Cottages at the Colony of Sherman Oaks #4

Allegation investigated: Staff speak inappropriately to a resident in care Staff do not treat a resident with respect

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent visit to deliver findings for the above allegations. The LPA arrived at 3:14PM and met with Administrator Anna Lee. Entrance interview conducted. On 06/03/2026, LPA Huynh conducted an initial complaint visit. Between 2:01PM and 4PM, the LPA conducted a physical plant tour and interviewed four (4) residents, two (2) staff, and the Administrator. Records were provided via email on 06/04/2026. During today’s visit, the LPA and Staff toured the physical plant at 3:17PM, and no immediate concerns were observed. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegations: “Staff speak inappropriately to a resident in care” and “Staff do not treat a resident with respect” It was reported that Staff #1 (S1), Staff #2 (S2), and the Administrator spoke inappropriately and did not treat Resident #1 (R1) with respect. R1 described S1 as “rude” and “obnoxious,” stating that S1 would often badger R1 after they asked simple questions. R1 did not provide information regarding S2’s conduct and reported that the Administrator was very helpful in resolving concerns. R1 stated that they could no longer tolerate the treatment they received and requested relocation. They further disclosed that they also had conflict with other residents and their families. R1 expressed satisfaction with the facility they were relocated to and stated that the two (2) facilities “were like night and day.” Interview with S1, S2, and other residents revealed that R1 was frequently disruptive, initiated arguments with staff and residents, and was not satisfied with the accommodations made. Staff reported responding to R1’s behavior by remaining calm and explaining the facility’s rules and expectations, which R1 refused to accept. When staff needed assistance in managing resident behaviors, they communicated with the Administrator for guidance. Residents did not have concerns regarding staff conduct or level of service provided. They stated that S1 and S2 go above and beyond to ensure residents’ needs are met and remain respectful. Residents acknowledged that R1 frequently caused trouble with staff over minor issues and often complained; however, the residents did not agree with R1’s claims. The residents additionally did not observe S1 or S2 act maliciously or treat R1 with disrespect. The Administrator expressed no concerns regarding staff performance and was confident in staff’s ability to handle all situations appropriately. For more difficult situations, staff maintained open communication with the Administrator and utilized them as a resource. The Administrator stated that due to R1’s mental diagnoses, their perception of reality was severely affected, and R1 frequently attempted to manipulate staff into bending policies for their benefit. Report Continued on LIC 9099-C Due to R1’s frequent complaints, the Administrator relocated S1 and S2 to another facility to mitigate ongoing issues. R1 continued to complain about the replacement staff because they did not operate the same way S1 and S2 did. R1 was ultimately relocated to another facility operated by the same Licensee and Administrator, where it was reported that R1 was doing well and happier. Physician’s Report dated 05/31/2026 documented diagnoses for R1 including schizophrenia, depression, bipolar disorder, and anxiety. Psychiatric visit summaries indicated R1 saw their psychiatrist once a month and experienced “persistent paranoia, anxiety, and inconsistent reporting of incidents involving facility staff.” R1’s paranoid behavior was worsening, and medications were adjusted or discontinued accordingly. Staff were to monitor R1 and maintain a calm, structured environment. Based on interviews and record review, although the allegations may have happened or are valid, there is insufficient evidence to prove the violations did or did not occur; therefore, the allegations are deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 29-AS-20260602080806

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 10:30AM. The LPA met with the Administrator Anna Lee and informed them of the reason for the visit. Entrance interview conducted. Beginning at 11:08AM, the LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The following was observed: OUTDOOR AREA: The rear yard had a shaded patio area equipped with furniture in good condition for resident and visitor use. Exits and passageways were free of obstruction. There were two (2) emergency side exits with a self-latching gate. There was a shed that contained storage and emergency water. The facility had a secured garage that was converted into two (2) staff rooms and had general storage and laundry machines in operating condition. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. A fireplace was observed in the living room that was screened and inoperable. Required postings were observed in the entryway. The facility maintained a comfortable temperature throughout the visit and nightlights were observed throughout the hallways. Report Continued on LIC 809-C KITCHEN: The LPA observed knives stored inaccessible in the kitchen. Kitchen appliances were clean and in operable condition. The facility had a sufficient supply of perishable and non-perishable food. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. Emergency food was stored in the pantry with a secured medication closet nearby. BEDROOMS/RESTROOMS: There were seven (7) total bedrooms: six (6) private resident rooms and one (1) secured staff room. The facility was approved for one (1) bedridden resident in Bedroom #5. Bedroom #6 had a direct exit to the outside. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in the hallway cabinet. There were three (3) total restrooms in the facility: one (1) private and two (2) shared. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured between 107.6 degrees F and 110.7 degrees F which is within the required range per regulation. RECORDS: Record review began at 11:29AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Fire extinguishers were observed and last serviced on 10/07/2025. Emergency disaster drills are conducted quarterly, with the last documented drill on 03/02/2026. Smoke and carbon monoxide detectors were tested at 11:56AM and were operational. Report Continued on LIC 809-C MEDICATIONS: Medication review began at 11:59AM. Medications were centrally stored and kept inaccessible in a closet. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates and were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Mar 10, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 02/25/2025. Upon arrival, the LPA was greeted by staff who then contacted the Administrator, Anna D. Lee telephonically. The Administrator arrived at approximately 10:22 a.m., and at this time, the reason for the visit was explained. Entrance interview. During today’s visit, at 10:24 a.m., the LPA along with the Administrator toured the physical plant areas to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: The LPA inspected the kitchen area at 10:28 a.m. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed furniture in the common areas to be in good condition. The facility maintained a comfortable temperature. The LPA observed required postings by the main entrance. There is a fireplace in the living room; adequately screened. The LPA observed six (6) resident bedrooms, which were furnished appropriately and had sufficient lighting. The LPA observed two (2) resident restrooms, which were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The LPA observed cameras in the common areas and outside perimeter. All indoor and outdoor passageways were free from obstructions in case of an emergency. No bodies of water noted at the time of the visit. Report Continued on LIC 809C... Report Continued from LIC 809... Records: Records review began at approximately 10:35 a.m. Five (5) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current appraisal. All resident files were in order. Three (3) personnel records including the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Files were complete. Administrator’s Certificate is active until 01/11/2027. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. Documents were observed to be reviewed and updated annually as required. The facility’s policies and procedures as it pertains to infection control are adequate. Fire extinguisher was observed to be fully charged and serviced on 10/08/2024. Emergency disaster drills are conducted quarterly; last drill was conducted on 03/03/2025. Medications: Medications review began at approximately 11:55 a.m. Medications are centrally stored in a locked cabinet adjacent to the kitchen. Medications appeared to be given as prescribed. Exit interview conducted. No citations issued. Report was reviewed and a copy was issued.the state’s words, verbatim · CDSS document, Apr 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff, Claudette Marasigan and explained the reason for the visit. Entrance interview conducted. Starting at 11:20AM, the LPA along with Staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Facility is a single-story residence that consists of six (6) resident bedrooms, three (3) staff rooms, and three (3) restrooms. The LPA observed one (1) fire extinguisher which was fully charged and last serviced 10/08/2024. The smoke alarms and carbon monoxide detectors were tested and functioned properly at the time of the visit. There is a fire door by the main hallway leading into the resident bedrooms. Facility has an adequate amount of emergency food and water; properly stored. The LPA observed all required postings in the hallway near the entrance area. The auditory alarms on the exit doors were tested and functioned properly at the time of visit. KITCHEN: The LPA inspected the kitchen/food service area at 11:40AM. Knives and sharps were observed locked and inaccessible in a kitchen drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 11:41AM, the hot water temperature was measured in the kitchen sink, and it measured at 106.5 degrees Fahrenheit. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The fireplace was adequately screened at the time of the visit. There is a working telephone on premises. Report Continued on LIC 809C... Report Continued from LIC 809... The LPA observed a complete first-aid kit and manual. Cameras observed in the common areas. No obstructions or hazards were observed inside or out. RESTROOMS: The LPA observed all resident bathrooms. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 11:26AM, the hot water temperature was measured in resident bathrooms, and they measured within the required range at the time of the visit. Proper hand washing signs were observed posted inside bathrooms. BEDROOMS: There are six (6) bedrooms for resident use. All bedrooms are designated as private rooms. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a closet by the hallway with additional clean linens and towels for resident use. LAUNDRY ROOM: The laundry room, which includes a washer and a dryer were observed locked and inaccessible to residents at the time of the visit. Detergents and cleaning solutions were observed in a locked closet inside the laundry room inaccessible to residents in care. BACKYARD: The backyard has a covered patio area with patio furniture for resident use. The LPA observed a shed for storage purposes. All passageways were observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms and auditory alarms. Cameras were observed in the outside perimeter. No bodies of water noted at the time of the visit. INTERVIEWS: The LPA conducted three (3) resident interviews during the inspection. No concerns were noted. MEDICATIONS: Medications are centrally stored in a locked cabinet adjacent to the kitchen. The LPA will review medications at a later date. FILE REVIEW: The LPA will review facility files at a later date. Due to time constraints an LPA will return to complete the annual at a later date. No citations issued. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 25, 2025

Allegation investigated: Staff took inappropriate pictures of resident's body.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver findings for the allegation listed above. LPA met with Administrator Anna Lee and explained the reason for the visit. On 05/02/2024, the Department received a complaint regarding staff taking inappropriate pictures of Resident #1’s (R1) body. The complaint was referred to Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Heidy Bendana. On 05/03/2024, from 9:55am to 11:45am, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the allegation listed above. LPA Urena met with administrator Anna Lee and explained the reason for the visit. At 10:05am, the LPA interviewed the administrator, and at 10:30am the LPA requested and reviewed records pertinent to the complaint. The LPA advised the administrator that the case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Heidy Bendana. Continues on LIC 9099C... Unsubstantiated Pg. 2 On 05/08/2024, from approximately 9:38am to 10:23am, Investigator Bendana conducted interviews with R1, the administrator and facility field supervisor (S1). In addition, the Investigator reviewed photographs and facility file documents related to R1. A review of the Home Health Certification & Plan of Care for R1 listed the start date as 01/21/2023. Diagnosis included zoster (shingles), heart failure and chronic pain. R1 is a fall risk with limited ambulation. R1 is forgetful at times, needs prompting under stressful or unfamiliar conditions. R1’s Physician’s Report, dated 11/06/2023, lists the primary diagnosis as mild cognitive disorder and cerebral infraction with sequelae. R1 is listed to be confused/disoriented at times, depressed but can follow instructions. R1 requires assistance with Activities of Daily Living (ADLs) and is non-ambulatory. The Resident Appraisal for R1, dated 01/12/2024, documents R1 uses a walker and requires assistance and supervision during ambulation. R1 has periods of forgetfulness and confusion, has no interest in social activities, and is in bed most of the time. A review of the Photo/Video Consent & Release document revealed that the photographs are not made part of the resident record. Photographs are periodically taken for internal or safety purposes, such as to be shared with medical personnel. Text printouts were reviewed, dated 03/12/2024 at 1:21pm, the administrator texted R1’s resident representative regarding photo and video consent forms. The administrator explained skin checks are done weekly and photos are used to document no skin issue. The form was signed 04/03/2024 by R1’s resident representative. During the investigation, the administrator provided a printout of R1’s photographs taken. On 05/06/2024, at approximately 3:34pm hours, S1 conducted a skin check on R1. The skin check consisted of vitals. It is noted R1 had on and off pain in their legs and back. No skin breakdown noticed. Photographs of heel, feet, and bottom of both feet were taken. On 01/18/2024, at approximately 9:38am, S1 conducted a skin check on R1. The photographs are of R1’s torso and chest area affected by shingles. R1 is lifting R1’s top, nipples are not visible, R1’s face is not visible. Photograph is focused on the affected area. Continues on LIC 9099 C...pg. 3 Pg. 3 The investigation further revealed, on 05/02/2024, at 3:11pm, the Los Angeles Police Department, Van Nuys Patrol Division officers responded to the facility due to a phone call from R1. A card was left indicating a report only was taken by law enforcement. Based on the information obtained during the investigation, R1 stated they were not touched inappropriately by facility staff. R1 stated S1 conducts skin checks weekly to check for bed sores. Interviews and documents show skin checks are conducted weekly by S1. S1 asks and informs residents about photographs taken to document bed sores, shingles, or redness. The photographs taken were not sexual in nature. During the interview, R1 showed signs of confusion. Nevertheless, R1 felt safe in the facility. R1 disclosed they had previously refused photographs to be taken and S1 respected R1’s request. Documentation provided by the administrator, included a signed consent for photographs; signed by R1’s resident representative. Based on the information obtained and statements made, the Department did not find sufficient evidence to support the allegation that staff took inappropriate pictures of R1’s body. Therefore, the allegation “staff took inappropriate pictures of resident's body” is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Jun 10, 2024 · control 29-AS-20240502114023

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Emily Peraldi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. At 12:30 p.m., the LPAs met with the Administrators, Anna Bernice D Lee and Claudette Marasigan and explained the reason for the visit. Entrance interview. At 12:45 p.m., the LPA along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. The facility is a single-story residential home with nine (9) bedrooms, six (6) for resident use and three (3) for staff use, two (2) of which are inside the ADU and three (3) bathrooms. The LPAs observed the Accessory Dwelling Unit (ADU) that was previously the garage. The Administrator stated that the ADU will not be for resident use. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. LPA observed a two (2) hallway closet with extra towels and linens for resident use. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Starting at 12:56 p.m., the hot water temperature was measured in bathrooms, and measured between 108.5 and 110.4 degrees Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. KITCHEN: The LPAs observed the kitchen and dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food labels were observed for expiration dates. At 12:49 p.m., the kitchen water temperature was measured at 111.7 degrees Fahrenheit. Medications are located in a locked cabinet adjacent to the kitchen. A first aid kit is located near the kitchen. Continued on LIC-809-C. OUTDOOR SPACE: At 12:46 p.m., the LPA observed the back patio which has a covered outdoor area with a table and chairs for resident use. There are two gates on each side of the house designated for an emergency exits. The property is gated. Passageways were free and clear from obstruction. There are no bodies of water on the premises. COMMON AREAS: The LPAs observed common areas to be relatively clean and properly furnished. The LPAs observed the fire extinguisher to be fully charged and last serviced on 10/12/2023. At 1:03 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. All exits have functioning auditory devices and were operational at the time of the visit. Facility telephone was observed during the time of the visit. LPAs observed cameras in the common areas, and throughout the exterior perimeter of the facility. Night lights were present in the hallways. Laundry units are located inside the laundry room. Cleaning solutions, chemicals and hazardous items were inaccessible and locked away inside a locked closet near the laundry area. RECORD REVIEWS: Starting at 12:35 p.m., the LPAs conducted a file review for all residents and staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All files were in order. The Administrator’s certificate is active and expires on 01/11/2025. The LPAs requested a copy of valid liability insurance and Facility Emergency Plan and Infection Control Plan. The last emergency disaster drill took place on 03/01/2024. At approximately 1:50 p.m., the LPAs conducted a review of medication and medication documentation with staff for six (6) residents. Three (3) out of three (3) residents with PRN medications did not have the PRN authorization form on file. At 2:05 p.m., the Administrator printed out the PRN authorization forms for the three (3) residents. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 9, 2024