Savant of Burbank East

Allegation investigated: Staff do not ensure that resident's incontinence needs are met. Staff do not assist resident with receiving phone calls.

On 09/01/26, Licensing Program Analyst, (LPA) Raymond Comer, conducted an initial 10-day complaint visit to investigate the above allegation(s). LPA presented official CDSS identification badge, met with the Executive Director, and reason for the visit was disclosed. At 8:30 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegations, Between 8:55am and 9:30am, LPA obtained and reviewed Facility roster, Personnel roster, Resident#1s (R1's) Physician Report, Sevice Plan, and other pertinent documentation. Between 9:50am and 11:00am, LPA interviewed the Executive Director, and three (3) staff. Between 11:15am, and 1:45pm, LPA interviewed nine (9) of of a total of ninety (90) residents. [LIC9099C] Continued Unsubstantiated Allegation: Staff do not ensure that resident's incontinence needs are met. Reporting Party (RP) alleges that staff do not provide R1 timely incontinence assistance. LPA's interview with facility's Executive Director revealed the following: They refute the allegation, stating to LPA that R1 sustained an unwitnessed fall in early August 2026 and was sent to hospital for assessment/treatment. Upon R1's return to the facility, R1 receives intensive "Habilitation Hours" assistance from caregivers responding to residents on a 1-caregiver to 5-resident ratio. Executive Director stated that R1 is provided consistent and timely incontinence assistance by staff at least three (3) times daily, or more as needed. Staff check on R1 a minimum of every two hours to ensure R1's satisfactory health outcomes. Additionally facility has provided R1 with a walker, and wheelchair to enhance mobility, and that rehabilitation therapy (provided by Bonum Home Health) has recently begun for R1. LPA's interviews with three (3) staff revealed the following: All staff refute the allegation, stating to LPA that R1 is provided timely and consistent incontinence assistance at least three (3) times daily, or more as needed. LPA interviewed nine (9) out of ninety (90) residents, which revealed the following: All nine (9) out of nine (9) residents interviewed (including R1) stated they are satisfied with staff incontinence assistance and other ADL assistance and had no health/safety concerns. LPA's records review of R1's file revealed the following: R1's physician's report (LIC 602) shows that R1 is challenged with schizophrenia, motor paralysis, and "refuses hygiene". Report shows that R1 lacks impulse control and exhibits aggressiveness by spreading feces on facility chairs. R1's service plan requires R1 to receive full staff assistance for bathing, dressing, toileting, and oral care. During LPA's interview with R1, LPA observed the following: R1 was lying in his bed dressed appropriately and appeared comfortable. R1's room was clean and free of odor. Based on LPA observations, and interview of records staff, and residents, there was not sufficient evidence to verify that staff are neglecting R1's needs for incontinence assistance. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not ensure that resident receives phone calls. It is alleged that staff do not allow/provide assistance for R1 to receive phone calls from family members, nor respond to voice messages by R1's family members. LPA's interview the Executive Director revealed the following: They refute the allegation, stating that R1's family members have been provided with work cell numbers to both Med-tech and Wellness director staff to assist in communicating with R1. Additionally, R1 with has been provided with a cellphone for them to communicate with anyone at will. LPA's interviews with three (3) staff revealed the following: All staff refute the allegation, stating to LPA that when calls are received by the facility on R1's behalf, staff take the facility's cellphone to R1 to receive the those calls. Phone screen shots provided by staff show that R1 received both phone calls and text communication from family members. LPA interviewed nine (9) out of ninety (90) residents, which revealed the following: All nine (9) out of nine (9) residents interviewed (including R1) stated they are satisfied with assistance and phone access provided by staff to residents. Based on interviews with R1, other residents, and staff: this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted; copy of this report provided.the state’s words, verbatim · CDSS document, Sep 1, 2026 · control 31-AS-20260826134807

Allegation investigated: Staff did not shower resident in care Staff did not ensure that the resident's incontinence care needs were properly met at the facility Staff did not keep the resident's room free of pests Staff did not provide proper transfer assistance to residents in care

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint visit at this facility to investigate the above allegation(s). LPA met with Imelda Villanueva-Executive Director and explained the reason for the visit is to close out the investigation and render findings. Initial investigation was conducted by LPA Shahbazian on 07/14/26. LPA had previously requested documents pertaining to the investigation and had interviewed residents and staff. At approximately 9:40am, LPA conducted a physical plant tour of the common areas and kitchen; no immediate health or safety risks were observed during today's visit. In regards to allegation: Staff did not shower resident in care. It is alleged that: Resident #1 (R1)’s Monday shower was skipped by a caregiver. LPA's interviews revealed the following: The Administrator stated that there are (5) caregivers assigned to am and pm shifts and 2 or more caregivers during night Continued on 9099-C Unsubstantiated shift but if there is a staff shortage, staff from other shifts or agency staff are called in for assistance. Administrator stated staff shower residents two times a week or more, if accidents occur. There are times that residents refuse to be showered but staff return at a later time to shower residents and if refused again, staff notate the refusal. (7) Caregivers and (1) witness stated they are assigned to 12-16 residents per shift, of whom only 7-8 residents need total assistance with activities of daily living (ADL)s and approximately 7-8 residents are independent. All staff interviewed stated they ensure residents are showered two times a week or more, if accidents occur, sometimes even several times a day. In addition all (7) staff mentioned if residents refuse to be showered, staff return at a later time to shower residents and if refused again, staff notate refusal log, but refusal rarely happens. LPA interviews with residents revealed the following: (4) residents stated they are capable of showering themselves and using the restroom on their own. (5) residents stated staff assist them with showering two times or more per week, changing them and assisting with other needs. During interview with R1, they did not recall the exact showering schedule but stated staff shower them at least two or three times a week and did not have any concerns. LPA reviewed the shower logs for months of June and July 2026 and did not notice that R1’s shower needs were not met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. In regards to allegation: Staff did not ensure that the resident's incontinence care needs were properly met at the facility. It is alleged that several residents had double diapers, including Resident 1 (R1), who was not kept clean. LPA's interviews revealed the following: The Administrator stated that there are (5) caregivers assigned to am and pm shifts and 2 or more caregivers during night shift but if there is a staff shortage, staff from other shifts or agency staff are called in for assistance. (7) caregivers and (1) witness stated they are assigned to 12-16 residents per shift, of whom only 7-8 residents need total assistance with ADLs and approximately 7-8 residents are independent and capable of managing their own ADLs. All (7) staff stated they ensure residents are usually clean and dry, when they start their shifts. They check on residents with incontinence needs every hour, sometimes residents are taken to the bathroom or sometimes changed in bed. Sometimes residents have accidents in bed, even several times a day and they are always cleaned, changed and clothing or bed sheets are changed. All (7) staff and (1) witness stated they make sure residents’ incontinence clothing are always clean and dry and they never put on double diapers. LPA interviews with residents revealed the following: R1 stated staff always check on R1 and make sure pull ups are clean, otherwise they clean R1 and pull up are changed and R1 is never double diapered. Continued on 9099-C (4) residents stated they use the restrooms by themselves. (4) residents stated staff check on them every hour and especially after meals to ensure their toileting needs are met, staff take them to use the restroom, clean and change their pull ups but they have never been double diapered. 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. In regards to allegation: Staff did not keep the resident's room free of pests. It is alleged that there were roaches in one of rooms. LPA interviewed the Administrator and Maintenance Director, who stated that staff or residents notify them of any issues in resident rooms or common areas and a maintenance order is placed. Maintenance Director stated a professional pest control company comes to the facility, twice a month, once in the morning and one at night, for preventive measures. The pest control company is responsible for addressing any rodent or insect issues but there has been no issues since end of last year. The pest control company uses chemicals safe for humans. LPA interviewed (7) staff and (10) residents who stated they have not seen any infestations in rooms or common areas. LPA visited common areas, kitchen and multiple rooms in both floors and did not observe any insects or signs of infestation. 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. In regards to allegation: Staff did not provide proper transfer assistance to residents in care. It is alleged that transfers for patients that cannot bear weight are done without any hoyer lifts, which is both risking the caregiver and the patient's safety. LPA's interviews revealed the following: The Administrator stated facility only has two residents that are heavy and require 2-3 staff assistance for transfer. All staff, including the agency staff are trained in transferring, lifting and repositioning residents and there are continuous training on resident care. Facility has a mechanical hoyer lift and transfer boards, which staff sometime use to transfer heavy or non-weight bearing residents but generally caregivers ask each other for assistance if needed. Interviews with (7) caregivers and (1) witness stated they are assigned to 7-8 residents in need of total assistance with ADLs and they are capable of transferring themselves to beds, showers and wheelchairs and don’t require 2-3 staff transferring assistance. All staff interviewed mentioned that they prefer to assist the residents themselves and generally do not use the hoyer lift but if they need help, they communicate with other caregivers to transfer residents. LPA Interviewed (10) residents, (5) residents stated that are independent. (5) residents mentioned generally they are able to transfer or reposition themselves but staff always assist them for safety purposes. 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 was conducted with and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 31-AS-20260710110726

Allegation investigated: Licensee does not ensure facility has sufficient staffing to meet the care needs of residents in a prompt manner

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced 10 day complaint visit at this facility to investigate the above allegation(s). LPA met with Imelda Villanueva-Executive Director and explained the reason for the visit. At 11:10 am, LPA conducted a physical plant tour; no health and safety issues were observed. In regards to allegation, Licensee does not ensure facility has sufficient staffing to meet the care needs of residents in a prompt manner. It is alleged that: As the only caregiver, they were assigned to approximately 50 residents, about 30 of whom required extensive assistance with daily living activities. Continued on 9099-C Unsubstantiated LPA interviews revealed the following: The Administrator stated that there are 4 caregivers (or more) assigned to am and pm shifts and 2 or more caregivers during night shift but if there is a staff shortage, staff from other shifts or agency staff are called in for assistance. In addition Med Techs are also available to assist resident care. (7) Staff and (1) witness stated the caregivers are assigned to 12-16 residents per shift, of whom only 7-8 residents need total assistance with activities of daily living (ADL)s and approximately 7-8 residents are independent and capable of managing their own ADLS. All staff unanimously stated there are never assigned to assist more than 12-16 residents and there is always enough staff coverage and sometimes agency staff are called in to assist in case of shortages. Witness also corroborated the information provided by the staff and stated have never seen the facility to be understaffed and residents are checked on every 1-2 hours or more. All staff stated they ensure residents care is provided timely, every hour, and if they are busy with a resident, they communicate with other staff members and they help each other with showering residents at least two time or more per week, change residents, transfer residents to wheelchairs and provide ADL. LPA interviews with residents revealed the following: (4) residents stated they are capable of showering themselves and using the restroom on their own. (5) residents stated staff assist them with showering two times or more per week and with changing them, cleaning the rooms and other needs. All residents stated that staff check on them on regular basis. During the physical plant inspection, LPA pulled the assistance cord in three rooms, in both floors and staff responded between 1-4 minutes. Based on LPA interviews, and observation, there is not sufficient information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 31-AS-20260706094026

Allegation investigated: Staff are not meeting resident's needs. Facility staff did not provide nutritious meals to resident in care resulting in weight loss. Facility staff enrolled resident in hospice without responsible party's notification.

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint visit at this facility to investigate the above allegation(s). LPA met with Imelda Villanueva-Executive Director and explained the reason for the visit is to close out the investigation and render findings. Initial investigation was conducted by LPA Shahbazian on 05/21/26. LPA had previously requested documents pertaining to the investigation and had interviewied residents and staff. In regards to allegation, Staff are not meeting resident's needs. It is alleged that: Resident #1 (R1) is bedridden and on hospice and staff does not regularly check on the resident. LPA interviewed the Administrator who stated resident is considered non-ambulatory but not bedridden. R1 receives assistance with activities of daily living (ADL)s including incontinence care, grooming, cleaning the room and laundry but showers are provided twice weekly by the hospice nurse. LPA interviewed five (5) care Continued on 9099-C Unsubstantiated staff who indicated they check on R1 on regular basis to assist with incontinence, grooming and other needs. Interview with witness revealed they had visited R1, possibly a year ago and but noticed resident’s hair matted and nails to be long. Witness stated they are aware that R1 has been on hospice for a while and R1 is receiving ADLs. Witness also stated that they communicate with R1, who informed them that staff are providing care and R1 has no concerns. LPA conducted interviews with nine (9) residents. Four (4) stated they take their own showers and use the restroom on their own but there is always staff to assist. Five (5) residents stated that staff check on them every hour or two hours to assist with any needs such as toileting and that they are showered two times a week. All nine (9) stated the trash is picked up, rooms and bedding are clean daily, with weekly room deep cleaning and laundry service. LPA interviewed R1 who stated ‘nurse’ comes two times a week and provides bed showers but staff assist them with daily grooming of hair, changing of clothing, incontinence care. Resident stated staff encourage them to walk, use wheelchair and to get out of bed but R1 chooses to stay in bed. R1 also stated the staff always check on R1 and “it seems staff are always here”. LPA reviewed R1’s physician record, where R1 is listed as non-ambulatory and not bedridden. Review of records indicate facility and hospice staff are providing necessary care services. 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. In regards to allegation, Facility staff did not provide nutritious meals to resident in care resulting in weight loss. LPA interviewed the Administrator and kitchen staff who stated R1 prefers to stay in their room and does not participate in activities or come to the dining room. Kitchen staff verified that R1 is on diabetic, no salt and soft mechanical diet and chooses not to eat pork. LPA was provided copy of daily and special menus and kitchen staff stated menus are posted throughout the facility and residents order their daily meals but meals can be prepared upon special request. Five (5) staff interviewed stated even though R1 stays in the room but they inform R1 of the daily menu and special menu and ask R1 their preference for each meal. LPA interviewed nine (9) residents and all of them stated they are happy with the meals/snacks/fruits and food is nutritious but if they don’t like the meals, kitchen staff will prepare a special meal for them. LPA visited R1 and observed a caregiver with R1 who was encouraging R1 to finish the lunch. LPA interviewed R1 who stated generally R1 likes the food but sometimes prefers to eat the dessert, such as ice cream, but staff are watching the plates and encourage to finish the plate. R1 stated they choose to stay in the room and every day staff inform them of the menu and ask their preference of each meal. LPA observed reviewed the physician record from 03/06/25 and compared to face sheet dated 02/10/26, which revealed R1's weight was reduced from 160 pounds to 137.2 pounds. LPA observed R1’s plate to include fish, potato, juice and ice Continued on 9099-C cream. LPA also reviewed the regular and special meal menu and verified that there are always multiple selections for each meal, including juices and vegetables. 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. In regards to allegation, Facility staff enrolled resident in hospice without responsible party's notification. Upon interview with Administrator, if was revealed that resident was refusing showers, ADLs or care and physician had contacted a hospice agency to provide care. Administrator stated R1 is self-responsive and had signed the admission records and hospice contract themselves. R1’s family was notified by telephone call, after R1 was accepted to hospice care. During the visit on 06/12/26, Administrator stated that as of 05/29/26, R1’s family requested hospice care to be stopped and facility will be responsible for providing care now. LPA interviewed R1 who stated they were aware that a ‘nurse’ would be providing care and they signed the hospice contract but R1 did not recall the exact admission date when hospice care started. LPA reviewed the admission and hospice admission record and observed that R1 had sign both documents themselves. 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. Exit interview conducted; all above allegations were UNSUBSTANTIATED. A copy of the report was provided to the administrator.the state’s words, verbatim · CDSS document, Jun 12, 2026 · control 31-AS-20260513154913

Allegation investigated: Staff are not meeting resident's needs. Facility staff did not provide nutritious meals to resident in care resulting in weight loss. Facility staff enrolled resident in hospice without responsible party's notification.

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint visit at this facility to investigate the above allegation(s). LPA met with Imelda Villanueva-Executive Director and explained the reason for the visit is to close out the investigation and render findings. Initial investigation was conducted by LPA Shahbazian on 05/21/26. LPA had previously requested documents pertaining to the investigation and had interviewied residents and staff. In regards to allegation, Staff are not meeting resident's needs. It is alleged that: Resident #1 (R1) is bedridden and on hospice and staff does not regularly check on the resident. LPA interviewed the Administrator who stated resident is considered non-ambulatory but not bedridden. R1 receives assistance with activities of daily living (ADL)s including incontinence care, grooming, cleaning the room and laundry but showers are provided twice weekly by the hospice nurse. LPA interviewed five (5) care Continued on 9099-C Unsubstantiated staff who indicated they check on R1 on regular basis to assist with incontinence, grooming and other needs. Interview with witness revealed they had visited R1, possibly a year ago and but noticed resident’s hair matted and nails to be long. Witness stated they are aware that R1 has been on hospice for a while and R1 is receiving ADLs. Witness also stated that they communicate with R1, who informed them that staff are providing care and R1 has no concerns. LPA conducted interviews with nine (9) residents. Four (4) stated they take their own showers and use the restroom on their own but there is always staff to assist. Five (5) residents stated that staff check on them every hour or two hours to assist with any needs such as toileting and that they are showered two times a week. All nine (9) stated the trash is picked up, rooms and bedding are clean daily, with weekly room deep cleaning and laundry service. LPA interviewed R1 who stated ‘nurse’ comes two times a week and provides bed showers but staff assist them with daily grooming of hair, changing of clothing, incontinence care. Resident stated staff encourage them to walk, use wheelchair and to get out of bed but R1 chooses to stay in bed. R1 also stated the staff always check on R1 and “it seems staff are always here”. LPA reviewed R1’s physician record, where R1 is listed as non-ambulatory and not bedridden. Review of records indicate facility and hospice staff are providing necessary care services. 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. In regards to allegation, Facility staff did not provide nutritious meals to resident in care resulting in weight loss. LPA interviewed the Administrator and kitchen staff who stated R1 prefers to stay in their room and does not participate in activities or come to the dining room. Kitchen staff verified that R1 is on diabetic, no salt and soft mechanical diet and chooses not to eat pork. LPA was provided copy of daily and special menus and kitchen staff stated menus are posted throughout the facility and residents order their daily meals but meals can be prepared upon special request. Five (5) staff interviewed stated even though R1 stays in the room but they inform R1 of the daily menu and special menu and ask R1 their preference for each meal. LPA interviewed nine (9) residents and all of them stated they are happy with the meals/snacks/fruits and food is nutritious but if they don’t like the meals, kitchen staff will prepare a special meal for them. LPA visited R1 and observed a caregiver with R1 who was encouraging R1 to finish the lunch. LPA interviewed R1 who stated generally R1 likes the food but sometimes prefers to eat the dessert, such as ice cream, but staff are watching the plates and encourage to finish the plate. R1 stated they choose to stay in the room and every day staff inform them of the menu and ask their preference of each meal. LPA observed reviewed the physician record from 03/06/25 and compared to face sheet dated 02/10/26, which revealed R1's weight was reduced from 160 pounds to 137.2 pounds. LPA observed R1’s plate to include fish, potato, juice and ice Continued on 9099-C cream. LPA also reviewed the regular and special meal menu and verified that there are always multiple selections for each meal, including juices and vegetables. 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. In regards to allegation, Facility staff enrolled resident in hospice without responsible party's notification. Upon interview with Administrator, if was revealed that resident was refusing showers, ADLs or care and physician had contacted a hospice agency to provide care. Administrator stated R1 is self-responsive and had signed the admission records and hospice contract themselves. R1’s family was notified by telephone call, after R1 was accepted to hospice care. During the visit on 06/12/26, Administrator stated that as of 05/29/26, R1’s family requested hospice care to be stopped and facility will be responsible for providing care now. LPA interviewed R1 who stated they were aware that a ‘nurse’ would be providing care and they signed the hospice contract but R1 did not recall the exact admission date when hospice care started. LPA reviewed the admission and hospice admission record and observed that R1 had sign both documents themselves. 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. Exit interview conducted; all above allegations were UNSUBSTANTIATED. A copy of the report was provided to the administrator.the state’s words, verbatim · CDSS document, Jun 12, 2026 · control 31-AS-20260513154913

Allegation investigated: Staff did not address a change in resident's condition Staff does not keep the facility free of odor

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint visit at this facility to investigate the above allegation(s). LPA met with Imelda Villanueva-Executive Director and explained the reason for the visit is to close out the investigation and render findings. Initial investigation was conducted by LPA Shahbazian on 03/17/26 and 06/09/26. LPA had previously requested documents pertaining to the investigation and had interviewied residents and staff. In regards to allegation, Staff did not address a change in resident's condition. It is alleged that: Resident #1 (R1) has progressive dementia that requires evaluation and intervention. LPA reviewed R1’s physician reports and individual service plan and interviewed the Administrator and eight (8) staff members. Interviews with Administrator revealed that R1 was assessed by physician and by assisted living program nurse. Interviews with eight (8) staff revealed that R1 needs assistance with activities of daily living (ADL)s Continued on 9099-C Unsubstantiated and staff check of R1 on hourly basis or more. Four (4) staff members stated that they check on R1 on hourly basis and assist R1 with incontinence care or toileting. Administrator and four (4) care staff stated that R1 does not have dementia. LPA interviewed R1 who stated their diagnosis is not dementia and they denied having memory or dementia related symptoms. R1 stated they need assistance with ADLs and staff always remind R1 to wear incontinence clothing but R1 does not always want to wear incontinence clothing and is able to use the restroom on their own. R1 stated staff assist them with toileting and incontinence care several times a day and provide all necessary ADLs. LPA reviewed physician reports and individual service plan (ISP). LPA observed that R1 has been assessed multiple times but there is no indication of a diagnosis of dementia or changes in resident’s ADL services. 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. In regards to allegation, Staff does not keep the facility free of odor. It is alleged that: Resident #1 frequently urinates in their clothing and hangs wet clothing to air dry the items on bedrail or shared bathroom. LPA interviewed the Administrator who stated they have been several occasions that resident refused to wear incontinence clothing but staff check of R1 on hourly basis to ensure toileting needs are met. Of eight (8) staff interviewed, four (4) care staff mentioned that they encourage R1 to wear incontinence clothing and that R1 has been compliant. The care staff stated that they check on R1 on hourly basis for ADLs and toileting; they remind R1 to use the restroom but R1 prefers to use the restroom on their own. Care staff mentioned they make sure resident is clean and has a fresh/dry incontinence clothing all the time and they bathe residents at least twice a week or more, due to accidents. Four (4) staff mentioned that there were a few times when R1 had accidents in bed and removed the clothing to air dry but staff noticed and changed/washed the clothing and the sheets. Upon reminding resident about hourly bathroom checks, R1 is hardly having accidents and/or soiled clothing. R1 was provided a lided hamper, which is kept in the closet, which all dirty clothes are maintained. Interviews with three (3) housekeepers revealed that they check on each resident on daily basis to ensure rooms are clean, trash is emptied and all dirty clothes/linens are sent to be washed. LPA conducted interviews with nine (9) residents. Four (4) stated they take their own showers and use the restroom on their own but there is always staff to assist. Five (5) residents stated that staff check on them every hour or two hours to assist with any needs such as toileting and that they are showered two Continued on 9099-C times a week. All nine (9) residents stated the trash is picked up, rooms and bedding are clean daily, with weekly room deep cleaning and laundry services. LPA visited various resident rooms randomly and all rooms were observed to be clean and without odor. During LPA’s first visit on 03/17/26, LPA had observed two pieces of clothing on R1’s bed. LPA interviewed R1 who stated they used to remove their clothing to put in the closet but staff take their dirty clothing from the hamper and wash them several times a week. R1 mentioned that staff ensure R1 uses the restroom and change diaper and linens and shower R1 twice a week. During the visit on 06/09/26 LPA did not observe any clothing hanging in resident’s room and did not smell any odor in the room or the closet hamper and observed the room to be clean. 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. Exit interview conducted; all above allegations were UNSUBSTANTIATED. A copy of the report was provided to the administrator.the state’s words, verbatim · CDSS document, Jun 12, 2026 · control 31-AS-20260312154340

Allegation investigated: Staff speaks inappropriately to resident Staff did not ensure resident's showering needs are met Staff hits residents Staff did not ensure resident was assisted with dressing Staff did not respond to resident's calls for assistance in a timely manner Staff threatens residents

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced complaint visit at this facility to investigate the above allegation(s). LPA met with Silvia Valdez-Executive Director at Savant of Burbank West and explained the reason for the visit is to deliver findings. The initial complaint investigation was conducted by LPA Jose Tan on 08/12/2025 and pertinent documents were gathered, including records for Resident 1 (R1). On 10/24/2025 and 01/22/2026 LPA Nadia Shahbazian conducted subsequent complaint investigation visits and interviewed residents and staff members. Regarding the allegation: Staff speaks inappropriately to resident. It is alleged that Staff 1 (S1) was speaking about Resident 1 (R1) in Spanish with another staff member. Interviews with the Administrator and (8) staff revealed that all residents are treated with dignity. Staff do not raise their voice at residents. Continued on 9099-C Unsubstantiated (3) staff mentioned that sometimes residents raise their voices to the staff or are rude towards the staff but staff never disrespect residents, as per their training and regulations. During interviews with staff, LPA Shahbazian noticed there are several staff who speak Spanish with residents or with other staff but all (8) staff interviewed stated they do not speak about residents in public and they maintain residents confidentiality. 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. Regarding the allegation: Staff did not ensure resident's showering needs are met. It is alleged that R1 did not receive showers for 3 weeks, prior to going to the rehab center. Based on Incident Report dated 06/08/2025 R1 was sent to hospital on 06/04/2025. Another Incident report dated 07/7/2025 reflects that R1 was sent to hospital on 07/06/2025. Incident Report dated 08/01/2025 states that R1 requested to be transferred to Skilled Nursing Facility on 07/28/2025 and resident was transferred to Mar Vista Rehab Center. LPA Shahbazian reviewed facility hospital logs regarding R1. It was revealed that R1 was in hospital from 06/04/2025-06/27/2025 and from 07/06/2025-07/25/2025. Based on June 2025 and July 2025 shower logs, staff showered R1 on 06/02/2025, 06/29/2025, 07/03/2025 and 07/27/2025. In addition, interviews with (5) residents revealed they take their own showers and do not require staff assistance. (5) residents stated staff shower them two times weekly, or more and (1) resident stated they receive showers once a week by staff. All (8) staff interviewed stated they provide biweekly showers to residents, unless they decline and if so, residents sign a decline form. Based on interviews and record review, it was revealed that R1 was in hospital several times in June and July 2025, therefore was not present at the facility to receive regular biweekly showers. 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. Regarding the allegation: Staff hits residents. It is alleged that R1 witnessed S1 hitting 2 -3 male residents in the hallway. Interview with (8) staff revealed staff never hit any residents and they are aware of resident rights and facility policies. LPA Shahbazian interviewed (11) residents, (4) of whom were male residents. All (11) residents stated staff are nice and they do not hit residents and staff treat residents with respect. 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. Regarding the allegation: Staff did not ensure resident was assisted with dressing. It is alleged that staff were supposed to help R1 to get dressed but they would not. Interviews with R1 revealed she was not assisted with dressing by staff. (8) staff revealed that some residents are able to groom and dress themselves and do not need staff assistance. All (8) staff interviewed stated they assist residents with dressing, changing incontinence underwear and grooming on daily basis and sometimes several times, if needed. In addition, interviews with (5) residents revealed they dress themselves and do not require staff assistance. (5) residents stated that staff assist them with dressing and grooming daily. 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. Regarding the allegation: Staff did not respond to resident's calls for assistance in a timely manner. It is alleged that R1 would press the call button but staff would not help. Interview with R1 revealed that they would press the call button and staff would not come or sometimes staff would come and then say they’ll be back. R1 then would press the call button again for assistance. LPA interviewed (11) residents and only (2) mentioned that staff come late sometimes perhaps within 10 minutes. (9) residents stated staff assist them regularly and timely. (8) staff revealed that they check on residents every 2-3 hours or more, if necessary. All (8) staff stated they respond to call button between 3-10 minutes but if they are busy, staff communicate with each other or with the concierge, to ensure another staff assists the resident in need. During the visit on 10/24/2025 LPA Shahbazian pulled the assistance cord in several rooms and staff responded within few minutes: The cord was pulled In room #240 at 3:05pm and staff responded at 3:09pm, in room# 221 the cord was pulled at 3:12pm and staff responded at 3:15pm and at room# 107 LPA pulled the cord at 3:23pm and staff responded at 3:25pm. 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. Regarding the allegation: Staff threatens residents. It is alleged that administrator makes threats to all residents. Interviews with (10) residents revealed that no staff member has threatened them and they feel comfortable to speak with the administrator or the staff. Interviews with the administrator and (2) witnesses revealed that R1 was not threatened and never notified them of being disrespected at the facility. Interviews with the administrator and (8) staff revealed that they do not threaten or speak with residents in rude manner. (2) staff mentioned that they encourage residents to speak with the administrator directly. 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 deficiency cited during this visit. All above allegations were UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 31-AS-20250807132808

Type of visit: Case Management - Other

On 05/21/26 Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced case management visit and met with Silvia Valdez-Executive Director and explained the reason for the visit. The facility is under Compliance Plan for two years, effective 02/11/2026. LPA asked for staff and resident rosters and reviewed records for four (4) residents to ensure compliance with required documents. LPA interviewed (4) residents and (3) staff members as well. From 12:25 PM - 12:50 PM, LPA conducted a physical plant tour; no immediate health or safety risks were observed during today's visit. No deficiencies were observed. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 21, 2026

Allegation investigated: Staff inappropriately sent resident to the hospital. Staff did not ensure resident had colostomy bags. Staff are not meeting residents needs.

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced subsequent visit for the above allegation. LPA met with business office manager, Marili Barajas (S2) and explained the reason for the visit. On 4/23/2026, LPA Ngo-Castaneda conducted a records review of the resident's file and other relevant documents, including the physician's report, admission agreement, medical records, LIC 500 (staff roster), resident roster, and other pertinent documents. On 5/20/2026, LPA toured the physical plant at 9:40 AM. At 10:04 AM, LPA interviewed the administrator and facility staff. At 10:18 AM, LPA interviewed a total of twelve (12) residents. Allegation: Staff inappropriately sent resident to the hospital. Continue to LIC 9099-C Unsubstantiated It was alleged that staff inappropriately sent the residents to the hospital. Interview conducted on 4/23/2026 at 12:00PM with facility administrator, revealed that resident #1 (R1) was brought to the hospital on 4/12/2026 at 4:10 PM to due to colostomy bags leak. Resident #2 (R2) was brought to the hospital on 4/12/2026 at 10:15 AM due to observation of maggots in R2’s stool and was discharged without conducting a stool check or laboratory exams. Incident report revealed R1 was sent to the hospital due to colostomy bag was leaking and abdominal pain. Medical record review revealed R1 was discharge immediately and returned to the facility for colostomy care and gastritis. For R2, medical record revealed on 4/13/2026 at 8:25 AM, R2 was sent to the hospital again for abdominal pain and for laboratory exams. Medical records review revealed that R2 labs were eventually tested after the second visit on 4/13/2026. Interview with facility residents revealed that they are sent to the hospital when requested and necessary. Interview with staff revealed that residents are assessed first for their concerns and will be sent to the hospital when needed/ necessary. Based on interviews and record review, there is insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff did not ensure resident had colostomy bags. It was alleged that facility staff did not ensure that resident #1 (R1) had supplies of a colostomy bag in the facility. Interview with residents revealed that the facility supplies all the residents' needs in the facility including colostomy bags for them and never runs out. Interview with administrator revealed no other residents in the facility uses colostomy bag. Record review and invoices revealed that the facility purchases R1’s colostomy bags every two (2) weeks on auto-ship each order includes 20 pieces. Interview with residents revealed that they have no issues with the facility supplying their needs. Interview staff revealed that if residents need supplies, a request is sent to the administrator, and the administrator provides the supplies for the residents. Based on interviews, observation, and record review, there is insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Continue to LIC 9099-C Allegation: Staff are not meeting residents needs. It is alleged that facility staff are not meeting residents' needs. R1 colostomy bag was leaking. Interview with S1 revealed that they always meet residents' needs, but facility staff are not trained to change R1 colostomy bag. An interview with the facility administrator revealed that R1 has a physician order that R1 should change their own colostomy bag. Staff revealed that R1 changes their own colostomy bag, and they're not trained. Interview with R1 revealed that they changed their own colostomy bag, and the staff do not get involved. Interview with residents revealed they are getting all the supplies they need, and facility never run out of supplies. Residents expressed no concerns and informed LPA that staff are providing them with all their needs. During the physical plant tour conducted on 4/23/2026 and 5/20/2026, LPA observed adequate supplies in the facility. LPA also observed that staff respond to residents' requests for supplies and meet their needs promptly. Therefore, based on interviews and LPA observation, interview, and record review, this allegation is deemed unsubstantiated at this time. No deficiency cited during this visit. Exit interview conducted, and a copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 20, 2026 · control 31-AS-20260413155335

Allegation investigated: Staff stole resident’s belongings.

On Monday, 04/27/26, Licensing Program Analyst, (LPA) Raymond Comer, conducted an initial 10-day complaint visit to investigate the above allegation. LPA presented official CDSS identification badge, met with the Administrator, and reason for the visit was disclosed. At 10:10 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, Between 10:20 am and 10:45 am, LPA interviewed the Administrator. Between 10:55 am, and 11:35 am, LPA interviewed three (3) staff. Between 11:40 am, and 1:00 pm, LPA interviewed eight (8) residents. At 1:15 pm, LPA received and reviewed Facility roster, Personnel roster, Resident#1 (R1) Physician Report, Appraisal, and other pertinent documentation. [LIC9099C] Continued Unsubstantiated Allegation: Staff stole resident’s belongings. Resident#1 (R1) was transferred to a skilled nursing facility for extended evaluation, and did not receive all of their personal belongings. After multiple attempts to communicate the issue, staff did not respond, causing R1 to believed that staff had stolen their personal belongings. LPA Interviews revealed the following, Both Administrator, and Staff, refute the allegation, stating that the majority of R1's personal belonging were transported and received by R1. However, the items reported as "stolen" were in fact locked in a dresser requiring a key, which was in R1's possession. The locked dresser was opened by maintenance staff, and per Administrator and S1, R1's personal items were gathered, packaged, and were initially scheduled for staff transport to R1 on Friday, 5/01/26. LPA observed R1's identified personal items (costume jewelry, sunglasses, toiletries, jackets, scarves, bed comforter, bedsheets, and pillows) as packaged in cardboard moving boxes, which were secured in the facility's maintenance room; locked and inaccessible to residents/unauthorized staff. LPA observed Administrator contact R1, via phone, informing them that their identified personal items were located and were delivered to R1 today, 4/27/26 at 1:30 pm. LPA interviews with residents revealed the following: Eight (8) out of a total of eighty-nine (89) total residents stated not suspecting, nor having any personal items stolen by staff, and are satisfied with facility's safekeeping of their personal belongings. Based on LPA interviews, and observation, their is not sufficient information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. Exit interview conducted, and a copy of the report was issued to the administrator.the state’s words, verbatim · CDSS document, Apr 27, 2026 · control 31-AS-20260420153931

Type of visit: Required - 1 Year

On 02/27/2026, at 9:15 am Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced required annual inspection. LPA met with Regional Director of Operations - Lisa Pham and explained the reason for the visit. The facility is under Compliance Plan for two years, effective 02/11/2026. A Noncompliance Conference was held on 02/11/2026 at the Woodland Hills South Regional Office. Facility management have agreed to the terms of the compliance plan. Facility is licensed as a two-story building. Fire clearance approved for one hundred (100) non-ambulatory residents; ages 60 and above, ten (10) of whom may be bedridden. Hospice waiver is approved for thirty (30) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. From 12:25pm to 1:20pm, LPA conducted a tour of the physical plant, with the staff and observed the following: The Reception area is located immediately upon entrance. Required postings were displayed at the reception area. Facility’s main door is the primary entry/exit access. The facility has five (5) exit doors on the first floor, (including the front entry) and three (3) exits on the second floor. Facility has one elevator. LPA observed three (3) evacuation chairs at each stairwell. Continued on 809-C KITCHEN: Facility has a commercial kitchen which is kept locked and inaccessible to residents. Appliances included a industrial refrigerator, freezer, convection oven, microwaves, ice-maker and juice dispensing machines. LPA observed an adequate supply of perishable foods for two (2) days, and non-perishable food supply for seven (7) days, which were stored in the refrigerator, freezer, and pantry. Food was properly labeled and marked with expiration and/or purchase dates. Emergency food was observed in a separate walk-in pantry. Sharps are stored in the kitchen drawer and all chemicals were kept in a locked storage room, across the kitchen. LPA observed records of special dietary needs and weekly menu in the kitchen. All kitchen surfaces, floors, walls and appliances were maintained in clean and sanitary condition. COMMON AREAS: Facility is a two-story building. The first floor has a lobby/living room, a television room, dining room, hair salon and outside and an inside patio areas. There are common area bathrooms, in both floors. Second floor has an activity room. Common area floors and hallways were clean and without obstructions, all furnishings were observed to be clean and in good condition. Multiple dual smoke/carbon monoxide detectors are installed, hardwired, and interconnected throughout the facility. Multiple fire extinguishers were observed throughout both floors and all the fire extinguishers were last inspected on 05/08/2025 by Delta Fire Company, which is privately owned. Delta Fire Company conducts quarterly smoke/carbon monoxide detector and fire alarm testing, the last test was conducted on December 2025. There are cameras installed in common areas of the home, including the hallways and patios. In addition facility offers telephone access and wi-fi access to residents in care. There are three stairwells and one elevator in the building; evacuation chairs were observed atop each stairwell. Roof is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. SURROUNDING GROUNDS: The passageways and entrance to the home was clear of obstruction. Facility has an outdoor patio and an indoor patio area. LPA observed two sets of patio furniture with two umbrellas, in each patio. There are no bodies of water in the facility. LAUNDRY ROOMS: There are two laundry rooms, one on each floor, with two washers and two dryers in each room. Chemicals and detergents were stored in a locked room on the second floor, near the laundry room, inaccessible to residents. Continued on 809-C BEDROOMS: LPA toured multiple resident bedrooms on both floors. Of all bedrooms inspected, all were observed to be clean and contained required furnishings and bedding. At 11:57am in room# 123, LPA pulled the assistance cord; caregiver responded within 1 minute. Also at 12:06pm in room# 212 LPA pulled the assistance cord; a caregiver responded within 2 minutes. BATHROOMS: LPA inspected common area bathrooms in the hallway and several bathrooms in resident rooms. All inspected bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, non-slip mats). Hot water temperature measured between 108.7° F. and 119.2° F; within the required range. At 12:14pm in bathroom# 222, LPA pulled the assistance cord; a caregiver responded within 1 minute. MEDICATIONS: Facility's Wellness Room is located on the first floor, in which all medications are securely locked, inaccessible to residents. With the assistance of Wellness Coordinator, LPA reviewed Medication Administration Records (MARs) for nine (9) residents and compared them to the medication count and found no discrepancies. A First Aid kit and the First Aid Manual was observed in the Wellness Room. In addition to the plant tour, LPA reviewed the facility's infection control plan and disaster plan. Facility conducts quarterly Fire Disaster and Emergency drills, the last drill was conducted on 01/29/2026. LPA obtained a copy of liability insurance and auto insurance with expiration date of 01/01/2027. Administrator's Certificate expiration date is 06/14/2026. Due to time constraints, LPA was unable to complete today's annual inspection. LPA will return to facility to review staff and resident records and to conduct interviews at a later date. Exit Interview Conducted / A Copy of the Report provided to Regional Director of Operations.the state’s words, verbatim · CDSS document, Feb 27, 2026

Allegation investigated: Staff did not prevent inappropriate interaction between residents

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced initial 10 day complaint visit at this facility to investigate the above allegation(s). LPA met with Imelda Villanueva-Executive Director and explained the reason for the visit. At 12:15pm, LPA requested resident and staff roster and documents pertaining to the investigation: Resident 1 (R1)'s Admission Record, Physician Report, resident appraisal, and incident reports. At approximately 12:55pm, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected; no immediate health or safety risks were observed during today's visit. Between 12:15pm - 02:50pm, LPA conducted interviews with the Administrator, staff members and residents. Continued on LIC9099-C Unsubstantiated Regarding allegation: Staff did not prevent inappropriate interaction between residents It is alleged that R1's roommate has been mentally and verbally abusing R1. During interviews with staff, all staff stated that R1 has been intimidating their previous roommate (R2), several residents and also the current roommate (R3). R1 has been preventing staff to enter their room, in order to provide assistance to the previous roommate. All staff mentioned that they felt uneasy to enter R1's room to clean or to attend to R1 or to the roommate. Administrator transferred R2 to a room across R1's room and assigned a new roommate (R3) to R1. Based on interview with staff and R3, it was revealed that R1 is intimidating R3 as well. Staff have asked R1 to speak to Administrator directly and express any concerns they have with the past or current roommate but R1 refuses to speak with the Administrator. R3 informed LPA that initially R1 was nice but currently R1 has been giving R3 difficulty at nights and whenever R1 comes to the room. R3 is trying to stay out of the room, as much as possible, to avoid confrontation. In addition, all staff mentioned to LPA that R1 is rude and verbally abusive to staff and several other residents. Based on interview with the Administrator, staff and residents, this allegation is deemed Unsubstantiated at this time. An exit interview was conducted, and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 13, 2026 · control 31-AS-20260111201238

Allegation investigated: Facility staff yells at residents in care. Facility staff did not treat resident with dignity and respect. Facility staff did not ensure communication in a timely manner.

Licensing Program Analysts (LPA) Leslie Ngo-Castaneda conducted an initial complaint visit to the facility to investigate the above allegation. LPA met with the administrator, Imelda Villanueva, and advised them about the visit. At 12:00 PM LPA conducted a physical plant tour to ensure the health and safety of the clients in care. It was alleged that facility staff yelled at resident #1 (R1). To investigate the allegation, on 12.29.2025, LPA interviewed fourteen (14) residents and six (6) staff from 12:08 AM to 2:32 PM. At 2:33PM, LPA reviewed and receive copies of documents pertaining to the investigation: staff roster, resident roster, R1 physician report, identification and emergency information, resident appraisal, and incident reports. An entrance interview was conducted. Allegation #1: Facility staff yells at residents in care. Continue to LIC 9099-C Unsubstantiated During interviews with staff, all staff stated they always treat residents with respect and dignity. Staff #1 (S1) added that they would never yell at the residents in care. During residents interviews, revealed that staff treat them with dignity and respect. Interviews with residents revealed that they are happy and have not experienced such treatment from staff. During LPA visit, it was observe that staff speaks to the residents calmly and kindly. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation #2: Facility staff did not treat resident with dignity and respect. Regarding the above allegation, it is alleged that the facility staff did not treat R1 with dignity and respect. Interviews from residents revealed that they are happy and have not experience such treatment from staff. Interviews with staff revealed that they treat all their residents with respect and dignity. Upon review of facility records there was no information to support the allegation. Based on observations, record reviews, and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation #3: Facility staff did not ensure communication in a timely manner. It was alleged that the facility staff did not communicate R1 issues to corporate. Interviews from residents revealed that they are happy and have not experience such miscommunication from staff. Interviews with staff revealed that they communicate all residents' concerns to their supervisors and facility executive director immediately. Interview with residents reveal that they are happy with the communication that they receive from the facility staff and executive dirctor. During LPA visit, it was observed that when residents raised their concerns and issues, staff assists residents immediately and reports the issue to their superiors and executive director. Therefore, based on interviews, observation and record review, this allegation is deemed Unsubstantiated at this time. No health and safety hazards noted during the visit. An exit interview was conducted, and a copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 31-AS-20251224161857

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Huma Rahimi met with Imelda Villanueva - Executive Director for a case management visit. The purpose of the case management visit is to address a deficiency observed during the course of investigation control # 31-AS-20241220150010. Deficiency observed was not alleged however are related to the complaint. During the course of the investigation control # 31-AS-20241220150010 the following was observed: It was discovered that the licensee failed to properly reassess and conduct a ongoing reappraisals and or needs and service plan for change in condition for resident #1(R1) in timely manner. Deficiency issued and appeal rights explained. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Oct 22, 2025

87463-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,......This requirement is not met as evidenced by: Based on record review and interviews the licensee did not comply with the section cited above by not updating R2's Appraisal Needs and Services upon observing change in condition which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: Administrator agreed to complete and update Appraisal Needs and Services Plan for R2 and provide training to all staff to meet R2's and all other residents needs accordingly.The POC is cleared as of 08/04/25.

Allegation investigated: Staff yelled at resident. Staff did not maintain a comfortable environment for residents.

This is an amended version of the original report issued on 07/29/2025. The amendment was made to correct the deficiency cited on form LIC 9099D and LPA conducted interview with five (5) additional residents. At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit. LPA was greeted by the front desk receptionist Karla Calemente and the Administrator was contacted. LPA met with the Administrator and explained the reason for the visit. An initial complaint visit was conducted on 12/23/2024. At 10:20 AM, LPA requested client and staff roster. At 10:30 AM, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:45 AM, LPA conducted a physical plant tour. Between 11:15 AM – 2:45 PM, LPA conducted an interview with the Administrator, Business Office Manager, Wellness Director, Wellness Coordinator, a MedTech, two (2) staff, and eight (8) out of twelve (12) residents who were able to communicate. Continue on LIC 9099C Substantiated Staff yelled at resident: It was reported that staff #1 (S1) yelled at Resident #1 (R1) when R1 was trying to close Resident #2 (R2) door to lessen the sound of R2’s screams. To investigate this allegation LPA conducted an interview with the Administrator and it was revealed that S1 is reported to be rude to some residents in care. Furthermore, LPA was informed that the facility is in the process of taking action to address S1’s conduct and performance. Additionally, interviews with Staff #2 (S2) and a MedTech confirmed the information provided by the Administrator. Moreover, LPA reviewed LIC 500 (Staff Roster) and observed that S1 is currently scheduled in the staff roster. Lastly, interviews with the residents confirmed S1 yelling at residents in care. Based on the information gathered through interviews this allegation is deemed Substantiated. Staff did not maintain a comfortable environment for residents: It was reported that Resident #2 (R2) is screaming/yelling incoherently creating uncomfortable environment to other residents in care. To investigate this allegation LPA conducted an interview with the Administrator, BOM, a MedTech, and two (2) staff and all parties interviewed admitted that R2 does scream when he/she needs assistance. Furthermore, interviews also revealed that R2 screams does create an uncomfortable environment to other residents. During the initial visit on 12/23/2025, LPA also heard R2 screaming extremely loud creating an uncomfortable environment. Moreover, LPA conducted a file review of R2 and did not observe that the facility either notified R2's Physician nor updated the Appraisal Needs and Services Plan to meet and address R2’s needs appropriately. Lastly, interviews with eight (8) out of twelve (12) residents also confirmed that R2 screams day and night, which makes the other residents uncomfortable. Based on interviews, record review, and LPA’s observation this allegation is deemed Substantiated. Deficiencies issued and appeal rights explained and given. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 31-AS-20241220150010

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 5, 2025

87468.1 Personal Rights of Residents in all Facilities (a) Residents in all residential care facilities for the elderly shall...(1) To be accorded dignity in their personal relationships with staff, .... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above by permitting Staff #1 (S1) to be disrespectful towards residents, which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Licensee to conduct an in-service training to all staff on the cited section and issue a written notice to Staff #1 (S1)

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 5, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable...... This requirement is not met as evidenced by: Based on the observation and interviews the Licensee did not comply with the section cited byexposing other residents to uncomfortable environment which was caused by R1's screaming/yelling which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: The Executive Director and staff already conducted a training on Personal Rights of Residents and LPA was provided a copy of the training and the POC is cleared during today's visit.

Allegation investigated: Staff is stealing resident’s money for personal use. Staff cut resident’s hair without consent. Staff not keeping up with resident’s hygiene. Staff did not assist resident in a timely manner.

Licensing Program Analyst (LPA) Nadia Shahbazian and Licensing Program Manager (LPM) Eva Miller conducted an unannounced subsequent complaint visit. LPA/LPM met with Imelda Villanueva - Administrator and explained the reason for the visit. At 9:00 AM LPA/LPM requested resident and staff roster. From 9:15 AM - 12:45 PM, LPA/LPM conducted interviews with 10 out of 97 residents and staff including, the Administrator, one Caregiver, Business Office Manager, Wellness Director and Wellness Coordinator. Information obtained during interviews was consistant with information documented during the previous complaint visit conducted on 03/19/2025. All allegations remain Unsubstantiated. Exit interview conducted. A copy of the report provided to the administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 28, 2025 · control 31-AS-20250312082529

Allegation investigated: Insufficient supervision contributed to residents sustaining injuries.

On 04/09/2025 Licensing Program Analysts (LPA) Evelin Rios and Nadia Shahbazian conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegation. LPAs met with Imedla Villanueva, Executive Director and explained the reason for today’s visit. Executive Director placed Nirjara Acharya, Vice President of Operations and Lisa Pham the Regional Director on speaker phone to listen to report. On 10/17/24, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator, Jose Santana. (Continued on LIC9099-C) Substantiated (Continued from LIC9099) On 10/23/2024 at 10:20 a.m., LPA Evelin Rios initiated the complaint visit. LPA Rios conducted physical plant tour and obtained copies of the facility records such as, Personnel Report, Training Records, Unusual Incident/Injury Reports (UIRs), Preplacement Appraisal Information, Physician’s Report, Function Report, and Face Sheet. LPAs, Evelin Rios and Abeye Duguma conducted interviews with residents. On 10/23/2024 LPAs, Evelin Rios and Abeye Duguma conducted interviews with residents. Regarding the allegation that due to insufficient supervision contributed to residents sustaining injuries, it was alleged that resident #1 (R1) had multiple falls in the facility and had at least on one occasion had been on the floor for hours. Documentation such as but not limited to, Unusual Incident Reports obtained in the facility describe R1 as having multiple falls on 10/14/2024 and 10/15/2024 including on or around 5/04/2024, 7/08/2024, 9/01/2024, and 10/10/2024 resulting in R1's hospitalization While the facility, responded to R1’s falls on 5/04/2024 and 9/01/2024 by arranging for physical therapy and rehabilitation, the facility retained R1 despite knowing R1 required a higher level of care. Facility staff instead instructed R1 to activate their bedroom pull cord whenever requiring toileting assistance. On 9/20/2024, R1’s primary care physician’s office advised the facility that R1 might need to transfer to a skilled nursing facility (SNF) due to R1’s need for “constant monitoring,” but the facility retained R1 for almost another month, during which R1 sustained at least five falls. IB investigator Jose Santana’s interview with the facility’s Administrator, Imelda Villanueva justified retaining R1 because she said arrangements were already in process, as early as August 2024, to relocate R1 to a SNF. Villanueva also admitted that in the interim, the facility was not able to meet R1’s needs. The facility did not consider providing a one-on-one caregiver or obtaining a fall mat, motion sensor, or bed alarm for his safety until the time R1 could relocate. Based on the information gathered during the investigation, the allegation is deemed Substantiated at this time. An immediate civil penalty (See LIC 421C/Civil Penalty Assessment-Immediate) of $500.00 was assessed on this day of the visit for violations that resulted in injury wherein the facility failed to provide the necessary care for R1. If the Department determines that the underlying violation resulted in serious bodily injury, the licensee will be notified that an increase of civil penalties will be assessed based on Health and Safety Code §1569.49(f). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 9, 2025 · control 31-AS-20241017131331

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 10, 2025

87464(f)(1) Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on IB interviews and R1’s records review, the licensee-administrator failed to ensure that R1 was properly supervised which resulted in R1 sustaining serious injuries from multiple falls which posed an immediate health and safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: R1 is no longer in the facility. 1. Administrator will submit a statment of understanding on the cited regulation and provide a copy to CCLD by POC due date 04/01/25. 2. Administrator states an all staff in-service training regarding supervising residents has been conducted. Sign-in sheets and training topics will be provided by POC due date 04/01/25.

Allegation investigated: Licensee does not ensure the facility is in good repair. Staff did not respond to resident's call button in a timely manner. Staff did not assist resident with obtaining medical care. Staff did not provide resident with personal care supplies. Staff did not ensure resident rooms are cleaned adequately. Staff denied resident food. Staff spoke to resident in an inappropriate manner.

Licensing Program Analyst (LPA) Abeye Duguma conducted a subsequent complaint visit to the facility to investigate the above allegations. LPA met with Betty Jerez and explained the reason for the visit. ---Licensee does not ensure the facility is in good repair It was alleged that on 06/17/2024 facility had no hot water for two (02) days and the last three to four months, the air conditioner and thermostat do not work and it gets up to 89° Fahrenheit in their room. To investigate the allegation LPA conducted a physical plant tour and requested documents at around 10:30a.m., interviewed three (03) staff and nine (09) residents from around 12:00p.m.– 2:00p.m. During the physical plant tour, LPA observed that hot water was in working order and measured an average 112.6 degrees Fahrenheit. LPA also observed thermostats in working order including the room in question. (CONT. on LIC9099-C) Unsubstantiated A review of the maintenance notes revealed that the hot water problem was reported on 06/17/2024 and resolved 06/19/2024. During interviews with staff, all staff stated the issue was brought to their attention and it was resolved swiftly. Staff added they are not aware of any thermostat issues. During interviews with residents, all resident stated they do not recall the incidents of hot water and air conditioning issues and are not currently experiencing any. Based on observations, interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff did not respond to resident's call button in a timely manner. It was alleged that when they use the call button staff never respond to assist. To investigate the allegation LPA conducted a physical plant tour at around 10:30a.m., interviewed three (03) staff and nine (09) residents from around 12:00p.m.– 2:00p.m. During the physical plant tour, LPA selected four (04) rooms at random and observed an average response time of six (06) minutes. During interviews with staff, all staff stated they respond to calls within five (05) minutes average and never ignore them. During interviews with residents, all resident stated staff respond to call buttons within five (05) to ten (10) minutes. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not assist resident with obtaining medical care. It was alleged that staff say they are busy or do not have time when resident asked for help with scheduling a doctor's appointment. To investigate the allegation LPA interviewed three (03) staff and nine (09) residents from around 12:00p.m.– 2:00p.m. During interviews with staff, all staff they always assist residents with scheduling appointments and do not refuse assistance to anyone. Staff #1 (S1) added, if one (01) staff is busy, then they will ask someone else to assist that resident to schedule a doctor’s appointment. (CONT on LIC 9099-C) During interviews with residents, all resident stated staff are assisting with obtaining medical care. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff did not provide resident with personal care supplies. It was alleged that staff do not give enough towels because they run out of clean towels. To investigate the allegation LPA conducted a physical plant tour at around 10:30a.m., interviewed three (03) staff and nine (09) residents from around 12:00p.m.– 2:00p.m. During the physical plant tour, LPA observed clean towels available. During interviews with staff, all staff stated residents have plenty of clean towels available and they do not deny or hide clean towels from residents. During interviews with residents, all resident stated they have enough clean towels available. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not ensure resident rooms are cleaned adequately. It was alleged that resident room gets too dirty with only once-a-week service. To investigate the allegation LPA conducted a physical plant tour at around 10:30a.m., interviewed three (03) staff and nine (09) residents from around 12:00p.m.– 2:00p.m. During the physical plant tour, LPA observed four (04) rooms at random and observed that all rooms were clean. During interviews with staff, all staff stated residents’ rooms are cleaned by housekeeping once a week and caregivers do light cleaning daily. During interviews with residents, all resident stated they feel the once a week housekeeping and caregivers doing light cleaning is sufficient. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (CONT. on LIC9099-C) ---Staff denied resident food. It was alleged that staff tells residents there is no more food even if there is some. To investigate the allegation LPA conducted a physical plant tour at around 10:30a.m., interviewed three (03) staff and nine (09) residents from around 12:00p.m.– 2:00p.m. During the physical plant tour, LPA observed a kitchen sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. During interviews with staff, all staff stated they do not lie about the availability of food or deny residents food. S1 added residents are offered breakfast, lunch, dinner and snacks. During interviews with residents, all resident stated staff does not lie about or deny them food. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff spoke to resident in an inappropriate manner. It was alleged that staff are mean and tell resident to “get out of my face” or “don’t talk to me.” To investigate the allegation LPA conducted a physical plant tour at around 10:30a.m., interviewed three (03) staff and nine (09) residents from around 12:00p.m.– 2:00p.m. During the physical plant tour, LPA observed staff being mean to residents. During interviews with staff, all staff stated they they are not mean and treat all resident with dignity and respect. During interviews with residents, all resident stated staff treat them with dignity and respect and don’t say things to them like, “get out of my face” or “don’t talk to me.” Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Interview conducted and a copy of the report issued.the state’s words, verbatim · CDSS document, Mar 30, 2025 · control 31-AS-20240619163442

Allegation investigated: Staff are not properly addressing issue with bedbugs

At around 9:30AM, Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to deliver the findings for the above stated allegations. LPA met with Executive Director (ED), Imelda Villanueva, and explained the reason for the visit. ---Staff are not properly addressing issue with bedbugs. It was alleged that facility has bedbugs and do not have the correct treatment plan set up to get rid of the problem. To investigate the allegation, on 07/24/24 LPA Antonia Alvizar-Ettima conducted a physical plant tour, interviewed nine (09) residents and five (05) staff at around 1:50p.m. and requested documents at 2:40p.m. At the time of inspection, LPA Alvizar-Ettima did not observe bed bugs in R1’s room. Document reviewed from ORKIN Pest Control revealed that R1’s room #228 was inspected and treated for bed bugs. (CONT. LIC9099-C) Unsubstantiated During interviews with staff, maintenance staff revealed that resident #1 (R1) room #228 did have bed bugs. However, staff followed bed bug procedures to address the bed bugs in R1’s room as soon as R1 reported to staff. On 06/26/24 R1’s room was treated by ORKIN Pest. Five (05) days later ORKIN Inspector returned to conduct a follow up on bed bugs and R1 refused entrance of ORKIN Inspector in their room. Fourteen (14) days later R1 agreed to have room treated for bed bugs and the next day ORKIN Inspector treated R1’s room again. During interviews with residents, R1 revealed that they have not seen any bed bugs in their room recently. All other residents stated they have not seen bedbugs. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 21, 2025 · control 31-AS-20240719155324

Allegation investigated: Licensee does not provide residents with sufficient living space. Licensee does not provide residents with a safe living environment. Licensee is not addressing mildew at facility.

At around 9:30AM, Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to deliver the findings for the above stated allegations. LPA met with Executive Director (ED), Imelda Villanueva, and explained the reason for the visit. ---Licensee does not provide residents with sufficient living space. It was alleged resident (R1)’s room is too small for two residents to move around. To investigate the allegation on 05/29/2024 at 3:20p.m., LPA Antonia Alvizar-Ettima conducted a physical plant tour, requested documents and interviewed one (01) staff and one (01) resident. On 01/22/2025 LPA Alvizar-Ettima conducted a physical plant tour at approximately 11:15a.m. and interviewed one (01) additional staff and nine (09) out of ninety-five (95) additional residents between 11:45am -1:05p.m. (CONT. LIC9099-C) Unsubstantiated During the physical plant tour, LPA Alvizar-Ettima observed that R1’s room is similar in size as the other rooms in the facility with enough space and clear paths to navigate the room safely. During interviews with staff, all staff stated all bedrooms have sufficient living space including R1’s bedroom. During interviews with residents, R1 stated room is too small for two residents to move around. All other residents stated the rooms have sufficient living space and had not concerns. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Licensee does not provide residents with a safe living environment. It was alleged that there is only one pull alarm signal in R1’s room that R1 and roommate has to share. To investigate the allegation on 05/29/2024 at 3:20p.m., LPA Antonia Alvizar-Ettima conducted a physical plant tour, requested documents and interviewed one (01) staff and one (01) resident. On 01/22/2025 LPA Alvizar-Ettima conducted a physical plant tour at approximately 11:15a.m. and interviewed one (01) additional staff and nine (09) out of ninety-five (95) additional residents between 11:45am -1:05p.m. During the physical plant tour, LPA Alvizar-Ettima observed all interviewed residents had a pull alarm string within their reach in room including R1. During interviews with staff, all staff stated pull alarms signal have a string for each resident to pull for assistance and this is a safe living environment. During interviews with residents, R1 stated there is only one pull alarm signal in R1’s room that R1 and roommate has to share. All other residents stated the do not have an issue sharing the pull alarm signal with their roommate. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Licensee is not addressing mildew at facility. It was alleged that rooms #228 and #214 have mold on the wall. To investigate the allegation on 05/29/2024 at 3:20p.m., LPA Antonia Alvizar-Ettima conducted a physical plant tour, requested documents and interviewed one (01) staff and one (01) resident. (CONT. on LIC9099-C) On 01/22/2025 LPA Alvizar-Ettima conducted a physical plant tour at approximately 11:15a.m. and interviewed one (01) additional staff and nine (09) out of ninety-five (95) additional residents between 11:45am -1:05p.m. During the physical plant tour, LPA Alvizar-Ettima did not observe any mildew in rooms #228 and #214. During interviews with staff, all staff stated that mildew is always addressed in the facility. During interviews with residents, R1 stated rooms #228 and #214 have mold on the wall. All other residents stated there was no mildew in the facility and they had no concerns. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 21, 2025 · control 31-AS-20240524142719

Allegation investigated: Staff is stealing resident’s money for personal use. Staff cut resident’s hair without consent. Staff not keeping up with resident’s hygiene. Staff did not assist resident in a timely manner.

On 3/19/2025 @ 10:30am Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced complaint visit to investigate the above allegations. LPA met with the facility Administrator, Imelda Villanueva at 11:00am and explained to her the reason of the visit. To investigate the allegations LPA conducted, record reviews, interviews and a physical plant tour beween,11:00am and 4:00pm. Regarding the allegation: Staff is stealing resident’s money for personal use. It was reported that staff was stealing resident, R1's money from their account and facility refused to provide account statement. Interviews with, administrator, S1 and office business manager, S2 reveal that all R1's funds are accounted for. The facility managed R1's money, and S2 provided R1 with R1's account statement every first of the month. S1 and S2 confirmed that a copy of R1's account statement was also provided to the family member who was also R1's POA-power of attorney. A copy of R1's account statement was obtained by LPA for review. LPA reviewed R1's account statement which shows all the transactions that are credited and debited into R1's account. LPA's review of R1's account statement reveal that R1's funds are accounted for. LPA conducted interviews with ten (10) residents and resident interviews reveal that facility staff do not steal their money for personal use. R1 is no longer in the facility. Based on the information obtained, there is insufficient evidence to prove that staff stole resident's money for personal use. Therefore, the allegation is deemed Unsubstantiated at this time. Continue to LIC 9099-C Unsubstantiated Regarding the allegation: Staff cut resident’s hair without consent. It was alleged that staff cut resident's (R1) hair without consent. LPA's interviews with administrator, S1 and and interviews with ten (10) out of ten (10) residents, indicated that no resident at this facility has received a haircut without their consent. LPA observed that this same allegation was previously investigated under the following complaint control number 31-AS-20240917153803 and was previously substantiated and facility was cited on 12/09/2024. R1 is no longer in the facility. At this time, based on the information obtained, there hasn't been any facility staff cutting resident's hair without their consent. Therefore, the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff not keeping up with resident’s hygiene. It was alleged that facility staff neglected to trim R1's nails. Interview with Wellness Director, S4 and facility staff (S2) revealed that there was always staff present to assist R1 with their nail care. In regards to R1's nails, S2 and S4 stated that a podiatrist came once a month to care of R1's nails and in addition, staff also clipped R1's nails at least once a week. R1 is no longer in the facility. Interviews made with ten (10) of ten residents do not corroborate with the allegation. Interview with residents revealed that they are satisfied with staff attending to their hygiene needs and that their nail care needs are being met. Based on the information obtained, there was insufficient evidence to prove that staff are not keeping up with resident hygiene specifically nail care. Therefore, the allegations are deemed Unsubstantiated at this time. Regarding the allegation: Staff did not assist resident in a timely manner. It was alleged that R1 fell and facility did not assist R1 in a timely manner. Interview with facility staff, S2 revealed that they were not able to assist R1 when R1 fell because R1 did not inform any facility staff that they had fallen. R1 only revealed about their fall to another resident, resident - R2. Interview with a resident, R2 confirmed that R1 did not inform any facility staff about their fall. R2 also confirmed that they were the only resident R1 disclosed about their fall. R1 is no longer in the facility. Interviews made with ten (10) of ten residents do not corroborate with the allegation. Interviews with the residents revealed that facility staff have always assisted residents in a timely manner. Therefore, the allegations are deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report provided to the administrator.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 31-AS-20250312082529

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Nadia Shahbazian and Raymond Comer conducted an unannounced site visit continuation of the required annual inspection conducted on 03/17/2025. LPAs met with Executive Director, Imelda Villanueva and explained the reason for the visit. The following remaining inspection domains were observed, reviewed and inspected: Bedrooms: LPA toured multiple resident bedrooms on both floors for safety, privacy, and comfort (Bedroom#’s 201, 203, 205, 223, 235, 240, 103, 105, 112, 118). The bedrooms were inspected and observed to maintain required furnishings and sufficient lightings, bed linens, and blankets. All bedrooms were observed to be clean and clear of obstructions. At 11:38am in room# 240, LPAs pulled the assistance cord; caregiver responded within 2 minutes. Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, non-slip mats, anti-slip floor stripping). Hot water temperature measured between 112.3 °F. and 113.2°F; within the required range. At 2:01pm in bathroom# 118, LPAs pulled the assistance cord; caregiver responded within 5 minutes. SURROUNDING GROUNDS: The passageways and entrance to the home was clear of obstruction. Facility has an outdoor patio and an indoor patio area, both areas were observed to be shaded, with tables with sufficient seating for the residents. Outdoor furniture observed to be in good condition. There are no bodies of water in the facility. The facility has cameras in common areas of the home; no cameras in resident rooms or bathrooms. Laundry: Facility has two (2) laundry rooms, one (1) in each floor with total of four (4) washers and four (4) dryers. LPAs observed all the machines in functional capacity. Laundry detergents, cleaning agents and other toxins are secured in locked storages, inaccessible to residents. Medications: Facility has a Wellness Room adjacent to the lobby, in which all medications are securely locked\inaccessible to residents. LPAs reviewed Medication Administration Records (MARs) for six (6) residents and compared them to the medication count and found no discrepancies. Multiple First Aid kits and the First Aid Manual were observed in the Wellness Room. Resident records: All records were observed as locked and inaccessible to residents. A total of ten (10) resident files were reviewed for current IPP and/or Needs and Services plans, physician reports, and admission agreements. Resident records appeared to be complete and current. Staff records: All records were observed as locked and inaccessible to residents. A total of six (6) Staff files were reviewed. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current. There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility Administrator.the state’s words, verbatim · CDSS document, Mar 18, 2025

Type of visit: Required - 1 Year

On 03/17/25, 9:30 am Licensing Program Analysts (LPAs) Nadia Shahbazian and Raymond Comer conducted an unannounced required annual inspection. LPAs met with Executive Director, Imelda Villanueva and explained the reason for the visit. Facility is licensed as a two-story building. Fire clearance approved for one hundred (100) non-ambulatory residents; ten (10) of whom may be bedridden. Hospice waiver approved for thirty (30) residents. At 10:20 am, LPAs conducted a tour of the physical plant with the Administrator and observed the following: Facility’s main door is the primary entry/exit access. In addition, the facility has eight (8) exit doors, four (4) exits on each floor. Screening/Reception area is located immediately upon entrance. Required postings were displayed at the reception area. Facility provides dementia care; LPAs observed delayed egress system working properly. Facility temperature is comfortable; wall thermostat displays a setting of 74.0° Fahrenheit. Physical plant was inspected for cleanliness; LPAs observed the facility as clean, sanitary, and appropriately furnished. Continued on 809-C Fire Detection/Protection system is present in the facility. Multiple dual smoke/carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Each room is equipped with fire suppression equipment. Multiple fire extinguishers were observed throughout of the facility. All fire extinguishers were serviced on 04/03/2024. Evacuation chairs were observed atop each stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Emergency disaster plan is posted; last disaster drill was conducted on 12/17/2024. Last fire inspection was performed on 05/13/2024. Kitchen: Facility’s kitchen was observed to be clean, sanitary, and inaccessible to residents. LPAs observed an adequate supply of perishable foods for two (2) days, and non-perishable food supply for seven (7) days located in the refrigerator, freezer, and pantry. Food was properly labeled and stored. Emergency food is stored in a separate locked area. Sharps are stored in the kitchen; inaccessible to residents. Detergents and chemicals were locked in a storage room across from the kitchen. Common Areas: First floor has a dining room, living room, lobby/television room, outside and an inside patio area. Second floor has an activity room. Common areas observed to be clean and furnishings observed to be in good condition. No obstructions or hazards were observed. Due to time constraints, LPAs were unable to complete today's annual inspection. LPAs will complete the inspection at a later date. Exit interview was conducted, and copy of the report was given to facility Administrator.the state’s words, verbatim · CDSS document, Mar 17, 2025

Type of visit: Case Management - Health Checks

At 11:20 a.m. on 03/04/25, Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced case management visit. LPA and LPM met with the administrator and disclosed the reason for the visit. Today’s case management visit was conducted in conjunction with a collateral visit for complaint #31-AS-20250303144817 to ensure the three (03) residents relocated from Rossmoyne Hills (197610495) were afforded their health and safety at their current home. LPA toured the facility at 11:30 a.m. today, interviewed the administrator at 11:35 a.m., Resident #5 (R5) at 11:40 a.m., and Resident #3 (R3) at 12:35 p.m., and conducted a record review of pertinent files including but not limited to the staff and client rosters at 12:45 p.m. Interview with the administrator revealed Resident #1 (R1) left the facility yesterday to live with their family. Interviews with R3 and R5 revealed they enjoy their current facility, and all of their needs are taken care of. LPA and LPM concluded the visit and provided contact information to both residents in care. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 4, 2025

Allegation investigated: Neglect in care and supervision contributed to residents death.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Imelda Villanueva and explained the reason for the visit. --- Neglect in care and supervision contributed to resident’s death. It was alleged that resident’s roommate tried to assist resident while choking but was unsuccessful, that there was only one (01) caregiver in the facility on the 1st floor and staff responded to the call for help ten (10) hours after expiration. To investigate the allegation, on 12/04/2024, LPA requested pertinent documents at around 11:00a.m., interviewed five (05) staff from 11:30a.m. to 1:00p.m. and nine (09) residents from 1:00p.m. to 3:30p.m. (CONT on LIC9099-C) Unsubstantiated A review of hospice records revealed Resident #2 (R2) was receiving hospice services for a terminal illness and last visit by hospice agency professional was 08/30/2024. Death Report states that on 09/02/2024 resident was found unresponsive at 4:15p.m., emergency arrived at 4:30p.m., paramedics pronounced resident dead at 5:16p.m. and coroners picked up resident at 10:20p.m. Visitor’s Log does not show R2 had a visitor on 09/02/2024. A review of staff schedule for 09/02/2024 shows facility had three (03) caregivers and one (01) MedTech for both morning and afternoon shifts. A review of Physician’s Report and Needs and Services Plan does not indicate R2 had swallowing difficulties. During interviews with staff, all staff stated resident was found unresponsive by MedTech Staff #1 (S1) as they were making medication rounds. S1 checked vitals, requested emergency services, and attempted to resuscitate R2. Staff #2 (S2) added paramedics and police arrived, then shortly after, the coroners. During interviews with residents, Resident #1 (R1) stated they did not witness anything, does not know the name of the alleged neglected resident, and only heard from others what happened. Resident #3 (R3) stated they did not find their roommate R2 choking or try to assist R2 while choking. R3 stated they found R2 deceased and that it looked like R2 was sleeping. R3 called out for help and staff came within thirty (30) minutes, however, R3 also stated R2’s doctor was in the room before staff arrived but did not attempt to resuscitate. R3 contrarily added that it was the doctor who called out for help. All other residents stated they are unaware of anyone choking to death or staff failing to aid anyone choking. Based on record reviews and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jan 23, 2025 · control 31-AS-20240927130858

Allegation investigated: Facility is in disrepair Staff do not keep the facility free from odor Staff do not ensure that resident's toileting needs are met Staff do not treat residents with dignity or respect Staff do not provide residents with daily activities.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Imelda Villanueva and explained the reason for the visit. ---Facility is in disrepair It was alleged that Resident #1's (R1) toilet was leaking for two (02) months before it was fixed. To investigate the allegation, LPA conducted a physical plant tour at around 10:00a.m., requested pertinent documents at around 11:00a.m., interviewed five (05) staff from 11:30a.m. to 1:00p.m. and nine (09) residents from 1:00p.m. to 3:30p.m. During the physical plant tour, LPA did not observe any leaking toilets. (CONT on LIC9099-C) Unsubstantiated A review of the facility maintenance log indicates the leak was reported 09/26/24 at around 1:00p.m. and repaired 10/01/24 at around 12:45p.m. During interviews with staff, Staff #2 (S2) stated facility had to change the angle stop, cut back the pipe and insert a new valve further in to seal it. S2 added the whole process took about a week and arrangements were made for the two (02) occupants during repairs so as not to disrupt their care. All other staff stated they are unaware of any leaking toilets during the time in question. During interviews with residents, R1 stated toilet was leaking for two (02) months before it was fixed but now it is working properly. R1 also confirmed that arrangements were made for them to use a different toilet while staff performed repairs. All other residents stated they are unaware of any leaking toilets. Although toilet was leaking, facility took the necessary steps for expedited repairs and provided residents with an easily accessible alternative. Based on observations, record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff do not keep the facility free from odor It was alleged that facility consistently smells like urine and feces. To investigate the allegation, LPA conducted a physical plant tour at around 10:00a.m., interviewed five (05) staff from 11:30a.m. to 1:00p.m. and nine (09) residents from 1:00p.m. to 3:30p.m. During the physical plant tour, LPA did not experience consistent malodor. During interviews with staff, all staff stated it does not consistently smell like urine and feces. During interviews with residents, R1 stated the hallways are always smelling, and facility does not do a good job of keeping the place free from odor. All other residents stated they do not believe the facility consistently smells like urine and feces. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff do not ensure that resident's toileting needs are met It was alleged that residents are left lying in their own waste. To investigate the allegation, LPA interviewed five (05) staff from 11:30a.m. to 1:00p.m. and nine (09) residents from 1:00p.m. to 3:30p.m. (CONT. LIC9099-C) During interviews with staff, all staff stated residents are not left soiled for an extended time and caregivers check and change residents every two (02) to three (03) hours or more if needed. During interviews with residents, R1 stated residents are left soiled for an extended time and caregivers are not attending to resident needs. All other residents stated staff do not leave residents lying soiled for an extended time. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff do not treat residents with dignity or respect It was alleged that staff speak inappropriately to residents. To investigate the allegation,LPA interviewed five (05) staff from 11:30a.m. to 1:00p.m. and nine (09) residents from 1:00p.m. to 3:30p.m. During interviews with staff, all staff stated they treat all residents with dignity and respect. During interviews with residents, R1 stated staff are rude and speak inappropriately to other residents. R1 added that ever since Staff #3 (S3) joined, it has been much better. One (01) out of nine (09) residents stated staff “sometimes” speak to residents inappropriately. All other residents stated staff treat residents with respect and dignity. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff do not provide residents with daily activities It was alleged that there are no activities for residents in the facility. To investigate the allegation, LPA conducted a physical plant tour at around 10:00a.m., requested pertinent documents at around 11:00a.m., interviewed five (05) staff from 11:30a.m. to 1:00p.m. and nine (09) residents from 1:00p.m. to 3:30p.m. During the physical plant tour, LPA observed activities calendar posted on the walls and copies of the activities being distributed. LPA also observed residents participating in activities. A review of the facility’s activities calendar shows multiple activities for residents to participate in daily. During interviews with staff, all staff stated they have an activities coordinator and there are plenty of activities for residents to participate in. (CONT. on LIC9099-C) During interviews with residents, R1 stated they do have activities, but they are upstairs, and if they put it downstairs near the television area, a lot more people would participate. R1 added that the games they offer are not very entertaining. All other residents stated facility has activities for residents to participate in. Based on observations, record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 31-AS-20240927130858

Allegation investigated: Staff forced resident to cut resident's hair.

This is an amended to the original report issued 9.26.2024. Additional information was added to clarify the investigation. A subsequent visit is made today 12.9.2024 at the facility to close out the investigation regarding the above allegation. Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an initial complaint visit to address the allegation mentioned above. LPA was greeted by Megan Torres (S2) who is the wellness director of the facility. At 11 AM Imelda Villanueva (S1) who is the executive director (ED) arrived and LPA explained the reason for the visit. Entrance interview conducted. At 10 AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care. Continue to LIC 9099-C Substantiated Allegation: Staff forced resident to cut resident's hair. Regarding the allegation above it is alleged that staff forced resident to cut resident's hair. Interviews with executive director (ED), six (6) staff, and nine (9) out of ten (10) residents, who were able to communicate, indicated that no resident gets a haircut against their will. In addition, LPA was provided with pictures of R1 from September 12, 2024 and LPA observed that shoulder length haircut was cut from waist length with R1 consent because their hair was very tangled. During initial visit on 9.26.2024 R1's hair was tidy with no tangles. LPA interview R1 on 10.15.2024 at 11:14AM at the common area. Interview revealed that R1 does not want to get a hair cut. Interview with staff revealed that R1 needed a haircut because their hair was very tangled irregardless of R1 not agreeing to get a haircut at that time. Staff did not produced a new Appraisal Needs and Service Plan (LIC 625) to address R1 hair issue. Staff failed to call R1 Power of Attorney (POA) to ask permission to cut R1's hair. Deficiency will be cited on LIC 9099-D. Based on information obtained through interviews and record reviews this allegation is deemed substantiated at this time. Exit interview conducted. A copy of this report was given to Executive director.the state’s words, verbatim · CDSS document, Dec 9, 2024 · control 31-AS-20240917153803

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 9, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on LPA interview and record review, staff violated R1 personal rights of cutting their hair w/o family permission, which poses an immediate health & safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2024

Plan of correction: The Administrator will review regulation 87468.1(a)(3) and submit a written statement ensuring that they will adhere to them. POC: 12.9.2024

Allegation investigated: Staff handle resident in a rough manner Staff are not addressing the residents dental needs

Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted a complaint visit to the facility to conclude the allegation regarding the above allegations. The ten day visit was made by LPAs Tan and Cava on November 6, 2024. Today’s investigation consisted of interviews, record review and a physical plant inspection. Staff handle resident in a rough manner: In regards to the allegation, it was reported that when Resident 1 (R1) went to the hospital, R1 was observed with bruises on the leg and arm. It was further reported that R1 commented that staff was rough when they were getting assistance with bathing. Staff was not identified by R1 or the reporting party. Moreover, no witnesses were identified. Interviews with the administrator and staff deny the allegation. No concerns or reports were ever made by R1. Interviews with administrator and staff, and record review also reveal that R1 is prescribed a blood thinner medication, and had dialysis at least three times per week. Unsubstantiated Interviews with ten (10) of ten residents do not corroborate with the allegation. Based on the information obtained, there was insufficient evidence to prove staff handled R1 in a rough manner. Therefore, the allegation is deemed Unsubstantiated at this time. Staff are not addressing the residents dental needs: In regards to the allegation, it was reported that R1’s dental hygiene appears to have been neglected because R1 had a severe dental decay. Interviews with administrator and staff deny the allegation, stating incidental medical and dental needs, including making appointments are met. Both administrator and staff adds that R1 was also capable of making their own appointments for their medical, dental and dialysis appointments. R1 never expressed to them any concerns that staff are not meeting their assistance with dental needs. During their stay at the facility, R1 had never complained of oral or tooth pain. Moreover, staff stated that R1 is able to take care of their hygiene needs. R1 no longer lives at the facility. They moved out 11/03/23. Review of R1’s records reveal that R1 has the capacity to dress and groom self, and is not at risk if allowed direct access to personal grooming and hygiene items. Interviews with ten (10) of ten residents do not corroborate with the allegation of staff not being able to assist with their medical or dental needs. Based on the information obtained, there was insufficient evidence to prove staff did not address R1’s needs. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 31-AS-20241106121450

Allegation investigated: Staff mishandled a resident's personal belongings- Staff mishandled a resident's medications-

On Friday, 11/15/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced initial 10-day complaint visit at the facility to investigate the above allegation(s). LPA met with the Administrator, Imelda Villanueva, and the reason for the visit was disclosed. At 09:15 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation(s), LPA received facility resident roster, and staff roster. At 9:35 am, LPA conducted a review of Resident 1's (R1) file. Between 10:00 am and 11:30 am, LPA interviewed the Administrator, four (4) Staff, eight (8) Residents, and R1's Responsible Family Member (F1), via cellphone. [LIC 9099C]- Continued Unsubstantiated Allegation: Staff mishandled a resident's personal belongings- It was reported that Staff did not provide assistance to Resident#1 (R1) upon moving out from the facility. The Reporting Party (RP) states R1 is concerned about the safekeeping of their personal items left at the facility. LPA's review of R1's file, interviews with Staff, Residents, and Responsible Family Member, revealed the following: Staff state that R1 did not provide any verbal, nor documented, pre-notification prior to their final exiting of the facility. Per Staff, R1 did not like anyone touching their personal belongings and refused assistance from Staff when offered. Staff was told by R1 that "someone would come and pick my stuff later". Staff confirm that a friend of R1 did arrive later in the day to pick up a portion of R1's belongings; R1's remaining belongings are secured in the bedroom that R1 previously occupied, which is now locked and inaccessible to residents. LPA interview with R1's responsible family member (F1) reveals they are aware that Staff have stored R1's remaining belonging for safekeeping. F1 confirms to LPA that they will be picking up R1's remaining belongings on November 16, 2024, and that R1 is in agreement with the scheduled pick up date. Seven (7) out of eight (8) residents interviewed by the LPA state that Staff provides them satisfactory service regarding the safekeeping of their personal belongings. Based on the information obtained through LPA observation, records review, and interviews, it cannot be proven that staff is failing to provide safekeeping of residents personal belongings. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff mishandled a resident's medications- It was reported Staff did not allow R1 to take possession of their medications upon their final exit from the facility. LPA observations, interviews with Staff, Residents, and Responsible Family Member (F1) revealed the following: Staff state that R1 refused to sign the medical release form allowing R1 to accept their medications. Per Staff, R1 said they "would come back later" to sign the release, and pick up their medications. LPA observation of medication room found all of R1's medications stored in safekeeping, to be given to R1 upon their return. [LIC 9099C]- Continued F1 stated to LPA that, on November 16, 2024, they would be arriving with R1 to assist in the pick up of R1's belonging and medications. LPA review of R1's file reveals MAR records showing proper daily medications distribution to R1 by Staff from R1's date of admission, (DOA) until their final exit from the facility. Eight (8) out of eight (8) residents interviewed by LPA state that Staff provide required monitoring and distribution of resident medications. Based on the information obtained through LPA observations, and interviews, it cannot be proven that staff is failing to safeguard residents' personal belongings. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 31-AS-20241108153231

Allegation investigated: Staff did not properly supervise resident, resulting in resident falling.

On 11/12/2024 at 10:40 am Licensing Program Analyst (LPA), Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegations. LPA met with Administrator Imelda Villanueva and explained the reason for the visit. At 11:30 AM LPA Casillas conducted a physical plant tour. During the investigation, interviews and record reviews were made from 11:00 am to 2:30 pm. LPA requested resident roster, Liability Insurance, and LIC 500. LPA requested copies of pertinent information relevant to the investigation including but not limited to resident records, and any other documents pertaining to the investigation. Continued on LIC9099-C Unsubstantiated Allegation: Staff did not properly supervise resident, resulting in resident falling. It is alleged that staff did not properly supervise resident, resulting in resident falling. Regarding this allegation, it is reported that Resident #1 (R1) sustained injuries from a fall while ambulating with a walker when R1 felt dizzy and fell. It is further reported that R1 was left on the floor while a chair was secured. Interview with Administrator denied the allegation and revealed that R1 has not been left unsupervised, and that there has been no fall reported by staff or residents. It was also revealed based on record review that R1 is capable of walking without assistance and has no reported falls or injuries. Interview with ten (10) residents revealed that they are independent and have no issues with falls or being left unsupervised. Interview with five (05) staff revealed that no residents have reported a fall within the last few weeks, nor have staff witnessed any residents falling. Interview with R2 revealed that R1 may have made up that R1 fell as no one witnessed the alleged fall. Therefore, based on observations, record reviews and interviews this allegation is deemed unsubstantiated. No citation issued. Exit interview conducted. Copy of report given to Administrator.the state’s words, verbatim · CDSS document, Nov 12, 2024 · control 31-AS-20241104163555

Allegation investigated: Staff do not ensure room temperatures are maintained at 68 degrees as required.

At approximately 10:20 a.m., Licensing Program Analysts (LPA), Evelin Rios arrived at the facility in response to the above-mentioned allegation. LPA met with Imelda Villanueva the Executive Director (ED) and explained the reason for the visit. Entrance interview conducted at approximately 10:39 a.m. with ED. LPA requested resident and staff roster. At approximately 10:47 a.m., LPA conducted a physical plant tour with the ED to ensure the health and safety of the residents in care. From approximately 11:00 a.m. to 12:30 p.m. LPA Rios with the assistance of LPA Abeye Duguma interviewed fifteen (15) out of ninety three (93) residents. At approximately 12:30 p.m. LPA Rios interviewed five (5) staff and the ED. Allegation: Staff do not ensure room temperatures are maintained at 68 degrees as required. In regards to the allegation it was reported, the room gets cold at night and in the morning. (Continue to LIC9099-C) Unsubstantiated (Continued from LIC9099) LPAs interviews with five (5) out of the fifteen (15) residents revealed they have been cold at night. LPA interviews with ten (10) out of the (15) residents interviewed revealed they are not cold at night most stating at least in the morning their rooms can become hot to the point where they keep their doors open. LPAs were able to interview residents sharing the same room in two instances. Those interviews revealed one roommate wanted it warmer while the other was fine with the temperature and preferred it cooler. LPA's observation of thermostats revealed the temperature was varying from 72 to 78 degrees Fahrenheit. LPA's interview with the ED revealed their is one thermostats in every three rooms that control temperature for those three rooms. Ed also revealed it is difficult to adjust the temperature to satisfy the residents as some may want it warmer and others may want it colder. To ease complaints regarding temperature the facility has a set temperature of 74 - 75 degrees Fahrenheit in the rooms. According to the ED the thermostat is adjusted when residents request the room to be warmer or colder. A comfortable temperature may very from minimum of 68 degree F, to between 78 degrees F, and 85 degrees F, therefore based on interviews and observation this complaint is deemed Unsubstantiated. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 23, 2024 · control 31-AS-20241018135433

Allegation investigated: Staff did not ensure residents personal property was safe guarded Facility bathroom is in disrepair

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above allegation. LPA met with Imelda Villanueva and explained the reason for the visit. ---Staff did not ensure residents personal property was safe guarded It was alleged that Resident #2 (R2) stole items like crackers and patrician packets from Resident #1 (R1). To investigate the allegation, on 10/09/2024 LPA requested documents at around 11:00am, interviewed four (04) staff from 12:00pm to 1:30pm and interviewed nine (09) residents from 1:30pm to 3:30pm. A review of Resident #1’s (R1) record review indicates that file has an appendix of resident personal property and valuables document which clearly states that R1 refused inventory and signed it. LPA also reviewed the departments records and did not find incident reports regarding theft of R1’s or any other residents’ belongings going missing around the period in question. (CONT. on LIC9099-C) Unsubstantiated During interviews with staff, all staff stated they are not aware of R2 stealing anything from R1. During interviews with resident, all residents stated they have not experienced any issues with theft and feel that their belongings are safe guarded. LPA was unable to interview R1. Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility bathroom is in disrepair It was alleged that the bathroom in the common room has been out of order for four (04) days. To investigate the allegation, on 10/09/2024 LPA requested documents and conducted a physical plant tour at around 11:00am, interviewed four (04) staff from 12:00pm to 1:30pm and interviewed nine (09) residents from 1:30pm to 3:30pm. During the physical plant tour, LPA observed common bathroom in working order. LPA also selected three (03) additional bathrooms at random and observed everything to be in working order. A review of the maintenance work order shows that there were no issues with the common bathroom during the time in question. During interviews with staff, all staff stated they are unaware of any common bathrooms being in disrepair. During interviews with resident, all residents stated they are not aware of any common bathrooms being out of order. Based on observations, record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 23, 2024 · control 31-AS-20240702155732

Allegation investigated: Staff do not ensure care needs of residents are being met Staff do not ensure a safe environment is provided for residents in care Staff do not speak to residents in an appropriate manner Licensee does not ensure staff are able to communicate with residents

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above allegation. LPA met with Imelda Villanueva and explained the reason for the visit. --- Staff do not ensure care needs of residents are being met It was alleged that residents yell for help in the cafeteria, but staff just ignore residents. To investigate the allegation, on 10/09/2024 LPA conducted a physical plant tour at around 11:00am, interviewed four (04) staff from 12:00pm to 1:30pm and interviewed nine (09) residents from 1:30pm to 3:30pm. During the physical plant tour, LPA observed staff being attentive to residents’ needs during meal service. During interviews with staff, all staff stated they do not ignore residents when they call out for assistance. During interviews with resident, all residents stated they do not feel ignored by staff. (CONT. on LIC 9099-C) Unsubstantiated Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not ensure a safe environment is provided for residents in care It was alleged that there is a rug in front of the coffee station and a corner of the rug flips up and several residents have almost tripped on it. To investigate the allegation, on 10/09/2024 LPA conducted a physical plant tour at around 11:00am, interviewed four (04) staff from 12:00pm to 1:30pm and interviewed nine (09) residents from 1:30pm to 3:30pm. During the physical plant tour, LPA did not observe any flipped up rugs or other tripping hazards throughout the facility. During interviews with staff, all staff stated they are unaware of any flipped-up rugs in the facility that might be a tripping hazard. During interviews with resident, all residents stated they are unaware of any tripping hazards near the coffee station. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not speak to residents in an appropriate manner It was alleged that the staff are rude and dismissive to residents. To investigate the allegation, on 10/09/2024 LPA interviewed four (04) staff from 12:00pm to 1:30pm and interviewed nine (09) residents from 1:30pm to 3:30pm. During interviews with staff, all staff stated they are never rude or dismissive when speaking to residents. During interviews with resident, all residents stated they feel staff treat them with dignity and respect. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (CONT. on LIC9099-C) --- Licensee does not ensure staff are able to communicate with residents It was alleged that staff do not speak or understand English. To investigate the allegation, on 10/09/2024 LPA interviewed four (04) staff from 12:00pm to 1:30pm and interviewed nine (09) residents from 1:30pm to 3:30pm. During interviews with staff, all staff stated they are able to communicate with all residents effectively. During interviews with resident, all residents stated they are able to communicate with staff and that they are able to meet all of their needs. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 9, 2024 · control 31-AS-20240702155732

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 safeguard resident's personal belongings Staff did not consult with resident's authorized representative regarding the sigining of documents Staff did not provide resident's authorized representative with records Staff are not meeting resident's hygiene needs Staff are not meeting resident's diapering needs

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the Executive Director (ED), Imelda Villanueva, and advised her of the complaint. Today's investigation consisted of interviews with staff and residents. LPA also conducted a record review and a physical plant inspection. Staff did not safeguard resident's personal belongings: In regards to the allegation, it was reported that licensee failed to safeguard Resident 1's (R1) money from their account. It was also reported that R1's clothing/undergarments have gone missing. Interviews with the office busines manager/Staff 1 (S1) reveal that all of R1's finances are accounted for. The facility does manage R1's money, and they do provide R1 with statements and ledgers for transactions that are credited and debited into R1's account. In regards to missing funds, or $3400 that is unaccounted for, S1 stated Unsubstantiated that payment went towards R1's life insurance to pay for cremation. R1 signed the forms for this on 04/15/24. A copy of this was obtained for review. In regards to R1's clothing and undergarments, nothing was ever reported missing. Review of R1's Personal and Property Valuables (LIC 621) confirm no entry for clothing or undergarments. Based on the information obtained, there was insufficient evidence to prove that staff did not safeguard the resident's personal belongings. Therefore, the allegation is deemed Unsubstantiated at this time. Staff did not consult with resident's authorized representative regarding the signing of documents: In regards to the allegation, it was reported that R1, and or their responsible person was not consulted in signing an advanced directive for cremation. According to both the ED and S1, R1 was responsible for themselves until receiving Power of Attorney (POA) on 08/28/24. Prior to that, R1 managed their own affairs. Interview with R1 could not corroborate with the allegation made. Review of R1's records confirm that they signed an application with their life insurance for their cremation service, on 04/15/24, which was prior to the POA taking over for R1's decisions regarding their health care and finances. Based on the information obtained, there was insufficient evidence to prove that R1 and/or their authorized representative were not consulted with signing of documents. Therefore, the allegation is deemed Unsubstantiated at this time. Staff did not provide resident's authorized representative with records: In regards to the allegation, it was reported that R1's POA did not receive R1's records that were requested. These records include R1's bank statements or facility ledgers for R1's cash resources. Interview with S1 confirm that the facility handles cash for R1. S1 does deny the allegation of not providing R1's POA with these records. S1 stated there was a mis-communication with the POA because the facility had an incorrect email address for the POA on file, which the initial request for records were sent. The requested records for R1's statements has since been emailed to the POA's correct email address on 09/04/24. Copy of this email transaction was obtained to confirm it was sent and receipt. Based on the information obtained, the allegation of staff not providing R1's POA with records that were requested are deemed Unsubstantiated at this time. Staff are not meeting resident's hygiene needs/Staff are not meeting resident's diapering needs: In regards to the allegation, it was reported that facility staff is not showering R1, or washing R1's hair. It was also reported that staff are not meeting R1's incontinent needs by changing her diapers regularly, or clipping R1's toenails. Interview with administrator and staff deny the allegation. There is always staff presence to assist R1 with their hygiene and incontinent needs. R1 gets checked on every two hours to make sure they didn't have any accidents due to their incontinence. In regards to R1's toenails, the ED stated there is a podiatrist that comes once a month to manicure R1's nails, but in addition, staff also clips R1's nails at least once a week. Interview with S2 confirms that R1's nails are cut, or at least checked every week to insure it hasn't outgrown. Interviews made with ten (10) of ten residents do not corroborate with the allegations. Residents deny the allegation, and are satisfied that their needs are being met. Based on the information obtained, there was insufficient evidence to prove that staff are not meeting resident hygiene or incontinent needs. Therefore, the allegations are deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 31-AS-20240905114457

Allegation investigated: Staff does not ensure resident's grab bars are in good repair resulting in resident sustaining falls Staff is emotionally abusing resident

At 10:15a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced initial visit for the above noted allegations. LPA met with the E.D. and explained the reason for the visit. At about 10:20a.m. LPA request and received maintenance report, staff resident & rosters. At 10:45a.m. LPA and E.D. conducted a physical plant tour, interviewed randomly selected nine (9) residents including resident (R1) in their room and inspected grab bars in bathroom. At approximately 12:15p.m. LPA interviewed E.D., Maintenance Staff, Wellness Coordinator and Receptionist. LPA asked questions relevant to the nature of the complaint. At 1:50p.m. LPA reviewed documents obtained. 1) Staff does not ensure resident's grab bars are in good repair resulting in resident sustaining falls. It was alleged that resident (R1) did not have safe grab bar and sustained a few falls in bathroom. Continue on 9099c Unsubstantiated Interview with resident R1 reveal that grab bars were fixed about a month ago and had no concerns. Other residents interviewed did not express any concerns regarding grab bars not in good repair. Residents indicated that their grab bars are secured, sturdy and they feel safe using them. Staff interviews reveal that all residents grab bars in bathroom are in good repair and safe. Staff (S1) indicated that R1 asked him to fix the grab bars in bathroom and S1 fixed it. R1 was happy that S1 fixed the problem. During physical plant inspection, LPA observed R1’s and other resident’s grab bars in good repair. A review of Maintenance Report dated 06/14/2024 indicates that R1 requested for grab bar in restroom to be fix and signed by S1. Based on interviews and observation there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 2) Staff is emotionally abusing resident. It is alleged that resident R1 would like to be called by last name. Interview with resident R1 reveal that did not agreed with the allegation. R1 indicated that staff call them by their last name and appreciated it. R1 indicated that E.D. is nice and makes sure that staff are treating residents appropriately. Other residents also verified that staff do not emotionally abuse residents. Resident indicated that staff are respectful, helpful and have no concerns about emotionally abuse. Staff interviews reveal that residents are never emotionally abused. Staff are always calling residents by the name they wish to be called. E.D. have not received any complaints about staff emotionally abusing residents. During physical plant inspection, LPA did not observe staff emotionally abusing residents. Based on interviews and observation there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit interview is conducted and copy of report was provided to Executive Director.the state’s words, verbatim · CDSS document, Jul 3, 2024 · control 31-AS-20240627085253

Allegation investigated: Staff did not prevent a resident from disturbing another resident

Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Imelda Villanueva and informed her the reason of the visit. The following was determined: It was alleged staff did not prevent a resident from disturbing another resident. During today’s visit, from 12pm to 230pm, LPA conducted a physical plant inspection, interviews, and reviewed resident and facility documents. Staff reported to LPA, that resident # 1 (R1) had issues with the roommate, resident # 2 (R2). LPA interviewed (R2), who confirmed the issues with (R1). To resolve the problem and the conflict, facility staff relocated (R1) to a different room with a new roommate. (R1) reported to LPA, the issues are resolved, and both residents are getting a long and mind their own business. LPA determined, that the facility can not always ensure that there will be no issues among residents who have roommates, but in an effort to resolve the conflict, the facility relocated (R1) and made the necessary changes. Therefore, based on interviews, the allegation is Unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 25, 2024 · control 31-AS-20240617232750

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

Licensing Program Analyst (LPA) Tuesday Cabiness conducted the initial complaint visit, and met with Administrator Imelda Villanueva, who was informed the reason of the visit. It was alleged that staff does not safeguard resident’s personal belongings. During the visit, from 1030am to 130pm, LPA conducted a physical plant inspection, conducted interviews and reviewed resident and facility documents. From the information obtained, resident # 1 (R1) complained to staff that their personal belongings were missing, and could not identify the resident that allegedly took the items. Staff interviewed residents and (R1), as well as checked facility cameras in the common areas. Cameras revealed, no-one but staff were entering the room. Facility conducted an internal investigation, which revealed,( R1) giving conflicting statements pertaining to the items that were alleged to be stolen. LPA interviewed (R1), and the items reported missing, were not consistent what was reported to facility staff. Therefore, based on interviews, there is insufficient evidence to prove the allegation, and it’s Unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 25, 2024 · control 31-AS-20240619115048

Allegation investigated: Unused portion of resident's rent was not refunded

At 9:50a.m Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced initial visit for the above noted allegation. LPA met with the E.D. and explained the reason for the visit. At 10:20a.m. LPA and E.D. conducted a physical plant tour. Between 10:40a.m. to 11:30a.m. LPA interviewed E.D. and Business Office Manager (B.O.M.). LPA asked questions relevant to the nature of the complaint. At 11:45a.m. LPA obtained copies of R1’s Admission Agreement, Authorization Agreement for Pre-Authorized Payment, Resident Fund Management Service, Payer Detail Ledger, Rent Rate Increase Notice, Refund Explanation, Staff and Resident rosters relevant to the investigation. At 11:50a.m. LPA reviewed documents obtained. 1. Unused portion of resident’s rent was not refunded. It was alleged that facility did not refund R1’s prorated amount of rent. Continue on 9099c Unsubstantiated Staff interviews reveal that on 04/09/2024 R1 moved out of the facility. R1 did not provide facility a verbal/written Notice of Intent to Vacate. ED indicated that on 5/14/2024 R1 was informed that a requested for refund was submitted to Savant Corporate Office. R1’s monthly rate was $1418.07 however R1 paid an additional $6.93 for the the of April towards previous balance due. R1's daily rate is $47.27. $47.27 x 21= $992.65. R1 had a previous balance of $207.81 for late payments. R1 will receive a refund of $784.84 in a form of a check. LPA interview with B.O.M. indicated that corporate office is currently processing R1’s refund request and will be mailed to R1 as soon as possible. LPA attempt several times to interview R1 via-phone and was unsuccessful. Overall, facility staff have been in communication with R1 regarding the refund. As of 04/11/2024 B.O.M terminated the withdraw of Direct Deposit from R1’s bank account. A review R1’s Admission Agreement indicates that verbal/written Notice of Intent to Vacate the facility requires a resident to provide a 30-day advance notice of intent to move or vacate the premises. Facility refund conditions will not contain an advance notice of intent to vacate, believing that would be a resident’s rights violation. Based on interviews and documents review there is an insufficient information to support the allegation. Therefore, allegation is UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit interview is conducted and copy of report was provided to Executive Director.the state’s words, verbatim · CDSS document, May 29, 2024 · control 31-AS-20240521132318

Allegation investigated: Staff verbally abused resident Staff financially abused a resident in care

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Executive Director Imelda Villanueva and explained the reason of the visit. LPA conducted physical plant tour at 9:10 AM, requested copies of facility documents relevant to the investigation at 9:43 AM and interviewed staff and residents between 10:15 AM to 1:15 PM. Regarding the allegation that staff verbally abused resident, it was alleged that two (2) staff went to Resident #1 (R1) and cussed R1. LPA's interview with R1 on 01/17/24 revealed that there was no other person in R1's room when the alleged cussing occurs but R1 and the staff. LPA's interview with Staff #1 (S1) on 01/27/24 at 11:31 AM and Staff #2 (S2) today at 11:37 AM revealed that both staff denied cussing of verbally abusing R1. LPA's interview with ten (10) residents on 01/17/24 and additional five (5) residents between 10:15 AM to 1:15 PM today, revealed that fifteen (15) out of fifteen (15) residents or more than 15% of the current census, did not experience nor witness S1 and S2 cussing or verbally abusing any resident. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Regarding the allegation that staff financially abused a resident in care, it was alleged that R1 loaned money to S2 but did not pay R1 back. LPA's interview with R1 on 01/17/24 revealed that R1 did not have any witness nor was able to provide any proof that R1 loaned money to S2. LPA's interview with S2 today at 11:37 AM, revealed that S2 did not ask for a loan from R1 to any resident of the facility and was aware that it was against the facility rule. The alleged incident was reported to local law enforcement on 01/15/24 but was classified by the law enforcement as false report of theft. Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, May 29, 2024 · control 31-AS-20231027164534

Allegation investigated: Staff does not ensure resident has adequate storage space for personal belongings. Resident was not accorded assistance by staff after having fallen. Staff does not ensure resident is accorded dignity in her personal relations ships with staff, residents. Staff do not ensure resident is spoken to in an appropriate manner. Staff do not ensure medications are dispensed as prescribed to resident in care.

On 05/08/24, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted a subsequent unannounced visit to the facility and was greeted by Marili Barajas, Business Office Manager. LPA explained the purpose of this visit is to gather additional information and deliver findings for the allegations mentioned above. The investigation consisted of the following: An initial complaint visit was completed by LPA Antonia Alvizar on 09/22/2023. A subsequent visit was completed by LPA Perry Scott on 05/08/2024. LPA investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R10). Resident/Staff Roster, Admission Agreement, Needs and Service Plan, Face sheets/ID and Emergency Information, Pre-Appraisal, Physician's Report, and the Medication Administration Record for R1 were obtained from the facility. Report continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Staff does not ensure resident has adequate storage space for personal belongings. The details of the complaint alleged that the facility does not provide the resident with adequate storage space for personal belongings. On 05/08/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Staff does not ensure resident has adequate storage space for personal belongings. All staff (S1-S4) stated that all residents have the required storage space as it pertains to Title 22 regulations. Each resident has a dresser, nightstand, and a shared closet with their roommate. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff does not ensure resident has adequate storage space for personal belongings. Residents stated that they have adequate space in their room which includes a dresser, nightstand, lamp, and closet space that they share with their roommate. LPA toured the bedrooms and observed that the residents have a large room with enough space to accommodate a bed for each resident, chest of drawers, nightstand, and enough closet space that is shared by two roommates. Based on interviews and observations, there is insufficient evidence to support the allegation that Staff does not ensure resident has adequate storage space for personal belongings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 2- Resident was not accorded assistance by staff after having fallen. The details of the complaint alleged that the facility did not assist the resident after the resident fell in the facility. On 05/08/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Resident was not accorded assistance by staff after having fallen. All staff (S1-S4) stated that R1 did not fall in the facility because someone kicked their walker, and they do not have a record of R1 falling in the facility. They state if a resident fell, the staff is fully trained to assist the resident and would not leave the resident on the ground and certainly not ignore them. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Resident was not accorded assistance by staff after having fallen. Residents stated that the staff are responsive to their needs and are happy with the care and supervision they are receiving from the staff. They state that if they were to fall on the ground, they are confident that the staff would help them. They also stated they had no knowledge of a resident falling because someone kicked their walker. Based on interviews, there is insufficient evidence to support the allegation that Resident was not accorded assistance by staff after having fallen. 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. Report continued on LIC9099-C Allegation # 3- Staff does not ensure resident is accorded dignity in her personal relations ships with staff, residents. The details of the complaint alleged that the facility does not ensure the resident is accorded dignity in her personal relationships with staff and residents; and that they are being harassed by another resident. On 05/08/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Staff does not ensure resident is accorded dignity in her personal relations ships with staff, residents. All staff (S1-S4) stated that R1 and all residents are accorded dignity with their relationships with staff and residents. Staff stated that the R1 has a history of not getting along with other residents. Staff also stated that the resident had to change rooms on multiple occasions because R1 could not share space with other residents because R1 would complain that they were disturbing R1. They stated if R1s roommate had a visitor, R1 would complain that they were talking too much and harassing R1. Moreover, the staff stated that R1 was never happy at the facility. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff does not ensure resident is accorded dignity in her personal relations ships with staff, residents. Residents stated that they were happy with the care and supervision being provided to them, and that the staff does ensure they are accorded dignity in their relationships with staff and residents. The residents further stated that they have not been harassed nor have they harassed anyone. Based on interviews, there is insufficient evidence to support the allegation that Staff does not ensure resident is accorded dignity in her personal relations ships with staff, residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 4- Staff do not ensure resident is spoken to in an appropriate manner. The details of the complaint alleged that the staff speaks to the resident in an inappropriate manner. In that the staff yells and speaks rudely to the resident. On 05/08/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not ensure resident is spoken to in an appropriate manner. All staff (S1-S4) stated that R1 has never been spoken to disrespectfully or in an inappropriate manner. They state that they treat all the residents with dignity and respect. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not ensure resident is spoken to in an appropriate manner. Residents stated that they have never been spoken to in an inappropriate way nor have they witnessed any other resident being yelled at or intimidated by another staff or resident. Based on interviews, there is insufficient evidence to support the allegation that Staff do not ensure resident is spoken to in an appropriate manner. 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. Report continued on LIC9099-C Allegation # 5- Staff do not ensure medications are dispensed as prescribed to resident in care. The details of the complaint alleged that the facility did not dispense the correct medication for the resident. On 05/08/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not ensure medications are dispensed as prescribed to resident in care. All staff (S1-S4) stated that R1 always received their medication as prescribed but that the resident has a history of refusing their medication and they can’t force the resident to take it. LPA reviewed the Medication Administration Record and observed that from 08/01/23 -10/31/2023 the resident refused to take their medication repeatedly. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not ensure medications are dispensed as prescribed to resident in care. Residents stated that they always get their medication as prescribed by their physician and that the staff gives it to them at the correct times. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure medications are dispensed as prescribed to resident in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with Marili Barajas, Business Office Manager, and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, May 16, 2024 · control 31-AS-20230919142727

Allegation investigated: Staff do not accord resident privacy. Staff are not assisting resident with care needs.

On 05/08/24, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted a subsequent unannounced visit to the facility and was greeted by Marili Barajas, Business Office Manager. LPA explained the purpose of this visit is to gather additional information and deliver findings for the allegations mentioned above. The investigation consisted of the following: An initial complaint visit was completed by LPA Antonia Alvizar on 09/11/2023. A subsequent visit was completed by LPA Perry Scott on 05/08/2024. LPAs investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R10). Resident/Staff Roster, Admission Agreement, Needs and Service Plan, Face sheets/ID and Emergency Information, Pre-Appraisal, Physician's Report, and the Medication Administration Record for R1 were obtained from the facility. Report continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Staff do not accord resident privacy. The details of the complaint alleged that the facility does not give the resident privacy and the staff walks in on them without notice when the resident is changing or taking a shower. On 05/08/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not accord resident privacy. All staff (S1-S4) stated that R1 and all residents are accorded privacy in their everyday lives. Staff further state that when they must enter the resident’s room, they knock first to alert them that they are entering the room. And when they do enter, they are only there to check on the well-being of the resident, to clean the room, assist the resident with their personal care needs, or to assist the resident with their activities of daily living. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not accord resident privacy. Residents stated that they did not have any problems with the staff giving them their privacy in their room or to have a private conversation with other residents or staff. And that the staff knocks before they come into their room and announces who they are and why they are here. Based on interviews, there is insufficient evidence to support the allegation that Staff do not accord resident privacy. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 2- Staff are not assisting resident with care needs. The details of the complaint alleged that the facility did not assist the resident with care needs. On 05/08/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Staff are not assisting resident with care needs. All staff (S1-S4) stated that R1 and all residents are given assistance with their care needs and according to their care plan. Staff stated that R1 was independent and needed minimal assistance with their care needs. However, the staff stated that when R1 needed assistance with personal care needs or assistance with ADL’s, the staff was there to provide the resident with anything the resident was incapable of doing by themselves. LPA reviewed the Preplacement Appraisal dated 05/21/23 and the Physicians Report dated 05/08/23 and observed that the resident needed minimal assistance with personal care needs. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff are not assisting resident with care needs. Residents stated that they were happy with the care and supervision being provided to them, and that their personal care needs are being met by the staff. They also stated that whenever they ask for assistance from the staff, it is given. Report continued on LIC9099-C Based on interviews, there is insufficient evidence to support the allegation that Staff are not assisting resident with care needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with Imelda Villanueva, Administrator, and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, May 16, 2024 · control 31-AS-20230911081750

Allegation investigated: Unlawful eviction. Staff speak inappropriately to resident in care. Facility is in disrepair. Staff withheld resident's mail. Staff do not safeguard resident's belongings. Residents smoke inside the facility.

On 05/15/24, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted a subsequent unannounced visit to the facility and was greeted by Imelda Villanueva, Administrator. LPA explained the purpose of this visit is to gather additional information and deliver findings for the allegations mentioned above. The investigation consisted of the following: An initial complaint visit was completed by LPA Antonia Alvizar on 05/16/2023. A subsequent visit was completed by LPA Perry Scott on 05/15/2024. LPA investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R10). Resident/Staff Roster, Pre-Placement Appraisal, ID/Emergency Info, Client Personal property, Admission Agreement, Warning Letter, House Rules, ISP, & Physicians Report for R1 were obtained from the facility. Report continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Unlawful eviction. The details of the complaint alleged that the facility is evicting the resident on 05/10/2023 and the resident has not been issued an eviction notice. On 05/15/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 5 of 5 staff denied the allegation that the resident was given an Unlawful eviction. All staff (S1-S5) stated that the resident was never under the threat of eviction. Staff stated that the resident has a hoarding problem and was given a warning letter to address this problem. S1 stated that R1 has been doing better with this issue and seems to have it under control and no eviction is forthcoming. LPA interviewed R1-R10 about the allegation and 10 of 10 residents that were interviewed denied the allegation that the facility issued them an Unlawful eviction. Residents stated that they have never been issued an eviction notice by the facility and are all in good standing. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the facility issued an Unlawful eviction. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 2- Staff speak inappropriately to resident in care. The details of the complaint alleged that the facility staff yells at the resident and calls the resident names. On 05/15/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 5 of 5 staff denied the allegation that Staff speak inappropriately to resident in care. All staff (S1-S5) stated that they have no knowledge of R1 being spoken to disrespectfully or in an inappropriate manner and deny that the resident has ever been called names by the staff. They state that they treat all the residents with dignity and respect. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff speak inappropriately to resident in care. Residents stated that they have never been spoken to in an inappropriate way nor have they witnessed any other resident being yelled at or intimidated by another staff or resident. Based on interviews, there is insufficient evidence to support the allegation that Staff speak inappropriately to resident in care. 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. Report continued on LIC9099-C Allegation # 3- Facility is in disrepair. The details of the complaint alleged that the facility does not have any air conditioning or heating. On 05/15/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 5 of 5 staff denied the allegation that the Facility is in disrepair. All staff (S1-S5) stated that the facility does have air conditioning and heating in all rooms of the facility. LPA toured the facility and bedrooms and observed that the rooms are equipped with a working air conditioner and heating unit; and that the facility is not in disrepair. LPA interviewed R1-R10 about the allegation and 10 of 10 residents that were interviewed denied the allegation that the Facility is in disrepair. Residents stated that the facility and their rooms are equipped with an air conditioner and a heating unit; and that the facility is not in disrepair. Based on interviews and observations, there is insufficient evidence to support the allegation that the Facility is in disrepair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 4- Staff withheld resident's mail. The details of the complaint alleged that the facility staff withholds the residents mail and sometimes it is lost by staff. On 05/15/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 5 of 5 staff denied the allegation that the Staff withheld resident's mail. All staff (S1-S5) stated that they have never withheld R1s mail and that once the mail is received it must be sorted and organized for each resident. Once that happens the residents can come to the front desk and pick up their mail. S1 further stated that if residents don’t come and pick up the mail for a couple of days, the staff takes it to their room. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff withheld resident's mail. Residents stated that they have never had their mail withheld from them and are satisfied with the facility and the way they process and distribute the mail. Based on interviews, there is insufficient evidence to support the allegation that the Staff withheld resident's mail. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 5- Staff do not safeguard resident's belongings. The details of the complaint alleged that the facility staff steals and/or loses the residents clothing. On 05/15/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 5 of 5 staff denied the allegation that Staff do not safeguard resident's belongings. All staff (S1-S5) stated that they have not had any complaints of theft in the facility and no knowledge of anyone complaining about theft. S1 stated the facility gives lock boxes to residents that have cash or valuables that they want to keep safe in their rooms. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not safeguard resident's belongings. Residents stated that they have not had any of their personal items stolen while living at the facility; and the staff does safeguard their belongings. Based on interviews, there is insufficient evidence to support the allegation that Staff do not safeguard resident's belongings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 6- Residents smoke inside the facility. The details of the complaint alleged that the residents smoke in the facility. On 05/15/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 5 of 5 staff denied the allegation that Residents smoke inside the facility. All staff (S1-S5) stated that residents are not allowed to smoke in the facility and if it is found that they are they are given a verbal and written warning to stop this behavior. If it persists, they may be evicted for not following the house rules. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Residents smoke inside the facility. Residents stated that they have no knowledge of anyone smoking in the facility. They stated that it is not allowed and those who choose to smoke must go outside to the patio area. Based on interviews, there is insufficient evidence to support the allegation that Residents smoke inside the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with Imelda Villanueva, Administrator, and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, May 16, 2024 · control 31-AS-20230509163313

Allegation investigated: Staff did not prevent a resident from causing harm to another resident while in care. Visitor vandalized a resident's room while in care.

On 05/14/24 at 9:35 am Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit to render findings. LPA met with Executive Director Imelda Villanueva as the Purpose of today’s visit was explained. The investigation consisted of the following: On 04/21/23 LPA Antonia Alvizar interviewed R1. On 05/14/24 LPA Villegas obtained copies of the following: staff and resident roster(s) and facility rules, LPA also obtained copies of the following for R1; Facesheet, admission agreement, physicians report, needs and service plan, physician’s orders MAR for April, May, and June 2023, and the following documents for R2; facesheet, admission agreement, physicians report, pre-appraisal, physician’s orders MAR for March and April 2023, resident’s departure form, medication release form for R2, documented room changes for R2. On 05/14/24 LPA Villegas interviewed residents #3-10 (R3-R10), staff #1-4 (S1-S4), and Executive Director (ED). Allegation: Staff did not prevent a resident from causing harm to another resident while in care Unsubstantiated The investigation revealed the following: Allegations: Staff did not prevent a resident from causing harm to another resident while in care. It is being alleged that R2 would often curse at R1 and yell threats. On 05/14/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above. Per ED, R1 and R2 came to ED on 04/12/24 to report verbal feud, ED offered a room change which would have been R2’s 4th room change however room change was not done as R2 was taken to LADMC for psychological evaluation on 04/13/23 and on 04/14/23 R2 was discharged from the facility by responsible party. 05/14/24 LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported there are de-escalation procedures in place to ensure all residents are happy and comfortable. Per 4 of 4 staff, room changes take place when roommates are not getting along. On 04/21/23 LPA Alvizar interviewed R1 regarding the allegation above, per R1 staff did not prevent R2’s relative from yelling and cursing at R1. R1 denied R2 causing harm to R1. LPA was unable to interview R2 since R2 is no longer a resident at the facility and R2 whereabouts are unknown at this time. On 05/14/24 LPA interviewed R3-R10 regarding the allegation above, 7 of 7 residents interviewed denied the allegation above and reported feeling safe at the facility. LPA unable to interview R2 are no longer receiving care at Burbank Senior Villa East. On 05/14/23 LPA conducted records review and observed document listing all dates R2 had room changes due to not getting along with roommates. Based on interviews conducted and records reviewed their were no witnesses or documentation to corroborate that R2 yelled / cursed or causes harm to R1, therefore the allegation is unsubstantiated. Allegation: Visitor vandalized a resident's room while in care It is being alleged that on 04/14/23 R1’s belongings were vandalized by R2’s relative. It is alleged during the incident R1 property was damaged. On 05/14/24 LPA interviewed ED regarding the allegation above, ED confirmed that an incident did occur on 04/14/23 between R1 and R2’s relative as R2 was in the process of being moved out of the On 05/14/24 LPA interviewed S1-S4 regarding the allegation above, 1 of 4 staff interviewed reported being present when the incident occurred and reports assisting ED with de-escalating the incident. 1 of 4 staff continued to report that ED called the police right away and assisted with removing R2 and R2’s relative from the bedroom to ensure safety. 3 of 4 staff interviewed reported not having any details on the incident. On 04/21/23 LPA Alvizar interviewed R1 regarding the allegation above, per R1 R2’s relative made it into the bedroom and began throwing belongings out of the closet resulting in a wooden divider to be cracked. On 05/14/24 LPA interviewed R3-R10 regarding the allegation above, 7 of 7 residents interviewed denied the allegation above and reported that their belongings have not been vandalized while living at the facility. LPA unable to interview R2 as R2 is no longer receiving care at Burbank Senior Villa East. On 05/14/24 at 10 am LPA conducted a review of the facility and there is no documentation of any similar incidents occurring at the facility. On 05/14/24, LPA reviewed R1 Property Inventory sheet and did not observe a room divider documented. LPA reviewed the incident report for the occurrence, and it does not indicate any of R1 belongings were vandalized. Based on interviews conducted and records review, on 04/14/23 an incident occurred between R1 and R2’s relative, records detail that during the incident a room divider was cracked but no other damage was noted. Interviews with witnesses conducted did not corroborate R2 relative cracking the room divider. There is no photographic evidence or surveillance footage to support the allegation. Based on interviews and records reviewed there is not enough evidence to support the allegation 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 violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director Imelda Villanueva, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 14, 2024 · control 31-AS-20230418144741

Allegation investigated: Staff did not provide requested records to resident's responsible party. Staff falsified documents. Staff did not provide resident proper notice of rate increase.

On 05/14/24, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to this facility and was greeted by Administrator (A1: Imelda Villanueva). LPA explained the purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: An initial 10-Day visit was conducted by (LPAs) Gary Tan, Gina Saucedo and Leslie Castaneda on 11/03/23 who met with Regional Director Nirjara Acharya. (LPA) Dabuet requested copies of files for resident #1 (R1’s) ID and Emergency Information (dated: 05/11/22) Admissions Agreement (dated: 05/11/22), Physicians Report LIC 602A (dated: 05/10/22), Preplacement Appraisal Information LIC 603 (dated: 01/29/22), Functional Capability Assessment LIC 9172 (dated: 05/11/22), Arkansas Teacher Retirement System Retirement Income Verification (dated: 07/27/22), Burbank Senior Villa East Notification Letter Services Increase (date: xx xx xx), Resident Council Meeting Log (dated: 09/25/23), Burbank Senior Villa East Invoice (dated: 10/2023), Resident Detail Ledger (dated: 11/2022 thru 06/2024), Payer Open Charges (dated: 11/2022 thru 11/2023), Resident Summary Ledger (dated: 11/2022 thru 06/2024), Lebleuchateau, Inc. Statement (dated: 04/30/24), Supplemental Security Income checks, Personal Check (dated: 03/04/24),Facility Resident Roster (dated: 05/10/24) and Personnel Report LIC 500 (dated: 05/10/24). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not provide requested records to resident’s responsible party. The details of the complaint alleged that facility staff failed to provide records requested by the responsible party for resident #1 (R1). The complainant reported on multiple occasions requesteed a ledger documenting the payments made by (R1) to ensure accuracy. The complainant claimed to have been informed that the records were located at the corporate office. According to resident #1 (R1’s) Identification and Emergency Information LIC 601 (dated: 05/11/22) and Admissions Agreement (dated: 05/11/22), (R1) was admitted at Burbank Senior Villa East on 05/11/22. On 05/10/24, between 10:37 am – 11::01 am, the Department interviewed resident #1 (R1). (R1) stated that this matter has been resolved and had received all the necessary documents requested. On 05/10/24, between 11:05 am – 11:31 am, the Department interviewed business manager staff #1 (S1). (S1) claimed to have provided (R1’s) responsible party with the following: (R1’s) Payer Ledger, Retirement Income Verification, Statement Invoice (dated: 10/2023), Notice of Rate Increase Letter, Payer Detail Ledger (11/22 thru 11/23), Copies of SS1 and SSA checks total amount of $1327.82, Personal check in amount of $400 and Admissions Agreement on 11/02/23 through an email process. The request was made by email from (R1’s) responsible party on 10/23/23 and evidence of email communications from (S1) and the responsible party on 10/27/23 and 11/02/22. (S1) confirmed that the facility cooperated with (R1’s) responsible party and provided all the necessary records requested. However, the (R1’s) ledger for prior months beginning 05/22 through 10/22 were in another accounting software program with the facility’s corporate office, and will take some additional days to obtain a copy. (S1) reported that (R1’s) responsible party did not request again for the statement aside from what (S1) provided on 11/02/23, and considered request to have been fulfilled. A review of (R1’s) general ledger indicated (R1) was admitted with the amount for basic service of $1231.77 on 05/11/22. A reassessment of (R1’s) Medi-Cal with a shared cost brought the basic services to increase by $1344.82 effective 01/01/23. Effective 01/01/24 (R1’s) basic services increased to $1398.07. (R1) continued to make payments of $1,200.77 and $1327.82 and not the full amount which resulted in an open totaling balance of $215 as of 10/27/23. (Evaluation Report continues LIC 9099-C) According to (S1), (R1) has a monthly retirement benefit from Arkansas Teacher Retirement for $185.00. (S1) stated the facility had no access to this retirement benefit in which goes directly to (R1’s) checking account associated with (R1’s) family member. Evidence of payment for the remaining balance owed by (R1) was paid in full on 03/04/24 by (W1) check #6853. Currently, (R1) has a zero outstanding balance as of 05/14/24. The Department reviewed all the records provided to (R1’s) responsible party along with the Statement from Lebleuchateau, Inc. (dated: 04/30/22 through 11/01/22) the missing statement (R1) claimed not to have received and found to be complete and accurate. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. Allegation #2: Staff falsified documents. It is alleged the admission agreement signed on 5/11/2022 by (R1) was altered. According to the complainant the (date and basic rate amount were modified). On 05/10/24, between 11:05 am – 12:37 pm, the Department interviewed administrator #1 (A1) and business manager staff #1 (S1). (A1-S1) both denied falsifying any service records for residents. An examination of (R1's) Admission Agreement, provided by the facility and compared it to the copy provided by (R1's) responsible party, appeared to have no modifications, the copy is identical, complete, and accurate. Furthermore, resident #5 (R5’s) Admission Agreement was reviewed in comparison to (R1’s) Admission Agreement, which revealed no differences and no modifications. Based on the information gathered, there is no sufficient evidence to support the allegation mentioned above. Allegation #3: Staff did not provide resident proper rate increase. The details of the complaint alleged the staff failed to provide resident #1 (R1) with a proper notice of a rate increase. According to the complainant the facility provided a Notice Letter of Rate Increase to (R1) on 10/27/23, which appeared with no date in the letter and gave the impression of being modified with a whiteout. (Evaluation Report continues LIC 9099-C) On 05/10/24, between 10:37 am – 11::01 am, the Department interviewed resident #1 (R1). (R1) stated that this matter has been rectified. However, when presented with a copy of a Notice Letter of Rate Increase for 2024, (R1) could not recall ever receiving a copy. On 05/10/24, between 11:05 am – 11:31 am, the Department interviewed business manager staff #1 (S1). (S1) provided a copy of the Notice Letter of Rate Increase that was presented to (R1) in late October 2023. (S1) claimed that all residents received the Notice Letter of Rate Increase effective 01/01/24, in person or it was placed inside their mailboxes. On 05/10/24, between 11:32 am – 12:05 pm, the Department interviewed (7) out of (7) residents #2 - #8 (R2-R8). Four (4) out of seven (7) claimed to have received the Notice Letter of Rate Increase. Three (3) out of seven (7) could not recall or claimed not to have received the notice. On 05/10/24, between 12:10 pm – 12:37 pm, the Department interviewed administrator #1 (A1). (A1) verified that it was (A1’s) signature on the Notice Letter of Rate Increase distributed to all the residents residing at Burbank Senior Villa East. Nevertheless, (A1) did not observe that a date was omitted from the letter generated by the business office. (A1) reported aside from a written notice given to the residents, the topic of rate increase for 2024 was presented during the Resident Council Meeting held on 09/25/24. A review of the Notice Letter of Rate Increase revealed it did not have a date, though it did not appear to be altered. Resident Council Meeting Log indicated that the topic of rate increase for January 2024 was discussed at the meeting. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. The Department could not obtain additional statements related to the allegations in this complaint from family member (W1) due to unreturned calls. Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegations mentioned in this complaint. 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. No deficiencies were cited. An exit interview is conducted with Imelda Villanueva and a copy of the report is provided.the state’s words, verbatim · CDSS document, May 14, 2024 · control 31-AS-20231102163819

Allegation investigated: Resident sustained unexplained injuries while in care.

On 05/10/24 at 09:21 am Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit to render findings. LPA met with Executive Director Imelda Villanueva as the Purpose of today’s visit was explained. The investigation consisted of the following: On 05/08/24 LPA Villegas obtained copies of the following; staff and resident roster(s), a list of all residents that require assistance with bathing/ADL log, facility rules. LPA also obtained copies of the following for R1-R4; Facesheet, admission agreement, physicians report, needs and service plan, MAR for April, May, and June 2023. On 05/08/24 LPA Villegas interviewed residents #5-12 (R5-R12), and staff #1-4 (S1-S4). On 05/09/24 LPA interviewed Executive Director (ED) and requested incident report pertaining to the allegation above. The investigation revealed the following: Unsubstantiated Allegation: Resident sustained unexplained injuries while in care. It is being alleged that resident obtained an un-witnessed fall on 08/04/23 that resulted in a swollen left cheek, and a bruised eye. On 05/09/24 LPA interviewed ED regarding the allegation above, Ed denied the allegation above and reported being unaware of residents fall until it was reported by Norwalk community hospital. ED continued to report that resident believes resident can still walk and resident tries to get up without assistance. ED reports staff conduct rounds every two hours to ensure resident care and safety. On 05/08/24 between 10:30 am-11:45 am, LPA interviewed R5-R12 regarding the allegation above, 8 of 8 residents interviewed denied the allegation and reported not sustaining any injury due to staff neglect. On 05/08/24 LPA was unable to interview R1 as R1 did not wish to conduct interview. On 05/09/24 LPA attempted to interview W1 but was unable to make any contact. On 05/08/24 between 12:18 pm -1:17 pm, LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above. 4 of 4 staff interviewed reported rounds are conducted every 2 hours, however report residents have call buttons residents can use if residents require assistance. On 05/10/24 LPA obtained a copy of LIC 624 dated 08/09/23 that states facility staff sent R1 to Norwalk Community hospital for further evaluation. Per LIC 624, while at the hospital R1 had no recollection of un-witnessed fall. 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 with Executive Director Imelda Villanueva, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 10, 2024 · control 31-AS-20230808125834

Allegation investigated: Staff does not prevent resident from disturbing another resident.

On 00/00/24 at 9:20 am Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit to render findings. LPA met with Executive Director Imelda Villanueva as the Purpose of today’s visit was explained. The investigation consisted of the following: On 05/08/24 LPA Villegas obtained copies of the following; staff and resident roster(s) and facility rules, LPA also obtained copies of the following for R1-R4; Facesheet, admission agreement, physicians report, needs and service plan, MAR for April, May, and June 2023. On 05/08/24 LPA Villegas interviewed residents #5-12 (R5-R12), and staff #1-4 (S1-S4). On 05/09/24 LPA interviewed Executive Director (ED). The investigation revealed the following: Allegation: Staff does not prevent resident from disturbing another resident. Unsubstantiated It Is being alleged residents are having loud conversations outside of peer’s bedroom while peer is sleeping. On 05/09/24 LPA interviewed ED regarding the allegation above, Ed denied the allegation above. Per ED, residents have the right to gather in common areas but are asked to not to speak so loudly when outside of a peer’s bedroom. ED continued to report that staff will offer a different common area with privacy for residents to gather. On 05/08/24 between 12:18pm-1:17pm, LPA interviewed R5-R12 regarding the allegation above, 8 of 8 residents interviewed denied the allegation and reported feeling safe at the facility. LPA was unable to interview R1 as R1 did not want to be interviewed. On 05/08/24 between 12:20pm-1:17pm, LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above. 4 of 4 staff interviewed reported rounds are conducted every 2 hours, and that if needed there are de-escalation procedures that take place to ensure conformability and safety. On 05/08/24 LPA conducted a tour of the facility and did not observe any immediate health and safety concerns. 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. Exit interview conducted with Executive Director Imelda Villanueva, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 10, 2024 · control 31-AS-20240116144428

Allegation investigated: Staff do not distribute resident's medications as prescribed. Staff do not meet resident's dietary needs. Staff do not assist resident with bathing.

On 05/10/24 at 9:10 am Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit to render findings. LPA met with Executive Director Imelda Villanueva as the Purpose of today’s visit was explained. The investigation consisted of the following: On 05/08/24 LPA Villegas obtained copies of the following; staff and resident roster(s), facility menus for April, May, and June 2023, a list of all residents that require assistance with bathing/ADL log, list of residents who have dietary restrictions/ modified diets, and facility rules. LPA also obtained copies of the following for R1-R4; Facesheet, admission agreement, physicians report, needs and service plan, MAR for April, May, June, and July 2023. On 05/08/24 LPA Villegas interviewed residents #5-12 (R5-R12), and staff #1-4 (S1-S4). On 05/09/24 LPA interviewed Executive Director (ED) and left a voicemail to dietary director. The investigation revealed the following: Unsubstantiated Allegation: Staff do not distribute resident's medications as prescribed. It is being alleged that staff do not distribute residents’ nausea medication as prescribed for residents dialysis. On 05/09/24 LPA interviewed ED regarding the allegation above, Ed denied the allegation above and reported all medications are administered by med techs as prescribed by physician. Per ED, medications will only be withheld from residents if the physician has ordered medications to be held.On 05/08/24 between 10:30 am-11:25am, LPA interviewed R5-R12 regarding the allegation above, 8 of 8 residents interviewed denied the allegation and reported receiving medication daily. LPA was unable to interview R1 as R1 is no longer receiving care at Burbank Senior Villa East. On 05/08/24 between 12:20pm-1:17pm, LPA interviewed S1-S4 regarding the allegation above, 3 of 4 staff interviewed denied the allegation above and reported that med techs administer medications, and that no medications are withheld from residents. 3 of 4 staff reported that when a resident refuses medication, med techs will take back the medication, wait 10-15 minutes and offer the medication once again, if a resident continues to refuse medications staff will document the refusal. 1 of 4 staff interviewed denied the allegation above and reported med tehcs administer medications, however 1 of 4 staff interviewed reports having no knowledge of medication procedures. On 05/09/24 LPA conducted a medication administration review for 8 residents and did not observed any discrepancies. On 05/09/24 LPA reviewed MAR for R1, no discrepancies were observed as MAR has documentation reporting PRN medication is provided when requested. Allegation: Staff do not meet resident's dietary needs. It is being alleged that staff are not providing resident with lunch when resident leaves the facility for dialysis. On 05/09/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above and reported that staff offer to have meals packed when a resident will be out of the facility for medical appointments. On 05/08/24 between 10:30 am-11:25am, LPA interviewed R5-R12 regarding the allegation above, 8 of 8 residents interviewed denied the allegation above and reported having all necessary meals. On 05/08/24 between 12:20 pm-1:17pm, LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above, and reported that residents dietary needs are being met. On 05/08/24 LPA toured facility kitchen and observed menus posted, and enough food supply for facility size. LPA was unable to interview R1 as R1 is no longer receiving care at Burbank Senior Villa East. On 05/10/24 LPA reviewed physicians report that indicated R1 required a renal diet while in care. On 05/10/24 at 11 am LPA spoke to W1 regarding the allegation above, per W1 the facility kitchen will provide alternative meals for resident to accommodate dietary needs. W1 continued to report that menus are reviewed weekly and are adjusted accordingly. Allegation: Staff do not assist resident with bathing. It is being alleged that that staff do not bathe resident twice per week as required. On 05/09/24 LPA interviewed ED regarding the allegation above, Ed denied the allegation above and reported that the facility has an ADL log which staff will use to document what and when residents are showered. ED continued to report that residents are provided with showers two times a week unless a resident refuses. On 05/08/24 between 10:30 am-11:25am, LPA interviewed R5-R12 regarding the allegation above, 8 of 8 residents interviewed denied the allegation and reported staff assist with showers 2 times a week or more if needed. LPA was unable to interview R1 as R1 is no longer receiving care at Burbank Senior Villa East. On 05/08/24 between 12:20 pm-1:17pm, LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above. 4 of 4 staff interviewed reported residents are assisted with showers 2 times a week which is documented on the facilities ADL log. On 05/09/24 LPA reviewed ADL log for April, May, and June 2023 and observed that residents are provided with showers regularly, LPA reviewed shower log for R1 and did not observe any discrepancies, shower log shows R1 is provided with showers regularly. 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(s) is unsubstantiated. Exit interview conducted with Executive Director Imelda Villanueva, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 10, 2024 · control 31-AS-20230630094119

Allegation investigated: Staff handle resident roughly. Staff have not ensured resident has closet space. Resident's room is malodorous. Staff do not shower resident as required. Staff are not assisting resident with incontinence needs timely. Facility exposes resident to maintenance dust. Staff do not ensure resident's room is free of roaches

On 05/10/24, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to this facility and was greeted by Administrator (A1: Imelda Villanueva). LPA explained the purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: An initial 10-Day visit was conducted by (LPA) Antonia Alvizar on 09/22/23 who met with Administrator Villanueva. (LPA) Dabuet requested copies of files for resident #1 (R1’s) Admissions Agreement (dated: 04/27/23), Physicians Report LIC 602A (dated: 04/21/23), Preplacement Appraisal Information LIC 603 (dated: 05/04/23), Facility Shower Log (dated: April 2023 thru June 2023), Consent for Emergency Medical Treatment LIC 627C (dated: 04/27/23), Release of Resident Medical Information LIC 605 (dated: 04/27/23), Resident Personal Property and Valuables LIC 621 (dated: 04/27/23), Personal Rights of Resident LIC613-C (dated: 04/27/23) Facility Resident Roster (dated: 05/02/24), Personnel Report LIC 500 (dated: 05/02/24), and Identification and Emergency Info LIC 601 (dated: 04/27/23) (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff handle resident roughly. The details of the complaint alleged that resident #1 (R1) was handled inappropriately by staff #2 (S2). The complainant reported that (R1) was handled by (S2) and had thrown (R1) on the bed face first. (R1) hurt the small toe when (S2) shoved (R1) foot forcefully. According to resident #1 (R1’s) Admissions Agreement (dated: 04/27/23) and Identification and Emergency Information LIC 601 (dated: 04/27/23), (R1) was admitted at Burbank Senior Villa East on 04/27/23. Voluntary termination of residency on 06/30/23 by (R1) due to needing a higher level of care. On 05/08/24, between 10:30 am – 11:45 am, the Department interviewed (8) out of (9) residents #2 - #9 (R2-R9) were complimentary of the staff and stated they adequately are serviced with their daily needs. (R2-R9) were unable to confirm this allegation that staff had mishandled them inappropriately. On 05/08/24, between 12:20 pm – 01:17 pm, the Department interviewed (4) out (4) staff #1-#4 (S1-S4) who refuted this allegation. (S2) denied ever handling (R1) in a forceful manner and stated these accusations were false. (S2) described (R1) as an unpredictable resident who had some pleasant and complimentary days, and some discouraging days, and would embellish stories. (S1-S4) reported that all staff have taken mandatory “Physical Care Training” in-service training. On 05/09/24, between 11:09 pm – 11:51 pm, the Department interviewed administrator #1 (A1). (A1) claimed this allegation is not true. (R1) was never handled inappropriately by staff. Our staff are mandated reporters and if an incident like this happened it would have been reported. (A1) stated this type of action on our residents is unacceptable and would warrant an investigation and disciplinary action or termination. (A1) stated there have been no reports from (R1) on any of our staff including (S2) of their unsatisfactory services. Based on the information gathered, there is no sufficient evidence to validate the allegation mentioned above. Allegation #2: Staff have not ensured resident has closet space. Allegation #3: Resident's room is malodorous. It is alleged that resident #1 (R1) was not provided a closet space. The complainant reported that (R1) was not provided a closet space for (R1’s) clothing. The complainant claimed (R1’s) former roommate had lots of personal belongings piled up and made the room smell. (Evaluation Report continues LIC 9099-C) *This report serves as an amendment to clarify the finding. It does not supersede the complaint investigation findings reflected on the report created on 05/10/24. On 05/08/24, between 10:30 am – 11:45 am, the Department interviewed (8) out of (9) residents #2 - #9 (R2-R9) claimed to have no issues with closet space. (R2-R9) verified that rooms are shared rooms and that closet space is shared with the roommate. (R2-R9) claimed they had not been exposed to offensive odor in their rooms or common areas. On 05/08/24, between 12:20 pm – 01:17 pm, the Department interviewed (4) out (4) staff #1-#4 (S1-S4) that (R1) was provided with closet space. (R1) did not have a private room and all rooms had shared closet spaces with their roommates. (S1-S4) were unaware that (R1) had issues with closet space. (S1-S4) recalled providing daily services in (R1’s) and did not observe any malodorous odor. (S1-S4) House cleaning is performed weekly which includes removal of any unpleasant offensive odor. On 05/09/24, between 11:09 pm – 11:51 pm, the Department interviewed administrator #1 (A1). (A1) communicated that (R1) was in a shared room under contract. Each room shared a built-in closet space. One-half the closet space is for each resident. (A1) explained when (R1) moved in on 04/27/23 (R1’s) roommate was in the hospital and that the stay was undetermined. (R1) desired that the roommate's belongings be removed from the room as (R1) felt comfortable having the room alone. (A1) stated the roommate was entitled to residential rights and could not handle or remove any of the roommate's personal belongings while the resident was in the hospital indefinitely. On 05/08/24, between 01:10 pm - 1:31 pm, Licensing Program Analyst (LPA) inspected (R1’s) rooms #225, #112, #224, #226, #227 and #228 observed built-in closet space for each room and no unwholesome odor. An observation of housekeeping staff was conducting cleaning service on each floor. A review of (R1’s) Admissions Agreement (dated: 04/27/23 page 5) Basic Services Lodging noted (R1) was under contract with a shared room. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. Allegation #4: Staff do not shower resident as required. Allegation #5: Staff are not assisting resident with incontinence needs timely. It is alleged resident #1 (R1) is not being provided routine showers and is not assisted with incontinence needs timely. The complainant claimed that (R1) had only one shower in four weeks and that staff are not changing (R1) timely. The complainant did not offer additional information on these matters such as a date, time, or individuals involved. (Evaluation Report continues LIC 9099-C) On 05/08/24, between 10:30 am – 11:45 am, the Department interviewed (8) out of (9) residents #2 - #9 (R2-R9) verified being assisted with bathing at least two or three times weekly. (R2-R9) claimed to have never experienced a missed shower as it was always offered by schedule. (R2-R9) stated the staff are responsive in assisting with diaper changes two or three times daily or as needed. On 05/08/24, between 12:20 pm – 01:17 pm, the Department interviewed (4) out (4) staff #1-#4 (S1-S4) and asserted this allegation is misleading. (S1-S4) explained staff attend to each resident based on their shower schedules. Each resident may be scheduled for two to three showers weekly. (S2) claimed as primary care staff to (R1), expressed there is no truth to the statement that (R1) was not bathed in four weeks. (S2) communicated that (R1) is bathed according to shower logs three baths weekly. (S1-S4) stated that the care staff does incontinent checks morning, afternoon, and evening or as required. (S2) said that (R1) required more than two hours of checks and diapers were changed more frequently than the average. On 05/09/24, between 11:09 pm – 11:51 pm, the Department interviewed administrator #1 (A1). (A1) claimed shower logs dispute this claim. (R1) was provided bathing three times weekly as noted under the Admissions Agreement contract. (A1) reported having at least three care staff on each floor and a med-tech to assist with incontinence for residents. (R1) was under observation every two hours and was changed more frequently due to (R1’s) physical health impairment. According to (R1's) Admission Agreement (dated: 04/27/23) and Physicians Report (dated: 0421/23), Facility Shower Logs (dated: April - June 2023), the required assisted daily living (ADL) services were noted, and at the appropriate frequency. Shower logs revealed (R1) received the required weekly bathing needs. Based on the information gathered, there is no sufficient evidence to validate the allegations mentioned above. Allegation #6: Facility exposes resident to maintenance dust. Allegation #7: Staff do not ensure resident’s room is free of roaches. The details of the complaint alleged resident #1 (R1) was exposed to maintenance dust and pests. The complainant reported that (R1’s) room and hallway went through interior construction and were exposed to maintenance specks of dust. Furthermore, the facility failed to ensure (R1’s) room was free from roaches. (Evaluation Report continues LIC 9099-C) On 05/08/24, between 10:30 am – 11:45 am, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (8) out of (9) residents #2 - #9 (R2-R9) claimed they had not been exposed to any maintenance dust. (R2-R9) claimed that their rooms are free from pests and have no issues with roaches in the facility. On 05/08/24, between 12:20 pm – 01:17 pm, the Department interviewed (4) out (4) staff #1-#4 (S1-S4) claimed to be unaware of any general construction work done in (R1’s) room or adjacent hallway that would have exposed (R1) to dust. (S2) stated if the resident had some repairs that involved major work in their room; the facility offers the resident a vacant room to occupy while the room is under construction. The facility has a contract with a reputable pest control company to service the facility according to (S2-S4). (S2-S4) unaware of (R1’s) pest issues as there has been on service request for pest control to service (R1’s) room. On 05/09/24, between 11:09 pm – 11:51 pm, the Department interviewed administrator #1 (A1). According to (A1) there has been no general construction work performed in (R1’s) room that would have exposed the resident to maintenance dust. The facility is under contract with Orkin Pest Company to eradicate pests in the facility. (A1) stated there have been no service requests on a record made by (R1) regarding pests in (R1’s) room. The facility is contracted with Orkin on a semi-monthly service according to contract #3396414. On 05/08/24, between 01:10 pm – 1:31 pm, the Department inspected (R1’s) rooms #225, #112, #224, #226, #227, #228, and the facility’s kitchen and did not observe any pests or interior construction on the premises. Based on the information gathered, there is no sufficient evidence to support the allegations mentioned above. On 05/03/24, at 11:43 am, the Department contacted resident #1 (R1) who did not wish to be interviewed and was unable to obtain statements for all allegations associated with this complaint. Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegations mentioned in this complaint. 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. No deficiencies were cited. An exit interview is conducted with Imelda Villanueva and a copy of the report is provided.the state’s words, verbatim · CDSS document, May 10, 2024 · control 31-AS-20230517152426

Allegation investigated: Staff did not order residen's oxygen tank. Resident sustained a stage 1 pressure injury due to staff neglect. Staff are retaliating against resident due to authorized representative asking questions about resident's care. Resident's a/c is in disrepair.

On 05/10/24, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to this facility and was greeted by Administrator (A1: Imelda Villanueva). LPA explained the purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: An initial 10-Day visit was conducted by (LPA) Antonia Alvizar on 09/22/23 who met with Administrator Villanueva. (LPA) Dabuet requested copies of files for resident #1 (R1’s) ID and Emergency Information (dated: 08/17/23) Admissions Agreement (dated: 08/17/23), Physicians Report LIC 602A (dated: 08/07/23), Preplacement Appraisal Information LIC 603 (dated: 0728/23), Skilled Home Health Inc Certification and Plan of Care (dated: 0823/23 – 10/21/23), Skilled Home Health Inc, Progress Notes (dated: 08/22/23 – 10/21/23), Department of Health Care Services (DHCS) Individual Service Plan (dated: 06/02/23), Consent for Emergency Medical Treatment (dated: 08/17/23), Facility Resident Roster (dated: 05/02/24) and Personnel Report LIC 500 (dated: 05/02/24). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not order resident’s oxygen tank. The details of the complaint alleged that resident #1 (R1) was without an oxygen tank for several days. The complainant reported that an oxygen tank was required when (R1) was transferred from a skilled nursing facility (SNF) on 08/16/23. (R1) was sent without oxygen by the (SNF) and informed that Burbank Senior Villa East would be providing the equipment. The complainant added that (R1) again did not have an oxygen tank on 09/18/23 and that (R1’s) level was down 70%. According to resident #1 (R1’s) Identification and Emergency Information LIC 601 (dated: 08/17/23) and Admissions Agreement (dated: 08/17/23), (R1) was admitted at Burbank Senior Villa East on 08/17/23. A voluntary terminated of residency on 10/31/23 by (R1) due to needing a higher level of care. On 09/22/23, between 09:00 am – 03:00 pm, Licensing Program Analyst (LPA) Antonia Alvizar interviewed resident #1 (R1) using Language Link Translator Operator #16459. (R1) stated that staff did order an oxygen tank and no further information was provided. On 05/08/24, between 10:30 am – 11:45 am, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (8) out of (9) residents #2 - #9 (R2-R9) claimed to have no issues with oxygen tank as it is not a prescribed equipment authorized by their medical physician. (R7) a former oxygen tank user reported never having issues obtaining an equipment through home health or primary physician. On 05/08/24, between 12:20 pm – 01:17 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (4) out (4) staff #1-#4 (S1-S4) who denied knowing (R1) not having an oxygen tank on 08/17/23 and 09/18/23. (S1-S4) acknowledged that (R1) required the equipment and that home health with (R1’s) primary physician is responsible for ordering the equipment. (S1-S4) stated (R1) was never without access to an oxygen tank. (S1-S4) stated if (R1’s) physician's order did not arrive timely, (R1) would be provided with a substitute supplied by the facility. (Evaluation Report continues LIC 9099-C) On 05/09/24, between 11:09 pm – and 11:51 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed administrator #1 (A1). (A1) claimed this allegation is false. (A1) stated that (R1) was admitted to the facility on 08/17/23 with no oxygen tank. The facility provided a substitute for (R1) the same day until (R1) was admitted on home health on 08/23/23. (A1) stated that a family representative for (R1) preferred a portable oxygen tank that is not covered through (R1’s) insurance which required an out-of-pocket deductible, and that the family did not want to pay the extra cost. (A1) explained while the family was contemplating the decision, it held up the home health’s request for equipment. (R1) was supplied with a substitute oxygen tank in place by the facility until home health equipment arrived. According to (A1) during the treatment of (R1) at the facility, (R1) was never provided with a portable oxygen tank and was never out of the equipment. A review of Skilled Home Health, Inc. Admission Order (dated: 08/23/23) indicated Oxygen 2 liters were ordered as confirmed the facility. Based on the information gathered, there is no sufficient evidence to support the allegation mentioned above. Allegation #2: Resident sustained a stage 1 pressure injury due to staff neglect. A pressure injury stage 1 is alleged to have occurred to resident #1 (R1). According to the complainant due to staff neglect, (RI) sustained about 2-3 mm wound but not enough to warrant hospitalization for (R1). On 09/22/23, between 09:00 am – 03:00 pm, Licensing Program Analyst (LPA) Antonia Alvizar interviewed resident #1 (R1) using Language Link Translator Operator #16459. (R1) claimed did not sustain a pressure injury. (R1) declared not to have any pressure injury. On 05/08/24, between 10:30 am – 11:45 am, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (8) out of (9) residents #2 - #9 (R2-R9) claimed never had any types of wounds while in care at this facility. (R2-R9) did not know any residents being cared for with any pressure injuries. (Evaluation Report continues LIC 9099-C) On 05/08/24, between 12:20 pm – 01:17 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (4) out (4) staff #1-#4 (S1-S4) claimed to not know about (R1) with pressure injury. (S1-S4) claimed (R1) was on home health and that the home health nurse would have been the primary source to address any wounds. (S1-S4) reported that incontinent residents are being repositioned, and changed diapers every two hours, or as required. Body checks are performed during these services and are documented if any change in condition. On 05/09/24, between 11:09 pm – 11:51 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed administrator #1 (A1). (A1) claimed this allegation is untrue. (A1) explained that (R1) was diagnosed with Dermatitis according to the Department of Health Care Services (DHCS) Individual Service Plan (dated: 06/02/23) a condition that caused inflammation in the skin and was admitted to the facility with a simple skin tear originated from the (SNF). (R1) was under Skilled Home Health, Inc., effective 08/23/23 until (R1’s) was discharged on 10/31/23. Skilled Home Health assessed and treated the wound with a wound specialist. (A1) claimed the facility staff were only responsible for (R1’s) non-medical care since the facility is a non-medical care facility. A review of Skilled Home Health, Inc. records revealed (R1) was treated for a skin condition by a wound care specialist (dated: 09/20/23, 09/25/23, 10/02/23, 10/04/23, and 10/09/23). Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. Allegation #3: Staff are retaliating against resident due to authorized representative asking questions about resident’s care. It is alleged that (A1) retaliated against (R1’s) authorized representative due to inquiring questions about (R1’s) care. The complainant reported paramedics were dispatched as a retaliation due to questions about (R1’s) pressure injury. The complainant did not offer further information on this matter. On 09/22/23, between 09:00 am – 03:00 pm, Licensing Program Analyst (LPA) Antonia Alvizar interviewed resident #1 (R1) using Language Link Translator Operator #16459. (R1) indicated that staff treated (R1) well. (Evaluation Report continues LIC 9099-C) On 05/08/24, between 10:30 am – 11:45 am, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (8) out of (9) residents #2 - #9 (R2-R9) reported are complimentary of the staff and they have not experienced any retaliation from staff including (A1). On 05/08/24, between 12:20 pm – 01:17 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (4) out (4) staff #1-#4 (S1-S4) and asserted this allegation is false. (S1-S4) stated they treated residents and family representatives professionally. (S1-S4) stated this type of behavior is considered harassment and the facility has a zero-tolerance policy for any type of harassment. On 05/09/24, between 11:09 pm – 11:51 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed administrator #1 (A1). (A1) claimed this allegation is incorrect. (A1) there no retaliation happened with any residents or family representatives. (A1) explained that 911 was called on 09/11/23, the request was made by home health due to (R1) experiencing shortness of breath (SOB) and Emesis and had nothing associated with (R1’s) pressure injury. (A1) stated to have been accessible and accommodating to (R1’s) authorized family representatives when inquiries of (R1’s) care. A review of Skilled Home Health, Inc. records (dated: 09/11/23) revealed 911 was dispatched and home health services were placed on hold. Services resume for (R1’s) care after hospital discharge within an episode of care. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. Allegation #4: Resident's a/c is in disrepair. It is alleged that resident #1 (R1’s) air conditioning (a/c) was not operable. The complainant reported that it was 105 degrees in Los Angeles and these vulnerable residents need a/c. The complainant did not offer additional information on this matter such as a date, time or individuals involved. On 09/22/23, between 09:00 am – 03:00 pm, Licensing Program Analyst (LPA) Antonia Alvizar interviewed resident #1 (R1) using Language Link Translator Operator #16459. (R1) expressed that a/c worked. (Evaluation Report LIC 9099-C) On 05/08/24, between 10:30 am – 11:45 am, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (8) out of (9) residents #2 - #9 (R2-R9) described to have never had issues with their air conditioning units their rooms or a/c units in the common areas. On 05/08/24, between 12:20 pm – 01:17 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (4) out (4) staff #1-#4 (S1-S4) recollection on this matter is that (R1’s) a/c unit never had issues. (S1-S4) there is no work order for maintenance for repair. On 05/09/24, between 11:09 pm – 11:51 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed administrator #1 (A1). (A1) informed that (R1’s) air conditioning unit always worked. Each room is equipped with programmable thermostat. Often the residents will tinker with the unit or remove batteries preventing proper operation of the unit. According to (A1) most of rooms have clear thermostat cover with lock. (R1’s) a/c unit did not have lock box cover. On 05/08/24, between 01:10 pm – 1:31 pm, Licensing Program Analyst (LPA) inspected (R1’s) room #112, #224, #225, #226, #227 and #228 and tested the air conditioning units in working condition. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. (LPA) Ernand Dabuet could not obtain additional statements related to the allegations in this complaint from (R1) due to unreturned calls. Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegations mentioned in this complaint. 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. No deficiencies were cited. An exit interview is conducted with Imelda Villanueva and a copy of the report is provided.the state’s words, verbatim · CDSS document, May 10, 2024 · control 31-AS-20230919092517

Allegation investigated: Licensee does not keep facility elevators maintained in operating condition Staff did not ensure a resident attended a scheduled appointment

At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced initial complaint visit. LPA met with the Administrator, Imelda V. Villanueva, and disclosed the reason for the visit. During course of the investigation, interviews and record review were made. At 10:15 AM, LPA requested resident and staff roster. At 10:20 AM, LPAs requested copies of pertinent information which include, but not limited to Physician’s Report, Addmission Agreement, Hospital Discharge Papers, Appraisal Needs and Services Plan, Invoices, and etc., relevant to the investigation. At approximately 10:30 AM, LPA conducted a physical plant tour. Between 11:45 AM – 2:30 PM, LPA conducted an interview with the Administrator, Maintenence Director, three (3) Staff, an Home Health Nurse, and nine (9) out of ten (10) residents who were able to communicate. Continue on LIC 9099C Unsubstantiated Licensee does not keep facility elevators maintained in operating condition: It's alleged that the elevator had been out for six months to a year. During the visit, LPA was able to use the elevator to go upstairs and observed the elevator being operational and working without any problem. Additionally, LPA reviewed Special Incident Reports (SIRs) for the elevator being out for one (1) or two hours to a day for three (3) different occasions due to a leak in hydraulic oil. Moreover, the facility has a monthly scheduled service with Elevator Support Services, Inc company to maintain and service the elevator on a regular basis. Interviews with nine (9) out of ten (10) residents who were able to communicate, the Administrator, Maintenance Director, and three (3) staff confirmed that the elevator was out for a very short period; however, it was repaired and operational right away. Based on the observation, document review, and interviews the above allegation is unsubstantiated at this time. Staff did not ensure a resident attended a scheduled appointment: It is alleged that on 04/18/2024, resident # 1 (R1) missed their scheduled doctor appointment due to the lack of transportation. To investigate the above allegation LPA reviewed documents and it was revealed that R1 did not have a scheduled appointment on 04/18/2024, with Olive View, UCLA Medical Center. Moreover, LPA was informed that the facility provides transportation services to all residents three (3) days a week (Mondays, Wednesdays, and Fridays). Even though the facility does not provide transportation services on Thursdays, the facility still accommodated to take R1 to an Emergency Room for medical evaluation. Additionally, interviews with nine (9) out of ten (10) residents who were able to communicate confirmed that they never missed any scheduled doctor’s appointments, and the facility provides them with transportation services as needed. Based on the documents review and interviews the above allegation is unsubstantiated at this time.the state’s words, verbatim · CDSS document, Apr 29, 2024 · control 31-AS-20240419091845

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Antonia Alvizar-Ettima and Gary Tan conducted an unannounced Required One (1) year at this facility today. LPAs met with Executive Director, Imelda Villanueva and explained the reason for the visit. The facility has an approved mitigation and infection control plan on file. LPA Alvizar-Ettima and LPA Tan utilized the Compliance and Regulatory Enforcement (CARE) tools. A tour of the physical plant was conducted at 9:20 AM with Executive Director and Wellness Coordinator, Reyna Garcia and the following was noted: The facility consists of a two-story structure that contains the following: Entrance / Lobby 1, an office for staff, and Lobby 2 / TV room areas for residents’ use, an interior courtyard, a dining room, a kitchen, a laundry room on first and second floors, storage space on first and second floors. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located in the lobby. Sign in sheet, hand sanitizer, gloves and masks are available. Some staff were observed to be wearing mask during this visit. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. Laundry room on the first and second floors and was observed to be locked. Laundry detergents, cleaning agents and other toxins are stored space in the second floor locked storage inaccessible to the residents. There are fire extinguishers throughout the facility hallways on all two (2) floors, all extinguishers were last serviced on March 31, 2023. Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lit. The bathroom was checked for cleanliness and proper operation. LPA observed that there are appropriate grab bars in the showers and toilets. The hot water temperature measure was at a range of 108.9°F to 116.6°F. There were enough clean linen available in the closets. Medications were kept in a locked medication carts in the medication room. The medications were observed to be locked and inaccessible to residents. There are multiple complete First Aid kits located in the medication room. Facility emergency disaster plan was reviewed. Facility disaster drill was last conducted on 02/21/2024. A fire inspection by the LAFD was last performed on 06/15/2023 valid until 10/31/2024. In addition to the physical plant inspection, residents and staff records were reviewed. There is no body of water at the facility. Back and front yard passageways were observed to be clear from obstruction. There is a shaded area in front of the building for residents. LPAs reviewed randomly selected files of five (5) residents and six (6) staff. Residents’ and staff files appear to be complete and updated. No Health and safety issues observed. Exit interview conducted. A copy of this report issued.the state’s words, verbatim · CDSS document, Mar 17, 2024

Allegation investigated: Staff do not treat resident with respect.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with the Executive Director, Imelda Villanueva, and explained the reason for the visit. --- Staff do not treat resident with respect. It was alleged that staff dismisses Resident #1 (R1) and won't have the electrical issue checked out. To investigate the allegation, on 02/14/2024 LPA conducted a physical plant tour at around 10:00 AM, interviewed four (04) staff between 11:00 AM – 12:30 PM and interviewed nine (09) residents from 1:00 PM to 2:30 PM. During physical plant tour LPA did not witness or feel any electrical issues. During interviews with staff, all staff stated that they do not see any electrical issues that would cause R1 pain and offered to have resident moved to another room. (CONT on LIC9099-C) Unsubstantiated All staff added that they volunteered to help R1 find a more suitable place that would give them comfort but R1 refused. During interviews with residents, R1 stated that staff are dismissive about the pain caused by the electricity in the walls and are not respectful as they are trying to get rid of them. R1 added that staff gives unreasonable orders to rearrange their room. The remaining eight (08) out of nine (09) residents stated that they are treated with respect and feel that staff are not dismissive. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Feb 14, 2024 · control 31-AS-20240213123732

Allegation investigated: Staff do not provide adequate hygiene care to resident.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with the Executive Director, Imelda Villanueva, and explained the reason for the visit. --- Staff do not provide adequate hygiene care to resident. It was alleged that Resident #1 (R1) smelled awful and looked like R1 had not bathed in a long time. To investigate the allegation, on 02/14/2024 LPA conducted a physical plant tour at around 10:00 AM, interviewed four (04) staff between 11:00 AM – 12:30 PM and interviewed ten (10) residents from 1:00 PM to 2:30 PM. During physical plant tour and interviews, LPA did not experience any malodor and all interviewed residents were clean and well-groomed including R1. (CONT on LIC9099-C) Unsubstantiated During interviews with staff, all staff stated that residents who require shower assistance have a schedule and are showered two (02) to three (03) times a week or more if needed. During interviews with residents, six (06) out of ten (10) residents stated that they have a shower schedule and staff adhere to it. Three (03) out of (10) residents stated they are independent and do not require shower assistance. LPA was unable to complete interview with R1 as they repeatedly changed their response to the same interview question. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Feb 14, 2024 · control 31-AS-20240206085857

Allegation investigated: Staff did not keep facility free of insects Staff are stealing residents personal belongings

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegations. LPA met with Executive Director Imelda Villanueva and explained the reason for the visit. LPA conducted a physical plant tour at 9:23 AM, requested facility documents relevant to the investigation at 10:12 AM, reviewed records between 10:15 AM to 11:30 AM and interviewed staff and residents between 11:30 AM to 1:30 PM. Regarding the allegation that Staff did not keep facility free of insects, it was alleged that the facility has roaches. LPA's record review today between 10:15 AM to 11:30 AM, revealed that the facility has a contracted pest control company that inspects the facility twice a month to ensure that there is no infestation at the facility. LPA's interview with ten (10) residents or 10% of the current census between 11:30 AM to 1:30 PM revealed that no one among the ten (10) residents interviewed saw any roaches in their room or anywhere. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Regarding the allegation that Staff are stealing residents’ personal belongings, it was alleged that staff have stolen shoes, clothing, and jewelry from Resident #1 (R1). LPA's record review today revealed that R1 did not declare anything on own Personal Property and Valuables form (LIC 601) and the Facility Inventory of Personal Effects was also blank but signed by R1. R1 also reported to the police and a police report dated 01/15/24 was issued to the facility for false report of theft. LPA's interview with ten (10) residents today also revealed that ten (10) out of ten (10) residents are not missing personal belongings while living at the facility. Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jan 17, 2024 · control 31-AS-20231027164534

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility did not take necessary precautions to prevent the spread of COVID-19

Licensing Program Analyst (LPA) Antonia Alvizar made an unannounced complaint visit for the above stated allegation. LPA met the Executive Director, Imelda Villanueva and explained the reason for the visit. Facility did not take necessary precautions to prevent the spread of COVID-19 It is alleged that several residents have tested positive for COVID-19 they are in common areas together and not in quarantine. Staff diagnosed with COVID-19 were required to work. To investigated this allegation at 10:20 a.m., LPA conducted a physical plant tour. At 11:00 a.m., LPA interviewed residents, staff and about 2:00 p.m. reviewed facility records. LPA obtained copies of staff and resident roster, unusual incident reports and pertinent documents relevant to the investigation. During inspection, LPA Alvizar interviewed six (6) residents that had tested positive for COVID -19, two (2) randomly selected out of nine-four (94) residents including resident #1 (R1). Continue on LIC 9099c Unsubstantiated Continuation from LIC 9099 Upon inspection, LPA observed that some staff were wearing mask. Residents that tested positive for COVID -19 interviewed during this visit indicated that mask were provided, meals were provided in room, re-tested for COVID -19, and asked to stay in room until they don’t have the symptoms. The randomly selected residents indicated that mask were provided and weekly COVID-19 were conducted. R1 agree that Administrator mandated all residents and staff to wear a mask and also provided mask. R1 also agreed that Administrator request all residents to be tested for COVID-19 weekly. LPA conducted interview with Administrator and four (4) staff. Interviews indicated that facility is following COVID -19 protocol for both residents and staff that tested positive for COVID -19. Staff #1 (S1) that tested positive for COVID -19 said that could not work until obtaining a negative test result. Administrator indicated that all staff testing positive for COVID -19 are mandated not to work at all until test negative then they can return to work. Staff and residents interviews revealed that facility did take necessary precautions to prevent the spread of COVID-19. Record review revealed that on 12/26/2023 facility tested resident for COVID -19 using PrimeLab test results. Administrator indicated upon learning of positive COVID -19 residents test results. Staff provided mandated positive COVID -19 residents to isolated, provided mask to all residents and staff and followed COVID -19 protocol. On 01/03/2024 facility tested residents for COVID – 19 and results were negative some residents refused to be tested again because they had no symptoms. Based on inspection, interviews and record review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jan 8, 2024 · control 31-AS-20231229132112

Allegation investigated: Questionable Death

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to deliver the findings for the above-mentioned allegation. LPA met with Nirjara Acharyan and explained the reason for the visit. On 01/27/23, a self-reported incident was received by the Woodland Hills Adult and Senior Care Regional Office. The incident was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator Dennis Douglas. A subsequent complaint regarding this incident with the allegation of questionable death was filed on 02/10/23, wherein Resident #1 (R1) was reported to have jumped off of the rooftop of the building of this facility resulting in a hospitalization and eventually, death of R1. (continued to LIC 9099-C) Substantiated (continued from LIC 9099) On 02/03/23 at around 9:13 AM, LPA conducted a case management to follow up on the above stated incident. LPA obtained copies of the facility records relevant to the investigation and interviewed staff and residents and conducted a thorough physical plant inspection. During the course of the investigation, Investigator Doulglas interviewed the administrator and obtained records from Burbank Police Department (BPD), Hospital and County Medical Examiner. LPA’s interview with staff on 02/03/23 at around 12:30 PM revealed that only the maintenance staff has access to the third floor leading to the roof as it was off limits to residents and other staff and was always locked. Further interview revealed that staff were working on the roof to fix a leak but must have left the door unlocked giving R1 access. LPA’s interview with another two (2) staff also revealed that after the incident happened, police came, and these two (2) staff escorted the police to the rooftop and observed that the door leading to the rooftop was unlocked. The police were immediately able to enter and found the portable oxygen machine of R1 on the rooftop. Investigator Douglas review of the information obtained from BPD revealed that the incident was ruled out as suicide by jumping off the roof of the facility. Based on the information gathered during the course of the investigation, the allegation is deemed substantiated at this time. Citation issued, appeal rights discussed and given. Exit interview conducted. Copy of this report issued. (continued from LIC 9099-A) Executive Director Nirjara Acharyan talked to R1 and obtained R1's approval for the withdrawal for January 2023's rent which R1 consented on 02/10/23. On 02/14/23 however, the staff received a notice from R1's bank that R1's account was closed and was not able to withdraw the rent money for January 2023. R1 subsequently agreed to a payment plan for R1 to pay an extra amount aside from R1's regular rent to cover for the missed January 2023 rent until fully paid. Regarding the allegation that Staff failed to prevent a resident from being harmed by another resident, it was alleged that on an unknown date a resident beat up another resident. LPA's interview with the administrator today between 12:30 PM to 1:45 PM revealed that there was an aggressive resident used to live at the facility but was discharged since April of this year due to the resident's attitude and aggression toward other residents. Further review also revealed that the facility always reports any incident pertaining to this resident who was given several warning letters, eviction notices and eventually was sent to hospital for 51/50 hold and never got back to the facility. Regarding the allegation that Staff failed to provide a safe and comfortable environment for residents, it was alleged that R1 was being harassed by two (2) staff and two (2) residents, R1 was urged by these two staff members and two residents to commit suicide. LPA's interview with staff today between 12:30 PM to 1:45 PM revealed that the two (2) staff mentioned by the reporting party (RP) denied any altercation or any misunderstanding with R1 and LPA's interview with Resident #3 (R3) who was mentioned by the RP revealed that R1 did not have depression nor any suicidal ideation during their conversation. Further, R3 denied harassing or mistreating R1 nor witnessed anyone, staff or resident in any way. LPA's record review and interview with staff also revealed the second resident mentioned by RP was non-existent as there was no one by that name used to live in the facility. Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Dec 6, 2023 · control 28-AS-20230210122615

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 6, 2023

To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Licensee did not ensure that the roof top was locked and inacessible to resident resulting to resident jumping off the rooftop of the building resulting to hospitalization and eventual death. This poses an immediate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: Regional director agreed to ensure that the access to the rooftop will remain locked at all times by submitting a statement to this effect and put a big sign that only the staff are allowed to enter.

Allegation investigated: Staff do not respond to resident's call button in a timely manner

Licensing Program Analyst (LPA) Antonia Alvizar made an initial complaint visit to investigation of the above stated allegation. LPA met the Executive Director (ED), Imelda Villanueva and explained the reason for the visit. Staff do not respond to resident's call button in a timely manner. It is alleged that no one answers call light, the staff come two (2) hours later and sometimes staff never answer it at all. To investigate this allegation, At 10:15AM LPA requested resident and staff roster. LPA and ED conducted physical plant tour at 10:30AM. During physical plant tour LPA turned on the call button on room #218 and other randomly selected resident rooms. LPA requested copies of R1’s file which include the following documents: Emergency Information, Physician Rport, Individual Service Plan, and other relevant documents Unsubstantiated to the investigations at 11:00AM and interviewed ED and three (03) staff and ten (10) residents randomly selected between 10:45:00AM to 3:30PM. During physical plant tour LPA Alvizar tested call button for room #218 and observed staff answering to call button within eight minutes. In addition, LPA tested other randomly selected resident's call button and staff answered the call between three (3) to eight (8) minutes. R1 indicated that staff do answer to call button but it takes longer then expected. R2 indicated that when press the call button staff respond fast. Staff interviews revealed that they respond to all button calls from residents in a timely manner. Six (06) out of ten (10) residents stated that staff do respond to call button but sometimes they takes them a while to answer. Three (03) out of ten (10) residents indicated that they do not used the call button. One (01) out of ten (10) residents indicated that they use their phone to call staff for assistance. Based on inspection, observation and interviews, there is no sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate Health and Safety hazard is noted during this visit. Exit interview conducted and a copy of the report was provided to Villanueva.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 31-AS-20231117092248

Allegation investigated: Resident's bathroom is in disrepair Staff do not provide residents with towels

Licensing Program Analyst (LPA) Antonia Alvizar made an initial complaint visit to investigation of the above stated allegations. LPA met the Executive Director (ED), Imelda Villanueva and explained the reason for the visit. 1. Resident's bathroom is in disrepair. 2. Staff do not provide residents with towels. It is alleged that room #209 bathroom does not have a shower head and R1 is unable to take a shower. To investigate these allegations, At 10:15AM LPA requested resident and staff roster. LPA and ED conducted physical plant tour at 10: 30AM, requested copies of R1’s file which include the following documents: Emergency Information, Physician Rport, Individual Service Plan, and documents relevant to the investigations at 11:00AM and interviewed ED and three (03) staff and ten (10) residents randomly selected between 10:45:00AM to 3:30PM. Unsubstantiated During physical plant tour LPA Alvizar inspected room #209 and observed a shower head operating perfectly fine. R1 indicated that bathroom has a shower head and is able to take a shower. Staff interviews revealed that residents have not complaint about bathrooms being in disrepair. Ten (10) out of ten (10) residents stated that they have a working shower head. Based on inspection, observation and interviews, there is no sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 2. Staff do not provide residents with towels. It is alleged that staff has not brought any towels to R1. To investigate this allegation LPA conducted interviews. R1 indicated staff have provided towels but it took a while before receiving them. Staff interviews revealed that residents are always provided towel plus additional towels upon request. Ten (10) out of ten (10) residents stated that staff always provide a towel but sometimes staff take a little longer then expected. Overall, staff do provide clean towels when requested. LPA observed caregiver’s cart filled with clean towels during today’s visit. Based on inspection, observation and interviews, there is no sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate Health and Safety hazard is noted during this visit. Exit interview conducted and a copy of the report was provided to Villanueva.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 31-AS-20231113162002