Brookdale Nohl Ranch

Allegation investigated: Staff verbally abused resident

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the faciltiy and explained the reason for the visit. The Department received the complaint on June 8th, 2026. During the initial visit conducted on June 16th, 2026 the Department walked through the facility and interviewed staff and residents. Regarding the allegation Staff verbally abused resident, the investigation revealed the following: It was reported that on June 7th, 2026 during a hoyer lift transfer Resident 1 (R1) was refusing assistance. It was then reported that Staff 1 (S1) and Staff 2 (S2) continued with the transifer despite R1's refusals. Per incident report provided S1 was training S2 and S1 advised S2 to continue with the transfer. It was reported S1 made remarks to R1. Per Report of Suspected Depedent Adult/Edler Abuse dated June 07, 2026 the facility reported the issue to Community Care Licensing, Ombudsman, Hopsice and the local police department. Substantiated Executive Director Sarah DeVore stated that S1 was suspended pending investigation and ultimately was terminated. Sarah stated that resident's rights are of utmost importance and the facility does not tolerate abuse. Sarah reported the police were at the facility twice and no other follow up was conducted regarding the incident. Therefore based on the preponderance of evidence through interviews and reports reviewed the allegation that staff verbally abused resident is determined to be SUBSTANTIATED, meaning the complaint allegation as valid and that a violation has occurred. Based on above findings deficiencies are being cited per California Code of Regulations Title 22 Division 6 chapter 8. An exit interview was conducted and a copy of this report was provided. Per interviews with Executive Director Sarah DeVore, that S2 had to move their body across R1 to roll R1 over and place the hoyer lift net for transfer. Sarah stated that S2 did not restrain R1 by placing their body over R1. 2 out of 2 staff stated deny restraining any residents. Per hospice notes dated June 8, 2026 a body assessment was conducted and no injuries were noted. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation Staff physically restrained resident against their will is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 18, 2026 · control 22-AS-20260611133245

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 24, 2026

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by S1 making remarks while continue care that R1 had refused or did not want. This poses a potential personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 18, 2026

Plan of correction: S1 was terminated and staff discussion conducted

Allegation investigated: Staff are not following the residency agreement Staff are not preventing cigarette smoke from entering the building Staff speak disrespectfully to residents

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the faciltiy and explained the reason for the visit. The Department received the complaint on June 8th, 2026. During the initial visit conducted on June 11th, 2026 the Department walked through the facility and interviewed staff and residents. Regarding the allegation staff are not folloiwng the residency agreement, staff are not preventing cigarette smoke from entering the building, and staff speak disrespectully to residents, the investigation revealed the following: It was alleged that staff are not following the residency agreement regarding smoking in the community. Per admission agreement, no smoking is allowed in the community. LPA Mendivil toured three floors of the building and did not observe any odor of smoke or cigarettes. Per interviews with 3 out of 3 staff, staff stated they have not witnessed or smelled any residents smoking in the facility. Per interview with Executive Director Sarah DeVore, Sarah stated no smoking is allowed within the community. Unsubstantiated Sarah stated there is a smoking area that is outside of the facility. Sarah stated that a smoking area was designated due to having multiple residents that were smokers. Sarah stated smoking in building would not be tolerated and could lead to warnings and evictions. Sarah explained that someone that smokes may retain the scent of the cigarettes, but denies anyone smoking in the building or right in front of the doors. Sarah stated the designated smoking area is off to left of the community. It was alleged that staff speak disrespectfully to residents, 3 out of 3 staff deny speaking disrespectfully to residents. Sarah reported that during a resident council meeting when the issue of smoking was brought up, Sarah asked that residents provide a date/time of the incident so it can be investigated right away. Sarah stated at no point did she speak disrespectfully to residents. 2 out of 2 residents interviewed stated no one has spoken to them disrespectfully. Therefore based on the preponderance of evidence through records reviewed, observation and interviews the allegations staff are not following the residency agreement, staff are not preventing cigarette smoke from entering the building, and staff speak disrespectfully to residents, are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 18, 2026 · control 22-AS-20260608110809

Type of visit: Required - 1 Year

On August 21, 2026, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced required one-year annual inspection. Upon arrival, LPA Haddadin introduced himself, explained the purpose of the visit, and was granted entry into the facility by staff. Executive Director/Administrator (ED/AD) Sarah DeVore arrived shortly thereafter and assisted LPA Haddadin throughout the inspection. The facility is a five-level structure licensed to serve 164 non-ambulatory residents and has a hospice waiver for 25 residents. At the time of the visit, the facility had 112 residents in care per the roaster provided by ED. LPA Haddadin toured the interior and exterior areas of the facility with staff. No bodies of water, safety hazards, or obstructions were observed on the premises. Ten resident rooms and all common areas were inspected. Resident beds and bedding supplies were observed to be in good condition, and adequate lighting was provided throughout the inspected areas. Resident bathrooms were clean and operational. The hot water temperatures measured in all ten resident bathrooms ranged from 111.2 to 119.6 degrees Fahrenheit. The facility was observed to be clean, sanitary, and appropriately furnished. Personal hygiene products, cleaning supplies, toxic substances, and sharp objects were securely stored and inaccessible to residents. {***CONTINUE809C***} The kitchen was inspected and contained an adequate supply of food consisting of at least two days of perishables and seven days of nonperishables. Food items were properly stored and maintained. The outdoor patio area included shaded seating with tables and chairs for residents’ use. LPA Haddadin reviewed four staff records and four resident records. All records reviewed were complete and up to date. Based on observations made during today’s inspection, no deficiencies are being cited pursuant to Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Executive Director/Administrator Sarah DeVore at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 21, 2026

Allegation investigated: Staff did not ensure resident took medication as prescribed Staff retaliated against resident for exercising their rights

On this day Licensing Program Analyst (LPA) Jenifer Tirre made a subsequent visit for complaint investigation. LPA Tirre stated purpose of visit and met with Executive Director Sarah Devore. The investigation consisted of staff and resident interviews and review of Resident 1’s (R1) facility records. The Investigation was completed by department and revealed the following: On November 20, 2025, the department received allegations that Staff did not ensure resident took medication as prescribed and Staff retaliated against resident for exercising their rights. Regarding the allegation staff did not ensure resident took medication as prescribed, interviews were conducted with staff and residents, the following information was provided: Eight of eight staff members interviewed stated that residents received assistance with their medications from Medication certified staff such as Medication Technicians, Clinical Nurse, Resident Care Coordinator and additional care staff that are certified and trained. Eight of Eight staff members stated Medication Certified staff go from room to room with medication cart and assist with medications. CONTINUED ON 9099C Unsubstantiated Four of Eight Staff members who are Medication certified stated that they review Resident care chart and place medications inside small container cups and hand over cups to residents in hand. Certified staff stated that they watch Residents take medications from cup and visually confirm the medications have been taken by resident. Certified staff state that they log in residents Medication Administration Record (MAR) whether or not medications were taken. Eight of Eight staff interviewed all stated that they do not force Residents to open their mouths to confirm medications are swallowed. Seven Residents were interviewed and the following was mentioned, regarding staff ensuring residents take medications as prescribed. Five of seven residents stated that the require assistance with medications and state that staff either go to resident apartment or dining area to assist with meds. Five of five residents stated that Staff hand over meds and waits till residents take medications before leaving. Three of five residents that require assistance with meds stated that staff inform resident of medication given before handing over. Two of five residents stated they are not made aware of what medications are given. Department reviewed R1’s Medication Administration Record from January 2024 to November 2025 and Review of R1’s record shows that R1 was being assisted with medications and beginning on September 12, 2025 records show R1 began to refuse medications frequently. R1’s Physician’s report dated 11/4/2022 has a diagnosis of Traumatic Brain Injury (TBI) and states under medication management that not able to administer prescription meds. Resident 1’s appraisal dated November 2, 2022 states resident needs help with medication, and notes "administered to them and observe resident taking medications, do not leave with resident". Based on conflicting information provided in investigation, the allegation staff did not ensure resident took medication as prescribed has not met the preponderance of evidence, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED. Regarding allegation Staff retaliated against resident for exercising their rights was investigated and the following information was provided: Eight of eight staff members interviewed stated they have never retaliated against a resident for exercising their rights. Eight of eight staff stated they have never witnessed other team members retaliate against a resident and all staff interviewed stated that they respect the personal rights of residents in care. Interviews with seven residents revealed that five of seven residents stated they have not had any issues with staff members and feel that staff respect residents personal rights. Two of seven residents stated that they have had issues with staff members respecting their personal rights and claim staff need to be properly trained on resident rights. Based on information provided, the preponderance of evidence has not been met, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Sarah Devore and copy of reports were provided.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 22-AS-20251120151058

Type of visit: Case Management - Annual Continuation

On December 12, 2025, Licensing Program Analysts (LPAs) Eboni Bentley and Jenifer Tirre conducted an unannounced required 1-Year Annual Continuation visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs introduced self and were granted entry into the facility by staff, after stating the purpose of the visit. Executive Director/Administrator (ED) Sarah DeVore arrived at the facility and remained to assist during the visit. The facility is a five-level structure licensed to operate for 164 non-ambulatory residents with a hospice waiver for 25. All required postings were observed in the entry way of the facility. The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the correct size. Emergency disaster drills were last conducted on November 18 and November 28, 2025. First aid kit contains all the necessary elements. Smoke alarms and carbon monoxide detectors were lasted inspected by Johnson Controls on October 3 and October 8, 2025, per the inspection report. Nineteen fire extinguishers were observed throughout the facility. All were mounted, charged, and last serviced on June 1, 2025. Liability Insurance is effective February 1, 2025 through February 1, 2026. Cleaning supplies and sharp items were observed inaccessible to residents in care. LPA conducted an audit of ten resident files, six staff files, and medication and medication administration review. Staff interviews were conducted. No deficiencies are being cited during today's visit. An exit interview was conducted, and a copy of this report was provided to Executive Director/Administrator Sarah DeVore at exit.the state’s words, verbatim · CDSS document, Dec 9, 2025

Type of visit: Required - 1 Year

On November 26, 2025, Licensing Program Analysts (LPAs) Eboni Bentley and Jenifer Tirre conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs introduced self and was granted entry into the facility by staff, after stating the purpose of the visit. Executive Director/Administrator (ED) Sarah DeVore arrived at the facility and remained to assist during the visit. The facility is a five-level structure licensed to operate for 164 non-ambulatory residents with a hospice waiver for 25. LPAs observed residents in care and conducted interviews. During the visit, LPAs toured inside and outside of the physical plant with staff. There were no bodies of water or obstructions on the premises. Ten resident rooms and all common areas were inspected. Beds and bedding supplies were in good condition and adequate lighting was provided. Bathrooms were found to be clean and operational. Water temperature in ten out of ten resident bathrooms measured between 111.2 degrees F to 119.6 degrees F. LPAs observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two day supply of perishable and seven day supply of non-perishable food available and maintained properly. LPAs toured the patio and observed shaded seating areas with a table and chairs for residents to sit outside. No Deficiencies are being cited during today's visit. An annual continuation will follow.An exit interview was conducted, and a copy of this report was provided to Executive Director/Administrator Sarah DeVore at exit.the state’s words, verbatim · CDSS document, Nov 26, 2025

Allegation investigated: Staff verbally abuses residents Resident wandered away from the facility due to lack of supervision Resident sustained a fall while in care and staff did not assist resident in a timely manner Resident was left outside the facility for extended periods Facility is in disrepair Facility has mold Residents’ rooms are not being cleaned properly Facility has an outbreak of flu due to unsanitary conditions of the facility Staff did not prevent resident from being harmed by other residents

Licensing Program Analyst (LPA) Celine Rodriguez conducted a continuation visit to the facility for the complaint and to deliver the findings. LPA Rodriguez explained the purpose of today's visit and was greeted by Executive Director (ED) - Sarah Devore and Resident Care Coordinator (RCC) - Kim Bennett. It was alleged that staff verbally abuses residents. LPA Rodriguez conducted a total of 7 resident interviews of which all 7 interviews did not corroborate with the allegation by stating that staff are nice, helpful, and denied of being a victim of verbal abuse or witnessing it. LPA Rodriguez conducted a total of 3 staff interviews of which all 3 interviews did not corroborate with the allegation. Per staff interviews, staff are required to complete a training on abuse prior to taking care of residents and are not allowed to be on the floor until training is completed. Per record review, LPA Rodriguez observed that all staff have completed abuse training, resident rights, and how to care for residents. During the tour of the facility, LPA Rodriguez observed that residents were happy and socializing with staff and other residents. Unsubstantiated 1 out of the 3 staff interviews also stated that staff will remind residents to eat if they do not come down, or even offer to bring the food to their room. Per record review, facility will tailor meals to residents in accordance with their physician report if it is stated that the resident has dietary needs and restrictions. Per observation, facility serves breakfast, lunch, dinner, and snacks, with choices of dairy, meat, grains, fruits, and vegetables. It was alleged that staff did not ensure residents’ have clean linens. LPA Rodriguez conducted a total of 7 resident interviews, and 3 staff interviews, of which all 10 interviews did not corroborate with the allegation by stating that staff clean and do laundry daily to ensure that residents have clean linens. The 3 staff interviews also stated that there is a schedule that staff must follow to ensure that each resident’s linens are being cleaned timely. Per record review, LPA Rodriguez observed that there is a designated staff member who is responsible for laundry and cleaning. During the tour of the facility, LPA Rodriguez observed staff cleaning resident rooms and also washing a resident’s bedsheets. It was alleged that staff did not safeguard resident’s personal belongings. LPA Rodriguez conducted a total of 7 resident interviews, and 3 staff interviews, of which all 10 interviews did not corroborate with the allegation by stating that residents are responsible for their own belongings. Per record review, residents are informed upon admission that they are responsible for their own belongings. It was alleged that staff did not provide a safe and comfortable environment for residents. LPA Rodriguez conducted a total of 7 resident interviews, and 3 staff interviews, of which all 10 interviews did not corroborate with the allegation by stating that there are no complaints that have been made about the facility not being safe or comfortable. All 7 resident interviews expressed their satisfaction with the facility and the care being provided and confirmed that there were no health and safety concerns. During the tour of the facility, LPA Rodriguez observed residents to be happy, socializing, engaging in their preferred activities. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided. It was alleged that resident wandered away from the facility due to lack of supervision. LPA Rodriguez conducted a total of 7 resident interviews of which all 7 interviews did not corroborate with the allegation by stating that there are enough staff members present at the facility and enough supervision is being provided. 3 out of the 7 resident interviews also specified that there were changes in management that was made around 2 years ago when current Executive Director (ED) - Sarah Devore was hired, and since then, there have been great improvements with staffing. LPA Rodriguez conducted a total of 3 staff interview of which all 3 interviews did not corroborate with the allegation by stating that if a resident attempts to wander away from the facility, there are alarms at the exit door that alert staff to attend to the resident. Per record review of resident 1 (R1) physician report, LPA Rodriguez observed that resident 1 (R1) is does not exhibit any wandering behavior. During the tour of the facility, LPA Rodriguez observed that the auditory exit alarms were operational and that there is staff present at the front to redirect residents if needed. It was alleged that resident sustained a fall while in care and staff did not assist resident in a timely manner. LPA Rodriguez conducted a total of 7 resident interviews of which all 7 interviews did not corroborate with the allegation by stating that each resident has a pendant button that they press when they need help, to which staff respond quickly to assist. All 7 resident interviews also stated that staff are “very good” at obtaining medical attention, and in a timely manner. LPA Rodriguez conducted a total of 3 staff interview of which all 3 interviews did not corroborate with the allegation by stating that residents are educated on how to utilize their pendant button and that the response time for staff is no longer than 10 minutes. Per record review of the pendant report, staff responded to the resident’s call buttons between 4 to 17 minutes. Per additional record review, when a resident sustains a fall, staff conducts a body check and will contact 911 and also report to the health and wellness director. It was alleged that resident was left outside the facility for extended periods. LPA Rodriguez conducted a total of 7 resident interviews, and 3 staff interviews, of which all the interviews did not corroborate with the allegation and denied of having any knowledge about an incident of a resident being left outside. 2 of the resident interviews, and 1 of the staff interviews stated that if a resident was outside for a long period of time, it was due to personal preference, and that resident will come back inside the facility at a later time. LPA Rodriguez did not observe any incidents or documentation that reported of a resident being left outside. It was alleged that facility is in disrepair. LPA Rodriguez conducted a total of 7 resident interviews of which all 7 interviews did not corroborate with the allegation by stating that the facility is nice and clean. 3 of the resident interviews disclosed that there was a time where there were repairs being done in the dining room due to a flood, but stated that the facility quickly resolved it. LPA Rodriguez conducted a total of 3 staff interview of which all 3 interviews did not corroborate with the allegation. 2 of the staff interviews revealed that there was a time where the lobby was under maintenance and construction due to a flood from the rain. Per record review, LPA Rodriguez observed that the facility contacted an external company to assist with repairing the damages from the rain within in a timely manner. During the tour of the facility on 3/1/2024, LPA Rodriguez observed that there were maintenance workers and repairmen present, and actively working in the first level of the facility. It was alleged that facility has mold. LPA Rodriguez conducted a total of 7 resident interviews of which all 7 resident interviews did not corroborate with the allegation. LPA Rodriguez conducted a total of 3 staff interviews, of which 1 of the staff interviews corroborated with the allegation stating that during the construction, when the carpet was removed, it was discovered that there was mold on the floor, however contacted a company to address it. Per record review, LPA Rodriguez observed receipts from the maintenance companies that assisted with the removal of the mold. During the tour of the facility, LPA Rodriguez did not observe any mold within the facility. It was alleged that residents’ rooms are not being cleaned properly. LPA Rodriguez conducted a total of 7 resident interviews of which all 7 interviews did not corroborate with the allegation by stating that staff are constantly cleaning and that their rooms and laundry are always cleaned. LPA Rodriguez conducted a total of 3 staff interview of which all 3 interviews did not corroborate with the allegation by stating that there is a daily schedule for staff to clean resident rooms and do laundry. Per record review, LPA Rodriguez observed that the facility creates a schedule and has a log of which staff member is responsible for cleaning the rooms. During the tour of the facility, LPA Rodriguez conducted random room checks and observed that each resident room was clean, kept free of hazards, no odor, and was sanitary. It was alleged that facility has an outbreak of flu due to unsanitary conditions of the facility. LPA Rodriguez conducted a total of 7 resident interviews of which all 7 interviews did not corroborate with the allegation by stating that facility is sanitary and stated that when there was a flu and COVID outbreak, the staff are proactive with cleaning and implementing procedures to limit the spread. LPA Rodriguez conducted a total of 3 staff interviews of which all 3 interviews did not corroborate with the allegation by stating that the facility has an Infection Control plan that is adhered to if there is an outbreak, however the facility is to always remain sanitary whether there is an outbreak or not. Per record review, LPA Rodriguez observed that the facility has an Infection Control plan that is up to date, along with general protocols for when a resident gets sick such as hand-washing, covering their mouth, masking, disinfecting areas, and being evaluated by their doctor. It was alleged that staff did not prevent resident from being harmed by other residents. LPA Rodriguez conducted a total of 7 resident interviews of which all 7 interviews did not corroborate with the allegation by verifying that they feel safe at the facility and denied of ever been harmed by, and also denied of ever witnessing another resident harm another. 5 out of the 7 resident interviews stated that they all get along with each other and enjoy socializing. LPA Rodriguez conducted a total of 3 staff interview of which all 3 interviews did not corroborate with the allegation by stating that there has not been an incident of a resident harming another. Per record review, there were no reports or notes of a resident harming another. During the tour of the facility, LPA Rodriguez observed that residents were happy, socializing with each other, and participating in activities. **Continued on LIC9099-A**the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 22-AS-20240227140230

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPAs) Edward Kim and Eboni Bentley made unannounced case management visit regarding a self-reported incident on the relocation of 29 residents from Brookdale Ocean House- License # 198204758, 2107 Ocean Ave, Santa Monica, CA 90405, to Brookdale Nohl Ranch -License # 306002955 due to mandatory evacuation orders from Fire Advisory. LPAs met with Administrator Sarah Devore from Brookdale Nohl Ranch and explained the purpose of the visit. During the visit, LPAs Kim and Bentley conducted a health and safety check and no concerns observed. LPA reviewed and obtained resident and staff rosters for both facilities, as well as Fire inspection and testing dated January 24, 2024. Per interview with the licensee, 29 residents have been relocated to Brookdale Nohl Ranch. The facility has sufficient beds, hygiene supplies, beddings, linens, and everyone has a designated room. All rooms have an ensuite bathroom. The activity room is converted to a dining room for the Brookdale Ocean House residents. The dining room is large enough to accommodate all residents with staggered dining schedules. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. Medications, MARs, and files of the Brookdale Ocean House residents have been transferred to Brookdale Nohl Ranch and stored in a medical cart in the wellness center. 26 Brookdale Ocean House residents are fully ambulatory, use no assistance devices, and do not require any incontinent care. 3 Brookdale Ocean House residents are non-ambulatory, all three use wheelchairs, and do not require any incontinent care. The Licensee stated both facilities use the same vendors, pharmacy and home health agencies, which allows them to provide the same level of continued care for the residents. The facility also has licensed LVN's on staff at Brookdale Nohl Ranch to care for insulin residents. Report continued in LIC 809-C. There is sufficient staffing available to provide care for resident of both facilities. It has been verified that a routine Fire inspection and testing was completed on January 24, 2024, and a fire drill was conducted on November 18, 2024. The licensee confirmed all families, responsible parties, DMH, regional centers for the Brookdale Ocean House residents have been notified about the relocation either via calls, texts, or emails. The licensee stated that current Brookdale Nohl Ranch residents will not be affected by this relocation and will not share rooms with Brookdale Ocean House residents. An exit interview was conducted, and a copy of this report was provided to Executive Director Sarah Devore.the state’s words, verbatim · CDSS document, Jan 10, 2025

Allegation investigated: Staff did not administer prescribed medication to a resident in care. Staff is smoking a vape pen inside of the facility. Staff did not properly bathe a resident in care.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on July 03, 2024. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Sarah DeVore. LPA explained the reason for the visit. This Department has investigated the complaint alleging that staff did not administer prescribed medication to a resident in care, staff is smoking a vape pen inside of the facility and staff did not properly bathe a resident in care. Resident 1 (R1) was admitted to the facility on February 28, 2024. Regarding the allegations, the following was revealed: During the course of the interviews six of seven individuals interviewed denied the allegations. During the course of the investigation LPA reviewed documents including the Physician Report (LIC602A) dated March 15, 2024 for R1. Per Physician Report R1 is able to administer own prescription medications. During the course of the interviews with residents, R1 stated that staff administer her medications properly and timely. Per R1 she is not aware if she takes pain killers and/or Norco. CONTINUED ON LIC9099-C... Unsubstantiated LPA reviewed documents including the Medication Administration Record (MAR) dated July 01, 2024 to July 31, 2024 for R1. Per MAR R1 was prescribed Acetaminophen 500 MG. Per MAR Acetaminophen 500 MG was prescribed as Pro Re Nata (PRN)/as needed. Per tylenol.com Acetaminophen is the primary ingredient in Tylenol. Regarding the allegation that staff is smoking a vape pen inside of the facility, the following was revealed: During the course of the interviews with residents, R1 reported that she has not witnessed staff smoking a vape inside the facility. Per R2 she has not seen staff or the Director smoking inside the facility. Documents reviewed included the 2024 Brookdale Associate Handbook. Per Brookdale Associate Handbook under Smoke-Free Environment it states smoking and the use of tobacco products are allowed only in designated areas outside of the buildings. During the initial visit on July 11, 2024 and today's visit LPA observed a designated smoking area located on the first floor. Regarding the allegation that staff did not properly bathe a resident in care, the following was revealed: During the course of the interviews with residents, R1 stated that staff assist her with her showers and reported that staff do a great job. Per R1 she has not complaints. LPA reviewed documents including the Personal Service Plan dated July 01, 2024 for R1. Per Personal Service Plan R1 needs assistance with showers two times per week. Per Personal Service Plan R1 prefers to shower on Sundays and Thursdays between 5:00 pm and 6:00 pm. During the course of the interviews with staff, Staff 1 (S1) reported that no resident has complained about not being showered properly. Per S2 staff do their best when bathing the residents and stated that residents get two showers per week. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPAs conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 22-AS-20240703101647

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to conduct a Required - 1 year inspection. LPA identified herself and met with Business Office Manager (BOM) Lisabelle Paranda. Administrator (AD) Sarah DeVore was informed and arrived shortly after. LPA verified and confirmed Administrator's certificate expires on 01/26/2026. Facility appears clean, safe and sanitary. The facility is a five level structure licensed for 164 non-Ambulatory residents with a hospice waiver for 15. This facility offers Residential Care for the Elderly. LPA observed residents in care and staff members on duty. LPA, along with BOM Paranda toured the interior and exterior portions of the facility. The first floor is for common areas which includes kitchen, dining area, theater room, activities room, hair salon and some storage rooms. Kitchen was in good repair and inaccessible to the residents. Food supplies, linens, toxics, medications, personal hygiene items were checked. LPA toured the kitchen and saw a walk-in refrigerator and freezer. Residents were eating in the dining area which was observed to be clean and in good repair. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were mounted and charged. Smoke detectors are centrally wired and checked by the local Fire Department. Emergency/Fire Drills are conducted last one being 10/04/2024. Resident rooms were selected at random for inspection from floors 2 through 5. Resident rooms were observed with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Resident bathrooms were observed to be in good repair and provided with grab bars. Hot water was within regulatory requirements. LPA noticed PUB 475 poster posted in a prominent location. Facility has an outside patio with shaded seating for residents and guest. Grounds were free of tripping hazards. Staff and resident records were reviewed. Medication was observed to be in a centrally stored location and medication reviewed appeared to have been dispensed accurately. (cont on LIC809C) Emergency evacuation posted and observed, along with other required posters. There are locked areas for toxics and cleaning supplies throughout the facility. A call system was in place. The facility has a hospice waiver for 15 and 3 residents are receiving hospice care services at this time. Home Health services provided to residents if needed. Hospice and Home Health files are available for review. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report and Advisory was discussed with the AD DeVore and a copy with Advisory was sent to email on file.the state’s words, verbatim · CDSS document, Oct 28, 2024

Allegation investigated: Staff are not cleaning facility properly.

Licensing Program Analyst (LPA) Jessica Cho made a subsequent unannounced visit to deliver the findings into the above allegation. LPA met with Operations Specialist (OS) Tierny Wilburn and stated the purpose of the visit after reviewing the allegation. During the initial complaint inspection conducted on January 31, 2024, between 3:05pm to 5:00pm, the following were observed: LPA and OS Wilburn toured and inspected all common areas on levels 1-3. There are no common areas on levels 4-5. There is a strong odor lingering in the lobby past the living room and by the north elevator. The odor was still present on today's date as well. Food particles and dust have accumulated below the dining tables, and the floor was sticky. The floor of the north/south elevator were sticky and had a strong smell of urine inside the north elevator. The floor in the four bathrooms located on the first floor were sticky and had a smell of urine. LPA and OS Wilburn observed two full trash bags in front of units 344 and 345 which were immediately removed from the hallway and disposed during inspection. The laundry sink on the 3rd floor required a deep cleaning due to the soap buildup. Pile of leaves were observed surrounding the dog park on the third floor and the patio area on the second floor. Substantiated Based on the observations, the preponderance of evidence standard has been met, therefore the following allegation: Staff are not cleaning facility properly is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. A deficiency is being cited on the attached LIC 9099D. An exit interview was conducted with Operations Specialist Tierny Wilburn, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Feb 9, 2024 · control 22-AS-20240126094209

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 16, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observation with OS Wilburn, facility was not clean, safe, and sanitary on levels 1-3 which poses a potential, Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 9, 2024

Plan of correction: OS Wilburn stated that the facility will provide photos of areas that have been cleaned, to provide a cleaning schedule of all common areas, to provide proof of training to housekeeping staff, and to submit an Acknowlegement of Understanding of the said regulation to LPA via email by POC due date.