City View La

Allegation investigated: Staff did not safeguard resident's personal belongings. Staff did not ensure resident received adequate food service. Staff did not ensure resident was appropriately clothed. Licensee did not ensure a functioning signal system was accessible to resident.

On 06/30/26, the department conducted an unannounced complaint visit to investigate the allegations listed above. The department met with Business Office Manager, Avi Silver, and the purpose of the visit was explained. The department was granted access to the facility. Executive Director, Mendy Ginsburg, joined the department for the visit shortly after. The investigation consisted of the following: On 02/25/26, the department received the following documents: staff roster, resident roster, menu for February 2026, alternative meal menu, Physician’s report for resident #1 (R1), Service Plan for R1, Safeguard for Personal belongings for R1, Admission Agreement for R1, Laundry/Cleaning schedule, and an email between S1 and R1’s family member. The department conducted interviews with staff #1-#2 (S1-S2), and witness #1 (W1). Continued on LIC9099-C Unsubstantiated On 06/30/26, the department received the facility’s menu for the months of May-June 2026. The department conducted interviews with staff #3-#6 (S3-S6), residents #2-#9 (R2-R9), and attempted to interview R1. Additionally, the department conducted a tour of the facility. The investigation revealed the following: Allegation: Staff did not safeguard resident's personal belongings. It has been alleged that a resident’s wallet, letterman’s jacket, and glasses were missing. On 02/25/26, and 06/30/26, the department conducted interviews with S1-S6. Of those interviewed, 6 out of 6 staff denied the allegation. An interview with S1 revealed that R1 had reported some of their personal belongings missing, but they were found days after in the residents room after staff assisted in locating the items. On 06/30/26, the department conducted interviews with R2-R9, and attempted to interview R1, but was unable to as they are no longer in the facility. Of those interviewed, 8 out of 8 residents could not corroborate with the allegation. Based on observation, interviews conducted, and a review of records, 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 the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff did not ensure resident received adequate food service. It was alleged that the resident requested an alternative meal for dinner; however, staff did not provide the requested meal. As a result, the resident reportedly did not receive dinner, and the resident's family arranged for food to be delivered to the facility at approximately 10:00 p.m. because the resident had not eaten. On 02/25/26, and 06/30/26, the department conducted interviews with S1-S6. Of those interviewed, 6 out of 6 staff denied the allegation. 6 out of 6 staff said residents receive three meals a day, snacks in between, and that they have alternative meals as well. 6 out of 6 staff said residents receive their breakfast between 7:00 am - 9:00 am, lunch at 12:00 pm, and dinner at 5:00 pm, 7 days a week. Continued on LIC9099-C On 06/30/26, the department conducted interviews with R2-R9, and attempted to interview R1, but was unable to as they are no longer in the facility. Of those interviewed, 8 out of 8 residents could not corroborate the allegation. 8 out of 8 residents said they receive three meals a day, snacks in between, and that they have alternative meals as well. 8 out of 8 residents said they receive their breakfast between 7:00 am - 9:00 am, lunch at 12:00 pm, and dinner at 5:00 pm, 7 days a week. On 06/30/26, during the records review, the department observed copies of the facility’s menu. The facility serves three meals per day: breakfast, lunch, and dinner, and snacks between meals, with an option for alternative meals. Based on the menu reviewed, the facility’s meals appeared consistent with these guidelines and Title 22 food service requirements. Based on observation, interviews conducted, and a review of records, 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 the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff did not ensure resident was appropriately clothed. It was alleged that a resident was mistakenly dressed in their roommate's clothing. It is also being alleged that the resident reportedly brought the error to the caregiver's attention and requested to be changed into their own clothing; however, the caregiver allegedly refused to assist with changing the resident into the correct clothing. On 02/25/26, and 06/30/26, the department conducted interviews with S1-S6. Of those interviewed, 6 out of 6 staff could not corroborate the allegation. On 06/30/26, the department conducted interviews with R2-R9, and attempted to interview R1, but was unable to as they are no longer in the facility. Of those interviewed, 8 out of 8 residents could not corroborate the allegation. Based on observation, interviews conducted, and a review of records, 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 the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continued on LIC9099-C Allegation: Licensee did not ensure a functioning signal system was accessible to resident. It is being alleged that the call light in a resident’s bathroom was not working. On 02/25/26, and 06/30/26, the department conducted interviews with S1-S5. Of those interviewed, 6 out of 6 staff could not corroborate the allegation. An interview with S5 revealed that the facility routinely tests residents’ call lights to ensure they are functioning properly. An interview with S1 revealed that staff respond to residents’ call lights promptly. S1 further stated that the facility does not maintain logs documents call light calls and/or their response times. On 06/30/26, the department conducted interviews with R2-R9, and attempted to interview R1, but was unable to as they are no longer in the facility. Of those interviewed, 8 out of 8 residents could not corroborate the allegation. Interviews with 8 out of 8 residents revealed that they have not experienced any issues with their call lights. Based on observation, interviews conducted, and a review of records, 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 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. On 06/30/26, the department received the facility’s menu for the months of May-June 2026. The department conducted interviews with staff #3-#6 (S3-S6), residents #2-#9 (R2-R9), and attempted to interview R1. Additionally, the department conducted a tour of the facility. The investigation revealed the following: Allegation: Staff did not assist resident with toileting needs in a timely manner. It was alleged that a resident requested assistance after using the toilet but was left waiting for approximately one hour without help. The resident called the fire department for assistance getting off the toilet because staff did not respond. On 02/25/26, and 06/30/26, the department conducted interviews with S1-S5. Of those interviewed, 3 out of 6 staff corroborated the allegation, and 3 out of 6 staff could not corroborate the allegation. 6 out of 6 staff said residents are checked on and changed (if needed) every 2 hours and as needed. An interview with S1 revealed that R1 had been seated on the toilet in the bathroom by a caregiver during a routine check. S1 stated that they did not believe that R1 activated the call light to request assistance and instead contacted 911. S1 further stated that emergency personnel responded to the facility following the 911 call. An interview with S2 revealed that R1 had been seated on the toilet in the bathroom for an unknown period of time. S2 stated that R1 attempted to call staff for assistance; however, staff did not respond. S2 further stated that as a result, R1 called 911 to request assistance. On 06/30/26, the department conducted interviews with R2-R9, and attempted to interview R1, but was unable to as they are no longer in the facility. Of those interviewed, 8 out of 8 residents could not corroborate the allegation. Based on interviews conducted which were 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 and Chapter 8 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 11-AS-20260222155138

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 7, 2026

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, furnishings and equipment. This has not been met as evidenced by: Based on interviews conducted, staff failed to answer the call light in a timely manner. This violation poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2026

Plan of correction: The facility will conduct an in service staff training in regards to answering call lights. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Elvira Gonzalez or via email at elvira.gonzalez@dss.ca.gov by the POC due date.

Allegation investigated: Staff yelled at a resident in care.

On 06/22/2026, LPA Pamela Bunker conducted an initial visit to gather information regarding the allegation mentioned above. LPA met with Mendy Ginsberg, Executive Director, and Avener Silver, Business Office Manager, and explained the purpose of today's visit. LPA was granted entry to the facility. The investigation consisted of the following: On 06/22/2026 at 1:00 p.m.., the Department requested and reviewed the staff and resident's records and obtained copies of the following documents: Personnel Report (06/21/26), Resident Roster (06/22/26), Admission Agreement (04/21/25), Identification and Emergency Information (08/27/2024), Physician's Report (09/25/24), Medical Assessment (09/25/24), Consent Forms (08/23/2024), Functional Capability Assessment (08/23/2024), Preplacement Appraisal Information (08/23/2024), Appraisal, Needs and Service Plan (05/28/2026), and Personal Rights (08/23/2024), Interviews were conducted with Staff Members #1 and #4 (S1-S4) as well as with residents #1 through #5 (R1-R5). See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2. Investigation revealed the following: Allegation: Staff yelled at a resident in care. On June 22, 2026, between 1:00 p.m. and 4:30 p.m., the Department conducted interviews with Staff #1 through Staff #4 (S1–S4). 4 out of 4 staff members stated that staff do not yell at any residents in care. They reported that residents are provided with a safe, healthful, and comfortable environment, and that staff provide the necessary care and supervision to meet each client's needs. 4 out of 4 staff members also confirmed that residents are allowed to have pets; however, the facility is not responsible for the pets or their related linens and laundry. S1–S4 stated that the facility maintains a zero-tolerance policy for resident mistreatment. All staff interviewed (4 out of 4) denied the allegation. On June 22, 2026, between 1:00 p.m. and 4:30 p.m., the Department interviewed Residents #1 through #5 (R1–R5). When asked whether staff yell at residents, 4 out of 5 residents stated that staff do not yell at residents and that they have never witnessed staff yelling at any resident. Resident #1 (R1) explained that they wear a hearing aid, and staff sometimes need to speak louder so the resident can hear them. All five residents reported that the staff provides a safe environment. Each resident stated that staff offer adequate care and supervision tailored to their individual needs. All residents confirmed that they feel safe in the facility and that staff maintain a respectful and supportive atmosphere. 5 out of 5 residents stated that they are allowed to have pets; however, they are responsible for caring for their own animals. 4 out of 5 residents denied the allegation. On June 22, 2026, the Department also reviewed the resident admission agreement dated April 21, 2025. The agreement indicates that weekly laundry services are included for residents, as reflected in the signed documentation. While residents are permitted to have pets, they are responsible for laundering their pets’ items, as the facility does not provide laundry services for pet-related belongings. See continued LIC9099-C page 3 Continued LIC9099--C page 3 Based on interviews, available evidence, observation, information received, and records reviewed, there was not enough sufficient evidence to support the allegations. 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. LPA Bunker provided Mendy Ginsberg, Executive Director, with copies of the LIC9099 and LIC9099-C Complaint Investigation Reports. An exit interview was conducted.the state’s words, verbatim · CDSS document, Jun 22, 2026 · control 11-AS-20260615165649

Allegation investigated: Staff do not ensure that outside vendors maintain resident privacy during the provision of services

On 05/12/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to City View LA and was greeted by Administrator Mendy Ginsberg (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S6, residents R1-R8. LPA Calderon obtained the following records: Activities Calendar (January to May 2026). Admission agreement. Toured the facility with S1 The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff do not ensure that outside venders maintain resident privacy during the provision of services. This complaint alleged that the facility staff did not stop venders from taking pictures and videos of residents in care. Records review indicate the following: Activities Calendar (dated January to May 2026) checked the calendar and there are no names listed for a vendor in question. Checking the blank Admission agreement, LPA Calderon noted consent to photograph waiver. Interviews indicate the following: R1-R8 deny the allegation. S1 indicates that S1 could not find a match in S1 vender list for the vender in question. S1 indicates that no staff or vender would take a video or picture of a resident without permission. S1 indicates that the facility admission agreement has a waiver that allows the facility to take and use the resident picture or video for the facility business use. S2-S6 deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure that outside vendors maintain resident privacy during the provision of service” 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 Mendy Ginsberg (S1).the state’s words, verbatim · CDSS document, May 12, 2026 · control 11-AS-20260506154751

Allegation investigated: Staff hit resident. Staff handled resident in a rough manner.

On 05/06/26, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegations. LPA met Wellness Director Marcia McKay and the purpose of the visit was explained. Investigation consisted of the following: On 05/06/26, the Department obtained a copy of the Resident Roster (05/04/26), Personnel Report (dated 05/03/26), April 2026 Work Schedule and Resident #1’s Physician’s Report and Plan of Care, and Unusual Incident Report. LPA conducted twelve staff interviews (S1 – S12) and eight resident (R1 – R8) interviews. Continue to LIC9099-C. Unsubstantiated Allegation: Staff hit resident. It is alleged Staff #1 (S1) hit Resident #1 (R1) while providing incontinence care. Record review of Incident Report (04/27/26) revealed Resident #1 (R1) reported that while Staff #2 (S2) and Staff #1 (S1) were repositioning her, S1 aggressively pushed R1 onto left side, resulting in pain to the left fifth finger and upper left arm. Interview with R1 indicated S1 hit R1 on the elbow and yanked R1’s finger around. R1 also indicated S1 did not use a sheet to reposition R1 but poked R1 with S1’s fingers. Seven out of seven resident interviews (R2 – R8) indicated staff have not hit them. One private caregiver (W1) indicated staff has not hit resident in care. Interview with S1 indicated R1 accused S1 of hitting R1 as S1 was repositioning R1. S1 indicated S1 did not hit R1. S2 indicated S1 did not hit R1 on the elbow nor yank R1’s finger around. S2 indicated that prior to repositioning, they placed R1’s arm on top of R1. At that moment, R1 accused them of hitting R1. S3 – S4 did not witness the incident but saw two scratches on S1’s arm. Seven out of seven staff interviews (S5, S7 – S12) indicated they have not witnessed staff hit residents. Regarding the allegation, “Staff hit resident,” based on interviews and record reviews, 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(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff handled resident in a rough manner. Record review of Incident Report (04/27/26) revealed Resident #1 (R1) reported that while Staff #2 (S2) and Staff #1 (S1) were repositioning R1, S1 aggressively pushed R1 onto left side, resulting in pain to the left fifth finger and upper left arm. The Executive Director conducted an internal investigation with the involved staff and found that their actions did not appear to be overly aggressive. Review of Medical Assessment (12/05/25) revealed R1 has chronic pain syndrome, has motor impairment/paralysis (left sided hemiplesia) and needs assistance with bathing, grooming, and toileting. Review of Service Plan (11/24/25) revealed R1 needs full two-person assistance with toileting in the morning, afternoon, and evening. Notes reveal R1 resists care at times. Please report this as needed. Interview with R1 indicated R1 and S1 had a tug-a-war with the blanket and finally S1 snatched the blanket off R1. R1 also indicated S1 did not use a sheet to reposition R1 but poked R1 with S1’s fingers. R1 indicated S1 and Staff #2 (S2) pulled R1 like a “wish-bone”. Seven out of seven resident interviews (R2 – R8) indicated staff are not rough with them. Continue to LIC9099-C. One private caregiver (W1) indicated staff are not rough with resident in care. Interview with S1 indicated S1 did not reposition R1 roughly with the bedsheet and did not snatch the blanket from R1. S2 indicated S1 was not rough with R1. S4 indicated R1 is sensitive to touch. Eight out of eight staff interviews (S5 – S12) indicated they have not witnessed staff handle residents in a rough manner. Regarding the allegation, “Staff handled resident in a rough manner,” based on interviews and record reviews, 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(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were issued. An exit interview was conducted and a copy of this report was provided to the Executive Director Mendy Ginsburg.the state’s words, verbatim · CDSS document, May 6, 2026 · control 11-AS-20260430092048

Allegation investigated: Staff do not ensure that residents are provided quality food while in care. Licensee is not addressing pest infestation at the facility.

On 03/26/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. LPA was met by Vanita Harris - Business Office Manager (S1) and the purpose of the visit was explained. S1 and LPA toured the facility. The investigation consisted of the following: On 03/26/26 the California Department of Social Services (CDSS) requested and reviewed facility documents and toured the facility and facilities' kitchen and dining room. CDSS interviewed ten (10) out of one-hundred-twenty (120) residents and five (5) out of sixty-six (66) staff. The investigation revealed the following: Regarding the allegation “Staff do not ensure that residents are provided quality food while in care”, it is being alleged that nutritious food is not being provided. Record reviews revealed that adequate foods are being delivered, three (3) times a day; Breakfast, Lunch & Dinner. Also listed on March 2026 dining menu is the following, "Alternate dishes are always available. See server for details." Report continues, please see LIC9099-C. Unsubstantiated Interviews revealed the following: Six (6) out of ten (10) residents (R1, R3, R7-R10) and all five (5) staff (S1-S5) 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 “Licensee is not addressing pest infestation at the facility.”, it is being alleged that cockroaches are around hallways and in dining room consistently. CDSS observation have confirmed that the department observed the facilities' kitchen and dining room. There are no live cockroaches nor cockroach bodies located within the kitchen or dining room. Record reviews have revealed that on 02/06/26, 02/19/26 and 02/20/26 that there has been pest control visits conducted at the facility. Interviews have revealed the following: Seven (7) out of ten (10) residents (R1, R3, R4, R7-R10) and four (4) out of five (5) staff (S1, S3-S5) 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. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Vanita Harris and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 11-AS-20260324083953

Allegation investigated: Staff caused injuries to a resident.

On February 06, 2026, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Mendy Gingsberg Executive Director and Marcia McKay, Wellness Director greeted the (LPA). (LPA) explained the purpose of the visit is to investigate the allegation mentioned above. The investigation included a collection of records, and an observation of the facility. The Department obtained several documents, including the Personnel Report LIC 500 (dated 01/17/26), the Resident Roster (dated 01/21/26), service records for Resident #1-#3 Identification and Emergency Information LIC 601, Face Sheet & Emergency Info, Service Plan, Resident Appraisal LIC 603A, Medical Assessment for Residential Care Facilities for the Elderly LIC 602A, Incident Report LIC 624, and other pertinent records associated with this complaint. (Evaluatiion Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff caused injuries to a resident. It is alleged that staff caused injuries to Resident #1 (R1). Reports suggest that due to staff negligence, the staff member caused (R1) to fall out of the wheelchair and sustained head, knee, and fracture injuries. According to the report, (R1) was being pushed in a wheelchair by staff who took a fast turn, causing (R1) to fall out of the wheelchair. The incident occurred at City View on January 15, 2026, requiring emergency hospitalization. No additional details regarding this allegation have been provided. On February 06, 2026, between 10:00 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of five (5) cannot corroborate this claim of (R1’s) fall was due to staff negligence in care. (S1) clarified that the fall did not occur due to any negligence on (S1's) part. On January 15, 2026, (R1) was being wheeled into the activity room when (R1) leaned forward and subsequently slipped out of the wheelchair before (S1) had the opportunity to assist. (S1) confirmed that (S1) had made a turn to navigate around oncoming obstacles, noting that the turn was executed carefully and was not a sharp or reckless turn. (S1) reported that (R1) received immediate medical assistance for a head injury and was uncertain about any injuries to the lower body at that time since (R1) was fully clothed. (S1) through (S5) confirmed (S1)'s account of the incident and were unaware that (R1) had sustained additional injuries to the knee, including a fracture, until the hospital provided this information. (S2-S3) noted that (R1) is on medications that increase sensitivity and the risk of injury due to the prescribed medication. (S2-S3) verified that (R1) had not been assessed as a fall risk and had never experienced a fall while at the facility. (S1 and S4-S5) verified completion of mandated staff training including fall prevention, proper positioning, back injury prevention, hoyer lift usability, and timely response to call lights. On February 06, 2026, between 10:35 AM and 02:00 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Nine (9) out of ten (10) cannot support this claim. All nine residents require assistive devices and report that staff are careful and attentive when assisting with mobility. Furthermore, none of the nine residents have experienced falls or injuries due to staff negligence or lack of care. Resident #1 (R1) was interviewed, but due to (R1’s) health condition, (R1) was unable to engage in a conversation. (Evaluation Report continues LIC 9099-C) On February 04, 2026, between 11:02 AM and 12:20 PM, the Department interviewed witnesses identified as Witness #1 and Witness #2 (W1-W2). Two (2) out of two (2) witnesses could not corroborate this claim. (W1) is close to (R1) and noted that (R1) sometimes slips out of (R1's) wheelchair. (W1) asked (R1's) doctor about using a seat belt, but the doctor did not approve it. (W1) also mentioned that (R1) takes several medications that can make (R1) less stable and affect (R1's) skin condition, which increases the risk of injuries. (W2) provided extra care services two times a week from November 2025 to January 2026. (W2) said that (R1) was not assessed for fall risk and that there were no falls or injuries during the care. (W2) worked alongside the facility staff and never observed any negligence or neglect in the care provided by the staff. On January 21, 2026, the Department inspected the area of the activity room where the incident occurred and did not observe any health or safety issues. A review of Resident #1 (R1’s) service record included Medical Assessment for Residential Care Facilities for Elderly LIC 602A (dated 006/05/25), Identification and Emergency Information LIC 601 (dated 03/19/18), Face Sheet and Emergency Info (dated 08/21/24) Service Plan (dated 10/12/25), Resident Appraisal LIC 603A (dated 10/27/22), Morse Fall Scale (dated 10/227/22), OC Hospice Care , Inc Record (dated 11/11/25), Unusual Incident Report LIC 624 (dated 01/20/26 & 10/12/25) Facility Progress Report (dated 01/28/26). Further review of Medication Administration Record (dated 12/01/25 – 12/31/25) revealed (38) medications are prescribed, with (19) significantly increasing the risk of falls. Additionally, (2) medications thin the blood, making individuals more prone to injuries (ref: National Institute of Health NIH). Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. 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 is Unsubstantiated. No deficiencies were cited An exit interview was conducted with Marcia McKay, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 11-AS-20260120103235

Allegation investigated: Staff did not ensure that the facility was kept free of pests.

On 2/3/26, at 9:45am, the department conducted an initial complaint visit to the facility and was greeted by Mendy Ginsburg, Executive Director. The department explained the purpose of this visit is to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegation mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R10). The department received the following facility documents: Resident Roster (Date: No Date), Staff Roster (Dated:1/31/2026), Pest Control Invoices (Dated: 9/05/2025, 10/2/2025, 11/11/2025, 12/05/2025, 01/06/2026), and Pest Control Logs (Dated: 10/02/2025-02/02/2026) from the facility. Report Continued on LIC909-C Unsubstantiated The investigation revealed the following: Allegation- Staff did not ensure that the facility was kept free of pests. The details of the complaint alleged that the facility has pests. It was reported that there are a lot of roaches in the building including the kitchen, dining areas, and residents’ rooms. It was also reported that the facility smells like poison. On 2/3/2026, from 10:00am-2:00pm, the department interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 4 of 5 staff denied the allegation that Staff did not ensure that the facility was kept free of pests. A majority of the staff stated that they have not seen any roaches, mice, rats, or other vermin in the facility. While one staff member acknowledged that they have seen a few roaches in the past. All staff, however, stated that the facility does have a pest management company that comes out and services the building several times per month for pests. The department interviewed residents (R1-R10) about the allegation and 7 of 10 residents that were interviewed stated that they have not seen any pests in the facility. While 3 of 10 acknowledged that they have seen a few roaches in the past. They also state that the facility does have a pest control company that services the building when they tell them that they have seen pests. The department reviewed the Pest Control Invoices (Dated: 9/05/2025, 10/2/2025, 11/11/2025, 12/05/2025, 01/06/2026) and Pest Control Logs (Dated: 10/02/2025-02/02/2026) and observed that the facility has ongoing pest control maintenance twice a month by Professional Pest Management. The department toured the kitchen, dining areas, restrooms, medication rooms, activity rooms, beauty salon, and resident rooms: 201, 209, 307, 309, 313, 402, 404, 406, 416, 414, 423, 515B, 516B, 518A, and 521 and did not observe any roaches or other pests in the facility on this investigation visit. The department did not observe any pest control smells such as poison to kill pests either. Based on observations, interviews, and records reviewed, there is insufficient evidence to support the allegation that the Staff did not ensure that the facility was kept free of pests. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited for this complaint investigation. An exit interview was conducted with Mendy Ginsburg, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 11-AS-20260126130801

Type of visit: Case Management - Deficiencies

On November 10, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit to the facility in connection with the Annual Inspection visit on September 20, 2025. The LPA met with Business Director Vanita Harris and explained the purpose of the visit. The Department determined the facility was not incompliance with Title 22 Regulations and was cited as follows: 87355(e)(2) - Criminal Record Clearance The inspection revealed that the facility did not comply with Title 22 regulations, LPA identified staff #1, #2, #3 did not have Criminal Clearance Background Transfer Request LIC 9182 and were not associated with this facility. (S1-S3) did not appear in CDSS Guardian Background Clearance System. Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies are issued and an exit interview is conducted with Vanita Harris. A copy of this report is provided along with the appeal rights.the state’s words, verbatim · CDSS document, Nov 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Nov 11, 2025

87355 Criminal Record Clearance - (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above. LPA identified staff #1, #2, #3 did not have Criminal Clearance Background Transfer Request LIC 9182 and were not associated with this facility. (S1-S3) did not appear in CDSS Guardian Background Clearance System. This violation which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 10, 2025

Plan of correction: Licensee is to ensure that all staff prior to working in the facility obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by POC due date. Proof of Correction due date: 11/11/25 at ernand.dabuet@dss.ca.gov Citation: Corrected 10/24/25 with all three staff members transfer association in Guardian.

Allegation investigated: Staff does not ensure that resident's toileting needs are met

On 10/16/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit to deliver these findings. LPA was met by Mendy Ginsberg (S2) and the purpose of the visit was explained. On 06/19/25 Licensing (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. LPA was met by staff two, Vanita Harris - Business Office manager (S2), and the purpose of the visit was explained. The investigation consisted of the following: On 06/19/25 LPA requested and reviewed facility documents including: staff roster (dated: 06/14/25), resident roster (dated: 06/19/25), Resident one, Residents six and seven (R1, R6-R7) physician's reports and R1's admission paperwork and R1's caretrack (care plan). LPA interviewed five (5) out of one-hundred and nine (109) residents and five (5) out of seventy-six (76) staff. Residents six and seven (R6-R7) were unavailable for interview, due to their current medical condition. Report continues, please see LIC9099C. Substantiated The investigation revealed the following : record reviews have revealed that three (3) out of three (3) residents (R1, R6-R7) are not Able to Care for Own Toileting Needs. Although the date mentioned is 06/08/25, R1's caretrack (care plan) shows that R1 has not received toileting assistance on three (3) consecutive occasions, dated 06/01/25. Three (3) out of five (5) residents and three (3) out of five (5) staff interviewed have agreed the allegation has taken place. 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. Please see attached LIC9099-D. Licensee does not agree with the fact that they are being cited. Licensee has also terminated the staff responsible prior to LPA's investigation. One (1) deficiency was cited during today's visit, please see LIC9099-D. An exit interview was held with staff four, Mendy Ginsberg (S4), and a copy of the facilities' deficiency, appeal rights and this report have been provided to Mendy Ginsberg.the state’s words, verbatim · CDSS document, Oct 16, 2025 · control 11-AS-20250609142659

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Oct 16, 2025

87625 Managed Incontinence (b) In addition to Section 87611,..., the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This has not been met as evidenced by: LPA's record reviews and interviews conducted with staff and residents where the licensee has failed to provide incontinent care to a resident(s), which poses/posed a potential health risk to residents in carethe state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: LPA and Licensee have agreed to ensure associated staff have conducted an in-staff training to make sure staff are informed on their work to be completed, specifically their duty to care for incontinent residents. Licensee will ensure that staff who have failed to meet this requirement have the potential to lose their position(s). Licensee does not agree with the fact that they are being cited. Licensee had terminated the staff responsible prior to LPA's investigation. Licensee will forward the in-staff meeting to LPA Leon at MARIO.LEON@DSS.CA.GOV

Allegation investigated: Staff does not ensure that resident's toileting needs are met

On 10/16/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit to deliver these findings. LPA was met by Mendy Ginsberg (S2) and the purpose of the visit was explained. On 06/19/25 Licensing (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. LPA was met by staff two, Vanita Harris - Business Office manager (S2), and the purpose of the visit was explained. The investigation consisted of the following: On 06/19/25 LPA requested and reviewed facility documents including: staff roster (dated: 06/14/25), resident roster (dated: 06/19/25), Resident one, Residents six and seven (R1, R6-R7) physician's reports and R1's admission paperwork and R1's caretrack (care plan). LPA interviewed five (5) out of one-hundred and nine (109) residents and five (5) out of seventy-six (76) staff. Residents six and seven (R6-R7) were unavailable for interview, due to their current medical condition. Report continues, please see LIC9099C. Substantiated The investigation revealed the following : record reviews have revealed that three (3) out of three (3) residents (R1, R6-R7) are not Able to Care for Own Toileting Needs. Although the date mentioned is 06/08/25, R1's caretrack (care plan) shows that R1 has not received toileting assistance on three (3) consecutive occasions, dated 06/01/25. Three (3) out of five (5) residents and three (3) out of five (5) staff interviewed have agreed the allegation has taken place. 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. Please see attached LIC9099-D. Licensee does not agree with the fact that they are being cited. Licensee has also terminated the staff responsible prior to LPA's investigation. One (1) deficiency was cited during today's visit, please see LIC9099-D. An exit interview was held with staff four, Mendy Ginsberg (S4), and a copy of the facilities' deficiency, appeal rights and this report have been provided to Mendy Ginsberg.the state’s words, verbatim · CDSS document, Oct 16, 2025 · control 11-AS-20250609142659

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Oct 16, 2025

87625 Managed Incontinence (b) In addition to Section 87611,..., the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This has not been met as evidenced by: LPA's record reviews and interviews conducted with staff and residents where the licensee has failed to provide incontinent care to a resident(s), which poses/posed a potential health risk to residents in carethe state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: LPA and Licensee have agreed to ensure associated staff have conducted an in-staff training to make sure staff are informed on their work to be completed, specifically their duty to care for incontinent residents. Licensee will ensure that staff who have failed to meet this requirement have the potential to lose their position(s). Licensee does not agree with the fact that they are being cited. Licensee had terminated the staff responsible prior to LPA's investigation. Licensee will forward the in-staff meeting to LPA Leon at MARIO.LEON@DSS.CA.GOV

Allegation investigated: Staff are not following resident's special diet order

On 10/15/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unannounced, complaint visit at the facility to deliver these findings. LPA was met by staff five, Vanita Harris - Business Office Manager (S5), and the purpose of the visit was explained. The investigation consisted of the following: On 05/21/25 LPA requested and reviewed facility documents, inlcuding resident roster (dated: 05/21/25), resident special diet list (dated 05/21/25) staff roster (dated: 05/05/25), four (4) physician's special diet orders and toured the first (1st) and fourth (4th) floors of the facility. LPA interviewed six (6) out of one-hundred and five (105) clients (R1 through R6) and four (4) out of seventy-six (76) staff (S1 through S4). On 07/16/25 LPA requested resident roster (dated 07/16/25) and toured the third (3rd) and fifth (5th) floors of the facility. LPA interviewed three (3) residents (R7 through R9) and three (3) staff (S7 through S9). Resident(s) six (R6) and nine (R9) have denied holding an interview with LPA. Report continues, please see LIC9099C. Substantiated The investigation revealed the following: Regarding the allegation, “Staff are not providing resident with enough food to meet resident's needs”, it has been alleged that a resident is not provided enough protein in their daily diet. On 05/21/25, at around 09:30AM toured the facility’s kitchen and observed three (3) residents’ special dietary orders (R2-R4), located on the cork board as LPA entered the kitchen. At around 1:00PM, LPA collected four residents’ (R1-R4) dietary orders. Upon review of four residents’ dietary orders (DO), R1’s physicians’ DO does not mention any increase in protein for R1. During an interview with R1, R1 mentions that he is provided with about one and a half (1.5) chicken breasts, instead of three (3) chicken breasts as requested. Interviews revealed that three (3) out of four (4) residents and seven (7) out seven (7) staff have not agreed with this allegation. Based on LPA’s observation, 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 did not safeguard resident's belongings”, it is being alleged that nine (9) residents’ underwear have not been returned after being provided to housekeeper(s). On 05/21/25, at around 1:00PM, LPA requested any documentation of residents’ concerns regarding their personal belongings. LPA reviewed a residents’ safeguard of personal belongings, in which does not mention nine (9) pair of underwear. Interviews revealed that three (3) out of seven (7) residents and seven (7) out seven (7) staff have not agreed with this allegation. Based on LPA’s observation, 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. Report continues, please see LIC9099C. Regarding the allegation, “Staff do not answer residents calls for assistance timely”, it is being alleged that a resident must wait about one (1) hour to have their incontinence supply changed. At around 1:00PM, LPA reviewed a residents’ “caretrack” regarding toileting provided to a resident. According to caretrack, a resident was provided toileting assistance at 9:00PM and at 11:00PM, 01:00AM, 03:00AM and at 05:00AM. Interviews revealed that six (6) out of seven (7) residents and seven (7) out of seven (7) staff have denied the allegation has taken place. Based on LPA’s 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 did not administer resident's meds timely causing resident to miss medications”, it is being alleged that a residents’ cream was not administered on the date of 05/08/25. At around 1:00PM, LPA reviewed a residents’ caretrack. On 05/08/25, caretrack notes the cream mentioned as having been provided at the following times: 08:00AM, 12:00PM and 5:00PM. Interviews have revealed that five (5) out of seven (7) residents and seven (7) out of seven (7) staff have denied the allegation has taken place. Based on LPA’s 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 has been one deficiency cited during today's visit, please see LIC9099D. An exit interview was held with Vanita Harris - Business Office Manager and a copy of this report has been provided. Regarding the allegation, “Staff are not following resident's special diet order”, it is being alleged that the facility is not following a residents' physician diet order. On 05/21/25, at around 09:30AM, LPA toured the facility’s kitchen and observed three (3) residents’ special dietary orders (R2-R4), located on the cork board as LPA entered the kitchen. R1’s diet was not observed. At around 1:00PM, LPA collected four residents’ (R1-R4) dietary orders (DO). R1’s special diet was created by their physician on 04/30/25, yet was not posted as other residents’ (R2-R4) DO was. Interviews revealed that four (4) out of seven (7) residents have agreed that the allegation has taken place. Based on LPA’s observation, 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. One deficiency was cited during today's visit, please see LIC9099D. An exit interview was conducted with Vanita Harris - Business office manager (S5) , and a copy of facilities’ appeal rights and this report has been provided.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 11-AS-20250513155247

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Oct 15, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This has not been met as evidenced by: based on LPA's observation, interviews and record reviews in which the licensee failed to follow R1's physician diet order, which poses a potential health risk related to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: Upon identification of this deficiency, facility placed R1's physician diet orders with other residents' physician diet orders, located on the kitchen's cork board, for facility cooks to review prior to serving food items to residents in care. Furthermore, administrator and kitchen supervisor will implement a verification log in which all diet orders will be verified within 24 hours of a resident's admission, or any dietary change(s), and a copy will be posted on the kitchen's cork board to make sure the facility is following residents' physician diet orders to remain compliant under title 22 regulation.

Type of visit: Required - 1 Year

On 09/20/25, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Wellness Director Marcia McKay. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (166) non-ambulatory elderly adults of ages 60 and above. Currently, the facility has (69) residents in Assisted Living, (46) in Memory Care (4) in hospice care. The facility is approved for (14) hospice residents. The facility is a six-story structure located in a commercial neighborhood. It consists of the following: (21) resident bedrooms in Memory Care and (71) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, an activity room, a dining area, a private dining room, a kitchen, a rooftop patio, a lobby, (8) public restrooms, a gym, and subterranean parking. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #205, #207, #303, #321, #402, #407, #507 and #511. All call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.1 – 115.5 degrees F. A comfortable temperature was maintained in the facility at 72-75 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Evaluation Report continues LIC 809-C Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Administration Records (MAR) was observed to be maintained in order and accurate. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. LPA conducted an audit of resident #1-#5 (R1-R5) service files, and staff #1-#5 (S1-S5) personnel files. The facility has is current on Community Care Licensing (CCL) license annual dues. DEFICIENCIES: During staff file review between 11:30am - 12:30pm, the following required items were not in the files: Staff #1, #2 and #3 did not have a Criminal Clearance Background Clearance Transfer. No Criminal Clearance Transfer Request LIC 9182 on file or appears on the Department of Social Services Guardian Background Check System. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D). Technical Advisory Violation issued (see LIC9102) Immediate Civil Penalty issued. An exit interview conducted with Marcia McKay and a copy of report and appeal rights provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *the state’s words, verbatim · CDSS document, Sep 20, 2025

Allegation investigated: Staff did not provide medication assistance to residents in care in a timely manner

On 07/25/2025 Licensing (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. LPA was met by staff one, Mendy Ginsberg – Executive Director (S1), and the purpose of the visit was explained. The investigation consisted of the following: On 07/24/2025 LPA requested and reviewed facility documents including: staff roster (dated: 07/24/2025), resident roster (dated: 07/2025), seven (7) resident records (R1-R7), listed as follows: physician's reports (LIC-602a) and Appraisal Needs and Services (Dated: various). LPA interviewed three (3) residents (R3 - R5) out of one-hundred and nine (111) residents and one (1) out of seventy-six (76) staff. On 07/25/2025 LPA obtained two (2) staff training records (S4 and S8). LPA requested and reviewed seven (7) resident records (R1-R7), listed as follows: Electronic Medication Administration Record(s) (eMAR) (dated: 06/01/2025 through 07/24/25) and LPA toured the second, third, and fourth (2nd, 3rd, 4th) floors and interviewed five (5) residents (R1 and R2, R6 through R8) and six (6) staff (S1 and S3 through S7). Report continues, see LIC9099-C. Unsubstantiated The investigation revealed the following: Regarding the allegation, “Staff did not provide medication assistance to residents in care in a timely manner", is has been alleged that residents are missing meals due to a delay in medication administration. On 07/24/2025 through 07/25/2025, from 9:00AM through 4:45PM LPA interviewed eight (8) residents and seven (7) staff (S1 through S7). Six (6) out of eight (8) residents and all seven (7) staff interviewed have not agreed the allegation has taken place and that all residents are always provided a meal. Record reviews have indicated all seven (7) eMAR(s), dated between 06/01/2025 though 07/24/2025, show all seven (7) residents (R1 through R7) have received all medication administration during the dates listed above. Record reviews have also revealed that S4 and S8 have completed their initial and ongoing (yearly) training, as mandated under Title 22 regulation. 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.the state’s words, verbatim · CDSS document, Jul 25, 2025 · control 11-AS-20250718085047

Allegation investigated: Staff do not allow resident to keep and have access to personal possessions

On 07/25/2025 Licensing (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. LPA was met by staff one, Mendy Ginsberg – Executive Director (S1), and the purpose of the visit was explained. The investigation consisted of the following: On 07/24/2025 LPA requested and reviewed facility documents including: staff roster (dated: 07/24/2025), resident roster (dated: 07/2025), seven (7) resident records (R1-R7), listed as follows: physician's reports (LIC-602a) and Appraisal Needs and Services (Dated: various). LPA interviewed three (3) residents (R3 - R5) out of one-hundred and nine (111) residents and one (1) out of seventy-six (76) staff. On 07/25/2025 LPA obtained two (2) staff training records (S4 and S8). LPA requested and reviewed seven (7) resident records (R1-R7), listed as follows: Electronic Medication Administration Record(s) (eMAR) (dated: 06/01/2025 through 07/24/25) and LPA toured the second, third, and fourth (2nd, 3rd, 4th) floors and interviewed five (5) residents (R1 and R2, R6 through R8) and six (6) staff (S1 and S3 through S7). Report continues, see LIC9099-C. Unsubstantiated The investigation revealed the following: Staff do not allow resident to keep and have access to personal possessions”, is has been alleged that staff are not allowing residents access to their personal hygiene products. On 07/24/2025 through 07/25/2025, from 9:00AM through 4:45PM LPA interviewed eight (8) residents and seven (7) staff (S1 through S7). Seven (7) out of eight (8) residents and all seven (7) staff interviewed have not agreed the allegation has taken place and that all residents are assisted with their activities of daily living. Record reviews have indicated five (5) out of seven (7) residents, those diagnosed with dementia, or their responsible party(ies), have all received a copy of "Memory Care Consent" form (dated: various) which indicates that residents are able to obtain a copy of the facilities' "plan of operation" if there are any concerns regarding the storage of personal items. This form informs residents, or their responsible parties, that staff are able to provide proper care to residents diagnosed with dementia (Title 22, Chapter 6, CCR 87705). 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.the state’s words, verbatim · CDSS document, Jul 25, 2025 · control 11-AS-20250717112752

Allegation investigated: Staff do not ensure that resident's personal care hygiene needs are met. Staff do not ensure that resident is provided clean bedding while in care. Staff do not safeguard resident's personal possessions.

On 07/23/2025, at 8:16am, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent complaint visit at this facility to deliver the complaint findings. During today’s visit, LPA met with Vanita Harris, Business Office Manager and explained the purpose of the visit. The investigation consisted of the following:An initial complaint visit was completed by the department on 04/25/2025 and LPA conducted interviews with Administrator (A1), Staff (S1-S7) and Residents (R1-R6) from 9:54am - 3:03pm. On 07/23/2025, LPA continued interviews with Staff (S8-S10) Resident (R7-R10), between the hours of 8:28am - 10:45am. Report continues on LIC 9099-C Unsubstantiated On 04/25/2025, the department received the following documents: Resident Roster (received 04/25/2025), Staff Roster (dated 04/19/2025), All of R1's LIC 601 Identification & Emergency Information - dated 12/14/2022, LIC 602: Physician Report for RCFE - dated 12/19/2022, LIC 603A: Resident Appraisal- dated 12/22/2022, LIC 621:Resident Personal Property & Valuable - dated 12/14/2022, LIC 622:Centrally Stored Medication Record - received 04/25/2025, Residence & Care Agreement - dated 12/14/2022, Resident Assessment - received 04/25/2025, Service Plan - dated 03/25/2025, Resident Care Summary (March 2025) - received 04/25/2025, Medication List (for R1) - received 04/25/2025, Admission Order (dated 12/21/2022, Dietary Order - dated 12/19/2022 & Consent for Alcoholic Beverages - dated 12/19/2022. The investigation revealed the following: Allegation 1 – Staff do not ensure that resident's personal care hygiene needs are met. It is alleged that the facility failed to ensure the resident's personal care hygiene needs are being met. The reporting party stated R1 is not often clean, has not bathed or has been assisted with bathing, teeth cleaned in several days. On 04/25/2025, between the hours of 11:41am -12:15pm, LPA interviewed A1 who denied the allegation. A1 stated that based on the resident service plan for scheduled bathing and or assistance with hygiene is agreed upon from the resident, the resident's family and the facility. A1 states R1 has refused for personal care hygiene which is documented in the progress notes. Most staff confirm that personal care hygiene is provided according to protocol despite resident’s frequent refusals, which are documented and communicated. Some staff not involved or unaware due to role. On 04/25/2025 & 07/23/2025, between the hours of 9:54am - 1:56pm and 8:57am, interviewed 10 staff regarding the allegation: 6 out of 10 staff denied the allegation. 4 out of 10 staff were unaware of the allegation. 3 of staff stated that R1 has refused personal care hygiene multiple times which has been documented and the family has been notified. 4 of the staff stated they never interacted with R1's hygiene only assist with showering the residents who reside on the 2nd, 4th, and 5th 1 of the staff stated only within the first 4 weeks of being hired, she wasn't sure of R1's change in hygiene route or willingness to be assigned to assisted. 3 of the staff stated it's not in their job duties since they are either the facilities the Family Specialist, Housekeeper and or Maintenance. Report continues on LIC 9099-C On 04/25/2025 and 07/23/2025 between the hours of 1:28pm – 3:03pm and 8:28am - 10:40am, the department interviewed residents (R1–R10) about the allegation. 9 out of 10 residents denied the allegation. 1 out of 10 residents did not confirm or deny the allegation. 9 of the residents stated they are independent and don't need assistance personal hygiene care. On 07/08/2025 & 07/22/2025 between the hours of 10:30-2:30pm & 12:25pm - 12:30pm, LPA reviewed R1's LIC 603A, Service Plan and Resident Care Summary and observed the following: under the services need section help with bathing and help with dressing, hair care, and personal hygiene is checked no. In Resident Assessment for bathing R1 needs max full assistance with moderate/max assist with bathing -1 person assist 2x per week (details: shower chair, shower) allow independence, encourage and assist as needed. For grooming needs its moderate with standby assistance for morning/bedtime grooming. For oral care need it is moderate with standby assistance/prepare items(5) with details of assistance with morning/bedtime dental care and wears dentures. The service plan under the exceptions section on 03/04/2025, 03/05/2025, and 03/11/2025 R1 refused bathing after staff tried three times, and R1 become violent towards staff. Based on records review, interviews, and observations, LPA did not find sufficient 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. The investigation revealed the following: Allegation 2 – Staff do not ensure that resident is provided clean bedding while in care. It is alleged that the facility isn't providing clean bedding for the resident. The reporting party stated R1 is not often clean and sheets covered in urine and feces. On 04/25/2025, between the hours of 11:41am -12:15pm, LPA interviewed A1 who denied the allegation. A1 stated everyday R1's bedding is checked and changed everyday. A1 also stated if R1's bedding is soiled overnight bedding is always replaced and properly hygiene. On 04/25/2025 & 07/23/2025, between the hours of 9:54am - 1:56pm and 8:57am, interviewed 10 staff regarding the allegation: 7 out of 10 staff denied the allegation stating bedding is changed daily and or as needed. 3 out of 10 staff did not confirm or deny the allegation stated being unaware of how it done and or its not within their job description. The staff such as housekeeping and the family of R1 shared the responsibility for bedding. Bedding is changed regularly according to policy, with immediate changes when soiled. No direct evidence found that clean bedding was not provided. Report continues on LIC 9099-C On 04/25/2025 and 07/23/2025 between the hours of 1:28pm – 3:03pm and 8:28am - 10:40am, the department interviewed residents (R1–R10) about the allegation. 1 of 10 resident confirmed the allegation who stated a delay in replacing soiled sheets. 8 out of 10 residents denied the allegation who stated bedding is changed frequently on a weekly basics. 1 out of 10 residents did not confirm or deny the allegation due to not remembering. On 07/22/2025, between the hours of 1:30pm - 1:40pm, LPA conducted a records review and observed the following: on the service plan, it states under the additional services requested R1's daughter does R1's laundry. Based on records review, interviews, and observations, LPA did not find sufficient 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 3 – Staff do not safeguard resident’s personal possessions. The investigation revealed the following: It is alleged that the resident's personal possessions are not being safeguarded by the staff. The reporting party stated R1 clothes and jewelry were missing On 04/25/2025, between the hours of 11:41am -12:15pm, LPA interviewed A1 who denied the allegation. A1 stated the LIC 621 is in place for any items would like to safe kept in an area throughout the facility for personal items. For Memory Care all doors are automatically locked. The facility will conduct an investigation if needed by looking at the camera throughout the facility. If staff takes residents personal belonging it’s an immediate termination. Also A1 states R1 has been observed to misplace items and the facility has photo proof. Report continues on LIC 9099-C On 04/25/2025 and 07/23/2025 between the hours of 1:28pm – 3:03pm and 8:28am - 10:40am, the department interviewed residents (R1–R10) about the allegation. 3 out of 10 staff denied the allegation. 7 of 10 staff did not confirm or deny the allegation. 1 of the staff emphasize being made aware of R1's missing items due misplacing their personal belongings such as shoes and or undergarments which were later found. On 04/25/2025 and 07/23/2025 between the hours of 1:28pm – 3:03pm and 8:28am - 10:40am, the department interviewed residents (R1–R10) about the allegation. 1 out of 10 resident confirmed the allegation. 8 out of 10 residents denied the allegation. 1 out of 10 residents did not confirm or deny the allegation. 1 of the residents stated money and jewelry were stolen by staff. 8 of the residents stated no having an issues with their personal items missing as the resident keep track of their own belongings. 07/22/2025, between the hours of 1:30pm - 1:40pm, LPA conducted a records review of R1's LIC 621 Client/Resident Personal Property and Valuables dated on 12/14/2022 which stated a silver watch and a gold watched are located in a jewelry box. On 07/23/2025, at the time of LPA concluding interviews, LPA was unable to follow up with R1 in regards to this matter due to R1 no longer resides at the facility as of May 2025. Based on records review, interviews, and observations, LPA did not find sufficient 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. No deficiencies were cited for this allegations. An exit interview was conducted, and a copy of this report was provided to Vanita Harris, Business Office Managerthe state’s words, verbatim · CDSS document, Jul 23, 2025 · control 11-AS-20250424091353

Allegation investigated: Illegal eviction

On 07/10/25, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced follow-up visit to deliver findings to the mentioned complaint. The LPA was met by Executive Director, Mendy Ginsburg, and additional staff members. The investigation consisted of the following: On 06/06/2025, LPA Richard reviewed and obtained facility records which consisted of Staff Roster, Client Roster, House Rules, Resident #1 (R1) records, including Physician’s Report, (dated 03/04/25) Admission Agreement, (dated 03/06/24), Identification and Emergency Information (LIC 601),(dated 03/06/25), Resident Appraisal (LIC603), Unusual Incident Reports, (dated 03/24/25, 05/08/25, 05/23/25). Glenhaven Discharge Report (dated 05/19/25). Interviews were conducted with three (3) staff (S1-S3), and five (5) residents (R2-R6), and Sherman Oak Hospital staff #1(W1). Allegation: Illegal eviction. Report continues, please see LIC9099-C Unsubstantiated The complaint states that resident #1 (R1) was taken to hospital number two (#2), after being discharged from hospital number one (#1), and the facility informed R1 that R1 could not return because they were unwell. On 07/06/25, LPA Richard interviewed the Executive Director, who denied the allegation and stated that the resident is still in the hospital, and the hospital staff does not know when the resident will be discharged from #2. On the same day, LPA Richard interviewed five residents (R2-R6), all of whom denied ever receiving an eviction notice. LPA Richard also spoke with three staff members, all of whom denied the allegation and stated that they were not aware of any illegal eviction taking place at the facility. Additionally, LPA Richard interviewed a staff member from Sherman Oaks Hospital (W1), who confirmed that the facility had not issued any eviction notice to R1 or R1's responsible party because the resident is still hospitalized. W1 stated that the agency is currently seeking a new facility for R1, as R1 requires a higher level of care. As of 07/06/25, the resident remains hospitalized in Sherman Oaks Hospital after being transferred from Huntington Hospital, and it is unclear when R1 will be released. The LPA also reviewed records of an Unusual Incident/Injury Report dated 05/23/25, which indicated that the resident was transferred to Huntington Hospital and remained hospitalized. On 06/06/25, LPA conducted record reviews, which did not indicate that the Department of Social Services received any documentation from the facility regarding an eviction notice for the resident. Regarding the allegation, “Illegal Eviction,” based on 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(s) 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 provided to the Executive Director, Mendy Ginsburg.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 11-AS-20250602081602

Allegation investigated: Staff did not ensure a comfortable environment was provided for residents.

On 06/26/25, Licensing Program Analyst (LPA) Regina Cloyd conducted a(n) initial visit on to gather information regarding the above allegation. LPA met with Business Office Manager Vanita Bush and the purpose of the visit was explained. Investigation consisted of the following: On 06/26/25, LPA obtained a copy of the Resident Roster, Personnel Report (dated 06/21/25). LPA conducted ten (10) staff (S1 – S10) and ten (10) resident (R1 – R10) interviews and toured the 2nd, 4th, and 5th floors (including chemical storage unit on the 5th floor). LPA observed rooms (209, 210, 212, 408, 400, 408, 409, and 423). Investigation revealed the following: Allegation: Staff did not ensure a comfortable environment was provided for residents. Nine (9) out nine (9) staff interviews denied the allegation. Nine (9) out nine (9) staff interviews indicated that they have not received any complaints concerning the cleaning of the facility and bedroom. Continue to LIC9099-C. Unsubstantiated Ten (10) out of ten (10) staff interviews indicated that the facility remains at a comfortable temperature. Eight (8) out (8) staff interviews indicated that the residents have adequate lightening in their rooms. Ten (10) out of ten (10) resident interviews denied the allegation. Ten (10) out of ten (10) resident interviews indicated that they have no complaints concerning the cleaning of the facility and bedroom. Nine (9) out ten (10) resident interviews indicated that the facility remains at a comfortable temperature. Ten (10) out of ten (10) resident interviews indicated that the residents have adequate lightening in their rooms. LPA toured the second, fourth, and fifth floor and observed that a comfortable environment was provided to the residents. LPA observed Windex, Multi-Purpose Cleaner, and a Freshener in the chemical storage unit. LPA observed that the residents’ room were at a comfortable temperature and had adequate lightening. Regarding the allegation, “Staff did not ensure a comfortable environment was provided for residents,” based on 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(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were issued. An exit interview was conducted and a copy of this report was provided to the Executive Director Mendy Ginsburg.the state’s words, verbatim · CDSS document, Jun 26, 2025 · control 11-AS-20250619151939

Allegation investigated: Staff did not assist resident with getting off the floor Staff did not check on resident in a timely manner

On 04/15/25 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. LPA was met by staff one, Vanita Harris Business Office Manager (S1), and the purpose of the visit was explained. LPA was granted entry to the facility. The investigation consisted of the following: On 04/07/25 LPA printed personnel report summary. On 04/10/25 LPA obtained the Personnel Report (dated 03/31/25), resident roster (dated 04/10/25). On 04/15/25 LPA toured the first, second and fourth (1st, 2nd & 4th) floors of the facility. On 04/15/25 LPA requested and reviewed facility documents, including copies of face sheets, Needs and Services plan, Physician's reports of three (3) resident's (R1-R3). LPA also obtained staff schedule for the month of April, 2025 (printed 04/15/25). LPA requested four (4) staff records (S2, S5-S6, S8) and between 09:40AM and 1:00PM LPA interviewed five (5) staff (S1-S5) and between 2:00PM and 4:30PM LPA interviewed three (3) staff (S6-S8), four (4) residents (R1-R4) and one witness (W1). R4 was not available to be interviewed, due to current medical status. S1 was not able to answer LPA's questions, as that is beyond their work duties. Report continues, see LIC9099-C. Unsubstantiated Investigation revealed the following: Regarding the allegation, “Staff did not assist resident with getting off the floor”. It has been alleged that a resident was not assisted out from being stuck between the bed and night stand for an extended period. Record reviews revealed that four (4) staff (S2, S5-S6, S8) present on the date in question have conducted all required training as a caregiver and as a Med-Tech. Between 09:40AM and 1:00PM LPA interviewed five (5) staff (S1-S5) and between 2:00PM and 4:30PM LPA interviewed three (3) staff (S6-S8), four (4) residents (R1-R4) and one witness (W1). R4 was not available to be interviewed, due to current medical status. S1 was not able to answer LPA's questions, as that is beyond their work duties. Seven (7) out of Eight (8) staff (S2-S8), Three (3) out of three (3) residents (R1-R3) and one (1) witness (W1) interviewed have denied the allegation has taken place. Seven (7) out of Eight (8) staff (S2-S8) have provided accurate details on emergency protocol. 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 did not check on resident in a timely manner”. It is being alleged that a resident was discovered stuck between the bed and night stand. Record reviews revealed that four (4) staff (S2, S5-S6, S8) present on the date in question have conducted all required training as a caregiver and as a Med-Tech. Between 09:40AM and 1:00PM LPA interviewed five (5) staff (S1-S5) and between 2:00PM and 4:30PM LPA interviewed three (3) staff (S6-S8), four (4) residents (R1-R4) and one witness (W1). R4 was not available to be interviewed, due to current medical status. S1 was not able to answer LPA's questions, as that is beyond their work duties. Seven (7) out of Eight (8) staff (S2-S8), Three (3) out of three (3) residents (R1-R3) and one (1) witness (W1) interviewed have denied the allegation has taken place. S8 notified LPA that if a fall is unwitnessed, staff are not to relocate a resident without the assistance of a skilled medical professional. 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 zero (0) deficiencies cited during today's visit. An exit interview was conducted with Vanita Harris, Business Office Manager (S1), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 11-AS-20250410144015

Allegation investigated: Staff did not ensure medication dispensed to resident was as prescribed Staff did not meet resident's dietary needs

On 04/10/25 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met Mendy Ginsburg, Executive Director (S1), and the purpose of the visit was explained. LPA was granted entry to the facility. S1 and LPA toured the facility. The investigation consisted of the following: On 04/10/25 LPA requested and reviewed facility documents, including the following: Personnel Report (dated 03/31/25), resident roster (dated 04/10/25), copy of a resident's face sheet, medication list, and communications between the facility and a resident's primary psychiatrist, along with incident reports regarding a resident. LPA obtained the facilities' diet report of all 105 residents (dated 04/02/25), facilities' dietician's kitchen report for the dates of January, 2025 (01/25) and March, 2025 (03/25) and LPA reviewed facilties' communications between staff and management regarding any changes involving residents and their dietary needs. LPA interviewed six (6) out of one-hundred and five (105) residents (R1-R6) and ten (10) out of seventy-five (75) staff (S1-S10). Report continues, see LIC9099-C. Unsubstantiated Investigation revealed the following: Regarding the allegation, "Staff did not ensure medication dispensed to resident was as prescribed". It has been alleged that a resident's medication has been changed without notifying the primary psychiatrist or the responsible parties of a resident. LPA conducted record reviews of the changes mentioned in a resident's medication (MED) list, as follows: LPA reviewed an unusual Incident / Injury Report (LIC624) (dated 03/20/25) noting a resident was observed by staff nine (S9) to have altered behavioral and mental status. On 03/27/25, the resident's primary psychiatrist, sent a new order to this facility. LPA reviewed the facilities' order request on 03/29/25, to the pharmacy. On 04/10/25, between 10:00AM and 1:00PM, LPA interviewed seven (7) staff (S1-S10). S2 and S9 were not present at the facility nor available for LPA's interview call. Between 2:00PM and 4:00PM, LPA interviewed four (4) residents (R2, R4-R6). R1 was not available for interview. R3 preferred not to be interviewed. All eight (8) staff interviewed (S1, S3-S8, S10) and four (4) out of four (4) residents interviewed (R2, R4-R6) have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has/has not been met. 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. Regarding the allegation, "Staff did not meet resident's dietary needs". It has been alleged that a resident requires a special diet, as ordered from their physician, and that staff do not follow a residents' special diet. Furthermore, a resident, at times, does not receive a meal from the kitchen. Between 10:00AM - 10:30AM, LPA observed the "diet report" posted in the kitchen. LPA requested facilities' communications between staff and management regarding any changes involving residents and their food and observed those communications between February, 2025 (02/25) and April, 2025 (04/25) which noted six (6) new residents, including their diet plan, and one (1) request to hold nutrition (fasting) for a resident. LPA conducted record reviews of the facilities' diet report and observed 105 residents' dietary restrictions. On 04/10/25, between 10:00AM and 1:00PM, LPA interviewed eight (7) staff (S1, S3). S2 and S9 were not present at the facility nor available for LPA's interview call. Between 2:00PM and 4:00PM, LPA interviewed five (5) residents (R1-R5). R3 preferred not to be interviewed. Report continues, see LIC9099-C. All eight (8) staff interviewed (S1, S3-S8, S10) and four (4) out of four (4) residents interviewed (R2, R4-R6) have denied the allegation has taken place. have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has/has not been met. 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. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff one, Mendy Ginsburg (S1) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 11-AS-20250403142558

Type of visit: Case Management - Other

On 03/26/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced case management visit to City View LA, LLC. The purpose of today’s visit was to serve the Order to Licensee/Facility of Immediate Exclusion from Facility for Staff #1 (S1). LPA Cloyd met with Executive Director Mendy Ginsberg. LPA reviewed the posted work schedule and S1 is expected to arrive to work on 03/27/25. LPA Cloyd delivered a copy of the immediate exclusion letter to the Executive Director and explained that S1 has to be disassociated from the facility immediately. An exit interview was conducted and a copy of this report was provided to the Executive Director Mendy Ginsberg.the state’s words, verbatim · CDSS document, Mar 26, 2025

Allegation investigated: Staff do not ensure facility provides food of good quality Staff do not ensure facility provides adequate planned activities Staff does not ensure facility is kept free of pests

On 11/7/2024, the Department of Social Services (DSS) - Community Care Licensing Division (CCLD) staff delivered findings for the allegations listed above. CCLD staff explained the purpose of the visit to Executive Director - Mendy Ginsburg. The investigation consisted of the following: On 10/23/2024, CCLD staff interviewed 13 out of 98 residents and 7 out of 52 staff. CCLD staff toured the kitchen, dining room, activity room, and the gym. CCLD staff requested and gathered records such as, Resident records, Staff records, and Facility records. On 11/6/2024, CCLD staff reviewed interviews conducted, facility records, and facility website. Unsubstantiated The investigation revealed the following: Regarding the allegation “Staff do not ensure facility provides food of good quality”, it is being alleged that the facility does not provide many food options and does not serve healthy well-balanced meals (e.g. serves too many carbohydrates). Interviews conducted with residents revealed the following: 8 out of 13 residents denied the allegation; 4 out of 13 residents agreed with the allegation; 1 out 13 residents did not know if alleged allegation had occurred. Interviews conducted with staff revealed the following: 5 out of 7 staff denied the allegation; 2 out of 7 staff did not know if alleged allegation had occurred. Records reviewed indicated the following: facility menu from September 2024 to October 2024 offers a protein option during breakfast, lunch, and dinner. Facility menus state, “Alternate dishes are always available.” The “Alternative Menu” has vegetarian options and offers protein heavy meals. Observations indicated the following: on 10/23/2024 during lunch time, CCLD staff observed that residents were being served well-balanced meals; CCLD staff also observed residents receiving alternative meal options. Regarding the allegation, 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 is unsubstantiated. Regarding the allegation “Staff do not ensure facility provides adequate planned activities”, it is being alleged that the facility’s planned activities are not mentally challenging nor engaging for residents in care; Furthermore, it is being alleged that there are not enough exercise options for residents in care. Interviews conducted with residents revealed the following: 8 out of 13 residents denied the allegation; 2 out of 13 residents agreed with the allegation; 3 out 13 residents did not know if alleged allegation had occurred. Interviews conducted with staff revealed the following: 5 out of 7 staff denied the allegation and 2 out of 7 staff agreed with the allegation. Records reviewed indicated the following: facility activity calendar from August 2024 to October 2024 demonstrates that the facility offers various forms of physical activities (e.g. shake it off Zumba), independent activities (e.g. painting/drawing), group activities (e.g. group karaoke), activities that are mentally challenging (e.g. brain teaser), and outings. Facility website indicates the following: the facility offers Tuesday outings to the community for example going to museums and shopping centers. Observations indicated the following: the facility has a 24-hour gym with exercise equipment and a large tv; residents can go in and exercise along with exercise videos. On 10/23/2024, CCLD staff observed a resident teaching three residents how to play poker in the activity room. Regarding the allegation, 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 is unsubstantiated. Regarding the allegation “Staff does not ensure facility is kept free of pests”, it is being alleged that the facility has pests, and the facility is doing nothing to address the issue. Interviews conducted with residents revealed the following: 8 out of 13 residents have not seen pests in the facility and 5 out 13 residents have seen pests in the facility. Interviews conducted with staff revealed the following: 5 out of 7 staff denied the allegation and 2 out of 7 staff did not know if alleged allegation had occurred. Records reviewed indicated the following: a pest control company services the facility twice a month. Observations revealed the following: on 10/23/2024, CCLD staff did not observe live pests in the facility. Regarding the allegation, 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 is unsubstantiated. No deficiencies were cited. A copy of this report was provided to Executive Director Mendy Ginsburgthe state’s words, verbatim · CDSS document, Nov 7, 2024 · control 11-AS-20241014140107

Allegation investigated: Resident sustained pressure injuries while in care Staff places double diapers on resident in care Resident in care was illegally evicted

On 10/10/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit to deliver findings for the above allegations. LPA met with Executive Director, Mendy Ginsburg, and the purpose of today’s visit was explained. During a subsequent visit on 09/13/24, LPA interviewed Staff S1, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Identification and Emergency Information form, R1’s Face Sheet, R1’s Staff Notes, Special Incident Report (SIR) for R1, Physician Admission Orders, emails, Service Receipt, Statement, Resident Assessment, and Admission Agreement. During an initial visit conducted on 12/05/23, LPA toured the facility, interviewed Staff (S1-S7), interviewed Resident (R2-R10), and received documents pertinent to the investigation. The documents received and reviewed were the Staff Roster, Resident Roster, Incontinent Resident List, Resident Admission Agreement, resident Appraisal, Needs and Service Plan, Physician’s Report, and Nurse Notes. The investigation revealed the following: Unsubstantiated Allegation: Resident sustained pressure injuries while in care The complaint allegation alleges that a resident had redness and was bleeding when being cleaned and was taken to the hospital and was treated for an open sore. During record review, LPA reviewed R1’s Physician Report, dated 10/25/23, that indicates R1 does not have a history of skin condition or breakdown. LPA received and reviewed R1’s medical records from Kaiser Permanente-West Los Angeles from R1’s Emergency Room visit on 11/02/23 that stated in the ED Notes on 11/03/23 at 0345 “Noted pt (patient) to have mild excortication on coccyx,” on 11/03/23 at 1325 “Assessed Pt buttocks no redness noted,” and on 11/04/23 at 0703 “No blood noted in brief. No skin breakdown noted.” Additionally, in the Final Emergency Department Assessment on 11/03/23 at 1222 states R1 was treated for a rash. LPA did not observe a diagnosis of a pressure injury. During interviews with Staff S1-S7, were asked how often incontinent and non-ambulatory residents are checked for pressure injuries, seven (7) out of seven (7) stated residents are checked regularly for pressure injuries, during changing, bathing, and dressing. During interviews with Residents R2-R10, were asked if they have gotten pressure wounds by not being changed or being turned, seven (7) out of nine (9) stated they have not gotten any pressure wounds. Additionally, two (2) of the nine (9) residents stated they do not require assistance with changing or turning. Allegation: Staff place double diapers on resident in care The complaint allegation alleges that a resident was placed in double diapers. During record review, LPA reviewed R1’s Physician’s Report and Staff Notes and did not observe a notation of Resident R1 being placed in double diapers. LPA received and reviewed staff training regarding care for residents who require incontinent care. During interviews with Staff S1-S7, were asked if any residents are placed in double diapers, seven (7) out of seven (7) stated they do not place residents in double diapers. S6 stated some residents like to put a pad in their diapers. Additionally, during interviews, staff were asked how often incontinent residents are assisted with changing, seven (7) out of seven (7) stated incontinent residents are changed every two (2) hours but there are a few who require additional checking and changing. During interviews with Residents R2-R10, were asked if they have been placed in a double diaper, four (4) out of nine (9) stated they have not been placed in double diapers. Additionally, five (5) out of nine (9) stated they do not require assistance with incontinent care and do it themselves. Allegation: Resident in care was illegally evicted The complaint allegation alleges that the facility could not take a resident back into the memory care unit because the unit was full, saying the family discharged the resident from the facility. During record review, LPA did not observe an eviction notice for any residents in October, November, or December 2023. LPA received and reviewed emails from 11/06/23 that stated R1 was not returning to facility and the family is requesting a refund. Additionally, LPA received and reviewed a Service Report dated 11/06/23 for R1 that indicates R1 was taken to the hospital on 11/02/23 and the Responsible Person decided not to bring R1 back to the facility. LPA received and reviewed the Statement which indicates the family was provided with a refund (check # 1318) on 11/06/23. Additionally, LPA received and reviewed medical records from Kaiser Permanente West Los Angeles Medical Center, that indicates, on page 33, the Responsible Person of R1met with the Social Worker on 11/03/23 at 4:52pm and the ED Case Management Notes states the “Responsible Person wishes to have the patient placed in a different facility…because it wasn’t a good fit for the patient.” During an interview with Staff S1, was asked if there have been any residents who have been evicted in the past 2 months, S1 stated no, there have been no evictions in the past few months. Additionally, S1 was asked if there were any residents who have left or been discharged from the facility in the past month, S1 stated R1 was transferred to the hospital and the family decided not to bring R1 back. During interviews with Residents R2-R10, were asked if they have been threatened or given an eviction notice while living in the facility, seven (7) out of nine (9) stated they have not been threatened or given an eviction notice. 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(s) did or did not occur, therefore the allegation is unsubstantiated. LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Mendy Ginsburg, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 11-AS-20231127094216

Allegation investigated: Staff did not notify authorized representative of resident's fall Staff did not seek timely medical care for resident Staff lost resident's dentures

On 10/03/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit to deliver findings for the above complaint. LPA met with Business Manager, Vanita Harris, and the purpose of today’s visit was explained. During a subsequent visit conducted on 07/18/24, Licensing Program Analysts (LPAs), Wendy Gibbs and Deborah Lee, met with Executive Director, Mendy Ginsburg and the purpose of the visit was explained. During that visit, LPA toured the facility, interviewed Staff (S5-S7), and interviewed Residents R2-R11. During LPA’s initial visit on 06/26/24, LPA Wendy Gibbs, conducted an unannounced visit to the facility. LPA met with Executive Director, Rena Hisch, and Regional Executive Director, Mendy Ginsburg, and the purpose of the visit was explained. During that visit, LPA toured the facility, interviewed Staff (S1-S4), and received documents pertinent to the investigation. The documents received and reviewed include Staff Roster, Resident Roster, Resident Physician’s Report, Needs and Service Plan, Resident Progress Notes, Admission Agreement, Safeguard of valuable, and Special Incident Reports (SIR) regarding falls and refusal (1) Unsubstantiated of additional medical care. The investigation revealed the following: Allegation: Staff did not notify authorized representative of resident’s fall The complaint allegation alleges that the resident’s responsible person was not notified of the residents fall when it occurred and was notified in an email the following day. During review of resident R1’s Progress Notes dated on 06/16/24, LPA observed R1 was found on the floor by a caregiver, 911 was called, and the POA was called. It was indicated in the Progress Notes the POA told facility staff to cancel 911. Additionally, below the note it was indicated R1’s Responsible Person was notified as well as the Primary Care Physician. The Notes indicate on 06/19/24, R1’s Responsible Person refused to sign the Refusal of 911 Service, Transport and/or Evaluation form. Additionally, during file review LPA observed on the Resident Roster, Resident Progress Notes, Admission Agreement, and Identification and Emergency Information indicates who R1’s Responsible Person is. During an interview with R1’s responsible party, stated they were not informed of R1’s fall till they came to the facility on 06/17/24. During the interview the responsible party stated they knew about the fall before the facility informed them because the facility staff called their sibling. Additionally, the responsible party stated they refused to sign the Refusal Form because they were never informed of 911 being called or canceled and they confirmed with their sibling that the facility staff did not mention anything about calling 911. (2) Continued on LIC9099-C During interviews with Staff S1-S7, were asked when a resident’s responsible party is notified of a residents fall, seven (7) out of seven (7) stated the responsible party is notified right after 911 is called. During interviews with Residents R2-R11, were asked if the facility staff notify their responsible person or family if they experience a fall, or are not feeling well, six (6) out of ten (10) stated yes, their family is notified if they have a fall or are not feeling well. Two (2) of the residents interviewed stated they have not experienced a fall or incident requiring their responsible party to be notified, and one (1) resident stated they do not report their falls to the facility staff. Allegation: Staff did not seek timely medical care for resident The complaint allegation alleges that residents responsible party denied 911. During file review, LPA observed R1’s Progress Notes dated on 06/16/24, LPA observed R1 was found on the floor by a caregiver, 911 was called, and the POA was called. It was indicated in the Progress Notes the POA told facility staff to cancel 911. Additionally, below the note it was indicated R1’s Responsible Person was notified as well as the Primary Care Physician. LPA observed in the notes that no injury was noted, R1 had no complaints of pain or discomfort, and staff conducted frequent checks. During interviews with R1’s Responsible Party, stated facility staff called their sibling, who is listed as an Other Person to be Notified In Emergency and not person indicated as the Responsible Person. Additionally, the responsible party stated they were asked to sign a Refusal of 911 Service, Transport and/or (3) Continued on LIC9099-C Evaluation form and they refused to sign the Refusal Form because they were never informed of 911 being called or canceled. R1’s Responsible Party called and confirmed with their sibling that the facility staff did not mention anything about calling 911. During interviews with Staff S1-S7, were asked when is medical personnel called or a resident transferred to the Emergency Room due to a fall, seven (7) out of seven (7) stated 911 is called when the resident is experiencing pain, has an injury, hits their head, are unresponsive, unable to get up, or depending upon the medications they are on that might cause bleeding. During interviews with Residents R2-R11, were asked if they receive medical assistance when needed, nine (9) out of ten (10) stated they receive medical assistance when needed. Allegation: Facility did not safeguard residents personal belongings/Staff lost resident’s dentures The complaint allegation alleges that the facility staff threw out a resident’s dentures. During file review LPA reviewed the Resident R1’s Client/Resident Personal Property and Valuables (LIC621) form and observed dentures listed under personal property. Additionally, LPA observed on the Physician’s Report and Needs and Service Plan indicates that R1 has dentures. On the Admission Agreement, LPA (4) Continued on LIC9099-C observed on page 16 under Your Property Right and Obligations section C. Damage to Your Property states the facility is not responsible “unless the loss or damage was caused by our negligence or that of our employees.” Additionally, in the Admission Agreement under the Shared Risk Agreement states in section E. Risk of Property Loss 1. “resident and their representatives accept and acknowledge that personal items, including but not limited to items of clothing, prescription glasses, dentures, or hearing aids, may be lost or misplaced. The Community accepts no responsibility for the loss of a resident’s personal property, unless due to the negligence of the Community or that of its employees.” The Admission Agreement was sign by R1’s Responsible Party on 04/29/22, under the statement “by signing this Shared Risk Agreement, you agree and acknowledge that the Community has informed you that it does not and cannot offer a risk-free environment…you agree to reside in the Community with full awareness and acceptance of the inherent risks at the Community.” During interviews with Residents R2-R11, were asked if they have had any items go missing while living in the facility, seven (7) out of ten (10) stated they have not had any items go missing while living at the facility. During interviews with Staff S1-S7, were asked how the facility safeguards residents personal belongings, seven (7) out of seven (7) stated they recommend residents to lock their doors to their rooms. Additionally, staff stated it is recommended to residents and responsible parties to inventory residents’ personal property, and to not bring expensive items or large sums of money to the facility. (5) Continued on LIC9099-C During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. LPA did not observe or cite any deficiencies. An exit interview was conducted with Business Manager, Vanita Harris, and a copy of this report was provided. (6)the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 11-AS-20240620162835

Allegation investigated: Staff locked resident inside their room. Staff did to meet resident's dietary needs. Staff did not allow resident to have personal food items.

On 09/27/24 Licensing Program Analyst (LPA) Elvira Gonzalez conducted a subsequent complaint investigation at the above facility to deliver findings on the allegations listed above. LPA met with Administrator Mendy Ginsburg and explained the purpose of the visit. The investigation consisted of the following: On 09/09/24, LPA received the Staff Roster, Client Roster, interviewed resident #1 (R1), and staff #1-#3 (S1-S3). Additionally, LPA and Venita Harris toured a portion of the facility, but due to time constraints were unable to finish the tour. On 09/19/24, LPA Gonzalez toured the facility, reviewed records, and received copies of R1’s Service Plan, Preplacement Appraisal Information, Physician’s Report, and Admission Agreement. Interviews conducted with residents #2-#7 (R2-R7), and staff #4-#7 (S4-S7). Furthermore, LPA and Administrator Mendy Ginsburg toured the entire facility. On 09/26/24 LPA reviewed the facility’s House Rules included in the Plan of Operation. Administrator Mendy Ginsburg provided a copy of the Residence and Care Agreement to LPA via email. Unsubstantiated The investigation revealed the following: Regarding the allegation "Staff locked resident inside their room,” it is alleged that the facilities Administrator Mendy Ginsburg asked to see a resident’s phone after observing a resident taking photos of other residents. When the resident refused giving up their phone, Mendy Ginsburg told the resident they would be confined to their room. An interview conducted with Administrator Mendy Ginsburg on 09/09/24 revealed that he saw R1 taking pictures of other residents without their consent, and that is not allowed in the facility. Mendy Ginsburg denies telling R1 that they would be confined to their room as a form of punishment but told them they would not be allowed in the dining room if they were going to take pictures of other residents without their consent and violating their privacy. An interview conducted with R1 on 09/09/24 revealed that while having dinner in the dining room, they took pictures of some residents that were eating outside food, after being told by staff that they were not allowed to bring outside food into the dining room. Mendy Ginsburg the administrator saw R1 taking pictures and asked them for their phone. R1 stated they refused to give Mendy their phone, which led to Mendy telling R1 they would be confined to their room until further notice. On 09/09/24 LPA interviewed S2-S3, and on 09/19/24 LPA interviewed R2-R7 and S4-S7. Interviews revealed the following: 6 out of 7 staff interviewed, revealed that they were not aware of any resident being confined to their room. 6 out of 7 residents interviewed revealed that they didn’t know or had heard of any resident being confined to their room. Based on observation, evidence gathered, interviews conducted, and records reviewed, there was not enough supportive evidence to concur with the reported 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 Regarding the allegation “Staff did to meet resident's dietary needs,” it is alleged that the facility does not adhere to resident’s dietary restrictions. On 09/09/24 LPA interviewed S1-S3, and R1. On 09/19/24 LPA interviewed S2-S7 and R2-R7. 7 out of 7 staff interviewed stated that the facility always follows the resident’s dietary needs. 5 out of 7 residents interviewed revealed that the facility does meet all the resident’s dietary needs. 5 out of 7 residents interviewed stated that they are very satisfied with the services and food that is being provided to them. Based on observation, evidence gathered, interviews conducted, and records reviewed, there was not enough supportive evidence to concur with the reported 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. Regarding the allegation “Staff did not allow resident to have personal food items,” it is alleged that the facility does not allow any outside food into the facility. On 09/09/24 LPA interviewed S1-S3, and on 09/19/24 LPA interviewed S4-S7. 5 out of 7 staff members interviewed indicated that the residents are allowed to bring outside food into the facility. On 09/09/24 LPA interviewed R1, and on 09/19/24 LPA interviewed R2-R7. 2 out of 7 residents interviewed stated that residents are not allowed to bring any outside food into the facility, while 5 out of 7 residents interviewed stated that they are unsure if they allowed to bring outside food into the facility. Based on observation, interviews conducted, and records reviewed, there was not enough supportive evidence to concur with the reported 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 Administrator Mendy Ginsburg, and a copy of this report along with appeal rights was provided.the state’s words, verbatim · CDSS document, Sep 27, 2024 · control 11-AS-20240906101758

Type of visit: Case Management - Other

On 09/27/24, Licensing Program Analyst (LPA) Elvira Gonzalez conducted a case management inspection visit at this facility. LPA met with Mendy Ginsburg, Administrator, and explained that the purpose of the visit is in association with a complaint investigation conducted on 09/09/24 and on 09/19/24 for complaint # 11-AS-20240906101758. During the investigation visit on 09/19/24, LPA Gonzalez observed a sign that read “No Outside Food or Drink” in the dining room while conducting a facility tour. A review of the facility’s House Rules included in the facility’s Plan of Operation, and the Resident Handbook provided by the Administrator Mendy Ginsburg does not state that residents are not allowed to bring any outside food into the facility and/or the dining room. Technical Violation – Advisory Notes(LIC 9102) issued during this visit. No Deficiencies were identified during this inspection visit. An exit interview was conducted, and a copy of this report was provided to Mendy Ginsburg.the state’s words, verbatim · CDSS document, Sep 27, 2024

Type of visit: Case Management - Annual Continuation

On 09/19/23 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent annual required visit using the CARE Inspection Tool. This visit is a continuation of the last visit LPA made on 09/09/24. LPA met with Administrator Mendy Ginsberg, and explained the purpose of today’s visit. The facility is licensed to operate for (166) non-ambulatory elderly adults of ages 60 and above. The facility is approved for (14) hospice residents. The facility is a six-story structure located in a commercial neighborhood. It consists of (21) resident bedrooms in Memory Care and (71) resident bedrooms in Assisted Living, with a bathroom in each unit. There is an activity room, a dining area, a private dining room, a kitchen, a rooftop patio, a lobby, (8) public restrooms, a gym, and a subterranean parking lot. LPA and Business Office Manager, Venita Harris toured the physical plant on 09/09/24 but due to time constraints were unable to fully inspect the entire facility. On 09/19/24, LPA and Mendy Ginsberg conducted another full inspection of the entire physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. LPA inspected the following rooms: #201, #211, #307, #303, #423, #400, #418, #516 and #514. Bathrooms were operational with water temperature measuring between 105 - 120 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Continued LIC 809-C Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Administration Records (MAR) was observed to be maintained in order and accurate. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA reviewed 7 resident files, and 7 staff files. The facility is current on Community Care Licensing (CCL) license annual dues. An exit interview conducted and a copy of report and appeal rights was provided to Mendy Ginsberg.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Required - 1 Year

On 09/09/24 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA Gonzalez met with Business Office Manager, Venita Harris and explained the purpose for the visit. Due to time constraints and technical difficulties, a hand written report was processed and provided. LPA will return at a later date to conclude the annual inspection. An exit interview was conducted, and a copy of the report was emailed to Business Office Manager Vanita Harris.the state’s words, verbatim · CDSS document, Sep 9, 2024

Allegation investigated: Staff are not following food services sanitation practices which protect the food from contamination. Residents are fed contaminated foods. Facility is not kept free of pests. Facility kitchen is not kept clean. Staff yells at residents in care.

On 08/22/2024 Licensing Program Analyst (LPA) Regina Cloyd and LPA Hollie Enriquez conducted a subsequent complaint investigation at the above facility to address the following allegation. LPA met with Executive Director Mendy Ginsburg and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPAs toured the kitchen and dining room, reviewed five staff records, and interviewed nine residents and nine staff members. Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Monday, October 09. 2023. 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 Executive Director Mendy Ginsburg. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: Interviews conducted. LPA Bunker asked questions relevant to the nature of the complaint. LPA Bunker requested copies of supporting documents. During today's visit, we toured the facility kitchen for cleanliness. Continue to LIC9099-C. Unsubstantiated We did not observe any litter, rodents, vermin, or insects. The food was protected against contamination. Staff and residents interviewed stated staff do not yell at residents in care. Due to time constraints, LPA Bunker will return at a later date to conclude the visit. There were no deficiencies cited. Exit interview conducted. Allegation(s): Staff are not following food services sanitation practices which protect the food from contamination. The investigation revealed the following: Regarding the allegation "Staff are not following food services sanitation practices which protect the food from contamination,” it is being alleged that dishes are not washed properly and cleaning supplies such as rags to clean the dishes are rotten and moldy. On 10/09/23, LPA Bunker observed that the food was protected against contamination. On 08/22/24, LPA Enriquez observed an Alsco bag for both clean and soiled rags in the kitchen. Seven (7) out of seven (7) kitchen and dining staff interviews, including the Executive Director, indicated that the soiled rags go into a designated bag and are picked up by the vendor weekly. Interview with the Executive Director also indicated that the facility has received Alsco services prior to October 2023. LPA also observed that the kitchen has a three step cleaning process and a commercial dishwash sanitizer machine. Six (6) out of nine (9) staff interviews indicated that the dishes are rinsed, slightly washed, and ran through the dishwasher. Four (4) out of nine (9) resident interviews indicated that the utensils and dishware appeared to be clean and that staff washed them. Five (5) out of nine (9) resident interviews indicated that utensil looked moderately cleaned and occasionally have some food remnants or grease on them. Regarding the allegation “Staff are not following food services sanitation practices which protect the food from contamination,” based on observation and interviews, 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. Continue to LIC9099-C. Allegation(s): Residents are fed contaminated foods. The investigation revealed the following: Regarding the allegation "Residents are fed contaminated foods,” it is being alleged that poultry such as chicken and meats are being left out for over a day and is then being fed to elders. LPA observed a deep freezer of frozen meats, thawed meats in the original packaging and in bins on the lowest rack in the refrigerator, and the designated sink for rinsing meats after thawing. Seven (7) out of nine (9) staff interviews indicated that frozen meats are thawed in the refrigerator and then moved to the sink for preparation. One (1) out of nine (9) staff members was unaware of the process but stated that she/he has never seen food left out. Six (6) out of nine (9) resident interviews indicated that the quality of food and meats are good. Two (2) out of nine (9) residents did not like the quality of food and meats but acknowledged that the meat was not spoiled or rancid. Record review reveals that two (2) Cooks, the Dining Room Manager, Culinary Director, and Kosher Director all have valid California Food Handler cards or course completion certificates. Regarding the allegation “Residents are fed contaminated foods,” based on observation, interviews, and record review, 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. Allegation(s): Facility is not kept free of pests. The investigation revealed the following: Regarding the allegation "Facility is not kept free of pests,” it is being alleged that the kitchen has a huge pest and rodent issue (roaches, rats, etc). On 10/09/23, LPA Bunker toured the facility kitchen for cleanliness and did not observe any litter, rodents, vermin, or insects. On 08/22/24, LPA Enriquez did not observe signs of rodents or vermin in the kitchen. Five (5) out of seven (7) staff interviews indicated that the facility had a rodent and/or vermin issue in October 2023. Four (4) out of seven (7) staff interviews indicated that the issue was addressed. Two staff members were unsure. Continue to LIC9099-C. Eight (8) out of nine (9) resident interviews indicated they have never seen any rodents (rats or mice) in the entire facility. Record review revealed that the facility received pest control services on 09/07/23, 09/14/23, 09/21/23, 10/05/23, 10/19/23, 11/02/23, and 11/16/23. Each work order included services in the kitchen and dining room area. Regarding the allegation “Facility is not kept free of pests,” based on observation, interviews, and record review, 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. Allegation(s): Facility kitchen is not kept clean. The investigation revealed the following: Regarding the allegation "Facility kitchen is not kept clean,” it is being alleged that the kitchen is extremely dirty. On 08/22/24, six (6) out of seven (7) staff interviews indicated that the kitchen is cleaned daily. One staff member indicated that the dining room remained cleaned. One staff member was unsure of the kitchen cleaning schedule. Interview with the Culinary Director indicated that once they finish cooking, they clean the line and the mats. At 11:30 AM, after breakfast but before lunch, LPA toured the kitchen and observed some disorganization but no sanitation issues. Regarding the allegation “facility kitchen is not kept clean,” based on 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. Continue to LIC9099-C. Allegation(s): Staff yells at residents in care. The investigation revealed the following: Regarding the allegation "Staff yells at residents in care,” it is being alleged that staff yell at residents when residents ask for certain things such as snacks or food. On 08/22/24 8:39 AM and 12:25 PM, LPA Enriquez observed three servers attending to the meal needs of the residents and one to two caregivers stationed at the entryway who assisted with activities of daily living. Eight (8) out of nine (9) staff interviews indicated they have not yelled at residents when they requested for snacks or food. Nine (9) out of nine (9) resident interviews indicated staff has never yelled at them at for anything and would receive a snack if requested. Regarding the allegation “Staff yells at residents in care,” based on observation and interviews, 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 Executive Director Mendy Ginsburg.the state’s words, verbatim · CDSS document, Aug 22, 2024 · control 11-AS-20231002144008

Allegation investigated: Illegal eviction

On 8/7/2024 Licensing Program Analyst (LPA), Troy Watson and Licensing Program Manager(LPM) Stephanie Cifuentes conducted a subsequent complaint visit regarding the allegations listed above. LPA and LPM were greeted by the Administrator Mendy Ginsburg, the purpose of the visit was explained and LPM Cifuentes and LPA Watson were allowed access to the facility grounds. The investigation consisted of the following: On 8/30/2023 LPA Pamela Bunker initiated the complaint investigation. Interviews conducted and copies of supporting documents were requested. On 8/7/2024 LPA Watson and LPM Cifuentes interviewed Mendy Ginsburg, Executive Director. LPA and LPM requested and received copies of the following documents: Residence and Care Agreements for Residents 1-Residents 4 (R1-R4), Face Sheets and Emergency Information for R1-R4, 30-day Eviction Notice for R1, Billing statement for R1 dated 8/1/2024 covering time period of 12/31/2022 to 5/1/2024, letter from R1 dated 4/3/2024 stating he would be leaving the facility. LPA Watson and LPM Cifuentes could not interview R1 as he left the facility on 4/29/2024. Continued on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Illegal Eviction It is alleged that facility served resident with an eviction notice and would not take payment. On 8/7/2024 LPM Cifuentes and LPA Watson reviewed facility records, which included a 30-day eviction notice given to R1 on 8/17/2023 for nonpayment of rent. A fax confirmation sheet shows a copy of the notice was faxed to Community Care Licensing Division(CCLD) on the same day. LPA and LPM reviewed the eviction notice and noted it complies with Title 22 regulations. LPA Watson and LPM Cifuentes also reviewed billing statement for R1 dated 8/1/2024 covering period of 12/31/2022 to 5/1/2024. Billing statement show R1 did not pay full amount of rent for several months which led to receiving an eviction notice. Statement also shows that payment was taken for month of August and posted to R1’s account. On 8/7/2024 LPA Watson and LPM Stephanie Cifuentes interviewed Administrator Mendy Ginsburg regarding the allegation. Administrator Ginsburg stated R1 was issued an eviction notice for failure to pay rent, notice was sent to CCLD and Title 22 regulations were followed. Administrator Ginsburg added that R1 quickly paid past due amount and eviction was rescinded. Based on the information gathered, interviews conducted, and an analysis of records reviewed, 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. An exit interview was conducted with Mendy Ginsburg, and a hard copy was provided.the state’s words, verbatim · CDSS document, Aug 7, 2024 · control 11-AS-20230821154629

Allegation investigated: Staff serve food of poor quality.

On 07/03/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation. LPA met with Administrator Rena Hirsch and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA toured the kitchen, dining room, and storage space, reviewed records, and interviewed (10) residents and (10) staff members. The investigation revealed the following: Regarding the allegation "Staff serve food of poor quality,” it is being alleged that staff serve cold food. LPA observed dish warmers to keep the food warm. Four (4) out of six (6) staff members, including the Administrator, indicated that food warmers are used to keep the dishes warm. Plus, the Cook indicated that the facility avoided serving hot meals while the kitchen was being remodeled. Seven (7) out of ten (10) residents indicated that the food is served warm and that staff is willing to reheat it when requested. Continue to LIC9099-C. Unsubstantiated It is also being alleged that the facility sometimes run out of nonperishables for breakfast. Record review revealed that the facility serves hot and cold cereal in addition to oatmeal, waffles/muffins, and eggs. Six (6) out of eight (8) residents indicated that alternative nonperishables are provided for breakfast. Seven (7) out of eight (8) staff members, including the Administrator, indicated that alternative nonperishables are provided for breakfast if the facility runs out of one nonperishables. It is also being alleged that the Licensee will not serve a particular type of protein. Record review reveals that the facility serves a variety of protein options. Interview with the Administrator indicated that the facility will order (cater out) other protein options to accommodate residents with special requests. Finally, it is being alleged that the facility uses paper plates, plastic forks, and paper napkins. LPA observed metal silverware and cloth napkins in the dining hall. Staff and residents indicated that plasticware was only used while the kitchen was being remodeled. Regarding the allegation “Staff serve food of poor quality,” based on observation, record review, and interviews, 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 Administrator Rena Hirsch.the state’s words, verbatim · CDSS document, Jul 3, 2024 · control 11-AS-20240628091240

Type of visit: Case Management - Other

On 6/12/2024, Licensing Program Analyst LPA Alfonso Iniguez conducted a Case Management visit to follow up on the incident between (R#1 and R#2) reported to the Regional Office on 6/10/24. LPA was greeted by Marcia McKay, Wellness Director, who explained that the purpose of the visit was to gather records. On 6/10/24, the regional office received a phone call from the facility and reported that, approximately at 5:30 AM on 6/10/24, (S#1) walked into the activity room and saw (R#1) engaging in inappropriate activity with (R#2). (S#1) promptly intervened and separated the two residents. The following documents were provided to LPA Iniguez during the visit: *Copy of SRI dated 6/10/24. *Copy of Staff Schedule for June 2024. *Copy of Resident Roster. *Copies of staff timecards dated 6/9/24 and 6/10/24. *Copies of (R#1) and (R#2) complete file (admissions agreement, wellness assessment, LIC 602A, admissions orders, consent forms, LIC 603A, LIC 601, advance directives, Identification cards, LIC 613-C). Missing Items: *A copy of the video footage will be retrieved by the department by a later day. 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 Marcia McKay / Wellness Director.the state’s words, verbatim · CDSS document, Jun 12, 2024

Allegation investigated: Licensee does not assist resident with arranging medical care.

On 05/16/24, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to this facility and was greeted by Regional Executive Director Mendy Ginsberg (ED #1). LPA explained the purpose for today’s visit is to gather information for the allegation mentioned above. The investigation consisted of the following: An initial 10-Day visit was conducted by (LPA) Ernand Dabuet who met with Regional Executive Director Mendy Ginsberg. (LPA) requested copies of files for resident #1 (R1’s) ID and Emergency Information (dated: 05/16/24) Residence and Care Agreement (dated: 08/03/23), Physicians Report LIC 602A (dated: 08/11/23), Preplacement Appraisal Information LIC 603 (dated: 09/22/23), Medication Review Report (dated: 05/16/24), Release of Resident Medical Informaiton LIC 605 (dated: 09/15/23, Consent for Emergency Medical Treatment (dated: 09/22/23), Facility Resident Roster (dated: 05/16/24) and Personnel Report LIC 500 (dated: 05/13/24). Interview conducted with residents #1-#10 (R1-R10), Wellness Director staff #1 (S1), and Regional Executive Director (ED#1). (Evaluation Report continues LIC 9099-C) Unsubstantiated (ED1-S1) claimed the facility was always in assistance to assist with (R1)’s medical care. (ED1) denied ever communicating to (R1) that the facility was in the process of transferring (R1) to another facility once the insurance matter was resolved. On 05/16/24, between 10:44 am – 11:55 am, the Department interviewed (9) out of (9) residents #2 - #10 (R2-R10) who were complimentary of staff. (R2-R10) expressed the staff is responsive and attentive in assisting with medical care appointments. (R2-R10) indicated they are truly happy living at the facility and the services the care staff provided. As a result of the Department reviewing (R1)'s Physician Report LIC 602A (dated: 08/11/23) and Pre-Preplacement Appraisal Information LIC 603A (dated: 09/22/23) it was discovered that (R1) is in good physical status, can self-care, and is in a safe mental state. Based on the information gathered, there is no sufficient 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 allegation mentioned in this complaint. 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 is conducted with Mendy Ginsberg and a copy of the report is provided. INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Licensee does not assist resident with arranging medical care. The details of the complaint alleged that facility staff failed to assist resident #1 (R1) in arranging an appointment to see a medical doctor for posterior capsule opacification. The complainant claimed the licensee stated that the facility cannot meet (R1)’s needs and is waiting for insurance to be handled and that (R1) will be transferred to another facility. The complainant did not provide further details on the matter. According to resident #1 (R1)’s Residence and Care Agreement (dated: 08/03/23), (R1) was admitted at City View on 09/22/23. On 05/16/24, between 01:23 pm – 01:37 pm, the Department interviewed resident #1 (R1). (R1) who is currently not at the facility was interviewed by telephone. (R1) claimed that facility staff did not refuse to assist (R1) in making the medical appointment, it was the process that was frustrating in getting an appointment. (R1) confirmed that (R1) was with a Health Maintenance Organization (HMO) insurance carrier and that (R1)'s preferred medical doctor was not a participant in the HMO contract. (R1) understood that (R1) required to change medical insurance carrier to be seen by (R1)’s preferred physician and that it indeed has taken a long process. Otherwise, (R1) claimed that everything is satisfactory with the facility staff at City View. (R1) stated that this matter has been resolved. On 05/16/24, between 10:29 am – 12:10 pm, the Department interviewed Regional Executive Director #1 (ED1) and Wellness Director Staff #1 (S1). (ED1 and S1) both denied this allegation. A few months ago, (R1) approached (S1) about making a medical appointment for posterior capsule opacification for (R1). (R1) enrolled in CareMore Medical Group (HMO) when (R1) was admitted at City View was signed to this medical plan by a CareMore representative in September 2022. The result of signing with CareMore (HMO), (R1)’s primary care physician is not a participant provider in this plan. (R1) preferred (R1)'s primary physician and that meant having to terminate with CareMore (HMO) and enroll with California Medicaid Health Program to have access to (R1)’s preferred primary medical physician. (S1) reported that (R1) did not understand the process and wanted the issue to be resolved instantly. (S1) explained that there is a process. (S1) claimed effective 04/30/24, (R1) terminated medical insurance coverage with CareMore (HMO), and effective 05/01/24, (R1) was enrolled with California Medicaid Health Program. (Evaluation Report continues LIC9099-C)the state’s words, verbatim · CDSS document, May 16, 2024 · control 11-AS-20240507154250

Allegation investigated: Resident sustained a fracture while in care. Facility did not seek resident timely medical attention

On 04/25/024 Licensing program analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit to render investigation finding. LPA met with Executive Director Mendy Ginsburg as the purpose of today’s visit was explained. The investigation consisted of the following: On 08/02/2022 Licensing Program Analyst (LPA) Antonia Alvizar initiated a complaint investigation for the allegation listed above. LPA Alvizar obtained copies of the roster for resident roster, Needs and Services Plan, Physician Report, Admission Agreement, Incident Report, Hospice Notes, Case Notes, Medication Logs, Emergency and Identification Information for residents #1-#3(R1-R3). LPA also obtained a copy of staff Personnel Records, Trainings, Staff write-up's and Employment Application for staff #1-#3 (S1-S3). LPA reviewed and obtained facility documentation pertinent to the allegations. On 08/01/2022 the case was referred to California Department of Social Services (CDSS) Investigations Branch, the case was assigned to IB Investigator Douglas Real. On 09/21/2022 investigator Douglas Real interviewed Resident #1-3 (R1-R3), and staff #1-4 (S1-S4). On 08/04/23 Licensing program Substantiated analyst (LPA) Lizeth Villegas conducted a subsequent visit regarding the above allegation. LPA met with Executive director Mendy Ginsburg. LPA Villegas obtained copies R1's complete file, S1's employee file, S1's training verification, menus for the month of June, July and August 2022, a copy of Food handlers’ certificate, and a list of all incontinent residents and Incontinence Care Procedures. On 08/04/23 LPA Villegas interviewed Residents # 2-8 (R2-R8), Executive Director (ED), and staff #2-5 (S2-S5). On 03/22/24 LPA Villegas interviewed support staff #1-3 (SS1-SS3). On 04/25/24 LPA Villegas interviewed R9-R12. Allegation: Resident sustained a fracture while in care It is alleged on 7/28/2022, Caregiver #1 assisted Resident #1 with transferring from R1 wheelchair to the toilet so that R1 could use the restroom. Once CG1 placed R1 on the toilet R1 fell forward which resulted in R1 sustaining bruising and a fracture. As apart of the investigation IB investigator conducted a review of R1 file which revealed R1 was admitted to the facility on 6/6/2022 and was admitted in the memory care unit based on R1 medical diagnosis. According to R1 Physicians Report dated 5/21/2022 indicates R1 required full assistance with toileting. Review of R1 Wellness Assessment dated 6/5/2022 revealed R1 required weight bearing assistance with to get in and out of bed, chair, car and etc. The file review also revealed R1 was a fall risk due to R1 falls that occurred prior to R1 admission to the facility. On 09/21/2022, IB investigator interviewed Caregiver #1-#4 (CG1-4) regarding the allegation and 1 of 4 caregivers interviewed denied working the day of the incident and denied witnessing the incident; 3 of 4 caregivers interviewed Were working during the incident and confirmed being aware R1 had an incident in the bathroom. 3 of 4 caregivers interviewed stated they usually use 2 caregivers to transfer and assist residents that could not assist with the transfers from Wheelchair, bed or toilet. CG #1 was interviewed and stated CG1 witness the incident and stated she took R1 to use the toilet by herself because the other Caregiver was assisting another resident and R1 requested to use the restroom. CG1 stated she transferred R1 from wheelchair to the toilet and when CG1 attempted to assist R1 with R1 pants the resident leaned forward to get toilet paper and fell into the wall. CG1 asked R1 if R1 was ok and R1 replied yes and CG1 took R1 to the bed. Allegation: Facility staff failed to seek timely medical attention. It is alleged on 7/28/2022, Caregiver #1 assisted Resident #1 with transferring from R1 wheelchair to the toilet so that R1 could use the restroom. Once CG1 placed R1 on the toilet R1 fell forward which resulted in R1 hitting R1 head and falling. CG1 did not seek any medical attention with the knowledge R1 had hit R1 head and had an injury to the face. As apart of the investigation IB investigator conducted a review of R1 file which revealed R1 was admitted to the facility on 6/6/2022 and was admitted in the memory care unit based on R1 medical diagnosis of Dementia. According to R1 Physicians Report dated 5/21/2022 indicates R1 required full assistance with toileting. Review of R1 Wellness Assessment dated 6/5/2022 revealed R1 required weight bearing assistance with to get in and out of bed, chair, car and etc. The file review also revealed R1 was a fall risk due to R1 falls that occurred prior to R1 admission to the facility. On 09/21/2022, IB investigator interviewed Caregiver #1-#4 (CG1-4) regarding the allegation and 1 of 4 caregivers interviewed denied working the day of the incident and denied witnessing the incident; 3 of 4 caregivers interviewed Were working during the incident and confirmed being aware R1 had an incident in the bathroom. 3 of 4 caregivers interviewed stated they usually use 2 caregivers to transfer and assist residents that could not assist with the transfers from Wheelchair, bed or toilet. CG #1 was interviewed and stated CG1 witness the incident and stated she took R1 to use the toilet by herself because the other Caregiver was assisting another resident and R1 requested to use the restroom. CG1 stated she transferred R1 from wheelchair to the toilet and when CG1 attempted to assist R1 with R1 pants the resident leaned forward to get toilet paper and fell into the wall. CG1 asked R1 if R1 was ok and R1 replied yes and CG1 took R1 to the bed. IB investigator interviewed Witness #1 (W1) and W1 stated when W1 arrived to the facility during dinner on 7/29/2022 W1 asked staff to take R1 to the emergency room due to severe bruising to the face. Based on interviews conducted and records reviewed staff failed to ensure R1 received timely medical attention after a fall in which R1 hit R1 and the next day once bruising became more prominent staff still did not seek medical attention until urged to do so by R1 responsible party. Based on Investigators interviews which were conducted with Program Manager, residents, staff and records review, 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) and Chapter (8) are being cited on the attached LIC9099-D. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” Civil Penalties Assessed in the amount of 500 dollars. Exit interview conducted, appeal rights were discussed, and a copy of this report was provided. complete file, S1's employee file, S1's training verification, menus for the month of June, July and August 2022, a copy of Food handlers’ certificate, and a list of all incontinent residents and Incontinence Care Procedures. On 08/04/23 LPA Villegas interviewed Residents # 2-8 (R2-R8), Executive Director (ED), and staff #2-5 (S2-S5). On 03/22/24 LPA Villegas interviewed support staff #1-3 (SS1-SS3). On 04/25/24 LPA Villegas interviewed R9-R12. Allegation: Food is not of good quality It is alleged that the food being served at the facility is not of good quality. On 08/04/23 LPA Villegas interviewed ED regarding the above allegation, Ed denied the allegation above. Per ED the facility serves different types of food daily, the menu is reviewed by dietician monthly and dietary meetings are held once a month. On 08/04/23 LPA Villegas interviewed S2-S5 regarding the above allegation, 3 of 4 staff interviewed denied the allegation above. 1 of 4 staff interviewed reported being unaware of kitchen protocols. On 08/04/23 interviewed Residents # 2-8 (R2-R8) regarding the above allegation, 7 of 7 residents interviewed denied the allegation above and reported they are accommodated with food substitutions when needed. LPA was unable to interview R1 as R1 is no longer receiving care at the facility. Allegation: Facility staff failed to meet resident incontinence needs It is being alleged that staff leave residents in soiled diapers. On 08/04/23 LPA Villegas interviewed ED regarding the above allegation, ED denied the allegation above and stated residents are being checked on every 2 hours. Per ED the number of times residents are being changed depends on their level of care. On 08/04/23 LPA Villegas interviewed S2-S5 regarding the above allegation, 4 of 4 staff interviewed reported residents are changes multiple times a day. 08/04/23 interviewed Residents # 2-8 (R2-R8) regarding the above allegation, 7 of 7 residents interviewed reporting not requiring assistance with incontinence needs. On 04/25/24 LPA Villegas interviewed R9-R12, 4 of 4 residents interviewed reported staff are assisting with incontinence needs every 2 hours. 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, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 11-AS-20220801112329

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2 · Plan of correction due date: Apr 26, 2024

Additional Personal Rights of Residents in All Facilities … Residents in All Facilities…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff... This requirement is not met as evidence by: Based on interviews conducted and records reviewed as a part of the investigation the facility staff failed to properly supervise a resident who was at risk for falls to prevent injuries which resulted in the resident sustaining a fracture to the right arn and bruising to face.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Licensee shall ensure all staff that provide direct care receive training from an appropriate profession in Care for Persons with Dementia, Emergency Procedures and Personal Rights of Residents. Licensee shall submit the plan for the trainings and submit sign in sheets to LPA once trainings are completed. AN IMMEDIATE 500 CIVIL PENALTY IS ASSESSED.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Apr 26, 2024

Observation of the Resident-The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation... This requirement is not met as evidence by: Based on interviews and records review staff observed R1 had head injuries and bruising after a fall and failed to immediately ensure R1 received medical attention timely. This is an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Licensee will shall submit a plan to the department of the steps the Licensee will take to ensure all residents receive timely medial attention to LPA by POC due date. Licensee shall ensure all staff receive training in emergency procedures and submit sign in sheet by POC due date.

Allegation investigated: Staff spoke inappropriately to a resident

On 11/15/23, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Director, Mendy Ginsburg, and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility. The investigation consisted of the following: On 10/18/23 LPA reviewed resident files and toured the facility. LPA reviewed and requested copies of the following records: Client Roster, Staff Roster, resident files and admissions agreements. The investigation revealed the following: Cont'd 9099-C Unsubstantiated Allegation: Staff spoke inappropriately to a resident On 10/18/23 LPA conducted interviews with both staff and residents. LPA Shirley reviewed facility files. During file review, found there to be no evidence of harassment, nor write ups for mistreatment of clients in care. LPA interviewed all staff, staff 1 – staff 8 (S-1 – S-8). LPA asked if staff speak to residents inappropriately. Of those interviewed 8 out of 8 stated no. LPA interviewed residents 1 – resident 8 (R-1 – R-8). LPA asked residents, if staff yelled at them or spoke to them inappropriately. Of those interviewed, 7 out of 8 answered, No. Based on information gathered, the department did not find sufficient evidence to support allegations "Staff spoke inappropriately to a resident.” 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 LIC 9099 was provided to Director Mendy Ginsburg.the state’s words, verbatim · CDSS document, Nov 15, 2023 · control 11-AS-20231012154658