Beverly Hills Terrace

Allegation investigated: Staff are not properly trained to assist resident with CPAP Staff are not able to effectively communicate with resident. Facility failing to provide sufficient staffing Resident requires a higher level of care

On 07/23/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Administrator, Ella Naygas, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA interviewed Resident R1 and received Staff In-Service Training Logs. During the initial visit on 05/12/2026, LPA inspected the facility, interviewed Staff S1-S6, interviewed Residents R2-R6, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Personnel Report (August 2025), Resident Roster (05/07/2026), Physician’s Reports (various dates), Appraisal/Needs & Service Plans (various dates), Inter-Facility Transfer Report (dated 12/19/2025), Office Progress Notes from Internal Medicine & Nephrology, UCLA (dated 01/21/2026), Kaiser Permanente After Visit Summary (dated 01/22/2026 – 01/26/2026), Cedars Sinai After Visit (dated 02/05/2026), West Hollywood Healthcare & Wellness Center Face Sheet (dated 03/26/2026) West Hollywood Healthcare & Wellness Center Transfer/Discharge Report (dated 04/10/2026), Unsubstantiated West Hollywood Healthcare & Wellness Center Order Summary Report (dated 04/10/2026), West Hollywood Healthcare & Wellness Center Discharge Planning Review Form (dated 04/10/2026). The investigation revealed the following: Allegation: Staff are not properly trained to assist resident with CPAP The allegation alleges that the resident is unable to operate the CPAP properly and staff on scene also do not know how the CPAP functions. During a visit conducted on 07/23/2026, LPA observed staff assisting R1 in their room with their oxygen and other equipment. During record review, LPA received and reviewed a Staff In-Service Training Log from April 2026, regarding how to properly assist with the CPAP machine. In the residents room, LPA observed the directions for the machine are next to it on the counter. During interviews with Staff S1-S6, were asked if they have been trained on how to assist R1 with the CPAP machine, six (6) out of six (6) stated yes, they have received training on assisting R1 with the CPAP machine. During interviews with R1-R6, were asked if they feel staff are properly trained, six (6) out of six (6) stated yes, the staff are properly trained. During an interview with Resident R1, was asked if staff assist them with their CPAP machine, R1 stated yes, they do. Additionally, R1 was asked if they believe staff are trained to assist with their CPAP machine, R1 stated yes, the staff were in the room receiving training when it was delivered and set up, they know how to use it. During the course of the investigation, LPA was unable to find evidence to support the allegation. 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. Allegation: Staff are not able to effectively communicate with resident. The allegation alleges there is an English language barrier. During interviews, LPA was able to effectively communicate with Caregivers and Management staff. LPA observed staff assisting and speaking with residents throughout the facility without an issue. During interviews with Staff S1-S6, were asked if they have had any issues communicating with residents due to a language barrier, six (6) out of six (6) stated no, they have had no language barrier issues communicating with residents. During interviews with Residents R1-R6, were asked if they are able to effectively communicate with staff, six (6) out of six (6) stated they are able to effectively communicate with staff. During the course of the investigation, LPA was unable to find evidence to support the allegation. 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. Allegation: Facility failing to provide sufficient staffing The allegation alleges that there is only one caregiver, a nurse, and manager working during the day. During the facility visit, LPA observed three (3) caregivers, the Administrator, Administrator Assistant, maintenance, housekeeping, and kitchen staff working. During record review, LPA received and reviewed the Personnel Report (LIC500). LPA observed that on the AM shift there are three (3) caregivers scheduled, on the PM shift there are two (2) caregivers scheduled, and on the NOC shift there are two (2) caregivers scheduled to work. During interviews with Staff S1-S6, were asked if they feel there is enough staff on each shift to meet the needs of residents, six (6) out of six (6) stated yes, they feel there is enough staff on each shift. Additionally, four (4) out of six (6) staff stated there are only 25 residents who require assistance and 10 who require a total assist. During interviews with Residents R1-R6, were asked if they feel there is enough staff to provide supervision and assistance to residents, six (6) out of six (6) stated yes, they believe there is enough staff on each shift. During the course of the investigation, LPA was unable to find evidence to support the allegation. 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. Allegation: Resident requires a higher level of care The allegation alleges emergency personnel have expressed they believe a resident requires a higher level of care. During record review, LPA received and reviewed the Physician’s Report for Residential Care Facilities for the Elderly (dated 11/03/2025) that indicates R1 does not require assistance with bathing, dressing, grooming, toileting, or transferring. R1 does require assistance with mediations, oxygen, and their CPAP machine. Additionally, LPA received and reviewed five (5) residents Physicians Report for Residential Care Facilities for the Elderly (dated 12/17/2025 and 01/07/2026). LPA observed that a total of six (6) out of six (6) residents do not require assistance with bathing, dressing, grooming, toileting, or transferring. LPA received and reviewed Appraisal/Needs and Services Plan for six (6) residents. LPA observed six (6) out of six (6) residents Appraisal/Needs and Service Plans indicated residents are able to perform activities of daily living (ADL) and require assistance with medication management. LPA observed resident R1 requires assistance with equipment such as oxygen, CPAP, and nebulizer. During interviews with Staff S1-S6, were asked if they feel any residents require a higher level of care, three (3) out of six (6) stated yes, they feel R1 requires a higher level of care because they take assist with putting on their mask and the resident takes it off. During interviews with Residents R1-R6, were asked if they believe any of the residents at the facility require a higher level of care, six (6) out of six (6) indicated they do not believe any of the residents require a higher level of care. Additionally, LPA asked R1 if they believe they require a higher level of care, R1 stated no, they do not believe they require a higher level of care. During the course of the investigation, LPA was unable to find evidence to support the allegation. 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. LPA did not observe or cite any deficiencies. An exit interview was conducted with Caregiver, Yesenia Robles, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 11-AS-20260512084504

Allegation investigated: Staff threatened a resident in care. Staff stole resident's personal items. Staff spoke inappropriately to residents in care.

On 06/02/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to deliver an amended report. * This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 05/07/26. * On 05/07/26, Licensing Program Analyst (LPA) Elvira Gonzlaez conducted an unannounced complaint to investigate the above mentioned allegations. LPA met with Administrator, Ella Naygas, and the purpose of the complaint was explained. LPA was granted entry to the facility. The investigation consisted of the following: On 05/07/26, the department requested the following documents: staff roster, and resident roster. The department conducted interviews with staff #1-#5 (S1-S5) and residents #2-#6 (R2-R6) and attempted to interview resident #1 (R1). Additionally, the department conducted a tour of the facility. Unsubstantiated Furthermore, on 06/02/26, the department received a copy the in-service training sign-in sheet titled “Residents’ Personal Rights”, and conducted an interview with R1. The investigation revealed the following: Allegation: Staff threatened a resident in care. It is being alleged that a staff member has threatened to physically hurt a resident. On 05/07/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff said they treat all residents with dignity and respect. On 05/07/26, the department conducted interviews with R2-R6, and attempted to interview R1, but they were not in the facility. On 06/02/26, the department conducted an interview with R1 via telephone. Of those interviewed, 6 out of 6 residents could not corroborate the allegation. 5 out of 6 residents said staff treat them with dignity and respect, and that they feel safe in this facility. Based on observation, and interviews conducted, there is insufficient 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 stole resident’s personal belongings. On 05/07/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff said they treat all residents with dignity and respect. On 05/07/26, the department conducted interviews with R2-R6, and attempted to interview R1, but they were not in the facility. On 06/02/26, the department conducted an interview with R1 via telephone. Of those interviewed, 6 out of 6 residents could not corroborate the allegation. Based on records reviewed, and interviews conducted, there is insufficient 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 spoke inappropriately to resident’s in care. It is being alleged that a staff member has been verbally abusing a resident for the past 16 years. On 05/07/26, the department conducted interviews with S1-S5. Of those interviewed, 4 out of 5 staff denied the allegation. 4 out of 5 staff said they treat all residents with dignity and respect. On 05/07/26, the department conducted interviews with R2-R6, and attempted to interview R1, but they were not in the facility. On 06/02/26, the department conducted an interview with R1 via telephone. Of those interviewed, 6 out of 6 residents could not corroborate the allegation. On 06/02/26, the department conducted a review of the in-service training sign-in sheet titled “Residents’ Personal Rights” and observed that 16 staff members completed the training on 01/22/26. Based on observation, and interviews conducted, there is insufficient 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. No deficiencies were observed during this investigation. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 11-AS-20260430115156

Allegation investigated: Staff did not prevent inappropriate interactions between residents. Staff did not safeguard a resident's mail. Staff did not safeguard a resident's personal belongings. Staff locked a resident out of the facility. Staff did not prevent resident from financially abusing another resident.

On 06/02/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to deliver an amended report. * This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 04/01/26. * On 04/01/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to further investigate the above mentioned allegations and deliver findings. LPA met with Assistant Administrator, Cecilia Torres, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On 03/19/26, LPA Gonzalez obtained copies of the following documents: staff roster, resident roster, and documentation where residents sign once they have received their mail correspondence. LPA Gonzalez conducted interviews with staff #1-#4 (S1-S4), and residents #2-#6 (R2-R6), and attempted to interview resident #1 (R1). Additionally, LPA conducted a tour of the entire facility, and inspected resident bedrooms, and common areas. Unsubstantiated The investigation revealed the following: For the allegation: Staff did not prevent inappropriate interactions between residents. It is being alleged that a resident has endured resident on resident abuse. On 03/19/26, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. On 03/19/26, LPA Gonzalez conducted interviews with R2-R6, and attempted to interview R1, but was unable to as R1 no longer lives at the facility and could not be reached via telephone number provided. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. 5 out of 5 residents said that they feel safe at this facility. On 03/19/26, LPA Gonzalez conducted a tour of the facility, including resident bedrooms and common areas. No negative resident-to-resident interactions were observed during the inspection. Based on observations, and interviews conducted, there is insufficient 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. For the allegation: Staff did not safeguard a resident's mail. It is being alleged that facility staff does not monitor the mail. On 03/19/26, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. An interview with S1 revealed that they provide the residents with their mail and then ask them to sign a form confirming that they receive their mail. On 03/19/26, LPA Gonzalez conducted interviews with R2-R6, and attempted to interview R1, but was unable to as R1 no longer lives at the facility and could not be reached via telephone number provided. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. 5 out of 5 residents said that staff has not mismanaged their mail. On 03/19/26, LPA Gonzalez conducted a review of a folder containing residents’ signatures documenting receipt of their mail. Based on observations, and interviews conducted, there is insufficient 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. For the allegation: Staff did not safeguard a resident's personal belongings. It is being alleged that staff did not prevent a resident’s clothing, Cochlear Implant processor and replacement from being stolen. On 03/19/26, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. An interview with S1 revealed that they advise residents to label all of their belongings. S1 said that all residents are advised to lock their room doors when leaving their room, and that they all have a key to their room. S1 said that such clothing, or Cochlear Implant processor were never reported missing. S1 said all they can do is enforce good behavior and continuously give the residents advice. On 03/19/26, LPA Gonzalez conducted interviews with R2-R6, and attempted to interview R1, but was unable to as R1 no longer lives at the facility and could not be reached via telephone number provided. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. 5 out of 5 residents interviewed stated that none of their personal belongings had been missing or stolen. Based on observations, and interviews conducted, there is insufficient 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. For the allegation: Staff locked a resident out of the facility. It is being alleged that staff have engaged in illegal lockouts of residents. On 03/19/26, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. An interview with S1 revealed that the front door is locked at 7:00 PM for safety purposes. S1 stated that residents are instructed to ring the doorbell, at which time staff will open the door and allow entry. S1 further stated that residents are able to enter the facility through either the front or side door at all times. Continued on LIC9099-C On 03/19/26, LPA Gonzalez conducted interviews with R2-R6, and attempted to interview R1, but was unable to as R1 no longer lives at the facility and could not be reached via telephone number provided. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. 5 out of 5 residents said they have not been locked out of the facility. Based on observations, and interviews conducted, there is insufficient 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. For the allegation: Staff did not prevent resident from financially abusing another resident. It is being alleged that staff did not prevent acts of financial forgery. It is further alleged that staff did not prevent a resident from fraudulently obtaining credit cards and accessing funds belonging to another resident, resulting in unauthorized debt, required payments, and liens placed on the victim resident’s checking account. On 03/19/26, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. On 03/19/26, LPA Gonzalez conducted interviews with R2-R6, and attempted to interview R1, but was unable to as R1 no longer lives at the facility and could not be reached via telephone number provided. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. 5 out of 5 residents said they’ve never experienced any type of financial abuse. Based on observations, and interviews conducted, there is insufficient 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, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 11-AS-20260309091056

Allegation investigated: Staff threatened resident in care. Staff stole resident's personal items. Staff spoke inappropriately to residents in care.

On 05/07/26, Licensing Program Analyst (LPA) Elvira Gonzlaez conducted an unannounced complaint to investigate the above mentioned allegations. LPA met with Administrator, Ella Naygas, and the purpose of the complaint was explained. LPA was granted entry to the facility. The investigation consisted of the following: On 05/07/26, the department requested the following documents: staff roster, and resident roster. The department conducted interviews with staff #1-#5 (S1-S5) and residents #2-#6 (R2-R6) and attempted to interview resident #1 (R1). Furthermore, the department conducted a tour of the facility. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff threatened a resident in care. It is being alleged that a staff member has threatened to physically hurt a resident. On 05/07/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff said they treat all residents with dignity and respect. On 05/07/26, the department conducted interviews with R2-R6, and attempted to interview R1, but they were not in the facility. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. 5 out of 5 residents said staff treat them with dignity and respect, and that they feel safe in this facility. Based on observation, and interviews conducted, there is insufficient 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 stole resident’s personal belongings. On 05/07/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff said they treat all residents with dignity and respect. On 05/07/26, the department conducted interviews with R2-R6, and attempted to interview R1, but they were not in the facility. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. Based on records reviewed, and interviews conducted, there is insufficient 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. Continued on LIC9099-C Allegation: Staff spoke inappropriately to resident’s in care. It is being alleged that a staff member has been verbally abusing a resident for the past 16 years. On 05/07/26, the department conducted interviews with S1-S5. Of those interviewed, 4 out of 5 staff denied the allegation. 4 out of 5 staff said they treat all residents with dignity and respect. On 05/07/26, the department conducted interviews with R2-R6, and attempted to interview R1, but they were not in the facility. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. Based on observation, and interviews conducted, there is insufficient 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. No deficiencies were observed during this investigation. An exit interview was conducted, and a copy of this report was provided to Ella Naygas.the state’s words, verbatim · CDSS document, May 7, 2026 · control 11-AS-20260430115156

Allegation investigated: Staff did not prevent inappropriate interactions between residents. Staff did not safeguard a resident's mail. Staff did not safeguard a resident's personal belongings. Staff locked a resident out of the facility. Staff did not prevent resident from financially abusing another resident.

On 04/01/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to further investigate the above mentioned allegations and deliver findings. LPA met with Assistant Administrator, Cecilia Torres, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On 03/19/26, LPA Gonzalez obtained copies of the following documents: staff roster, resident roster, and documentation where residents sign once they have received their mail correspondence. LPA Gonzalez conducted interviews with staff #1-#4 (S1-S4), and residents #1-#5 (R1-R5). Additionally, LPA conducted a tour of the entire facility, and inspected resident bedrooms, and common areas. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: For the allegation: Staff did not prevent inappropriate interactions between residents. It is being alleged that a resident has endured resident on resident abuse. On 03/19/26, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. On 03/19/26, LPA Gonzalez conducted interviews with R1-R5. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. 5 out of 5 residents said that they feel safe at this facility. Based on observations, and interviews conducted, there is insufficient 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. For the allegation: Staff did not safeguard a resident's mail. It is being alleged that facility staff does not monitor the mail. On 03/19/26, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. An interview with S1 revealed that they provide the residents with their mail and then ask them to sign a form confirming that they receive their mail. On 03/19/26, LPA Gonzalez conducted interviews with R1-R5. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. 5 out of 5 residents said that staff has not mismanaged their mail. On 03/19/26, LPA Gonzalez reviewed a folder containing residents’ signatures documenting receipt of their mail. Based on observations, and interviews conducted, there is insufficient 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. Continued on LIC9099-C For the allegation: Staff did not safeguard a resident's personal belongings. It is being alleged that staff did not prevent a resident’s clothing, Cochlear Implant processor and replacement from being stolen. On 03/19/26, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. An interview with S1 revealed that they advise residents to label all of their belongings. S1 said that all residents are advised to lock their room doors when leaving their room, and that they all have a key to their room. S1 said that such clothing, or Cochlear Implant processor were never reported missing. S1 said all they can do is enforce good behavior and continuously give the residents advice. On 03/19/26, LPA Gonzalez conducted interviews with R1-R5. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. 5 out of 5 residents interviewed stated that none of their personal belongings had been missing or stolen. Based on observations, and interviews conducted, there is insufficient 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. For the allegation: Staff locked a resident out of the facility. It is being alleged that staff have engaged in illegal lockouts of residents. On 03/19/26, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. An interview with S1 revealed that the front door is locked at 7:00 PM for safety purposes. S1 stated that residents are instructed to ring the doorbell, at which time staff will open the door and allow entry. S1 further stated that residents are able to enter the facility through either the front or side door at all times. On 03/19/26, LPA Gonzalez conducted interviews with R1-R5. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. 5 out of 5 residents said they have not been locked out of the facility. Based on observations, and interviews conducted, there is insufficient 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. Continued on LIC9099-C For the allegation: Staff did not prevent resident from financially abusing another resident. It is being alleged that staff did not prevent acts of financial forgery. It is further alleged that staff did not prevent a resident from fraudulently obtaining credit cards and accessing funds belonging to another resident, resulting in unauthorized debt, required payments, and liens placed on the victim resident’s checking account. On 03/19/26, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. On 03/19/26, LPA Gonzalez conducted interviews with R1-R5. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. 5 out of 5 residents said they’ve never experienced any type of financial abuse. Based on observations, and interviews conducted, there is insufficient 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, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 1, 2026 · control 11-AS-20260309091056

Allegation investigated: Facility staff do not prevent the using/selling of drugs at the facility. Facility staff do not provide adequate activities for residents in care. Facility staff spoke inappropriately to residents. Facility staff do not ensure that residents are provided with their medications as prescribed. Facility staff do not ensure that residents are provided with a safe environment while in care. Facility staff do not provide an adequate amount of food portions to residents in care. Facility staff did not ensure the facility was kept free of pests. Facility staff denied resident access to a telephone. Facility staff did not treat clients with dignity and respect.

On 03/26/26 at 10:00 am Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Administrator as the purpose of today’s visit was explained. The investigation consisted of the following: On 03/18/26 LPA Villegas obtained copies of the staff and resident roster, facility menu, March 2026 activity calendar, and squash exterminating invoices from November 2025- February 2026. LPA also obtained copies of the following documents for resident #1 (R1) Emergency ID form, appraisal dated: 2/8/24, admission agreement dated: 8/20/2020, Physicians report dated:01/14/26, needs and service plan dated: 3/25/25, medication list, and a signed agreement from R1 regarding policy and procedures. On 03/18/26 from 10:30am-11am Unsubstantiated LPA conducted Interviews residents #1-5 (R1-R5), and from 11:30 am-12:10 pm LPA conducted interviews with staff #1-5 (S1-S5). On 02/18/26 from 12:10 pm-1pm LPA observed lunch service and toured the facility kitchen. The investigation revealed the following: Allegation: Facility staff do not prevent the using/selling of drugs at the facility. It is being alleged that there is extensive drug activity occurring at the facility, including drugs being used and sold. On 03/18/26 from 10:30 am-11:20 am LPA conducted Interviews with (R1-R5) regarding the allegation above. 1 of the 5 residents interviewed confirmed the allegation above and reported observing peers smoking marijuana and selling crack in the facility patio. 4 of the 5 residents interviewed denied the above allegation. On 03/18/26 from 11:30am-12:10 pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of the 5 staff interviewed denied the allegation above and reported that residents smoke marijuana outside of the facility. On 03/26/26 LPA conducted a tour of the facility and observed resident smoking cigarettes in the smoking patio. Allegation: Facility staff do not provide adequate activities for residents in care. It is being alleged that residents have not been provided with any activities and residents are to remain in their rooms throughout the day. On 03/18/26 from 10:30 am-11:20 am LPA conducted Interviews with (R1-R5) regarding the allegation above. 2 of the 5 residents interviewed confirmed the allegation above, and reported that the TV is on throughout the day in the common areas. 3 of the 5 residents interviewed denied the allegation above and reported there are activities provided. On 03/18/26 from 11:30am-12:10 pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of the 5 staff interviewed denied the allegation above and reported that activities are always offered however residents do not participate. Additionally, 5 of 5 staff reported that staff will encourage residents to participate in activities, however residents will leave the group mid activity. On 03/26/26 LPA conducted a review of the March 2026 activity calendar which is also posted on the facility bulletin board, LPA observed that there is a different activity scheduled everyday. Allegation: Facility staff spoke inappropriately to residents. It is being alleged that facility staff frequently yell and scream at residents for no apparent reason. On 03/18/26 from 10:30 am-11:20 am LPA conducted Interviews with (R1-R5) regarding the allegation above. 1 of the 5 residents interviewed confirmed the allegation above and reported that most staff are treating the resident like an awful person. 4 of the 5 residents interviewed denied the above allegation. On 03/18/26 from 11:30 am-12:10 pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of the 5 staff interviewed denied the allegation above. Additionally, 1 of the 5 staff interviewed stated that their voice projects as they speak loudly but has never called a resident in care a bad name. Allegation: Facility staff do not ensure that residents are provided with their medications as prescribed. It is being alleged that residents are not provided with their medications on time, as medications are sometimes delayed by 30 minutes to an hour. On 03/18/26 from 10:30 am-11:20 am LPA conducted Interviews with (R1-R5) regarding the allegation above. 1 of the 5 residents interviewed confirmed the allegation above and reported that staff occasionally do not provide medications because they didn't have it available. 4 of the 5 residents interviewed denied the above allegation and reported receiving their medications on time. On 03/18/26 from 11:30 am-12:10 pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of the 5 staff interviewed denied the allegation above and reported that the only time residents do not obtain their medications is when residents our out in the community during medication time. Allegation: Facility staff do not ensure that residents are provided with a safe environment while in care. It is being alleged that facility is an unsafe environment due to incidents of stealing and conditions that are not healthy for other residents. On 03/18/26 from 10:30 am-11:20 am LPA conducted Interviews with (R1-R5) regarding the allegation above. 1 of the 5 residents interviewed confirmed the allegation above and reported that there have been many times where belongings have gone missing. 1 of 5 residents reported having items stolen in the past but states that it was not reported to staff. 3 of the 5 residents interviewed denied the above allegation. On 03/18/26 from 11:30 am-12:10 pm LPA conducted interviews with S1-S5 regarding the allegation above. 4 of the 5 staff interviewed denied the allegation, and reported that when theft is reported by a resident staff will assist with searching for missing item. 1 of the 5 staff interviewed reported having no knowledge regarding the allegation or the protocol when theft is reported. Allegation: Facility staff do not provide an adequate amount of food portions to residents in care. It is being alleged that facility staff often provide residents with small food portions to avoid running out of food. On 03/18/26 from 10:30 am-11:20 am LPA conducted Interviews with (R1-R5) regarding the allegation above. 1 of the 5 residents interviewed confirmed the allegation above and reported that the portions served have gotten smaller over the years and that some food is good and some is bad. 4 of the 5 residents interviewed denied the above allegation and reported having no concerns about the portions provided. On 03/18/26 from 11:30am-12:10 pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of the 5 staff interviewed denied the allegation above, and reported that residents get (3) meals and snacks daily. Additionally, staff reported that residents can get a second serving upon request after all residents have been provided with a tray. On 02/18/26 from 12:10 pm-1pm LPA observed lunch service and toured the facility kitchen. LPA observed a walk-in pantry that was stocked and labeled with expiration dated, facility has a walk-in fridge and freezer that was fully stocked, LPA observed boxes being thrown out as if there was a delivery made. Allegation: Facility staff did not ensure the facility was kept free of pest. It is being alleged that the facility recently had bed bugs and a roach infestation. On 03/18/26 from 10:30 am-11:20 am LPA conducted Interviews with (R1-R5) regarding the allegation above. 3 of the 5 residents confirmed the allegation above, 1 of the 5 residents denied the allegation above, and 1 of the 5 residents stated they have seen pest in the past. Additionally, 5 of the 5 residents interviewed reported that the facility does have someone coming to treat the facility for pest. On 03/18/26 from 11:30 am-12:10 pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of the 5 staff interviewed denied the allegation above and reported that the facility does not have a pest infestation. 5 of 5 staff stated that roaches and bedbug have been observed in the past, however the pest control services treats the facility monthly. 2 of the 5 staff interviewed also reported that the facilities maintenance department steams the bedrooms everyday in between pest control services. On 03/24/26 LPA conducted a review of the squash exterminating invoices from November 2025- February 2026, LPA observed that facility exteriors, windows, doors, laundry rooms, restrooms, trash areas and all cracks and crevices are being treated on top of (5) bedrooms. Per squash exterminating invoices, the last time live pest activity observed was in October 2025. On 03/26/26 LPA conducted a tour of the facility and inspected (8) bedrooms (106,111,114,115,118, 219, 226, 229), and did not observe any pest activity, LPA also observe housekeeping actively cleaning rooms on the 1st and 2nd floor. obtained a copy of the housekeeper job description. On 03/26/26 LPA called witness #1 (W1) but was not able to obtain any information regarding the allegation above. On 03/26/26 LPA did a review of unusual incident reports submitted to CCLD by the facility, LPA observed that on on 03/17/26 the facility reported that resident in care refused to have their bedroom sprayed for pest. Allegation: Facility staff denied resident access to a telephone. It is being alleged that resident in care is denied access to make and receive phone calls. On 03/18/26 from 10:30 am -11:20 am LPA conducted Interviews with (R1-R5) regarding the allegation above. 5 of the 5 residents interviewed denied the above allegation. On 03/18/26 from 11:30 am-12:10 pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of the 5 staff interviewed denied the allegation above. On 03/26/26 LPA conducted a tour of the facility and observed a land line with (1) phone mounted on each floor of the facility. Allegation: Facility staff did not treat clients with dignity and respect. It is being alleged that the facility Administrator has told a resident in care that Administrator will make the resident homeless. On 03/18/26 from 10:30 am -11:20 am LPA conducted Interviews with (R1-R5) regarding the allegation above. 1 of the 5 residents interviewed confirmed the allegation above and reported that staff do not treat resident with dignity and respect. 4 of the 5 residents interviewed denied the above allegation and reported feeling respected and are treated with dignity. On 03/18/26 from 11:30 am-12:10 pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of the 5 staff interviewed denied the allegation above. Additionally, 1 of 5 staff interviewed reported that although the facility can issue 30 day eviction notices, the facility can not throw any resident out in the street. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 11-AS-20260311092359

Allegation investigated: Facility staff does not ensure residents are spoken to in an appropriate manner. Staff physically abused a resident.

On 03/17/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannouced subsequent visit regarding the above mentioned allegations. The purpose of the visit is to make a correction to page 2 and add additional information not included on the report dated 02/11/26. All findings remain the same. LPA met with Assistant Administrator, Cecilia Torres, and the purpose of the visit was explained. LPA was granted entry to the facility. On 02/11/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted a subsequent unannounced complaint visit to investigate the above mentioned allegations. LPA met with Assistant Administrator, Cecilia Torres, and explained the purpose of the visit. LPA was granted entry to the facility. Continued on LIC9099-C Unsubstantiated The investigation consisted of the following: On 02/05/26, LPA Gonzalez obtained copies of the following documents: staff roster, and resident roster. LPA Gonzalez interviewed staff #1-#5 (S1-S5), and resident #1-#6 (R1-R6). Additionally, LPA conducted a tour of the entire facility, and inspected resident bedrooms, and common areas. Furthermore, Ella Naygas agreed to send pest control invoices for the months of December-February 2026 to LPA via email. On 02/09/26, LPA Gonzalez receives pest control invoices from Squash Exterminating (dated: 12/09/25, and 01/30/26). Furthermore, on 02/11/26, LPA Gonzalez conducted an interview with staff #6 (S6) and received a copy of the Service Agreement for pest control services from Squash Pest Control. The investigation revealed the following: For the allegation: Facility staff does not ensure residents are spoken to in an appropriate manner. It is being alleged that the administrator yells at everyone at the facility. On 02/05/26, LPA Gonzalez conducted interviews with S1–S5, and on 02/12/26, LPA conducted an interview with S6. Of those interviewed, 6 out of 6 staff denied the allegation. 6 out of 6 staff said they treat all residents with dignity and respect. On 02/05/26, LPA Gonzalez conducted interviews with R1-R6. Of those interviewed, 4 out of 6 residents could not corroborate the allegation, and 2 out of 6 residents corroborated the allegation. 4 out of 6 residents said staff treat them with dignity and respect. Based on observation, and interviews conducted, there is insufficient 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. For the allegation: Staff physically abused a resident. It is being alleged that the administrator pushed a resident. On 02/05/26, LPA Gonzalez conducted interviews with S1–S5, and on 02/12/26, LPA conducted an interview with S6. Of those interviewed, 6 out of 6 staff denied the allegation. 6 out of 6 staff said they treat all residents with dignity and respect. On 02/05/26, LPA Gonzalez conducted interviews with R1–R6. Of those interviewed, 5 out of 6 residents could not corroborate the allegation, and 1 out of 6 residents corroborated the allegation. 4 out of 6 residents said staff treat them with dignity and respect. Continued on LIC9099-C Based on observation, and interviews conducted, there is insufficient 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, and a copy of the report was provided to the Cecilia Torres.the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 11-AS-20260127111928

Allegation investigated: Staff did not assist resident with incontinence care needs in a timely manner. Staff did not seek timely medical attention for resident.

On 2/19/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator Assistant, Cesilia Torres and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 12/2/25 LPA Shirley reviewed copies of the following records: Resident Roster, Identification and Emergency Information, Admission Agreement, Notice of Rent Increase, Physician’s Report, Appraisal/Needs and Services Plan, Incontinence Tracking Sheet for10/25 and 11/25, Special Incident Report, Consent for Emergency Medical Treatment and medical records from Cedars Sinai. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 5 (S1 – S5), and Resident 1 – Resident 5(R1-R5). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not assist resident with incontinence care needs in a timely manner. It is being reported that 911 dispatch was called to this facility. During Emergency Staff assessment of R1 the resident was found to be drenched in their urine. On 2/10/26, LPA Felisa Shirley reviewed R1’s Physician Report dated, 2/4/25 and observed that R1 is not able to care for his own toileting needs. During review of the November, 2025 Incontinence Tracking sheet, LPA Shirley noted that on 11/22/25, R1 was serviced every 2 hours by initialed staff until the time he was transferred to Cedars Sinai Medical Center. Per interview with S5 on 12/2/25 the residents are changed every two hours and as needed. LPA Shirley interviewed S-1 on 12/2/25 and was told that R1 is sometimes able to remove the diaper on his own to go to the bathroom. LPA interviewed staff 1 – staff 5(S-1 – S-5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5(R1 – R5). Of those who interviewed 3 out of 5 denied the allegation. Two residents use the bathroom on their own. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not assist resident with incontinence care needs in a timely manner,” therefore, the allegation is unsubstantiated. Allegation: Staff did not seek timely medical attention for resident. It is being reported that R1 was ill due to the negligence of facility staff. On 2/10/26, LPA Shirley reviewed the medical records from Cedars Sinai stating date of arrival, 11/22/25 R1’s diagnosis was dehydration. During review of requested unusual incident report dated 11/24/25, LPA Shirley noted that R1 told staff that he was not feeling well and he requested to go to the hospital. LPA Shirley Con'd on 9099-C interviewed S2 and S3 on 12/2/25. Both staff stated that upon arrival to R1’s room on 11/22/25, R1 appeared to be ill so S2 called 911. LPA interviewed staff 1 – staff 5(S-1 – S-5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5(R1 – R5). Of those who interviewed 5 out of 5 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not seek timely medical attention for resident,” 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 Administrator Assistant, Cesilia Torres.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 11-AS-20251125092903

Allegation investigated: Facility staff does not ensure residents are spoken to in an appropriate manner. Staff physically abused a resident.

On 02/11/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted a subsequent unannounced complaint visit to investigate the above mentioned allegations. LPA met with Assistant Administrator, Cecilia Torres, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On 02/05/26, LPA Gonzalez obtained copies of the following documents: staff roster, and resident roster. LPA Gonzalez interviewed staff #1-#5 (S1-S5), and resident #1-#6 (R1-R6). Additionally, LPA conducted a tour of the entire facility, and inspected resident bedrooms, and common areas. Furthermore, Ella Naygas agreed to send pest control invoices for the months of December-February 2026 to LPA via email. On 02/09/26, LPA Gonzalez receives pest control invoices from Squash Exterminating (dated: 12/09/25, and 01/30/26). Furthermore, on 02/11/26, LPA Gonzalez conducted an interview with staff #6 (S6) and received a copy of the Service Agreement for pest control services from Squash Pest Control. Unsubstantiated The investigation revealed the following: For the allegation: Facility staff does not ensure residents are spoken to in an appropriate manner. It is being alleged that the administrator yells at everyone at the facility. On 02/05/26, LPA Gonzalez conducted interviews with S1–S5, and on 02/12/26, LPA conducted an interview with S6. Of those interviewed, 6 out of 6 staff denied the allegation. 6 out of 6 staff said they treat all residents with dignity and respect. On 02/05/26, LPA Gonzalez conducted interviews with R1-R6. Of those interviewed, 4 out of 6 residents could not corroborate the allegation, and 2 out of 6 residents corroborated the allegation. 4 out of 6 residents said staff treat them with dignity and respect. Based on observation, and interviews conducted, there is insufficient 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. For the allegation: Staff physically abused a resident. It is being alleged that the administrator yells at everyone at the facility. On 02/05/26, LPA Gonzalez conducted interviews with S1–S5, and on 02/12/26, LPA conducted an interview with S6. Of those interviewed, 6 out of 6 staff denied the allegation. 6 out of 6 staff said they treat all residents with dignity and respect. On 02/05/26, LPA Gonzalez conducted interviews with R1–R6. Of those interviewed, 5 out of 6 residents could not corroborate the allegation, and 1 out of 6 residents corroborated the allegation. 4 out of 6 residents said staff treat them with dignity and respect. Based on observation, and interviews conducted, there is insufficient 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, and a copy of the report was provided to the Cecilia Torres. The investigation revealed the following: For the allegation: Staff did not ensure facility is free from pests. It is being alleged that there are bedbugs, mites, spiders, and cobwebs all over the facility. On 02/05/26, LPA Gonzalez conducted interviews with S1–S5, and on 02/12/26, LPA conducted an interview with S6. Of those interviewed, 6 out of 6 staff stated they did not agree with the full allegation. However, staff acknowledged there is an ongoing issue with bed bugs within the facility. During interview, S1 reported the bed bug issue has been ongoing at the facility. S1 stated that upon notification of bed bug activity, staff remove items from the affected room, clean and treat the area, and disinfect the room. S1 reported that pest control services are provided twice a month and additionally as needed. On 02/05/26, LPA Gonzalez conducted interviews with R1-R6. Of those interviewed, 6 out of 6 residents interviewed corroborated the allegation. On 02/11/26, LPA Gonzalez reviewed Service Agreement for pest control services from Squash Exterminating Pest Control dated 10/21/25. Documentation indicate that the facility agreed to two (2) service visits per month for general pest control services. Additionally, LPA reviewed pest control service records from Squash Exterminating Pest Control dated 12/09/25 and 01/30/26. Records indicate the facility received routine general pest control services. Documentation reflects that no live pest activity was observed or reported during either service visit. On 02/05/26, LPA Gonzalez and Ella Naygas toured the facility and inspected rooms #108, #114, #117, #207, #209 and other common areas. LPA observed a live bed bug on the wall near a resident’s bed, what appeared to be blood stains on the wall. Additionally, while conducting an interview, LPA observed visible bite marks on a resident’s arms. Based on observation, interviews conducted, and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, is being cited, please see attached LIC-9099D. An exit interview was conducted, and a copy of this report was provided to Cecilia Torres.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 11-AS-20260127111928

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 25, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observations and interviews conducted, the licensee did not maintain a clean and sanitary environment for residents in care. On 02/05/26, LPA observed live bed bug activity in the facility. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: Administrator and staff will meet to develop a plan to eradicate the bed bug infestation. LPA suggested the facility should consider additional pest control service treatments, as well as other treatments such as a bed bug heat treatments until bed bug activity is eradicated. Proof of treatment and corrective actions will be submitted to LPA Gonzalez via email by POC due date.

Allegation investigated: Licensee is retaliating against resident for filing complaints. Licensee does not ensure that resident is provided a safe environment while in care. Licensee does not ensure that resident's personal belongings are safeguarded while in care.

On 01/16/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above mentioned allegations. LPA met with Assistant Administrator, Cecilia Torres, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On 01/16/26, LPA Gonzalez obtained copies of the following documents: staff roster, resident roster, Admission Agreement for R1, House Rules for R1, and Resident Personal Property and Valuables for R1. Additionally, LPA Gonzalez interviewed staff #1-#4 (S1-S4) resident #1-#5 (R1-R5) and attempted to interview resident #6 (R6). Additionally, LPA conducted a tour of the facility, and inspected resident bedrooms, and common areas. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: For the allegation: Licensee is retaliating against resident for filing complaints. On 01/16/26, LPA Gonzalez conducted interviews with S1–S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said they treat all residents with dignity and respect. On 01/16/26, LPA Gonzalez conducted interviews with R1-R5, and attempted to interview R6, but was unable to as R6 was out of the facility. Of those interviewed, 3 out of 5 residents could not corroborate with the allegation, and 2 out of 5 residents said they do fear retaliation should they file a complaint against the facility. 3 out of 5 residents said staff treat them with dignity and respect. Based on observation, and interviews conducted, there is insufficient 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. For the allegation: Licensee does not ensure that resident is provided a safe environment while in care. It is alleged that one or more residents threatened and engaged in aggressive behavior toward another resident. On 01/16/26, LPA Gonzalez conducted interviews with S1–S4. Of those interviewed, 4 out of 4 staff denied the allegation. An interview with S1 revealed that R1 and R6 have engaged in aggressive behavior toward each other in the past; however, staff immediately intervened, mediated the situation, and separated the residents. S1 stated that there have been no reports or incidents involving residents engaging in threatening or aggressive behavior within the past 30 days. On 01/16/26, LPA Gonzalez conducted interviews with R1–R5 and attempted to interview R6; however, R6 was unavailable due to being out of the facility. Of those interviewed, 4 out of 5 residents were unable to corroborate the allegation. 4 out of 5 residents reported that they feel safe in the facility. On 01/16/26, LPA Gonzalez reviewed the facility’s incident reports and did not observe any Special Incident Reports (SIRs) involving residents engaging in threatening or aggressive behavior within the past 30 days. Continued on LIC9099-C Based on observation, records reviewed, and interviews conducted, there is insufficient 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. For the allegation: Licensee failed to ensure that residents’ personal belongings are safeguarded while in care. It is alleged that staff, including the facility Administrator, Ella Naygas, entered a resident’s room and removed personal belongings, including clothing, cell phones, snacks, and vitamins. On 01/16/26, LPA Gonzalez conducted interviews with S1–S4. Of those interviewed, 4 out of 4 staff denied the allegation. An interview with S1 indicated that residents are allowed to lock their rooms and are provided with a key. S1 stated they have never removed clothing or cell phones from R1’s bedroom. S1 reported that unprescribed medication was removed from R1’s room due to potential health and safety concerns, as it was not prescribed by R1’s physician. S1 stated they explained the reason for the removal to R1, and R1 indicated understanding. On 01/16/26, LPA Gonzalez conducted interviews with R1–R5 and attempted to interview R6; however, R6 was unavailable due to being out of the facility. Of those interviewed, 3 out of 5 residents were unable to corroborate the allegation. 4 out of 5 residents said they are allowed to lock their rooms and have been provided with a key. Based on observation, records reviewed, and interviews conducted, there is insufficient 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. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of the report was provided to the Cecilia Torres.the state’s words, verbatim · CDSS document, Jan 16, 2026 · control 11-AS-20260109121510

Allegation investigated: Staff are mistreating a resident. Staff inappropriately locked in a resident. Staff exposed a resident to harmful material. Staff did not afford a resident privacy. Staff unlawfully evicted a resident. Staff mishandled a resident's personal belongings.

On 01/08/26, LPA Gonzalez conducted a subsequent complaint visit to further investigate the allegations listed above and deliver findings. LPA met with Assistant Administrator Cesilia Torres, and the purpose of the visit was explained. LPA was allowed entry to the facility. The investigation consisted of the following: On 10/16/25, LPA Gonzalez conducted interviews with staff #1-#4 (S1-S4), residents #2-#7 (R2-R7), and attempted to interview resident #1 (R1). LPA requested the following documents: staff roster, resident roster, and Notice of Unlawful Detainer for R1. Additionally, LPA toured the facility, and inspected resident bedrooms, and common areas. On 01/08/26, LPA Gonzalez requested the following documents: Admission Agreement, House Rules, and 30-day eviction notice for R1. Contininued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff are mistreating a resident. It is being alleged that R1 was illegally moved from room #229 to #218. On 10/16/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said they treat all residents with dignity and respect. On 10/16/25, LPA Gonzalez conducted interviews with R2-R7, and attempted to interview R1, but was unable to as R1 was out of the facility, and LPA was unable to reach R1 via telephone. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. 6 out of 6 residents said staff treat them with dignity and respect. Based on records reviewed, observation, and interviews conducted, there is insufficient 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 inappropriately locked in a resident. It is being alleged that R1 was illegally locked out with a plastic cup on the door. On 10/16/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 3 out of 4 staff denied the allegation. On 10/16/25, LPA Gonzalez conducted interviews with R2-R7, and attempted to interview R1, but was unable to as R1 was out of the facility, and LPA was unable to reach R1 via telephone. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. Based on records reviewed, observation, and interviews conducted, there is insufficient 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 exposed a resident to harmful material. It is being alleged that R1 was placed in an asbestos laden room. On 10/16/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. Continued on LIC9099-C On 10/16/25, LPA Gonzalez conducted interviews with R2-R7, and attempted to interview R1, but was unable to as R1 was out of the facility, and LPA was unable to reach R1 via telephone. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. Based on records reviewed, observation, and interviews conducted, there is insufficient 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 afford a resident privacy. It is being alleged that staff charged in a residents room at 7 AM while they were sleeping. On 10/16/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said they knock on the door before entering the residents room. On 10/16/25, LPA Gonzalez conducted interviews with R2-R7, and attempted to interview R1, but was unable to as R1 was out of the facility, and LPA was unable to reach R1 via telephone. Of those interviewed, 6 out of 6 residents denied the allegation. Based on records reviewed, observation, and interviews conducted, there is insufficient 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 unlawfully evicted a resident. On 10/16/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. An interview with S1 revealed that there are two residents who are being lawfully evicted. On 10/16/25, LPA Gonzalez conducted interviews with R2-R7, and attempted to interview R1, but was unable to as R1 was out of the facility, and LPA was unable to reach R1 via telephone. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. Continued on LIC9099-C On 01/08/26, LPA Gonzalez reviewed R1’s Admission Agreement, which was signed and dated on 04/11/23 by R1 agreeing to pay the monthly fees. LPA reviewed the facility’s House Rules, which were signed and dated by R1 on 04/11/23. LPA reviewed a 30-day eviction notice dated 09/18/24, and it noted that R1 was to be evicted as of 10/18/24 due to R1 failing to pay rent to the facility. LPA reviewed an Unlawful Detainer Eviction Notice dated 08/08/25. Based on records reviewed, observation, and interviews conducted, there is insufficient 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 mishandled a resident's personal belongings. It is being alleged that R1’s eviction paperwork along with most of their belongings have been stolen. On 10/16/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. On 10/16/25, LPA Gonzalez conducted interviews with R2-R7, and attempted to interview R1, but was unable to as R1 was out of the facility, and LPA was unable to reach R1 via telephone. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. Based on records reviewed, observation, and interviews conducted, there is insufficient 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. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Assistant Administrator Cecilia Torres.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 11-AS-20251006223935

Allegation investigated: Staff allow residents to be left in soiled clothing for extended periods of time. Resident sustained unexplained bruises. Staff do not ensure resident receives adequate bathing services. Staff does not ensure resident is free of mal odors. Staff do not observe changes in residents health care needs.

On 01/08/26, LPA Gonzalez conducted a subsequent complaint visit to further investigate the allegations listed above and deliver findings. LPA met with Assistant Administrator Cesilia Torres, and the purpose of the visit was explained. LPA was allowed entry to the facility. The investigation consisted of the following: On 09/03/25, LPA Gonzalez conducted interviews with staff #1-#4 (S1-S4), and residents #1 (R1). LPA requested the following documents: staff roster, resident roster, and resident’s bath schedule. LPA reviewed R1’s service records and requested copies of the following documents: Facesheet, Physician's Report, Needs and Services Plan, and shower log notes. Additionally, LPA and Cesilia Torres toured the facility, and inspected resident bedrooms, and common areas. On 10/16/25, LPA Gonzalez conducted interviews with resident #2-#6 (R2-R6). Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff allows resident to be left in soiled clothing for extended periods of time. It is being alleged that R1 was observed with filthy and soiled clothing. It is also being alleged that R1 only has one pair of underwear. On 09/03/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said residents receive a change of clothing daily and as needed. 4 out of 4 staff said that resident who require incontinence care are changed every 2 hours, and as needed. 4 out of 4 staff said that R1 has more than one pair of underwear. On 09/03/25, LPA Gonzalez conducted an interview with R1. On 10/16/25, LPA Gonzalez conducted interviews with R2-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. 6 out of 6 residents said staff had never left them in soiled clothing for an extended period of time. 6 out of 6 residents said they receive a change of clothing daily. 6 out of 6 residents said they own more than one pair of underwear. On 09/03/25, LPA Gonzalez conducted a tour of the facility and inspected R1’s bedroom (#118). LPA observed the room to be clean, sanitary, and in good order. LPA observed clean clothing stored in R1’s drawer space, including more than one pair of clean underwear available for R1’s use. Based on records reviewed, observation, and interviews conducted, there is insufficient 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: Resident sustained unexplained bruises. It is being alleged that R1 had red and purple bruises all over their arms and was walking in pain. On 09/03/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said that R1 has not sustained any unexplained injuries or unwitnessed falls. An interview with S1 revealed that they believe the spots on R1 are more like aging spots and not bruises. Continued on LIC9099-C On 09/03/25, LPA Gonzalez conducted an interview with R1. On 10/16/25, LPA Gonzalez conducted interviews with R2-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. 6 out of 6 residents said they have not sustained any unexplained injuries or unwitnessed falls. An interview with R1 revealed that they have never been physically abused at the facility, and that they don’t believe they have bruises on their arms, but rather more like aging spots. Additionally, on 09/03/25, while speaking with R1, LPA did not observe R1 to have any red and/or purple bruises all over their arms. Based on records reviewed, observation, and interviews conducted, there is insufficient 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 do not ensure resident receives adequate bathing services. It is being alleged that R1 only receives a bath once a week. It is also being alleged that staff never fully wash R1, causing a buildup of feces on their bottom. On 09/03/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said that residents receive 2 showers a week. An interview with S2 revealed that S2 is responsible for assisting R1 with bathing. S2 stated that R1 is scheduled to receive two showers per week; however, R1 often declines bathing, and during those times may receive only one shower per week. On 09/03/25, LPA Gonzalez conducted an interview with R1. On 10/16/25, LPA Gonzalez conducted interviews with R2-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. 6 out of 6 residents said they bathe 2-3 times a week. An interview with R1 revealed that staff offer to assist them with bathing several times a week, but they chose to only bathe once a week. R1 said staff do a good job in assisting them with bathing, and that denied staff leaving buildup feces in their bottom. During a review of records, LPA reviewed caregiver notes and observed documentation indicating that R1 refused to shower on 07/02/25, 07/18/25, 07/30/25, and 08/08/25. LPA also reviewed the facility’s Bath Schedule, which indicated that all residents are scheduled to receive at least two showers per week. Based on records reviewed, observation, and interviews conducted, there is insufficient 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 does not ensure resident is free of mal odors. It is being alleged that a resident smelled very bad. On 09/03/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. An interview with S1 revealed that when staff observe an odor indicating a resident may require hygiene assistance, staff will request that the resident shower and change their clothing. On 09/03/25, LPA Gonzalez conducted an interview with R1. On 10/16/25, LPA Gonzalez conducted interviews with R2-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. Additionally, on 09/03/25, while speaking with R1, LPA observed that R1 was wearing clean clothing and did not observe any odors emanating from R1. Based on records reviewed, observation, and interviews conducted, there is insufficient 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 do not observe changes in residents health care needs. It is being alleged that R1 could barely walk but did not have a cane or a walker for support. On 09/03/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff stated that R1 has not sustained any unexplained injuries or unwitnessed falls. 4 out of 4 staff stated that R1 has not complained about having any pain. 4 out of 4 staff stated that R1 is ambulatory. 4 out of 4 staff stated that R1 refuses to use a walker. On 09/03/25, LPA Gonzalez conducted an interview with R1. On 10/16/25, LPA Gonzalez conducted interviews with R2-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. An interview with R1 revealed that R1 does not require the use of a walker and stated that they do not wish to use one. R1 reported that both their physical therapist and physician have recommended the use of a walker; however, R1 declined to use the device. Additionally, on 09/03/25, while speaking with R1, LPA observed R1 ambulating independently without the use of an assistive device. Continued on LIC9099-C During a review of records, LPA reviewed R1’s Physician’s Report (dated: 01/20/25), which indicated that R1 is ambulatory and does not require the use of an assisted device. Based on records reviewed, observation, and interviews conducted, there is insufficient 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. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Assistant Administrator Cecilia Torres.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 11-AS-20250826111643

Allegation investigated: Staff did not prevent a resident from developing pressure injuries. Staff do not ensure that residents' dietary needs are met. Staff do not observe residents for change in condition. Staff did not assist resident with grooming. Staff do not maintain facility sanitary.

**This report supersedes the previous report created on 10/17/2025 to correct and clarify findings. ** On 12/18/2025 at approximately 08:06 AM, Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit to re-deliver findings to the facility listed above. LPA Watson met with the administrator Ella Nayagas, and the purpose of today’s visit was explained. LPA was given access to the facility. The investigation consisted of the following On 10/16/2025 between 10:20 AM – 04:58 PM, the department requested, reviewed, and obtained copies of the Staff Roster (08/01/2025) and Resident Roster (10/11/25). CONTINUED ON LIC9099-C Unsubstantiated On 10/17/2025 at approximately 08:48 AM, the department requested and obtained the following documentation: Admission Agreement, Physician’s Report (01/20/25), Appraisal Needs and Services (10/02/2024), and Monthly Menu Plan, Staff Log Notes (01/04/25) and Medical Records (02/01/25-03/29/25). On 10/16/2025 at approximately 10:20 AM, the department conducted interviews with Staff #1-#5 (S1-S5), Beverly Hills Home Health Care/LVN (W1) and Residents #2-#7 (R2-R7). The investigation revealed the following: Allegation: Staff did not prevent a resident from developing pressure injuries. This complaint is alleging that R1 sustained pressure injuries on the backside of their body and was hospitalized with these injuries on 3/18/25. The department conducted an interview with the Administrator/ Bella Naygas, Staff #1 (S1), the Administrator, S1, who stated that the facility provided meals to Resident #1 (R1) over a two day period 03/16/25 - 03/18/25. During this time, R1 consistently refused both food and fluids. In response, to R1 not eating the staff offered Ensure as a nutritional supplement, but R1 also refused that. On the second day that R1 declined food, including Ensure, the facility arranged for him to be transferred to So Cal Culver City Hospital. Following his transfer to hospital R1 did not return to the facility after discharge. S1 stated R1 did not sustain pressure injuries while in care. Staff #1 (S1) stated that residents are monitored closely daily, for changes in skin conditions and caregivers report any changes. The department conducted an interview with the Beverly Hills Home Health Care Nurse /LVN (W1) revealed that she visits the facility between 8:00 AM – 11:00 AM, seven days per week, and assists R1 as well as other facility residents. The LVN stated repositioning residents, hygiene needs, skin injuries and infection prevention are part of ongoing staff training. The department obtained and reviewed R1’s medical records from So Cal Culver City Hospital and found R1 was admitted for lethargy and dehydration from 3/18/25-3/25/25. The department was unable to find evidence of R1 having sustained pressure injuries on the backside of their body. Additionally, the hospital records reflected skin assessments were conducted daily while R1 was hospitalized. On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Residents #2–#7 (R2–R7). The department asked the residents if staff neglected to prevent them from developing pressure injuries. Of those interviewed, 6 out of 6 residents denied the allegation. An attempt to interview Resident #1 (R1) was made; however, R1 was hospitalized at the time of the visit and could not be interviewed via telephone. CONTINUED ON LIC9099-C On 10/16/2025, the department interviewed Staff #1–#6 (S1–S6) and found 6 out of 6 staff denied the allegation Staff did not prevent R1 from developing a pressure injury. Based on records, observations, interviews conducted, and an analysis of evidence gathered, the department found no evidence to support the allegation mentioned above. 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 do not ensure that residents’ dietary needs are met. This complaint is alleging R1 was malnourished at the facility and that “all of the residents" at the facility, appeared to be underweight. The department conducted an interview with the Administrator, S1, who stated R1 was diabetic and (3) sugar-free meals and an evening snack were provided to R1 daily. When R1 refused to eat, an Ensure was provided. S1 stated that the facility is supporting 8 Residents who have diabetes and special diets. The facility ensures their food is sugar-free. The department obtained and reviewed a Monthly Menu that revealed the facility is providing food to ensure Residents dietary needs are met.On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Residents #2–#7 (R2–R7) and 6 out of 6 Residents denied the allegation. An attempt to interview Resident #1 (R1) was made; however, R1 was not at the facility at the time of the visit and could not be reached by phone. On 10/16/2025 between 10:20 AM – 04:58 PM, the department interviewed Staff #1–#6 (S1–S6) and 6 out of 6 staff denied the allegation.On 10/17/2025 between 10:20 AM – 04:58 PM, the department requested, obtained, and reviewed the weekly menu plan from the facility, which showed that the resident in question was offered three meals a day plus two snacks daily. Interviews with residents revealed that they were served three meals and two snacks daily. The department obtained and observed the monthly dietary menu provided by the facility, which reflected that residents were provided with three meals a day plus snacks. Interviews with R2–R7 and S1–S6 revealed that food is served to the residents according to their dietary needs. CONTINUED ON LIC9099-C Based on records, observations, interviews conducted, and an analysis of evidence gathered, the department found no evidence to support the allegation mentioned above. 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 do not observe residents for changes in conditions This complaint is alleging R1 may have required a higher level of care at a hospital or Skilled Nursing Facility. The department conducted an interview with the Administrator, Staff #1 (S1), who stated R1 had a Home Health LVN (W1), who worked 8:00 am -11:00 am seven days a week with R1. A1 stated the caregivers report all changes in conditions. Additionally, the facility has a wound specialist and a general physician to perform routine checks on all the residents. A1 stated Resident health issues are addressed immediately. On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Residents #2–#7 (R2–R7) 6 out of 6 Residents express no concerns about staff monitoring changes in condition. An attempt to interview Resident #1 (R1) was made; however, R1 was not at the facility at the time of the visit and could not be contacted by phone. On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Staff (S#1-S#6) and 6 out of 6 staff denied the allegation. Staff interviewed stated that they monitor Residents and report any signs of change. Based on records, observations, interviews conducted, and an analysis of evidence gathered, the department found no evidence to support the allegation mentioned above. 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. CONTINUED ON LIC9099-C Allegation: Staff did not assist residents with grooming. This complaint is alleging that R1’s fingernails RP observed Daniel's fingernails to be three inches long. On 10/16/2025 between 10:20 AM – 04:58 PM, The department conducted and an interview with the Administrator, Staff #1 (S1), who stated the facility have staff who assist the residents with their grooming. The Administrator (S1) stated that every Friday the facility has a beauty shop open to assist the residents with hair and provide shaving services. Additionally, S1 stated R1 received assistance with grooming and R1’s nails were trimmed when they appeared to be overgrown by caregivers. This would occur in combination with R1’s shower.On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Residents #2–#7 (R2–R7) and 5 out of 6 Residents stated they are independent and do require assistance with grooming. 1 out of 6 Residents stated assistance was provided when showering. An attempt to interview Resident #1 (R1) was made; however, R1 was not present at the facility and could not be reached by phone. On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Staff #1–#6 (S1–S6) and 6 out of 6 Staff interviewed denied the allegation. S2 stated she assist Residents with their showers, nails, hair, and brushing teeth.Based on records, observations, interviews conducted, and an analysis of evidence gathered, the department found no evidence to support the allegation mentioned above. 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 do not maintain facility sanitary. This complaint is alleging the facility has cobwebs, dirt and debris, and “greasy grimy” fingerprints on the doors walls as well as baseboards. The department conducted an interview with the Administrator, Staff #1 (S1), who stated the facility is cleaned daily by three housekeepers. A1 states two housekeepers clean the facility from 7:00 AM – 3:00 PM, and the third works from 10:00 AM – 5:00 PM daily. On 10/16/2025, at 4:30 pm the department toured the facility and outside grounds. The department observed the facility to be clean and sanitary. During the facility tour, LPA Watson observed staff members mopping and gathering trash in bins. CONTINUED ON LIC9099-C On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Residents #2–#7 (R2–R7) and 6 out of 6 Residents denied the allegation. The Residents interviewed stated there is approximately two staff members cleaning regularly on each floor. An attempt to interview Resident #1 (R1) was made, but R1 was not at the facility at the time of the visit. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. 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 the Administrator Ella Naygas and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 11-AS-20250324094301

Allegation investigated: Staff yells at a resident Staff allows a resident to smoke inside the facility Staff did not meet the residents toileting needs

On 12/11/2025, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent complaint investigation to deliver findings regarding the allegations mentioned above and met with Administartor Assistant Cesilia Torres. The investigation consisted of the following: On October 15, 2025, at approximately 10:00 AM, during which LPA met with Administrator Assistant Cesilia Torres and conducted a tour of the facility, including resident rooms. The investigation consisted of the following: interviews with seven staff members (S1–S7) and seven residents (R1–R7), as well as a review of relevant records such as the personnel report, incident reports, admission agreements, staff training records, and the current resident roster. Investigation revealed the following: regarding the allegation that staff yell at residents, 6 staff denied the allegation and 1 was unsure; among the residents, 5 disagreed, 1 agreed, and 1 did not respond. Please see report continuation on (LIC9099-C) Unsubstantiated No staff were observed yelling at residents during the visit, and training records confirmed instruction on resident rights and respectful care. Records reviewed multiple in-service trainings teaching and reminding staff to treat residents with dignity and respect. Although the allegation may have occurred, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. Concerning the allegation that staff allow residents to smoke inside the facility. Interviews revealed that 1 resident agreed, 5 disagreed, and 1 did not respond; all staff (S1-S7) denied the allegation and confirmed that residents are consistently redirected to the designated outdoor smoking area. Records reviewed revealed that Admission agreements prohibit indoor smoking, and during the visit, residents observed smoking in the designated patio area. Although the allegation may have occurred, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. Regarding the allegation that staff did not meet residents’ toileting needs, it was alleged that R1’s toilet was not repaired in a timely manner. Interviews with residents (R1-R7) revealed that 6 residents disagreed and 1 agreed, noting the issue was resolved; among staff, 6 disagreed and 1 was unsure. Toilets were observed to be operational during the visit. The maintenance staff stated that the toilet was clogged and repaired the same day using a plumbing snake and confirmed that maintenance issues are often communicated verbally and not formally logged to address them quickly. A maintenance work log notebook is maintained at the facility, with entries dated 02/21/2024 to 09/22/2024, documenting completed task orders and corresponding room numbers. Although the allegation may have occurred, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. Based on observations, interviews, and records reviewed, there is insufficient evidence to support the allegations; therefore, the allegations are unsubstantiated. No deficiencies were cited during today’s visit, and an exit interview was conducted with the administrator.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 11-AS-20251008084423

Allegation investigated: Staff wrongfully evicted resident.

On 11/19/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above mentioned allegation. LPA met with Assistant Administrator, Cecilia Torres, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On 11/19/25, obtained the facility’s staff and resident rosters. LPA reviewed resident #1’s (R1’s) service records and obtained copies of the following records: 30-day Eviction Notice (dated 07/02/25), Unlawful Detainer Eviction Notice (dated 08/08/25), Admission Agreement (signed and dated 04/11/23), Identification and Emergency Information, Admission Record, Physician’s Report (dated 03/12/23), Appraisal & Needs and Services Plan (dated 04/02/25), Personal Rights, and House Rules (dated 04/11/23). Additionally, LPA Gonzalez interviewed staff #1-#2 (S1-S2) and attempted to interview R1. Unsubstantiated The investigation revealed the following: Allegation: Staff wrongfully evicted a resident. It is being alleged that staff wrongfully evicted a resident. On 11/19/25, LPA Gonzalez conducted interviews with S1–S2. Of those interviewed, 2 out of 2 staff denied the allegation. An interview with S1 revealed that R1 was served with a 30 eviction notice on 09/18/24 and was also served with an Unlawful Detainer Eviction Notice dated (dated 08/08/25). S1 stated that R1 is being evicted because of non-payment. S1 stated that the facility has not received a payment from R1 since 09/05/23. S1-S2 stated that the 30-day eviction notice was submitted to CCLD in a timely manner. On 11/19/25, LPA Gonzalez attempted to interview R1 but was unable to as R1 was not in the facility and couldn’t be reached via telephone. On 11/19/25, LPA Gonzalez reviewed R1’s Admission Agreement, which was signed and dated on 04/11/23 by R1 agreeing to pay the monthly fees. LPA reviewed the facility’s House Rules, which were signed and dated by R1 on 04/11/23. LPA reviewed a 30-day eviction notice dated 09/18/24, and it noted that R1 was to be evicted as of 10/18/24 due to R1 failing to pay rent to the facility. LPA reviewed an Unlawful Detainer Eviction Notice dated 08/08/25. Based on records reviewed, and interviews conducted, there is insufficient 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. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of the report was provided to the Cecilia Torres.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 11-AS-20251112150550

Allegation investigated: Staff did not prevent a resident from developing pressure injuries. Staff do not ensure that residents' dietary needs are met. Staff do not observe residents for change in condition. Staff did not assist resident with grooming Staff do not maintain facility sanitary

On 10/17/2025 LPA Watson conducted a subsequent complaint visit to deliver findings to the facility listed above. LPA met with the Marketing/Care Giver Yesenia Robles, and the purpose of today’s visit was explained. LPA was given access to the facility. The investigation consisted of the following: On 10/16/2025 Licensing Program Analyst (LPA) Watson requested, reviewed, and obtained copies of the Staff Roster, Client Roster, On 10/17/2025 LPA Watson requested and obtained the following documentatin : Admission Agreement, Physicians Report, Appraisal Needs and Services and Monthly Menu Plan. On10/16/2025 LPA Watson conducted interviews with Staff #1-Staff #6 (S1-S6) and Residents #2- Residents #7 (R2-R7). CONTINUED ON LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not prevent a resident from developing pressure injuries. On 10/16/2025 LPA Watson conducted interviews with Residents #2- Residents #7 (R2-R7). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit.LPA Watson asked the residents if staff neglected to prevent them from developing pressure injuries. Of those interviewed, 6 out of 7 residents denied the above allegation. On 10/16/2025 LPA Watson interviewed Staff #1- Staff #6 (S1-S6). LPA Watson asked the staff if they met the residents’ dietary needs. Of those interviewed, 6 out of 6 staff denied the above allegation. On 10/17/2052, LPA Watson requested documentation and incident reports, from the on duty nurse and staff interviewed, and found that there was no documented evidence of pressure injuries developed by the resident in care. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. 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 do not ensure that residents' dietary needs are met. On 10/16/2025 LPA Watson conducted interviews with Residents #2- Residents #7 (R2-R7). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit. LPA Watson asked each resident interviewed if staff did not ensure their dietary needs were met. Of those interviewed, 6 out of 7 residents denied the above allegation. On 10/16/2025 LPA Watson interviewed Staff #1- Staff #6 (S1-S6). LPA Watson asked the staff if they assisted residents with their dietary needs. Of those interviewed, 6 out of 6 staff denied the above allegation. On 10/17/25 LPA Watson requested, obtained and reviewed the weekly menu plan from the facility and it showed that the resident in question was offered three meals a day plus snacks. Based on the information gathered, interviews conducted, and review of records LPA Watson found no evidence to support the allegation mentioned above. 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. CONTINUED ON LIC9099-C Allegation: Staff do not observe residents for change in conditions. On 10/16/2025 LPA Watson conducted interviews with Residents #2- Residents #7 (R2- R7). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit. LPA Watson asked the residents if staff monitored them for any change in conditions. Of those interviewed, 6 out of 7 residents interviewed denied the above allegation. On 10/16/2025 LPA Watson asked the staff if they observed residents for change in conditions. 6 out of 6 staff interviewed denied the above allegation. LPA Watson requested, obtained and reviewed staff log notes and found that there was no documented evidence of changes in conditions about the residents. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. 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 assist residents with grooming. On 10/16/2025 LPA Watson conducted interviews with Residents #2- Residents #7 (R2-R7). LPA Watson asked the residents if staff neglected to assist them with their grooming. An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit. Of those interviewed, 6 out of 7 residents denied the above allegation. On 10/16/2025 LPA Watson interviewed Staff #1- Staff #6 (S1-S6). LPA Watson asked the staff if they assisted residents with their grooming needs. Of those interviewed, 6 out of 6 staff denied the above allegation. LPA Watson interviewed 6 staff members and 6 residents and all of those interviewed stated that staff assisted residents with grooming. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. 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. CONTINUED ON LIC9099-C Allegation: Staff do not maintain sanitary facilities. On 10/16/2025 LPA Watson conducted interviews with Residents #2- Residents #7 (R2-R7). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit. LPA Watson asked the residents if staff maintained the facility to be sanitary. Of those interviewed, 6 out of 7 denied the above allegation. On 10/16/2025 LPA Watson interviewed Staff #1- Staff #6 (S1-S6). LPA Watson asked the staff if they maintained the facility clean and sanitary. Of those interviewed, 6 out of 6 denied the above allegation. LPA Watson conducted a tour of the facility and found the facility to be clean and in good repair. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. 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 the Marketing / Care Giver Yesenia Robles and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 11-AS-20250324094301

Allegation investigated: An adult in the facility pushed a resident in care.

On 10/17/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegation listed above. LPA met with the Assistant Administrator Cesilia Torres, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 10/17/2025, interviews were conducted, and records were reviewed. Interviews were conducted with Resident 1 (R1) to Resident 6 (R6) and Staff 1 (S1) to Staff 5 (S5). Facility records were reviewed which consisted of Personnel Report dated 08/2025, Resident Roster, and Staff In Service Training on Personal Rights dated 05/15/2025. Unsubstantiated The investigation revealed the following: Allegation: “An adult in the facility pushed a resident in care.” Interviews conducted with R1 to R6 revealed the following: 5 out of 6 residents denied the allegation, and 1 out of 6 residents agreed with the allegation. Interviews conducted with S1 to S5 revealed the following: 5 out of 5 staff denied the allegation. Record review of the Staff In Service Training on Personal Rights dated 05/15/2025 revealed the following: the document has staff signatures acknowledging that staff have attended the training, furthermore, the document states that staff will treat residents with “dignity.” Records review of Unusual Incident Reports for 08/2025 to 10/2025 revealed the following: there are no Unusual Incident Reports indicating that a person (e.g. staff/resident/visitor) pushed a resident in care. Observations on 10/17/2025 revealed the following: the Department did not observe residents/staff pushing residents in care. Based on the department’s interviews, observations, and records reviewed this allegation is 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. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Assistant Administrator Cesilia Torres.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 11-AS-20251013171648

Allegation investigated: Staff do not keep the facility free from infestation

On 10/15/2025 at approximately 10:00AM, Licensing Program Analyst (LPA) Jose Anguiano conducted a complaint visit to the above allegation. During the facility tour, LPA observed live bed bugs on the wall near a resident’s bed, blood stains on the walls and floors of the rooms toured, and visible bite marks on residents’ arms. Staff members confirmed the presence of bed bugs during interviews. Due to the observed conditions and confirmed infestation, a deficiency was cited under Title 22, Section 87303. An exit interview was conducted with Cesilia Torres, and a copy of this report and LIC 9099D was provided. Substantiatedthe state’s words, verbatim · CDSS document, Oct 15, 2025 · control 11-AS-20251008084423

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 29, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on observations and interviews, the licensee did not maintain a clean and sanitary environment. On 10/15/2025, LPA observed live bed bugs in the facility. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: Administrator and staff will meet to develop a plan to eradicate the bed bug infestation. Proof of treatment and corrective actions will be submitted by 10/29/2025. jose.anguiano@dss.ca.gov

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff yell at resident Staff do not safeguard resident's personal belongings

On 09/18/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unannounced, visit to the facility. LPA was met by staff two, Cesilia Torres - Assistant Administrator (S2), and the purpose of the visit was explained. The investigation consisted of the following: On 07/09/25 LPA requested and reviewed facility documents, including the staff and resident rosters (dated: 06/25/25), and obtained the following documents of resident 1 (R1): Emergency ID form (dated: 05/18/16), admission agreement (dated: 08/08/20), physicians report (dated:12/16/24), needs and services plan (dated: 02/08/24), preplacement appraisal (dated: 02/08/24), safe guarded cash resources (dated, and signed: 09/09/20), copies of seven (7) incidents involving various residents (dated from 05/01/25 through 07/03/25) and LPA toured the facility to conduct observations and interviews. LPA interviewed seven (7) out of fifty-nine (59) residents and four (4) out of twenty-seven (27) staff. On 09/18/25 LPA conducted a subsequent, unannounced, complaint visit to deliver these findings. Report continues, see LIC9099-C Substantiated The investigation revealed the following: Regarding the allegation, “Unlawful Eviction”, it is being alleged that a resident has received an eviction notice that was taped on their door upon a resident’s return to the facility. Interviews revealed the following; six (6) residents (R2 through R7) and all four (4) staff (S1 through S4) have denied the allegation has taken place. R1 has stated that they received the document during the evening of 07/02/25. Record reviews have indicated the following: a resident has received a “Thirty day notice to quit premises” (dated: 06/26/25) from “Dennis P. Block & Associates, APC”. Our division, Community Care Licensing (CCL) has not received any notification of any eviction notice related to a resident in question. The dates reviewed and dates provided do not match. This “eviction” does not meet This document has not been signed, nor does it include Title 22, Eviction Procedures 87224(a)(1-4). Interviews have revealed six (6) out of seven (7) (R2-R7) and all four staff (S1-S4) have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation, “Staff do not ensure resident receives mail in a timely manner”, it is being alleged that a resident does not receive their mail. Interviews revealed the following: Three (3) residents (R4. R6, R7) have agreed the allegation has taken place, while one resident (R4) is not sure. All four staff (S1-S4) have denied the allegation has taken place. LPA observations revealed the following: On 07/09/25, around 11am, LPA observed the United States Postal Service dropping off residents’ mail. Throughout the day, LPA did observe staff providing mail to residents in care as each resident passed by the front lobby. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been two (2) deficiencies cited during today's visit. Please see LIC9099D. During today's visit, there have been two (2) deficiencies cited. Please see LIC9099D. An exit interview was held with Cesilia Torres - Assistant Administrator and a copy of facilities' appeal rights, the deficiencies cited, plans of corrections and a copy of this report has been provided. Regarding the allegation, “Staff yell at resident”, it is being alleged that the administrator and other staff yell at a resident. Interviews revealed the following: three (3) out of seven (7) residents (R1, R4, R7) and three (3) out of four (4) staff (S2-S4) have agreed the allegation has taken place, while one (1) resident was not sure. Record reviews have indicated that S1-S4 have met training standards, Title 22, 87411(c)(3)(C) “Personnel Requirements – General” which include “Personal rights” of residents in care. LPA’s observations have indicated that the behavior of staff at the facility respond negatively when addressed harshly by residents in care, which does not meet previous trainings under 87411(c)(3)(C) “Personal rights”. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. Please see LIC9099D. Regarding the allegation, “Staff do not safeguard resident's personal belongings”, it is being alleged that a resident is missing multiple personal items. Interviews revealed the following: four (4) out of seven (7) residents (R1-R4) and one (1) staff have agreed the allegation has taken place. Record reviews revealed the following: seven residents (R1-R7) have got personal property inventory within their files, but that they are not kept up to date. According to Health and Safety Code section 1569.153(c), the facility does not keep records of the items missing, as reported from residents. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. Health and safety code 1569.313(c) is being cited on the attached LIC 9099D. Please see LIC9099D. During today's visit, there have been two (2) deficiencies cited. Please see LIC9099D. An exit interview was held with Cesilia Torres - Assistant Administrator. A copy of facilities' appeal rights, the deficiencies cited, plans of corrections and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 11-AS-20250703102651

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 26, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to...87468.1,...the following personal rights: (4) To...supervision, and services...meet their individual needs and are delivered by staff that are sufficient in..., and competency...to meet their needs. This has not been met as evidenced by: Based on LPA observations and interviews conducted, the licensee did not ensure care and supervision were delivered to meet R1's personal needs which poses a potential health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: The Co-Administrator and LPA have agreed that the facility will hold an in-staff training surrounding 87468, 87468.1 and 87468.2. Specifically regarding staff's response when staff have been negatively provoked by residents in care. The document will indicate which sections of these regulation (s) have been covered, the date and time of the training held, with staff signatures, and by whom the training was held with. Co-Administrator/Administrator will forward these training(s), via email, to LPA at MARIO.LEON@DSS.CA.GOV

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.153(c) · Plan of correction due date: Sep 26, 2025

1569.153 Theft and loss program; standards, property inventories and surrender of personal effects; secured areas (c) Documentation of...documented theft and loss record(s)...past 12 months shall be made available to the state department of Social Services...in response to a...complaint. This has not been met as evidenced by: based on record reviews and interviews conducted, licensee did not ensure that documentation of items lost or stolen from R1-R4 for the past 12 months were on file which poses a potential health, safety and personal rights risk risk to clients in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: The Administrator and LPA have agreed that the facility will conduct an updated inventory for residents in care. The facility will also require residents to report new items, valued above $25 and will update their LIC9059 - PERSONAL PROPERTY PROCEDURES (RCFE). Co-Administrator/Administrator will inform LPA via confirmation of 1569.153(c) , via email, and continue to log incidents between residents in care at MARIO.LEON@DSS.CA.GOV

Type of visit: Required - 1 Year

On 08/6/25, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced required – annual inspection and met Administrator Bella Naygas then later with Cecilia Torres/Assistant Administrator. The facility is licensed to operate for (110) non-ambulatory elderly adults of ages 60 and above. The facility is approved for (15) hospice residents. Currently, the facility has (61) residents The facility is a two-story building located in a commercial neighborhood. It consists of the following: (55) resident bedrooms. Each room has a bathroom, an activity room, a dining area, a library, a kitchen, a courtyard patio, a lobby, (2) public restrooms, and subterranean parking. LPA Iniguez and the Administrator toured the physical plant. There were no obstructions on the premises, a covered jacuzzi was in the back yard. LPA inspected a total of (6) bedrooms and (6) 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 properly measured between 105F° and 120F°. 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 6/11/25. A review of (4) residents' service files and (4) staff personnel files. LPA reviewed (4) 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 the liability insurance will be emailed to LPA. 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 Cecilia Torres/Assistant Administrator.the state’s words, verbatim · CDSS document, Aug 6, 2025

Allegation investigated: Facility staff did not ensure resident's room was maintained clean. Facility staff did not ensure change in condition was brought to the attention of resident's physician. Facility staff spoke inappropriately to resident.

**This report supersedes the report created and delivered on 05/28/25. This report is to clarify findings. On 05/28/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above-named allegations. LPA met Assistant Administrator, Cesilia Torres, and Caregiver Yesenia Robles, and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 05/28/25, LPA requested and received the following documents: staff roster, resident roster, Identification and Emergency Information, Physician’s Report, Admission Agreement, Preplacement Appraisal Information, and Needs and Services Plan for resident #1 (R1). Additionally, LPA conducted interviews with staff #1 - #5 (S1-S5), residents #2 - #7 (R2-R7) and attempted to interview R1. Furthermore, LPA and Caregiver, Yesenia Robles toured the facility. Unsubstantiated The investigation revealed the following: Allegation: Facility staff did not ensure resident's room was maintained clean. It is being alleged that this facility, including a resident’s room, is dirty. On 05/28/25 between 10:45 AM and 12:00 PM, LPA Gonzalez interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that resident’s rooms are deep cleaned at least once a week, and as necessary. On 05/28/25 between 01:05 PM and 02:20 PM, LPA interviewed R2-R7. Based on interviews conducted, 6 out 6 residents interviewed stated their rooms are cleaned daily and deep cleaned once a week. 6 out of 6 residents interviewed stated that staff maintain their room and the facility is clean and sanitary. 6 out of 6 residents interviewed stated that they are satisfied with the services provided to them at this facility. LPA Gonzalez and Yesenia Robles toured the facility. LPA inspected rooms #110, #108, #209, public restrooms, and common areas. LPA observed the rooms and facility to be clean and sanitary at the time of inspection. 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: Facility staff did not ensure change in condition was brought to the attention of resident's physician. It is alleged that a resident was experiencing heart problems and was having trouble breathing. It is also alleged that staff did nothing to assist the resident. On 05/28/25 between 10:45 AM and 12:00 PM, LPA interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed could not validate this allegation. 5 out of 5 staff interviewed stated that they were not aware of a resident experiencing heart and breathing problems. 5 out of 5 staff interviewed stated that they actively monitor the residents for any change in condition. 5 out of 5 staff interviewed stated that staff ensures to notify the Administrator, and they will then notify the residents physician if there is a change in condition in the resident. S1 stated that they were not aware of any resident experiencing heart and breathing problems. S1 stated that staff monitor the residents closely, and if any significant changes are observed, the protocol is to notify the administrator immediately and to seek prompt medical attention. On 05/28/25 between 01:05 PM and 02:20 PM, LPA interviewed R2-R7. Based on interviews conducted, 6 out of 6 residents interviewed could not corroborate this allegation. 6 out of 6 residents interviewed stated they are not aware of a resident experiencing heart and breathing problems. 6 out of 6 residents interviewed stated that staff ensures to notify their physician if there is a change in their condition. 6 out of 6 residents interviewed stated that they are satisfied with the services provided to them at this facility. Based on observation, records reviewed, 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: Facility staff spoke inappropriately to resident. It is being alleged that facility Administrator, Bella Naygas, does not want a resident at this facility and is insulting and uncooperative. On 05/28/25 between 10:45 AM and 12:00 PM, LPA interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that they are not aware if Administrator Bella Naygas does not want a resident at this facility. 5 out of 5 staff interviewed stated that they have not observed Administrator Bella Naygas insulting and/or being uncooperative with a resident. S1 denied the allegation. S1 stated that they have not insulted any resident. S1 stated that they always try and cooperate with the residents at this facility. 5 out of 5 staff interviewed stated that they treat all residents with dignity and respect. On 05/28/25 between 01:05 PM and 02:20 PM, LPA interviewed R2-R7. Based on interviews conducted, 6 out of 6 residents interviewed could not corroborate this allegation. 6 out of 6 residents interviewed stated that they are not aware if Administrator Bella Naygas wants a resident out of this facility. 6 out of 6 residents interviewed stated they have not observed Administrator Bella Naygas insult or be uncooperative with any resident. 6 out of 6 residents interviewed stated that all staff treat them with dignity and respect. 6 out of 6 residents interviewed stated that they are satisfied with the services provided to them at this facility. 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. An exit interview was conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 11-AS-20250519111713

Allegation investigated: Staff did not prevent resident from stealing other resident's personal items.

**This report supersedes the report created and delivered on 06/12/25. This report is to clarify findings. On 06/12/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above-named allegations. LPA met with Administrator, Bella Naygas, and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 06/12/25, LPA requested and received the following documents: staff roster, resident roster, Identification and Emergency Information, Physician’s Report, Needs and Services Plan, and Resident Personal Property and Valuables. Interviews conducted with staff #1-#5 (S1-S5), residents #2-#6 (R2-R6), and attempted to interview resident #1 (R1) but was unable to. Furthermore, a tour of the facility was conducted. Substantiated The investigation revealed the following: Allegation: Staff did not prevent resident from stealing other resident's personal items. It is being alleged that residents are stealing paperwork from another resident. On 06/12/25 between 10:45 AM and 12:00 PM, LPA Gonzalez interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed stated that there is a resident that is known to take other resident’s belongings, but they try and prevent that resident from doing so. 4 out of 5 staff interviewed stated that they have observed management constantly talk with the resident about not taking others personal belongings, but it hasn’t stopped that resident from taking other residents belongings. An interview conducted with S1 revealed that they have tried talking to the resident on multiple occasions, but it doesn’t work. S1 stated that they have also warned the resident multiple times about doing this. S1 stated that they try and watch and monitor the resident closely, to try and avoid the resident from going into other resident’s rooms, and/or taking other resident’s belongings, and stated that it’s hard to always do so. S1 stated that they served this resident with a 30-day eviction notice, but the resident refuses to leave the facility. On 06/12/25 between 01:05 PM and 02:00 PM, LPA interviewed R2-R6 and attempted to interview R1. Based on interviews conducted, 5 out 5 residents interviewed stated that they are aware of a resident stealing other resident’s belongings. 5 out of 5 residents interviewed stated that they have seen staff talking with this resident’s belongings, but they don’t know what else is being done. Based on observation, record review, and interviews conducted, the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited, please see the attached LIC 9099-D. An exit interview was conducted and a copy of this report along with appeal rights was provided. The investigation revealed the following: Allegation: Staff did not prevent resident from being defrauded while in care. On 06/12/25 between 10:45 AM and 12:00 PM, LPA Gonzalez interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that they do not have access to any resident’s personal information and/or bank accounts. 5 out of 5 staff interviewed stated that they have not committed any fraud against any resident. 5 out of 5 staff interviewed stated that all residents are treated with dignity and respect. On 06/12/25 between 01:05 PM and 02:00 PM, LPA interviewed R2-R6 and attempted to interview R1. Based on interviews conducted, 5 out 5 residents interviewed denied the allegation. 5 out of 5 residents interviewed stated that staff does not have access to their personal information and/or bank accounts. 5 out of 5 residents interviewed stated that they are satisfied with the services provided to them at this facility. Based on observation, records reviewed, 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. An exit interview was conducted and a copy of this report along with appeal rights was provided.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 11-AS-20250609130020

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Jun 26, 2025

87468.2(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (25) To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154. This requirement was not met as evidence by: Based on observation and record review, facility staff failed to protect the property of the residents from theft or loss. This poses a potential health and safety risk to residents in care. Based on observation, interviews conducted, and record review, facility staff failed to protect the property of the residents from theft or loss. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: The Administrator will email a plan of correction to elvira.gonzalez@dss.ca.gov by the POC due date.

Allegation investigated: Staff did not ensure facility is free from pests.

On 6/23/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Assistant Administrator, Cesilia Torres and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 6/23/25 LPA requested and reviewed copies of the following records: Resident Roster, Staff roster, and fumigation service records from Orkin for the last 3 months. LPA Shirley conducted a facility tour including the kitchen and rooms 228 and 229. LPA interviewed Staff 1 – Staff-9 and Resident 1 – Resident 6. Con'd on 9099-C Substantiated The investigation revealed the following: Allegation: Staff did not ensure the facility was free from pests On 6/23/25, LPA Felisa Shirley reviewed fumigation service reports from Orkin dated, 5/23/25, 4/11/25 and 3/27/25. Upon review of service reports, LPA Felisa Shirley observed that on all 3 reports the facility listed above has been treated for live activity of both cockroaches and bed bugs. LPA Shirley toured the facility with S9 and inspected room #229 and observed rust-colored splotches on the pillowcase of a resident. During the tour of the facility’s kitchen, LPA Shirley observed live activity. LPA interviewed staff 1 – staff 9 (S-1 – S-9). LPA asked, does staff ensure that this facility is free from pest. Of those interviewed 9 out of 9 stated yes. LPA interviewed resident 1 – resident 6 (R-1 – R-6). LPA asked clients, does staff ensure that this facility is free from pest. Of those interviewed, 6 out of 6 answered, yes. Based on CCLD staff's record review, observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6), is being cited, please see attached LIC-9099D. Deficiencies were cited during today's visit. An exit interview was conducted, and plans of corrections were developed, with Cesilia Torres. A copy of this report and appeals rights were provided.the state’s words, verbatim · CDSS document, Jun 23, 2025 · control 11-AS-20250613163955

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a)(1) · Plan of correction due date: Jul 7, 2025

80087(a)(1) Buildings and Grounds The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The licensee shall take measures to keep facility free of flies and other insects Based on observations and interviews conducted, this facility has an ongoing problem with bed bugs and roaches. LPA Shirley reviewed service reports indicating treatment of live activity, LPA observed a live roach in the kitchen and a tour to room 229, LPA observed blood spots on the resident’s pillowcase which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 23, 2025

Plan of correction: The licensee shall take measures to keep the facility free of bed bugs and other insects. Submit the written plan on how the facility will control the ongoing problem with bedbugs and roaches at the facility and in resident’s bedrooms by the POC due date of 7/7/25. Please forward copies of plan to LPA Felisa Shirley at felisa.shirley@dss.ca.gov or fax to 424-544-1016

Allegation investigated: Facility staff did not ensure resident's room was maintained clean. Facility staff did not ensure change in condition was brought to the attention of resident's physician. Facility staff spoke inappropriately to resident.

**This report supersedes the report created and delivered on 05/28/25. This report is to clarify findings. On 05/28/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above-named allegations. LPA met Assistant Administrator, Cesilia Torres, and Caregiver Yesenia Robles, and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 05/28/25, LPA requested and received the following documents: staff roster, resident roster, Identification and Emergency Information, Physician’s Report, Admission Agreement, Preplacement Appraisal Information, and Needs and Services Plan for resident #1 (R1). Additionally, LPA conducted interviews with staff #1 - #5 (S1-S5), residents #2 - #7 (R2-R7) and attempted to interview R1. Furthermore, LPA and Caregiver, Yesenia Robles toured the facility. Unsubstantiated The investigation revealed the following: Allegation: Facility staff did not ensure resident's room was maintained clean. It is being alleged that this facility, including a resident’s room, is dirty. On 05/28/25 between 10:45 AM and 12:00 PM, LPA Gonzalez interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that resident’s rooms are deep cleaned at least once a week, and as necessary. On 05/28/25 between 01:05 PM and 02:20 PM, LPA interviewed R2-R7. Based on interviews conducted, 6 out 7 residents interviewed stated their rooms are cleaned daily and deep cleaned once a week. 6 out of 7 residents interviewed stated that staff maintain their room and the facility is clean and sanitary. 6 out of 7 residents interviewed stated that they are satisfied with the services provided to them at this facility. LPA Gonzalez and Yesenia Robles toured the facility. LPA inspected rooms #110, #108, #209, public restrooms, and common areas. LPA observed the rooms and facility to be clean and sanitary at the time of inspection. 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: Facility staff did not ensure change in condition was brought to the attention of resident's physician. It is alleged that a resident was experiencing heart problems and was having trouble breathing. It is also alleged that staff did nothing to assist the resident. On 05/28/25 between 10:45 AM and 12:00 PM, LPA interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed could not validate this allegation. 5 out of 5 staff interviewed stated that they were not aware of a resident experiencing heart and breathing problems. 5 out of 5 staff interviewed stated that they actively monitor the residents for any change in condition. 5 out of 5 staff interviewed stated that staff ensures to notify the Administrator, and they will then notify the residents physician if there is a change in condition in the resident. S1 stated that they were not aware of any resident experiencing heart and breathing problems. S1 stated that staff monitor the residents closely, and if any significant changes are observed, the protocol is to notify the administrator immediately and to seek prompt medical attention. On 05/28/25 between 01:05 PM and 02:20 PM, LPA interviewed R2-R7. Based on interviews conducted, 6 out of 7 residents interviewed could not corroborate this allegation. 6 out of 7 residents interviewed stated they are not aware of a resident experiencing heart and breathing problems. 6 out of 7 residents interviewed stated that staff ensures to notify their physician if there is a change in their condition. 6 out of 7 residents interviewed stated that they are satisfied with the services provided to them at this facility. Based on observation, records reviewed, 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: Facility staff spoke inappropriately to resident. It is being alleged that facility Administrator, Bella Naygas, does not want a resident at this facility and is insulting and uncooperative. On 05/28/25 between 10:45 AM and 12:00 PM, LPA interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that they are not aware if Administrator Bella Naygas does not want a resident at this facility. 5 out of 5 staff interviewed stated that they have not observed Administrator Bella Naygas insulting and/or being uncooperative with a resident. S1 denied the allegation. S1 stated that they have not insulted any resident. S1 stated that they always try and cooperate with the residents at this facility. 5 out of 5 staff interviewed stated that they treat all residents with dignity and respect. On 05/28/25 between 01:05 PM and 02:20 PM, LPA interviewed R2-R7. Based on interviews conducted, 6 out of 7 residents interviewed could not corroborate this allegation. 6 out of 7 residents interviewed stated that they are not aware if Administrator Bella Naygas wants a resident out of this facility. 6 out of 7 residents interviewed stated they have not observed Administrator Bella Naygas insult or be uncooperative with any resident. 6 out of 7 residents interviewed stated that all staff treat them with dignity and respect. 6 out of 7 residents interviewed stated that they are satisfied with the services provided to them at this facility. Continued on LIC9099-C 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. An exit interview was conducted with Caregiver, Yesenia Robles, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 11-AS-20250519111713

Allegation investigated: Staff did not prevent resident from stealing other resident's personal items.

On 06/12/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above-named allegations. LPA met with Administrator, Bella Naygas, and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 06/12/25, LPA requested and received the following documents: staff roster, resident roster, Identification and Emergency Information, Physician’s Report, Needs and Services Plan, and Resident Personal Property and Valuables. Interviews conducted with staff #1-#5 (S1-S5), residents #2-#6 (R2-R6), and attempted to interview resident #1 (R1) but was unable to. Furthermore, a tour of the facility was conducted. Continued on LIC9099-C Substantiated The investigation revealed the following: Allegation: Staff did not prevent resident from stealing other resident's personal items. It is being alleged that residents are stealing paperwork from another resident. On 06/12/25 between 10:45 AM and 12:00 PM, LPA Gonzalez interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed stated that there is a resident that is known to take other resident’s belongings, but they try and prevent that resident from doing so. 4 out of 5 staff interviewed stated that they have observed management constantly talk with the resident about not taking others personal belongings, but it hasn’t stopped that resident from taking other residents belongings. An interview conducted with S1 revealed that they have tried talking to the resident on multiple occasions, but it doesn’t work. S1 stated that they have also warned the resident multiple times about doing this. S1 stated that they try and watch and monitor the resident closely, to try and avoid the resident from going into other resident’s rooms, and/or taking other resident’s belongings, and stated that it’s hard to always do so. S1 stated that they served this resident with a 30-day eviction notice, but the resident refuses to leave the facility. On 06/12/25 between 01:05 PM and 02:00 PM, LPA interviewed R2-R6 and attempted to interview R1. Based on interviews conducted, 5 out 6 residents interviewed stated that they are aware of a resident stealing other resident’s belongings. 5 out of 6 residents interviewed stated that they have seen staff talking with this resident’s belongings, but they don’t know what else is being done. Based on observation, record review, and interviews conducted, the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited, please see the attached LIC 9099-D. An exit interview was conducted and a copy of this report along with appeal rights was given to Caregiver, Yesenia Robles. The investigation revealed the following: Allegation: Staff did not prevent resident from being defrauded while in care. On 06/12/25 between 10:45 AM and 12:00 PM, LPA Gonzalez interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that they do not have access to any resident’s personal information and/or bank accounts. 5 out of 5 staff interviewed stated that they have not committed any fraud against any resident. 5 out of 5 staff interviewed stated that all residents are treated with dignity and respect. On 06/12/25 between 01:05 PM and 02:00 PM, LPA interviewed R2-R6 and attempted to interview R1. Based on interviews conducted, 5 out 6 residents interviewed denied the allegation. 5 out of 6 residents interviewed stated that staff does not have access to their personal information and/or bank accounts. 5 out of 6 residents interviewed stated that they are satisfied with the services provided to them at this facility. Based on observation, records reviewed, 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. An exit interview was conducted and a copy of this report along with appeal rights was given to Caregiver, Yesenia Robles.the state’s words, verbatim · CDSS document, Jun 12, 2025 · control 11-AS-20250609130020

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Jun 26, 2025

87468.2(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (25) To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154.the state’s words, verbatim · CDSS document, Jun 12, 2025

Plan of correction: The Administrator will email a plan of correction to elvira.gonzalez@dss.ca.gov by the POC due date.

Allegation investigated: Facility staff did not ensure resident's room was maintained clean. Facility staff did not ensure change in condition was brought to the attention of resident's physician. Facility staff spoke inappropriately to resident.

On 05/28/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above-named allegations. LPA met Assistant Administrator, Cesilia Torres, and Caregiver Yesenia Robles, and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 05/28/25, LPA requested and received the following documents: staff roster, resident roster, Identification and Emergency Information, Physician’s Report, Admission Agreement, Preplacement Appraisal Information, and Needs and Services Plan for resident #1 (R1). Additionally, LPA conducted interviews with staff #1 - #5 (S1-S5), residents #2 - #7 (R2-R7) and attempted to interview R1. Furthermore, LPA and Caregiver, Yesenia Robles toured the facility. Unsubstantiated The investigation revealed the following: Allegation: Facility staff did not ensure resident's room was maintained clean. It is being alleged that this facility, including a resident’s room, is dirty. On 05/28/25 between 10:45 AM and 12:00 PM, LPA Gonzalez interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that resident’s rooms are deep cleaned at least once a week, and as necessary. On 05/28/25 between 01:05 PM and 02:20 PM, LPA interviewed R2-R7. Based on interviews conducted, 7 out 7 residents interviewed stated their rooms are cleaned daily and deep cleaned once a week. 7 out of 7 residents interviewed stated that staff maintain their room and the facility is clean and sanitary. 7 out of 7 residents interviewed stated that they are satisfied with the services provided to them at this facility. LPA Gonzalez and Yesenia Robles toured the facility. LPA inspected rooms #110, #108, #209, public restrooms, and common areas. LPA observed the rooms and facility to be clean and sanitary at the time of inspection. 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: Facility staff did not ensure change in condition was brought to the attention of resident's physician. It is alleged that a resident was experiencing heart problems and was having trouble breathing. It is also alleged that staff did nothing to assist the resident. On 05/28/25 between 10:45 AM and 12:00 PM, LPA interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed could not validate this allegation. 5 out of 5 staff interviewed stated that they were not aware of a resident experiencing heart and breathing problems. 5 out of 5 staff interviewed stated that they actively monitor the residents for any change in condition. 5 out of 5 staff interviewed stated that staff ensures to notify the Administrator, and they will then notify the residents physician if there is a change in condition in the resident. S1 stated that they were not aware of any resident experiencing heart and breathing problems. S1 stated that staff monitor the residents closely, and if any significant changes are observed, the protocol is to notify the administrator immediately and to seek prompt medical attention. On 05/28/25 between 01:05 PM and 02:20 PM, LPA interviewed R2-R7. Based on interviews conducted, 7 out of 7 residents interviewed could not corroborate this allegation. 7 out of 7 residents interviewed stated they are not aware of a resident experiencing heart and breathing problems. 7 out of 7 residents interviewed stated that staff ensures to notify their physician if there is a change in their condition. 7 out of 7 residents interviewed stated that they are satisfied with the services provided to them at this facility. Based on observation, records reviewed, 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: Facility staff spoke inappropriately to resident. It is being alleged that facility Administrator, Bella Naygas, does not want a resident at this facility and is insulting and uncooperative. On 05/28/25 between 10:45 AM and 12:00 PM, LPA interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that they are not aware if Administrator Bella Naygas does not want a resident at this facility. 5 out of 5 staff interviewed stated that they have not observed Administrator Bella Naygas insulting and/or being uncooperative with a resident. S1 denied the allegation. S1 stated that they have not insulted any resident. S1 stated that they always try and cooperate with the residents at this facility. 5 out of 5 staff interviewed stated that they treat all residents with dignity and respect. On 05/28/25 between 01:05 PM and 02:20 PM, LPA interviewed R2-R7. Based on interviews conducted, 7 out of 7 residents interviewed could not corroborate this allegation. 7 out of 7 residents interviewed stated that they are not aware if Administrator Bella Naygas wants a resident out of this facility. 7 out of 7 residents interviewed stated they have not observed Administrator Bella Naygas insult or be uncooperative with any resident. 7 out of 7 residents interviewed stated that all staff treat them with dignity and respect. 7 out of 7 residents interviewed stated that they are satisfied with the services provided to them at this facility. Continued 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. An exit interview was conducted with Caregiver, Yesenia Robles, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 28, 2025 · control 11-AS-20250519111713

Allegation investigated: Staff neglect resulted in a resident to be hospitalized

Community Care Licensing Division (CCLD) staff conducted an unannounced visit to Beverly Hills Terrace Facility on 05/15/2025 and was greeted by Administrator Bella Naygas (S1). CCLD staff explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. The investigation consisted of the following: On 09/24/2024 CCLD staff interviewed Administrator S1, toured the facility and requested a copy of the Register of Resident Roster, Personnel Report LIC 500, Incident report (dated 08/26/2024), Admission Agreement (dated 08/23/2024), West Hollywood Healthcare and Wellness Center (dated 08/23/2024) and other documents pertinent to the allegation associated with this complaint. On 11/21/2024 CCLD staff interviewed R1’s primary doctor W1. On 11/22/2024 CCLD interviewed staff S2. On 12/11/2024 CCLD staff interviewed resident R1. On 11/24/2024 CCLD staff obtained a copy R1’s West Hollywood Healthcare and Wellness Center medical records. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff neglect resulted in a resident to be hospitalized. It is being alleged that staff did not ensure resident received dialysis treatment causing resident to have a heart attack. Record reviews indicate the following: The facility admission agreement indicates that R1 was admitted to the facility on 08/23/2024. West Hollywood Healthcare and Wellness Center medical records indicates that R1 was sent to the hospital on 08/26/2024 due to unrelated medical conditions. On 08/27/2024 R1 had a fall while at the hospital, hospital staff checked R1 and R1’s pulse was low, R1 suffered a heart attack while at the hospital. Hospital records indicate the resident had numerous preexisting medical conditions affecting R1’s health. Interviews revealed the following: 2 out of 2 staff deny the allegation. S1 indicates on 08/24/2024 R1 was sick and refused to be taken to the hospital. R1 denied the allegation, R1 indicates that R1 has missed dialysis in the past and it has not led to heart attacks. R1’s doctor W1 reported that R1 had numerous medical issues and W1 indicated that R1 missing one day of dialysis did not result in R1 having a heart attack. Based on interviews and supporting documentation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, the allegation of “staff neglect resulted in a resident to be hospitalized” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Bella Naygas S1.the state’s words, verbatim · CDSS document, May 15, 2025 · control 11-AS-20240923141512

Allegation investigated: Staff mismanaged resident's medication.

On 04/28/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted a subsequent unannounced visit to further investigate and deliver findings for the above-named allegation. LPA met Assistant Administrator, Cesilia Torres, and the purpose of the visit was discussed. LPA was granted access into the facility. The investigation consisted of the following: On 02/05/25, LPA Gonzalez interviewed staff #1-#2 (S1-S2), witness #1 (W1) and resident #1 (R1). Additionally, LPA requested and received the following documents for R1: Facesheet, Physician's Report, Medication/PRN List, and the Medication Administration Record (MAR) for the month of January 2025. On 04/28/25 LPA Gonzalez reviewed resident files and their MARs. LPA requested and received the following documents: staff roster, resident roster, and Medication Administration Records (MAR) for three (3) residents the month of January 2025. LPA interviewed staff #3- #4(S3-S4) and residents #2-#6 (R2-R6). Furthermore, LPA and Assistant Administrator Cesilia Torres toured the facility. Unsubstantiated The investigation revealed the following: Allegation: Staff mismanaged resident’s medication. It is being alleged that a resident from Garfield Terrace #198602243 who was temporarily staying at this facility, did not receive their medications as prescribed while they were at this facility. It is also being alleged that this facility is not organized with the resident’s medications. On 02/05/25 between 10:30 AM and 11:30 AM, LPA interviewed S1-S2, and on 04/28/25 between 11:45 AM and 12:30 PM, LPA interviewed S3-S4. Based on interviews conducted, 4 out of 4 staff interviewed stated that they have not mismanaged any residents’ medication. 4 out of 4 staff interviewed stated that no resident’s medications from Garfield Terrace were mismanaged during their temporary stay at this facility. 4 out of 4 staff interviewed stated that the resident’s medication is always kept organized and readily available for distribution. An interview conducted with S1 revealed that R1 did receive their medications as prescribed. S1 stated that there were no MARs for the residents from Garfield Terrace during their stay. S1 stated that the facility staff from Garfield Terrace came with and provided the medications for each of their residents, and that they administered the provided medications to the residents as prescribed. On 02/05/25 LPA interviewed R1, and on 04/28/25 between 01:35 PM and 02:20 PM, LPA interviewed R2-R5. Based on interviews conducted, 5 out 6 residents interviewed stated they always received their medications as prescribed. 5 out 6 residents interviewed stated that the facility is organized with their medications and have not had an issue with their medications being distributed timely and as prescribed. 5 out 6 residents interviewed stated that they are not aware of a resident from Garfield Terrace not receiving their medications during their stay. 5 out 6 residents interviewed stated that they are satisfied with the services being provided to them at this facility. LPA conducted records review of the Medication Administration Record’s for the month of January 2025 for three (3) residents and observed them to be complete and in order and did not observe any discrepancies. Continued on LIC 9099-C Based on records review, interviews conducted 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 during this investigation. An exit interview was conducted with Assistant Administrator, Cesilia Torres, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 28, 2025 · control 11-AS-20250130081306

Allegation investigated: Staff did not treat resident with dignity or respect Staff sprayed chemicals at resident.

On 4/3/2025,Licensing Program Analyst (LPA) Bernadette Allen and Licensing Program Manager (LPM) Stephanie Cifuentes conducted an unannounced visit to initiate and deliver findings for the alleged allegations. LPA identified herself and met Bella Neygas Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 4/3/2025 LPA Allen reviewed files for residents 1 - resident 5 (R1-R5), interviewed (R1-R5) and staff 1- staff 5 (S1-S5). LPA Allen requested and received the following documents: Staff roster(LIC 500), resident roster dated 4/3/2025, and facility notes for 3/26/2025. LPA Allen also briefly toured first floor of facility. Continued on page 9099-C Unsubstantiated Investigation revealed the following: Allegation: Staff did not treat resident with dignity or respect It is alleged that the facility staff pushed, yelled, and threatened the residents in care. On 4/3/2025 LPA interviewed Ella Naygas Administrator, who revealed that a conversation was had with resident 1 (R1) regarding disruptive behavior in the dining area that did not result in yelling, threatening, or pushing of the resident. At 9:40 AM LPA Allen interviewed resident 1- resident 5 (R1-R5), of those interviewed, 4 out of 5 residents all stated that the staff members at the facility treat them with dignity and respect at all times. LPA Allen interviewed staff members staff 1- staff 5 (S1-S5), of those interviewed 5 out of 5 stated they have always and will continue to treat the residents in care with dignity and respect. Allegation: Staff sprayed chemicals at resident. It is being alleged that staff sprayed cleaning chemicals at resident. At 9:40 AM LPA Allen interviewed resident 1- resident 5 (R1-R5), 4 out of 5 residents stated that have not been sprayed with chemicals by any staff members. LPA Allen interviewed staff 1- staff 5 (S1-S5), of those interviewed 5 out of 5 have not sprayed or witnessed any residents being sprayed with chemicals. In addition, during interviews, housekeeping staff demonstrated their cleaning process where cleaning solutions are sprayed on a towel and surfaces are wiped down and not sprayed on surfaces which are then wiped. At 11:45 AM, LPA also observed the housekeeping cart locked in the storage area with (3) three labeled spray bottles of cleaning supplies inaccessible to residents. On 4/3/2025 LPA Allen reviewed facility records. Facility daily notes show that on 3/26/2025 housekeeping reported that a resident entered a room that was not theirs. When resident noted that staff was in the room, resident then alleged that staff had sprayed them with the cleaning solution. Based on interviews, file review and observation during the investigation, the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Ella Naygas Administrator at conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 11-AS-20250327100544

Allegation investigated: Staff speak inappropriately to resident. Staff discourage resident from filing complaints. Staff tamper and withhold resident’s mail for extended periods. Staff discards residents’ mail.

*This report was created to clarify findings.It does not supersed the report delivered on 02/10/25. On 02/10/2025, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced subsequent complaint investigation at the facility listed above. LPA Watson arrived at the facility and was greeted by the administrator Ella Naysberg. LPA Watson explained the purpose of the visit was to deliver findings and was granted entry. The investigation consisted of the following: On 02/06/2025 LPA Troy Watson interviewed staff #1- staff #5 (S1-S5) and interviewed residents #1- residents #5 (R1-R5). LPA Watson requested, received, and reviewed the Personnel Report LIC 500, Resident Census / Active List, and signature signings of in - coming received mail documentation. CONTINUED ON LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff speak inappropriately to residents. On 02/03/25 the department reviewed the facility files and found no incident reports relating to the allegation. On 02/06/2025 the department conducted interviews with staff#1 – staff #5 (S1-S5). The department asked the staff if they had spoken inappropriately with the residents. Of those interviewed, 5 out of 5 staff denied the allegation. On 02/06/2025 the department interviewed residents #1 – residents #5 (R1-R5). The department asked residents if staff had spoken inappropriately to them. Of those interviewed, 4 out 5 residents denied the allegation. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff discourage resident from filing complaints On 02/03/25 the department reviewed the facility files and found no incident reports regarding the allegation above. On 02/06/2025 the department conducted interviews with staff#1 – staff #5 (S1-S5). The department asked the staff if they discouraged residents from filing complaints. Of those interviewed, 5 out of 5 staff denied the allegation. On 02/06/2025 the department conducted interviews with residents # 1 – residents #5 (R1-R5). The department asked residents if staff discouraged them from filing complaints. Of those interviewed 4 out 5 residents denied the allegation. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff tamper and withhold resident’s mail for extended periods. On 02/03/25 the department reviewed the facility files and found no incident reports regarding the allegation above. On 02/06/2025 the department conducted interviews with staff#1 – staff #5 (S1-S5). The department asked the staff if they tamper and withhold resident’s mail for extended periods of time. Of those interviewed, 5 out of 5 staff denied the allegation. On 02/06/2025 the department conducted interviews with residents #1 – residents # 5 (R1-R5). The department asked residents if staff tampered and withheld residents’ mail. Of those interviewed 4 out 5 residents denied the allegation . Based on the information gathered, there is insufficient evidence to support the stated allegation. CONTINUED ON LIC9099-C * This report serves as an amendment to clarify findings, it does not supersede the complaint investigation findings reflected on report created on 03/12/2025. Allegation: Staff discards residents’ mail On 02/03/25 the department reviewed the facility files and found no incident reports regarding the allegation above. On 02/06/2025 the department conducted interviews with staff#1 – staff #5 (S1-S5). The department asked the staff if they discard resident’s mail. Of those interviewed 5 out of 5 staff denied the allegation. On 02/06/2025 the department conducted interviews with residents #1 – residents #5 (R1-R5). The department asked residents if staff discarded their mail. Of those interviewed 4 out 5 residents denied the allegation. Based on the information gathered, there is insufficient evidence to support the stated allegation. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the Care Giver Alba Luz Lopez .the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 11-AS-20241120150825

Allegation investigated: Staff did not ensure the safety of food provided to residents. Staff did not ensure a safe environment was provided for residents.

On 3/4/2025 LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Bella Naygas / Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#5) and Resident’s interviews (R#1-R#6). LPA obtained and reviewed the following documents: Resident Roster (dated 3/1/2025), staff roster (dated 3/1/25), Facility’s Dietitian Notes (dated: 11,29,2024-12,27,24 and 1,5,25), (R#1)’s Physicians Assessment (dated:6/12/24), Facility’s cook California Food Handler Certificate (dated: 6/25/2024) and a Physical tour of the kitchen. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff did not ensure the safety of food provided to residents. The details of the complaint alleged that (R#1) and other residents in care are getting food poisoning from facility’s food. On March 4, 2025, at approximately 9:00 AM, during records review, LPA Iniguez observed (R#1)’s medical history binder; there are no hospital medical records regarding (R#1) going to the hospital due to food poisoning. In addition, LPA Iniguez reviewed the facility’s dietitian notes (dated November, December 2024, and January 2025); the facility dietitian comes every month to conduct a kitchen evaluation where she checks the kitchen’s cooler, freezer, food storage areas, beverage areas, and overall areas. Furthermore, LPA reviewed the facility’s Cook California Food Handler Certificate (dated 6/25/2024); the certificate expires on 6/25/2027. Moreover, at approximately 12:30 PM, LPA Iniguez conducted a physical tour of the kitchen; LPA observed the kitchen areas were clean and well organized; also, LPA observed that the cook and kitchen staff followed safety food preparation guidelines when preparing meals for the residents in care and staff. On March 4, 2025, at approximately 9:30 AM, during an Interview with the Administrator (A#1), she stated that the facility offers three meals per day plus snacks to all residents in care and sometimes facility staff. Also, (A#1) stated that the food served at the facility is safe to consume, and the facility has a dietitian who comes every month to ensure the kitchen areas, and the food are up to code. In addition, (A#1) stated that there are no incidents regarding (R#1) or other residents getting food poisoned by the food they eat here. Evaluation Report continues LIC 9099-C... On March 4, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#6), (5) out of (6) stated that the facility offers them three meals per day plus snacks between meals, also they stated that they have never got food poison or sick by the food the facility provided to them. On March 4, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that the facility provides three meals per day to all residents in care and sometimes facility staff. Also, they stated that the food the facility serves to the residents in care is safe to consume, and there have been no incidents regarding (R#1) or other residents getting food poisoned by the food they eat here. Allegation: Staff did not ensure a safe environment was provided for residents. The details of the complaint alleged that (R#1) is getting stalked by unknow cloaked figure. On March 4, 2025, at approximately 9:30 AM, during an Interview with the Administrator (A#1), she stated that they had never received a complaint from (R#1) or another resident regarding an unknown cloaked individual stalking residents in the facility. In addition, (A#1) stated that the facility ensures the safety of the residents by conducting daily room checks, a sign-in system at the entrance of the facility, and a facility staff that monitors who comes in and out. On March 4, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#6), (5) out of (6) stated that they have never seen an unknown cloaked individual stalking them, also, they stated that they feel safe living here. Evaluation Report continues LIC 9099-C... On March 4, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that they had never received a complaint from (R#1) or another resident regarding an unknown cloaked individual stalking residents in the facility. In addition, (5) out of (5) facility staff stated that the facility ensures the safety of the residents by conducting daily room checks, a sign-in system at the facility's entrance, and a facility staff that monitors who comes in and out. 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 Bella Naygas / Administrator.the state’s words, verbatim · CDSS document, Mar 4, 2025 · control 11-AS-20250225112313

Allegation investigated: Staff did not prevent resident from being physically assaulted at the facility Staff stole resident's personal property Staff did not ensure the facility was kept free of pests Staff did not prevent resident from destroying another resident's property Staff did not allow resident to access facility common area Knives were made accessible to residents in care Facility is in disrepair Staff made resident deliver food to other residents Staff made resident deliver food to other residents

On February 27,2025, Community Care Licensing Department staff Deborah Lee conducted an unannounced complaint visit to the address the allegations listed above. The department staff met with Cecilia Torres, Assistant Administrator; the purpose of the visit was discussed and Department staff was granted access to the facility. The investigation consisted of the following: The department conducted a tour of facility both inside and out, made observation of kitchen set up and elevator, reviewed and obtained copies of client roster, staff roster, R1's Pysician's report for RCFEs (dated 12/16/24), preplacement appraisal and Needs and service plan for R1 (dated 2/8/24), requested elevator service recorded (to be emailed to the department). Interviews were conducted with 6 staff (S1-S6), Administrator (A1) and 6 residents (R1-R6). Page 1 of 6 Unsubstantiated Investigation revealed the following: Allegation: Staff did not prevent resident from being physically assaulted at the facility It is being alleged that R1 has been chronically abuse by staff for “years” and physically assaulted by a resident. On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 assures the department that she has looked into the allegation, and it is not true. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed (6 ) out of (6 ) denied abusing R1 or any other resident. (6) out of (6) stated that they have never witnessed any other staff abusing R1 or any other resident. Additionally, (6) out of ( 6 ) staff stated that they have never witness R1 being physically assaulted by another resident. On 2/27/25 the Department interviews (R1-R6). Of those interviewed, (5) out of (6 ) stated that they have never been assaulted by staff or another resident. (1) out of (6) stated that they have been physically assaulted by staff and a resident. On 2/27/25 the department reviewed R1’s file and found that there have been no incident reports of physical abuse by staff nor resident. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff stole resident's personal property. It is being alleged that staff has stolen “a lot” of R1’s clothing and other “necessities.” On 2/27/25 the Department interviewed (A1) regarding the allegation above. page 2 of 6 A1 stated that there is no evidence of any staff stealing from residents. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed (6) out of (6) stated that they have never stolen anything from a resident and haven’t witness any other staff stealing from a resident. The department conducted interviews with (R1-R6). Of those interviewed (5) out of (6) stated that staff have never stolen anything from them. (1) out of (6) stated that staff has stolen personal property from them. On 2/27/25 the department reviewed R1’s file and found that there have been no incident reports of theft committed by staff as indicated in the complaint. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff did not ensure the facility was kept free of pests It is being alleged that the facility has roaches and bed bugs. On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 stated that there has been no issues of bedbug or roaches in facility that the facility gets fumigated, and the maintenance worker sprays the rooms frequently as a preventative measure. Additionally, housekeeping staff frequently check for bugs due to some residents eating in their rooms which may cause roaches to appear. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed (5) out of (6 ) denied that the facility has roaches and bedbugs. (1) out of (6) stated that they have roaches and bedbugs sometimes, but it is taken care of in a timely manner. The department conducted interviews with (R1-R6). Of those interviewed (5) out of (6) stated that they have not seen a roach or a bedbug and denied having been bitten by a bedbug (1) out of (6) stated that the facility is full of roaches and bedbugs and states that she has been bitten by a bedbug while at the facility. Based on the information gathered, there is insufficient evidence to support the stated allegation. Page 3 of 6 Allegation: Staff did not prevent resident from destroying another resident's property. It is being alleged that a resident has broken R1’s entry door “10 times,” broke “7 televisions.” On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 stated that a resident and another resident frequently have altercations with each other and one of them tends to break things to blame the other to “get her in trouble.” A1 further stated that repairs are done timely to fix items that are broken. On 2/27/25, the Department conducted interviews with (S1-S6), of those interviewed (4) out of (6 ) stated that there is some property destruction. (2) out of (6) have never witness property destruction. The department conducted interviews with (R1-R6). Of those interviewed (5) out of (6) stated that they do not know anything about a broken TV or a broken door. (1) out of (6) stated that there is major property destruction caused by a resident at the facility. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff did not allow resident to access facility common areas. It is being alleged that staff won’t let R1 eat in the dining room. On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 stated that no one is restricted from common areas, however when a resident is causing a disruption, they are told that they have to calm down or leave the area. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed (5) out of (6 ) stated that no resident is restricted from a common area however one resident who is disruptive have been asked to leave the area unless she calms down. The department conducted interviews with (R1-R6). Of those interviewed (5) out of (6) stated that no resident is asked to leave a common area or is not allowed to be there. (1) out of (6) stated that she is band from the dining area. Based on the information gathered, there is insufficient evidence to support Page 4 of 6 the stated allegation. Allegation: Knives were made accessible to residents in care It is being alleged that R1 has been chased with knives in the facility by another resident. On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 stated that residents don’t have access to knives in the facility, however on occasion a resident would bring something into the facility that is not allowed. On one occasion a resident did have a knife but it was immediately confiscated once discovered. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed ( 5 ) out of ( 6 ) stated that they have never witnessed a resident in possession of a knife. The department conducted interviews with (R1-R6). Of those interviewed (5 ) out of (6) stated that they have never seen another resident with a knife. (1) out of (6) stated that they have seen another resident with a knife and she was chase by the resident with the knife. On 2/27/25 the department observed the kitchen area during facility walkthrough and found that the knives are inaccessible to residents in care. The knives are locked in an area where residents do not have access to. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Facility is in disrepair. It is being alleged that there was no working elevator in the facility for 1 ½ years. On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 stated that the elevator is working, however about a year ago, the elevator was not work. A1 further stated that the elevator is maintained on a regular basis. On 2/27/25, the Department conducted interviews with (S1-S6), of those interviewed (6 ) out of ( 6 ) stated that the elevator has been working properly. The department conducted interviews with (R1-R6). Of those interviewed (5 ) out of (6) stated that the elevator has been working consistently. (1) out of (6) stated that the elevator is always broken. Based on the information gathered, there is insufficient evidence to support the stated allegation. Page 5 of 6 Allegation: Staff made resident deliver food to other residents. It is being alleged that R1 is being used to deliver food to other residents. On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 stated that no resident is allowed to bring another resident food, that is the staff’s job. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed (5) out of ( 6 ) stated that they have not witness a resident taking food to another resident. The department conducted interviews with (R1-R6). Of those interviewed (5) out of (6) stated that no resident takes food to another resident. (1) out of (6) stated that she is asked to take food to other residents. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff spoke inappropriately to resident in care. It is alleged that R1 is “constantly humiliated, screamed at and threatened.” On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 denied above allegation. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed ( 6 ) out of (6 ) stated that that they have never humiliated, screamed or threatened a resident in care. The department conducted interviews with (R1-R6). Of those interviewed ( 5 ) out of (6) stated that they have never been humiliated, screamed at or threatened by staff. (1 ) out of (6) stated that she is always humiliated, screamed at and threatened by staff. Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegations above 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 are UNSUBSTANTIATED. No deficiencies were cited for the above allegations. Exit interview was conducted. A copy of this report was provided to Cecilia Torres, Assistant Administrator Page 6 of 6the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 11-AS-20250225153700

Allegation investigated: Staff speak inappropriately to resident. Staff discourage resident from filing complaints. Staff tamper and withhold resident’s mail for extended periods. Staff discards residents’ mail.

On 02/10/2025, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced subsequent complaint investigation at the facility listed above. LPA Watson arrived at the facility and was greeted by the administrator Ella Naysberg. LPA Watson explained the purpose of the visit was to deliver findings and was granted entry. The investigation consisted of the following: CONTINUED ON LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff speak inappropriately to residents. On 02/03/25 the department reviewed the facility files and found no incident reports relating to the allegation. On 02/06/2025 the department conducted interviews with staff#1 – staff #5 (S1-S5). The department asked the staff if they had spoken inappropriately with the residents. Of those interviewed, 5 out of 5 staff answered no. On 02/06/2025 the department interviewed residents 1 – residents 5 (R1-R5). The department asked residents if staff had spoken inappropriately to them. Of those interviewed, 4 out 5 residents answered no. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff discourage resident from filing complaints On 02/03/25 the department reviewed the facility files and found no incident reports regarding the allegation above. On 02/06/2025 the department conducted interviews with staff#1 – staff #5 (S1-S5). The department asked the staff if they discourage residents from filing complaints. Of those interviewed, 5 out of 5 staff answered no. On 02/06/2025 the department conducted interviews with residents 1 – residents 5 (R1-R5). The department asked residents if staff discouraged them from filing complaints. Of those interviewed 4 out 5 residents answered no. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff tamper and withhold resident’s mail for extended periods. On 02/03/25 the department reviewed the facility files and found no incident reports regarding the allegation above. On 02/06/2025 the department conducted interviews with staff#1 – staff #5 (S1-S5). The department asked the staff if they tamper and withhold resident’s mail for extended periods. Of those interviewed, 5 out of 5 staff answered no. On 02/06/2025 the department conducted interviewed with residents #1 – residents # 5 (R1-R5). The department asked residents if staff tampered and withheld residents’ mail. Of those interviewed 4 out 5 residents answered no. Based on the information gathered, there is insufficient evidence to support the stated allegation. CONTINUED ON LIC9099-C Allegation: Staff discards residents’ mail On 02/03/25 the department reviewed the facility files and found no incident reports regarding the allegation above. On 02/06/2025 the department conducted interviews with staff#1 – staff #5 (S1-S5). The department asked the staff if they discard resident’s mail. Off those interviewed 5 out of 5 staff answered no. On 02/06/2025 the department conducted interviewed with residents #1 – residents # 5 (R1-R5). The department asked residents if they discard residents’ mail. Of those interviewed 4 out 5 residents answered no. Based on the information gathered, there is insufficient evidence to support the stated allegation. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the assistant administrator Cecelia Torres.the state’s words, verbatim · CDSS document, Feb 10, 2025 · control 11-AS-20241120150825

Allegation investigated: Staff did not prevent resident from taking another resident’s belongings

The investigation consisted of the following: On 02/06/2025, Community Care Licensing Division (CCLD) Staff conducted a complaint investigation at the above facility to address the following allegations. CCLD Staff met with Administrator Bella Naygas and explained the purpose of the visit. CCLD Staff conducted resident and staff interviews, toured the facility, and reviewed resident records. Allegation: Regarding the allegation "Staff did not prevent resident from taking another resident’s belongings,” it is being alleged that Resident #2 (R2) broke the doorknob, enter the room, and took a bag containing cellphones, boots, and snacks from Resident #1 (R1). Continue to LIC9099-C. Unsubstantiated R1’s Personal Property and Valuables does not include cellphones nor boots. Six out of seven resident interviews indicated they have not witnessed R2 break into R1’s room and steal items. Two out of three staff interviews indicated they have not received any complaints about R2 breaking into R1’s room to steal items. Administrator indicated she has not witnessed R2 breaking into R1’s room to steal items and Maintenance has replaced R1’s lock eight times. On 02/06/25, LPA observed R1’s doorknob being inoperable and R1 is unable to lock R1’s bedroom door upon exiting. Regarding the allegation “Staff did not prevent resident from taking another resident’s belongings," based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Caregiver Yesenia Robles.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 11-AS-20250128170803

Type of visit: Case Management - Deficiencies

On 02/06/2025, Community Care Licensing Division (CCLD) Staff conducted a case management visit at the above facility and met with Staff Yesenia Robles. The purpose of the visit was to investigate complaint #11-AS-20250128170803. During the facility tour, CCLD Staff observed two damaged doorknobs for Resident #1 and Resident #2. Resident #1 (R1) is unable to lock R1's door when exiting the room. Deficiencies were issued (see LIC809-D). An exit interview was conducted and plans of correction developed. A copy of this report and appeals rights was reviewed and left with Staff Yeenia Robles.the state’s words, verbatim · CDSS document, Feb 6, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 18, 2025

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents... This requirement was not met as evidence by: Based on observation, CCLD Staff did not observe Resident #1' and #2's doorknob to be in good repair which poses a potential safety risk for residents in care.the state’s words, verbatim · CDSS document, Feb 6, 2025

Plan of correction: The Licensee will repair Resident #1 and #2's doorknobs and email evidence to regina.cloyd@dss.ca.gov by the POC due date.

Allegation investigated: Staff are coecing resident into using the facilities medical services. Staff are preventing resident from being seen by her physician. Staff did not keep resident's personal information confidential. Staff had residents inappropriately sign a document. Staff are mishandling resident's finances. Staff did not allow resident's vistor in her room.

On 02/26/24, at 9:00am, Licensing Program Analyst (LPA) Mario Leon conducted an initial complaint visit to the facility and was greeted by Cesilia Torres, Assistant Administrator. LPA explained the purpose of this visit is to conduct interviews, gather facility files, and render findings in the complaint. The investigation consisted of the following: The department investigated the allegation mentioned in this complaint and conducted interviews with staff (S1-S2) and residents (R1-R6). Additionally, the department obtained the following documents: Resident Roster (No Date), Staff Roster (Dated: 07/2024), Admission Agreement (Dated: 07/20/2021), Physician’s Report (Dated: 02/06/2024), Appraisals/Needs and Services Plan (Dated: 01/30/2024), Identification and Emergency Information (Dated:11/28/2009) and an Internal document signed by resident R1 (Dated: 01/10/2024) from the facility. Complaint Investigation Report Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1-Staff are coercing resident into using the facilities medical services. The details of the complaint alleged that the facility staff are coercing resident (R1) into using their in-house doctor and not giving the resident a choice to use R1s own doctor. On 02/26/24, from 09:30am-3:00pm, the department interviewed staff (S1-S2) and residents (R1-R6) regarding the allegation. 2 of 2 staff (S1- S2) denied the allegation that the facility Staff are coercing resident into using the facilities medical services. All staff (S1-S2) stated that the facility does not coerce residents into using their in-house doctors. They state that it is offered as a convenience because some residents do not like to go out and other residents’ doctors are far away. Staff (S1) stated that (R1) used to see R1s primary doctor but recently R1 wasn’t feeling well. R1 requested to see our in-house doctor, because R1 said R1 was having difficulty seeing R1s doctor. We called the relative to let them know of the new doctor but the relative claims no responsibility. The staff states that all residents have a choice in choosing the doctor of their choice. The department interviewed residents R1-R6 about the allegation and 5 of 5 residents that were interviewed denied the allegation that Staff are coercing resident into using the facilities medical services. The majority (5 of 6) residents interviewed stated that the facility does not coerce them into using the facilities in-house doctors and that they do have a choice in choosing what doctors they see. Based on interviews, there is insufficient evidence to support the allegation that the Staff are coercing resident into using the facilities medical services. 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 #2- Staff are preventing resident from being seen by their physician. The details of the complaint alleged that the facility is preventing the resident (R1) from seeing their own doctor and keeps pushing them into using the in-house doctors. On 02/26/24, from 09:30am-3:00pm, the department interviewed staff (S1-S2) and residents (R1-R6) regarding the allegation. 2 of 2 staff (S1- S2) denied the allegation that the facility Staff are preventing resident from being seen by her physician. All staff (S1-S2) stated that the facility did not prevent the resident from seeing their doctor. They state that the resident (R1) made a choice to use their in-house doctor because it was more convenient. The department reviewed an Internal document signed by resident R1 (Dated: 01/10/2024) that stated that R1 made the decision on their own to see the in-house doctor and to use the facilities Home Health Services voluntarily. The department interviewed residents R1-R6 about the allegation and 5 of 5 residents that were interviewed denied the allegation that Staff are preventing resident from being seen by their physician. The majority (5 of 6) residents interviewed stated that they chose to use the facilities in-house doctors voluntarily and was not forced by the staff. Complaint Investigation Report Continued on LIC9099-C Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are preventing resident from being seen by their physician. 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 #3- Staff did not keep resident's personal information confidential. The details of the complaint alleged that the facility shared the resident (R1) personal information with other residents. On 02/26/24, from 09:30am-3:00pm, the department interviewed staff (S1-S2) and residents (R1-R6) regarding the allegation. 2 of 2 staff (S1- S2) denied the allegation that the facility Staff did not keep resident's personal information confidential. All staff (S1-S2) stated that the facility does not and did not share R1s personal information with other residents. They state that two residents witnessed R1 signing a document that stated that R1 wanted to use the in-house doctor and the facilities Home Health Services voluntarily. They state that no personal information was provided or seen by the residents. The department reviewed an Internal document signed by resident R1 (Dated: 01/10/2024) that stated that R1 made the decision on their own to see the in-house doctor and to use the facilities Home Health Services voluntarily. Two staff and two witnesses also signed the document, and no confidential personal information was indicated in the document. The department interviewed residents R1-R6 about the allegation and 5 of 5 residents that were interviewed denied the allegation that Staff did not keep resident's personal information confidential. The majority (5 of 6) residents interviewed stated that the facility has not shared any of their personal information or other residents’ information with them. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not keep resident's personal information confidential. 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 #4- Staff had residents inappropriately sign a document. The details of the complaint alleged that the facility staff had the resident (R1) sign a document inappropriately. On 02/26/24, from 09:30am-3:00pm, the department interviewed staff (S1-S2) and residents (R1-R6) regarding the allegation. 2 of 2 staff (S1- S2) denied the allegation that the facility Staff had residents inappropriately sign a document. All staff (S1-S2) stated that the facility does not have any resident sign any paperwork or documents that is inappropriate. They state the document in question was a document signed by the resident (R1) declaring their intent to use the in-house doctors. They state that the resident new what the document was and why they were signing it and in no way was it an inappropriate document to sign. Complaint Investigation Report Continued on LIC9099-C The department reviewed an Internal document signed by resident R1 (Dated: 01/10/2024) that stated that R1 made the decision on their own to see the in-house doctor and to use the facilities Home Health Services voluntarily. The department interviewed residents R1-R6 about the allegation and 5 of 5 residents that were interviewed denied the allegation that Staff had residents inappropriately sign a document. The majority (5 of 6) residents interviewed stated that the facility has never had them sign documents that were inappropriate. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff had residents inappropriately sign a document. 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 #5- Staff are mishandling resident's finances. The details of the complaint alleged that the facility is mishandling the residents (R1) finances. On 02/26/24, from 09:30am-3:00pm, the department interviewed staff (S1-S2) and residents (R1-R6) regarding the allegation. 2 of 2 staff (S1- S2) denied the allegation that the facility Staff are mishandling resident's finances. All staff (S1-S2) stated that the facility does not handle R1s finances and that R1 handles their own finances. They state that when it is time for the resident to pay their rent, R1 writes out the check and gives it to administration to cash. They state at no time have they ever mishandled R1s finances because R1 handles their own. The department interviewed residents R1-R6 about the allegation and 5 of 5 residents that were interviewed denied the allegation that Staff are mishandling resident's finances. R1 stated that R1 handles their own finances and banking. The majority (5 of 6) residents interviewed stated that the facility has not mishandled their finances. Based on interviews, there is insufficient evidence to support the allegation that the Staff are mishandling resident's finances. 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 #6- Staff did not allow resident's visitor in their room. The details of the complaint alleged that the facility does not allow the resident to have visitors in their room. On 02/26/24, from 09:30am-3:00pm, the department interviewed staff (S1-S2) and residents (R1-R6) regarding the allegation. 2 of 2 staff (S1- S2) corroborated the allegation that the facility Staff did not allow resident's visitor in her room. All staff (S1-S2) stated that they’re allowed to have visitors but only in the patio area or the T.V. room. They are allowed to go out over the weekend with their family as well. Rooms are shared, that’s why they meet on the patio or the T.V. room. Complaint Investigation Report Continued on LIC9099-C The department interviewed residents R1-R6 about the allegation and 5 of 5 residents that were interviewed corroborated the allegation that Staff did not allow resident's visitor in her room. The majority (5 of 6) residents interviewed stated that they are allowed visitors but not in their rooms because the rooms are shared, and they don’t want to disturb their roommates. They state that visitors are welcomed in the patio area or the television room. Based on interviews, there is sufficient evidence to support the allegation that the Staff did not allow resident's visitor in her room. However, the reason for that is that the residents’ rooms are shared, and they will not have any privacy. Visitors are instructed to visit in the patio area or the television room; therefore, the allegation is Unsubstantiated. No citations were issued for this complaint. An exit interview was conducted with Cesilia Torres, Assistant Administrator, and a copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 11-AS-20240220120353

Allegation investigated: Staff did not prevent resident from being sexually abused by other residents. Staff are serving contaminated food to residents in care. Staff does not ensure residents are spoken to in an appropriate manner. Staff are over medicating resident.

On 11/07/24 Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit to deliver findings. LPA met with Administrator Ella as the purpose of today's visit was explained. The investigation consisted of the following: On 11/04/24 LPA obtain copies of the staff and resident rosters, pertinent documents to the complaint for Resident #1, and a copy of the menu for the month of November 2024. On 11/04/24 LPA conducted a tour of the facility kitchen and there are no immediate health and safety concerns. On 11/04/24 between 9:48 am- 12:30am LPA conducted interviews with residents #1-6 (R1-R6), and between 12:30pm-1:30 pm interviews were conducted with staff 1-3 (S1-S3). On 11/07/24 LPA conducted interview with Administrator (A1). The investigation revealed the following: Allegation: Staff did not prevent resident from being sexually abused by other residents. It is being alleged that several male residents on the same floor as R1 are sexually harassing R1 every day. On 11/07/24 LPA conducted interview with A1 regrading the allegation above, A1 denied the Unsubstantiated allegation above and reported the facility has not experienced sexual abuse allegations prior to this one. Per A1, staff will investigated allegation, and report the allegation to CCLD if and when abuse is reported by a resident in care. On 11/04/24 between 9:48 am- 12:30pm LPA conducted interview with R1 regarding the allegation above, R1 reports being assaulted by (2) male residents on September 8th, 2024. Per R1, R1 did not report the assault to staff however R1 called LAPD to make a report. On 11/04/24 between 9:48 am- 12:30pm LPA conducted interviews with residents #2-6 (R2-R6) regarding the allegation above, 5 of 5 residents interviewed denied the allegation above. On 11/04/24 between 12:30pm-1:30 pm LPA conducted interviews with staff 1-3 (S1-S3) regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. On 11/04/24 LPA reviewed UCLA health ER discharge summary dated 09/07/24, there was no indication of sexual assault. On 11/04/24 LPA reviewed the incident report submitted to CCLD on 09/07/24 regarding the allegation above. Allegation: Staff are serving contaminated food to residents in care It is being alleged that the food being serve tastes bad and makes R1 feel sick when R1 consumes it. On 11/07/24 LPA conducted interview with A1 regarding the allegation above, A1 denied the allegation above and reported that the facility has a dietician who visits and inspects the kitchen and menu every month. On 11/04/24 between 9:48 am- 12:30pm LPA conducted interview with R1 regarding the allegation above, R1 states R1 becomes dizzy and nauseous when drinking the cherry juice from the container and believes the drug dealers from down the street are putting PCP into the juice. On 11/04/24 between 9:48 am- 12:30pm LPA conducted interviews with residents #2-6 (R2-R6) regarding the allegation above, 4 of 5 residents interviewed denied the allegation above, 1 of 5 residents interviewed sates the yogurt and milk is sometimes sour. On 11/04/24 between 12:30pm-1:30 pm LPA conducted interviews with staff 1-3 (S1-S3) regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. On 11/04/24 LPA conducted tour of the facility kitchen, LPA observed pantry to have expiration dates on can goods, kitchen was clean and organized at the time of visit. Allegation: Staff does not ensure residents are spoken to in an appropriate manner It is being alleged that the facility administrator is rude to and yells at residents. On 11/07/24 LPA conducted interview with A1 regarding the allegation above, A1 denied the allegation above and reported staff have to speak loudly and repeated themselves often when communicating with residents in care. On 11/04/24 between 9:48 am- 12:30pm LPA conducted interview with R1 regarding the allegation above, R1 reports It is not the staff who screams racist things at R1 it is another resident in care. On 11/04/24 between 9:48 am- 12:30pm LPA conducted interviews with residents #2-6 (R2-R6) regarding the allegation above, 2 of 5 residents interviewed confirmed the allegation above and reported the administrator is rude and disrespectful to residents in care, 3 of 5 residents interviewed denied the allegation above. On 11/04/24 between 12:30pm-1:30 pm LPA conducted interviews with staff 1-3 (S1-S3) regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. Allegation: Staff are over medicating resident It is being alleged that the facility psychiatrist comes into R1’s room at night with 2 LVN's and administers R1 prescribed medication and injection to make R1 sleep. On 11/07/24 LPA conducted interview with A1 regarding the allegation above, A1 denied the allegation above and reported all medications are administrator as prescribed. On 11/04/24 between 9:48 am- 12:30pm LPA conducted interview with R1 regarding the allegation above, per R1 facility psychiatrist with LVN’s are going into R1’s room at night to try to give R1 5 needles of 100 milligrams each. On 11/04/24 between 9:48 am- 12:30pm LPA conducted interviews with residents #2-6 (R2-R6) regarding the allegation above, 5 of 5 residents interviewed denied the allegation above. On 11/04/24 between 12:30pm-1:30 pm LPA conducted interviews with staff 1-3 (S1-S3) regarding the allegation above, 3 of 3 staff interviewed denied the allegation above, 1 of 3 staff interviewed reported having no knowledge on medication administration procedures. On 11/04/24 LPA Villegas conducted review of MAR for October 2024 and there is no indication that R1 receives any injectable medications. On 11/05/24 LPA conducted interview with witness #1 (W1) regarding the allegation above, W1 denied the allegation and reported R1 does not have any injectable medications prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted Administrator Ella Naygas, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 11-AS-20241101103650

Allegation investigated: Staff are not safeguarding resident's personal possessions.

On 10/30/24 Licensing program analyst (LPA) Villegas conducted an initial complaint visit regarding the allegations above. LPA met with Administrator Ella Naygas as the purpose of today's visit was explained. The investigation consisted of the following: On 10/30/24 LPA obtain copies of the staff and client rosters, and obtained the following documents for resident 1 (R1): Emergency ID form,admission agreement dated 04/11/23,MAR for October 2024, physicians report dated: 03/12/23 ,needs and service plan dated 03/08/24, preplacement appraisal 02/08/24, appraisal 02/08/24, telecommunication device notification dated 04/11/23, client personal property and valuables dated and signed 04/11/23, copies of (2) 30 day eviction notices that were sent to CCLD on 07/26/24 and 09/18/24. On 10/30/24 LPA conducted a tour of the facility and there are no immediate health and safety concerns. On 10/30/24 between 9:30 am- 11:30am LPA conducted interviews with clients 1-6 (C1-C6), and between 11:35am- 1:30pm interviews were conducted with staff 1-4 (S1-S4). Unsubstantiated The investigation revealed the following: Allegation: Staff are not safeguarding resident's personal possessions. It is being alleged that Lifeline tablets and phones are stolen from C1. On 10/30/24 between 11:35am- 1:30pm LPA interviewed S1 regarding the allegation above, S1 denied the allegation above and reported safeguarding is part of the admission agreement however clients or clients responsible party can refuse to complete the safeguard document. On 10/30/24 between 11:35am- 1:30pm LPA conducted interviews with S2-S4, 3 of 3 staff interviewed denied the allegation above. On 10/30/24 between 9:30 am- 11:30am LPA conducted interviews with C1, C1 denied the allegation above, and reported having cellphone in C1's possession. LPA observed C1 to have (2) cellphones at the time of interview. On 10/30/24 between 9:30 am- 11:30am LPA conducted interviews with C2-C6, 3 of 5 clients interviewed denied the allegation above, 1 of 5 clients interviewed confirmed the allegation above, and 1 of 5 clients interviewed reported being admitted into the facility with no property nor valuables. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Administrator Ella Naygas, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 11-AS-20241023104859

Allegation investigated: Staff do not prevent residents from using illegal drugs at the facility. Staff did not adhere to admissions agreement.

On 10/25/2024 Licensing Program Analyst (LPA) Troy Watson conducted an unannounced complaint visit to the facility listed above. Upon arrival at the facility, LPA Watson met with Assistant Administrator Cesilia Torres. LPA Bunker explained the purpose of today's visit is to deliver findings for the complaint. The investigation consisted of the following: Interviews were conducted with staff members 1-2 (S1-S2) and residents 1-7 (R1-R7). LPA Bunker requested copies of the Personnel Report and Resident Roster, Physicians Report, preplacement appraisal, appraisal/needs and services plan for R1. LPA Bunker asked questions pertinent to the nature of the complaint.The investigation revealed the following: Allegation: Staff do not prevent residents from using illegal drugs at the facility. CONTINUE REPORT ON LIC9099C Unsubstantiated S1-S2 and R2-R7 stated that residents are not using illegal drugs within the facility and that drugs are strictly prohibited. S1-S2 noted that no one is selling crack cocaine to other residents inside the facility. S1-S2 and R2-R7 also stated that they had not observed any cocaine pipes containing crack cocaine within the facility. R1 stated residents are using and selling illegal drugs at the facility. No witnesses have observed the alleged incidents of residents using or selling illegal drugs at the facility. The department could not confirm whether illegal drugs are being used or sold at the facility. The department toured the facility and observed it is not a locked facility, and residents are free to come and go independently. R2-R7 interviewed also denied knowledge of illegal substances being used on the premises, and all residents denied personal use of illegal substances. S1-S2 interviewed denied knowledge of any illegal substances being used within the facility. S1-S2 and R2-R7 all denied the allegations.Based on interviews, available evidence, observation, information received, and records reviewed there was not enough 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 deemed unsubstantiated. Allegation: Staff did not adhere to admissions agreement The department interviewed S1-S2, and during interviews they indicated that staff adhered to residents’ admission agreements. R1 stated that, years ago, they paid $2,000.00 per month for room and board on two occasions, instead of the $1,418.00. However, S1-S2 clarified that the room and board fee was $1,398.07, with an increase to $1,418.07 effective December 1, 2024, while the resident’s P&I remained at $177.00. Staff provided copies of the resident’s admission agreement and a notice of the rent increase dated December 1, 2023, which the resident signed, agreeing to and acknowledging the rate based on the State of California rate chart. S1-S2 stated that the resident was never charged a $2,000.00 monthly fee, and R1 did not provide any documents or receipts to support the claim of paying $2,000.00 years ago. R2-R7 were interviewed, and they stated that their room and board was $1,398.07 prior to the December 1, 2023 increase to $1,418.07, and stated that staff adhered to their admission agreements. Both S1-S2 and R2-R7 denied the allegation. The department has determined that there is insufficient evidence to support the allegation, and both staff and residents denied the allegation. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough 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 deemed unsubstantiated.There were no deficiencies cited. An exit interview was conducted.A copy of this report was provided to the Administratorthe state’s words, verbatim · CDSS document, Oct 25, 2024 · control 11-AS-20240508095049

Type of visit: Case Management - Incident

,Licensing Program Analyst (LPA) Sparkle Day conducted a Case Management site visit to the facility to ascertain information pertaining to the Licensee-initiated Incident Report which occurred on 09/06/24. LPA met with Assistant Administrator Cecilia Torres who assisted with the visit. On 9/7/2024 R#1 informed Assistant Administrator Cecilia Torres that on 9/6/24 sometime after dinner her room mate R#2 allowed 4 guys into her room and she was raped by one of them. R#1 informed Asst Administrator that two of the guys that came in the room were R#3 and R#4 and the other guys were unknown. Asst Administrator called the Police immediately. When the police arrived R#1 was taken to the UCLA Medical Center Santa Monica and discharged the same day. During todays visit LPA interviewed the following residents: R#1, informed LPA that that never happened and do not know why someone would say that at all. R#2, informed LPA that she never allowed any guys in their room and R#1 is delusional. R#3 indicates he has never had any type of relationship with R#1, R#4 indicates he helped her set up an computer and has never had any relationship with her. LPA requested and received the following documents of R#1: Identification Emergency information sheet, Admission Record sheet, last Physician report dated 7/31/2024, Appraisal dated 7/20/24, Needs and Service Plan dated 7/20/24 and Discharge paper from hospital dated 9/7/2024. No citations were issued during this visit. Exit interview conducted with Asst Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 25, 2024

Allegation investigated: Resident had bedbugs on his person due to staff neglect Resident sustained a stage 1 pressure injury while in care due to staff neglect Resident had feces on his feet due to staff not meeting residents hygiene needs

Licensing Program Analyst (LPA) Sparkle Day conducted a visit to the facility to to deliver complaint investigation findings. LPA met with Assist Administrator, Cecilia Torres and the purpose of the visit was explained. On 09/14/2022 Licensing Program Analyst (LPA) Antonia Alvizar initiated this complaint investigation for the allegations listed above with Administrator Ella Naygas and Assist Administrator Cecilia Torres. During the initial visit LPA Alvizar requested resident roster, staff roster, physical plan and other service, such as medical records, pest control services and caregiver bathing documents on 09/14/2022. LPA Alvizar interviewed R(#1-#7) and S(#1- #5). A plant inspection of the facility was conducted Allegation #1: Resident had bedbugs on his person due to staff neglect It is alleged that R#1 had bedbugs on his person. During the 9/14/22 interviews, 0 out of 7 residents agreed with the allegation. 0 out of 5 staff agreed with the allegation. LPA Alvizar did not observe any bedbugs at time of visit. LPA Day reviewed records of pest control services which are conducted 2 times a month by Environworx Pest Control and more if needed. Based on interviews conducted, observation and pest control records services there is no sufficient evidence to corroborate the above allegation.LPA finds Unsubstantiated that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated Allegation #2: Resident sustained a stage 1 pressure injury while in care due to staff neglect It is alleged that Resident #1 (R#1) sustained a pressure injury while in care. During the 9/14/2022 interviews with LPA Alvizar 0 of 7 residents disagreed with the above allegation and did not know of any pressure injury. 0 of 5 staff disagreed with the allegation and did not know of any pressure injury. LPA Day reviewed last physician report dated 8/20/2022 and hospital discharge dated 9/3/2022 . LPA Day did not observe any diagnosis of pressure injury. Based on interviews conducted and medical records reviewed there is no sufficient evidence to corroborate the above allegation. Therefore LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3: Resident had feces on his feet due to staff not meeting residents hygiene needs It is alleged that R#1 had feces on his feet due to staff not meeting residents hygiene needs.. During the 9/14/2022 interviews of residents and staff with LPA Alvizar . 0 out of 7 residents disagreed with the allegation. 0 out of 5 staff disagreed with the allegation. Staff have a schedule for daily showers for residents and every 2 hours the briefs of incontinent resident are changed but if it is an emergency they change right away. Based on interviews conducted there is no sufficient evidence to corroborate the above allegation. Therefore LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, Sep 11, 2024 · control 11-AS-20220908111405

Allegation investigated: Staff withheld residents’ personal funds. Staff did not provide residents with adequate personal care supplies. Staff did not seek timely medical attention for resident. Staff inappropriately restrained resident.

On 09/07/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit at this facility. LPA was greeted by Assistant AdministratorAdministrator Cesilia Torres. LPA explained the purpose of this visit was to deliver findings for the allegations mentioned above. The investigation consisted of the following: An initial investigation visit on 09/04/24. A review of the Register of Resident Roster, Personnel Report LIC 500, Service records for resident #1 (R1-R4) including Physicians Report LIC 602A, Identification and Emergency Information LIC 601, Admission Agreement, Preplacement Appraisal Information LIC 603, Appraisal Needs/Services Plan LIC 625 and other documents pertinent to the allegations associated with this complaint. Interviews were conducted with Administrators #1-#2 (A1-A2), and residents #1-#9 (R1-R9). A tour of the facilty was conducted. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff withheld residents’ personal funds. The details of the complaint alleged residents’ personal funds are being with by staff. Information reported that staff withheld (P & I) funds and SSI money for residents #2-#4 (R2-R4) since they first arrived at the facility. On 09/04/24, between 10: 48 am - 02:00 pm, the Department interviewed (9) out of (10) residents #1- #R2-R10 (R2-R10) who denied having any issues with their funds managed by the facility. (R3-R4) mentioned that their main income is Supplemental Security Income (SSI) and that the facility is the payee. The basic monthly fee (rent) is deducted each month, and the rest is their Personal and Incidental (P&I). (R2 and R4) verified that they do not have an issue with the facility handling their funds, and they have had no discrepancies with their (P&I) funds. (R2) handles (R2’s) funds and is the payee to (SSI) and not the facility. On 09/04/24, between 09:38 am – 10:45 am, the Department interviewed administrators #1-#2 (A1-A2) reported having no questions or disagreements with the resident’s funds. (A1) stated that not all residents’ funds are being handled by the facility as some of the residents handle their personal funds and are the payee to their (SSI). (A1) verified that (R2) handled (R2’s) funds while (R3-R4) had the facility to their (SSI) as the payee and received (P&I) monthly. As a result of the Department reviewing (R2-R4’s) Admissions Agreement and Contract (dated: 08/20/20 - 07/20/24), and (R3-R4’s) Record of Client’s/Resident’s Safeguarded Cash Resources (dated: 01-05-24 through 09-05-25) along with Physicians Report LIC 602A where it revealed it is accurate and did not disclose any discrepancies and that (R3-R4) is not able to manage their own cash resources Based on the gathered information, there is no evidence to support the allegation mentioned above. Allegation #2: Staff did not provide residents with adequate personal care supplies. In the complaint, it was alleged that the resident was not provided with adequate personal care supplies by staff. It is reported that residents #2-#4 (R2-R4) did not have enough money to purchase their hygiene products and that the administrator did not provide personal care supplies to them. (Evaluation Report continues LIC 9099-C) On 09/04/24, between 10: 48 am - 02:00 pm, the Department interviewed (9) out of (10) residents #1- #R2-R10 (R2-R10) stated that had no issues obtaining personal care supplies from the facility. (R2-R4) had no concerns or issues with purchasing their personal care supplies as it is a preference. (R2-R4) is aware if they ever are out of personal care supplies, they can attain these from the facility. On 09/04/24, between 09:38 am – 10:45 am, the Department interviewed administrators #1-#2 (A1-A2) reported having no issues providing personal care supplies to their residents. (A1) stated we have an inventory supply of basic hygiene items for the resident’s disposal. (A1) stated residents must ask and no one is refused this service. (A1-A2) stated although some residents are aware that we do provide this service, will favor purchasing their personal care supplies at the preference. According to (A1), although the facility is only responsible for toilet paper and soap under their Admissions Agreement and Contract, the facility extends to provide residents with other hygiene supplies at no cost. The Department reviewed (R2-R4’s) Admission Agreement and Contract (dated: xx-xx-xx) which indicated that “basic hygiene items such as soap and toilet paper are provided”. “Other personal articles, i.e. toothpaste, mouthwash, shampoo, Kleenex, etc. are the responsibility of the resident or resident’s representative”. Based on the gathered information, there is no evidence to corroborate the allegation mentioned above. Allegation #3: Staff did not seek timely medical attention for resident. Allegation #4: Staff inappropriately restrained resident. It is alleged resident #4 (R4) was neglected medical attention in a timely manner and improperly restrained by staff. Information reported on 08/27/24, (R4) fell out of a wheelchair, and staff did not want to assist or dispatch an ambulance. Furthermore, (R4) was tied to the wheelchair with a long gown. On 09/04/24, between 10: 48 am - 02:00 pm, the Department interviewed (9) out of (10) residents #1- #R2-R10 (R2-R10) and claimed they were unable to corroborate these allegations that had not witnessed any resident not getting the medical attention or restrained. (R4) denied having fallen or had any accident requiring restraint to a wheelchair on 08/27/24. (R5) co-resident of (R4) verified that no such incident had occurred with (R4). (R5) never observed (R4) being restrained by any device. (Evaluation Report continues LIC 9099-C) On 09/04/24, between 09:38 am – 10:45 am, the Department interviewed administrators #1-#2 (A1-A2) and reported these allegations were false. (A2) stated to have been present on 08/27/24 and claimed that (R4) did not have a fall or had an accident. (R4) was lying on the floor of (R4’s) preference when (R4) was assisted by two caregivers to a wheelchair. (R4) did not exhibit pain or injuries, so there was no need to seek medical attention. (A2) denied (R4) ever being restrained of any devices. On 09/04/24, between 11:15 am – 11:45 am, the Department interviewed staff #1-#2 (S1-S2) and verified to have been present on 08/27/24 with (R4) and disputed these accusations. (S1-S2) confirmed that (R4) did not fall or have an accident. (S1-S2) assisted (R4) to a wheelchair while (R4) lay on the floor of (R4) own accord. (R4) was never restrained by the use of ties or devices to a wheelchair. As a result of the Department reviewing (R4’s) Admissions Agreement and Contract (dated: 08/28/20), Physicians Report LIC 602A (dated: 02/06/24), Appraisal/Needs and Service Plan LIC 625 (date: 12/20/23) revealed that (R4) has the capacity for self-care and is not considered a fall risk. A review of Facility Progress Notes (dated: 08/27/24) verified the incident with (R4) was no fall/accident and no restraint was observed on 08/27/24. Based on the gathered information, there is no evidence to support the allegation mentioned above. An interview with resident #1 (R1) was not available. (R1) refused to participate in an interview. Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegations mentioned in this complaint. Although the allegation may have happened or is 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 is conducted with Cesilia Torres, and a copy of the report is provided.the state’s words, verbatim · CDSS document, Sep 7, 2024 · control 11-AS-20240828155936

Allegation investigated: Staff do not treat residents with dignity or respect Staff do not safeguard resident's personal items Staff do not address resident behavior Staff do not ensure that sharp objects are inaccessible to residents Staff do not keep the facility free from cockroaches Staff do not keep the facility free from bed bugs Staff do not keep the facility clean and sanitary Resident's door is in disrepair

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Friday, August 30, 2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Assistant Administrator Cesilia Torres. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: Interviews were conducted with staff members 1-3 (S1-S3), resident 1 (R1), and residents 3-7 (R3-R7). Resident 2 (R2) was unavailable for an interview after multiple attempts. S1-S3 stated that the resident's door was never broken on three occasions. Ms. Torres and LPA Bunker conducted an on-site tour. During today's visit, no sharp knives or hazardous items were accessible or visible, as they were stored in a locked kitchen cabinet. We did not observe any cigarette butts anywhere, nor were any cockroaches, bed bugs or lice discovered. We also inspected the door and doorknob of room #229. Ms. Torres successfully unlocked the door using the facility's master key, and the resident of room #229 demonstrated the ability to unlock the door with R1's personal key. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 These tests confirmed that the doorknob in room #229 can be unlocked and is fully functional and in good repair. The overall condition of the facility was evaluated as clean, safe, sanitary, and well-maintained. LPA Bunker requested copies of supporting documents. Allegation #1 Staff do not treat residents with dignity or respect Interviews were conducted with staff members 1-3 (S1-S3) and residents 3-7 (R3-R7). They all stated that the staff always treated residents with dignity and respect and that the staff did not disrespect any residents. S1-S3 and R3-R7 stated staff does not scream and yell at residents, staff ensures residents are safe, healthy, and in a comfortable environment, and that residents' daily needs are met. R1 stated that the staff screams and yells at residents. R2 was not available for an interview. S1-S3 stated they do their best to keep residents free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other punitive actions that may interfere with their daily living functions. S1-S3 and R3-R7 denied the allegation. Allegation #2 Staff do not safeguard resident's personal items Interviews were conducted with staff members 1-3 (S1-S3) and residents 3-7 (R3-R7), states staff does safeguard resident's personal items and mail. R1 stated staff stole mail and personal items. S1-S3 stated that R1 stole and was caught on camera stealing from staff and other residents. S1-S3 stated the police came to the facility looking for R1 because the neighbors reported that R1 was stealing in the neighborhood. R1 would not allow the police officers inside the room to do a search. S1-S3 stated staff safeguarded residents' personal belongings in accordance with Title 22 Regulations. S1-S3 and R3-R7 denied the allegation. Allegation #3 Staff do not address resident behavior Interviews were conducted with staff members 1-3 (S1-S3) and residents 3-7 (R3-R7), stated staff does address resident behavior. S1-S3 states if there is a concern they will address the problem immediately. They do everything they can to resolve any issues that occur and a resident is having. S1-S-3 and R3-R7 denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation #4 Staff do not ensure that sharp objects are inaccessible to residents Interviews were conducted with staff members 1-3 (S1-S3) and residents 3-7 (R3-R7), who stated staff does ensure that sharp objects are inaccessible to residents. S1-S3 and R3-R7 stated they did not witness any resident being chased with a knife. R2 was unavailable for an interview. R2 was out in the community. S1-S3 stated that the staff ensures that care and supervision are met to meet residents' needs. S1-S3, R1, and R3-R7 denied the allegation Allegation #5 Staff do not keep the facility free from cockroaches LPA interviewed S1-S3 and R3-R7 who stated that the facility did not have any cockroaches. S1-S3 and R3-R7 stated that the facility has a pest control company that provides ongoing pest control treatment to the facility. S1-S3 and R3-R7 stated that an exterminator comes out to the facility regularly to ensure that the facility is free from cockroaches. R2 was not available for an interview. R2 was out in the community. Based on the records review, a record of pest control services are conducted 2 times a month by Enviroworx Pest Control and more if needed LPA did not observe cockroaches in the facility during today's visit. S1-S3 and R3-R7 denied the allegation. Allegation #6 Staff do not keep the facility free from bed bugs LPA interviewed S1-S3 and R3-R7 who stated that the facility had bed bugs in the past. The facility no longer has any bed bugs. S1-S3 and R3-R7 stated that the facility has a pest control company that provides ongoing pest control treatment to the facility, and the exterminator comes to the facility to ensure that the facility is free from bed bugs. R2 was not available for an interview. R2 was out in the community. Based on the records review, a record of pest control services is conducted 2 times a month by Enviroworx Pest Control and more if needed. LPA did not observe any bed bugs in the facility during today's visit. S1-S3 and R3-R7 denied the allegation. Allegation #7 Staff do not keep the facility clean and sanitary LPA interviewed S1-S3 and R3-R7 who stated that housekeeping keeps the facility clean and sanitary at all times. S1-S3 and R3-R7 stated housekeeping cleans the facility every day. S1-S3 and R3-R7 stated the facility is clean, safe, sanitary, and in good repair at all times for the safety and well-being of clients, employees, and visitors. See continued LIC9099-C page 4 Continued LIC9099-C page 4 S1-S3 stated the facility staff take every measure to keep the facility free of cockroaches, bed bugs, flies, and other insects. S1-S3 and R3-R7 denied the allegation. Allegation #8 Resident's door is in disrepair. LPA interviewed S1-S3 and R3-R7, who all stated that the resident's door was not in disrepair. S1-S3 stated residents' bedroom doors and doorknobs are in working and operable condition. S1 and LPA Bunker toured seven resident bedrooms 108, 111, 113, 114, 115, 201, 215, 218, 219, 222, 228, and 229. During the tour, S1 and S2 checked the resident bedroom doorknobs, all doors were functioning properly. The door and doorknobs were found to be in working order in all resident rooms. R1 stated that R2 knocked on her door and broke the doorknob. S1-S3 and R3-R7 denied that the resident's door was in disrepair. Investigation revealed the following: Investigation revealed the following: Interviews with staff members 1-3 (S1-S3) and residents 3-7 (R3-R7) revealed that staff treat all residents with dignity and respect. S1-S3 stated that R1 frequently reported items as stolen or missing. However, after facility investigations, it was discovered that R1 was the individual caught stealing. S1-S3 stated that R1 was captured on camera stealing from the basement, as well as from both staff and other residents. S1-S3 explained that each resident is provided with a single cabinet secured by a padlock to enhance security and protect their valuable assets or confidential documents. R3-R7 stated that staff safeguard residents' personal belongings. S1-S3 and R3-R7 stated that staff appropriately address any aggressive behavior from residents, and sharp objects are kept inaccessible to them. S1-S3 and R3-R7 also stated that the facility does not have any cockroach or bed bug infestations. S1 provided copies of invoices from Enviroworx Pest Control and Orkin, confirming that the facility is free of insects, cockroaches, and bed bugs. S1-S3 and R3-R7 stated that the facility is clean, safe, sanitary, and well-maintained. S1-S3 mentioned that staff take every measure to keep the facility free of flies and other insects. S1-S3 stated that residents' bedroom doorknobs were in working and operable condition, and all doors were functioning properly. S1-S3 and R3-R7 stated that any problems the facility encounters are addressed and resolved immediately. If there were any issues, S1-S3 stated that staff would have reported them to the appropriate agencies in a timely manner. During today’s visit, no problems were observed, and the doorknobs were found to be in good condition. S1-S3 and R3-R7 all denied the allegations. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough 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 deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to Assistant Administrator Cesilia Torres. There were no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 30, 2024 · control 11-AS-20231201104045

Allegation investigated: Staff do not ensure the residents are properly fed Staff do not ensure the water source is safe for the residents

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Beverly Hills Terrace Facility on 08/21/2024 and was greeted by Administrator Ella Naygas (A1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Administrator (A1), staff (S1-S2), residents (R1-R7). LPA Calderon requested and reviewed copies of the following: Physician Report (dated 03/12/2023), Needs and Services Plan (dated 03/08/2024), incident report (dated 05/31/2024), admission agreement (dated 04/11/2023), 30-day eviction notices (dated 11/15/2023, 07/26/2024) for R1 and weekly meal plan. The investigation revealed the following: Unsubstantiated Regarding Allegation #1: Staff do not ensure the residents are properly fed. It is being alleged that staff did not feed residents and residents went hungry. LPA Calderon toured the facility with A1. During tour of the facility LPA noted the dining room was full of residents having lunch. LPA noted hot dogs and beans with bread was served. The food appeared to smell and look good to eat. LPA Calderon asked the 20 residents how the food was, and all replied the food was “great”. LPA noted a weekly meal plan posted outside the dining room area. Reviewed the weekly meal plan for the facility. The meal plan had 3 meals served daily and appeared to be balanced for resident’s needs. 3 out of 3 staff indicate that 3 meals are served daily, and no resident goes hungry for lack of food. R1 left the facility and could not be interviewed. 6 out of 7 residents indicate that 3 meals are served daily, and no resident goes hungry. 6 out of 7 residents indicate that a weekly meal plan is posted near the dining room area. Regarding Allegation #2: Staff do not ensure the water source is safe for the residents. It is being alleged that the facility water supply is not safe for residents to drink. LPA toured the facility with A1. LPA opened the bathroom faucet and the water appeared to be clear and had no smell. LPA observed the kitchen used filtered water for all meals. LPA Calderon entered the dining room for lunch and noted 20 residents having lunch. LPA Calderon asked the 20 residents how the water tasted, and all replied there were no issues with the water. 3 out of 3 staff indicate no issues with the facility water and no resident has made a complaint about the smell or taste of the water. R1 left the facility and could not be interviewed. 6 out of 7 residents indicate that they drink and shower with the facility water and have no concerns or issues with the facility water supply. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “staff do not ensure the residents are properly fed”, “staff do not ensure the water source is safe for the residents” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Ella Naygas A1.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 11-AS-20240815122554

Allegation investigated: Resident does not have access to room. Staff did not safeguard resident's personal belongings.

On 08/02/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced visit at this facility. LPA was greeted by the Administrato Ella Naygas. LPA explained the purpose of this visit was to deliver findings for the allegations mentioned above. The investigation consisted of the following: A copy of the facility's roster for residents and staff, service records for resident #1 (R1) Physician Report LIC 602A (dated: 03/12/24), Appraisal/Needs and Services Plan (dated: 03/08/24), and Unusual Incident Report LIC 624 (dated: 05/30/24 and 05/31/24), Physician’s Orders Medications List (dated: 07/07/24 - 08/06/24), and other records associated with this complaint. Interviews with residents #1-10 (R1-R10) and assistant administrator #1 (A1) and staff #1-#2 (S1-S2). A plant inspection of the facility of room #218 and the common areas. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Resident does not have access to room. In the complaint, it was alleged that resident #1 (R1) does not have access to (R1’s) room. The complainant stated that (R1) is not issued a key and that staff must give entry to (R1). The complainant did not provide further information about this matter. Investigation revealed resident #1 (R1) came from Sunray Healthcare Center. According to resident #1 (R1’s) Identification and Emergency Information LIC 601 (dated: 04/11/23), (R1) was admitted to Beverly Hills Terrance on 04/10/23. On 07/11/24, between 10:15 am - 01:00 pm, the Department interviewed (10) out of (10) residents #1 - #10 (R1-R10) who denied having issues accessing their room. (R1-R10) claimed they had been given a room key and disclosed the room numbers. (R1) stated the staff has never denied (R1) access to (R1’s) room. (R2-R10) claimed they had not observed any residents who were not issued a room key or were aware of residents not having a key and must be escorted to a room by staff. (R3-R10) praised the facility staff and mentioned they were responsive to their care and supervision. On 07/11/24, between 09:30 am – 01:30 pm, the Department interviewed assistant administrator #1 (A1), and staff #1 (S1) claimed this allegation was false. (A1-S1) stated that (R1) spends limited time inside the facility and spends most of the time out in the community to engage with other residents or be involved in any activities. (A1) explained that (R1) has been a resident for over a year, and during (R1's) residency, (R1) has misplaced or lost (R1’s) key several times. (A1) stated (R1) has never denied access to (R1’s) room and has been given a duplicate room key to access (R1’s) room. (A1-S1) claimed when they were seen (R1) did not have access to (R1’s) room. (A1-S1) stated that (R1) will occasionally refuse medication and behave disorderly if medication has not been taken. On 07/15/24, between 10:17 am – 10:45 am, the Department interviewed (1) out of (1) staff #2 who verified (R1) always has access to (R1’s) room. (S2) had intervened in an incident between (R1) and (R2) on 05/31/24. (S2) recalled intervening in a heated situation between (R1) and (R2) where (R1) was the integrator. (R1) was escorted to (R1’s) room while (S2) dispatched for additional staff assistance. (S2) reported when (R1) was escorted to (R1’s) room, (R1) had a key to unlock the room door. Based on the gathered information, there is no evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-C) Allegation #2: Staff did not safeguard resident's personal belongings. It is alleged resident #1 (R1’s) personal belongings are not safeguarded by the facility staff. The complainant reported there had been a theft from (R1’s) room and clothing had been damaged. The complainant did not provide further details on this matter. On 07/11/24, between 10:15 am - 01:00 pm, the Department interviewed (10) out of (10) residents #1 - #10 (R1-R10) denied having issues or concerns with their personal belongings safeguarded while a resident at this facility. Three (3) out of ten (10) residents claimed in the past they had some items missing or stolen from their room, but stated it is their carelessness for leaving their door ajar or unlocked. (R1) stated in the past some clothing had gone missing or was damaged but could not provide further details for clarification. On 07/11/24, between 09:30 am – 01:30 pm, the Department interviewed assistant administrator #1 (A1) and staff #1 (S1) claimed this allegation was untrue. (A1-S1) stated since (R1) spends the majority of (R1’s) time out in the community, the room is always empty. Only (R1) and management have access to (R1’s) room. (R1) has not reported any items stolen, missing, or damaged in (R1’s) room. (A1-S1) reported that (R1) has a history of misplaced/or lost room keys, so it is no surprise that (R1) would also assume that personal items are missing or lost as well. (A1) stated residents are given one cabinet with a padlock to fortify security to safeguard valuable assets or confidential documents. (A1-S1) stated that (R1) has two (2) padlock cabinets in (R1’s) room for convenience and security. (A1-S1) stated that (R1) is in a private room and the only resident that has access to (R1's) room. The facility does not do (R1's) laundry as (R1's) preference own washing and drying of clothes. On 07/15/24, between 10:17 am – 10:45 am, the Department interviewed (1) out of (1) staff #2 who indicated is unaware of any missing personal items taken from (R1’s) room. (S2) stated (R1) has not reported any personal belongings missing from (R1’s) room. (S2) explained that (R1’s) valuable items are in padlocked cabinets and that (R1) is the only one with a key. (S2) confirmed that (R1) has two (2) padlock cabinets that (R1) utilizes. On 07/11/24, between 01:30 pm – 01:59 pm, the Department inspected (R1’s) room #218 and observed two sides by side four (4) drawer dressers filled with clothes, multiple clothes piled on two (2) chairs, several clothes hanging on a bathroom towel rack and two (2) cabinets with two (2) padlocks shackled on each cabinet. (Evaluation Report continues LIC 9099-C) The Department identified the facility had surveillance cameras installed in the common areas for safety, security, and monitoring. As a result of the Department reviewing (R1’s) Physician Report LIC 602A (dated: 03/12/24), Appraisal/Needs and Services Plan (dated: 03/08/24), and Unusual Incident Report LIC 624 (dated: 05/30/24 and 05/31/24) verified (R1) is evaluated with a history of mental illness. A review of (R1’s) Physician’s Orders Medications List (dated: 07/07/24 - 08/06/24), revealed (R1) is on (11) routine medications. Six (6) out of eleven (11) prescribed medications have side effects on mental health according to the National Institute of Health (ref: NIH). Based on the gathered information, there is no evidence to support the allegation mentioned above. Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegations mentioned in this complaint. Although the allegation may have happened or is 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 is conducted with Ella Naygas, and a copy of the report is provided.the state’s words, verbatim · CDSS document, Aug 3, 2024 · control 11-AS-20240708123811

Allegation investigated: Resident's bathroom is in disrepair.

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, 07/31/2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Assistant Administrator Cesilia Torres. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: Interviews were conducted with staff members 1-3 (S1-S3) and residents 1-7 (R1-R7). LPA Bunker asked questions pertinent to the nature of the complaint. Allegation #1: Resident's bathroom is in disrepair: S1-S3 stated that the bathroom sinks in each resident's room are functioning properly, and none of the residents complained about their sink being backed up for five days. S1-S3 stated that the facility did not have a plumbing problem and did not have a plumber scheduled to come to the facility on Tuesday. R1-R7 stated that their bathroom sinks are working fine and reported no issues with their sinks. LPA Bunker requested copies of the Personnel Report and Resident Roster.See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Investigation revealed the following: Interviews with staff members 1-3 (S1-S3) and residents 1-7 (R1-R7) all stated that residents' bathroom sinks are in working and operable condition. S1 Cesilia Torres, S2 Norman Jones, and LPA Bunker toured seven resident's bedrooms and bathrooms in rooms 108, 111, 114, 215, 218, 219, and 228. During the tour, S1 and S2 turned on the sinks, flushed the toilets, and tested the bathtubs and showers. All fixtures were functioning properly, and the water was draining without any issues. S1-S3 and R1-R7 stated none of the sinks had been backed up for five days. S1-S3 also stated that the facility had not scheduled a plumber appointment for Tuesday. S1-S3 and R1-R7 stated if the facility experienced a plumbing problem or if a resident's bathroom sink was backed up, it would be addressed and resolved immediately. S1-S3 stated if there were an issue with the facility plumbing they would have reported the incident to all the appropriate agencies in a timely manner. During today's visit, no plumbing problems were observed, and the bathrooms were not in disrepair. S1-S3 and R1-R7 all denied the allegation. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough 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 deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to Assistant Administrator Cesilia Torres. There were no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Jul 31, 2024 · control 11-AS-20240724135550

Type of visit: Required - 1 Year

On 07/24/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met Administrator Bella Naygas. The facility is licensed to operate for (110) non-ambulatory elderly adults of ages 60 and above. Currently, the facility has (68) residents of which (0) are in hospice care. The facility is approved for (15) hospice residents. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (55) resident bedrooms. Each room has a bathroom, an activity room, a dining area, a library, a kitchen, a courtyard patio, a lobby, (2) public restrooms, and subterranean parking. The Administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the were facility clear of hazards. Eight (8) resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Continue to LIC809-C. Resident bathrooms were checked. Hot water temperature properly measured at 105F on the first floor and 120F on the second floor. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. Los Angeles Fire Department completed its equipment performance inspection on 07/08/2024. 5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates and required criminal record clearances or criminal record exemptions. 5 resident records were reviewed and, 5 out of 5 resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. No deficiencies are being cited. An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Assistant Administrator Cesilia Torres.the state’s words, verbatim · CDSS document, Jul 24, 2024

Allegation investigated: Staff did not prevent resident from being abused by another resident. Resident was chemically restrained while in care. Staff did not meet resident’s medical needs. Staff did not provide a safe and comfortable environment.

On 07/20/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced visit at this facility. LPA was greeted by the Administrato Ella Naygas. LPA explained the purpose of this visit was to deliver findings for the allegations mentioned above. The investigation consisted of the following: A copy of the facility's roster for residents and staff, service records for resident #1-#2 (R1-R2) Physician Report LIC 602A (dated: 03/12/24 and 01/17/24), Appraisal/Needs and Services Plan (dated: 03/08/24 and 02/08/24), and Unusual Incident Report LIC 624 (dated: 05/30/24 and 05/31/24), Physician’s Orders Medications List (dated: 07/07/24 - 08/06/24), and other records associated with this complaint. Interviews with residents #1-10 (R1-R10) and administrator #1 (A1) and staff #1-#2 (S1-S2). A plant inspection of the facility of rooms #218 and #229 and common areas. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not prevent resident from being abused by another resident. In the complaint, it was alleged that resident #1 (R1) was abused by another resident and that no action was taken by staff to prevent it. The complainant did not provide further information about this matter. Investigation revealed resident #1 (R1) came from Sunray Healthcare Center. According to resident #1 (R1’s) Identification and Emergency Information LIC 601 (dated: 04/11/23), (R1) was admitted to Beverly Hills Terrance on 04/10/23. (R1’s) Physicians Report LIC 603A (dated: 03/12/23) is diagnosed with mental illness. On 07/11/24, between 10:15 am - 01:00 pm, the Department interviewed (9) out of (10) residents #1- #R3-R10 (R1) (R3-R10) who denied having experienced physical assault while in care at this facility. (R1) (R3-R10) claimed not to have witnessed any physical altercations or assaults between residents. (R1) (R3-R10) commended the facility staff and mentioned they were responsive to their care and supervision. (R1) professed that (R2) had never engaged in physical contact or verbal interaction with (R1). (R2) claimed that (R1) has intimidated (R2) with verbal exchanges but no physical abuse. On 07/11/24, between 09:30 am – 01:30 pm, the Department interviewed assistant administrator #1 (A1) and staff #1 (S1) claimed this allegation was untrue. (A1-S1) stated that (R1) spends limited time inside the facility and spends most of the time out in the community to have any interactions with (R2). (A1) explained that (R1) and (R2) were friends and former roommates who had fallen out of friendship which led to some arguments between each other. There have been no physical or verbal abuse only disagreements with each other. (A1-S1) reported they have been separated from non-adjacent private rooms. (A1-S1) claimed when they are seen engaging with one another a staff will intervene to distance both residents from one another. (R1) and (R2) were both diagnosed with mental illness and behaved negatively when medications were not taken. On 07/15/24, between 10:17 am – 10:45 am, the Department interviewed (1) out of (1) staff #2 who verified (S2) had intervened in an incident between (R1) and (R2) on 05/31/24. (S3) recalled intervening in a heated situation between (R1) and (R2) where (R1) was the integrator. (R1) was escorted to (R1’s) room while (S2) was dispatched for additional staff assistance. (S3) claimed that there was no physical violence nor did the residents sustain any injuries. (Evaluation Report continues LIC 9099-C) As a result of the Department reviewing (R1’s-R2’s) Physician Report LIC 602A (dated: 03/12/24 and 01/17/24), Appraisal/Needs and Services Plan (dated: 03/08/24 and 02/08/24), and Unusual Incident Report LIC 624 (dated: 05/30/24 and 05/31/24) verified (R1 and R2)) both been evaluated with a history of mental illness. A review of (R1’s – R2’s) Physician’s Orders Medications List (dated: 07/07/24 - 08/06/24), revealed (R1) is on (11) routine medications and (R2) is on (8) prescribed medications. Twelve (12) out of nineteen (19) prescribed medications have side effects on mental health according to the National Institute of Health (ref: NIH).. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. Allegation #2: Resident was chemically restrained while in care. It is alleged resident #1 (R1) was chemically restrained while in care at this facility. The complainant reported (R1) is chemically dosed with an unknown grainy toxin. The complainant did not provide further details on this matter. On 07/02/24, between 10:15 am - 01:00 pm, the Department interviewed (10) out of (10) residents #1-#10 (R1-R10) whose medication management needs have been met nor have medications not been prescribed by their physician been administered. (R1-R10) reported not having experienced any side effects from medications. (R1) declined to have issues or concerns with medications administered by the facility. (R1) denied having any side effects from the medications. On 07/11/24, between 09:30 am - 01:30 pm, the Department interviewed (2) out of (2) assistant administrator #1 (A1), and staff #1 (S1) claimed this allegation was false. (A1) stated no recent modifications on (R1’s) medications. (A1-S1) reported that (R1) occasionally refused to take medications. (A1-S1) said the facility assisted with self-administration and did not force residents to take medication, hide medication without their knowledge, or otherwise violate their right to refuse. A review of (R1’s) Medication Administration Record (dated: 07/07/24 - 08/06/24) revealed (R1) is on (11) routine medications and (R2) is on(8) prescribed medications.. Based on the gathered information, there is no evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-C) Allegation #3: Staff did not meet resident’s medical needs. The details of the complaint alleged the facility did not meet resident #1 (R1) medical needs. The complainant did not provide further details on this matter. On 07/11/24, between 10:15 am - 01:00 pm, the Department interviewed (10) out of (10) residents #1-#10 (R1-R10) and confirmed the facility is capable of meeting resident’s medical needs. (R1) rejected having issues or concerns with medical necessities. (R2-R10) indicated the facility has in-house medical professionals who come to the facility to perform medical services for residents and are satisfied with the services provided. On 07/11/24, between 09:30 am – 01:30 pm, the Department interviewed assistant administrator #1 (A1) and staff #1 (S1) who claimed this allegation was false. (A1-S1) reported all residents must have medical care. (A1) indicated some residents have private primary physicians, and some are seen by in-house physicians. (A1-S1) reported that (R1) often is non-cooperative and will not want to be seen by the in-house medical physician. (A1) stated that (R1) is entitled to refuse medical assistance and medical services are not being forced upon (R1). A review of (R1’s) Identification and Emergency Information LIC 601 (dated: 04/11/23) and Physicians Report LIC 602A (dated: 03/12/23) verified that (R1) is under medical care and supervision provided by the in-house physician. Based on the gathered information, there is no evidence to corroborate the allegation mentioned above. Allegation #4: Staff did not provide a safe and comfortable environment. It is alleged the facility did not provide a safe and comfortable environment for resident #1 (R1). The complainant did not offer additional information on this matter. On 07/11/24, between 10:15 am - 01:00 pm, the Department interviewed (10) out of (10) residents #1-#10 (R1-R10) and verified the facility maintained a safe and comfortable environment for residents. (R1) denied having any concerns or issues and felt the facility provided a safe setting and comfortable place. (Evaluation Report continues LIC 9099-C) On 07/11/24, between 09:30 - to 01:30 pm, the Department interviewed (2) out of (2) assistant administrator #1 (A1) and staff #1 (S1) who confirmed that the facility does provide a safe and comfortable environment for resident in care. (A1-S1) claimed that there is no type of abuse at this facility and had no concerns. (A1) indicated only recent incidents were between (R1 and R2) with no physical assault and only verbal disagreements with one another. (A1) reported there is 24/7 care and supervision are provided by staff. According to (A1), the facility is equipped with surveillance cameras used to protect residents, staff, and visitors. It is added protection to deter away any activities of theft, vandalism break-ins, or any unwarranted activities. On 07/11/24, between 01:30 pm – 01:59 pm, the Department inspected (R1’s) room #218 and (R2’s) room #229 including the common areas and observed surveillance cameras on the premises. Based on the gathered information, there is no evidence to corroborate the allegation mentioned above. Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegations mentioned in this complaint. Although the allegation may have happened or is 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 is conducted with Ella Naygas, and a copy of the report is provided.the state’s words, verbatim · CDSS document, Jul 20, 2024 · control 11-AS-20240705143922

Allegation investigated: Facility staff did not meet resident's hygiene needs. Facility staff did not note a change in resident's condition. Facility staff did not seek resident timely medical attention. Facility staff did not ensure that resident was free from bed bugs. Facility staff neglect resulted in resident sustaining a pressure injury.

On 7/9/2024, Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced subsequent complaint visit to deliver complaint investigation findings. LPA Day met with Cecilia Torres,Asst Administrator and explained the purpose of today’s visit. The investigation consisted of the following: On 12/28/2022, LPA Lourdes Montoya toured the facility with the Administrator. LPA requested resident roster, staff roster, pest control invoices, and Resident #1's service records (Admission Agreement, Appraisal, Physician's Report, Doctor's/Hospital records, Home Health nurses notes and other pertinent records. LPA interviewed three staff (S1-S3). On 12/29/2022, LPA interviewed eight residents (R2-R9). R1 is in the hospital and not available for interview during LPA's visit. The investigation revealed the following: Allegation: Facility staff did not meet resident's hygiene needs. It is alleged that facility staff did not meet resident's hygiene needs. On 12/28/2022 between 11:55 am Unsubstantiated and 1:15 pm, LPA Montoya conducted interviews with three out of twenty-three staff (S1-S3). On 12/29/2022 from 9:40 am – 11:55 am, LPA interviewed eight out of seventy-one residents (R2-R9). R1 was in the hospital and not available for interview. Based on interviews conducted, eight out of eight residents (R2-R9) and three out of three staff (S1-S3) denied that facility staff did not meet resident's hygiene needs. Three staff (S1-S3) revealed staff are consistent with their hygiene assistance to R1 but sometimes R1 refuses the assistance. Based on records review, physician’s report shows R1 needs assistance with bathing, but is capable of dressing ,toileting and grooming himself . LPA did not observe R1 in the facility. LPA did not observe any residents with bad hygiene. Based on information gathered, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated Allegation: Facility staff did not note a change in resident's condition. It is alleged that facility staff did not note a change in resident's condition. On On 12/28/2022 between 11:55 am and 1:15 pm, LPA Montoya conducted interviews with three out of twenty-three staff (S1-S3). On 12/29/2022 from 9:40 am – 11:55 am, LPA interviewed eight out of seventy-one residents (R2-R9). R1 was in the hospital and not available for interview. Based on interviews conducted, eight out of eight residents (R2-R9) and three out of three staff (S1-S3) denied that facility staff did not note a change in resident's condition. Based on records review, R1 had a change of medical condition determined by a medical practitioner on 10/7/2022 and 12/20/2022 which was noted and R1 was sent to hospital which was noted. LPA did not observe any complaints during the visit that staff failed to note a change in resident’s condition. Based on information gathered,LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated Allegation: Facility staff did not seek resident timely medical attention. It is alleged that facility staff did not seek resident timely medical attention. On 12/28/2022 between 11:55 am and 1:15 pm, LPA Montoya conducted interviews with three out of twenty-three staff (S1-S3). On 12/29/2022 from 9:40 am – 11:55 am, LPA interviewed eight out of seventy-one residents (R2-R9). R1 was in the hospital and not available for interview. Based on interviews conducted, eight out of eight residents (R2-R9) and three out of three staff (S1-S3) denied that facility staff did not seek resident timely medical attention. Three staff (S1-S3) stated on 12/20/2022 around 12:40 AM, staff observed that R1 was not feeling well and looked pale. The administrator immediately called 911. Based on records review, paramedic came at 12:46 am which is noted. Based on information gathered, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated Allegation: Facility staff did not ensure that resident was free from bed bugs. It is alleged that facility staff did not ensure that resident was free from bed bugs. On 12/28/2022 between 11:55 am and 1:15 pm, LPA Montoya conducted interviews with three out of twenty-three staff (S1-S3). On 12/29/2022 from 9:40 am – 11:55 am, LPA interviewed eight out of seventy-one residents (R2-R9). R1 was in the hospital and not available for interview. Based on interviews conducted, three out of eight residents and three out of three staff revealed there were bed bugs in the past. A pest control company provides an ongoing pest control treatment to the facility. Six out of eight residents denied that facility staff did not ensure that resident was free from bed bugs. Based on records review, a record of pest control services are conducted 2 times a month by Environworx Pest Control and more if needed LPA did not observe bed bugs in the facility. Based on information gathered, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated Allegation: Facility staff neglect resulted in resident sustaining a pressure injury. It is alleged that facility staff neglect resulted in resident sustaining a stage 1 pressure injury. On 12/28/2022 between 11:55 am and 1:15 pm, LPA Montoya conducted interviews with three out of twenty-three staff (S1-S3). On 12/29/2022 from 9:40 am – 11:55 am, LPA interviewed eight out of seventy-one residents (R2-R9). R1 was in the hospital and not available for interview. Based on interviews conducted, eight out of eight residents (R2-R9) and three out of three staff (S1-S3) denied that facility staff neglect resulted in resident sustaining a pressure injury. Based on records review, R1 received Home health care from 10/15/22 to 12/13/2022 after which he was able to return to his previous level of functioning . LPA did not observe R1 in the facility. Based on information gathered, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 9, 2024 · control 11-AS-20221221113415

Allegation investigated: Staff neglect resulting in resident suffering from dehydration. Resident suffered falls while in care resulting in injuries.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced subsequent visit to the facility and was greeted by Administrator (A1: Aharon Striks). LPA spoke to A1 prior to entering the facility to conduct a risk assessment. A1 informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. The investigation consisted of the following: Licensing Program Analyst (LPA) Ana Soto conducted the unannounced 10-Day visit on 08/09/21 approximately 10:00 a.m. LPA initiated an investigation into the above-mentioned allegations and conducted a face-to-face interview with Asst. Administrator (A2: Clifford Johnson). LPA requested copies of the following documents: Physician’s Report (dated 07/30/2021), Pre-appraisal (dated 05/10/2021), Admissions Agreement (dated 05/10/2021, 07/31/2021), Appraisal/Needs and Services Plan (dated 09/05/2021), Medication Administration Record (July 2021). Unsubstantiated This complaint investigation was referred to the California Department of Social Services Investigations Bureau (IB) and was assigned to Investigator Olivia Spindola which included a review of Cedar Sinai Medical Center (CSMC), medical records (dated 07/31/2021); interviews conducted of Staff #1, #2, #3, #4; Residents #1, #4, #5, #6; Witness #2. An interview with Witness #1 was attempted, but to no avail at the close of this investigation. The investigation revealed the following: Regarding Allegation #1: Resident #1 was hospitalized on 07/31/21 at Cedar Sinai Medical Center (CSMC) and diagnosed with urinary retention, acute renal failure, altered consciousness, toxic metabolic encephalopathy. Resident #1 received a medical procedure on 08/05/21 at CSMC based on clinical history of diabetes militia II (DM2). Resident #1 was discharged from CSMC hospital on 08/10/21 with the diagnosis of inpatient rehab, DM2, dyslipidemia, hypertension, morbid obesity, bipolar disorder type, thrombocytopenia, and macrocytosis. Facility staff have the capability of meeting the resident’s medical needs; and Resident #1 can care for themself. A review of Resident #1’s Physician’s Report documented that the resident is ambulatory and could care for themself and does not require assistance. Interviews conducted of facility staff corroborated that although Resident #1 appears to not make the best decisions regarding their diabetic diet, facility staff ensures to monitor Resident #1’s water intake and medical care needs. Resident #1 admitted that the facility takes good care of them and is responsive to their needs. The food that is provided at the facility meets R1’s diabetic diet. Resident #1 admitted that they like to drink sodas and eat hamburgers when they are out in the community. Resident #1 stated that they get their sugar levels checked every morning and the resident can care for their own needs without assistance. Based on the evidence gathered and interviews conducted, and records reviewed, 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 of NEGLECT/LACK OF CARE AND SUPERVISION: Staff neglect resulting in resident suffering from dehydration is found to be UNSUBSTANTIATED. 03/13/24 Regarding Allegation #2: Resident #1 has a history of recurrent falls attributed to psychosis and morbid obesity. Resident #1’s platelets were between 120,000 to 160,000 for the last six (6) months as an outpatient. Possible thrombocytopenia secondary to Depakote; hyperkalemia secondary to CKD mild; metabolic acidosis, gait disorder. Iron panel suggestive of anemia of chronic disease. Resident #1 admitted that they recall going out to the community to purchase sodas at a store when R1 tripped and fell and hit their face and was hospitalized for the fall. Resident #1 stated that the facility takes good care of them and is responsive to their needs. A review of the Incident Report (dated 8/6/2021) documented that the resident sustained a fall outside the community and was transported to Cedar Sinai Medical Center (CSMC) for observation. Based on the evidence gathered and interviews conducted, and records reviewed, 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 of NEGLECT/LACK OF CARE AND SUPERVISION: Resident suffered falls while in care resulting in injuries is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to Administrator (A1: Aharon Striks).the state’s words, verbatim · CDSS document, Apr 4, 2024 · control 11-AS-20210806163809