Belmont Village Westwood

Type of visit: Required - 1 Year

On 6/19/2026, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Chris Schroeder /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (240) which (180) non-ambulatory and (60) bedridden. Approved hospice waiver for (20). Approved for delayed egress. The facility consists of 176 units of which 31 of those units have 2 bedrooms and 2 bathrooms. All other units have one bed and one bathroom. Facility also has a lobby area, 3 dining rooms and a bistro, kitchen, salon, theater, gym, several recreational spaces and patios. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA Iniguez and the Executive Director toured the physical plant. There is a body of water but there is fence and gated no obstructions on the premises. LPA inspected a total of (10) bedrooms and (10) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 108.5°F to 112.2°F, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drill was conducted on 6/16/26. Last date fire department came to inspect smoke detectors, carbon monoxide and sprinkler system was: 4/9/26. Delayed egress checked by LPA. A review of (5) resident records and (5) staff records were conducted. LPA Iniguez checked (5) Medication Administration Records (MAR) and no discrepancies were found. The first AID kit was checked. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA later. Facility Annual Fess current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Chris Schroeder / Executive Director.the state’s words, verbatim · CDSS document, Jun 19, 2026

Type of visit: Case Management - Other

On 12/12/2025, at approximately 8:30 AM, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced Case Management visit at the facility. LPA Iniguez met with Chris Schroeder, Executive Director, and explained the purpose of the visit. On September 19, 2025, the department received a Decision and Order (DO) against (S#1), stating that they are excluded from any care facility licensed by the department. This order (OD) is effective as of September 19, 2025. On 12/12/25, LPA Iniguez emailed Chris Schroeder/Executive Director(A#1), and he stated that nobody under the name of (S#1) worked before at the facility and they have not received the (DO) yet LPA Iniguez attached a copy of the (DO) in the email. On December 12, 2025, Licensing Program Analyst-LPA Alfonso Iniguez visited the facility, obtained the Personnel Report (LIC 500), and did not observe (S#1) listed on it. In addition, LPA Iniguez reviewed the Guardian together with (A#1) and did not observe (S#1) associated with it. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Chris Schroeder/Executive Director.the state’s words, verbatim · CDSS document, Dec 12, 2025

Type of visit: Case Management - Other

On 6/26/2025, at approximately 1:30 PM, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced Case Management visit at the facility. LPA Iniguez met with Chris Schroeder, Executive Director, and explained the purpose of the visit. On June 6, 2025, the department received a Decision and Order (DO) against (S#1), stating that they are excluded from any care facility licensed by the department. This order (OD) is effective as of 6/16/25. On 6/19/25, LPA Iniguez emailed Chris Schroeder/Executive Director(A#1), and he stated that nobody under the name of (S#1) worked before at the facility and they have not received the (DO) yet, LPA Iniguez attached a copy of the (DO) in the email. On June 26, 2025, Licensing Program Analyst-LPA Alfonso Iniguez visited the facility, obtained the Personnel Report (LIC 500), and did not observe (S#1) listed on it. In addition, LPA Iniguez reviewed the Guardian together with (A#1) and did not observe (S#1) associated with it. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Chris Schroeder/Executive Director.the state’s words, verbatim · CDSS document, Jun 26, 2025

Allegation investigated: Staff mishandle the residents medications

On 6/4/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Felisa Shirley arrived and spoke to the Director of Resident Care, Daisy Ceballos and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 6/4/25 LPA requested and reviewed copies of the following records: Resident file, Resident Roster, Staff roster, MAR for May 2025, Physicians Report, 4/1/25 and Identification and Emergency Information, 5/8/21. LPA Felisa Shirley conducted a tour of the facility and to the 3rd floor Medication Room. LPA Shirley interviewed Staff 1 – Staff-11(S1 – S11) and Resident 1 – Resident 10(R1 – R10). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff mishandle the resident’s medications On 6/4/25, LPA Shirley reviewed R1’s Medication Administration Record, (MAR) for May 2025. LPA Shirley observed that every medication listed was administered during the correct time frame. LPA Shirley reviewed list of medications for frequency and did not observe any specific times for medications listed. During the tour to the Medication room, LPA read every medication for instructions and did not observe any specific time for administration. Per review of R1’s file and interview with the Director of Resident Care, there were no orders nor request for medications to be given at a specific time. LPA Shirley interviewed staff 1 – staff 11 (S-1 – S-11). LPA asked, does staff mishandle resident’s medications. Of those interviewed 11 out of 11 stated no. LPA interviewed resident 1 – resident 10 (R-1 – R10). LPA asked, does staff mishandle your medications. Of those interviewed, 9 out of 10 answered, no and 1 answered yes. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above 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. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Director of Resident Care, Daisy Ceballos.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 11-AS-20250528120946

Type of visit: Required - 1 Year

On 5/22/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Chris Schroeder /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (240) elderly adults ages 60 and above, of which (180) can be non-ambulatory and (60) bedridden. Approved for delayed egress doors and secured perimeters. The facility has an approved hospice waiver for (20). Currently the facility has (174) residents. The facility consists of 176 units of which 31 of those units have 2 bedrooms and 2 bathrooms. All other units have one bed and one bathroom. Facility also has a lobby area, 3 dining rooms and a bistro, kitchen, salon, theater, gym, several recreational spaces and patios. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA Iniguez and the Executive Director toured the physical plant. There is a body of water that was secured and no obstructions on the premises. LPA inspected a total of (10) bedrooms and (10) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged over 120F°. The room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 4/17/25. A review of (10) residents' service files and (5) staff personnel files was maintained in order. LPA reviewed (10) Medication Administration Records (MARs) and found discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -Water temperature over 125F°, 124F° and 123F°. Type A citation. -Resident with without medication for a couple of days. Type B citation. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Chris Schroeder /Executive Director.the state’s words, verbatim · CDSS document, May 22, 2025

Allegation investigated: Facility staff is not providing adequate food service to residents. Facility staff are not ensuring safe handling of food. Facilty staff discourge Residents from reporting. Facilty staff yell at Residents. Facility staff do not ensure facility is kept clean.

On 3/6/2025 at approximately 8:30 AM, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Chris Schroeder / Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (F#1-F#4), (C#1-C#4), (O#1-O#5), Resident’s interviews (R#1-R#15) and Witnesses Interviews (W#1-W#14). LPA obtained and reviewed the following documents: Copies of facility menu for December 2024, January, February and March 2025, Copies of staff training regarding food handling, copies of facility cleaning schedule and copies of administrator training regarding personal rights of residents, copies of safe-serve certification for serving staff and an inspection of (15) residents rooms: 203, 529, 430, 428, 306, 622, 612, 305, 431, 513, 318, 504, 527, 327, 414 and (5) public restrooms and facility in-service training regarding Residents Personal Rights dated (3/13/24). Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Facility staff is not providing adequate food service to residents. The details of the complaint alleged that facility staff is not providing enough food for the residents in care. On March 6, 2025, at approximately 12:00 PM, during the records review, LPA Iniguez observed copies of the facility menu from December 2024, January, February, and March 2025; LPA Iniguez observed on the menus a variety of well-balanced meals provided to the residents in care with breakfast, lunch and dinner served daily and a standby menu that offers a variety of salads, sandwiches, wraps, omelets, starters, sides, entre, deserts, and beverages available upon residents requests. On March 6, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), he stated that the facility provides three meals per day: breakfast, lunch, and dinner, plus all the snacks the residents want. In addition, (A#1) stated that the amount and quality of food served at the facility are adequate for the residents in care. On March 6, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#13), (13) out of (13) stated that the facility provides three meals per day and good quality. On March 6, 2025, at approximately 9:00 AM, during interviews with facility staff (F#1-F#5, C#1-C#5, and O#1-O#5), (15) out of (15) stated that the facility provides three meals per day: breakfast, lunch and dinner, also, they stated that the food provided by the facility is adequate to the residents in care. Evaluation Report continues LIC 9099-C... On February 26, 2025, during interviews with witnesses (W#1-W#14) at approximately 9:00 AM, (13) out of (14) stated that the facility provides adequate, high-quality meals for their parents and the other residents in care. Allegation: Facility staff are not ensuring safe handling of food. The details of the complaint alleged that facility staff is not handling food in a safe way. On March 6, 2025, at approximately 12:00 PM, during the records review, LPA Iniguez observed (F#1-F#5) the California Food-Handler Training Certificate Program; all the certificates are current. On March 6, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), he stated that the serving staff receives outside and inside training regarding food handling by the California Food-Handler Training Program that is due every three years. On March 6, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#13), (12) out of (13) stated that they had not observed facility servers putting their fingers on the food. On February 26, 2025, during interviews with witnesses (W#1-W#14) from approximately 9:00 AM, (14) out of (14) stated that they had never witnessed serving staff putting their fingers on the residents’ meals. On March 6, 2025, at approximately 9:00 AM, during interviews with serving staff (F#1-F#5) (5) out of (5) stated that they are certified food handlers by the California Food Handler Training Program that is for the amount of three years. In addition, (5) out of (5) servers stated that they have never put their fingers or hand on the prepared meal for the residents. Evaluation Report continues LIC 9099-C... Allegation: Facility staff discourage Residents from reporting. The details of the complaint alleged that administrator is discouraging residents and family to call licensing. On March 6, 2025, at approximately 2:00 PM, during records review, LPA Iniguez observed the facility's in-service training (dated 3/13/24) regarding Residents' Personal Rights. LPA observed that the facility administrator (A#1) took the training. On March 6, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), he stated that he has never discouraged residents or their families from contacting the Community Care Licensing Department for complaints. On March 6, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#13), (13) out of (13) stated that they have never witnessed facility administrator (A#1) discouraging them or their families submitting a complaint to Community Care Licensing. On March 6, 2025, at approximately 9:00 AM, during interviews with office staff (O#1-O#5), (5) out (5) stated that they have never witnessed facility administrator (A#1) discouraging residents and their families calling Community Care Licensing. On February 26, 2025, during interviews with witnesses (W#1-W#14) at approximately 9:00 AM, (14) out of (14) stated that they have never been discourage by (A#1) to call Community Care Licensing Department. Evaluation Report continues LIC 9099-C... Allegation: Facility staff yell at Residents. The detail of the complaint alleges that facility administrator yells at family from residents in care. On March 6, 2025, at approximately 2:00 PM, during records review, LPA Iniguez observed the facility's in-service training (dated 3/13/24) regarding Residents' Personal Rights. LPA observed that the facility administrator (A#1) took the training. On March 6, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), he stated that he has never yelled at residents in care or their families. On March 6, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#13), (13) out of (13) stated that they had never witnessed facility administrator (A#1) yelling at them or their families. On March 6, 2025, at approximately 9:00 AM, during interviews with office staff (O#1-O#5), (5) out (5) stated that they have never witnessed facility administrator (A#1) yelling or screaming to the residents in care or their families. On February 26, 2025, during interviews with witnesses (W#1-W#14) at approximately 9:00 AM, (14) out of (14) stated that they have never been yelled or their parents by (A#1). Allegation: Facility staff do not ensure facility is kept clean. The detail of the complaint alleges that facility staff does not ensure residents rooms and public bathrooms are kept clean. Evaluation Report continues LIC 9099-C... On March 6, 2025, at approximately 1:00 PM, LPA Iniguez observed and review the facility’s housekeeping cleaning schedule, LPA Iniguez observed that the housekeeping cleaning schedule is once per week or as need it. On March 6, 2025, at around 1:00 PM, LPA Iniguez and the Executive Director inspected a total of (15) residents and (5) public restrooms. LPA Iniguez noted that the residents’ rooms and public restrooms were clean. On March 6, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), he stated that the facility is always clean, the housekeeping staff cleans the public restrooms once or twice a day, and the resident’s room every week or as needed. On March 6, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#13), (13) out of (13) stated that the facility, including their rooms and the public restrooms, was clean. On February 26, 2025, during interviews with witnesses (W#1-W#14) at approximately 9:00 AM, (13) out of (14) stated that the facility staff ensures the residents rooms and public restrooms are kept clean. On March 6, 2025, at approximately 9:00 AM, during interviews with cleaning staff (C#1-C#5), (5) out of (5) stated that the facility is clean, including the resident's room and public restrooms. Also, they stated that the facility's public restrooms get cleaned up to two times per day or as needed, and the resident's rooms every week or as needed. Evaluation Report continues LIC 9099-C... During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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. An exit interview was conducted, and a copy of the Complaint Report was given to Chris Schroeder / Executive Director.the state’s words, verbatim · CDSS document, Mar 6, 2025 · control 11-AS-20250218153221

Allegation investigated: Staff did not provide medication assistance in a timely manner to resident in care. Staff did not ensure resident's room was kept clean. Staff did not provide good quality foods to resident in care.

On 03/04/25, Licensing Program Analyst (LPA) Elvira Gonzalez, conducted an unannounced complaint visit to further investigate on the above listed allegations, and deliver findings. LPA Gonzalez met with Executive Director, Chris Schroeder, and the purpose of the visit was explained. LPA Gonzalez was granted access into the facility. The investigation consisted of the following: On 01/10/25, LPA Gonzalez requested and reviewed the following documents: staff roster, resident roster, and facility menus. Conducted interviews with staff #1-#8 (S1-S8), and residents #1-#5 (R1-R5). Additionally, LPA Gonzalez conducted a tour of the entire facility with Executive Director, Chris Schroeder, inspecting a total of nine rooms, the wellness center, kitchen, bistro, and common areas. On 02/28/25, LPA Gonzalez conducted interviews with resident#6-#10 (R6-R10) via telephone. Furthermore, on 03/04/25, LPA Gonzalez requested and reviewed Medication Administration Records dated 01/01/25 - 01/31/25 for R3, and R5-R6 and conducted an inspection of three (3) public restrooms with Executive Director, Chris Schroeder. Unsubstantiated The investigation revealed the following: Allegation: Staff did not provide medication assistance in a timely manner to resident in care. It is being alleged that there have been times where staff does not administer residents’ medication as prescribed. On 01/10/25, between 8:55 AM – 10:30 AM, LPA Gonzalez conducted interviews with S1-S8. Based on interviews conducted, 6 out of 8 staff interviewed denied the allegation. 6 out of 8 staff interviewed communicated that resident’s medication is administered on time and as prescribed by the physician. On 01/10/25, between 10:45 AM – 1:50 PM, LPA Gonzalez conducted interviews with R1-R5. On 02/28/25, between 2:00 PM – 3:445 PM, LPA Gonzalez conducted interviews with R6-R10. Based on interviews conducted, 6 out of 10 residents communicated that staff administers their medications on time and as prescribed by their physician. While 4 out of 10 residents communicated that they don’t know if staff administers other residents’ medication as prescribed, because they administer their own medication. 10 out of 10 residents interviewed stated they are satisfied with the services that are being provided to them. LPA Gonzalez conducted a record review of the MARs dated: 01/01/25 – 01/31/25 and did not observe any discrepancies or mismanaging of residents’ medication. Based on observation, interviews conducted, and a review of records, the department did not find sufficient evidence to support 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. Allegation: Staff did not ensure resident's room was kept clean. It is being alleged that a resident’s room, kitchen, and bathroom, was not clean. On 01/10/25, between 8:55 AM – 10:30 AM, LPA Gonzalez conducted interviews with S1-S8. Based on interviews conducted, 8 out of 8 staff interviewed denied the allegation. 6 out of 8 staff communicated that the residents’ rooms are cleaned once a week and as needed. S1 stated that housekeeping staff deep cleans the residents’ rooms once a week, and when needed. Continued on LIC9099-C On 01/10/25, between 10:45 AM – 1:50 PM, LPA Gonzalez conducted interviews with R1-R5. On 02/28/25, between 2:00 PM – 3:445 PM, LPA Gonzalez conducted interviews with R6-R10. Based on interviews conducted, 10 out of 10 residents interviewed communicated that their rooms are cleaned once a week, and as needed. 10 out of 10 residents communicated that staff always maintain their room and the facility clean and sanitary. LPA Gonzalez inspected rooms #103, #107, # 306, #307, #401, ##404, #502, #604, and #607, along with the facility Bistro, Josephine's Kitchen (facility diner), public restrooms and common areas. During the tours LPA observed the rooms, and facility to be clean and sanitary. LPA observed the public restrooms were clean and fully stocked with soap, toilet paper, and paper towels. Based on observation, and interviews conducted, the department did not find sufficient evidence to support 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. Allegation: Staff did not provide good quality foods to resident in care. It is being alleged that the food provided to the residents in care was observed to be of poor or low quality and the portions were small. On 01/10/25, between 8:55 AM – 10:30 AM, LPA Gonzalez conducted interviews with S1-S8. Based on interviews conducted, 8 out of 8 staff interviewed communicated that the facility serves good quality food, and the servings are ample. An interview with S1 communicated that the residents are served high quality, nutritious meals with a variety of options. S1 also stated that the residents are offered a second serving if they are not full. Some of the staff interviewed stated they have eaten at the facility, and that the food is good, and they feel the servings are ample. On 01/10/25, between 10:45 AM – 1:50 PM, LPA Gonzalez conducted interviews with R1-R5. On 02/28/25, between 2:00 PM – 3:445 PM, LPA Gonzalez conducted interviews with R6-R10. Based on interviews conducted, 10 out of 10 residents interviewed communicated that the food is good, and the servings are ample. Residents also stated that they can get a second serving if they’re still hungry. 10 out of 10 residents interviewed stated that they receive three meals a day and can get snacks whenever they’d like at the Bistro. LPA Gonzalez toured the Bistro, and the kitchen, and observed lunch being served. LPA observed that the food was visually appealing, and the portions served were ample. LPA reviewed the facility’s menus and observed that the menus had a variety of food options, serving nutritional, well-balanced meals, including protein, whole grains, vegetables, and fresh fruits. Based on observation, interviews conducted, and records reviewed, the department did not find sufficient evidence to support 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. An exit interview was conducted with Executive Director, Chris Schroeder, and a copy of this report and appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 4, 2025 · control 11-AS-20250102142915

Type of visit: Case Management - Other

On November 21,2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management visit. LPA met with Chris Schroeder /Executive Director and the purpose of the visit was explained. On September 18, 2024, during a subsequent complaint visit to another Residential Care Facility for the Elderly (RCFE), the Department found that the facility's surveillance cameras in the common areas were equipped with audio recording capabilities. This practice violated the privacy rights of the residents. Additionally, LPA Iniguez noted that the facility was not adhering to section 1569.153 of the Health and Safety Code regarding the admission of new residents. On November 21, 2024, LPA Iniguez and Executive Director Chris Schroeder reviewed the video surveillance cameras together. LPA Iniguez noted that the system does not have audio capabilities. Additionally, they reviewed a total of (17) residents' files and confirmed that the facility is in compliance with Section 1569.153 of the Health and Safety Code. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of this Case Management report was provided to Chris Schoeder / Executive Director.the state’s words, verbatim · CDSS document, Nov 21, 2024

Type of visit: Case Management - Other

On November 21,2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management visit. LPA met with Chris Schroeder /Executive Director and the purpose of the visit was explained. On 11/7/24, El Segundo Regional Office eceived an LIC 624 regarding (R#1) pushing down (R#2) in the dining room, causing (R#2) to fall on the floor. Facility staff promptly assisted (R2) and separated (R1) from the table. Facility staff assessed and contacted the PCP and families of (R1) and (R2). On 11/21/24, Licensing Program Analyst-LPA Alfonso Iniguez reviewed (R1)’s Physicians Report for Residential Care Facilities for the Elderly or LIC 602A dated 5/15/2024. LPA observed that it is marked on the form that (R1) does not have aggressive behavior. In addition, the Executive Director stated that this is the first time (R1) exhibited that kind of behavior. Also, ED stated that a new LIC 602A will be done for (R1). According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of this Case Management report was provided to Chris Schoeder / Executive Director.the state’s words, verbatim · CDSS document, Nov 21, 2024

Type of visit: Case Management - Other

On 8/30/24, Licensing Program Analysts (LPAs) Alfonso Iniguez and Yolanda Rosser conducted an unannounced Case Management visit at the community named above. The LPAs met with Chris Schroeder, the executive Director, and explained the reason for the visit. On 8/28/2024, the El Segundo Regional Office received reports of a male dressed as a service worker entering community care facilities in the Westwood area. The Executive Director stated that they conducted staff training for all facility staff regarding this event; also, the Executive Director said that they asked the fire marshal if we could locked at any external doors, but the fire marshal has yet to answer. In addition, he said that when visitors and vendors come into the facility, they must sign in before coming into the community. Also, the executive Director stated that the community has a security guard at nighttime from 10:30 PM to 7:00 AM. The Executive Director stated that on the day of the event, there were sufficient staff at the facility. In addition, no stolen items were reported from the resident's rooms. The Executive Director stated that some residents decided not to lock their doors, but the facility will bring this topic to the next resident council meeting. During this visit LPAs conducted the following: -A health and safety check of the facility. -Copies of the staff roster and resident’s roster. - images of the intruder of the day he went inside facility. -Copies of Staff in-service training During this visit LPAs conducted the following: -A health and safety check of the facility. -Copies of the staff roster and resident’s roster. -LPAs observed video recording of the day when the intruder went inside facility. -Copies of Staff in-service training According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Chris Schroeder /Executive Director.the state’s words, verbatim · CDSS document, Aug 30, 2024

Type of visit: Required - 1 Year

On 5/23/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Chris Schroeder /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (240) which (180) non-ambulatory and (60) bedridden. Approved hospice waiver for (20). Approved for delayed egress. The facility consists of 176 units of which 31 of those units have 2 bedrooms and 2 bathrooms. All other units have one bed and one bathroom. Facility also has a lobby area, 3 dining rooms and a bistro, kitchen, salon, theater, gym, several recreational spaces and patios. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA Iniguez and the Executive Director toured the physical plant. There is a body of water but there is fence and gated no obstructions on the premises. LPA inspected a total of (10) bedrooms and (10) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 108.5°F to 112.2°F, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drill was conducted on 4/25/24. Last date fire department came to inspect smoke detectors, carbon monoxide and sprinkler system was: 3/29/24. Delayed egress checked by LPA. A review of (10) residents' service files and (10) staff personnel files was maintained in order. LPA reviewed (10) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA later. Facility Annual Fess current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Chris Schroeder / Executive Director.the state’s words, verbatim · CDSS document, May 23, 2024

Allegation investigated: Facility staff did not assist resident with wearing clean clothing Facility staff did not assist resident with incontinence care Facility staff did not assist resident with showering Facility staff did not meet resident's dietary needs Facility staff did not assist resident with using hearing aids

Investigation Consisted of: Interview with Administrator(A#1), Facility Staff (S#1-S#5), Residents (R#1-R#6) and Reporting Party (RP). LPA Iniguez reviewed the following records: Staff Roster, Residents Roster, (R#1-R#5) Physicians Report for Residential Care Facilities for the Elderly or LIC 602, (R#1-R#5) Admissions Agreement, (R#1-R#5) Identification and Emergency Information LIC 625, (R#1-R#5) Appraisal/Needs Service Plan LIC 625, (R#1-R#5) Medication Administration Record (MARS) for the month of March 2024, copies of facility communication faxes to (R#1) primary physician dated: 11/18/23, 10/20/23 and 9/18/23, copies of facility menu and copies of facility brochure meals services. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Facility staff did not assist resident with wearing clean clothing. The details of the complaint alleged that facility staff are not assisting residents with wearing clean clothes. During the records review, LPA Iniguez examined the Service Plan Descriptions of (R#1), which had been set up by the resident and family upon admission. The facility staff conducted an assessment of the resident and suggested the appropriate services for their care. In (R#1)’s Service Plan Description, it was noted that they were enrolled in the Circle of Friends Service Plan (Assisted Living Area), which included weekly laundering of bed and linens and bath towels, daily bed making, and basic personal care. This service plan also included dressing and grooming assistance, standby assistance with showering as needed, or hands-on assistance with showering up to three times per week, and escort assistance to meals and activities while walking or by wheelchair. Additionally, LPA reviewed (R#1)’s Physician’s Report for the Residential Care Facilities for the Elderly (RCFE) LIC 602A, which indicated that (R#1) was able to bathe, dress, groom, feed themselves, and take care of their own toileting needs. During an interview with the Administrator (A#1), he mentioned that (R#1) communicates their needs and requirements effectively. (R#1) needs minimal assistance with grooming and changing; their clothes are washed every week and as needed. Regarding showering and continence, (R#1) needs hands-on assistance and some prompting from facility staff. Additionally, (A#1) stated that they prefer to encourage (R#1) rather than directly ask them, as it results in a more positive response. Evaluation Report continues LIC 9099-C During an interview with resident 1 (R#1), they stated that they change their clothes independently and do not require any assistance. Moreover, (R#1) mentioned that their clothes are clean when they change them. (R#1) said, “My clothes get clean here. I just put them in a laundry bag; my clothes are never soiled.” During interviews with residents (R#2-R#6), (5) out of (5) residents stated that they do not need any assistance in changing their clothes, and they can do it by themselves. Additionally, (4) out of (5) residents stated that they wash their clothes independently, and only one resident mentioned that the facility washes their clothes for them. During interviews with staff (S#1-S#3), (3) out of (3) staff members stated that every morning, caregivers encourage (R#1) to change and take a shower, rather than directly asking them if they want to. They have observed that using encouragement rather than direct questioning results in a more positive response from (R#1). The facility tries to assign caregivers that (R#1) is comfortable with, and if (R#1) refuses to shower during the morning shift (6:30 AM to 2:45 PM), the second shift (2:45 PM 11:00 PM) will encourage them to shower and change. If (R#1) still refuses to change, the caregivers will document their refusal and inform their physician and family. When it comes to washing (R#1)’s clothes, they are washed every week, and for other residents, clothes are washed every week or as needed, depending on the residents' requests. Evaluation Report continues LIC 9099-C Allegation: Facility staff did not assist resident with incontinence care. The details of the complaint alleged that facility staff are not assisting resident with their continence needs. During the records review, LPA Iniguez reviewed the Service Plan Descriptions of resident (R#1). The resident and family created this plan upon admission, and the facility staff assessed the resident and recommended the services that they thought would fit their care. In the case of (R#1)’s Service Plan Description under the Circle of Friends Service Plan (Assisted Living Area), the plan includes daily bed-making and toileting reminders and assistance. Moreover, LPA also reviewed (R#1)’s Physician’s Report for the Residential Care Facilities for the Elderly (RCFE) LIC 602A. The report indicates that (R#1) does not suffer from bladder or bowel impediment. During an interview with the Administrator (A#1), he stated that the facility is assisting (R#1) with their continence needs. In addition, (A#1) stated that (R#1)’s Residence and Service Agreement states that they receive essential services, including toilet reminders and daily bed making. During an interview with resident 1 (R#1), they stated that they do not need assistance with their continence needs. During interviews with residents (R#2-R#6), (5) out of (5) stated that they do not need assistance with their continence needs. During interviews with staff (S#1-S#3), (3) out of (3) stated that they are assisting (R#1) with their continence needs. In addition, (S#3) said that they go there every day to ensure (R#1)’s continence needs are met. If (R#1) refuses to get a continence change, they wait for 20 minutes, and then ask again if they want to get a change. If (R#1) refuses again, they wait and ask again. If (R#1) gets upset, they stop asking, respect their decision, and document their refusal. However, overall, (R#1) changes regularly. Evaluation Report continues LIC 9099-C Allegation: Facility staff did not assist resident with showering The details of the complaint alleged that facility staff did not assist resident with showering. During the records review, LPA Iniguez reviewed the Service Plan Descriptions of resident (R#1). The plan was set up by the resident and their family upon admission, and facility staff assessed the resident and recommended the services that they thought fit their care. In the case of (R#1)’s Service Plan Description under the Circle of Friends Service Plan (Assisted Living Area), the plan includes standby assistance with showering as needed or hands-on assistance with showering up to three times per week. Additionally, LPA reviewed (R#1)’s Physician’s Report for the Residential Care Facilities for the Elderly (RCFE) LIC 602A, which indicated that the resident could bathe themselves. During an interview with the Administrator (A#1), he stated that the staff generally help (R#1) at least three times per week or more if requested. The Administrator also confirmed that (R#1) has not refused to shower for more than three days. However, if (R#1) does refuse, the facility will contact their physician and representative. During an interview with resident 1 (R#1), they stated that they do not need assistance with showering and can do it themselves without staff assistance. During interviews with residents (R#2-R#6), (3) out of (5) stated that they can shower themselves without any assistance. Additionally, two out of five stated that they can shower themselves, but a caregiver is on standby just in case. During interviews with staff (S#1-S#3), (3) out of (3) staff members stated that they encourage (R#1) to shower at least three times per week or as needed. However, if they observe that (R#1) is getting upset or refusing, they will stop asking and document the refusal. Evaluation Report continues LIC 9099-C Allegation: Facility staff did not meet resident's dietary needs The details of the complaint alleged that facility staff are not meeting residents’ dietary needs. During a tour to the facility, LPA observed how the facility takes food orders for its residents. The system is similar to that of a restaurant, where residents order food from the caregiver who fills out breakfast, lunch, and dinner forms. In the form, there is a checkbox to mark dine-in or room service. They then place the form in a container, which the kitchen staff retrieves and types into the system. Once the order is submitted, it prints a receipt in the kitchen, showing who requested the meal. During the records review, LPA Iniguez examined (R#1)'s Service Plan Descriptions. The resident and their family set up this plan upon admission, and the facility staff assessed the resident to recommend the services that they think would fit their care. In the case of (R#1)'s Service Plan Description under the Circle of Friends Service Plan (Assisted Living Area), the service plan includes three meals daily, and snacks are available in the bistro between meals. Additionally, LPA reviewed (R#1)'s Physician's Report for the Residential Care Facilities for the Elderly (RCFE) LIC 602A. It is marked by (R#1)'s physician that they can feed themselves. Moreover, LPA reviewed a copy of the facility brochure on meal service, which states that the facility serves three meals per day and snacks between meals. Evaluation Report continues LIC 9099-C During an interview with the Administrator (A#1), he explained that generally, (R#1) comes to the dining room to eat their meals. The facility has both a dining room and a bistro area. If (R#1) wants to avoid coming down to eat their meals, they can order food from the staff, who then give the order to the kitchen staff. Once the order is in the kitchen, it prints a ticket order in the system with (R#1)'s order. Once the order is complete, the meal has the ticket information of what resident belongs to. In this case, it would be (R#1). During an interview with resident 1 (R#1), they mentioned that they eat two meals per day, breakfast and dinner. When asked if they get hungry at other times, they said no. Additionally, (R#1) stated that they have not lost weight in the past few months. The facility provides meals to (R#1) when needed. During interviews with residents (R#2-R#6), (5) out of (5) stated that they eat three meals per day, and there is always food available for them. Also, all (5) of them said that they have not lost weight because the facility staff provides them with meals regularly. During interviews with staff (S#1-S#3), (3) out of (3) stated that (R#1) likes to eat two meals per day and wants to have breakfast in their room. Additionally, (S#1) stated that they have not noticed any significant weight loss in (R#1). However, if they notice any weight loss, they will immediately notify (R#1)'s physician and family about it. Evaluation Report continues LIC 9099-C Allegation: Facility staff did not assist resident with using hearing aids The details of the complaint alleged that facility staff are not assisting residents with using their hearing aids. During a facility tour, LPA observed two wellness centers located on the 3rd and 5th floors. Inside these centers, the residents are charged for hearing aids if they choose to use them. On the other hand, some residents charge their hearing aids in their rooms. During an interview with the Administrator (A#1), he stated that the facility provides assistance to residents (R#1) with their hearing aids in two ways. Firstly, residents can keep their hearing aids in the wellness center, where the staff ensures that the hearing aids are charged during the nighttime. Then, the next day, the staff distributes the hearing aids to the residents. Secondly, if the residents want to keep their hearing aids with them, the facility staff assists those residents in charging the hearing aids for next-day use. In the case of (R#1), they choose to charge their hearing aids themselves, and the staff ensures that they do it correctly. During an interview with resident 1 (R#1), they said they keep their hearing aids in their room, and the facility staff ensures that (R#1)'s hearing aids are connected correctly. During interviews with residents (R#2-R#6), (5) out of (5) residents stated that they do not use hearing aids. During interviews with staff (S#1-S#3), (3) out of (3) stated that (R#1) keeps their hearing aids in their room and refuses to give them to the caregivers. However, the caregivers make sure that the hearing aids are charged correctly for the next day. Evaluation Report continues LIC 9099-C During this investigation, LPA found did not find sufficient evidence to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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. California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted, and a copy of the Complaint Report was given to Chris Schroeder /Executive Directorthe state’s words, verbatim · CDSS document, Mar 27, 2024 · control 11-AS-20240318110224