Alta Vista Gardens

Allegation investigated: Staff mismanaged resident's funds.

On 4/20/26, at 10:00 am, Licensing Program Manager (LPM) Naira Margaryan and Licensing Program Analyst, Raymond Comer, arrived to conduct an intial 10-day visit regarding the allegations listed above. LPM/LPA met with the Assistant Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. To investigate this allegation, LPM/LPA received resident and staff roster. At 10:00 am, LPM and LPA spoke with the Administrator over the phone. At 10:20 am, LPM/LPA spoke with the Assistant administrator, and Staff1 (S1). At 10:50 am, LPM/LPA interviewed four (4) out of twenty (20) residents recieving Person and Incidental (P&I) funds. Between 11:00 am, and 11:40 am, LPA's recieved and reviewed Resident#1's (R1's) Physician's report, Admission agreement, and Client personal property and valuables inventory log. [LIC 9099C]-Continued Substantiated Allegation: It was alleged that there were unknown transactions made on R1's EBT card. The Administrator verified using only #500.00 for R1's additional expenses. LPM/LPA interview with Administrator, and Staff#1 (S1) revealed the following: In March 2026, using R1's EBT card, staff made three (3) ATM withdrawals totaling 500.00 for the purchase of cigarette and soft drinks for R1's use. LPM/LPA interviews with four (4) out of twenty (20) residents receiving P&I funds stated the following: All four (4) residents interviewed stated that they receive P&I funds on a monthly basis and have no issues regarding financial assistance by staff. LPM/LPA review of documents revealed the following: R1's client/resident property and valuables inventory log omits receipt of R1's EBT card and record of withdrawal transactions made by staff on R1's behalf. Based on records review and interviews with Administrator, Staff, and Residents, facility staff failed to document withdrawals made from R1's EBT card, the allegation is substantiated. issued. No health and safety issues noted at the time of this visit. Exit interview conducted, deficiency issued, and copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 31-AS-20260410145838

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(by) · Plan of correction due date: Apr 30, 2026

87217(b) Safeguard of resident cash, personal property and valuables: Every facility shall take appropriate measures to safeguard residents' cash resources, person property and valuables...entrusted to the licensee...This requirement was not met as evidenced by. Based on overall investigation, the licensee mismanaged R1's fiances by failure to appropriately handle the EBT card while in facility's possession. This posses a potential health, safety and personal risk to residents in care.the state’s words, verbatim · CDSS document, Apr 20, 2026

Plan of correction: The administrator shall provide written plan of action explaining the steps they are going to take to ensure that residents' finances and/or personal belongings are safeguarded and documented as required. Documents made by submitted by POC date

Allegation investigated: Staff do not ensure that client's hygiene needs are met. Staff do not ensure resident's medications are taken as prescribed.

On 2/14/26, at 8:00 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegations listed above. LPA met with the Assistant Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. At 8:15 am, A physical plant tour of the facility was conducted by LPA; No health or safety issues observed. All residents observed during facility inspection appeared to be clean, groomed, with acceptable hygiene. To investigate this allegation, on 06/19/25, at 9:45 am, LPA Comer conducted initial visit, at which time a physical plant tour was conducted; no health and safety issues were observed. Between 10:10 am, and 11:15 am, LPA received resident and staff roster, and reviewed files relevant to the investigation which included, but were not limited to, Resident#1's (R1) Physician's report, Appraisal, MARs, and Admission's Agreement. Between 11:30 am and 1:45 pm, LPA interviewed Administrator, staff and residents. [LIC 9099C]-Continued Unsubstantiated Allegation: Staff do not ensure that client's hygiene needs are met. It was alleged that Resident #1 (R1) appears to have not showered/bathed for several days. LPA interviews with Administrator, and two (02) care staff, refute the allegation, stating to LPA that R1 frequently leaves the facility on early mornings, and does not return until late at night. Administrator and staff provide R1 constant encouragement, reminders, and offered assistance to help the resident in case they need help. However, R1 ignores reminders and refuses staff assistance. LPA interviewed six (6) out of a total census of sixty-nine (69) residents, which revealed that staff do provide satisfactory assistance regarding bathing, changing, and medications. LPA conducted a records review, which revealed that R1 requires reminders from staff to shower, change clothes, and keep up good hygiene. Records also reveal that R1 has a case worker that is aware that R1 perpetually resists staff's offers of hygiene assistance, and frequently leaves the facility in an unhygienic condition. Based on information gathered during the visit, these allegations are deemed unsubstantiated at this time. Allegation: Staff do not ensure resident's medications are taken as prescribed. It was alleged that Resident#1's (R1)has not taken their medication for several months. LPA interviews with Administrator, and two (02) care staff refute the allegation, stating to LPA that although R1 leaves the facility early mornings, and does not return until late at night, staff attempts to dispense medication to R1 in the morning, and later at night. They constantly remind R1 to take their medication before leaving the facility. However, R1 refuses staff assistance. LPA interviewed six (6) out of a total census of sixty-nine (69) residents, which revealed that staff do provide satisfactory medication assistance. LPA conducted a records review, which revealed the following: Monthly Medication Administration Records (MAR's) verified that staff attempted to dispense medication to R1 and they refused to take their medications when provided by staff. Based on the information gathered during this visit, these allegations are deemed unsubstantiated at this time. Exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 14, 2026 · control 31-AS-20250613113042

Type of visit: Required - 1 Year

On 2/14/26, at 8:00 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced annual inspection of the Facility. LPA met with the Administrative Assistant, and reason for the visit was disclosed. Facility is licensed as a two-story building. Fire clearance issued for fifty (50) non-ambulatory, and twenty (20) ambulatory, for total capacity of seventy (70) residents. Bedridden cleared six (6) residents. Hospice waiver approved for six (6) residents. At 8:15 am, LPA conducted a tour of the physical plant and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Wall thermostat displays a setting of 71.0°F, within the required range. Facility maintains an approved Mitigation and Infection Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted in January, 2026. [LIC809C-Continued] Fire Detection/Protection system is present in the facility. Smoke and carbon monoxide detectors are hardwired, interconnected and tested as "passed" inspection by Los Angeles Fire Department on 05/07/2025. Fire Extinguishers are located throughout the facility. (service date: October 13, 2025) Evacuation routes are clearly posted throughout the facility. Fire drills conducted January , 2026. Evacuation chairs were observed in stairwell leading out to street access. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Kitchen: At 9:15 am, kitchen was observed to be clean, with an adequate supply of perishables and non-perishable food located in multiple commercial refrigerators, freezer, and pantry. Food was properly labeled and stored. Emergency food is stored in a sub-floor area adjacent to the laundry room. Trash cans observed with lids. Knives and Sharps are secured and inaccessible to residents. No pesticides, nor poisons, were observed near any food areas. Medications: Medication room is located on first floor, near the building entrance. Medication room was observed to be inaccessible to residents. Medication documentation and implementation appeared to be complete. First aid kit, and manual stored in the medication office. Laundry: At 9:45 am, LPA observed laundry room, located on the sub-base level floor, to be clean and clear from obstruction. Laundry machines were observed functioning properly. Soap, toxins, and poisons observed to be locked and stored in basement area supply cabinet. Laundry is inaccessible to residents. Commons: LPA observed activities room, and dining room, located on the first floor. Outside patio area and surrounding area of the facility observed to be clean and clear from debris and obstruction. All common areas observed to have sufficient tables and chairs for seating. Furnishings are in fair condition. Bedrooms: At 10:25 am, LPA observed multiple resident bedrooms on all floors for safety, privacy, and comfort. (Bedroom#’s #21, #22, #23, #29, #31, #32, #33, #35) Bedrooms were inspected and observed to maintain required furnishing and sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear of obstructions. Bathrooms: LPA observed appropriate grab bars and non-slip flooring. Hot water temperature measured in range from 106.0°F through 111.0°F; within the required range. Bathrooms observed to be clean; hand towels are not shared. Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report was provided.the state’s words, verbatim · CDSS document, Feb 14, 2026

Allegation investigated: Staff did not seek medical attention for resident in care. Staff did not prevent resident from harming another resident in care.

On 7/26/2025 at approximately 9:40 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by staff and stated the reason for their visit was to conduct interviews, review documentation and deliver the findings of the complaint. The Administrator, Staci Marmershteyn was unavailable to attend today’s visit and designated lead staff, Debra Dapson as the facility’s designee. At 09:45 AM, LPA requested census, resident and staff roster. At approximately 10:00 AM, LPA conducted a physical plant tour, to ensure the health and safety of the residents. At 11:00 AM, LPA requested pertinent documentation pertaining to the investigation such as but not limited to: Physicians Report, Admission Agreement and the Centrally Stored/Destruction Medication (CSDMR). In between 11:15 AM – 1:00 PM, LPA attempted interviews with eight (8) residents (R1-R8), two (2) staff members (S1-S2) and conducted record review. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff did not seek medical attention for resident in care. It was alleged that R1 was not provided with medical attention. To investigate the allegation, LPA interviewed two (2) staff members and attempted to interview seven (7) residents. LPA’s interview with both staff members revealed that when they were made aware of R1 seeking treatment, they attempted to assist them but R1 declined. S2 stated that when they asked R1 if they required, “…medical attention…” R1 stated they did not want any. LPA attempted to interview R1 but R1 was not present during the visit and could not be reached. LPA’s interview with six (6) out of the seven (7) residents confirmed that if they needed medical attention the facility would provide such services. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not prevent resident from harming another resident in care. It was alleged that R1 was physically assaulted by R2 and staff did not prevent the altercation from occurring. To investigate the allegation, LPA interviewed two (2) staff members and attempted to interview eight (8) residents. LPA’s interview with both staff members revealed that R2 did not have a history of aggressive behaviors towards other residents, however R1 has had a history of aggressive behavior towards other residents. Interview with S1 revealed that when they became aware of a possible incident occurring between R1 and R2, they self-reported the incident on an Unusual Incident/Injury Report (SIR). LPA’s interview with S2 revealed that they removed R2 from their shared living space to help mediate the situation. Both staff members stated that R2 denied that they had physically assaulted R1. LPA’s interview with two (2) out of the eight (8) residents confirmed that they have had prior incidents involving R1’s aggressive behavior. Interview with R3 revealed that R1 would become upset with them and had even once restricted their access into shared spaces within the facility. Interview with R4 confirmed that they too had prior incidents regarding R1’s behavior. R4 stated that R1 always wanted to fight them and would, “threaten” them all the time. Interview with R3 and R4 confirmed that the facility did ensure to minimize said incidents by removing them away from R1 to ensure all could coexist safely. LPA’s interview with R5 revealed that their interactions with R2 were always amicable. LPA attempted to interview R2 but R2 no longer resides at the facility and could not be contacted. LPA attempted to interview R1, but they were not present during the visit and could not be contacted. LPA’s interview with R6, R7 and R8 revealed that they have not had any interactions with R1 and R2. LPA’s record review confirmed that the facility did report the incident to Community Care Licensing Division (CCLD). (Continue to LIC 9099-C) Further record review revealed that R1 has various medical diagnosis with some resulting in possible side effects including agitation. Based on interviews and record review, 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 conducted and a copy of this report was provided to the lead staff designee.the state’s words, verbatim · CDSS document, Jul 26, 2025 · control 31-AS-20250127093808

Type of visit: Required - 1 Year

On 12/05/24, 8:30 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced annual inspection of the Facility. LPA met with Facility Administrator, Staci Mamershteyn, and reason for the visit was disclosed. Facility is licensed as a two story building. Fire clearance issued for fifty (50) non-ambulatory, and twenty (20) ambulatory, for total capacity of seventy (70) residents. Bedridden cleared six (6) residents. Hospice waiver approved for six (6) residents. At 9:05 am, LPA conducted a tour of the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Facility provides dementia care; LPA observed delayed egress system working properly throughout all access points of the facility. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Wall thermostat displays a setting of 71.0°F, within the required range. Facility maintains an approved Mitigation and Infection Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted September, 2024. Fire Detection/Protection system is present in the facility. Smoke and carbon monoxide detectors are hardwired, interconnected and tested as "passed" inspection by Los Angeles Fire Department on 03/22/2024. Fire Extinguishers are located throughout the facility. (service date: October 31, 2024) Evacuation routes are clearly posted throughout the facility. Fire drill conducted September 09, 2024. [LIC809C-Continued] Kitchen: At 9:50 am, kitchen was observed to be clean and an adequate supply of perishables and non-perishable food located in multiple commercial refrigerators, freezer, and pantry. Food was properly labeled and stored. Emergency food is stored in sub floor area adjacent to the laundry room. Trash cans observed with lids. Sharps are stored in the kitchen and inaccessible to residents. No pesticides, nor poisons, were observed near any food areas. Medications: Medication room is located on first floor, near the building entrance. Medication room observed to be locked when unattended by staff. Medications are stored in separate compartments,by resident name. PPE, first aid kit, and manual stored in the medication office. LPA observed medications as prepared and dispensed to residents by medical technician staff. Laundry: At 10:20 am, LPA observed laundry room, located on the sub-base level floor, to be clean and clear from obstruction. Commercial laundry machines were observed to be in operating condition and inaccessible to residents. Laundry soap, toxins, and poisons observed to be locked and stored in basement area supply cabinet. Commons: At 10:35 am, LPA observed activities room, and dining room, located on the first floor. Outside patio area and surrounding area of the facility observed to be clean and clear from debris and obstruction. All common areas observed to have sufficient tables and chairs for seating. Bedrooms At 11:15 am, LPA observed random bedrooms, with bathrooms, located on the first and second floor to be appropriately furnished with sufficient lighting, bed linen and comforters on all beds. Bedrooms contain single and double occupancy. All bedrooms observed to be clean and clear from obstruction. Bathrooms: At 11:15 am, LPA observed random bathrooms, located in the bedrooms on the first and second floor. LPA observed appropriate grab bars and non-slip skid flooring in the bathtub. Hot water temperature measured in range from 109.2°F through 115.5°F; within the required range. Bathrooms observed to be clean and have sufficient soap and hand towels are not shared. Resident records: At 12:05 pm, Facility records room observed as locked and inaccessible to residents. A total of six (6) resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. LPA review of record revealed residents (R1) through (R6) reappraisal/needs and services plans were not updated within twelve (12) month period, as required. [LIC809C-Continued] Staff records: Facility records room was observed as locked and inaccessible to residents. A total of four (4) Staff files were reviewed. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current. Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D). Exit Interview Conducted, appeal rights discussed, and copy of the report provided.the state’s words, verbatim · CDSS document, Dec 5, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this as a result of the Licensee's failure to inform the Department about the Bankruptcy filed on 03/07/24. LPA met with Administrator Staci Mermerhteyn and inform of the reason for the visit. LPA's record review today revealed that the facility filed a Chapter 11 Bankruptcy on 03/07/24 and informed Long Term Care Ombudsman (LTCO) on 03/25/24 but no record of informing Community Care Licensing (CCL). Per California Health and Safety Code section 1569.686, you are hereby notified that a $100 civil penalty is being assessed per day. The total civil penalty for a continuous violation shall not exceed $2000. You will receive an invoice in the mail. Payment is due when billed. Payments must be made by a personal business or cashier's check or money order made payable to the "California Department Of Social Services". Please write the facility number and invoice number on your check and include copy of your invoice with the payment. You will find the invoice number on your invoice. DO NOT SEND CASH. The licensee was notified that a civil penalty is being assessed for failure to comply with this section and/or failure to report specified events, in writing, within 2 business days to the Department, the state long term ombudsman, all residents, and their representatives. Deficiency cited under Health and Safety code 1569.686. Pursuant to Health and Safety Code, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted/ Citations issued/ Civil Penalty assessed/ Appeal Rights discussed/ A copy of report was issued.the state’s words, verbatim · CDSS document, Jul 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.686(a)(3) · Plan of correction due date: Jul 26, 2024

A licensee shall notify the department, the State Long-Term Care Ombudsman, all residents... in writing, within two business days, of any of the following events, or knowledge of the event: (3) The licensee files for bankruptcy. This requirement is not met as evidenced by: Based on record review, the licensee failed to notify the department when they filed for bankruptcy, this poses an immediate health and safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: The Licensee agreed to review the Health & Safety Code pertaining to this specific section and will submit a statement of understanding

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.686(c) · Plan of correction due date: Jul 26, 2024

A licensee who fails to comply with this section may be liable for civil penalties in an amount not to exceed one hundred dollars ($100) for each day of the failure to provide notification required in this section. The total civil penalty shall not exceed two thousand dollars ($2,000). If a resident is relocated without the notification required by this section, and suffers transfer trauma or other harm to his or her health or safety, the department may also suspend or revoke the licensee's license and issue a permanent revocation of the licensee's ability to operate or act as an administrator of a facility anywhere in the state. Suspension or revocation proceedings pursuant to this subdivision shall be conducted in compliance with Section 1569.51. Based on record review, the licensee failed to notify the residents and the department of bankruptcy filing, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: A civil penalty of $2000 is assessed today. The Licensee agreed to review the Health & Safety Code pertaining to this specific section and will submit a statement of understanding.

Allegation investigated: Staff did not provide proper care to resident in care

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint visit to the facility to render the findings of the above noted allegation. LPA met with blank and explained the reason for the visit. It was alleged that Resident #1 (R1)'s overall health condition was changed, and facility staff did not provide required assistance to meet R1's needs. The complaint investigation was initiated by LPA Evelyn Rios on 07/26/23 and completed by the investigatior Philippe Miles from the Community Care Licensing Investigation Branch. During the investigation on 09/09/2023, Investigator Miles reviewed R1's facility file and hospital records previously requested and received on 08/29/2023. On 10/05/23, Investigator Miles conducted interviews with three (03) facility staff who were assisting R1 and a witness who was involved in R1's care. Staff revealed that due to changes in R1's health condition, R1 was transferred from assisted living to the memory care unit. Staff assisting R1 in the memory care unit noted significant changes in R1's conditon. Continue on 9099-C Substantiated Based on interviews and record review there is not sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was provided. R1 looked pale, was not eating well and had decrease in physical functions. However, staff was unable to explain when they started to notice changes in R1's condition and what additional services they were providing to R1 to meet resident's unmet needs. On 08/07/23, R1 was sent to the hospital after R1's family member visited the facility and requested to call 911. Prior to this visit on 05/17/24 at 11:00am, R1's facility files were reviewed. A physician report dated 07/23/23 did not disclose any information about changes in R1's condition observed by the facility staff. A completed needs and services plan for R1 was dated on 12/19/19 and not updated care and service plan was available for review. Hospital records revealed that at the time of admission to ED, R1 presented with an altered mental status, hypertension, and possible sepsis. Based on interviews and record review, there is sufficient information to support the allegation. Hence, the allegation is SUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 28, 2024 · control 31-AS-20230725132639

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: May 29, 2024

87464 Basic Services-(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified and providing...other basic servies...either directly or through outside resources. This requirement was not met as evidenced by: Resident #1 (R1) had a change in condition and it was not documented and additional services were provided. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2024

Plan of correction: The Licensee shall submit to Licesning in writing how they will ensure that the needs of all residents in care are met by close of business day on 5/29/24.

Allegation investigated: Resident sustained an unexplained fracture while in care Resident became malnourished while in care Facility retains a resident with a higher level of care needs

On 03/20/24, at 8:50am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Medical Technician, Deborah Dapson. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather additional information, conduct more interviews, and deliver findings for this complaint. On 12/12/2023, LPA Gina Saucedo initiated the complaint investigation. The complaint was referred to Investigations Branch (IB) on 12/12/23 and accepted one (1) out of the three (3) allegations mentioned above. The investigator was John Canto. On 03/20/24, at 8:50AM, LPA asked for census, staff, and resident roster. At 9:20AM, LPA conducted the physical tour with facility Administrator, Staci Marmershteyn. LIC 9099C-continued Unsubstantiated Regarding the allegation: Resident sustained an unexplained fracture while in care. It is being alleged that resident had facial edema, slight bruising to left eye and has a nasal fracture. On 12/13/23, IB Investigator, John Canto requested medical records from Norwalk Community Hospital. Resident #1 (R1) was transported there on 12/08/23 for hypertension and concerns with areas of the face, eyes, nose, and mouth. R1’s nasal deviation was noted as chronic. Upon admission to the hospital, R1 also had an altered mental status, hypertension, seizure disorder and dementia. On 12/11/23, it was noted on the CT Head Scan (without IV contrast) that there was no skull fracture; therefore, paranasal sinuses are normal as shown which confirms that R1 did not have any skull fractures. On 12/13/23, it was noted that R1 was sent to the emergency room due to edema of bilateral lower extremities. R1 had a history of bumping their head on the toilet and scooting on their knees. On 01/16/24, IB Investigator attempted to interview R1’s social worker but was unable to obtain an interview. On 02/06/24, IB Investigator Canto interviewed three (3) staff and one (1) out of three (3) residents. Two (2) residents were unable to participate due to their cognitive abilities. The three (3) staff were able to confirm that R1 was housed in the memory care unit, would scoot on their knees, would argue, steal from residents, and would overeat. The medical records from 12/12/23 for R1, shows no facial swelling and/or rashes and was normal. The nose also shows no mass or deformity. Based on the observation of the IB Investigator, interviews conducted, and record review, the allegation is UNSUBSTANTIATED. Regarding the allegation: Resident became malnourished while in care. It is being alleged that the resident is very confused, malnourished, and thin. LPA was able to obtain the Physician’s report of 2023 which shows Resident #1 (R1) weighed 121lbs, the physician’s report of 2020 showed a weight of 115lbs which showed that R1 gained weight. In addition, the weight at the time of hospital admittance on 12/08/23 shows that R1 weight at 80 kilograms (176 lbs.). LPA interviewed seven (7) out of eight (8) that confirmed R1 would eat their own food and ask others for their food or sometimes even steal other resident’s food. LPA interviewed seven (7) residents out of eight (8) that also confirmed that they can receive extra food from the kitchen if they are still hungry. LPA was also able to interview four (4) out of four (4) staff that confirmed that R1 would steal food and request extra food from staff and other residents. Therefore, based on the LPA's interviews, observations, and record review, the above allegation(s) UNSUBSTANTIATED. LIC 9099C-continued Regarding the allegation: Facility retains a resident with a higher level of care needs. It is being alleged that the resident needs a higher level of care due to their severe dementia. The facility Administrator was able to provide the LPA with the referral name and number to the Department of Health Services (DHS) in which the facility Administrator has made several attempts to help Resident #1 (R1) get a higher level of care. The facility Administrator confirmed that R1’s mental status has deteriorated since R1 has arrived at the facility. LPA was able to interview the DHS-Lisa Speights that oversees R1’s referral from the facility. DHS was able to confirm that the facility has made several attempts to try to get R1 more care and help but DHS stated it is not that easy. DHS stated there is several steps to this process and it will still take a while to get R1 to be moved from the above facility. LPA was able to interview four (4) staff that were able to state how each resident’s level of care differentiates between each other and how they provide that level of care. Four (4) out of four (4) staff also confirmed that R1’s level of care had deteriorated. LPA was also able to interview seven (7) out of eight (8) residents regarding their level of care. Seven (7) out of eight (8) residents confirmed that their level of care needs is met by the staff, case managers and social workers. Therefore, based on the LPA's interviews and record review the above allegation(s) is UNSUBSTANTIATED. An exit interview was conducted, no citations were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 31-AS-20231211162011

Allegation investigated: Staff are not providing a comfortable environment for resident Staff did not prevent resident from threatening another resident

At 12:00 p.m. on 10/26/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA toured the facility at 12:15 p.m., reviewed pertinent records at 12:30 p.m. including but not limited to medical assessments, functional capabilities assessments, preplacement appraisals, reappraisals, face sheets, admission agreements, government identifications, and needs and service plans, and interviewed three (03) facility staff members, two (02) case managers, and ten percent (10%) of residents, which equated to seven (07) out of seventy (70) residents, between 12:00 p.m. and 2:30 p.m. Unsubstantiated Regarding the allegation “Staff are not providing a comfortable environment for resident” it was alleged that Resident #1 (R1) was unsafe at the facility. Staff interviews revealed that residents often yell at one another but typically resolve their issues peacefully. No staff recalled recent or notable instances of yelling resulting in physical violence. Staff #1 (S1) stated at 12:00 p.m. today that R1 often bothered other residents when R1 ran out of money or cigarettes. Resident #2 (R2), who is R1’s current roommate, stated at 12:40 p.m. today that they respect and get along with R1. Resident #3 (R3), who was R1’s previous roommate, confirmed at 1:25 p.m. today that R1 annoyed them, so the facility changed their living arrangements to accommodate both R1’s and R3’s comfort. Interview with R1 at 1:30 p.m. today revealed that R1 felt safe and comfortable at the facility. Based on interviews, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not prevent resident from threatening another resident” it was alleged R2 threatened to hurt R1. Interview with S1 at 12:00 p.m. today revealed the facility was not aware of any threats, and staff had not reported any threats. Interview with R2 at 12:40 p.m. today revealed they occasionally yell with R1, though the two get along overall. R2 stated they have never threatened R1. Interview with R3 at 1:25 p.m. today revealed they R3 never threatened R1. Interview with R1 at 1:30 p.m. today revealed that R1 got on R2’s nerves and R2 got on R1’s nerves. R1 stated that although they felt they engaged in verbal altercations with R2, R3, and other residents in the past, R1 stated that is how residents spoke to one another at the facility. Interview with Staff #2 (S2) at 1:15 p.m. today confirmed that the facility is aware of the manner in which residents yell at one another, but staff intervene when necessary. Interview with R1’s neighbor, Resident #4 (R4) at 1:45 p.m. today revealed R1 and R2 yell but are friendly and peaceful overall. Based on interviews, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety hazards were noted during the time of this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 31-AS-20231017140458