Atria Glendale

Allegation investigated: Staff do not treat resident with dignity and respect. Staff did not meet resident's incontinence needs. Staff do not provide adequate food service. Staff do not provide a comfortable environment for residents.

On 7/29/2029 at approximately 10:40 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Executive Director, Lindsay Schroeder and stated the reason for their visit. To investigate the allegation(s), at approximately 11:00 AM, LPA conducted a physical plant tour. By 11:30 AM, LPA requested relevant documentation such as but not limited to: Admission Agreement, Physician’s Report, and Needs/Services. From 11:00 AM to 3:30 PM, LPA attempted interviews with six (6) residents (R1-R6), three (3) staff members (S1-S3), and conducted record review. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff do not treat resident with dignity and respect. It was alleged that S2 and S3 yelled at R1. To investigate the allegation, LPA attempted interviews with six (6) residents and three (3) staff members. LPA’s interview with R1 revealed they do not like certain staff including S2. Let it be noted during LPA’s interview with R1, two (2) staff members, who disclosed their names to LPA (S4 and S5) arrived to assist R1 with their call pendant being activated. Once they left, R1 stated S2 was one of the two (2) staff members. However, LPA’s interview with S1 revealed S2 is not working today nor present in the facility. LPA’s interview with five (5) of the six (6) residents interviewed revealed they have not been yelled at by staff nor have they witnessed staff to yell at other residents. LPA’s interview with R4 revealed if staff were to yell at them, “…they would yell right back” and their experience with the staff has been, “Great”. LPA attempted to interview S2, but they were not present during LPA’s visit. LPA attempted to interview S3, but S1 revealed there is no person by said name working at the facility. LPA’s record review of the facility’s Personnel Report, confirmed there to be no staff member by the alleged name provided within the complaint. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not meet resident's incontinence needs. It was alleged staff are not meeting R1’s incontinence needs. To investigate the allegation, LPA conducted interviews with three (3) incontinence residents. LPA’s interview with R1, revealed when staff have changed them, they have placed their brief on backwards and/or, “…too tight”. LPA’s interview with two (2) of the three (3) residents revealed staff help them with their diapering and showering needs with no complaints mentioned. LPA’s interview with S1 revealed R1 is alert and can make their needs know. Additionally, S1 stated that R1 can use their call pendant to call for assistance regarding their toileting needs. LPA’s record review of R1’s Medical Assessment for Residential Care Facilities for the Elderly, revealed R1 does not have cognitive issues and under Self-Care they are documented to be, “able to communicate” their needs. Further record review of R1’s Level of Care plan revealed R1 to be, “…independent with verbalizations and able to make needs know”. During LPA’s visit, LPA observed two (2) staff members assisting R1. Additionally, LPA observed R1’s call pendent to be located near them. During LPA’s visit, LPA did not observe residents’ rooms, including R1’s room, to omit odor. Based on interviews, record review, and observations there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Staff do not provide adequate food service. It was alleged the facility’s food is not warm nor adequate in portion servings. To investigate the allegation, LPA conducted interviews with six (6) residents. LPA’s interview with five (5) of the six (6) residents revealed they have no complaints of the food. LPA’s interview with R4, revealed the food is, “Good. It’s of good quality and you can order something else if needed”. During LPA’s physical plant tour, LPA observed various residents to be eating lunch in the dining room. LPA observed a variety of food offered from soup, salads, sandwiches, and entrees. LPA observed the kitchen to be sufficient with supplies of seven (7) day nonperishable food and two (2) day perishable foods. LPA observed kitchen staff to be preparing/cooking soup and breaded chicken on the stove. LPA observed the menu to offer a variety of food to meet residents’ nourishing needs. LPA observed residents’ plates to be well portioned. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not provide a comfortable environment for residents. It was alleged the facility’s temperature is, “freezing”. To investigate the allegation, LPA conducted interviews with six (6) residents. LPA’s interview with five (5) of the six (6) residents revealed they have no issue with the facility’s temperature. During LPA’s physical plant tour, LPA observed the facility’s temperature to range from 70-74 °F within different areas/floors of the facility. Additionally, LPA observed residents’ rooms to be equipped with their own thermostat. LPA observed residents’ thermostats to be in proper condition. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 31-AS-20260722153839

Allegation investigated: Staff are not providing residents with a refund

On 07/15/26, at 8:06am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Lindsay Schroeder, Executive Director. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 07/15/26, LPA Saucedo asked for the census, staff, and resident rosters. On 07/15/26, at 8:25am, LPA Saucedo conducted a physical tour, interviewed staff and delivered findings. LIC 9099C-continued Substantiated Regarding the allegation: Staff are not providing residents with a refund. It is alleged that Resident #1 (R1) has not received their community fee refund. During LPA's interview with R1's spouse they stated that themselves and their spouse moved into the community in March of 2026 with a community fee of $6,595.00 and moved out in May of 2026 and a portion of that community fee is owed back to them. During LPA's interview with Staff #1 (S1) they did confirm that a refund is owed to R1 and their spouse in the amount of 60% of the community fee portion of $6595.00. LPA obtained R1's and their spouse's Admission Agreement which confirms the community fee of $6595.00, the move in date of 03/12/26 and move out date of 05/03/26. Furthermore, page 10 of 29 Admission Agreement of the above facility confirms that during the second month of residency, the person(s) will be entitled to a refund of sixty (60%) of the balance after a fee of five hundred dollars (500) is deducted. Therefore, based on the interviews conducted and the Admission Agreement received the allegation(s) is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, an appeals right was provided and a copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 31-AS-20260710110129

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5)(E)(2)(b) · Plan of correction due date: Jul 29, 2026

87507(g)(5)(E)(2)(b) Admission Agreements...shall be refunded to an applicant, resident, or the applicant/resident’s representative in the following manner:b. A refund of at least 60 percent of the preadmission fee in excess of $500 shall be provided if the resident leaves the facility for any reason during the second month of residency. This requirement is not met by: Based on observation the licensee did not comply with the section cited above in that R1/R1's spouse did not get a portion of their community fee refunded to them which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: The Licensee/Administrator confirmed that R1/R1's spouse is owed a community fee refund and has completed the request today-07/15/26. Therefore, the POC is cleared on today's visit.

Allegation investigated: Staff do not provide adequate food service to residents Staff do not respond to resident calling for help Staff do not prevent loud noises from the elevator Staff refuses to assist resident with wheelchair Staff speaks disrespectfully to residents

On 07/15/26, at 8:06am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Lindsay Schroeder, Executive Director. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 07/15/26, LPA Saucedo asked for the census, staff, and resident rosters. On 07/15/26, at 8:25am, LPA Saucedo conducted a physical tour, interviewed staff, residents and delivered findings. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff do not provide adequate food service to residents. It is alleged that resident #1 (R1) is not getting steak and salmon but instead diner food. During LPA’s interview with R1, R1 confirmed that they are not getting steak and salmon everyday but they are getting food like “Denny’s”. R1 also mentioned that they are being charged services to have their food delivered to their room. LPA asked R1 if they are getting their three (3) meals a day and snacks and R1 stated, “yes.” LPA asked R1 if they are bedridden and R1 confirmed they have an electric wheelchair and non-ambulartory but rather the food be delivered to their room. During LPA’s interview with staff #1 (S1) and staff #2 (S2) they confirmed that R1 is part of the “Master Care Program” that helps provide R1 with finances to their meals but do not pay for R1's food delivered to their room so R1 would have to pay for that out of pocket. During LPA’s physical tour/observation of the food menu, LPA confirmed the food menu of Hot or Cold Cereal, Sausage Country Gravy and Biscuits, Bacon with Fresh Fruit and Coffee, Water, Milk and/or Juice. LPA took a picture of the food menu. LPA interviewed seven (7) additional residents that confirmed they do not have an issue with the food that is being provided at the above facility. Therefore, based on the interviews conducted and LPA’s observation of the food menu the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not respond to resident calling for help. It is alleged that resident #1 (R1) heard another resident yelling and when they pressed their pendant alarm the staff that responded told them not to worry about the other resident yelling. During LPA's interview with Resident #1 (R1), R1 confirmed that when they do press their pendant the staff respond. R1 stated I pressed my pendant in my room for someone else that I heard yelling. During LPA’s interview with three (3) staff they confirmed that all residents have their own pendants and if anyone needs help they can press their pendant and they will get help. During LPA’s physical tour, LPA observed residents being helped in their room and in the dining hall. LPA pressed two (2) pendants of two (2) residents and staff responded. LPA interviewed seven (7) additional residents that confirmed when they press their pendants and/or call for help staff do respond to them. Therefore, based on the interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff do not prevent loud noises from the elevator. It is alleged that the elevators are making a “boom-bang” noise. During LPA’s interview with R1, LPA asked R1 if the elevators are close to their room and R1 stated, “yes.” R1 also stated to LPA that the elevator makes noise sometimes not always. During LPA's physical tour, LPA did not hear any loud noises coming from the elevators. During LPA’s interview with three (3) staff they confirmed that the elevator is near R1's room but there is no loud noise coming from the elevators. LPA interviewed seven (7) additional residents that confirmed the elevators have not been making any loud noises. Therefore, based on the interviews conducted and LPA’s physical tour of the elevator the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff refuses to assist resident with wheelchair. It is alleged that staff did not help Resident #1 (R1) with their wheelchair. During LPA’s interview with R1, R1 confirmed that they needed help adjusting their wheelchair, but staff did not want to help them. LPA asked R1 if the wheelchair was electric or manual and R1 stated, “electric which was given to them by a family member.” LPA asked R1 what did the staff not help them with and R1 stated, “I needed the wheelchair adjusted to fit my body properly but the staff refused to touch the wheelchair.” During LPA’s interview with three (3) staff they confirmed that R1 was demanding their wheelchair to be fixed but no one in the facility can do that for R1 because it is a liability. Furthermore, one (1) staff out of the three (3) staff interviewed confirmed that R1 wanted them to fix their wheelchair but their response to R1 was that “I can only charge the wheelchair for you or if you have a manual wheelchair and I can help to escort you but otherwise I cannot fix it.” During LPA’s physical tour of R1's room and R1's interview, R1 observed R1 to have an electric wheelchair. Therefore, based on the interviews conducted and observation of R1's electric wheelchair the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff speaks disrespectfully to residents. It is alleged that staff speak rude to resident #1 (R1). During LPA’s interview with R1, R1 stated that one (1) of the staff speak rude to them and do not help them with their wheelchair. During LPA’s interview with three (3) staff they confirmed that R1 has been the one that has been rude to the caregivers and housekeepers. During LPA’s physical tour, LPA did not observe any staff being disrespecful to any of the residents. In addition, LPA interviewed seven (7) additional residents that confirmed staff speak to them with respect and have no issues with staff. Therefore, based on the interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issue, and a copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 31-AS-20260709134135

Type of visit: Required - 1 Year

On 04/28/26 at 8:25AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA met with Receptionist, Esther Rodas and LPA disclosed the purpose of the visit Lindsay Schroeder, Executive Director arrived shortly after. LPAs asked for the census, resident, and staff files. A physical tour was conducted at 8:50AM and observed the following: The maximum capacity of the facility is 113 non-ambulatory residents. Nine (9) of these residents can be bedridden. Hospice Waiver is for seven (7) only. The facility is a five (5) story building. The first, third, fourth and fifth buildings are for assisted living and second floor is for memory care only. The first floor consists of the following: a lobby/living room area with a large television, administrative offices, mailboxes, dining area next to the kitchen area, activities room with a television, theater room with a television, game area, bistro area with snacks and enclosed outdoor patios with furniture and shaded areas. The third floor has a gym. The memory care which is the second floor has delayed egress doors, it's own medication room, laundry and detergents locked and inaccessible to the residents, the dining area and activity area are together withe a large television and it has an enclosed patio area. There are two (2) elevators. There are several stairways. The only stairway that had evacuation chairs was the fifth floor. LIC 809C-continued Random Bedrooms were randomly selected to tour and were observed to have furniture, lighting, bedding, and televisions. Random Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested randomly and measured 113.5–114.1 degree Fahrenheit. The rooms have sage detectors used as call buttons that alert the staff when something is wrong. Fire extinguishers were observed throughout the facility and were fully charged dated 04/2025 and July 2025. There are fire extinguishers upstairs, downstairs and in the kitchen area. Fire sprinklers and fire alarms are located throughout the facility and are operable. Facility has two (2) designated medication room that is inaccessible to residents where all the medication is stored and locked in the memory care side of the facility. One is in the memory care area-second floor and the other one (1) is on the fourth floor. The medication system is called Extended Care Professional. Common Areas: These include the dining areas, activities room, television rooms: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 70-73-degree Fahrenheit. There are several temperature thermostats throughout the facility including resident rooms. There are several common bathrooms throughout the upstairs and downstairs area. The staff and resident bathrooms are not shared. There are trash cans with lids and covid signs posted in the common bathrooms. Sufficient supplies of toilet paper and napkins observed. The facility has no body of water. There is under ground parking that is clean, free of hazards and free from obstructions. The Kitchen: area was toured, and LPA observed sufficient supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The kitchen is located on the first floor. The assisted dining area has access to this kitchen, where at the time of the tour, different residents were observed having breakfast with proper feeding utensils/plates/cups. Next to the kitchen/dining room area is also a private area for residents to choose to eat alone. Against the wall of the kitchen on your is a Resident's Diet/Allergic Board and in the office area. LIC 809C-continued There are three (3) facility vehicles for resident use. Resident records/Staff records: LPA conducted a complete file review of seven (07) resident files. Staff records: LPA conducted a complete file review of six (6) staff records. There are no residents that have safeguarded cash resources at the facility. Administrative: The Insurance plan is dated as of 01/21/2027. There is an Emergency Disaster plan at the entrance of the facility towards the street, Personal Right sign, Rights of Resident Council, Licensee, Administrator Certificate and Ombudsman sign are behind the front desk on your right-side of the entrance of the facility. The liability insurance expires on 10/01/26. The last fire drill was in April 09, 2026. Deficiencies/Citations: There are several stairways. The only stairway that had evacuation chairs was the fifth floor. There are six (6) evacuation chairs total that are needed for each floor and each stairway. An exit interview was conducted, citation(s) were issued, appeals rights and a copy of this report was given to the Lindsay Schroeder, Executive Director.the state’s words, verbatim · CDSS document, Apr 28, 2026

Allegation investigated: The facility elevator is in disrepair

At 9:55a.m., Licensing Program Analyst (LPA) Antonia Alvizar-Ettima and Licensing Program Manager (LPM) Naira Margaryan conducted unannounced complaint visit to the facility to conduct additional investigation and resolve the above noted allegation. The facility elevator is in disrepair It was reported that one of the facility’s elevators has been out of service for several days. This is the second time in the past two months that the elevator has been in disrepair. To investigate the allegation, during initial visit on 11/17/25, at approximately 10:10a.m., LPA requested and received copies of the facility resident and staff rosters. At 10:15a.m., LPA and ED conducted a physical plant walk-through. LPA interviewed Maintenance Director, ED and staff S#1-S#3 (S1-S3). LPA Alvizar-Ettima also request copies of Conveyance Permit, e-mails from the elevator company and other pertinent documents. Cont. on LIC 9099-C Unsubstantiated Cont. from LIC 9099 At the time of this visit, between 1:30pm and 3:00pm LPA and LPM interviewed six (06) out of seventy-four (74) residents. Staff verified that one of the elevators was not working properly and they contacted the elevator company as soon as they noticed a problem. To fix the elevator, they needed to order some parts, and it was taking some time. Staff also revealed that they were using a second elevator trying to accommodate residents as much as possible. Residents revealed that while one of the elevators was out of order, they were using a second elevator and it was taking too long for them to go downstairs, especially for mealtimes. A review of facility records previously gathered at the facility verified that the tissue with the elevator was addressed immediately. However, facility has no control over the time frame that is required to fix the elevator. Overall investigation revealed that although one of the elevators was out of order there was a second elevator that they were using to assist residents. Therefore, based on interviews observation and record review, the allegation is unsubstantiated at this time. Exit interview conducted. Copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 31-AS-20251112164511

Allegation investigated: Licensee does not ensure there is enough staff to meed the needs of residents in care Staff do not ensure that resident is able to receive confidential phone calls

At 9:55a.m., Licensing Program Analyst (LPA) Antonia Alvizar- Ettima and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced subsequent visit to deliver finding to the above noted allegations. LPA met with Receptionist and granted entry to the facility. Receptionist called Executive Director (ED) and joined us. LPA explained the reason for this visit. During initial visit, on 07/18/25 at 10:10a.m., (LPA) Antonia Alvizar- Ettima made an initial visit at approximately 10:35a.m., LPA requests and receives copies of the facility resident and staff rosters, copies of the staff work schedule and other pertinent documents and conducted a physical plant walk-through. LPA interviewed five (05) out of twenty eight (28) residents, the Administrator and Memory Care Director (MCD). During this visit at 12:15p.m., LPA and ED conducted a physical plan tour and observed no health and safety hazard. Between 11:05am and 2:00PM additional interviews were conducted with five (5) staff and six (6) residents. Cont. on LIC 9099 - C Unsubstantiated License does not ensure there is enough staff to meet the needs of residents in care It was alleged that facility has a severe staffing shortage to meet the needs of residents because there is only one employee in the entire Memory Care floor and residents in Memory Care unit are not adequately supervised. During interview Administrator stated that staffing is scheduled in accordance and adjusted based on resident census. The Memory Care Director denied that the facility operates with insufficient staffing and reported that additional staff are scheduled during peak care hours and during staff shortage other available staff works overtime to cover. Staff interview revealed that staffing assignments are adequate to meet residents needs. Residents receive assistance as needed and the memory care unit is continuously supervised. Staff denied that residents are left unattended or residents’ care needs go unmet due to staffing levels. Interviews conducted with residents did not provide any information supporting the allegation. LPA review facility records which indicated that staffing levels was appropriate as per Memory Care residents’ census. During the Licensing visits, LPA observes sufficient staff present on site and providing assistance with activities of daily living. Residents at the Memory Care Unit were observed under staff supervision. No immediate health or safety concerns were observed. Based on interviews, records review and observations made, there is insufficient evidence to substantiate the allegation. Therefore the allegation is deemed unsubstantiated. Staff do not ensure that resident is able to receive confidential phone calls It was alleged that during the lunch hour, there is no one answering the phones at the front desk, only voicemail answers. The Memory Care residents are not even allowed to have a phone in their room or even a TV. Wheater they are able to respond or communicate to the calls Some memory care residents may not respond to the calls. If resident is not able to communicate than the calls may be transferred to the staff so they could assist residents with the calls. The residents interviewed during investigation, did not address any concerns regarding making and receiving calls. During Licensing Visits LPA observed front desk staff receiving and making calls as well as transferring phone lines to others. In addition, LPA made a call to the facility and staff present there responded to the call. Based on interviews and observation, there is no verifiable information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 31-AS-20250714121426

Allegation investigated: Staff are not properly supervising residents who may be a fall risk Staff are not answering resident call buttons in a timely manner Staff are not meeting residents bathing needs Staff are not properly notifying responsible parties of residents change in condition Staff did not seek timely medical attention for resident in care Staff did not adequately ensure residents room was clean and orderly Staff did not ensure residents laundry was washed Staff were not properly addressing pests in the facility

At 9:55am, Licensing Program Analyst (LPA Antonia Alvizar Ettema and Licensing Program Manager (LPM) Naira Margaryan conducted unannounced complaint visit to the facility to conduct additional investigation and resolve the above noted allegations. During Initial visit conducted on 09/05/25, LPA Alvizar inspected the facility. At 11:25 am, LPA spoke with Executive Director (ED) and Residents Care Director (RCD). LPA requested and received facility records, including but not limited to Resident(s) Identification information, physician report, preplacement appraisal, need and service plan and other relevant documents. At the time of this visit at 10:30am, LPA Alvizar and LPM Margaryan spoke with ED and at 12:15am LPA conducted inspection of physical plants and between 11:00am and 1:00pm, LPA and LPM interviewed five (5) staff and between 1:30pm-2:30pm interviewed six (6) out of seventy-four (74) residents. Staff are not properly supervising residents who may be a fall risk. Cont. on LIC 9909-C Unsubstantiated Cont. from LIC 9099 It was alleged that the resident #1 (R1) fell out of bed the day he was admitted to the facility. Staff revealed that fall risk residents are identified during initial assessment. Based on initial assessment, if the resident is a fall risk, they draft specific plan of action with preventive measures. R1 was fully independent and not a fall risk resident. Although R1 was not a fall risk, they requested assistance two (2) times. First time for fall incident and second time after injuring themselves in the bathroom. For both incidents R1 was assisted by the staff and no medical attention was required. Residents interviewed during this investigation did not address any concerns regarding their assistance. A review of R1’s facility file revealed that R1 was admitted as an independent resident. R1 was not identified as a fall risk and did not require frequent checks or specific supervision to prevent falls. No information or evidence was available to support the allegation. Therefore, based on interviews, and record review, the allegation is unsubstantiated at this time. Staff are not answering resident call buttons in a timely manner. It was alleged that R1 pushed the button on their neck alert and no one came to his room. R1 called family members to call the Facility so that they could pick him up. The Staff call 911 to lift R1. Staff interviewed during this visit revealed that when residents push their pendant usually, they try to respond as soon as possible. Sometime residents not only push call buttons, but also either call front desk or their responsible party may call front desk. Average time to respond is between 7 to 10 min. Staff #1 (S1) and staff #2 (S2) stated that R1 used their pendant 2 times and both times they responded within 5-7 minutes. The information provided during investigation does not support the allegation. Therefore, based on interviews, observation, and record review, the allegation is unsubstantiated at this time. Staff are not meeting residents’ bathing needs. It was alleged that on June 26, 2025, when R1 was getting ready for the doctor’s appointment, R1 smelled as if they hadn’t been bathed/showered in days. Staff indicated that they have shower schedule and they are following shower shceduel. Staff were unable to recall providing shower assistance to the R1. Other residents interviewed during this visit did not address any concerns regarding their bathing assistance. A review of R1’s record verifies that R1 did not require bathing assistance. The information provided during investigation does not support the allegation. Therefore, based on interviews and record review, the allegation is unsubstantiated at this time. Cont. on LIC 9099-C Cont. LIC 9099-C Staff are not properly notifying responsible parties of residents change in condition Staff did not seek timely medical attention for resident in care It was reported that R1’s foot was scratched and inflamed, and shown signs of infection and the facility did not report R1’s responsible party. R1 had inflammation on their foot and facility did not seek medical attention. R1 was sent to ER when they visited the doctor for routine appointment. Staff interviewed during investigation were unable to recall seeing R1’s foot swollen. They stated R1 was able to ambulate and never complained about their foot or legs getting swollen. S1 and S2 verified that there were 2 instances when they assisted R1 and both times R1 was assisted by the caregivers and med techs and did not articulate any pain or discomfort. R1 insisted that he does not require medical care. A review of R1’s file revealed that a resident did not have a health condition requiring specific follow up or medical assistance/care. R1’s health condition was not changed during their stay in the facility. Records verified the information provided by staff. Other residents interviewed during investigation did not reveal any information regarding their medical care or timely medical assistance. Based on interviews and record review, there is not enough information and/or evidence to verify the allegations. Therefore, the allegations are deemed unsubstantiated at this time. Staff did not adequately ensure residents’ room was clean and orderly Staff did not ensure residents laundry was washed Staff were not properly addressing pests in the facility It was reported that R1 room often had rotting food, trash was piled, laundry was not being washed, and there were bugs all over R1’s bed, clothes, and in the linen closet." During facility inspection LPA did not observe any food, piled trash or dirty laundry in residents’ rooms. Staff revealed that residents’ rooms are checked every day. The trash is picked up every morning and as needed. R1 was always ordering food in his room. They would take the tray there and after an hour they would go and pick up the food. No staff had seen rotten food or bugs all over R1’s room including closets. Staff also revealed that R1 was getting laundry service as per request. When R1 wanted their clothes to be washed or bed to be changed, they informed staff to come and pick up the laundry. Other residents interviewed during this visit had no issues regarding housekeeping or laundry services. The information available during this visit does not verify the allegations. Therefore, based on inspection, observation, interviews and record review, the allegations are unsubstantiated at this time. Exit interview conducted. Copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 31-AS-20250829141015

Type of visit: Case Management - Other

This case management visit is conducted in conjunction with Complaint # 31-AS-20250829141015 investigation to address the issues unrelated to the complaint. During complaint investigation, LPM Margaryan and LPA Alvizar-Ettima noted that facility may have insufficient staffing at the assisted living unit. LPM Margaryan also discussed reporting requirements and Executive Director (ED) was informed that there were at least 2 incidents pertaining to the former facility resident #1 (R1) that was not reported to the Licensing Department. In addition, ED was notified that during investigation LPA and LPM noted that while elevator was out, some of the residents were not accommodated for meal service. Other points of concern, including possible staffing shortage, also were discussed with ED. Therefore, at the time of this visit the citations were issued and recorded on LIC809D. Exit interview was conducted, appeal rights were discussed, and a copy of report was issued.the state’s words, verbatim · CDSS document, Jan 30, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 13, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following. (1)A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events.. (D) Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by. The Licensee did not ensure to report 2 serious incidents reflecting health and safety of the resident #1 (R1). This poses potential hazard to the health, safety and personal rights of the residents.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Executive Director will review Title 22 reporting requirements and will trained staff. Written information will be submitted CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468..2(1) · Plan of correction due date: Feb 13, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (1) To have a reasonable level of personal privacy in accommodations, personal care and assistance… This requirement was not met as evidenced by; The licensee did not ensure to provide timely reasonable accommodation to the residents while one of the elevators was not working. This poses a potential health, safety and personal right violation to residents in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Executive Director will review Title 22 reporting requirements and will trained staff. Written information will be submitted CCLD by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Antonia Alvizar-Ettima met with the Memory Care Director (MCD) and made an initial complaint # 31-AS-20250714121426 visit to this facility. This Case Management has nothing to do with complaint visit. During Complaint Investigation, LPA Alvizar-Ettima discovered the following Staff (S1) and (S2) have been present without a Criminal Background Clearance and Association to this facility. S1 stated their first day of work was 07/14/2025. S2 stated that their first day of work was 07/08/2025. LPA request/received staff S1 Nebraska and S2 California Driver’s License. LPA Alvizar-Ettima verified using Guardian Background System Check, staff S1 and S2 names did not appeared on facility roster. S1- Michelle L. Connot DOB: 10/31/1973 S2- Dawn Irene Monahan DOB: 08/11/1967 S1 indicated that she is an Entrim Executive Director of sister community in Nebraska. At about 11:30a.m., S1 left the facility to Burbank Airport and to take a flight to Nabraska. S1 indicated that she will not be returning back to this facility. During today’s visit S2 was Criminal Background Clearance and Associated to this facility. A citation and civil penalty were issued. Copy of this report was provided to Memory Care Director (MCD), Syrina Canezthe state’s words, verbatim · CDSS document, Jul 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(b)(2) · Plan of correction due date: Jul 21, 2025

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by: Based on interview and review of Guardian Background System Check facility Staff S1 and S2 are not criminal background clearanced and association to this facility. No documentation has been submitted to Community Care Licensing. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jul 18, 2025

Plan of correction: Memory Care Director (MCD) has agreed that S1 will not returning to facility until criminal background clearance and associate During today's visit S2 was criminal background clearance & associate. MCD provided a copy of proof clearing this citation.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted unannounced case management Annual Continuation visit to the facility. LPA met with ED and explained the reason for the visit. LPA informed ED that this visit was conducted to complete Required 1 year inspection initiated on 02/10/2025. During this visit at 1:45p.m., LPA and ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards in the facility. LPA was informed of several active cases of COVID-19 in the facility. At approximately 2:25p.m. LPA reviewed seven (07) out of seventy-five (75) residents records and they were complete at the time of this visit. LPA reviewed five (05) staff files and they had criminal record clearance and Cardiopulmonary Resuscitation (CPR) certificate at the time of this visit. All required documents were appropriately signed and dated. Exit interview was conducted. A copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Mar 25, 2025

Type of visit: Case Management - Health Checks

At 10:30 a.m. on 02/10/2025 Licensing Program Analyst (LPA) Antonia Alvizar-Etitma conducted an unannounced case management visit. LPA met with Executive Director, Peter Bonilla and disclosed the reason for the visit. Today’s case management visit was conducted to ensure the safety and welfare of evacuees from the RCFE- Continuing Care Retirement Community Montecedro (LIC# 197610430), due to Eaton Fire. At 11:15a.m. E.D. and LPA toured the facility. At approximately 11:50a.m. LPA interviewed four (04) out of five (05) residents from Montecedro. Interviews with residents reveal that they are doing well, Sage Glendale is meeting their needs and Montecedro is providing the service. LPA was not able to interview a resident because they were out of the community with family at the time of this visit. LPA observed all residents well kept, clean and groomed. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Feb 10, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required One (1) year inspection visit at this facility today. LPA met with Executive Director and explained the reason for the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. At 11:15a.m. LPA and E.D. toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is an RCFE with a capacity of 113, The census is currently 81. The facility is a five (05) story building with underground parking. The 1st floor consists of the following: a lobby area, administrative offices, dining area, activities room, T.V. room, kitchen, theater, conference room and outdoor patios. The 2nd floor is for Memory Care. The 3rd to 5th floor is for Assisted Living. The passageways and walkways are free of hazards and free from obstruction. The facility maintains a comfortable temperature at 75°F. There are carbon monoxide detector installed in the facility. Fire extinguishers are located all throughout the facility and last inspected on 04/25/2024. The fire extinguishers and carbon monoxide detectors were observed to be fully charged and in compliance. The facility is equipped with emergency pull alarm and sprinkler system. Facility Fire drill was last conducted on 01/08/2025. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. The facility has central air and heating accommodations. During today's visit, in addition to the physical plant inspection LPA interviewed eight (08) out of eighty-one (81) residents. A tour of the physical plant was conducted and the following was noted: Kitchen: The kitchen appliances and fixtures were functional. Food supplies was sufficient amount for two (02) days of perishable and seven (07) days of non-perishable was stored in covered containers at the appropriate temperatures. Cont. on LIC 809-C Knives and sharp objects were observed to be locked and inaccessible to residents. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to residents. Walls, ceiling, and floor is in good repair, ample supply of dishes, cups, glasses and utensils for the current census. Dining area: The dining area was observed to be neat, clean and in proper order. Walls, ceiling, tables, chairs and floor is in good repair.Laundry rooms: There are laundry rooms located on each floor of the building. All toxins such as laundry detergents, cleaning agents were observed to be inaccessible to the residents in laundry rooms. Medication: Medications are centrally stored in the locked medication stations located on floors two and three. The medications were observed to be locked and inaccessible to residents. There are multiple complete first aid kits in the facility. Bedrooms: LPA randomly selected resident’s apartments on each floor. Resident bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting. Hygiene for residents was observed and hallways/passageways are lit. There were enough clean linen available in the closets. Each resident’s apartment has their own restroom. Bathrooms: LPA randomly selected resident’s bathrooms on each floor. The bathrooms were observed to be clean properly supplied, functional fixtures and appropriate grab bars in showers and toilets. The hot water temperature measure range was between 106.3 – 119.3 degrees Fahrenheit within Title 22 Regulations. Common Areas: LPA observed common areas on every floor. All furnishings are in good repair, lighting is good, walls, ceiling and floors are also in good repair. Surrounding Grounds: The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. All passageways were observed to be clear from obstruction. The outdoor area was enclosed, and no bodies of water were observed. Due to time constraints, LPA had to terminate the visit and will return on a later date to complete the Required - 1 Year inspection by reviewing medication, residents and staff records. No health and safety issues noted at the time of this visit. An exit interview was conducted. A copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Feb 10, 2025

Allegation investigated: Facility staff are mismanaging resident's medication Facility staff are not cleaning resident's room

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with Becky Langdon and explained the reason for the visit. --- Facility staff are mismanaging resident's medication It was alleged that the facility has been mismanaging her Resident #1’s (R1) medications. To investigate the allegation, on 10/16/2024 LPA requested pertinent documents at around 10:00a.m. and interviewed four (04) staff from 11:00 AM to 12:00 PM. A review of the Medication Administration Records, Current Medication Request, Notice to Pharmacy and Transmission Requests revealed that resident was not given their medications as prescribed. (CONT. on LIC 9099-C) Substantiated During interviews with staff, Staff #1 (S1) and Staff #2 (S2) stated there was a delay in the notice to pharmacy process and that resident had a recent change in pain medications from “as needed” to scheduled that was also not given as prescribed. Based on record review and interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. --- Facility staff are not cleaning resident's room It was alleged that facility staff have not been cleaning R1’s room. To investigate the allegation, on 10/16/2024 LPA conducted a physical plant tour at around 10:15a.m. and interviewed four (04) staff from 11:00 AM to 12:00 PM. During the physical plant tour, LPA observed that all rooms were clean and well maintained. During interviews with staff, Staff #4 (S4) stated that Staff #3 (S3) that was assigned to the room did not communicate to S4 that, due to personal reasons and scheduling, they were no longer able to clean R1’s room and that there was some miscommunication which resulted in the resident’s room not being cleaned for a period of two weeks. Based on interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 16, 2024 · control 31-AS-20241014125547

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(5) · Plan of correction due date: Oct 18, 2024

Incidental Medical and Dental Care (a)(5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited by not assisting R1 with self-administered medications as prescribed which poses a potential health and safety and personal right risk to residents in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Administrator will submit a written letter by the POC due date stating that they will review Title 22 Division 6 Chapter 8 of the CA Code of Regulations 87465 Incidental Medical and Dental Care and that going forward will adhere to these regulations.

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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as R1’s room was not cleaned for an extended time.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: POC: Administrator will submit a written letter by the POC due date stating that they will review Title 22 Division 6 Chapter 8 of the CA Code of Regulations 87303 Maintenance and Operation and that going forward will adhere to these regulations.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced 1 year required inspection visit. LPA met with the Administrator Angela Smith and explained the reason for today's visit. This is an RCFE with a capacity of 113, The census is currently 69. The facility is a 5 story building with underground parking. The 1st floor consists of the following: a lobby area, administrative offices, dinning area, activities room, T.V. room, kitchen, theater, conference room and outdoor patios. The 2nd floor is for Memory Care. The 3rd to 5th floor is for Assisted Living. The passageways and walkways are free of hazards and free from obstruction. The facility also counts with two operable elevators. The facility fire clearance is maintained in conformity with State Fire Marshall regulations. The facility operates and is within capacity limits. Carbon monoxide and smoke detectors were tested and all were operable. No bodies of water were observed in or around the facility. The facility maintains a comfortable temperature of 75 degrees F. Hot water temperature was measured in the kitchen and in resident bathrooms and was within the required 105 degrees F and 120 degrees F. LPA observed the resident rooms to be properly furnished. Centrally stored medicines are kept in the medication room and are locked. There is a functioning call system in each residents' room. Outdoor and indoor passageways were observed to be free and clear of obstructions. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored. LPA observed there to be a minimum of one (1) week of nonperishable foods and two (2) days of perishable for the number of residents being served. Total daily diet has quality and quantity to meet resident's needs. The smoke detectors are hardwired and interconnected and observed to be operational. There are carbon monoxide detectors in the facility. Fire extinguishers are located throughout the facility and were last serviced in April of 2024 . The bathrooms were checked for cleanliness and proper operation. LPAs observed the appropriate grab bars in the showers and toilets. Medications-LPAs observed medication cart in the medication room to be locked and inaccessible to residents. There are eight (8) complete first aid kits. No health and safety issues noted at the time of this visit. Exit interview conducted. A copy of this report was issued and signature obtained.the state’s words, verbatim · CDSS document, Jul 3, 2024

Allegation investigated: Facility took payment but did not admit resident to facility

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with Executive Director Angela Monette-Smith and explained the reason for the visit. LPA conducted physical plant tour at 9:56 AM, requested copies of facility documents relevant to the investigation at 10:40 AM, interviewed the Executive Director at 11:00 AM and reviewed records between 11:30 AM to 12:15 PM. It was alleged that Resident #1 (R1)'s family member paid over $9,000.00 to the facility for R1 to be admitted at this facility but was not admitted. LPA's record review today between 11:30 AM to 12:15 PM revealed that it was the family member of R1 who decided not to move R1 to the facility. Further review also revealed that the family member of R1 paid a total of $9250.00 to the facility on 03/09/23 and demanded a refund on 04/12/23. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) The facility was about to refund the money to R1's family member on 04/14/23 but the check payment made by R1's family already bounced at that time, so no refund check was issued. Based on the information gathered during this and prior visit. The allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 28-AS-20230407154205

Type of visit: Case Management - Incident

An unannounced Case Management Incident visit was conducted on this day by Licensing Program Analyst (LPA) Rosaura Valenzuela. The purpose of this visit is to follow-up on an incident report that was submitted to Licensing on 4/04/24 regarding Resident #1 (R1). LPA met with LVN Mary Lou Dominguez and explained the reason for the visit. It was reported that on 3/31/2019 at approximately 3:21 pm staff received a call from R1's spouse indicating that R1 had overdosed on prescribed medication. 911 was called and R1 was transported to the hospital. On 4/08/2014, LPA Valenzuela spoke to LVN Mary Lou Dominguez. Interview revealed that R1 is still at the hospital. Facility is awaiting the discharge orders and to conduct a reappraisal before accepting R1 back to the community. LPA requested and reviewed the following documents: R1's physician report, medication list, pre-appraisal, and medication orders from the physician. Records revealed that R1 is depressed. R1 does have approval from their doctor to self-administer their own medication. Facility contacted the hospital and asked what the laboratory results were. Hospital staff indicated that blood work was unremarkable. Apparently R1 did not ingest the medication that was reported to have been taken. No health and safety issues noted. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 8, 2024