Arbor Vista

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

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

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

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

Allegation investigated: Staff made an inappropriate comment to a resident in care.

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced initial 10-day complaint investigation visit regarding the above allegation. LPA Gonzalez was greeted by Administrator Kim Commodore and the purpose of the visit was explained. The investigation consisted of the following: LPA Gonzalez requested and obtained copies of Resident Roster, Admission Agreement and Physician’s Report, interviewed staff #1-5 (S1- S5) and residents #1-#5 (R1-R5). continued on LIC9099C Unsubstantiated The investigation revealed the following: Regarding allegation “Staff made an inappropriate comment to a resident in care,” it was reported that R1 shared that during mealtime R1 was served and slammed "a big pile of food on the table" with staff saying, "so you can stop complaining." Interviews with residents revealed 5 out of 5 residents deny the allegation. R1 stated they did not complain. R1 stated sometimes they have a bad day and will vent but did not complain about staff speaking inappropriately. R1 stated they have no problems with staff and R1 does not feel staff speak inappropriately to residents. R1 stated sometimes staff speak with familiarity, like family, but not inappropriate. R3 stated staff are not inappropriate, “staff treat us good.” Interviews with staff revealed 5 out of 5 staff interviewed deny the allegation. S4 stated residents always talk to S4 and residents have not said anything about staff speaking inappropriately. S1 stated when residents express concerns, the concerns are addressed immediately. S1 stated they had not received any complaints from R1 indicating staff spoke inappropriately. S1 also stated that R1 has no problem with letting staff know when they have a concern. S2 stated staff are careful of the way they speak to residents. LPA observed lunch service and residents were happy and interacted well with serving staff. Based on observation, interviews and record review, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Administrator Kim Commodore.the state’s words, verbatim · CDSS document, May 19, 2026 · control 28-AS-20260513171632

Allegation investigated: Staff is sleeping in the same room as resident.

***This licensing report supersedes the licensing report delivered on 11/18/2025. The purpose of the visit is to add additional information not included in the report dated 11/18/2025. The findings will remain the same. *** On today’s visit, Licensing Program Analyst (LPA) Sanjay Vaid spoke with Administrator Kim Commodore and discussed the purpose of the visit. Today's census is 50. On 11/18/2025, Licensing Program Analyst (LPA) Sanjay Vaid conducted subsequential visit and met with Administrator-Kim Commodore and discussed the above-mentioned allegations. LPA Vaid and Commodore toured the facility and did not observe any health and safety concerns. On 5/21/25, Licensing Program Analyst (LPA) Sanjay Vaid conducted an initial visit and met with Assistant Administrator Theresa Webb and the reason for the visit was discussed. LPA Vaid and Webb toured the facility and did not observe any health and safety concerns. CONTINUED ON LIC 9099C..... Unsubstantiated The investigation consisted of; review of requested/obtained documents; staff roster, client roster, R1’s face sheet, R1 placement agency contact, R1’s physician report dated 09/09/2025, R1’s medical/health summary dated 08/19/2021, a court ordered examination/competency evaluation dated 03/02/2015, R1’s third party caregivers. Review of R1’s court order dated 04/09/2015. Interviews with staff, residents and witnesses and LPA observations. NOTE: Due to the displacement of individuals from 2025 Eaton Fires, The facility, has been housing residents on an emergency basis, including R1. Regarding the allegation: Staff is sleeping in the same room as a resident. It is alleged that a facility staff person is sleeping in the resident’s room. Five (5) out five (5) staff denied the allegation. Staff interviewed stated that no facility staff person is sleeping in a residents’ room. Staff interviewed stated the R1 is a placement from the Eaton Fire and is a temporary resident since 01/08/25. Three (3) of four (4) witnesses interviewed stated R1 has a court order that was issued in April 2015. The court order allows R1 to be placed in a behavioral facility with constant 1:1 staff supervision that is provided to R1 on 24-hour basis for seven (7) days a week. R1’s placement agency placed R1 in the facility on 01/08/25, as a result of being displaced due to the Eaton Fires and informed the facility administrator of the details of R1’s court order. According to W1, R1 needs continuous and constant 1:1 staff supervision, therefore, per the court order, R1 is assigned two third party caregivers (W2, W3). W2 provides care and supervision to R1 for 24 hours/ 6 days per week and W3 provides care and supervision to R1 for 24 hours/1 day per week. R1’s placement agency assigned W2, W3 a bed in R1’s room to monitor and provide support to R1’s due to R1s behaviors issues. Based on records reviewed, interviews conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Administrator Kim Commodore and a copy of LIC 9099, LIC 9099C were provided to Administrator Kim Commodore.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 28-AS-20250516103008

Allegation investigated: Staff is yelling at residents.

***This licensing report supersedes the licensing report delivered on 11/18/2025. The purpose of the visit is to add additional information not included in the report dated 11/18/2025 and to reissue the citation. The findings will remain the same and the previous citation issued on 11/18/2025 will be dismissed. *** On today’s visit, Licensing Program Analyst (LPA ) Sanjay Vaid spoke with Administrator Kim Commodore and discussed the purpose of the visit. Today census is ?? On 11/18/2025, Licensing Program Analyst (LPA) Sanjay Vaid conducted subsequential visit and met with Administrator Kim Commodore and discussed the above-mentioned allegations. LPA Vaid and Commodore toured the facility and did not observe any health and safety concerns. On 5/21/25, Licensing Program Analyst (LPA) Sanjay Vaid conducted the initial complaint investigation at the facility and was met by Assistant Administrator Theresa Webb, and the reason for the visit was discussed. LPA Vaid and Webb toured the facility and did not observe any health and safety concerns. CONTINUED ON 9099C............... Substantiated The investigation consisted of; review of requested/obtained documents; staff roster, client roster, R1’s face sheet, R1 placement agency contact, R1’s physician report dated 09/09/2025, R1’s medical/health summary dated 08/19/2021, a court ordered examination/competency evaluation dated 03/02/2015, R1’s third party caregivers. Review of R1’s court order dated 04/09/2015. Interviews with staff, residents and witnesses and LPA observations. NOTE: Due to the displacement of individuals from 2025 Eaton Fires, The facility, has been housing residents on an emergency basis, including R1. Regarding the allegation: Staff is yelling at residents. It is alleged that staff are yelling at residents in care. Five (5) of five (5) staff interviewed stated they are not yelling at residents in care. Three (3) of five (5) staff admit to raising their tone of voice to redirect residents, but never to degrade residents. Staff interviewed stated that R1 was displaced due to the Eaton Fire and R1 was placed at the facility on a temporary basis, since, 01/08/25. Staff #4-#5 (S4, S5) are from R1’s prior facility, which is also owned by the licensee. S4 and S5 are employed at R1’s former facility and perform wellness checks on their displaced residents on a weekly basis. Per LPA’s interview with W2, W2 recalls sitting with R1 in facility dining hall when S5 approached R1 about toileting concerns that were occurring during the night. W2 stated witnessing S5 humiliate and ridicule R1 in front of other residents by approaching R1 and offering R1 adult briefs. S5 and R1 began to argue, R1 called S5 degrading names and S5 then yelled at R1. According to W2, several other residents were present and observed the argument. Four (4) of seven (7) residents interviewed stated a few staff have become indifferent since the Eaton Fires and have taken their frustration upon residents. Based on LPAs interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the a found Above allegation is be substantiated. Citation is being issued on a LIC 9099D, California Code of Regulations, Title 22, Division 6 & Chapter number 8, are being cited on the attached LIC 9099D. Exit interview conducted with Administrator Kim Commodore and a copy of LIC 9099, LIC 9099C and LIC 9099D. Appeals rights discussed and a copy of appeal right were provided to Administrator Kim Commodore. Note Cite Section 87468.1 Personal Rightsthe state’s words, verbatim · CDSS document, Nov 18, 2025 · control 28-AS-20250516103008

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 21, 2025

87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This Requirement was not met by evidence of: Based on interviews, S5 approached R1 and W2 in the dining room and spoke to R1 about R1's nightly accidents causing R1 to feel ridiculed and humiliated in front of other residents.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Administrator to conduct Personal Rights in-service staff training. Submited in-service training to LPA on 11/25/2025.

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unnanounced 10-day complaint visit today to investigate the above mentioned allegation. LPA met with Kim Commodore, Administrator, and the reason for the visit was explained. The investigation consisted of the following: LPA, obtained copies of staff and resident rosters, toured the facility’s indoor and outdoor environment with a focus on inspecting the ceilings and roof, inspected (14) resident rooms, interviewed Staff 1 – Staff 7 (S1-S7) and Resident 1 – Resident 7 (R1-R7). LPA also conducted record reviews and obtained copies of the facility insurance policy renewal. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Facility is in disrepair. It is alleged that the facility has tarps over several parts of the facility's roof and that there may be leaks in the building which have not been addressed due to the rain. It is also alleged that several utility vans were observed parked close to the facility's main entrance and parking lot. Staffy deny the allegation. Interviews with (7) out of (7) staff indicated that the facility does not have leaks due to the rain. Staff indicated that they have not observed any leaks in any part of the facility. Staff further indicated that residents have not reported any leaks in the common areas of the facility or in resident rooms. Interviews with S1 and S2 indicated that the tarp was placed over the main office area as a preventative measure. S1 and S2 indicated that last year’s rain caused a minor leak in a corner of the main office; however, the leak was repaired, and water did not continue to drip down from the ceiling. S1 and S2 further indicated that maintenance staff conduct on-going checks of the physical plant to ensure that disrepairs get fixed in a timely manner. Interview with S1 indicated that their insurance carrier conducted an inspection in August, 2025, after the city’s fires which happened near the facility. S1 stated that the facility was found to be in good repair, including the roof for the whole building and renewal their policy was issued by their carrier after the inspection was finalized. S1 and S2 also indicated that no immediate repairs were needed and that the vehicles parked outside belong to the city who is rebuilding sidewalks in front of the facility. LPA inspected 14 resident rooms, including the second story part of the building, kitchen, dining area, offices, main activity room, hallways and the building’s roof. LPA observed the ceiling and roof to be free of leaks and there was no indication that water had been filtering in and staining the ceiling. Further inspection indicated that the tarp is placed over the main office area, and the tarp is not covering other parts of the building’s roof. During today’s visit, LPA observed that the utility vehicles were not present during the visit; however, the sidewalk outside of the facility by the parking lot is coned off to prevent pedestrian activity due to work being conducted to restore plumbing under the sidewalk. Signage observed by LPA further indicated that the cones are property of the city. Review of facility’s insurance documents indicated that on 8/22/25, the facility was able to renew their policy for the term ending in 1/1/2026. Policy indicates that the property meets criteria to continue with coverage of the policy as indicated by inspection of the facility, and its findings. Based on interviews, record reviews and observations, the allegation that the facility is in disrepair could not be corroborated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 17, 2025 · control 28-AS-20251114120011

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Christian Gutierrez conducted an unannounced Required-1 year visiting using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Assistant Administrator Maria Campos who assisted with today’s visit. Administrator Kim Commodore arrived shortly. The facility is licensed to serve the elderly ages 60 and above. First floor only was approved for non-ambulatory, with a hospice waiver for two (2). Facility has a food preparation waiver. The facility is a two-story building located in a residential/commercial area and consists of 69 rooms with private bathrooms (eight of these rooms are on the second floor), dining room, living room, kitchen, and outdoor patio. Resident bedrooms were randomly chosen for review on 1st and 2nd floor. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The residents’ bathrooms have the required grab bars and non-skid mats. The hot water was between 106.8-125.2 degrees, which is not within the required 105 - 120 degrees. Fire extinguishers were observed throughout the facility. Cleaning supplies and toxic substances are inaccessible to residents on first floor storage room. Kitchen was inspected. There is a sufficient supply of 2-day perishable and 7-day non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the library, dining room, living room, and patio areas. These areas are clean and have the required furniture. There are no firearms or weapons stored at the facility. All required postings were observed throughout the facility. Sufficient additional linens/towels were observed. The facility does not have a swimming pool or bodies of water on the premises. Passageways and exits are free of obstruction. SEE LIC 809C Five (5) staff files were reviewed and included Criminal clearance record, and health screening with TB. Staff were missing the annual training required. Two (2) out of six (6) residents files were reviewed and included physicians report, TB clearance, and needs and service plan. R1 was missing admission appraisal LIC 603, R2 admission appraisal and appraisal needs and service plan LIC 625, R3 physicians report LIC 602, admission appraisal LIC 603 and appraisal needs and service LIC 625, and R5 was missing admission appraisal LIC 603. Last fire/earthquake drill was conducted in July of 2025. Infectious control plan was reviewed. Two (2) staff, and four (4) residents were interviewed. Random resident medications were reviewed. Medications are centrally stored and locked. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview was held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 21, 2025

Allegation investigated: Staff does not treat resident with dignity and respect. Staff do not intervene when a resident is bullied by another resident.

Licensing Program Analyst (LPA), Mayra Cota, conducted an initial 10-day complaint visit to the facility to investigate the allegations mentioned above. LPA Cota, met with Kim Commodore, Administrator, and the reason for the visit was explained. The investigtion consisted of the following: LPA Cota, obtained copies of staff and resident rosters, toured common areas of the facility, including resident rooms, interviewed staff #1-6 (S1-S6) and residents #1-7 (R1-R7). Copy of Special Incident Report was also obtained at the time of visit. ***Continues on LIC 9099-C Unsubstantiated Regarding allegation Staff does not treat resident with dignity and respect. It is alleged that staff did not provide privacy when a resident brought up issues regarding another resident who pesters and bullies resident. It is also alleged that staff interrogated a resident while resident was upset and crying due to emotional distress and embarrassment caused by onlookers at the facility. During visit, interviews with S1-S6 revealed, residents are never interrogated when a concern is brought up to staff. Staff stated, residents can speak openly and are provided privacy to talk about their concerns in the administrative offices in which they can close the door to avoid any information from being divulged to others. Staff also stated, they conduct visits to resident rooms if they need to follow up on concerns privately with residents. Staff further indicated, confidentiality is accorded to residents by letting them report concerns without pressuring them to speak more than they want to share if a problem is reported. S1-S6 stated, they treat all residents with dignity and respect and reassure residents that they can report any concerns they have about staff or residents at any time and will work to bring their concerns to resolution. Interviews with R1-R7 revealed, residents can report concerns to staff confidentially. Residents stated, they know they can speak to administrative staff privately in their offices, privately. Residents also stated, they have no concerns about staff not furnishing private spaces to talk when they have concerns regarding facility staff or residents. Residents further indicated, staff conduct room visits to check in and talk to them privately if needed. Residents also stated, they are treated with respect and dignity by all staff, especially administrative staff. LPA observation indicated, administrative staff have two offices in which residents can visit to talk to staff at any time. The two administrative offices have comfortable space and seating area for residents. Residents were allowed to close the door to the administrator’s office to talk to LPA during time of visit. LPA observation also indicated, staff were observed making regular rounds to resident's rooms during the course of the visit. Staff and resident interviews and LPA observations, do not corroborate the allegation. ***Continues on LIC 9099-C Regarding: Staff do not intervene when a resident is bullied by another resident. It is alleged that resident reported to staff that they are living in a hostile environment due to a resident pestering and bullying resident. Interviews with S1-S7 indicated, they have not witnessed any resident on resident bullying nor any sort of pestering behavior. Staff stated, the facility hardly ever has any incidents in which bullying is reported; however, if concerns are brought up regarding any issues with residents or even with staff, they speak to parties involved privately in administrative offices to work on resolution. Staff indicated, facility informs all residents regarding their rights to report bullying and other issues to staff during Resident Council monthly meetings, and any opportunity to discuss the topic with residents. Staff also indicated that the facility has a reporting grievances policy in place and residents are highly encouraged to report any issue immediately. Interviews with (6) out of (7) residents revealed that they have no concerns regarding bullying or other pestering behaviors either from other residents or staff and furthermore, they have not witnessed bullying or pestering behavior from any residents toward other residents. Six (6) out of (7) residents stated, they like living at the facility and they feel supported by staff, especially the administrator to whom they can express their concerns, and they can talk to privately in the administrative offices to ensure privacy. One (1) resident stated, they do not recall an incident of bullying or pestering behavior toward a resident; however, resident stated, they know they can report any incident to administrative staff at any time. Staff and resident interviews do not corroborate the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, with Kim Commodore and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 28-AS-20250702093605

Allegation investigated: Staff do not ensure facility is free from pests

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 06/19/2025 to regarding the above allegation. During today’s visit, LPA Ramirez was greeted by Kim Commodore and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster Staff#1 - 4 interviews (S1 – S4), Resident#1-5 interviews (R1-R6), Pest Control Service Invoice dated 6/13/25, and physical plant tour. See 9099-C Substantiated The investigation revealed the following regarding the allegation: “Staff do not ensure facility is free from pests” It is alleged pests have been observed in the facility kitchen. Staff interviews conducted corroborated this allegation. Resident interviews conducted corroborated this allegation. During tour of kitchen area, LPA Ramirez observed several small black/brown pellet droppings under a wire shelf rack, and on top of canned goods in the facility pantry area. Although the facility maintains pest control services, interviews with staff revealed the facility has been unable to eliminate rodents from the kitchen area for at least 6 months. Interview with Administrator Commodore revealed the facility receives pest control services twice a month as part of routine maintenance but is still unable to eradicate rodents from the kitchen. This poses a immediate risk to the health, safety, or personal rights of persons in care. Per Title 22, Division 6, Chapter 8, Article 10- General Food Service Requirements- 87555(b)(2)- (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. Based on interviews and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. LPA Ramirez will issue one (1) type A deficiency. A copy of this report, 9099-D and appeals rights was provided. Exit interview was conducted. The investigation revealed the following regarding the allegation: “Staff do not treat resident with respect.” It is alleged staff do not treat resident with respect. Staff interviews conducted did not corroborate this allegation. Resident interviews conducted did not corroborate this allegation. During facility tour, LPA Ramirez observed staff-resident interactions were warm, respectful, and responsive to resident’s needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 28-AS-20250611155959

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(27) · Plan of correction due date: Jun 20, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met as evidenced by: LPA's observations of rodent droppings in kitchen and staff and resident interviews corroborating allegation. This poses a immediate risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: Administrator Kim Commodore agreed to send a plan to address how the facility plans to keep the kitchen area free from rodents. Proof from pest control services that the facility kitchen area is free from rodents, is due by July 1, 2025. Proof must be sent via email to LPA Ramirez.

Allegation investigated: Staff spoke inappropriately to resident.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Kim Commodore, Administrator and explained the purpose of the visit. The investigation consisted of the following: LPA reviewed and obtained copies of the staff & resident rosters, Staff #1 (S1) and Staff #2 (S2) in service training logs (Clients rights) and Write up/Consultation (dated 06/12/2025), Incident report (dated 04/14/2025), Pasadena Police information (Officer #5472) and Resident #1 (R1) - Resident #2 (R2) pertinent files. LPA also interviewed Staff #1 (S1) - Staff #4 (S4) and Resident #1 (R1) - Resident #6 (R6). In regards to the allegation "Staff spoke inappropriately to resident", it is alleged that approximately 2 months ago, R1 heard a loud noise from R2's room and found R2 on the floor under a walker. R1 helped and called for help. S1 entered and aggressively told R1 to move, while S2 also scolded R1. S1 continued to berate and embarrassed R1 for interfering in front of other residents in the dining area. It is also alleged that on 06/08/2025, when R1 asked S1 for more food, S1 responded, "You’re gonna get fat!" ******CONTINUED ON LIC9099-C***** Unsubstantiated Interviews conducted with (4) out of (4) staff members all denied the allegation. Staff members interviewed stated that they are naturally loud speakers, but they did not intend any disrespect to residents. Some staff also indicated that because some residents have hearing issues, they need to speak louder for them to hear. S4 denied the allegation regarding the incident on 06/08/2025 and stated that they did not body shame or make inappropriate comments to any residents. (5) out of (6) residents interviewed denied the allegation and indicated that staff treat them with respect and have not spoken improperly to them. LPA did not observe staff being disrespectful to residents, being loud or speaking in loud voices. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Kim Commodore, Administrator.the state’s words, verbatim · CDSS document, Jun 16, 2025 · control 28-AS-20250611092527

Allegation investigated: Staff abandoned resident at hospital.

LPA Vaid conducted an Initial 10-Day complaint investigation regarding the above allegation. LPA was met by Thersa Webb, Assistant Administrator. Administrator Kim Commodore joined shortly after. LPA discussed the purpose of the visit. LPA toured the facility with Administrator and did not observe any health and safety concerns. Investigation consisted of the following: interview of Staff #1 - Staff #5 (S1-S5); interviews of clients from client#1 through client #6 (C1-C6); requested, obtained, and reviewed client #1(C1) clients face sheet and ID, physicians report, client notes, house rules and admissions agreement. Staff roster and client roster. Regarding the allegation: Staff abandoned resident at hospital. It is alleged that the facility staff had abandoned client at the hospital after client was sent to hospital for medical and psych evaluations after being involved in incidents at the facility on 03/16/25 and 03/17/25. Continued on 9099C...... Unsubstantiated Witness 1 interviewed stated that their family member has substance problem, are trying to seek help through rehabilitation however the client is reluctant to go to the rehab program after claiming they need help. Witness 2 stated, that the facility did allow client to return after discharge from hospital on 03/17 and 03/18. Five (5) out of six (6) clients interviewed could not corroborate this allegation. Clients interviewed stated they saw the police and paramedics in the facility however do not know why they were there. One client stated they saw the client in their room on the 03/17 and 03/18 being unruly. Five (5) out of five (5) staff interviewed denied this allegation. According to Administrator Kim Commodore the client has had previous issues with violating house rules and admissions agreement. On 03/16, client was found with drugs and drug parahelia and was sent to the hospital by police and paramedics after being becoming aggressive and confrontational, client was released from the hospital and was allowed back to the facility. On 03/17/25, client was again aggressive and combative with staff and other facility clients. Clients were complaining of the unruly noise and breaking of furniture, staff call PET team to take client on 51/50 hold. PET team and staff found client unresponsive in their room and called 911. Police and paramedics came to the facility and announced client had drug overdose. Client was transported to the Hospital and police reports were made on 03/16 -PA 2025-20784 and 03/17-PA 2025-20814 respectively, family was notified of each incident. Kim Commodore stated, after speaking with clients’ family on 03/18/25 about the house rules and agreements violated and this being the clients first incident, the client would be able return to the facility. On Administrator Kim provided the client and their family with rehab facility options. On 03/21/25 Administrator Kim last spoke to client, he was going to phone company to get new phone, client was accompanied by staff to the phone company. On 03/22/25, while client was allegedly supposed to be in rehab. Staff discovered client had been at Arbor Vista facility destroying the room and ran away, staff called police and family was notified. Currently, client is at the hospital having been found overdosed by family member on 03/23/25 who are trying to admit client to the rehab facility. Based on interviews conducted and documents reviewed. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Copy of this report was provided to Administrator Kim Commodore.the state’s words, verbatim · CDSS document, Mar 24, 2025 · control 28-AS-20250319104152

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Vaid conducted an unannounced Case Management Health Checks visit regarding the evacuation of the residents from Bella Vista Lincoln facility. Administrator stated that on 1/13/25, facility at Arbor Vista 811 E Washington Blvd, Pasadena 91104. License # 197602925 started to receive eleven (11) residents/clients from Bella Vista Lincoln a licensed facility, 2612 N Lincoln Ave, Altadena 91001. Additionally, to conduct a health and checks visit regarding the Eaton fire incident on the relocation of (11) residents from facility Bella Vista at Lincoln, 2612 N. Lincoln Ave., Altadena, CA. 91001 - License # 198602253 to Arbor Vista 811 E Washington Blvd., Pasadena, CA. 91104 - License # 197602925 on 1/13/25. LPA met with Administrator, Kim Commodore and explained the purpose of the visit. During the visit, LPA Vaid conducted a health and safety check and no concerns observed. LPA reviewed and obtained the resident and staff rosters. Per interview with the Administrator eleven (11) residents of Bella Vista Lincoln relocated to the facility on 01/13/2025. (4) resident is still with family members and are expected to be back in the facility by the end to the weekend. LPA toured the facility, inspected random residents' bedrooms and bathrooms. LPA observed kitchen to be clean and orderly. Facility was offering bottled water as the tap water is undrinkable until 01/14/25. LPA interviewed random residents and indicated that they are aware and were instructed not to use tap water. Facility is now okay to use tap water as per Fire Advisory. The facility has sufficient beds, hygiene supplies, beddings, linens, and everyone has a designated room. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. The kitchen staff will be serving food using plates and utensils. Administrator posted signs on the elevator and common areas to remind residents not to use/consume tap water, until 01/14/2025. Medications, MARs, and files of the (11) residents that have been transferred to Arbor Vista in Pasadena were brought with them and stored in a secured place. All Bella Vista at Lincoln residents are fully ambulatory, use no assistive devices, and do not require any incontinent care. There is sufficient staffing available to provide care for residents. Five (5) staff from Bella Vista Lincoln have on the premises assisting the facility. ***Continued on LIC 809-C***....... Per the Administrator, it has been verified that a routine fire inspection and testing was completed on 12/30/2024 and fire drill was conducted with staff on 12/18/2024. Administrator has extra supply of masks and gloves. LPA informed the Administrator to reach out to CCL if any resources or assistance is needed. An exit interview was conducted, and a copy of this report was provided to Administrator Kim Commodore.the state’s words, verbatim · CDSS document, Jan 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) S Vaid conducted the required annual inspection. LPA met with Kim Commodore, Administrator and discussed the purpose of today’s visit. The facility is licensed to serve the elderly ages 60 and above. First floor only was approved for non-ambulatory, with a hospice waiver for two (2). The facility is a two story building located in a residential/commercial area and consist of 69 rooms with private bathrooms (eight of this rooms are in the second floor), dining room, living room, a kitchen, an outdoor patio. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for first floor only approved for non-ambulatory, with a hospice waiver for two (2). Staff are adhering to operational requirements. Physical Plant & Environment Safety: LPAs toured facility grounds. Smoke alarms and carbon monoxide detectors were observed. Both, smoke alarms and carbon monoxide detectors were tested and operable. Four fire extinguishers are located throughout the premises (service date of 02/05/2024). Water temperature measured as per Title 22 regulations, within 105-120 degree F. Bathrooms had non-skid surfaces and grab bars. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Staffing: Facility has reasonable staffing; staff was observed assisting residents with their activities and housekeeping duties cleaning rooms and commons areas. Continued on 809C.......... Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-1 through Staff #3 (S1-S3). Staff have their Health Screening and Tuberculosis Screening on file. Administrator license 7033366735 expires 10/10/2025. Resident Rights-Information: Resident rights are included in Resident files. The let-us-no and ombudsman posters were observed to be posted in the TV room. Planned Activities: Activity schedule/calendar is posted inside the activity room. There is an activity coordinator and activity assistant for this facility on weekly basis. Food Service: Dining area has adequate seating. Plates, cups and utensils are kept cleaned and stored properly. There are sufficient food supplies of 2-day perishable and 7-day of non-perishable items. The food is properly stored in the refrigerator. Posted menu observed on the refrigerator. Emergency food supply on 2nd floor. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Incidental M&D: The medications are centrally stored in the medication room and in bubble packs and/or original containers. Medications are administered as prescribed by the Physician. LPA reviewed four (4) residents medications, all medications are being administered as per physicians directions and orders. Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) to resident #4(R-4). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, ALW assessment and Resident Rights were observed. Resident files were inspected, and emergency contact information and health screenings were up to date for all residents. Disaster Preparedness: The facility has the Emergency Disaster Plan in place. Safety drills held monthly and quarterly with random drills types. Three time per day on each shift. No deficiencies noted on today's visit. Exit interview was held with Administrator.the state’s words, verbatim · CDSS document, Oct 28, 2024

Allegation investigated: Staff do not treat residents with dignity and respect. Staff yells at residents.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met with Kim Commodore (Director) and explained the reason for the visit. The investigation consisted of the following: LPA Mora obtained copies of the resident and staff rosters, interviewed Administrator, Staff 1 - Staff 3 (S1 - S3) and Resident 1 - Resident 10 (R1 - R10). The investigation revealed the following: regarding the allegations "staff do not treat residents with dignity and respect" and "staff yells at residents", it is alleged that the Administrator and S1 yell at the residents, and that S1 glares and bullies the residents. Administrator and staff denied the allegations. The majority of the residents interviewed could not corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was provided Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 14, 2024 · control 28-AS-20240307075653

Allegation investigated: Staff did not ensure safe keeping of a resident's personal property and cash.

Licensing Program Analysts (LPAs) Angelica Rea and Christian Gutierrez conducted an initial complaint visit in response to the allegation listed above. LPA met with Administrator, Kim Commodore, who assisted with today's visit. Regarding the allegation that : Staff did not ensure safe keeping of a resident's personal property and cash. The investigation consisted of review of resident #1s file, interviews with Administrator, Staff #1 - Staff #4 and interviews with Resident #1 - Resident # 5. Residents interviewed were unable to corroborate the allegation. Four out of five residents stated that staff do ensure the safe keeping of resident's personal property and cash. Four out of five residents stated that none of their belongings have ever been missing while they have lived at the facility. Staff interviewed denied the allegation. Administrator and four out of four staff stated that resident property and cash are safeguarded. Unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 28-AS-20240227094830

Allegation investigated: Staff made derogatory/racial statements towards resident. Staff yells at residents. Staff does not treat residents with dignity and respect.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit regarding the above allegations. The purpose of the visit was explained to Administrator Kim Commodore. The investigation consisted of: A physical plant inspection of the facility, record review, and interviews with staff (S1- S6) and residents (R2- R10). Resident (R1) was not interviewed because they are hospitalized as a result of behavior incident dated 12/11/2023. The following documents were obtained:R1's Face Sheet, Admission Agreement/packet, Physician Report, medication list, Welbe Health Pacific Pace provider agreement, three (3) incident reports, Client Notes, LIC, LIC 500 Personnel Report, and resident roster. See LIC 9099C for report continuation. Unsubstantiated Allegation: Staff made derogatory/racial statements towards resident. It is alleged a day shift staff (S2) has called resident (R1) a racial slur using the "N" word and also called them a "bald headed B word." A total of nine (9) residents were interviewed, of which two (2) residents stated that they have heard staff say derogatory words to residents. The residents did not want to disclose what was said, or the name(s) of staff. One (1) resident reported that R1 has cussed and threatened them. A total of six (6) staff were interviewed. All staff denied the allegation. They stated that resident (R1) is uncooperative and verbally, as well as physically aggressive towards staff. Staff reported that R1 says derogatory words/names to staff. It was also reported that R1 hit med-tech staff (S4's) forearm with the housekeeper's broom. None of the staff have heard other staff say derogatory words towards R1 or other residents. Per Client Notes, R1 has history of using derogatory words towards staff and residents, and not vice versa. There is insufficient evidence to corroborate the allegation. Allegation: Staff yells at residents. It is alleged that Administrator (S1) has been overheard yelling/screaming at residents and stating "If you don't like how I do things there's the door." The date(s) of the alleged yelling is unknown. A total of nine (9) residents were interviewed of which three (3) stated that they have heard Administrator yell down the hallway at residents in general, because they refused to stay in their rooms during a recent COVID virus outbreak isolation period. All staff denied the allegation, and acknowledged that Administrator has a loud voice tone that could be misconstrued as yelling, but when residents are addressed in a loud voice it is never in a disrespectful manner. Staff (S1) stated that they talk loud to both residents and staff, but never in a shouting or screaming manner. LPA confirmed that S1's natural voice tone is loud and residents are addressed in a respectful manner. Based on interviews conducted, the findings indicate that S1/Administrator's voice is boisterous but professional. Allegation: Staff does not treat residents with dignity and respect. According to information obtained it is alleged that facility staff speak to residents "like babies" and residents do not like it. Based on interviews conducted the allegation could not be supported because only one (1) resident out of nine (9) residents interviewed stated that S1 and S5 address residents in a babyish way because they try too hard to treat residents well. In addition, the resident stated that staff (S4) has been overheard getting impatient with residents and whining about residents. All staff interviewed stated they treat all residents with dignity and respect, and some residents are addressed in a more sweet and parental manner because they respond better to that approach, and it uplifts their mood and self esteem. LPA observed satisfactory staff treatment towards residents, as well as good rapport. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview and a copy of the report was issued to Administrator Kim Commodore.the state’s words, verbatim · CDSS document, Dec 14, 2023 · control 28-AS-20231212110800