1: Staff did not ensure residents dentures were cleaned. In the complaint, the facility staff is accused of not having resident #1 (R1)'s denture cleaned. A detailed explanation of this issue was not provided by the complainant. On 04/04/24 between 10:30 am to 03:00 pm, the Department interviewed (R1)’s family representative (W2) and reported concerns that (R1)’s dentures were always missing or lost. (W2) explained that (R1) had partial dentures as it was probably not cleaned regularly as it has gone missing. On 04/04/24 between 8:30 am to 03:30 pm, the Department interviewed (A1) and staff# 1 -#3 (S1-S3) denied the allegation. (A1 and S1) reported that (R1) wore partial dentures that were cleaned whenever they were not missing. (S1-S3) have reported there were occasions when (R1)’s dentures were discovered wrapped in tissue and disposed in (R1)’s wastebasket. (S3) claimed to have found it a couple of times in the wastebasket mistakenly disposed of by (R1). (A1-S1) claimed the facility had On-Site Dental Care to perform oral hygiene care on (R1) as indicated on progress notes (07/13/22; 08/22/22; 09/22/22,10/27/22; 12/06/22; 02/16/23). (Evaluation Report continues LIC 9099-C) According to Providence Hospice, Inc. Communication Log (dated: 12/11/22 – 07/19/23), notes indicated on 01/21/23, the hospice team spoke with (W3) and requested dentures for (R1). (W3) indicated (R1) lost denture two years back. Hospice scheduled (R1) for an oral X-ray on 02/16/23 was incomplete due to (R1) not willing to cooperate and (W3) was notified. On 04/04/24 between 09:00 am to 02:22 pm, the Department interviewed (9) out of (9) residents #2 - #10 (R2-R10) who had no issues with oral dental care. (R2-R10) confirmed that the facility provided residents who had no dental coverage on-site dental care. On 04/04/24 between 10:30 am to 03:00 pm, the Department interviewed family representatives (6) out of (6) witnesses #4 - #9 (W4-W9) claimed to have no issues with this matter. (W4-W9) were aware that on-site dental care was provided by the facility and found the service to be adequate and convenient for the residents in care. Based on the information collected, there is not enough evidence to corroborate the allegation mentioned above. Allegation #2: Staff did not ensure residents clothes were clean. Allegation #4: Staff did not safeguard residents’ personal property. It is alleged that resident #1 (R1) was seen often in dirty clothes and that (R1) was seen not in clothes that (R1) had ownership of. The complainant reported (R1) was seen often in dirty clothes and clothes that did not belong to (R1). The complainant claimed (R1)'s own clothes had (R1)’s name on them but (R1) was often seen in clothes that did not belong to (R1). The complainant did not have further details on these allegations. On 04/04/24 between 8:30 am to 03:30 pm, the Department interviewed (A1) and staff# 1 -#3 (S1-S3) all refuted these allegations. (A1 and S1) stated that (R1) was seen by a hospice aide twice weekly for dressing and grooming a part of (R1)’s daily routine. Maintaining good personal hygiene is vital to preventing ill health. (A1) and (S1-S3) expressed that (R1) required daily changes as (R1) was incontinent and would often soil clothing. (S1-S3) claimed that (R1) was only provided three outfits that would only last a few days. While clothing supplied by family members was laundered, (R1) will often be seen in donated clothing pieces. (S1-S3) claimed the clothing never appeared dirty and that donated clothing or recycled garments can never replace the appearance of new clothing. (Evaluation Report continues LIC 9099-C) On 04/04/24 between 10:00 am to 10:30 am, the Department interviewed hospice administrator witness #1 (W1) reported that (R1) was never seen in dirty clothing. (W1) claimed that a hospice aide assisted with dressing and grooming needs for (R1) twice a week. (W1) stated that her hospice team is mandated reporters, and if an act of neglect is observe it would be reported. On 04/04/24 between 09:00 am to 02:22 pm, the Department interviewed (9) out of (9) residents #2 - #10 (R2-R10) all claimed not to have concerns with their clothing appearance nor had issues with clothing not being safeguarded by staff. On 04/04/24 between 10:30 am to 03:00 pm, the Department interviewed family representatives (6) out of (6) witnesses #4 - #9 (W4-W9) reported to have no issues or concerns and that residents were found in presentable conditions and appearance in clothing when visits were conducted at the facility. A review of Providence Inc. Communication Log (dated: 12/11/22 – 07/19/23) revealed hospice aides assisted weekly with (R1)’s dressing and grooming. A review of facilities Caregiver Notes (dated: 04/04/23 – 07/10/23), One Hour Monitoring Log (dated: 04/01/23 - 07/10/23), Daily Body Check Log (dated: 02/02/22 – 07/10/23), Two Hour Incontinent Check Log (dated: 05/01/23 – 007/10/23) and Personal Care Log (dated: 05/24/23 -07/10/23) revealed (R1) is be assisted daily by staff self-care needs accordingly. Based on the information gathered, there is not enough sufficient evidence to corroborate the allegations mentioned above. Allegation #3: Due to staff neglect resident sustained pressure injuries. The complainant alleged due to facility staff negligence resident #1 (R1) sustained pressure injuries. The complainant indicated (R1) was receiving wound care and was uncertain about what stage of the wound. The staff failed to change the bandages promptly, resulting in further pressure injuries. Hospital records from Harbor UCLA Medical Center (dated: 07/14/23) indicated (R1) was admitted for general weakness and unresponsive. Medical records revealed (R1) sustained Coccyx Stage 3 pressure injury 3.5cm x 1.5 cm x 0.2 cm. Investigation revealed (R1) was admitted to Carson Assisted Living from Driftwood Nursing Center on 03/11/21. (R1) was under home health care with multiple home health agencies from (03/03/21 through 12/10/22) with a wound plan. (R1) continued wound care under Providence Hospice, Inc. from (12/11/22 through 07/19/23). (Evaluation Report continues LIC 9099-C) Providence Hospice, Inc. Communication Logs (dated: 12/11/22 – 07/19/23) revealed (R1) received continued wound care as noted in the progress notes. On 07/06/23, a wound assessment and treatment of Coccyx pressure ulcer wound is now a Staged 3. The treatment plan included three (3) times a week gauze and Hydrocolloid dressing or as needed or soiled was communicated. On 04/04/24 between 8:30 am to 03:30 pm, the Department interviewed (A1) and staff# 1 -#3 (S1-S3) all contested negligence played a role in (R1)’s care. (A1 and S1) stated when it came to (R1)'s wounds were treated by hospice medical professionals. (A1-S1) claimed the facility staff was only responsible for (R1)’s non-medical care since the facility is a non-medical care facility. (A1 and S1-S3) all stated that although they are not trained medical professionals, the facility staff is trained to take care of the residents and supervise them. (A1) stated bandages that are wet or soiled are changed by hospice only. (S1-S3) claimed Daily Body Checks, Two-Hour Incontinent Checks, and One-Hour Monitoring Checks were performed on (R1). (S1-S3) reported Caregiver Notes and Personal Care Logs as a means of communicating with staff regarding the resident's conditions verified that (R1) was receiving adequate care daily. On 04/04/24 between 10:00 am to 10:30 am, the Department interviewed hospice administrator witness #1 (W1) who reported that (R1) was under a wound care plan. Wound care treatment services continued with Providence Hospice, Inc. even after (R1) was discharged from (HUCLAMC) and was admitted to Rosecrans Care Center on 07/15/23. (W1) claimed the Carson Senior staff were not neglectful in (R1)’s care. (W1) found the facility staff was diligent, attentive, and responsive when it came to (R1)’s health care needs. On 04/04/24 between 09:00 am to 02:22 pm, the Department interviewed (9) out of (9) residents #2 - #10 (R2-R10) and reported the facility would act accordingly and immediately attend to the resident’s needs. On 04/04/24 between 10:30 am to 03:00 pm, the Department interviewed family representatives (6) out of (6) witnesses #4 - #9 (W4-W9) observed the facility staff to provide the appropriate level of care for residents and denied neglect or lack of care of residents. A review of Providence Inc. Communication Log (dated: 12/11/22 – 07/19/23), Concise Home Health Services Records (date: 03/12/21), Efficient Home Health Services, Inc Records (date: 07/13/21), and facilities’ Caregiver Notes (dated: 04/04/23 – 07/10/23), One Hour Monitoring Log (dated: 04/01/23 - 07/10/23), (Evaluation Report continues LIC 9099-C) Daily Body Check Log (dated: 02/02/22 – 07/10/23), Two Hour Incontinent Check Log (dated: 05/01/23 – 007/10/23) and Personal Care Log (dated: 05/24/23 -07/10/23) verified that (R1) was provided the appropriate wound care assistance. Based on the information collected, there is not enough evidence to support the allegation mentioned above. Allegation #5: Staff did not contact authorized representative when resident became unresponsive. The details of the complaint alleged that facility staff did not contact the authorized representative when resident #1 (R1) became unresponsive. The complainant reported that (R1)’s authorized representative was not contacted, and a non-Power of Attorney was contacted instead on 07/10/23 by staff when (R1) was hospitalized. On 04/04/24 between 8:30 am to 03:30 pm, the Department interviewed administrator #1 and staff #1 (A1 and S1) who claimed this accusation is not correct. (A1 and S1) explained that (R1) was under hospice care from (12/11/22 through 07/10/23) and that hospice is responsible for contacting the authorized representative. (S1) indicated that on 07/10/23 when (R1) was transported by Emergency Medical Services (EMS) to the hospital, the hospice nurse was attending to (R1) on that day. A hospice nurse contacted an authorized representative about the nature of (R1)'s condition, rather than a member of the facility staff. On 04/04/24 between 10:00 am to 10:30 am, the Department interviewed hospice administrator witness #1 (W1) who verified that their nurse was on duty on 07/10/23 when (R1) was found unresponsive. It is the role and responsibility of the hospice nurse to contact the authorized representative and not the facility staff. (W1) explained (R1)’s power of attorney was (W2) and had some ongoing health issues and was not available. (W1) claimed that when (W2) was not available the hospice team was instructed to contact a family member (W3) who resided out of state and an agreement that was arranged with Providence Hospice, Inc. (W1) stated the hospice team evaluates (R1)’s condition and provides updates the plan of care as symptoms and condition change, even on a day-to-day basis. On 04/04/24 between 10:30 am to 03:00 pm the Department interviewed family representative witness #3 (W3) who verified through hospice arrangement (W3) is to be contacted when (W2) is not available with (R1)’s condition. Six (6) out of six (6) witnesses #4 - #9 (W4-W9) reported although the residents are not in hospice, the facility staff provided updates and condition changes of residents to the authorized representative. (Evaluation Report continues LIC 9099-C) Providence Hospice, Inc. communication log (dated: 12/11/22 – 07/19/23) verified that the hospice nurse contacted (W2) with (R1)’s change in condition and requested to call 911 for further evaluation. The hospice medical doctor and care team were informed and adapted to the family member's decision. A review of Unusual Incident Report LIC 624 (dated: 07/10/23) the hospice nurse was at the facility who notified the facility staff to contact 911, and the nurse informed the family representative to have (R1) sent to the hospital. Based on the information gathered, the allegation mentioned above does not have sufficient evidence to support it. Allegation #6: Staff did not notice residents change in condition. It is alleged that facility staff did not observe (R1)’s change in condition. The complainant felt that the facility staff did not notice the resident's change in condition before the resident became unresponsive. (R1) was evaluated with Sepsis and a UTI when admitted to the hospital. On 04/04/24 between 8:30 am to 03:30 pm, the Department interviewed (A1) and staff# 1 -#3 (S1-S3) all refuted this allegation. (R1)'s medical needs were always taken care of by hospice medical professionals, according to (A1 and S1). (A1-S1) argued that the facility's staff were responsible only for (R1)'s non-medical care since the facility was a non-medical care facility. (A1 and S1-S3) all said that although they are not medical professionals, they are qualified to supervise and care for residents. (S1-S3) stated Daily Body Checks, Two-Hour Incontinent Check, and One-Hour Monitoring Check are performed in all shifts. (S1-S3) reported that the facility maintains Caregiver Notes and Personal Care Logs as a means of communicating with staff regarding the resident's care condition. On 04/04/24 between 09:00 am to 02:22 pm, the Department interviewed (9) out of (9) residents #2 - #10 (R2-R10) all claimed the staff were responsive to their care needs. The staff conducts routine checks throughout the day and will call out any resident’s change in condition that may require medical assistance. On 04/04/24 between 10:30 am to 03:00 pm, the Department interviewed family representatives (5) out of (6) witnesses #3 - #9 (W3-W9) expressed the facility staff are good at detecting and promptly reporting changes in resident's condition as it ensured the resident's well-being and safety. (Evaluation Report continues LIC 9099-C) A review of Harbor UCLA Medical Records (dated: 07/14/23) (R1’s) listed (17) active medications. Fourteen (14) out of (17) revealed potential side effects to unitary tract infection (UTI) or Sepsis according to (National Institute of Health NIH.gov). Facility Medication Administrator Record (MAR) (dated: 05/01/23 - 07/01/31/23) revealed that (R1) was on (27) active medications. Twenty-four (24) out of twenty-seven (27) had some association of potential side effects to (UTI) or Sepsis. A review of Providence Hospice, Inc. Communication Log (dated: 12/11/22 – 07//19/23) documented that the facility staff and hospice nurse were involved in (R1)’s change in condition. It was noted that facility staff alerted the hospice nurse of (R1)’s condition with no response starting in the morning of 07/10/23 per the staff report. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. The Department was not able to interview resident #1 (R1), due to her passing away on 07/25/223, so an interview was not possible. Based on the evidence gathered and interviews conducted, and analysis of records reviewed, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations of NEGLECT/LACK OF SUPERVISION in this complaint are found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to the Administrator (Ginger Enriquez).the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 11-AS-20230803103418

Allegation investigated: Staff neglected resident Staff withheld resident's medication Staff did not respond to resident's call assistance button in a timely manner

On 05/15/2024 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Carson Senior Assisted Living facility and was greeted by Administrator Ginger Enriquez (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Administrator A1, Staff S1-S3, Resident R1-R10, Witness W1. These interviews were conducted on 05/15/2024. LPA Calderon obtained and reviewed the following: Physician Report (dated 3/21/2024), Needs and Service plan (dated 05/15/2024), incident reports (date 05/10/2024 and 05/11/2024), Medical administration records (MAR) (date April, May 2024), preplacement appraisal (date 03/27/2024), call button log (date 04/10/2024) for R1. The investigation revealed the following: Unsubstantiated Regarding Allegation #1: Staff neglected resident. This complaint alleged that staff neglected R1. A1 states that no staff would ever neglect a resident in care. A1 states no staff would ever refuse to call 911. LPA Calderon interviewed S1-S3. 3 out of 3 staff state that they would never neglect a resident in care. 3 out of 3 staff state that staff member would not refuse to call 911 if needed or have words with a resident in care. LPA Calderon interviewed R1-R10. R1 states that staff refused to call 911 for R1 and staff called R1 names. R1 states that staff have neglected R1 care. 9 out of 10 resident states that staff do not neglect their care and they have no issues with staff. W1 states that W1 was aware of R1 calling 911 and staff refused to call 911. W1 states that unknown staff called R1 words that were hurtful. On 05/15/2024 LPA Calderon reviewed the following: Reviewed the Physician report (date 03/21/2024), R1 has health issues. Reviewed incident report (date 05/10/2024) R1 was having chest pain and staff called 911. Regarding Allegation #2: Staff withheld residents’ medication. This complaint alleged that staff withheld medication from R1. A1 states that at no time would any staff member refuse or withhold R1 or any medication from a resident in care. A1 states that accurate records are kept for any resident that takes medications. 3 out of 3 staff state that no staff would refuse or withhold any medication for R1 or any resident in care. 3 out of 3 staff state that accurate records are kept for each resident that takes medications. LPA Calderon interviewed R1-R10. R1states that staff refused to give medication to R1. 9 out of 10 residents state that no staff member has refused or withhold any medication. LPA interviewed W1 who states that facility staff refused to give medication to R1. LPA Calderon reviewed the MAR for (April, May 2024) for R1. LPA Could not find any errors for R1 MAR. Regarding Allegation #3: Staff did not respond to resident’s call assistance button in a timely manner. This complaint alleged that staff did not respond to R1 call button in a timely manner. A1 states that on average it takes 5 to 10 minutes for staff to answer resident call button. A1 states that every time a resident presses the call button the front desk answers and staff are sent to the resident’s room. 3 out of 3 staff state that it takes 5 to 10 minutes for staff to respond to a call button push. R1 states that R1 has pressed the call button and no staff responds. 9 out of 10 residents state that it takes 5 minutes for staff to respond to a call button. W1 states that W1 has noted no staff has responded to R1 call button push. LPA Calderon toured the facility and LPA pushed the call button for rooms 163, 273, 274 and 275. On average it took 5 minutes for staff to show up to the resident room and every time the call button was pushed the front desk answered. LPA Calderon noted 3 staff answered the call. Based on interviews, observations and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of “staff neglected resident” “staff withheld residents’ medication” “staff did not respond to resident’s call assistance button in a timely manner” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report were provided to the Administrator Ginger Enriquez (A1).the state’s words, verbatim · CDSS document, May 15, 2024 · control 11-AS-20240510162647

Allegation investigated: Illegal Eviction

On 04/18/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit at this facility. LPA was greeted by the Administrator Ginger Enriquez. LPA explained the purpose of this visit was to gather information for the allegation mentioned above and deliver findings. The investigation consisted of the following: A review of the facility's roster for residents and staff. Interviews with resident #1-#2 (R1-R2), administrator #1 (A1), staff #1 (S1) and witness #1-(W1-W2). Service records for resident #1 (R1), Physicians Report, Admission Agreement, Appraisal/Needs and Service Plan, and other pertinent documents associated with this complaint. A tour of the facility and (R1's) room. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Illegal Eviction. A review of (R1’s) Identification and Emergency Information LIC 601 (dated: 11/22/23), (R1) was admitted to Carson Senior Assisted Living on 11/22/23. According to facility Incident Reports LIC 624 (dated: 03/04/24 – 03/06/24), (R1) had three consecutive incidents involving staff on 03/04/24, 03/05/24, and 03/06/24, which led to (R1) being admitted at Harbor UCLA Medical Center, Exodus Recovery, Inc. Urgent Care Center and Southern California Hospital at Culver City. On 04/15/24, between 12:07 pm – and 12:57 pm the Department interviewed (2) out of (2) administrator #1 (A1) and staff #1 both denied the allegation. (A1) stated that she never issued a formal eviction notice to (R1). (A1) claimed (R1) remained a resident and that no personal belongings were removed from (R1’s) room. (A1 and S1) stated that (R1) has not been denied access inside the facility and continues to benefit from services provided by the facility. (A1) stated (R1) has received consultation on house rules. The administrator stated (C1) had three consecutive incidents on 03/04/24, 03/05/24, and 03/06/24, which would have warrant a formal eviction notice. (A1) added that if a formal eviction was implemented, (A1) would adhere to Title 22 regulations and notify Community Care Licensing in writing. In an interview with (S1), who was the staff involved in the incident on 03/06/24 with (R1), contacted 9-1-1. (S1) reported the Carson Sheriff's Department arrived at the facility and detained (R1). Later the Carson Sheriff escorted (R1) to Harbor UCLA Medical Center on 03/06/24 for medical evaluation. (A1) stated it was (R1’s) Laterman Petris Short Act (LPS) Social Worker and California State Public Guardian/Conservator who notified (R1) was transferred to Southern California Hospital at Culver City for further observation. (A1) claimed that a telephone discussion with (LPS) and the Public Guardian/Conservator about the possibility of relocating (R1) to another facility as (R1’s) needs and services may require a higher level of care. However, there have been no updates or fruition on the matter. On 04/15/24, between 01:12 pm – 01:22 pm, the Department conducted a telephone interview with (R1) who does not recall incidents that happened on 03/04/05, 03/05/25, and 03/06/24. (R1) claimed that no one at the facility has notified (R1) of an eviction and that no one has served (R1) with formal eviction in writing. (Evaluation Report continues LIC 9099-C) On 04/15/24, between 01:34 pm – 01:44 pm, the Department interviewed resident #2 (R2) a former roommate of (R1). (R2) claimed there is a reason that they are no longer roommates as (R1) does not adhere to the house rules. (R2) claimed not to have any knowledge of an eviction for (R1) but (R2) added it would not be a surprised as (R1) would be evicted, as (R1) does not follow the facility rules. On 04/15/24 at 01:23 pm – 01:33 pm, the Department interviewed California State Public Guardian/Conservator witness #1 (W1) for resident #1. (W1) confirmed that a conversation with (A1) discussed the possibility of transferring (R1) to another facility due to the incidents that occurred in March 2024 and that (R1) may require a higher level of care. (W1) stated there were no agreements of evicting the (R1) that came out of the discussion on 03/06/24. On 04/18/24 at 08:01 am – 08:23 am the Department interviewed (LPS) Social Worker witness #2 (W2) for resident #1. (W2) verified that a discussion of (R1) is being observed at Southern California Hospital at Culver City and the possibility of (R1) needing a higher level of care. (W2) claimed there were no arrangements for evicting the (R1) that came out of the discussion on 03/06/24. During the investigation on 04/15/24 and 04/18/24, the Department observed (R1) is included in the resident roster. The Department observed (R1's) personal possessions in (R1's) room. Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. 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. Although the allegation may have happened or is valid, there is not enough preponderance of evidence to evidence the alleged allegation is valid did or did not occur, therefore the allegation is "Unsubstantiated". An exit interview was conducted with Ginger Enriquez, and a hard copy was provided.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 11-AS-20240411145833

Type of visit: Required - 1 Year

On 04/05/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Ginger Enriquez. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (230) non-ambulatory elderly adults of which (10) may be bedridden ages 60 and above. Currently, the facility has (166) residents and (2) in hospice care. The facility is approved for (10) hospice residents. The facility is a two story structure located in a commercial neighborhood. It consists of the following: (35) resident bedrooms in Arbor Unit and (99) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, an activity room, a dining area, a kitchen, and outside patio area. LPA and administrator toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #13, #167, #163, #154, #2, #10,,#11, #17, #24 #213, #205 and #251, #257 and #271. All call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.2 – 115.5 degrees F. A comfortable temperature was maintained in the facility at 72 - 74 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Evaluation Report continues LIC 809-C Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. LPA conducted an audit of resident #1-#8 (R1-R8) service files, and staff #1-#8 (S1-S8) personnel files were in order and complete. The facility is current in CCLD annual fees. The facility has a current administrator certificate for Ginger Enriquez #6024770740 valid through 03/07/25 and Joe Goldman #6001171740 valid through 05/03/25. No deficiencies during this visit. An exit interview conducted with Ginger Enriquez and a copy of the report is provided.the state’s words, verbatim · CDSS document, Apr 5, 2024

Allegation investigated: Resident sustained a fracture while in care Staff failed to seek medical attention for resident in a timely manner

On 04/03/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit to the facility listed above to deliver complaint findings. LPA met with Assistant Administrator, Ginger Enriquez, and explained the purpose of today’s visit. On 04/28/23, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced complaint visit to the facility listed above. Upon arrival LPA Gibbs conducted a risk assessment before entering to ensure the facility is free of Covid-19. LPA Gibbs met with MedTech, Julie Ann Villanueva, and explained the purpose of today’s visit. We were later joined by Assistant Administrator, Ginger Enriquez. The visit consisted of LPA received documents pertinent to the investigation. The following documents were received and reviewed staff roster, client roster, physicians report, face sheet, preplacement appraisal, needs and service plan, nurse notes, and medication administration record (MAR) for R1. Continued on LIC9099-C Unsubstantiated The investigation consisted of the following: LPA conducted the initial 24-hour visit and requested copies of pertinent documents. The complaint was accepted by CCL IB Investigation Unit and assigned to IB investigator Heidy Bendana. IB investigator Bendana conducted and completed the investigation which included interviews with Assistant Administrator, facility staff, residents, resident R1’s conservator, Social Worker Director at Edgewater Skilled Nursing, and Harbor UCLA Medical Center Clinical Social worker, reviewed Harbor-UCLA Medical Center Medical Records, and resident R1 facility records. Allegation: Resident sustained a fracture while in care It is alleged staff failed to supervise Resident R1 resulting in hospitalization for a fracture. During file record review it was notated R1 is independent. R1’s Physicians Report indicated R1 was “Able to Leave Facility Unassisted,” Able to Bathe, Dress, Groom, and Feed Self,” and did not require assistance with using the restroom or transferring. Appraisal/Needs and Services Plan listed R1 as ambulatory with the capacity to self-care and able to do all ADL’s, there was no indication that R1 was a fall risk. R1 was not feeble or slow and did not require assistance. During interviews with Staff S1-S3, they were asked, by the IB investigator, if R1 required assistance, three (3) out of three (3) stated R1 is independent and did not require assistance. Additionally, Staff (S1-S3) were asked if they were aware of R1 falling, three (3) out of three (3) stated they did not know R1 experienced a fall until R1 reported it to the hospital. During an interview with Staff S2, told the IB investigator, on 04/26/23 R1 was in their rocking chair, their face droopy, their speech was stuttered and not normal, therefore S2 called 911. S2 was informed Continued on LIC9099-C by the hospital that R1 had a fall on 04/22/23. During an interview with R1’s Responsible Party (W1), conducted by IB investigator, stated they did not believe R1 was a fall risk. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff failed to seek medical attention for resident in a timely manner. It is alleged that staff did not seek medical attention for Resident R1 in a timely manner. It was reported that Resident R1 had a fall on April 22, 2023, that resulted in a left femoral neck hip fracture. During interviews, conducted by IB investigator, with Staff S1-S4, they were asked if they had any knowledge of the fall R1 had, four (4) out of four (4) stated they had no knowledge of R1 having a fall, they did not receive that information until R1 reported to the hospital on April 26, 2023, they had a fall on April 22, 2023. On April 26, 2023, Resident R1 was transferred to the hospital due to R1’s face being droopy, stuttering, and speech not being normal. During an interview with MedTech S2 stated on April 25, 2023, R1 told them they were having leg pain and had given them pain medication, and that in the past, R1 frequently complained of leg pain. Additionally, during an interview S2, stated they did not remember if R1 reported a fall. During interviews, conducted by the IB investigator, with Residents R2 and R3, two (2) out of two (2) stated they receive assistance and medical assistance in a timely manner. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were observed or cited. An exit interview was conducted with Assistant Administrator, Ginger Enriquez,, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 3, 2024 · control 11-AS-20230427130506

Allegation investigated: Staff threatened resident while in care. Staff did not safeguard resident's personal belongings. Staff did not provide a safe and comfortable environment for residents.

On 02/23/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit at this facility. The LPA was greeted by Ginger Enriquez, the administrator. The purpose of this inspection visit is to gather information regarding the allegations mentioned above and to deliver findings was explained to Enriquez. The investigation consisted of the following: A review of the facility's roster for residents and staff. Interviews with residents #1-#10 (R1-R11), staff #1-#3 (S1-S3), and administrator #1 (A1). A review of (R1's) Service Records, Physician's Report, Resident Appraisal, Face Sheet, Appraisal/Need and Service Plan, Admissions Physician's Orders, Resident Personal Property and Valuables, Admission Agreement, Medication Administration Record, and other pertinent records associated with the allegations. A tour of the facility on 02/23/24 and 11/08/23. (Evaluation Report continues LIC 9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff threatened resident while in care. Allegation #3: Staff did not provide a safe and comfortable environment for residents. The details of this allegation claimed that resident #1 (R1) was threatened by administrator #1 (A1). According to the reporting party (R1) was threatened by (A1) that (R1’s) personal property would be thrown away and that (A1) had threatened (R1) in the past. As a result of feeling threatened (R1) did not feel the facility provided a safe and comfortable environment for (R1) and other residents. On 02/23/24 at 12: 47 pm – 12: 58 pm the Department interviewed (R1) by telephone. (R1) claimed that (R1) had enjoyed living at the facility for (22). However, (R1) was threatened by (A1) who (R1) is unable able to identify by name. (R1) is unable to provide further information such as details on dates, times, and incidents that have occurred with (A1) where (R1) may have felt threatened. (R1) responded, "Yes", "I liked living there and I felt safe" when asked whether this facility provided a comfortable place to live. On 02/23/24 between 09:15 am – 10:30 am, the Department interviewed administrator #1 (A1), and staff #1-#3 (S1-S3) reported (4) out (4) verified that this allegation is untrue. (A1) claimed to have never threatened (R1) since (R1’s) residency at the facility. (S1) has simply followed up with (R1) regarding (R1’s) residency since (R1) had not returned to the facility since (R1’s) hospitalization on 09/12/23. (R1) had not given notice whether (R1) would remain as a resident. The facility continued to retain all of (R1's) personal property safeguarded and protected until (R1) had given notice to terminate residence. (S1-S4) stated that we have installed surveillance cameras, safety devices, smoke detectors, house rules, mandated elder abuse training, and emergency preparedness training to mitigate the risks of an unsafe environment. On 02/23/24 between 9:30 am – 11:50 am, the Department interviewed residents #2-#11 (R2-R11) (10) out (10) who are complimentary of (A1) and staff. (R2-R11) claimed they had not been threatened by (A1) or any of the staff. (R2-R11) all guaranteed they felt the facility has provided a safe and comfortable environment for residents. As a result of the information gathered, there is no evidence to support the allegations mentioned above. (Evaluation Report continues LIC 9099-C) Allegation #2: Staff did not safeguard resident’s personal belongings. The details of this allegation reported that the facility failed to safeguard resident #1 (R1’s) personal belongings. On 02/23/24 at 12: 47 pm – 12: 58 pm the Department interviewed (R1) by telephone. (R1) claimed the facility failed to safeguard her personal property on the day she was transported to Harbor Regional Medical Center on 09/12/23. (R1) claimed to have observed individuals in and out of (R1’s) room and that money that was stored in a portable refrigerator with a lock was stolen. (R1) could not describe the individuals nor unable to determine the roles of the individuals in the facility. On 02/23/24 between 09:15 am – 10:30 am, the Department interviewed administrator #1 (A1), and staff #1-#3 (S1-S3) reported (4) out (4) verified that this allegation is false. (A1 and S1) claimed (R1) has been a resident for 19 years and has never had any issues with property not safeguarded. (A1 and S1) reported when (R1) was admitted to the hospital on 09/12/23, (R1’s) personal belongings remained in the room locked. (A1) unaware of how long (R1) was going to be away from the facility placed all (R1’s) personal items in an unoccupied locked room room #203. The Department verified all the items listed on (R1’s) Resident Personal Property and Valuables LIC 624 which listed (14) personal property items and (14) were accountable. From 10:26 am – 10:29 am, the Department took photographs of the items as evidence. The Department observed a portable refrigerator sealed with a padlock required a key to open. On 02/23/24 between 9:30 am – 11:50 am the Department interviewed residents #2-#11 (R2-R11) (10) out of (10) all confirmed their personal belongings were safeguarded and have not gone missing. On 02/23/24 at 10:10 am, (R1) effectively voluntarily terminated her residency with the facility when (R1) authorized in writing for (R1’s) guardian witness #1 (W1) to retrieve (R1’s) personal property. As indicated in (R1’s) discharge summary, “(W1) went up to the storage room and picked out what (W1) wanted to take with (W1)”. (W1) declined to be interviewed by the Department. As a result of the information gathered, there is no evidence to support the allegation 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 violation, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Ginger Enriquez, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 11-AS-20231031134927

Allegation investigated: Facility failed to provide comfortable accomodations for residents in care.

On 01/18/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility. LPA was greeted by the Director of Resident Care Julie Villanueva. LPA explained the purpose of this visit is to gather information for the allegation mentioned above and deliver findings. The investigation consisted of the following: A review of the facility's roster for residents and staff. Interviews with staff #1-#6 (S1-S6) and witness #1-(W1). A review of the heating and air condition/HVAC invoice and other pertinent records associated with this complaint. A physical tour of the facility was conducted. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility failed to provide comfortable accommodations for residents in care. The details of the complaint alleged the facility failed to provide comfortable accommodations for residents. The complainant reported that the facility is without heat and it has been off for about a week with no plan to remedy the concern. The complainant did not provide further detailed information regarding this issue. On 01/18/24 between 9:01 am - 10:10 am, the Department interviewed (4) out of (6) staff who claimed there have been no complaints from residents in regards to heating in private rooms or the common areas. (S1-S4) stated a Resident Council meeting was held on 01/11/24 several topics were brought up during the meeting including heating accommodations. (S1-S2) claimed that the facility received multiple donated portable electric heaters and this was discussed in the meeting and it was offered to residents in need of equipment. (S3) claimed on 01/05/24, made arrangements with a reputable heating and air condition/HVAC company who came out to inspect and replace thermostats on 01/05/24 and 01/12/24 for several resident rooms and the main dining room. (S5-S6) claimed although the thermostat was replaced and it is in working condition, there is a problem with the circulation aspect with the HVAC system not blowing warm air through air vents. On 01/18/24 between 10:11 am - 11:37 am, the Department along with the maintenance supervisor (S3) inspected the entire facility. The inspection revealed in Arbor Hall area (2) out of (5) resident rooms did not have an operable HVAC system. In the Assisted Living area (2) out of (18) rooms did not have an operating HVAC system. Resident rooms that did not have an operable working HVAC systems were #5, #11, #165, and the main dining room. Room #165 did not have working thermostat between 01/05/24 through 1/18/24. Rooms inspected with working HVAC systems were the following: #2, #8, #17, #27, #37, #72, #140, #148, #158, #160, #221, #235, #241, #243, #253, #254, #255, #259, #268 and each room had of a comfortable range, between 68 degrees F. and 75 degrees F. On 1/18/24 between 1:04 pm - 1:15 pm, the Department conducted a phone interview to confirm services were performed by witness #1 (W1) the heating and air condition/HVAC company on 01/05/24 and 01/12/24. (W1) verified thermostats were serviced during the service dates mentioned. Based on information gathered, there is sufficient evidence to support the allegation mentioned above. (Evaluation Report continues LIC 999-C) Based on 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, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. Exit interview was conducted with Julie Villanueva, Director of Resident Care and a hard copy of the report along with appeal rights.the state’s words, verbatim · CDSS document, Jan 18, 2024 · control 11-AS-20240116151820

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 18, 2024

Maintenance and Operation (a) 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 is not met as evidenced by: Based on (observation), the licensee did not comply with the section cited above. LPA identified a non-working HVAC system for room #5, #11, #165 and the main dining room.immediate This violation] which poses a potential health and safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 18, 2024

Plan of correction: Licensee/Administrator will need to replace or repair the HVAC for room #5, #11, #165 and main dining area. The licensee will provide portable heaters for rooms mentioned above until services are completed. Proof of correction must be sent to LPA by email in a video at ernand.dabuet@dss.ca.gov by 02/18/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(2) · Plan of correction due date: Jan 25, 2024

87468.1 Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on (observation), the licensee did not comply with the section cited above. LPA observed non-working HVAC system for room #5, #11, #165 and the main dining room Facility failed to provide a healthful and comfortale environment. This violation which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 18, 2024

Plan of correction: Licensee/Administrator will need to provide working portable heaters for rooms #5, #11 and main dining room. Proof of correction must be sent to LPA by email in a video at ernand.dabuet@dss.ca.gov by 01/25/24.

Allegation investigated: Facility staff did not observe change in resident's health conditions. Facility neglected well care check ups for resident in care.

On 12/02/23, Licensing Program Analyst (LPA) Ernand Dabuet subsequent an unannounced complaint visit at this facility. LPA met with Med Tech Beverly Malacas, and explained the purpose of today's visit is to deliver findings for the the allegations mentioned above. The investigation consisted of the following: Interviews with staff #1-#5, residents #1-#10, witnessess #1-#5, review of staff roster, resident roster, (R1's) service records, medical records, Incontinent 2-hour check logs, and other pertinent documents associated to this complaint. A tour of the facility on 03/18/21, 07/30/21, 09/27/23, and 12/01/23. Evaluation Report continues on LIC 9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #3: Facility staff did not observe change in resident's health conditions. Allegation #4: Facility neglected well care checkups for resident in care. The details of the complaint alleged the facility did not observe the change in resident #1 (R1) condition and neglected the wellness care checkup for (R1). The complainant claimed the (R1) was exposed to an infection and had general weakness of muscles. A review of (R1's) service records and medical records revealed, (R1) medical checkups were performed with the in-house physicians. Records indicated physician visits listed: 09/20/18,11/19/18, 12/12/18, 08/28/19, 02/19/20, 12/17/19, 01/17/20, 02/19/20, 08/13/20, 08/17/20, 09/03/20, and 09/13/20. Psychiatric Assessments were conducted monthly from 12/12/18 through 12/31/20. Physician's Report LIC 602A was performed on annually on 11/19/18, 12/17/19, 01/20/20, and 02/19/20. (R1's) Appraisal/Needs and Services Plan LIC 625 were performed on 06/19/1810/16/19, 01/17/20. (R1) records indicated, that (R1) was being observed by staff every (2) hours daily on each shift according to Incontinent 2-hour check logs. On 09/27/23, interviews were conducted between 10:00 am and 3:11 pm with (9) out (9) residents #2 - #10 (R2-R10) were complimentary of staff. (R2-R10) recognized that staff have challenging duties and remain to be attentive and responsive. On 09/27/23, interviews were conducted between 10:37 am and 12:43 pm with (5) out (5) family representatives witness #1-#5 (W1-W5) reported they did not have any concerns for their health and safety and medical assistance was available for residents at all times. (W1-W5) described the care and supervision as sufficient. On 12/01/23, interviews conducted between 11:00 am and 1:00 pm (5) out of (5) staff # 1- #5 (S1-S5) claimed care and supervision for (R1) continuous around-the-clock daily. (S1-S2) claimed, (R1) did present a decline in his health condition. (R1) was being medically assessed in-house by medical professionals, and (R1's) wellness checkups were performed in the facility. Evaluation Report continues LIC 9099-C Several attempts to interview (R1) on 09/27/23 and 11/27/23 were unsuccessful. (R1’s) health condition prevented (R1) from carrying on full conversations. (R1's) Case Workers were not available for an interview. Based on all the information obtained during the investigation, there is no evidence to support the allegations mentioned above. Based on the 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 Beverly Malacas, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Dec 2, 2023 · control 11-AS-20210317104047

Allegation investigated: Facility neglect resulting in resident developing infection. Resident fell while in care.

On 12/01/23, Licensing Program Analyst (LPA) Ernand Dabuet subsequent an unannounced complaint visit at this facility. LPA met with Administrator Ginger Enriquez , and explained the purpose of today's visit is to to condcut staff interviews and deliver findings for the the allegations mentioned above. The investigation consisted of the following: Interviews with staff #1-#5, residents #1-#10, witnessess #1-#5, review of staff roster, resident roster, (R1's) service records, medical records, Incontinent 2-hour check logs, and other pertinent documents associated to this complaint. A tour of the facility on 03/18/21, 07/30/21, 09/27/23, and 12/01/23. (Evaluation Report continues on LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility neglect resulting in resident developing infection. The details of the complaint alleged staff neglected resident #1 (R1's) care, resulting in an infection. The complainant reported that (R1) has not had a wellness care checkup since 2018 which may have caused (R1) to have an inactive Hepatitis B. The complainant did not provide any further information. (R1) was at this facility on 08/27/18 according to (R1’s) Identification and Emergency Information LIC 601 (dated: 08/27/18) (R1) did not have a legal guardian, power of attorney, conservator, or family listed. (R1) was admitted with no history of hepatitis infection. Medical lab test results (date:8/29/18 and 08/14/19) presented no hepatitis. (R1) continued medical checkups with the in-house physicians. Records indicate physician visits as follows: 09/20/18,11/19/18, 12/12/18, 08/28/19, 02/19/20, 12/17/19, 08/13/20, 08/17/20, 09/03/20, and 09/13/20. Psychiatric Assessments were conducted monthly from 12/12/18 through 12/31/20. Medical records for (R1) revealed on 09/03/20 reportedly, the lab work unable to be drawn due to the insurance card not being verified by the lab company. Medical records for (R1) (dated: 04/13/22) enclose a history of chronic hepatitis B, chronic hepatitis C, alcoholism, drug abuse, and TB infection. According to (ref: Mayo Clinic), the Hepatitis virus is passed from person to person through blood, semen, or other body fluids, and unsafe injection or exposure to sharp instruments. The Physician's Report LIC 602 for (R1) states that (R1) is unable to leave the facility unassisted nor had wandering behavior. ( R1)'s medication remained constant during his residency at the facility, and no needle injections were required according to his Medication Administration Records. On 09/27/23, interviews conducted between 10:00 am and 3:11 pm with (9) out (9) residents #2-#10 (R2-R10) claimed they were all healthy and had not acquired any infections due to lack of care. (R2-R10) reported medical assistance is available from their primary physician or the in-house primary physicians and is always accessible. On 09/27/23, interviews conducted between 10:37 am and 12:43 pm with (5) out (5) family representatives witness #1-#5 (W1-W5) stating no concerns for the health care for the residents at this facility. (Evaluation Report continues on LIC 9099-C) Several attempts to interview (R1) on 09/27/23 and 11/27/23 were unsuccessful. (R1’s) health condition prevented (R1) from carrying full conversations. On 12/01/23, in interviews conducted between 11:00 am and 1:00 pm (5) out of (5) staff # 1- #5 (S1-S5) did not know how (R1) may have been exposed to an infection. (S3-S5) claimed that (R1) did not engage with others and was not intimate with any residents at the facility. Based on the information provided, it is unclear whether (R1) was exposed to or contracted the infection while in care at the facility. Therefore, based on all the information obtained during the investigation, there is no evidence to corroborate the allegation mentioned above. Allegation #2: Resident fell while in care. The complaint alleged resident #1 (R1) fell due to staff negligence while in care. The complainant (R1) fell off the bed and incurred bruises on the left side of the face. There was no further information provided by the complainant on this matter. A review of an incident report (dated: 03/01/21) revealed (R1) slid out of the wheelchair at 11:00 am on 03/01/21 while watching television in the activity room. The unwitnessed incident indicated (R1) sustained a minor bump on the upper left cheek and an ice pack was applied. There was no indication of an open wound. According to (R1’s) Physician’s Report LIC 602A, (R1), functional capabilities use a walker and a wheelchair unassisted (dated: 01/17/20). There is no indication in any of (R1’s) service records that (R1) was considered a fall risk and required constant supervision nor presented a history of falls. The facility notified the primary physician and Community Care Licensing (CCL) of this incident. A review of (R1) medications listed (R1) on Questiapine 200mg, Cetizine 10 mg, Aripirazole 10mg, and Norvasc 10mg. These medications all have side effects of simple unusual bleeding or bruising according to Mayo Clinic (ref. Mayo Clinic.org). On 09/27/23, interviews were conducted between 10:00 am and 3:11 pm with (9) out (9) residents #2-#10 (R2-R10) all confirmed to have no issue with accidents or falls while in care. (R2-R10) reported the care and supervision were adequate and felt safe while at the facility. (Evaluation Report continues LIC 9099-C) An interview on 12/01/23 at 9:30 am with staff # (S2) confirmed to have had knowledge of the incident on 03/01/21 documented the necessary information, and later contacted the proper authorities of the incident. (S2) at the time of the incident, (R1) did not have an open wound nor showed signs of bruises. (S2) reported that (R1) is non-ambulatory and can get around with the help of a walker or wheelchair. (S2) stated (R1) only needed assistance transferring in and out of bed. Interviews conducted on 12/01/23 at 11:00 am – 1:00 pm with (4) out (4) staff #1, #3 - #5 (S1-S5) confirmed that (R1) was not a fall risk and did not have a history of falls at the facility. A review of (R1’s) Incontinent 2-hour check logs revealed (R1) was being supervised every 2 hours daily by staff. Several attempts to interview (R1) on 09/27/23 and 11/27/23 were unsuccessful. (R1’s) health condition prevented (R1) from carrying on full conversations. Therefore, based on all the information obtained during the investigation, there is no evidence to corroborate the allegation mentioned above. Based on the 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 Ginger Enriquez, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Dec 1, 2023 · control 11-AS-20210317104047

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility has pests.

On 11/20/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a complaint visit at this facility. LPA was greeted by administrator Ginger Enriquez. This inspection visit is to gather information for the allegation mentioned above and deliver findings. The investigation consisted of the following: A review of the facility's roster for residents and staff. Interviews with residents #1-#10 (R1-R10), witnesses #1-(W1). A review of pest control contract and monthly services receipts. A physical tour of the facilty was conducted. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility has pests. The details of the complaint reported the facility has pests. The complainant reported the facility has "multiple cockroaches on the wall". The complainant did not provide further information on who was involved, where in the facility or when it took place. A full inspection of the entire facility was conducted by the Department, including the dining room, kitchen, activity rooms, library, medication, offices, public restrooms, and elevators. In Arbor Hall, the following rooms were inspected: #5, #7, #20, #21, #25, #26 and #27. In the Assisted Living, the following rooms were inspected: #2, #13, #20, #23, #30, #101, #102, #205, #209, #214, #267 and #284. During the inspection, no signs of pest infestation were observed on walls, floors, furnishings, or equipment. On 11/20/23 between 2:00 pm - 3:47 pm interviews with (7) out of (10) resident #1-#7 (R1-R7) indicated having no issues with pest in the common areas or individual rooms. (R8-R10) reported cockroaches were seen in their rooms; however, the facility sprays to eliminate the problem. Staff #1 (S1) stated the pest control company come to service the facility twice a week for the kitchen. Gam Exterminating Inc. comes to service the facility weekly or as needed. (S1) reported the facility has an annual service contract agreement with Gam Exterminating Inc. The facility provided maintenance service receipts along with the service contract as proof services are maintained. Based on the information gathered, the allegation mentioned above cannot be supported. 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 allegation mentioned above. 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 with Ginger Enriquez, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 11-AS-20231115152702