Canyon Trails at Topanga Senior Living

Allegation investigated: Staff did not provide proper supervision to residents in care Facility is not equipped with sufficient hygiene supplies to meet the needs of residents in care

Licesning Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility. LPA Smith was greeted by staff and disclosed the reason for the visit. Staff did not provide proper supervision to residents in care It was alleged that due to staff not providing proper supervision to memory care residents the residents are being found in the assisted living areas of the facility to include the patio areas. To investigate the allegation, on 04/15/26LPA Smith toured the facility with the Executive Director at approximately 10:25 a.m. From 12:00 p.m. to 3:00 p.m., LPA Smith interviewed six (6) staff members and three (3) residents and inspected seven (7) randomly selected resident rooms. Throughout the visit, LPA Smith also requested documents relevant to the investigation, including but not limited to the personnel report, resident roster, and hygiene invoices. During several visits to the facility, LPA Smith did not hear any door alarms sounding and did not observe any residents wandering, pushing on exit doors, or attempting to leave the memory care unit. Interviews with random staff assigned to the memory care unit revealed that no resident had been Unsubstantiated (Cont from 9099) found outside the secured area without supervision. All staff interviewed revealed all staff provide adequate supervision and more including encouraging memory care residents to participate in social activities, and the majority do participate; those who do not typically have visitors present or receive frequent staff checks. LPA Smith also observed memory care residents visiting with family in the patio area and resident assistants conducting routine room checks. Interviews with seven (7) residents on the assisted living side indicated they had not seen any memory care residents wandering in areas where they did not reside. Based on observations and interviews there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Facility is not equipped with sufficient hygiene supplies to meet the needs of residents in care. It was alleged that due to insufficient incontinent supplies staff are using a wash and bathroom tissue when providing incontinent care. LPA Smith reviewed three (3) Mckesson Supply invoices dated February 3, 2026, March 3, 2026, and March 18, 2026, each invoice showed orders of one (1) to two (2) cases of wipes and/or gloves. During the visit, LPA Smith observed incontinence supplies in the stockroom, including wipes, gloves, and diapers, and random resident rooms also contained gloves, wipes, and diapers readily available for use. All staff interviewed denied using bathroom tissue or washcloths on residents when providing incontinence care. Four (4) resident assistants stated that staff are required to follow each resident’s care plan and use the proper items as trained, including some residents have sensitive skin or allergies to certain ingredients and can use only approved supplies for incontinence care. All residents interviewed reported no concerns related to the allegation and stated that staff have not used bathroom tissue on them during incontinence care. Based on records review, observations and interviews there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No hazards observed at time of visit Exit Interview conducted/Copy of report given.the state’s words, verbatim · CDSS document, Jul 6, 2026 · control 31-AS-20260406130652

Allegation investigated: Licensee does not ensure that the facility is supplied with the necessary equipment to lift residents in care.

Licensing Program analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility to investigate the above allegation. LPA Smith was greeted by the executive director and disclosed the purpose of the visit. Licensee does not ensure that the facility is supplied with the necessary equipment to lift residents in care. It was alleged that the facility lacks the necessary equipment to lift residents with reduced mobility. To investigate on 05/15/26, LPA Smith interviewed two (2) staff at 10:45 am, requested copies of documents relevant to the investigation at 10:50am, interviewed eleven (11) residents and (6) additional staff from 11:15 am -3:50 pm. Interview with the executive director and wellness director reveal the facility does not have any residents in care that require transfer by Hoyer lift. The Executive director also revealed each shift has adequate staffing to cover additional assistance request from residents. All staff interviewed revealed that each shift has adequate staff to ensure residents’ that require Unsubstantiated (cont from 9099) and/or request a two-person assist receives it. Ten (10) of eleven (11) residents interviewed confirmed that additional staff are available for assistance and staff will ask them if they want additional staff to help with transfers. Two (2) residents revealed they transfer independently but staff still ask if they need any transfer assistance or an escort. Review of 6-8 random resident medical records did not contain any physician’s requirements to transfer residents with a Hoyer lift. Based on the information obtained during this investigation there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted/copy of this report was provided.the state’s words, verbatim · CDSS document, May 22, 2026 · control 31-AS-20260505124255

Allegation investigated: Residents are sustaining falls due to licensee neglect

Licensing Program analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility to investigate the above allegations. LPA Smith was greeted by the executive director and disclosed the purpose of the visit. Residents are sustaining falls due to licensee neglect. It was alleged residents are sustaining falls due to licensee neglect, specifically related to manual transfers. To investigate LPA Smith interviewed two (2) staff at 10:45 am, requested copies of documents relevant to the investigation at 10:50am, interviewed residents eleven (11) residents and (6) additional staff from 11:15 am -3:50 pm. Six (6) of nine (9) staff consistently stated that they have not observed any falls associated with manual transfers and stated that manual transfers are performed according to established procedures. The primary cause of recent falls involves residents not using their pendant to request assistance or attempting to ambulate without waiting for staff support per staff interviews. Ten (10) of eleven (11) residents interviewed confirmed that they receive assistance when they request it, five (5) of eleven (11) revealed that their falls occurred when they chose not to wait for staff or did not call for help, five (5) of eleven (11) Unsubstantiated (cont from 9099) residents have not had a fall or don't remember, and one (1) of eleven declined interview. Based on interviews there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted/copy of this report was provided.the state’s words, verbatim · CDSS document, May 15, 2026 · control 31-AS-20260505124255

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: Resident sustained a head injury due to staff neglect or physical abuse.

On 5/06/2026 at approximately 9:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced initial complaint visit to the facility to investigate the above allegation(s). LPA was greeted by staff and stated the reason for their visit. LPA met with the Executive Director, Peter Bonilla who assisted with today’s visit. To investigate the allegation, at 09:45 AM, LPA requested census, resident, and staff roster. At approximately 10:00 AM, LPA conducted a physical plant tour, to ensure the health and safety of the residents. At 11:00 AM, LPA requested pertinent documentation pertaining to the investigation such as but not limited to: Physician’s Report, Needs/Services and Pre-Appraisal. In between 11:30 AM – 1:30 PM, LPA attempted interviews with one (1) resident (R1), three (3) staff members (S1-S3) and conducted record review. (Continue LIC 9099-C) Unsubstantiated Regarding the allegation: Resident sustained a head injury due to staff neglect or physical abuse. It was alleged that resident one (R1) had an unwitnessed fall resulting in bruising. To investigate the allegation, LPA attempted interviews with one (1) resident and three (3) staff members. LPA attempted to interview R1 but due to their inability to validate the questions being asked, LPA terminated the interview. LPA’s interview with S2 revealed R1 was sent to the hospital on 4/26/2026 due to staff observing discoloration of their face. S2 stated R1’s representative, who was visiting during said incident (4/25/2026), declined medical services for R1. LPA’s interview with S3 revealed R1 was placed on a head monitoring chart due to the discoloration notated on their face. Per S3, a body check, including of the head, was conducted on R1. S3 stated on 4/26/2026, R1’s representative was contacted to inform them that R1 was being sent out to the hospital as a precautionary measure. When questioned if R1 could have been struck by another resident, S3 declined but did mention an Unusual Incident/Injury Report (SIRs) was submitted for an isolated incident where R1’s representative reported to have observed a resident (R2) strike R1’s hand. LPA’s record review confirmed that the facility did report both incidents to the appropriate reporting parties including Community Care Licensing Division (CCLD). LPA conducted a record review. LPA’s review of R1’s hospital discharge paperwork dated 4/30/2026 documented R1 to have been diagnosed with a nontraumatic hemorrhage. LPA conducted a supplementary record review, where a web search of R1’s diagnosis stated, “…bleeding that accumulates between the brain and its outer lining (dura mater) without being caused by a direct head injury…”. Further record review of R1’s discharge paperwork indicated their head scan results returned as, “stable”. Additional record review was conducted pertaining to R2. R2’s Physician’s Report regarding their behavioral expressions to document as follows: Lack of impulse control? No; Expressions of Frustration? No. During LPA’s physical plant tour, LPA conducted random room checks in both the Assisting Living and Memory Care residencies. LPA observed residents’ rooms to be neat, clean and organized. LPA did not observe there to be any obstructions in the residents’ rooms. Additionally, LPA observed R1’s bedroom to be in proper condition with no hazards in the bedroom’s walkways. During LPA’s physical tour, LPA observed R1 to appear to be in good health and participating in activities with their peers. LPA observed staff to be present throughout both wings of the facility. LPA observed sufficient amount of staff members to be present with residents in the Memory Care Unit. LPA’s record review of the Memory Care staff schedule for 4/25/2026 and 4/26/2026 did not showcase there to be any discrepancy. (Continue to LIC 9099-C) Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Wellness Director who was designated to sign today’s report.the state’s words, verbatim · CDSS document, May 6, 2026 · control 31-AS-20260428160817

Allegation investigated: Resident has unexplained bruises. Staff did not notice resident's change in condition. Staff did not notify authorized representative of bruises.

On 4/29/26, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted subsequent complaint visit to investigate the above allegations, and to deliver the final report. Upon arrival, LPA met with the Executive Director Peter Bonilla and explained the reason for the visit. During the initial complaint visit conducted by LPA Reed on 6/4/2025, LPA requested copies of pertinent information, which include but are not limited to the copies of Resident #1(R1) file / documents. On 6/3/2025, the complaint got forwarded to Investigations Branch (IB) for further investigation. During today’s visit, LPA Khurshudyan requested residents and staff rosters. LPA also conducted a physical plant tour to ensure health and safety of the residents are protected. No health and safety hazards noted during the visit. Continue on LIC9099-C Unsubstantiated Allegation: Resident has unexplained bruises. LPA Khurshudyan conducted interviews with eleven (11) residents in the Memory Care Unit who were able to communicate and respond to questions. All residents interviewed denied ever witnessing or hearing of any resident being physically abused or receiving bruises from physical abuse. Residents stated they liked the facility, felt comfortable living there, and felt adequately supervised by staff. LPA interviewed four (4) Staff members, who denied ever witnessing or being aware of any physical abuse that could have resulted in residents obtaining bruises. Staff reported that residents in the Memory Care Unit are monitored throughout the day, and any unusual skin discoloration, injury, or change in condition is reported to the Memory Care Director and/or management. To investigate the allegation, the Department also interviewed Memory Care Director MCD. MCD stated that R1 had ongoing behavioral issues and was frequently observed hitting hands on doors and walls and hitting self. The Memory Care Director (MCD) reported that R1 was being closely monitored due to behavioral changes and increased agitation. The MCD also confirmed that R1 was evaluated by a physician and diagnosed with a UTI on 5/24/2025. The Department attempted to interview R1; however, due to R1’s inability to respond and increased agitation, the interview was terminated. Although R1 had bruising and discoloration on the hands and left wrist, the information obtained during the investigation did not establish that the bruising resulted from physical abuse, neglect, or lack of supervision by facility staff. Based on interviews, record reviews, and all information obtained, there is insufficient evidence to determine that the bruising was unexplained due to neglect or abuse by the facility. Therefore, the allegation is Unsubstantiated. Allegation: Staff did not notice residents change in condition. The investigation conducted by LPA Khurshudyan, revealed that facility staff documented changes in R1’s behavior and condition beginning on or around 5/21/2025. Facility progress notes documented that R1 had increased behavior, agitation, difficulty with redirection, and possible symptoms related to UTI. Facility records documented that staff attempted to obtain a urine sample and continued to monitor R1. Continue on LIC9099-C Records also documented that R1 was sent to urgent care on 5/24/2025 and was prescribed medication for UTI. The Department also conducted interviews with facility staff, and it was reported that R1 had behavioral episodes, was aggressive and was self-harming. Based on interviews and records reviewed, LPA Khurshudyan determined that facility staff observed and documented R1’s change in condition, including behavioral changes, agitation, possible UTI symptoms, and skin discoloration. Staff also took steps to monitor R1, report concerns, coordinate with the responsible parties, and seek medical evaluation. Therefore, the allegation staff did not notice residents change in condition is Unsubstantiated. Allegation: Staff did not notify authorized representative of bruises. It was alleged that the authorized representative was not notified regarding R1 bruising/ discoloration. Records reviewed by LPA Khurshudyan confirmed that communication was documented between facility staff and R1’s family/responsible party regarding R1’s behavioral condition and agitation. LPA Khurshudyan also conducted interview with the Memory Care Direcotor MCD, who stated that staff were actively monitoring R1 and documented everything. On 5/23/25, a staff member reported observing discoloration on R1’s hands. The Memory Care Director (MCD) also stated that R1 was sent to Urgent Care on 5/24/25 with family for an evaluation of the discoloration and for a possible UTI. Later on 5/24/25, following the Urgent Care visit, R1’s family contacted the MCD to inquire about the bruising on R1’s hands. The MCD informed the family that the bruising could be related to R1’s agitation and self-harming behaviors, and also noted that R1 takes medication that may cause the skin to be prone to discoloration. Furthermore, MCD told family that more internal investigation will be conducted as well. During the course of investigation, the Department conducted interview with Memory Care Director who indicated that R1’s family and responsible parties were contacted regularly regarding resident’s behavior. Based on interviews and records reviewed the department determined there was insufficient evidence to establish that facility staff failed to notify R1’s authorized representative of R1’s bruising / discoloration or change in condition. Therefore, the allegation is Unsubstantiated. No deficiencies issues during today’s visit. Exit interview conducted and signed copy of the report delivered.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 31-AS-20250603083113

Allegation investigated: Staff do not ensure the facility is free of foul odors. Staff do not ensure the food being served is of good quality. Staff do not ensure resident's personal belongings are safeguarded. Staff restricted resident’s access to resident’s personal grooming items without authorization.

On 12/23/25 at approximately 5:45pm, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a subsequent visit to deliver final findings. LPA met with Ashley Hernandez – concierge staff and explained the reason for the visit. During the initial visit made on 11/27/2024, by LPAs Panushkina and Khurshudyan interviews and record reviews were made. At 9:45am, LPAs request resident and staff rosters, nine (9) residents files from Generation unit and Assisted Living unit. LPAs also requested copies of Admission Agreement, Appraisal Needs and Services, Physician Report, Unusual Incident Reports, MAR’s, Financial folder and pertinent documents relevant to the investigation. LPAs with the help of ALD Ms. Solorzano conducted a physical plant tour between 10:30am to 11:35am including the Generation Unit to ensure health and safety of the residents are protected. No health and safety hazards noted during the visit. Between 1:15pm – 2:30pm LPA Khurshudyan interviewed the Executive Director, Assisted Living Director, four (4) staff members and seven (7) out of nine (9) residents who were able to communicate. Continue on LIC9099-C Unsubstantiated During today’s visit, LPAs requested resident /staff rosters, and conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. No health and safety hazards were noted during the visit. Allegation: Staff do not ensure the facility is free of foul odors. It was alleged that the facility hallway smells of urine and feces. To investigate the allegation, LPA toured the Assisted Living (AL) and Memory Care (MC) hallways, common areas, and residents’ rooms. During the tour LPA did not observe strong or persistent odors of urine/feces. Interviews were conducted with nine (9) residents residing in the MC and AL, the Executive Director, Memory Care Director, and six (6) Staff/Caregivers. The majority of residents described the facility as generally clean and odor free. Residents who were able to communicate stated that the housekeepers do daily light cleaning and weekly deep cleaning to their rooms. LPA checked random residents’ rooms and observed trash bins to be empty, and no soiled diapers were present inside residents’ rooms. Interviews with staff members stated that occasional short-lived odors may happen and described procedures for promptly cleaning incontinence related incidents happening in common areas and removing soiled linens and trash. All interviewees denied ongoing odor concerns and confirmed that hallways and common areas are cleaned and sprayed daily. Based on observations and interviews, the allegation that staff do not ensure the facility is free of foul odors is Unsubstantiated. Allegation: Staff do not ensure the food being served is of good quality. It was alleged that the Staff do not ensure the food being served is of good quality. To investigate the allegation, LPA interviewed nine (9) residents residing in the MC and AL, the Executive Director, Memory Care Director, the Chef and six (6) Staff/Caregivers. LPA observed the meal service and reviewed the facility’s description of menu planning and substitutions. Residents interviewed regarding meal quality, variety, and whether they were regularly served poor quality food. Residents confirmed that meals are acceptable and varied. Residents also stated that there is always alternative food for each mealtime and added that variety of sandwiches are always available as a substitute for the main meal. Interviews with staff members stated sandwiches are served at times as part of meal options when residents refuse the main meal. Continue on LIC9099-C Interview with the Chef and review of weekly meal menu also confirmed that facility provides variety of good quality and nutritious food to all residents in care and they always have alternative food including deli sandwiches. Chef also added that the facility menu is being prepared, verified, and confirmed by the chef and the nutritionist. During the visit, the LPA observed residents being served lunch and did not notice any concerns regarding food quality. The meal provided appeared appropriate and well-prepared, and the LPA did not observe residents being served only sandwiches or any indication of poor-quality food. Based on observations and interviews, the allegation that staff do not ensure food served is of good quality is Unsubstantiated. Allegation: Staff do not ensure resident's personal belongings are safeguarded. It was alleged that staff do not ensure residents’ personal belongings are properly safeguarded. To investigate this concern, the LPA interviewed nine residents from the Memory Care (MC) and Assisted Living (AL) units, as well as the Executive Director, Memory Care Director, and six staff members, including laundry staff. Laundry staff explained their process for collecting, sorting, washing, drying, and returning clothing, noting that each resident follows an individual laundry schedule and that all loads are washed separately. They also stated that residents’ clothing is labeled with their names to prevent items from being misplaced. Residents interviewed reported that they have not experienced missing clothing after laundry service. Some residents mentioned that clean clothes are occasionally returned in bags, but staff later organize them in the closets. During room checks, the LPA observed only unwashed clothing in laundry baskets and did not find clean clothing stored in bags. Staff further explained that some Memory Care residents place their own clothes into bags because they believe they are preparing to leave the facility. All staff denied leaving clean clothing in bags for a long period of time after washing and stated that residents sometimes misplace their own items in different drawers or forget where they placed them. Staff also noted that residents, mainly residing in Assisted Living, occasionally give clothing to one another and later report the items missing. Interview with the Executive Director revealed that the facility conducted an internal investigation regarding a missing ring. Staff were interviewed and relevant areas were checked; however, no witness reported seeing or hearing anyone take the ring. The investigation did not reveal any suspicious behavior or evidence indicating how or when the ring went missing. Based on the observation and information gathered, the LPA did not obtain evidence that staff failed to safeguard residents’ belongings or that facility practices resulted in lost personal property. Therefore, the allegation is Unsubstantiated. Continue on LIC9099-C Allegation: Staff restricted resident’s access to resident’s personal grooming items without authorization. It was alleged that staff restricted a resident’s access to personal grooming items without authorization. To investigate this concern, the LPA interviewed nine residents from the Memory Care (MC) and Assisted Living (AL) units, as well as the Executive Director, Memory Care Director, and six staff members. Staff explained that certain toiletry items may be secured based on individual resident needs—such as cognitive impairment or required supervision—and that items are provided during ADL care to ensure residents receive appropriate oral hygiene and grooming support. Staff also noted that all bathroom cabinets in the MC unit are kept locked to protect residents’ health and safety, as some residents may wander into others’ rooms. Residents interviewed reported that staff assist them with hygiene and always provide necessary items. During room checks in the MC unit, the LPA observed that bathroom cabinets were locked, and no hygiene or potentially unsafe items were accessible without supervision. Based on these observations and interviews, the LPA determined that the facility safeguards residents’ health and safety by securing bathroom cabinets in the Memory Care unit; therefore, the allegation is Unsubstantiated. No Deficiency cited during today's visit. Exit interview conducted and a copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 31-AS-20241126090947

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Perchui Milena Khurshudyan, conducted unannounced Case Management visit - Incident to this facility and met with Peter Bonilla - Executive Director (ED) and Liliana Solorzano - Resident Care Director (RCD). LPA disclosed the reason for the visit. Today’s case management visit is to follow up on special incident report (SIR) reported to Community Care Licensing (CCL) on 10/25/2025 and to obtain additional information regarding the incident. On October 25, 2025, Community Care Licensing (CCL) received a Special Incident Report (SIR) from Memory Care Program Director – Diane Parras, reporting that Resident #1 (R1) residing in room # 223 in Memory Care Unit, attempted to escape from the facility. Interview with the ED and RCD revealed that R1 transferred to Memory Care unit two (2) days prior to the incident and did not show any signs of aggression or unusual behavior. Interview with R1’s roommate Resident #2 (R2) revealed that the day of the incident R1 was standing up at the sliding door starring outside and was walking inside the room not allowing R2 to sleep. R2 heard the sliding door open, however, fell asleep and couldn’t recall anything else after that. Additionally, interviews with staff revealed that approximately 2:20 am Staff 1 (S1) conducted routine checkup to R1s room and observed that R1 was still awake. Interviews also revealed that S1 came back again at around 2:35am and discovered that R1 managed to take off the installed hatch lock from the sliding door and had bed sheets tied on the balcony and climbed down to first floor landing in room # 121 balcony. 911 was immediately initiated and R1 got transferred to Northridge Hospital where R1 got evaluated and no fractures and / or injuries were found. After evaluation, R1 transferred to Kaiser Woodland Hills for further care and was admitted with diagnosis of paranoia. Continue on LIC809-C LPA conducted physical plant tour, checked six (6) random residents’ rooms and observed all residents’ rooms have balconies and sliding doors. Additionally, LPA observed and confirmed that all rooms have hatch locked installed on each sliding door which does not allow the doors to open beyond six (6) inches. After the incident, the management installed additional hatch locks and security alarm signals on the upper part of all sliding doors to protect residents’ safety and prevent incidents in the future. Lastly, during today’s visit, LPA requested the maintenance staff to remove one of the hatches and observed that it is not possible even for maintenance staff to remove the hatch lock without proper tools. The removal process took about 5 minutes. The facility followed all the appropriate protocols to prevent R1's elopement; and therefore, no deficiencies will be issued during today’s visit. Exit interview conducted, copy of the report delivered.the state’s words, verbatim · CDSS document, Oct 31, 2025

Type of visit: Required - 1 Year

On 9/18/2025, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a required Annual Inspection. Upon arrival LPA introduced herself at the front desk by showing her department badge, was greeted by the Executive Director (ED) Bonilla Peter and the Assisted Living Director (ALD) Liliana Solorzano. LPA explained the reason for the visit and requested staff and residents’ rosters for review. LPA Khurshudyan reviewed the required postings on a wall and used the inspection tool to complete today's visit. A tour of the physical plant was conducted at around 10:00am and the following was noted: The facility is fire cleared for one hundred twenty (120) Ambulatory residents, of which one hundred (100) may be Non-Ambulatory, and twenty (20) may be Bedridden. The facility also has a hospice waiver for twenty (20) residents. The facility is currently occupying ninety-six (96) residents. There is one main entrance being utilized at the facility. The facility is two-story building and has two (2) elevators, one for each wing: Memory Care unit and Assisted Living, LPA checked both elevators operate properly. The facility has a total of ninety (90) rooms. Assisted living with private rooms for all residents, and Memory Care Unit with private and/or shared rooms. Continue on LIC809-C LPA observed four (4) common bathrooms throughout the facility, all four bathrooms appeared clean and were functional. Bathrooms had signs, grab bars and paper towels. The kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days of non-perishable food. LPA observed a walk-in refrigerator and freezer stocked with adequate amount of frozen and fresh foods wrapped and stored appropriately. Food storage and preparation areas were clean and inaccessible to pests. Knives and sharps are observed to be locked, under supervision, and inaccessible to residents. A dietitian visits the facility every month. The daily menus were posted and available in the dining area. A restricted diet menu was also available for residents requiring special diets. The kitchen closes at 7:00pm and reopens at 5:30am. The common areas and dining room appeared neat and clean. The activity room and TV room were nicely furnished. The monthly activity schedule was posted and available for residents. The facility maintains a comfortable temperature at 73°F-75°F. The smoke and carbon monoxide detectors are hardwired, interconnected and centralized with automatic dispatch to the Los Angeles Fire Department. Last fire inspection was done on 2/24/2025. Fire extinguishers were located throughout the facility and observed to be fully charged and last inspected on 9/6/2024. LPA was informed that service date is already scheduled for next week and the service materials will be provided to LPA right away. LPA observed at least thirteen (13) fire extinguishers throughout the facility. LPA toured a random selection of resident rooms. All bedrooms were properly furnished and had appropriate bedding, linens and a lighting system. The call signal system was tested and functioned properly. Caregivers responded to call signals withing 1-2 minutes. Hallways were odorless and free of obstructions. Residents have enough personal hygiene products. The bathrooms were checked for cleanliness and proper operations. Towels and washcloths are not shared. There was enough clean linen available in each resident room. Hot water temperature measured between 114.3 and 117.2 degrees Fahrenheit. There is a separate Medication Room for Assisted Living and for Memory Care Unit. LPA observed properly labeled medications and residents’ medical files to be locked and inaccessible to residents in care. The facility maintains a complete first aid kit. The facility has three (3) laundry rooms located in the Assisted Living unit. The Laundry rooms observed to be locked. There is a resident laundry room on the second floor of the Assisted Living unit. Cleaning supplies, chemicals and detergents are stored inside the locked closets and inaccessible to residents. The facility has nice outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. All pathways are clear of obstruction. Continue on LIC-809C Between 11:35pm -1:55pm LPA conducted records review of ten (10) staff files and ten (10) residents’ records. Files were complete and updated. LPA collected LIC500, LIC9020. No health and safety hazards noted during today’s visit. No citations issued during today's visit. Exit interview conducted. Copy of this report provided.the state’s words, verbatim · CDSS document, Sep 18, 2025

Allegation investigated: Staff does not provide a safe environment for resident.

On 3/12/2025, Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted a subsequent complaint visit to the facility to investigate the above allegations. At the start of the visit, LPA met with the assisted living director (S2), Liliana Solorzano, and advised S2 about the purpose of the visit. At 8:30 AM, LPA conducted a physical plant tour to ensure the health and safety of the clients in care. An entrance interview was conducted. Allegation #1: Staff does not provide a safe environment for the resident. Regarding the allegation, “Staff does not provide a safe environment for the resident”. It was alleged that on March 8, 2025, Resident #1 (R1) was aggressive towards Resident #2 (R2), throwing water at R2, which made R1 feel unsafe living at the facility. Continue to LIC 9099-C Substantiated LPA interviewed twelve (12) out of ninety-four (94) residents who are available and seven (7) staff who were available at the facility. LPA obtained the following documents: physician report, admission records, LIC 601, resident roster, employee roster, and other relevant documents to the investigation at 2:30 PM. LPA interviewed R2 on 3/12/2025, the interview revealed that R1 would throw a cup of water, be aggressive, and yell racial slurs at R2. An interview with staff revealed that R2 is very friendly and sociable to everyone at the facility, and no other residents in the facility have any issues with R2. On 3/8/2025, 9-1-1 was called, and police arrived. Officers determined there was mutual battery with no arrest. During LPA interview with R1 on 3/12/2025 at 3:16 PM at the dining hall, LPA witnessed R2 tap R1 on the shoulder and greet R1. R1 got very upset, and yelled racial slurs and insults towards R2, calling R2 “monkey”. LPA witnessed no staff within reach to redirect R1 and R2. An interview with the executive director (S1), assisted living director (S2), and five (5) staff members revealed that R1 has been aggressive and angry towards R2 previously early this year. Record review for R1 revealed that R1 has been residing at the facility since 5/26/2021, and R2 has been residing at the facility since 1/10/2022. Staff are aware of the behavioral changes with R1, and the record review revealed that no resident re-appraisal was done. Based on interviews, observations, and record review, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 31-AS-20250307102333

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 10, 2025

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations Based on interviews and observation by LPA, staff did not comply with the section cited above where R1 is aggressive towards R2, which poses a potential Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: The executive director has agreed to update the service plans of Resident #1 (R1) and Resident #2 (R2) with instructions for staff intervention. And have either R1 or R2 reside in different floors/ schedule.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(c)(3) · Plan of correction due date: Sep 10, 2025

Interventions to be implemented to minimize the risks to the health and safety of the resident or others associated with the resident's behavioral expression. The licensee shall use the least restrictive intervention to manage the behavioral. expression based on the individual needs of the residentthe state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Administrator needs to submit R2 reappraisal to LPA

Allegation investigated: Facility elevator is in disrepair

On 5/28/2025 at approximately 10:00am, Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina conducted a subsequent complaint visit at this facility to conclude the investigation regarding the above allegation and to deliver the final report. Upon arrival LPAs met with the Executive Director Peter Bonilla and explained the reason for the visit. Entrance interview conducted. During the initial visit conducted on 03/27/25, LPA requested copies of pertinent information which include but not limited to the copies of new elevator parts receipts, copies of conversation/communication emails regarding the elevator maintenance schedule etc. relevant to the investigation. LPA also conducted interviews with the Executive Director, Assisted Living Director and a Building Service Director between 9:50am-10:30am. During today’s visit, LPA requested copies of resident and staff roster. At approximately 10:20am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Continue on 9099-C Unsubstantiated Allegation: Facility elevator is in disrepair. It was alleged that one of the facility elevators is in disrepair and has been out of service for at least four (4) months. During the physical plant tour, conducted on 03/27/25, LPA observed one (1) out of two (2) elevators was not operational. The interview with the Building Service Director revealed that the facility received new elevator parts in February of 2025 and the installation process started on 3/5/2025. LPA was also informed that the elevator will be fixed and fully operational by 04/01/2025. Moreover, the Building Service Director informed LPA that all non-ambulatory residents, visitors and family members are currently using the second elevator around the facility and those that are capable use the stairs, the staff members are impatient to finalize the process to have both staff and residents’ transfers with less complications. Lastly, during today’s visit LPAs used both elevators and observed that two (2) out of two (2) elevators are currently in good repair and operational. Based on LPAs inspection, observation, records review, and interviews, there is enough evidence to verify that the Executive Director of the facility and the Corporate took proper actions to handle the situation to repair the elevator. Additionally, all documents confirmed the receipts and the new parts invoices of the second elevator. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and signed report delivered.the state’s words, verbatim · CDSS document, May 28, 2025 · control 31-AS-20250324151719

Allegation investigated: Facility staff are not meeting resident's laundry needs. Facility is malodorous.

On 5/27/2025 Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina arrived at the facility to conduct a subsequent complaint visit to conclude the complaint and to deliver the final report. Upon arrival, LPAs met with the Executive Director Peter Bonilla and explained the reason for the visit. Entrance interview conducted. During the initial visit made by LPA Khurshudyan on 3/27/2025, LPA requested residnet and staff rosters. At 9:50am LPA also requested copies of pertinent information which include, but not limited to copy of laundry service schedule, copy of laundry service logging sheet, laundry staff / housekeeper work shift schedule and documents relevant to the investigation. Between 9:45am-11:00am LPA conducted an interview with the Resident Care Director, Memory Care Director, Building Service Director (BSD), one (1) laundry staff member and seven (7) out of nine (9) residents, who were able to communicate. Continue on LIC9099-C Unsubstantiated During today’s visit, LPAs requested resident /staff rosters, and conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. No health and safety hazards were noted during the visit. Allegation: Facility staff are not meeting residents’ laundry needs. It was reported that R1’s laundry service was not completed for the past two (2) Fridays as scheduled. To investigate the allegation, LPA conducted interviews with seven (7) out of nine (9) residents, who expressed no concerns regarding the above allegation and confirmed that they never had any issues with the laundry service they receive. The interview with the Building Service Director (BSD) revealed that, although they are in the process of hiring additional staff member for residents’ laundry needs, the laundry service was never behind and all residents in care received the service as it was scheduled. Additionally, review of the facility laundry schedule also confirmed that R1's laundry service is scheduled for every Tuesday instead of Fridays, and R1 received the services on March 11th and March 18th as scheduled. Based on observations, records review and interviews, there is enough evidence to confirm that all residents’ laundry services are being met on time as scheduled and never stay unfinished. Therefore, this allegation is UNSUBSTANTIATED at this time. Exit interview conducted. Copy of this report issued and delivered. Continue on LIC9099-C Allegation: Facility is malodorous. It was reported that a visitor noted a strong odor of urine in the Memory Care Unit. To investigate the allegation, interviews, records review, and observation was made by the LPA. Interview with two (2) housekeepers revealed that, although, they have deep cleaning scheduled for residents’ rooms once a week, they still do light cleaning every day to make sure there is no odor in the facility. Interviews with seven (7) out of nine (9) residents express no concerns. Residents confirmed they have no complaints regarding the odor, the housekeepers clean their rooms and the hallways every single day. In addition, LPA conducted interview with R4's Private Caregiver (PC), who stated that it’s been two (2) years since the PC visits the facility every day and never observed bad smell in the Memory Care unit. PC also stated that daily light cleaning and weekly deep cleaning gets done for each resident’s room. Interviews with the Memory Care Director and Resident Care Director also revealed that they have sufficient number of housekeepers to keep the facility clean and free of odors. During the visit, no urine odor or discomfort observed around the facility by the LPA. Based on interviews and observation, there is insufficient evidence to verify that the facility is malodorous. Therefore, the above noted allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted and a copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 28, 2025 · control 31-AS-20250324164113

Allegation investigated: Unlawful Eviction

At 09:30am, Licensing Program Analyst (LPA), Angela Panushkina conducted a subsequent visit to deliver final report. LPA met with the Executive Director and explained the reason for the visit. During the initial visit, conducted on 02/27/25, LPA requested resident and staff roster. At approximately 9:20am, LPA requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, copies of payment receipts, and potential documents relevant to the investigation. At 10:30am, LPA conducted a physical plant tour including the Memory Care Unit to ensure health and safety of the residents are protected. Between 10:45am – 11:30am, LPA interviewed Executive Director, Memory Care Director, and Business Office Director. During today's visit LPA conducted interviews with five (5) residents and obtained additional documents related to the investigation. Continue on LIC9099-C Unsubstantiated Allegation: Unlawful Eviction It was alleged that R1 had been unlawfully evicted due to non-payment. To investigate this allegation LPA conducted interviews with the Executive Director, Memory Care Director, and Business Office Director, during the initial visit. All parties interviewed informed LPA that R1 moved to this facility in August 2023. Based on R1’s Admission Agreement the monthly rent fee was $2800.00 not including $600.00 rate for care services. As of July 2024, R1 started the Program of All-Inclusive Care for the Elderly (PACE). During the interview with the Business Director, LPA was informed that per R1's POA request, the claim forms were submitted to the PACE program for the partial monthly amount of $1350.00 to cover the rents from October 2024 through January 2025. On 01/09/2025, the accumulation of non-payment rent amount totaled $6233.00 (including late fees). Thus, on February 10th 2025, the facility issued an Eviction Letter to POA for non-payment and submitted a copy to Community Care Licensing (CCL). Moreover, interview with the Executive Director revealed that upon admission, R1’s Power of Attorney (POA) signed the Admission Agreement acknowledging that “the monthly fee and all other applicable charges and fees are payable in advance by the first (1st) day of each calendar month, by ACH, check or money order…”. Despite previous discussions about the default balance, R1 and or R1’s POA made no attempts to settle the unpaid amount. LPA reviewed copy of the facility "Collections Policy" where indicated the following: "Each community is responsible for the collection of its' outstanding resident balances in a timely manner. If payment is not received by the 10th of the month, a 30-day notice may be given." Lastly, five (5) residents interviewed during today's visit confirmed that they are aware of the admission agreement, and they are also aware of the eviction rules. Based on interviews and document review, the facility properly issued R1’s eviction due to nonpayment. Therefore, the allegation is deemed Unsubstantiated, at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 28, 2025 · control 31-AS-20250226163205

Type of visit: Case Management - Other

On 5/7/2025 at 2:00pm, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced Case Management-Other visit to the above facility. LPA met with the Executive Director Peter Bonilla and explained the reason for the visit. LPA was informed that Resident #1 (R1) and Resident #2 (R2) who have been relocated from Santa Clarita Hills Senior living are currently residing in the above facility. At 2:20pm LPA requested LIC9020 and reviewed which confirmed that R1 and R2 are residing the above-mentioned facility. No deficiencies issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 7, 2025

Allegation investigated: Staff financially abused a resident in care.

At 9:00am, Licensing Program Analysts (LPA) Angela Panushkina and Perchui Milena Khurshudyan conducted a subsequent visit to deliver final findings. LPAs met with the Executive Director and Resident Care Director and explained the reason for the visit. During the initial visit made on 12/18/2024, by LPAs Panushkina and Khurshudyan interviews and record reviews were made. At 9:30am, LPAs requested resident and staff roster. At 9:35am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Reident Abuse and Neglect Policy, relevant to the investigation. At approximately 10:00am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:10am – 2:00pm, LPAs interviewed the Executive Director, Resident Care Director, Generation Program Director, five (5) staff and seven (7) out of nine (9) residents, who were able to communicate. Continue on LIC9099-C Substantiated Allegation: Staff financially abused a resident in care. The investigation findings revealed that Resident #1 (R1) had been living at this facility since June 19th, 2024, and was not able to manage own Cash Resources. Interview with R1’s Power of Attorney (POA) revealed that R1 was left with one (1) credit card for an emergency use only and the facility Business Director was aware of it. After receiving R1’s August 2024 credit card statement, POA discovered multiple charges made in the amount of $4,554.38. Upon discovery, POA immediately notified R1’s credit card fraud department and stopped the card for further usage. Since the card charges were used to purchase airline tickets, POA was provided with a name of the person who purchased the tickets. POA also notified the facility and was informed that the perpetrator is a Staff #1 (S1). LPAs conducted interviews with the Executive Director and Resident Care Director and were informed that the facility filed a police report. However, LPAs were also informed that S1 last worked on 07/26/2024, took Paid Time Off (PTO) and was scheduled to come back on 08/10/2024. S1 called out on 08/10/2024, 08/11/2024, 08/13/2024 and notified the facility that due to family emergency will not be available until 08/16/2024. On 08/16/2024, S1 did not show up to work nor called with any explanations. Instead, S1 sent a text on 08/17/2024 informing the facility that he/she failed to give the two (2) weeks’ notice. Due to S1’s history of attendance the facility terminated S1’s employment as of 08/19/2024. Although, the interview with the Executive Director and Resident Care Director revealed that they were unaware of the fraudulent activities until that information was provided to them by R1’s POA on 08/30/2024, the facility failed to take appropriate measures to safeguard residents’ cash resources which resulted in "Staff financially abusing a resident in care". Therefore, based on the information gathered, there is sufficient evidence to conclude that the above allegation is Substantiated. Deficiency issued per CA code of Regulations Title 22 on LIC-9099D Exit interview conducted, appeal rights explained, and a copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 31-AS-20241212171919

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Mar 6, 2025

Safeguards for Resident Cash, Personal Property, and Valuables: Every facility shall take appropriate measures to safeguard residents'... personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met as evidenced by: Based on interviews and record reviews, licensee did not comply with the section cited above by failing to take appropriate measures to safeguard R1's credit card, resulting in fraudulent use. This posed a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2025

Plan of correction: The Administrator has agreed to take approved vendored training on Safeguarding for Resident Cash, Personal Property and Valuables.

Allegation investigated: Staff hit resident in care. Staff pushed resident to the ground.

On 2/27/2025 Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Pnushkina conducted a subsequent complaint visit at this facility to conclude the investigation regarding the above allegations and deliver the final report. The initial visit was made by LPA Khurshudyan on 11/07/24. LPA met with the Executive Director Ivan Saa and advised them of the complaint. LPA’s investigation consisted of interviews with residents and staff, records review, and a physical plant inspection to insure the health and safety of the residents in care. LPA conducted physical plant tour at approximately 10:30am, requested copy of staff and resident rosters. No immediate health and safety concerns were observed. Continue on 9099-C Unsubstantiated Allegation: Staff hit resident in care. In regards to the allegation, it was reported that Resident 1 (R1) has scratches and bruises under the eye and on the body. The reporting party is not sure if these wounds were due to a fall, or abuse by facility staff, as it was also reported that staff slapped R1 in the face. Furthermore, the reporting party stated R1 was alleging that these injuries occurred by the staff member(s). No witnesses were identified, nor staff names were given to these allegations. Interviews made with the staff and Memory Care Director reveal that R1 lost their balance and hit her face on the egress door when trying to awol from the Memory Care Unit to Assistant Leaving Area. At approximately 1:27am on 11/3/2024, R1 was wondering in the memory care hallway, when became very agitated and tried to leave the memory care unit, while S1 tried to stop and redirect R1 back to their room R1 kicked S1 on the left knee, lost their balance and hit their left cheek on the egress door. S1 and S2 directed R1 to their room, first aid was given to R1’s face/cheek area, responsible party and primary doctor were notified. Incident Report (IR) was submitted to the Licensing. Interviews with five (5) of five residents made. All five could not corroborate with the allegations made. Based on the information obtained, there was insufficient evidence to prove that R1 sustained injuries due to staff hit R1. Therefore, this allegation deemed Unsubstantiated. Allegation: Staff pushed resident to the ground It was reported that on 11/4/2024 facility staff pushed resident #1 (R1) to the ground. To investigate this allegation, LPA conducted interviews and record review. Interviews made with four (4) staff members working night shift, revealed that R1 had another episode of aggressive behavior and was trying to awol from the facility. Throughout the night starting at approximately 10:30pm R1 started wondering on the hallways and entering to other resident’s rooms. Multiple times R1 was redirected back to their room, however, minutes later R1 was wondering in hallways again, taking elevator and going down from second floor to first floor. Minutes later R1 entering to room # 127, insisting its their room and refusing to leave. Resident from room #127 asked to take R1 out because its nighttime and wants to sleep. After several attempts to convince R1 to leave from room# 127, staff gently held R1s hand to redirect. R1 got agitated and tried to bite S1. After multiple unsuccessful attempts to convince R1 to go back to their room, R1 decides to stay in the hallway and sit on the bench. S1 and S2 continued with their daily work task by checking residents’ rooms, minutes later alarm turned on from one of the emergency exit egress doors which lead to the back alley of the facility. Continue on LIC9099-C By the time staff reached to the egress door, they found R1 on the floor. Staff called an ambulance and transported R1 to the hospital. Responsible party and primary doctor were notified. Incident Report (IR) submitted to Licensing. Interviews with seven (7) out of nine (9) residents revealed they have never witnessed or heard staff hit or bullied any resident in care. Based on interviews, record reviews and information gathered, there was insufficient evidence to prove that R1 was pushed to the ground by staff member(s). Therefore, this allegation deemed Unsubstantiated. No deficiency issued. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 31-AS-20241106150126

Type of visit: Case Management - Deficiencies

On 2/27/25 Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina, conducted an unannounced CASE MANAGEMENT visit at this facility to issue deficiency in conjunction with complaint control # 31-AS-20241106150126. LPAs met with facility Executive Director (ED) and explained the reason for the visit. LPAs conducted a physical plant walk through, at approximately 9:20am, to ensure that the facility is in compliance under Title 22 California Code of Regulations. At 9:50am, LPAs requested staff and resident rosters. During the initial complaint visit on 11/7/2024, LPA Khurshudyan conducted interviews and records review and informed that on 11/3/2024 around 1:30am R1 attempted to awol from the Memory Care unit and tried to exit the egress door to Assisted Living area. S1 and S2 (nights shift caregiver and MedTech) attempted to redirect R1 back to Memory Care unit, however, R1 got aggressive and while kicking S1’s left knee lost their balance and hit their face on the door. First aid was provided right away and with the help of S1 and S2 R1 went to their room. The following day on 11/4/2024 around midnight R1 had another episode of aggressive behavior and another attempt to awol from the Memory Care unit. Despite several attempts of redirecting R1 to their room, R1 opened the back exit egress door and was able to go outside and fell on the concrete. LPA conducted tour and observed that the egress door did properly work, however, when the alarm went off the facility did not have sufficient night shift caregivers on the floor to prevent the incident happening. R1 was transported to the hospital for further evaluation. Lastly, LPAs were informed that the Memory Care Unit had total of fifty-five (55) residents, two (2) of which had wandering behaviors. Also, two (2) staff members were scheduled for the night shift to cover 1st and 2nd floors by providing care and supervision. During interviews ED and Memory Care director confirmed that R1 had wondering behavior and numerous episodes of incidents got recorded of R1 being agitated towards staff and other residents in care and the incident happened due to failing to respond to egress door alarm in a timely manner. Deficiencies are cited and noted on LIC 809D. Exit interview conducted. Appeal rights explained. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(e)(7) · Plan of correction due date: Mar 6, 2025

Care of Persons with Dementia: (e) Licensees that use delayed egress devices on exterior doors… shall meet the following initial and continuing requirements: (7) Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents… This requirement is not met as evidenced by: Based on interviews and records review the licensee did not comply with the section cited above by not ensuring the staff responded to egress door alarm in a timely manner, resulting in injuries and hospitalization of R1. This posed a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2025

Plan of correction: Executive Director informed LPAs that the facility is actively looking to hire more staff. Copy of LIC500, reflecting new hired staff along with their required/completed training will be submitted to LPA by POC date.

Allegation investigated: Licensee does not keep facility elevators maintained in operating condition

Licensing Program Analyst (LPA) Abeye Duguma, Perchui Milena Khurshudyan and Angelica Segovia met with the Executive Director, Ivan Saa, conducted an unannounced initial complaint visit to the facility. ---Licensee does not keep facility elevators maintained in operating condition It was alleged that one of the facilities elevators has not been working for over one month. To investigate the allegation, LPAs conducted a physical plant tour at around 10:30a.m. and interviewed one (01) staff at around 11:45a.m. During the physical plant tour, LPAs observed one (01) out of two (02) elevators were not in working order. During interview with staff, Staff #1 (S1) stated facility has ordered a new elevator which will be installed and operational by 03/31/2025. S1 added that non-ambulatory residents are currently using the other elevator and those that are capable use the stairs. (cont. on LIC9099-C) Substantiated Based on observations and interview, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 27, 2024 · control 31-AS-20241127104832

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 30, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by; Based on observations, one (01) out of two (02) elevators in the facility is NOT in good repair which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 27, 2024

Plan of correction: The Licensee/Executive Director will submit documents showing all purchase dates, receipts and estimated repair date.

Allegation investigated: Staff mismanaged resident's funds

Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan, Abeye Duguma and Angelica Segovia conducted an initial 10 day complaint visit on 11/27/2024 to investigate the above allegation. LPAs met with Assisted Living Director (ALD) Liliana Solorzano and explained the purpose of the visit. Entrance interview condacted. During the course of the investigation, interviews and record reviews were made. At 9:45am, LPAs request resident and staff roster, nice (9) residents files from Generation unit and Assisted Living unit. LPAs also requested copies of Admission Agreement, Appraisal Needs and Services, Physician Report, Unusual Incident Reports, MAR’s, Financial folder and pertinent documents relevant to the investigation. LPAs with the help of ALD Ms. Solorzano conducted a physical plant tour between 10:30am to 11:35am including the Generation Unit to ensure health and safety of the residents are protected. No health and safety hazards noted during the visit. Continue on LIC9099-C Unsubstantiated Between 1:15pm – 2:30pm LPA Khurshudyan interviewed the Executive Director, Assisted Living Director and R1. It was reported that Staff mismanages resident's funds. Records review, interviews with staff and R1 revealed that all finances are being handled by the billing department. Additionally, Staff at the facility has no control over any resident's finances. ED provided documents were it was stated that R1 has full control over her finances and her payments are supposed to be paid through her long term care insurance directly to the billing department. R1 also stated that she has long term care insurance and payments are paid through insurance. Based on interviews and documentation review, there is insufficient evidence to verify that staff mismanaged resident's finances. Therefore, the allegation above noted allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 27, 2024 · control 31-AS-20241119111531

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma, Perchui Milena Khurshudyan and Angelica Segovia met with the Executive Director, Ivan Saa, for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 10:00 AM and the following was noted: There is one main entrance being utilized at the facility. LPAs toured a random selection of resident rooms. All bedrooms were properly furnished and had appropriate bedding and linens. There were bathrooms in each of the resident rooms. Bathrooms were properly supplied and had functional fixtures. Hot water temperature measured between 106.4 and 118.5 degrees Fahrenheit. The facility is fire cleared for one hundred twenty of which one hundred (100) may be non-ambulatory and twenty (20) bedridden and a hospice waiver for twenty (20). The facility is currently occupying ninety-two (92) residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for parking. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. (continued on LIC 809-C) Kitchen closes at 7:00p.m. and reopens at 5:00a.m. The common and dining room are neat and clean. The facility maintains a comfortable temperature at 74°F. The smoke and carbon monoxide detectors are hardwired, interconnected and centralized with automatic dispatch to the Los Angeles Fire Department. Fire extinguishers located throughout the facility and observed to be fully charged and last inspected 09/06/2024. The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. Towels and washcloths are not shared. There was enough clean linen available in each resident room. During the physical plant tour, LPAs experienced malodor in multiple rooms and hallways. This will be addressed on complaint control 31-AS-20241126090947. LPAs observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No other health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Nov 27, 2024

Allegation investigated: Due to insufficient staffing, resident was not checked on timely Staff locked resident in room

At 10:15a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegations. LPA met with the Resident Care Director (RCD) and Executive Director (ED) and explained the reason for the visit. During initial visit on 12/18/2023 at 10: 45a.m., LPA Alvizar request resident and staff roster. LPA and Residents Care Director (RCD) conducted a physical plant tour at approximately 11:05 a.m. including the Generation Unit (Dementia Care) to ensure health and safety of the residents. At 11: 55 a.m. LPA requested copies of Admission Agreement, Appraisal Needs and Services, Physician Report, Unusual Incident Reports, MAR’s and other pertinent documents relevant to the investigations. Between 2:00p.m. – 3:55p.m. LPA interviewed RCD, Generation Program Director (GPD) and three (03) staff that provided care in the Generation Unit. Prior to this visit on 10/07/2024 LPA Antonia Alvizar-Ettima reviewed the information and the documents Unsubstantiated previously obtained from the facility. At the time of this visit at 11:10a.m., LPA Alvizar-Ettima and RCD conducted a physical plan tour. During inspection, at approximately 11:30a.m. LPA attempted to interview nine (09) out of fifty-five (55) residents residing at Generation Unit. However, they were unable to respond to LPA’s questions. 1. Due to insufficient staffing, resident was not checked on time. It was alleged that R1 passed away in their room and staff did not know R1 had passed due to short staffing. Staff interviews reveal that they have sufficient staffing to check on residents timely. Resident Care Director(RCD) indicated that Generation Unit has a total of five (05) staff during the morning and evening shifts. There are three (03) staff during night shift. Residents are being checked out every two hours and as needed. They did not receive any complain about insufficient staffing. During this visit LPA observed residents in Generation Unit and they appeared to be clean and well groomed. A review of facility staff schedule supported the information provided by the staff Based on observation, interviews and records review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 2. Staff locked resident in room. It was alleged that staff would lock resident (R1) in room residing on the Generation Unit because R1 was a wander risk. Resident Care Director (RCD) and staff interviews reveal that the residents are not locked in the room. All bedroom doors can only be locked from inside by the resident. However, all staff members have a master key and can easily gain access. Interview with three (03) staff that provide care in the Generation Unit revealed that doors are always unlocked, when the resident is in the room, and the staff checks on them every two hours. Some residents carry their own key however they can always open the door from inside the room. RCD and staff indicated that when residents are out in common areas all resident doors are kept locked to prevent wandering residents from entering. During inspection, LPA visited five (05) random selected rooms including R1’s and observed that the door has no auto lock and can easily be opened. However, the door is kept locked from the outside and only a staff member with master key can gain access. Based on interviews and observation there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard are noted during this visit. Exit interview is conducted and copy of report was provided.the state’s words, verbatim · CDSS document, Oct 9, 2024 · control 31-AS-20231208105300

Allegation investigated: Resident sustained an unexplained injury while in care of the facility

On 9/12/2024 at 10:00am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a subsequent complaint visit to the facility to issue the findings regarding the above allegation. Upon arrival LPA Khurshudyan met with Assisted Living Director (ALD) Liliana Solorzano and Executive Direcotor (ED) Ivan Saa and explained the reason for the visit. Allegation: Resident sustained unexplained injuries while in care of the facility. It was alleged that on 06/22/24 resident #1 (R1) was observed with the bruise on his arm. To investigate the allegation initial ten-day visit was conducted on 7/18/2024 by LPA Khurshudyan. At the time of visit LPA obtained a copy of the staff and resident roster and requested residents’ files at 10:15am. At 10:30am, LPA conducted a physical plant tour including the Generation Unit to ensure health and safety of the residents are protected. In addition, between 10:50am and 2:30pm LPA reviewed files and interviewed eight (8) out of eighty-eight (88) residents; Continue on LIC9099-C Unsubstantiated four (4) from the Assisted Living, four (4) from Memory Care Unit and total of 8 staff members including Assisted Living Director, previous Generation Program Director and six (6) caregivers/Med-Techs. On todays visit, at 10:15am LPA Khurshudyan collected staff and resident rosters, toured the physical plant at 10:45am and interviewed additional four (4) staff and eight (8) out of ninety-two (92) residents between 11:00am to 1:00pm. Staff revealed that they did not witness any incident that could cause bruise on R1’s arm. No staff was able to explain how R1 was bruised. Interview with residents reveal that they are happy with the care provided to them by the staff, caregivers are very gentle, and no one had any concerns regarding possible physical or verbal abuse. The facility submitted Incident report to the Licensing Department informing that on 06/22/24, R1 had a skin tear which was noted by R1’s daughter. When asked, R1 was unable to recall the incident. Record revealed that R1 had Doctor appointment on 6/25/2024 and was evaluated by the Primary Physician at the Brandman center. Additional information gathered from Physician notes and Medication List revealed that R1 takes GNP Aspirin for blood circulation. Based on interviews and documentation review, there is insufficient evidence to verify when and how the injuries to R1’s arm occurred. There is no corroborating information/evidence to concur that R1 was bruised due to staff neglect. Therefore, the allegation above noted allegation is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 31-AS-20240708170641

Allegation investigated: Facility's Air conditioner is not working properly.

On 9/12/2024 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted initial ten day complaint visit to the facility to investigate the above noted allegation. Upon arrival, LPA met the Executive Direcotor (ED) Ivan Saa and Assisted Living Director Liliana Solorzano and explained the purpose of the visit. It was alleged that when outside temperatures reaches over 100-degree F, air conditioning system at the facility stops functioning in the residents rooms, especially on the 2nd floor. Even with 3 large fans, temperature in R1’s room was 90-degree F. To investigate the allegation at 10:45am LPA Khurshudyan inspected the facility including Randomly selected residents rooms and checked room temperature which was noted between 70 to 80 degree F. On the first and second floor LPA inspected total of 10 rooms (Room #s 121, 131, 133, 122, 214, 212, 218, 222, 206, 208) and conducted interviews with the residents present or residing in selected rooms. Continue on LIC9099C Substantiated Between 11:45am to 3:45pm LPA spoke with the Executive Director (ED) Ivan Saa, Maintenance Director (MD) Julio Arriaga, Generation Program Director (GPD) Diane Parras, and other staff, including Housekeepers and Caregivers attending residents residing in selected rooms. In addition LPA requested facility maintenance log documenting daily reports regarding repairs and reported issues with A/C system. Interviews revealed that the facility has one (1) 40 ton chiller for hundred (100) units/rooms and four (4) 3-5 ton AC for hallways and at times during heat wave A/C units may malfunction. Facility accommodated residents by providing portable ACs. ED Saa stated that during the portable AC installation process, residents were transferred to the dining area were the temperature was cool and more comfortable. Interview with Residents revealed the same information provided by the facility staff. A review of maintenance records verified the information received from interviews. ED stated that the facility is in the approval process of updating the AC system which will be more compatible with the large building. Although at the time of this visit the temperature in various resident’s rooms and common areas was within required range, based on the information revealed from interviews, and record review, there is a sufficient information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Under Title 22, Division 6, following citation was issued and recorded on LIC9099D. Maintenance and Operation 87303 (b)(2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. Exit interview was conducted, appeal rights discussed and a copy of report was issued.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 31-AS-20240909132246

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(2) · Plan of correction due date: Sep 12, 2024

Maintenance and Operation 87303 (b)(2) The facility shall cool rooms to a comfortable range, between 78 F and 85 F, or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement was not met as evidenced by: Based on interviews, record review and observations, the licensee did not comply with the section cited above as the facility AC was not functioning properly in residents rooms which poses a potential Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 12, 2024

Plan of correction: POC cleared - Facility installed portable ACs in residents rooms to accomodate comfortable temperature.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Perchui Milena Khurshudyan, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240708170641. LPA met with the Assisted Living Director (ALD) Liliana Solorzano and explained the reason for the visit. During the visit, LPA was informed that R1 was taken to West Hills Hospital on 06/15/2024, where it was determined that R1 had to be hospitalized. R1 stayed in the hospital from 6/15/24-6/19/24. On 6/22/2024 S1 noticed a skin tear on R1's leftforearm and reported to med-tech. However, no incident report was submitted to the Community Care Licensing Department (CCLD) in a timely manner for both incidents. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the ALD Solorzano admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the ALD that all staff members are mandated reporters and they are all responsible for reporting. LPA informed ALD Solorzano to submit an incident report that occurred on: • 06/15/2024 • 06/22/2024 Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Jul 18, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A)(B)(D) · Plan of correction due date: Jul 22, 2024

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalization on 06/15/24, and skin tear on left forearm on 6/22/24 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 18, 2024

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's incident report shall be submitted to LPA by POC date.

Allegation investigated: Staff unlawfully evicted a resident while in care.

At 9:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit to deliver final findings. LPA met with Liliana Solorzano, Resident Care Director, and disclosed the reason for the visit. During the initial visit made on 12/11/2023, by LPAs Rahimi and Panushkina, interviews and record reviews were made. On 12/11/2023 at 9:35 am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc. relevant to the investigation. At approximately 10:00am, LPAs conducted a physical plant tour. Between 10:10am – 2:00pm, LPAs interviewed the Administrator, Resident Care Director, Generation Program Director, five (5) staff and six (6) out of nine (9) residents, who were able to communicate. Continue on LIC 9099 Unsubstantiated Staff unlawfully evicted a resident while in care: Regarding the above allegation, interviews with the Administrator, and Resident Care Director revealed that the facility did not issue an eviction notice to Resident # 1 (R1). R1 was hospitalized on 11/27/2023. Once the facility was notified of changes in R1’s level of care, the facility made necessary arrangements prior to R1’s discharge from the hospital on 12/04/2023. The Licensee completed a new care plan for R1 and communicated with R1’s responsible party to hire 1:1 caregiver due to R1’s higher level of care. Although, the facility discussed the changes with R1’s responsible party, and they agreed to new terms, the Psychiatrist suggested that it would be better for R1 to be moved to another facility due to having unexplained suicidal episodes that triggers him/her not wanting to be at this facility. Four (4) days later on12/08/23, after R1 got discharged from the hospital, R1’s family decided to relocate R1 to a new facility without giving the facility a 30-day notice. Lastly, the total balance for 1:1 caregiver, hired through a 3rd party, was not paid by the family. Based on the interviews, review of the documents obtained, the allegation, “Staff unlawfully evicted a resident while in care” is unsubstantiated at this time.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 31-AS-20231201163146

Allegation investigated: Staff are financially abusing resident

At 12:00pm, Licensing Program Analyst (LPA) Angela Panushkina a subsequent visit to deliver final findings. LPA met with the Executive Director and Resident Care Director and explained the reason for the visit. During the initial visit made on 12/11/2023, by LPAs Panushkina and Rahimi, interviews and record reviews were made. At 9:30am, LPAs requested resident and staff roster. At 9:35am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc. relevant to the investigation. At approximately 10:00am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:10am – 2:00pm, LPAs interviewed the Administrator, Resident Care Director, Generation Program Director, five (5) staff and seven (7) out of nine (9) residents, who were able to communicate. Moreover, LPA contacted and interviewed Staff #1 (S1). Continue on LIC9099-C Substantiated The complainant’s concern was that staff financially abused a resident in care by cashing personal checks. The investigation findings revealed that Resident #1 (R1) had been living at this facility since May 26th, 2022. LPA reviewed the Admissions Agreement, Physician’s Report (dated on 05/12/2022), and Care Appraisal (dated on 10/30/23) which indicated that R1 is able to manage own Cash Resources. Interview with R1’s Trustee/Power of Attorney (POA) revealed that around October 2023, POA discovered that R1’s checkbook had gone missing. Upon discovery, POA placed a stop on all missing checks. However, no police report was filed. POA also informed LPA that during their review of the bank statements, POA discovered that eleven (11) checks were cashed and signatures on the checks were forged. Review of eleven (11) checks revealed that nine (9) out of eleven (11) check were payable to Staff #1 (S1). LPA interviewed S1 on (12/11/23) at (2:07pm). Interview revealed that on July 15, 2023, while taking a break, S1 found R1’s checkbook by an intersection near the facility and took it to their car. After the break, S1 returned to work and did not turn in the checkbook. Once S1’s shift was over at 10:30pm, S1 discovered that their car was stolen and filed a police report. However, S1 did not indicate in the report that R1’s checkbook was left in the car. Moreover, interview with S1 also revealed that as of 12/11/23, S1 failed to report the incident with R1’s checkbook to the Executive Director. Interviews with the Executive Director and a Business Office Director revealed that R1 never reported checks missing and they were unaware of the fraudulent activities, however when brought to their attention the Executive Director immediately placed S1 on a suspension and conducted their internal investigation. On 12/13/23, the Executive Director filed a Police Report and LPA receive a copy of the report on 02/19/24. Review of the Report revealed that R1’s checkbook disappeared from the room several months ago, but R1 was not aware about the transactions being made on his/her account until notified by R1’s attorney. Review of Police Report also indicated that R1 did not wish to prosecute. Lastly, Officer’s investigation revealed that nine checks were written to S1 for the amount of $8,140.00 and two checks to a person, not associated to this facility, for the amount of $1300.00. First check deposit was made on 06/29/23 and the last check was cashed on 11/30/23. During today's visit, the Executive Director informed LPA that as of 02/13/24, S1's employment was officially terminated. Based on the information gathered, there is sufficient evidence to conclude that the above allegation is Substantiated. Deficiency issued per CA code of Regulations Title 22 on LIC-9099D Exit interview conducted, appeal rights explained, and a copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 21, 2024 · control 31-AS-20231207111856

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87205(a) · Plan of correction due date: Feb 29, 2024

Accountability of Licensee Governing Body. The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation... welfare of the individuals it serves. This requirement is not met as evidenced by: Based on interview and record reviews, licensee did not comply with the section cited above. Facility Staff #1 (S1) fanancially abused R1 by cashing nine (9) out of eleven (11) checks, which poses/posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Feb 21, 2024

Plan of correction: Licensee is responsible for reimbursing R1's money paid to facility Staff #1 S1 in the amount of $9,440.00. During today's visit LPA received a proof of reimbusment. Deficiecy is cleard durng today's visit