Rosecrans Villa Residential Care

Allegation investigated: Staff failed to ensure a resident received meals.

On 09/17/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegations listed above. LPA met with the Administrator, Sandra Lopez, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 02/04/2026, a facility tour was conducted, interviews were conducted, and records were gathered. Resident 2 (R2) to Resident 13 (R13) and Staff 1 (S1) to Staff 7 (S7) were interviewed. Facility records were gathered which consisted of Resident Rosters, Employee Roster, Meal Menus, and Resident 1’s (R1) records. On 03/10/2026, Resident 1 (R1) and Witness 1 (W1) were interviewed. On 09/17/2026, records were reviewed. Unsubstantiated Investigation revealed the following: Allegation: “Staff failed to ensure a resident received meals”, it is being alleged that staff failed to ensure that R1 received their meals. Interviews conducted with S1 to S7 revealed the following: 7 out of 7 staff denied the allegation, furthermore, staff explained that they walked R1 to the dining room, brought them meals to their bedroom, and provided them with alternative meal options. Interviews conducted with R1 to R13 revealed the following: 13 out of 13 residents denied the allegation, additionally, R1 explained that staff brought them food, provided them with yogurt and alternative meal options, and staff never denied them of food, moreover, R1 explained that they did not like eating everything because they believed there was poison in the food. (Residents who were interviewed were composed of residents who required assistance with meals, for example, staff provided them with meal trays to their rooms.) Observations on 02/04/2026 revealed the following: Lunch time was observed and residents were observed being served a balanced meal with protein, carbohydrates, and vegetables, furthermore, residents who requested seconds were provided with a second plate. Staff were observed taking meal trays to residents’ rooms. Meal Menus reviewed revealed the following: Breakfast, lunch, and dinner are composed of balanced meals with portions of carbohydrates, protein, vegetables, and a side of dessert. The facility also provides snacks. Based on the interviews, observations, records reviewed this allegation is unsubstantiated. 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. An exit interview was conducted, and a copy of this report was left with the Administrator, Sandra Lopez.the state’s words, verbatim · CDSS document, Sep 17, 2026 · control 11-AS-20260130154914

Type of visit: Case Management - Deficiencies

On 09/17/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of this visit is to deliver a deficiency observed during the course of the investigation regarding complaint control number 11-AS-20260130154914. LPA met with the Administrator, Sandra Lopez, and the purpose of the visit was explained. LPA was granted entry to the facility. R1’s records reviewed revealed the following: · On 07/14/2023, R1 completed their Preplacement Appraisal Information. · On 01/24/2024, R1 refused medical attention. · On 05/06/2024, R1 completed the Identification and Emergency Information. The document stated that R1 is self-responsible. · On 06/05/2024, R1 completed a laboratory examination. · On 06/19/2024, R1 completed their Appraisal/Needs and Services Plan dated. The document does not mention weight loss, food intake, 51/50’s, and refusals for medical treatment. · On 06/21/2024 to 06/28/2024, R1 was placed in a 51/50 hold on for signs of decompensation. · On 01/02/2025, R1 completed a mental status examination · On 03/10/2025, the facility called the Los Angeles Country Department of Mental Health, and the Psychiatric Assessment Team assessed R1 and determined that R1 does not qualify for a 51/50 hold. · On 03/17/2025, the facility called Harbor UCLA Hospital via First Rescue Ambulance for R1 for skipping meals, losing weight and being gravely disabled. Los Angeles Country Department of Mental Health Psychiatric Assessment Team assessed R1 and placed R1 in a 51/50 hold. R1 did not return back to the facility after this date. · On 03/17/2025, R1 was admitted to Harbor UCLA Medical Center and discharged on 04/02/205. Emergency Documentation: “Medical Decision Making – Assessment and Plan by Problem – patient with paranoid schizophrenia who has not been eating. Plan for medical workup / evaluation for risk stratification for refeeding syndrome.” “History of Present Illness:…5150…with weight loss…has been paranoid about poison in food. Has lost 60 pounds over the past few months.” Reason for Admission Gravely Disabled/Hallucinations.” “Trauma Surgery: Nutrition consult…Advance diet as tolerated.” “Weight 41.7 kg” (91.93 lbs.). R1’s Weight Record from 1/2024 to 3/2025 condensed version of record reviewed revealed the following: · 1/11/2024 – Weight 135 pounds (lbs.) · 3/13/2024 – Weight 128 lbs. · 6/14/2024 – Weight 119 lbs. · 7/13/2024 – Weight 117 lbs. · 9/13/2024 – Weight 113 lbs. · 12/12/2024 – Weight 116 lbs. · 2/11/2025 – Weight 110 lbs. · 3/12/2025 – Weight 103 lbs. Refusal of Medical Attention and/or Hospitalization signed by R1 and facility personnel records reviewed revealed the following: · On 7/23/2024, R1 refused a physical exam. · On 9/5/2024, R1 refused medical attention for a small cut under left eye. · On 3/10/2025, R1 refused medical visit to Emergency Room for fingers appearing to be purple. “Resident fingers appear to be purple. R1’s vital signs were taken, and they appeared to be normal. · On 3/12/2025, R1 refused medical attention for “generalized weakness.” There were no records of an updated Re-Appraisals and/or Appraisal/Needs and Services Plan for observations of significant changes of condition which include weight loss, refusals of medical attention, and hospitalization's 51/50’s. A deficiency is being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator, Sandra Lopez.the state’s words, verbatim · CDSS document, Sep 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Sep 30, 2026

Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement was not met as evidence by: Based on record review the licensee did not comply with the section cited above by not following updating R1’s Pre-Admission Appraisal to document significant changes in conditions.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: The Administrator has agreed to create a plan to updated Pre-Admission Appraisals when residents go through significant changes in conditions and email plan to Socorro.Leandro@dss.ca.gov .

Allegation investigated: Staff did not prevent residents from attacking other residents Staff filed a false 5150 report on a resident Staff do not safeguard residents' personal belongings

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on the report created 7/22/26. On 7/22/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Sandra Lopez and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 7/22/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Admissions Agreement, Identification and Emergency Contact, Medical Assessment for Residential Care Facilities for the Elderly, Appraisal/Needs and Services Plan, Unusual Incident/Injury Report, Copy of Hawthorne P.D. Business Card, Application for up to 72 Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment and Administrator’s Progress Records. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 8 (S1 – S8), and Resident 1 – Resident 6 (R1-R6). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not prevent residents from attacking other residents It is being alleged that R1’s walking cane accidentally touched R6 as R1 was getting his food. On 7/22/26, LPA Felisa Shirley reviewed a Shift Report dated 5/31/26 written by S3. S3 reported that R1 was observed being aggressive with R6 as R1’s walking cane hit R6 as he squatted on floor near the dining room. During interview with S7 on 7/22/26, S7 went to R1’s room to assess his condition and determine the cause of his distress. As S7 attempted to gather additional information, R1 became increasingly agitated and began screaming in his room. LPA Shirley interviewed R6 on 7/22/26, regarding the reported altercation. When asked about the incident, the resident stated that they did not recall the altercation and was unable to provide any additional details. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 5 out of 6 denied the allegation. One resident confirmed the allegation and stated that it’s hard to explain, then they ended the interview. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not prevent residents from attacking other residents,” therefore, the allegation is unsubstantiated. Allegation: Staff filed a false 5150 report on a resident It is being alleged that R1 was put on a 72-hour 5150 hold. On 7/22/26, LPA Shirley observed an incident report dated 6/3/26, stating that R1 was placed on a 5150 hold by the Psychiatric Emergency Team, (PET) on 6/1/26, by the clinician due to R1 being a danger to others and escalating aggressive behaviors. During file review, LPA Shirley observed the Application for up to 72 Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment dated 6/1/26, due to escalating aggressive behavior and recent attempts to physically assault another resident. LPA Shirley received and reviewed a Shift Report written by S2 on 6/1/26, stating staff reported multiple incidents of unprovoked aggressive behavior from R1. Per interview with the Administrator, S1 on 7/22/26, R1 accidentally hit R6 with his cane and became very upset and aggressive. S1 stated that R1 didn’t want to speak to anyone. R1 would not open his door. R1 called the Hawthorne P. D. S1 stated that she facetimed the clinician. The clinician remained on the phone throughout the entire incident and directly witnessed and observed all events as they occurred. Based on his assessment of the situation, he made the clinical decision to place R1 on a 5150 involuntary psychiatric hold. Con'd on 9099-C LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. One staff did not know. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 4 out of 6 denied the allegation. One resident confirmed it and 1 didn’t want to talk. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff filed a false 5150 report on a resident,” therefore, the allegation is unsubstantiated. Allegation: Staff do not safeguard residents' personal belongings It is being alleged that when R1 returned to the facility on 6/8/26, he discovered that his refrigerator was turned off causing his food to spoil. Per interview with R1 on 7/22/26, R1 was away from the facility from 6/1/26 to 6/8/26. Upon returning to the facility, R1 stated that the Administrator, S1, had instructed S8 to turn R1’s refrigerator off in his absence. LPA Shirley interviewed S8 on 7/22/26, and S8 verified that they were not asked to turn R1’s refrigerator off. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 5 out of 6 denied the allegation. One stated again, she didn’t want to talk Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not safeguard residents' personal belongings,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Sandra Lopez.the state’s words, verbatim · CDSS document, Sep 9, 2026 · control 11-AS-20260715132715

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

Allegation investigated: Staff did not prevent residents from attacking other residents Staff filed a false 5150 report on a resident Staff do not safeguard residents' personal belongings

On 7/22/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Sandra Lopez and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 7/22/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Admissions Agreement, Identification and Emergency Contact, Medical Assessment for Residential Care Facilities for the Elderly, Appraisal/Needs and Services Plan, Unusual Incident/Injury Report, Copy of Hawthorne P.D. Business Card, Application for up to 72 Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment and Administrator’s Progress Records. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 8 (S1 – S8), and Resident 1 – Resident 6 (R1-R6). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not prevent residents from attacking other residents It is being alleged that R1’s walking cane accidentally touched R6 as R1 was getting his food. On 7/22/26, LPA Felisa Shirley reviewed a Shift Report dated 5/31/26 written by S3. S3 reported that R1 was observed being aggressive with R6 as R1’s walking cane hit R6 as he squatted on floor near the dining room. Per interview with R1 on 7/22/26, R6 was sitting directly in front of R1’s room. R1 stated that the incident was a verbal altercation as R1 told R6 to not block his room door as R1 is totally blind. R1 stated that R6 jumped up and began threatening him. R1 stated that he went into his room to avoid R6 and called Hawthorne P.D. LPA Shirley requested to view the incident on video and was told by the Administrator that she did not have access to retrieve the footage back to the incident date of 5/31/26. The Administrator further advised LPA Shirley that the camera installer informed her that the surveillance camera system can only store recorded video for up to two weeks. During interview with S7 on 7/22/26, S7 went to R1’s room to assess his condition and determine the cause of his distress. As S7 attempted to gather additional information, R1 became increasingly agitated and began screaming in his room. LPA Shirley interviewed R6 on 7/22/26, regarding the reported altercation. When asked about the incident, the resident stated that they did not recall the altercation and was unable to provide any additional details. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 5 out of 6 denied the allegation. One resident confirmed the allegation and stated that it’s hard to explain, then they ended the interview. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not prevent residents from attacking other residents,” therefore, the allegation is unsubstantiated. Allegation: Staff filed a false 5150 report on a resident It is being alleged that R1 was put on a 72-hour 5150 hold. On 7/22/26, LPA Shirley observed an incident report dated 6/3/26, stating that R1 was placed on a 5150 hold by the Psychiatric Emergency Team, (PET) on 6/1/26, by the clinician due to R1 being a danger to others and escalating aggressive behaviors. During file review, LPA Shirley Con'd on 9099-C observed the Application for up to 72 Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment dated 6/1/26, due to escalating aggressive behavior and recent attempts to physically assault another resident. LPA Shirley received and reviewed a Shift Report written by S2 on 6/1/26, stating staff reported multiple incidents of unprovoked aggressive behavior from R1. Per interview with R1 on 7/22/26, R6 was sitting directly in front of R1’s room. R1 stated that the incident was a verbal altercation as R1 told R6 to not block his room door as R1 is totally blind. R1 stated that R6 jumped up and began threatening him. R1 stated that he went into his room to avoid R6 and called Hawthorne P. D. Per interview with the Administrator, S1 on 7/22/26, R1 accidentally hit R6 with his cane and became very upset and aggressive. S1 stated that R1 didn’t want to speak to anyone. R1 would not open his door. R1 called the Hawthorne P. D. S1 stated that she facetimed the clinician. The clinician remained on the phone throughout the entire incident and directly witnessed and observed all events as they occurred. Based on his assessment of the situation, he made the clinical decision to place R1 on a 5150 involuntary psychiatric hold. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. One staff did not know. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 4 out of 6 denied the allegation. One resident confirmed it and 1 didn’t want to talk. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff filed a false 5150 report on a resident,” therefore, the allegation is unsubstantiated. Allegation: Staff do not safeguard residents' personal belongings It is being alleged that when R1 returned to the facility from the 5150 hold on 6/8/26, when he discovered that his refrigerator was turned off causing his food to spoil. On 7/22/26, LPA Shirley observed an incident report dated 6/3/26, stating that R1 was placed on a hold by the Psychiatric Emergency Team, (PET), clinician due to R1 being a danger to others and escalating aggressive behaviors. Per interview with R1 on 7/22/26, R1 was placed on a 5150 Con'd on 9099-C psychiatric hold from 6/1/26 to 6/8/26. Upon returning to the facility, R1 stated that the Administrator, S1, had instructed S8 to turn R1’s refrigerator off in his absence. LPA Shirley interviewed S8 on 7/22/26, and S8 verified that she was not asked to turn off R1’s refrigerator. During file review on 7/22/26, LPA Shirley observed a progress record from the Administrator dated 6/9/26, stating upon R1 returning from his 5150 hold, R1 reported that his cellphone was missing. Over the following 2 days, the Administrator attempted to contact the phone on multiple occasions but received no answer. R1 came to the front office, at which time the Administrator called R1’s phone and heard it ringing on R1’s person. On 6/11/26, R1 informed the Administrator that he had located his phone. R1 stated that he had forgotten where he left the phone prior to going to the hospital. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 5 out of 6 denied the allegation. One stated again, she didn’t want to talk Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not safeguard residents' personal belongings,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Sandra Lopez.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 11-AS-20260715132715

Allegation investigated: Staff do not distribute resident's medications as prescribed Staff do not safeguard resident's personal belongings

On 7/14/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Sandra Lopez and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 7/14/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Resident Face Sheet, Admission Agreement, Identification and Emergency Contact form, Physicians Report, Preplacement Appraisal, Appraisal Needs/Services Plan, Medication Administration Records, Residents Personal Property and Valuables, Unusual Incident Reports, Communications with Trust Representative. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 5 (S1 – S5), and Resident 1 – Resident 5 (R1-R5). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff do not distribute resident's medications as prescribed It is being alleged that R1 is not receiving his prescribed medications for an antibiotic and a sleep aid. On 7/14/26, LPA Shirley observed an incident report dated 4/27/26. LPA Felisa Shirley reviewed R1’s Medication Administration Records, (MAR’s) April 2026 thru July 2026. LPA Shirley also observed medication prescription for Amoxicillin dated 4/23/26. Upon review of the incident report, on 4/23/26 R1 was sent to Gardena Memorial Emergency Department due to facial swelling. R1 was cleared and released to return to Rosecrans Villa the same day with a prescription for Amoxicillin. The resident was prescribed the antibiotic with 20 tablets to be taken twice a day for 10 days with zero refills. A review of the MAR for April the Med-Tech administered the medication on 4/25, 4/26 and 4/27. Per interview with the Administrator (S1), R1 was sent to a Skilled Nursing Facility on 4/28/26 and did not return to Rosecrans Villa until 5/28/26. The antibiotic was prescribed and administered until the supply was exhausted at the Skilled Nursing Facility. LPA Shirley also observed that the medication for Mirtazapine has a standing order to be administered daily at bedtime. This regimen has continued until R1’s hospitalization on 6/16/26. Following R1’s return on 6/23/26, the medication was resumed and remains active. LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not distribute resident's medications as prescribed,” therefore, the allegation is unsubstantiated. Allegation: Staff do not safeguard resident's personal belongings It is being alleged that R1’s pants and shirts are missing. On 7/14/26, LPA Shirley observed and reviewed R1’s Resident Personal Property and Valuables form. LPA Shirley also received a copy of an emailed conversation between facility’s Administrator (S1) and R1’s Family Trust representative. The Resident Personal Property and Valuables form list 5 shirts and no pants as personal property when R1 arrived to this facility on 1/15/26. The email dated 2/4/26 between the Administrator and Trust Representative discusses R1 giving personal items away such as a jacket and a pair of shoes. The Administrator stated that she was not sure about other items that R1 may have given away. Con'd on 9099-C LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not safeguard resident's personal belongings,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Sandra Lopez.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 11-AS-20260709135133

Allegation investigated: Staff do not safeguard resident's personal belongings

On 6/4/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Sandra Lopez and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 5/12/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Certification for all Medication Technicians, Medication Administration Records (MAR’s), Assessment 4/9/26, Client/Resident Personal Property and Valuables Form LIC 621, Appraisal/Needs and Services Plan, Medical Assessment for Residential Care Facilities for the Elderly, LIC602A, Identification and Emergency Information, Admission Agreement, 8/19/25. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff- 6(S1 – S6), and Resident -1 – Resident – 10 (R1-R10). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff do not safeguard resident's personal belongings It is being reported that R1’s clothing are being stolen by her roommate. Upon reviewing R1’s Admission Agreement, LPA Felisa Shirley verified that the resident has been residing here since 8/19/25. On 6/4/26, LPA Shirley reviewed R1’s, Client/Resident Personal Property and Valuables form dated 8/19/25. On 6/4/26, LPA Shirley conducted a physical inventory count and compared it to R1’s inventory list; 3 items are unaccounted for. Per interview with R1 on 6/4/26, she sent items to the laundry room today. On 6/4/26, LPA Shirley went to the laundry room to tally the items sent for washing and updated R1’s inventory count. LPA escorted R1 to the laundry room on 6/4/26 to check the lost and found for her missing items, none of which were recognized as hers. Per LPA Shirley’s observation on 6/4/26, R1’s clothing is much smaller than her roommate, making it physically improbable that the roommate is taking R1’s clothing. LPA interviewed staff 1 – staff 6 (S1 – S6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 7 out of 10 denied the allegation, 2 confirmed the allegation and 1 was not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not safeguard resident's personal belongings,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Sandra Lopez.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 11-AS-20260507160358

Allegation investigated: Staff did not provide adequate supervision, resulting in resident being sexually abused. Staff are not ensuring inside of facility is free of marijuana smoke. Staff are not providing medical records to resident's responsible person.

On 06/03/26, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegations. LPA met with Administrator Sandra Lopez and the purpose of the visit was explained. Investigation consisted of the following: On 06/03/26, the Department obtained Personnel Report, Register of Residents, Work Schedule (May 2026), Resident Records (#1 - 9), interviewed Staff #1 – 9 (S1-S9) and Residents #1, 3 – 9 (R1, R3 – R9), toured the outdoor areas, and observed video recordings. Note: Resident #2 was out of the facility. LPA left voicemails for Staff #10 - #11. Investigation revealed the following: Allegation: Staff did not provide adequate supervision, resulting in resident being sexually abused. It is alleged another resident inappropriately touched Resident #1 (R1) and pushed R1 up against a wall to try to kiss R1. Seven out of eight staff interviews (S1 – S5, S7 – S9.)... continue to LIC9099-C. Unsubstantiated indicated there is adequate supervision. S6 indicated there is adequate supervision mainly in the mornings. Two out of four staff members (S1 - S2, S5-S6) indicated they have not received any complaints concerning R1 being sexually abused. Five out of seven resident interviews (R1, R3 - R8) indicated there is adequate supervision. Three out of five resident interviews (R1, R3 - R5, R9) indicated they feel safe at the facility. LPA observed video recordings from 05/23/26 3:00pm – 4:00pm and 05/24/26 3:00pm – 4:00pm and did not observe a male resident enter into R1’s bedroom. Regarding the allegation, “Staff did not provide adequate supervision, resulting in resident being sexually abused,” based on interviews and observations, 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, as a result, the allegation is Unsubstantiated. Allegation: Staff are not ensuring inside of facility is free of marijuana smoke It is alleged, on 05/24/26, there was marijuana smoke inside of the building "halfway down the hall" on the first floor. Six out of seven staff interviews (S1 – S7) indicated residents are not allowed to smoke marijuana inside of the facility. S1, S2, and S7 indicated there is a designated patio for smoking cigarettes and most residents smoke marijuana outside of the facility. S1 indicated that the neighbors smoke marijuana and it can also cause a smell. S2 indicated residents may come back into the facility smelling like marijuana. Six out of seven resident interviews (R1, R3-R8) indicated residents are not allowed to smoke marijuana in the facility. R9 indicated R9 is unsure. Review of Register of Residents (May 2026) revealed R1, R3 – R9 lives on the first floor. LPA observed an outdoor patio reserved for smoking near rooms 115, 112, 110, 109, 108, 106, 104, and the recreation room. LPA observed an outdoor patio for non-smokers near rooms 116, 114, 111, dining room, 122, 124, and beauty shop. LPA observed a rear parking lot where residents may smoke near the laundry rooms, dishwashing area and kitchen. LPA did not smell marijuana in the facility. Regarding the allegation, “Staff are not ensuring inside of facility is free of marijuana smoke,” based on record reviews and interviews, 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, as a result, the allegation is Unsubstantiated. Continue to LIC9099-C. Allegation: Staff are not providing medical records to resident's responsible person. Record review of R1’s Admission Agreement (08/19/25) revealed R1 signed off on own agreement. R1's Medical Assessment (08/01/25) revealed R1 signed off as the prospective resident or legal representative on 08/14/25. R1 is able to care for self and mental health is fair. R1's Identification and Emergency Information (08/19/25) revealed R1 is responsible for financial affairs. Three out of three staff interviews (S1 - S2, S5) indicated responsible persons may request medical records. S1, S2, and S7 indicated there have been no complaints from authorized persons being unable to access records. S1 indicated Resident #1 (R1) is self responsible and does not have a Power of Attorney. Five out of six resident interviews (R1, R3 - R7) indicated they or their responsible persons can have access to their medical records. R9 has never requested records. Regarding the allegation, “Staff are not providing medical records to resident's responsible person,” based on record reviews and interviews, 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, as a result, the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Administrator Sandra Lopez.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 11-AS-20260526094929

Allegation investigated: Staff mismanages resident's medication Staff do not prevent resident from menacing other resident

On 5/12/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Sandra Lopez and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 5/12/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Certification for all Medication Technicians, Medication Administration Records (MAR’s), Assessment 4/9/26, Client/Resident Personal Property and Valuables Form LIC 621, Appraisal/Needs and Services Plan, Medical Assessment for Residential Care Facilities for the Elderly, LIC602A, Identification and Emergency Information, Admission Agreement, 8/19/25. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff- 5(S1 – S5), and Resident -1 – Resident – 10 (R1-R10). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff mismanages resident's medication It is being reported that staff refuses to give R1 there medication at the right time. On 5/12/26, LPA Felisa Shirley reviewed an assessment by R1’s Primary Care Physician dated 4/9/26. This assessment states that R1 does not have the capacity to understand and make decisions. During review of the 4 Medication Technicians (Med Tech’s) training records on 5/12/26, LPA Shirley noted that all 4 Med Techs have the knowledge required to safely assist residents with prescribed medications. On 5/12/26, LPA Shirley reviewed 5 resident’s, including R1’s Medication Administration Records, (MAR’s) for the months of April and May. No discrepancies were identified during the review. Per interview with 2 Med Techs, S5 and S6 on 5/12/26, stated that R1 frequently checks in at the medication room, arriving every 15 minutes to inquire about her medication. Per interview with S6 on 5/12/26, the resident shows signs of forgetfulness. Per interview with S6 on 5/12/26, she stated, if the Med Tech are unavailable, R1 will inquire about the Med Techs whereabouts from non-med tech staff. On 5/12/26, LPA Shirley observed R1 in the hallway in the facility and had to identify myself to the resident and had to explain why I was here. During a tour of this facility at 12:04pm on 5/12/26 with S1, we passed by R1’s room and the resident asked S1 if it was time for her medication. On 5/12/26 at 1:15pm, LPA Shirley went to R1’s room to ask her a question and R1 inquired if it was time to take her medication. LPA interviewed staff 1 – staff 6 (S1 – S6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 8 out of 10 denied the allegation. One resident confirmed the allegation and 1 resident was not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff mismanages resident's medication,” therefore, the allegation is unsubstantiated. Allegation: Staff do not prevent resident from menacing other resident It is being reported that R1’s roommate has made sexually explicit comments to her while standing over her bed at night, which makes R1 very uncomfortable and anxious. During review of R1’s facility file on 5/12/26, LPA Felisa Shirley did not observe any reports of R1’s roommate that mentioned harassment of R1. During interviews on 5/12/26, the Administrator, (S1), stated that she has not received any complaints of harassment from R1 con'd on 9099-C regarding her assigned roommate. Per interview with the Administrator on 5/12/26, she did not receive a request for R1 to change rooms as S1 had no knowledge of R1 claims that her roommate was harassing her. Per interview with the Administrator, there are no reports of roommates harassing there roommates within the facility. LPA interviewed staff 1 – staff 6(S-1 – S-). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 6 out of 10 denied the allegation. Three resident confirmed the allegation and one resident was not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not prevent resident from menacing other resident,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Sandra Lopez.the state’s words, verbatim · CDSS document, May 12, 2026 · control 11-AS-20260507160358

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure that the resident's hygiene care needs were properly met at the facility

On 1/23/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding the allegation listed above. LPA met with the Administrator, Sandra Lopez, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 12/23/2025, a facility tour was conducted, interviews were conducted, and records were gathered. Resident 2 (R2) to Resident 11 (R11) and Staff 1 (S1) to Staff 4 (S4) were interviewed. On 1/23/2026, records were reviewed and Resident 1 (R1) and Staff 5 (S5) were interviewed. Facility records reviewed consisted of Resident Roster dated 12/2025, Employee Roster dated 7/2025, and Weekly Shower Schedules. Resident 1’s (R1) records were reviewed which consisted of Admission Agreement dated 5/8/2025, Physicians Report dated 5/8/2025, Appraisal/Needs And Services Plan dated 5/8/2025, Appraisal/Needs And Services Plan dated 1/20/2026, Unusual Incident Reports for the year 2025, Medical Documentation and other pertinent information. Unsubstantiated The investigation revealed the following: Allegation: “Staff did not ensure that the resident's hygiene care needs were properly met at the facility”, it is being alleged that R1’s hygiene care needs are not properly met at the facility. Interviews conducted with R1 to R11 revealed the following: 11 out of 11 residents denied the allegation, furthermore, R1 indicated that staff assist them with showers 2 to 3 times a week and staff assist them with picking out their clothing items each morning. Interviews conducted with S1 to S5 revealed the following: 5 out of 5 staff denied the allegation. Observations of residents revealed the following: On 12/23/2025, many residents were observed well groomed (for the residents that were not well groomed, residents indicated that facility staff assisted them with dressing in the morning and/or they had soiled their clothing after breakfast). On 1/23/2026, R1 was observed well groomed. Weekly Shower Schedules revealed the following: R1 receives assistance with showers on Tuesdays and Fridays. Residents that receive assistance with showers range from once a week to three times a week. R1’s Appraisal/Needs And Services Plan revealed the following: “Resident will be encouraged to remain as independent as possible and to complete their activities of daily living to the best of their ability…Resident will be encouraged to maintain good hygiene by bathing regularly”…person responsible “staff.” R1’s Physicians Report dated 5/8/2025 revealed the following: R1 is able to dress/groom self with assistance but R1 requires assistance with bathing. Based on the department’s observations, interviews, and records reviewed this allegation is unsubstantiated. 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, and a copy of this report was left with the Administrator, Sandra Lopez.the state’s words, verbatim · CDSS document, Jan 23, 2026 · control 11-AS-20251218122037

Type of visit: Case Management - Other

On 1/23/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding complaint control number 11-AS-20251218122037. LPA met with the Administrator, Sandra Lopez, and the purpose of the visit was explained. LPA provided technical assistance regarding: Assisting residents that use dentures - e.g. staff training's, resident appraisals, and physicians reports Eviction Procedures No deficiencies were provided. An exit interview was conducted, and a copy of this report was left with the Administrator, Sandra Lopez.the state’s words, verbatim · CDSS document, Jan 23, 2026

Type of visit: Required - 1 Year

On 10/15/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator, Sandra Lopez. The purpose of the visit was explained, and the LPA was allowed entry to the facility. This facility is licensed to serve 135 non-ambulatory residents ages 60 and above. A total of 109 residents are currently residing in this facility. The Annual Licensing Fees are current. Facility Layout: It is a two-story building located on a residential street. The building consists of 69 resident bedrooms, there are more than 69 bathrooms, 2 activity rooms, 1 medical office, several office spaces, 1 industrial kitchen, 1 dining room, 3 outside patio areas with shaded seating, 1 parking lot, and a front entrance lobby area. Outside Grounds: were toured and walkways around the facility were clear of hazards, and there are no security bars or weapons on the premises. There are outdoor tables and seating. Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. Community Indoor Space: One room has a television with plenty of seating; residents also get together in that room for activities. The other room is dedicated as the activity and they have access to board games, bingo, coloring, puzzles, crafts, etc. Resident Bedrooms: Several resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Bathrooms: Several resident bathrooms were toured; toilets, showers, and water faucets worked properly, and grab bars were secure. Adequate lighting and toiletries were accessible to residents. The hot water temperature measured 115.7 Fahrenheit. Medications: were inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Miscellaneous: Documents are posted as mandated. Last fire and earthquake drills were conducted on 08/25/2025. The sprinklers were inspected on 08/2025; fire alarms were inspected on 04/01/2025; the fire panel was inspected on 10/14/2024; all inspections determined that the facility is complying. There are several fire extinguishers around the facility, and they were last serviced on 10/06/2025. The facility has a designated resident landline telephone located next to the Medication Room. There is a videoconferencing device dedicated for resident use in the main office. 5 staff records were reviewed, and they all had required documentation. 5 resident records were reviewed, and they all had required documentation. The facility is currently doing some remodeling. The facility has installed new flooring on the second floor. The facility has submitted an Unusual Incident Report informing the Department of the renovations. The Department has advised the Administrator to create a remolding plan and a plan to maintain residents safe during remolding and submit said plans to the Department. No deficiencies are being cited based on observation and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report was left with the Administrator, Sandra Lopez.the state’s words, verbatim · CDSS document, Oct 15, 2025

Allegation investigated: Staff does not provide resident with appropriate sleeping accommodations.

On 09/18/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegation listed above. LPA met with Administrator Sandra Lopez and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 09/18/2025, facility tour was conducted, interviews were conducted, records were gathered and reviewed. Interviews were conducted with Resident 1 (R1) to Resident 11 (R11) and Staff 1 (S1) to Staff 4 (S4). Facility records were reviewed which consisted of Personnel Report dated 07/2025, Resident Roster dated 09/01/2025, and Resident Laundry Schedule. R1’s records were reviewed which consisted of Physicians Report dated 08/24/2020, Preplacement Appraisal Information dated 12/12/2024, and Appraisal/Needs and Services Plan dated 04/08/2025. Unsubstantiated The investigation revealed the following: Allegation: “Staff does not provide resident with appropriate sleeping accommodations”, it is being alleged that the facility has loud noises at night and because of this, residents’ are sleep deprived. Interviews conducted with R1 to R11 revealed the following: 10 out of 11 residents denied the allegation; 1 resident interview was inconclusive. Interviews conducted with S1 to S4 revealed the following: 4 out of 4 staff denied the allegation. Observations on 09/18/2025 revealed the following: all communal doors (not including resident apartment doors) in the first floor next to the kitchen area, laundry rooms, and exit to the parking lot were opened to see if doors slam shut and the doors did not slam shut. Communal doors were installed to prevent doors from slamming shut; doors closed slowly on their own. The emergency exit door that leads to the second floor has a commercial adjustable door closer and the door did not slam shut. The washer and dryers were observed operating and they made minimal noise; LPA went into the resident's apartment next to the laundry rooms and the LPA did not hear the washer or dryer operating. R1’s records reviewed revealed the following: there is no mention that R1 has been having a difficult time sleeping, is a light sleeper, nor that they suffer from sleep deprivation. Based on the department’s observations, interviews, and records reviewed this allegation is unsubstantiated. 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, and a copy of this report was left with the Administrator, Sandra Lopez.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 11-AS-20250910171631

Allegation investigated: Staff is witholding residents mail.

On 08/22/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegation. LPA met with Administrator Sandra Lopez and the purpose of the visit was explained. Investigation consisted of the following: On 08/22/2025, LPA obtained Personnel Report, Register of Residents, and interviewed Staff #1 – 10 (S1-S10) and Residents #1 – 10 (R1 – R10). Investigation revealed the following: Allegation: Staff is withholding residents mail. Staff interviews (S1 – S10) indicated that mail is passed out everyday by the Activities Director and staff has not received complaints from residents about not receiving their mail. Continue to LIC9099-C. Unsubstantiated The Administrator indicated that there is one resident who comes to the office every day requesting for mail or packages but there isn’t any there for the resident. Administrator indicated that the facility does not keep a mail log. The Activities Director indicated that mail is handed to the resident and not their roommate. If the resident is not at the facility, the mail will be stored in the office. Resident interviews (R3 – R4, R6, R8, R9) indicated that they have not had issues with mail. Resident interviews (R2, R7, R10) indicated they do not receive mail and have not heard mail complaints from other residents. Regarding the allegation, “staff is withholding residents’ mail,” based on interviews, 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, as a result, the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Administrator Sandra Lopez.the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 11-AS-20250818152758

Allegation investigated: Staff are forcing resident to take medication

On 06/18/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced continuation complaint investigation visit regarding the allegation listed above. LPA met with Administrator, Sandra Lopez and the purpose of the visit was explained. LPA was granted entry to the facility. Unsubstantiated Investigation consisted of the following: On 06/16/2025, interviews were conducted, and records were gathered. Interviews conducted consisted of 10 resident interviews [Resident 1 (R1) to Resident 10 (R10) were interviewed] and 2 staff interviews [Staff 1 (S1) to Staff 2 (S2) were interviewed]. Resident 1’s records were gathered which consisted of Admission Agreement dated 01/01/2024, Identification and Emergency Information dated 10/26/2022, Physicians Report dated 10/10/2022, and Medication Administration Records (MAR) from 02/15/2025 to 06/14/2025. Facility records were gathered which consisted of Resident Roster dated 06/2025, and Personnel Report dated 01/2025. On 06/18/2025, interviews were conducted, records were reviewed, and a facility tour was conducted. Interviews conducted consisted of 6 staff interviews [Staff 3 (S3) to Staff 8 (S8) were interviewed]. Records reviewed consisted of R1’s records and facility records. Facility tour consisted of the medication room and the department observed staff providing medication to residents. The investigation revealed the following: Allegation: “Staff are forcing resident to take medication”, it is being alleged that staff (specifically staff by the name of Karen) forces residents to take medication. Interviews conducted with R1 to R10 revealed the following: 1 out of 10 residents agreed with the allegation, and 9 out of 10 residents denied the allegation. Interviews conducted with S1 to S8 revealed the following: 8 out of 8 staff denied the allegation, furthermore, staff indicated that there is no staff by the name of Karen. Observations on 06/18/2025 of the medication room, revealed the following: medication technician provided medication to residents in care and did not force residents to take medication. Records reviewed of the Personnel Report dated 01/2025 revealed the following: there is no one with the name of Karen on the report. Resident 1’s records reviewed revealed the following: Physicians Report dated 10/10/2022 indicates that R1 is not able to manage their own medication nor able to administer their own injections; MAR from 02/15/2025 to 06/14/2025 indicates that R1 has been taking their medication. Based on the department’s observations, interviews, and records reviewed this allegation is unsubstantiated. 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, and a copy of this report was left with the Administrator, Sandra Lopez.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 11-AS-20250613170729

Allegation investigated: Financial abuse to resident. Staff are not ensuring that facility is free of pest. Staff are not ensuring residents are provided a safe environment.

On 04/04/2025, the California Department of Social Services (CDSS) Community Care Community Care Licensing (CCL) Licensing Program Analyst (LPA) Socorro Leandro conducted an initial unannounced complaint visit. LPA met with Administrator, Sandra Lopez and the purpose of the visit was explained. LPA was granted entry to the facility. Unsubstantiated The investigation consisted of the following: On 04/04/2025, a facility tour was conducted, records were reviewed, and interviews were conducted. The facility tour consisted of Resident 1’s (R1s) room. Interviews consisted of 3 staff interviews [Staff 1 (S1) to Staff 3 (S3) were interviewed] and 1 resident interviews (R1 was interviewed). Facility records reviewed consisted of Personnel Report dated 01/2025, Register of Facility Residents dated 01/01/2025, Pest Control documents from 01/2025 to 03/2025. Resident 1 (R1) records reviewed consisted of Admission Agreement dated 01/01/2024, Physicians Report dated 06/13/2024, Appraisal & Needs Services Plan dated 01/28/2025, pictures of his room dated 3/20/2024, Record of Resident’s Safeguard Cash Resources for the year of 2025, etc. The investigation revealed the following: Allegation: “Financial Abuse to resident”, it is being alleged that the facility is financially abusing R1. Interview conducted with the Administrator (S1) revealed the following: S1 denied the allegation. Interview conducted with R1 revealed the following: R1 denied the allegation. Records reviewed of R1’s Record of Resident’s Safeguard Cash Resources for the year of 2025 revealed the following: it depicts that R1 has been receiving their money and each entry has a staff signature and R1’s signature. Based on the interviews, records, and observations this allegation is unsubstantiated. 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. Allegation: “Staff are not ensuring that facility is free of pest”, it is being alleged that R1’s room has maggots, cockroaches, and flies. Observation on 04/04/2025 of R1’s room revealed the following: the department did not observe maggots, live cockroaches, and flies. Records reviewed of the Pest Control documents from 01/2025 to 03/2025 revealed the following: the Pest Control Company comes to the facility 4 times per month to 3 times per month, furthermore, R1’s room was fumigated on 02/07/2025, 02/25/2025, and 03/20/2025. Interview conducted with R1 revealed the following: R1 denied the allegation. Interviews conducted with S1 to S3 revealed the following: S1 indicated that R1 had been placed in 51/50 hold and during that time the facility deep cleaned his room, furthermore, S2 and S3 corroborated with S1’s story. Moreover, S1 to S3 indicated that as of right now R1’s room does not have maggots, flies, and roaches. Based on the interviews, records, and observations this allegation is unsubstantiated. 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. Allegation: “Staff are not ensuring residents are provided a safe environment”, it is being alleged that R1’s room is unsafe because they have a heather on their bed and staff does nothing to ensure that R1 has a safe environment. Observations on 04/04/2025 of R1’s room revealed the following: the department observed a heather on R1’s bed. Interview conducted with R1 revealed the following: R1 indicated that staff have informed him to remove the heater from their bed, but they do not feel that it is danger to place the heater on the bed, moreover, they get annoyed when staff moves their heater to the floor. Interviews conducted with S1 to S3 revealed the following: 3 out 3 staff denied the allegation, 2 out 3 staff indicated that they have talked to R1 about placing the heater on the floor, 2 out 3 staff indicated that they have moved the heater to the floor. Based on the interviews and observations this allegation is unsubstantiated. 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. No citations were provided. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Apr 4, 2025 · control 11-AS-20250327160411

Allegation investigated: Licensee does not ensure food served is of good quality Staff did not seek medical attention for resident in a timely manner

On 04/04/2025, the California Department of Social Services (CDSS) Community Care Community Care Licensing (CCL) Licensing Program Analyst (LPA) Socorro Leandro conducted an initial unannounced complaint visit. LPA met with Administrator, Sandra Lopez and the purpose of the visit was explained. LPA was granted entry to the facility. Unsubstantiated The investigation consisted of the following: On 04/04/2025, a facility tour was conducted, records were reviewed, and interviews were conducted. The facility tour consisted of the kitchen area. Interviews consisted of 5 staff interviews [Staff 1 (S1) to Staff 5 (S5) were interviewed] and 11 resident interviews [Resident 2 (R2) to Resident 12 (R12) were interviewed]. Facility records reviewed consisted of Personnel Report dated 01/2025, Register of Facility Residents dated 01/01/2025, Weekly Menu for Week 1 to Week 4, Dietary Consultant Reports from 01/18/2025, 02/16/2025, and 03/23/2025. Resident 1 (R1) records reviewed consisted of Admission Agreement dated 01/01/2024, Physicians Report dated 11/18/2023, Appraisal & Needs Services Plan dated 06/19/2024, Refusal of Medical Attention and/or Hospitalization documents, Medical Records, etc. The investigation revealed the following: Allegation: “Licensee does not ensure food served is of good quality”, it is being alleged that the facility food has poison and that is why it taste bad. Interviews conducted with S1 to S5 revealed the following: 5 out 5 staff denied the allegation. Interviews conducted with R2 to R12 revealed the following: 11 out of 11 residents denied the allegation. Observations of the kitchen on 04/04/2025 revealed the following: the department did not observe poisons in the kitchen area and observed food to be of good quality. Based on interviews and observations this allegation is unsubstantiated. Records reviewed revealed the following: Dietary Consultant Reports from 01/18/2025, 02/16/2025, and 03/23/2025 do not mention poison, moreover, on the latest report dated 03/23/2025 it indicates that food is of good quality. The Weekly Menu for Week 1 to Week 4 depicts breakfast, lunch, and dinner as being well balanced meals. Based on the interviews, records, and observations this allegation is unsubstantiated. 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. Allegation: “Staff did not seek medical attention for resident in a timely manner”, it is being alleged that staff did not seek timely medical attention for R1. Interviews conducted with the Administrator (S1) revealed the following: According to the Administrator the facility had attempted to seek medical attention for R1 but R1 refused to accept medical care. R1s records reviewed revealed the following: R1 had her physical on 11/18/2023. R1 refused medical attention on 01/24/2024. R1 had laboratory work done on 06/05/2024. R1 was placed in a 51/50 hold on 06/21/2024 to 06/28/2024 for signs of decompensation. R1 refused medical attention on 07/23/2024, 09/05/2024, and 03/10/2025. On 03/10/2025, the facility called the Los Angeles Country Department of Mental Health, and the Psychiatric Assessment Team assessed R1 and determined that R1 does not qualify for a 51/50 hold. On 03/17/2025, the Los Angeles Country Department of Mental Health Psychiatric Assessment Team assess R1 and places R1 in a 51/50 hold. Based on the interviews and records this allegation is unsubstantiated. 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. No citations were provided. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Apr 4, 2025 · control 11-AS-20250403095344

Allegation investigated: Staff contaminated residents' food Staff speak inappropriately to residents Staff threatened to evict resident

On 12/18/2024, the Department of Social Services (DSS) - Community Care Licensing Division (CCLD) staff conducted an unannounced complaint visit at this facility. CCLD staff was greeted by Administrator, Sandra Lopez. The investigation consisted of the following: The department interviewed 5 staff and 10 residents, toured the kitchen, reviewed facility records and Resident 1’s (R1) records. Unsubstantiated The investigation revealed the following: Regarding the allegation “Staff contaminated residents’ food”, it is being alleged that the kitchen staff are contaminating the facility food with feces, fentanyl, and drugs. Interviews conducted revealed the following: 8 out of 10 residents denied the allegation and 5 out of 5 staff denied the allegation. The departments observations revealed the following: the department toured the kitchen and did not observe feces, fentanyl, or drugs. Regarding the 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. Regarding the allegation “Staff speak inappropriately to residents”, it is being alleged that staff are mean to residents in care. Interviews conducted revealed the following: 9 out of 10 residents denied the allegation and 5 out of 5 staff denied the allegation. Regarding the 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. Regarding the allegation “Staff threatened to evict resident”, it is being alleged that the director told R1 that they were going to evict them. Interviews conducted revealed the following: R1 does not know if the facility is trying to evict them; The Administrator indicated that the facility has not given R1 an eviction notice nor warnings. Records reviewed of R1 revealed the following: there are no eviction notices nor warnings for R1. Regarding the 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 citations were issued. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Dec 18, 2024 · control 11-AS-20241216095515

Allegation investigated: Staff caused injury to resident Staff restrained resident

On 11/4/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Sandra Lopez, Administrator, and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 1/25/24 LPA Felisa Shirley requested and received copies of the following records: Staff Roster, Resident Rosters, admissions agreement, identification and emergency information, physician’s report, MAR, Letters of Conservatorship, Preplacement Appraisal Information, Client personal property and valuables. On 11/4/2024 LPA Shirley conducted a health and safety check and requested and received copies of medical records from Kindred – Paramount, List of Hospitalizations, SIR dated 1/22/24, internal communications and body check dated 1/19/24. LPA interviewed staff S-1 – S-5 and clients C-2 – C-10. The investigation revealed the following: Unsubstantiated Allegation: Staff caused injury to resident On 11/4/2024 the department conducted a review of facility files. During file review, the department reviewed medical records from Kindred Hospital Paramount specifically the Patient Care Summary which shows that C-1 was hospitalized from 1/9/24 to 1/19/24. Further review of hospital records shows that C1 was noncompliant, removing monitors, leads and IV’s. During file review, the department observed facility body check documented on 1/19/24 which documents the bruises found on C-1 when client returned from the hospital. The department reviewed the facilities internal communication logs dated 1/19/24, which stated that C-1 came back from hospital at 3:30pm with bruises on both arms, both legs and across his chest. The department requested body checks prior to hospital admission date of 1/9/2024. On 11/4/2024 the department interviewed Administrator Sandra Lopez, who state that a body check is only performed upon observation of bruises, or an incident having occurred. On 11/4/2024 the department interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked if staff caused injuries to residents? Of those interviewed, 5 out of 5 answered no. LPA interviewed Client-2 thru Client-10 (C-2 thru C-10). C-1 was not available to be interviewed. LPA asked clients if they have ever been injured by staff. Of those interviewed, 9 out of 10 answered no. Based on the information collected, an inspection of the facility, observation, record reviews, and interviews conducted, the Department found no evidence to support the allegations in this complaint. “Staff caused injury to resident,” therefore the allegation is unsubstantiated. Although the allegation 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 are Unsubstantiated. Allegation: Staff restrained resident On 11/4/2024 the department conducted a review of facility files. During file review, the department reviewed medical records from Kindred Hospital Paramount specifically the Patient Care Summary which shows that C-1 was hospitalized from 1/9/24 to 1/19/24. Further review of hospital records shows that C1 was noncompliant, removing monitors, leads and IV’s and in the section titled, “Activity intolerance,” on pages 4 and 8, hospital records show C-1 was restrained with B wrist restraints. During file review, the department observed facility body check documented on 1/19/24 which documents the bruises found on C-1 when client returned from the hospital. The department reviewed the facilities internal communication logs dated 1/19/24, which stated that C-1 came back from hospital at 3:30pm with bruises on both arms, both legs and across his chest. The department requested body checks prior to hospital admission date of 1/9/2024. On 11/4/2024 the department interviewed Administrator Sandra Lopez, who state that a body check is only performed upon observation of bruises, or an incident having occurred. LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, does staff restrain clients? Of those interviewed, 5 out of 5 answered no. LPA interviewed Client-2 thru Client-10 (C-2 thru C-10). C-1 was not available. LPA asked, have you ever been restrained by staff?” Of those interviewed, 9 out of 10 answered no. Based on the information collected, an inspection of the facility, observation, record reviews, and interviews conducted, the Department found no evidence to support the allegations in this complaint. “Staff restrained resident,” therefore the allegation is unsubstantiated. Although the allegation 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 are Unsubstantiated. An exit interview was conducted, and a copy of the LIC 9099 report was provided to Sandra Lopez, Administrator.the state’s words, verbatim · CDSS document, Nov 4, 2024 · control 11-AS-20240124143607

Allegation investigated: Staff did not ensure resident's doctor received resident's medical records

On 10/31/2024, the Department of Social Services (DSS) - Community Care Licensing Division (CCLD) staff conducted an unannounced complaint visit at this facility. CCLD staff was greeted by Administrator Sandra Lopez. CCLD staff explained the purpose of this visit. The investigation consisted of the following: On 10/31/2024, The department interviewed 10 out of 112 residents and 6 out of 35 staff. The department gathered facility records. Unfounded The investigation revealed the following: Regarding the allegation “Staff did not ensure resident's doctor received resident's medical records”, it is being alleged that resident’s doctor requested resident’s medical history from facility’s doctor and resident’s doctor has not received resident’s medical history. Interviews conducted revealed the following: The facility Administrator indicated that the facility does not have a physician on payroll. Records reviewed revealed the following: There is no physician on the current “Personnel Report” dated “04/01/24”. Regarding the allegation, the allegation is unfounded because the allegation is false, could not have happened, and/or is without a reasonable basis. No citations were issued. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 11-AS-20241030091044

Allegation investigated: Staff did not ensure the facility was free of pests Staff did not safeguard resident's personal belongings

On 10/31/2024, the Department of Social Services (DSS) - Community Care Licensing Division (CCLD) staff conducted an unannounced complaint visit at this facility. CCLD staff was greeted by Administrator Sandra Lopez. CCLD staff explained the purpose of this visit. The investigation consisted of the following: On 10/31/2024, The department interviewed 10 out of 112 residents and 6 out of 35 staff. The department toured resident rooms and the kitchen area. The department gathered facility records. Unsubstantiated The investigation revealed the following: Regarding the allegation “Staff did not ensure the facility was free of pests”, it is being alleged that the facility has roaches, and the facility is doing nothing to address the pest infestation. Interviews conducted revealed the following: 7 out of 10 residents indicated that have seen roaches in the facility but not a lot of them. 3 out of 10 residents indicated that they have not seen roaches in the facility. 10 out of 10 staff indicated: that they have seen roaches in the facility, the facility has very few roaches, and the facility hired a pest control company and they come to the facility on a regular basis to fumigate common areas and rooms. Invoices from a Pest Control Company dated from 07/2024 to 10/2024 indicated that they come to the facility three times per month; one visit is dedicated for the kitchen; two visits are dedicated to fumigating 10 rooms and common areas. On a monthly basis the Pest Control Company fumigates the kitchen area, 20 rooms, and common areas. Regarding the 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. Regarding the allegation “Staff did not safeguard resident's personal belongings”, it is being alleged that staff threw away resident’s food. Interviews conducted revealed the following: 8 out of 10 residents indicated that staff has not thrown away their personal food items. 9 out of 10 interviews conducted indicated that when staff clean residents’ bedrooms they do throwaway food that has gone bad for example gone moldy, smells bad, and looks inedible. Regarding the 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 citations were issued. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 11-AS-20241030091044

Type of visit: Case Management - Annual Continuation

On 09/12/2024 at around 1:10 PM, Licensing Program Analyst (LPA) Leandro conducted an unannounced continuation Required – 1 Year Inspection to the above-named facility and met with Administrator Sandra Lopez. LPA explained the purpose of the visit and was accompanied by Administrator inside and outside the facility during this inspection. Today's annual inspection consisted of records review: 5 staff records were reviewed, 5 out of 5 staff records had required documentation. 5 resident records were reviewed and, 5 out of 5 resident records had required documentation. Facility records were reviewed, and facility had current/required documentation. A technical assistance is being issued for facility not having a videoconferencing device on the premises. Administrator will work with the Licensee on this issue. No deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Sep 12, 2024

Allegation investigated: Staff did not assist resident with scheduling their medical appointments

On 09/06/2024 at around 08:00 AM Licensing Program Analyst (LPA) Leandro conducted a complaint investigation regarding the allegation listed above. LPA met with Administrator Sandra Lopez and the purpose of the visit was explained. The investigation consisted of the following: During today’s investigation LPA interviewed Resident 1 (R1), and 2 out of 35 staff. LPA reviewed Personnel Report, Register of Facility Residents, Plan of Operation, Medical Appointment Binders, and R1’s records. Unsubstantiated The investigation revealed the following: Regarding the allegation “Staff did not assist resident with scheduling their medical appointments,” it is being alleged that R1 has requested assistance in scheduling medical appointments for physical therapy per doctor’s orders, and a mammogram, but staff refused to assist R1 in scheduling their medical appointments. Interviews conducted reveal the following: R1 states “I have no idea” who schedules my appointments, I get free rides to go see my doctors. R1 goes on to explain that someone picks them up and someone schedules all her medical appointments, but she does not know who they are. 2 out of 2 staff interviews conducted indicated that R1’s medical provider has not requested physical therapy or a mammogram for R1, they have also tried assisting her with scheduling physical therapy, but R1’s insurance no longer cover physical therapy (R1 will have to pay out of pocket if they wish to receive physical therapy). Records review reveal the following: medical documentation for R1 does not state that R1 needs/requires physical therapy or a mammogram (the words physical therapy or mammogram are not mentioned in R1’s recent hospital visits nor medical appointments). R1 had an appointment with her primary physician on 08/15/2024 and 07/10/2024. Regarding the 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 citations were issued. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 11-AS-20240905103943

Type of visit: Required - 1 Year

On 09/06/2024 at around 1:00 PM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator Sandra Lopez. LPA explained the purpose of the visit and was accompanied by Administrator inside and outside the facility during this inspection. This facility is licensed to serve 135 non-ambulatory adults ages 60 and above. A total of 116 residents are currently residing in this facility. The Annual Licensing Fees are current. The facility is a two-story building located on a large street. The building consists of 69 resident bedrooms, there are more than 69 bathrooms, 2 activity rooms, 1 medical office, several office spaces, 1 industrial kitchen, 1 dining room, 3 outside patio areas with shaded seating, 1 back yard parking lot, and a front entrance lobby area. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. First aid kit is fully stocked with manual. Random residents’ bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. No deficiencies are being cited. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Sep 6, 2024