Encino Terrace Senior Living

Allegation investigated: Facility kitchen is in disrepair

Licensing program analyst (LPA) Tihesha Smith made an unannounced 10-day complaint visit to this facility to investigate the above allegations. LPA met with executive director and disclosed the reason for the visit. Facility kitchen is in disrepair It was alleged that the facility kitchen has ongoing leaks. To investigate the allegation LPA Smith interviewed the executive director at 9:38 am, requested documents relevant to the investigation at 9:45 am, conducted a tour of the facility to include but not limited the facility and common areas at approximately10:35 am and interviewed four (4) residents at approximately 10:30 am. Interview with the executive director revealed no issues with the facility kitchen and LPA Smith observed the facility kitchen to be clean and in good condition at the time of visit with dry floors and no leaks observed. Unsubstantiated (Cont from 9099) Based on observation and interview there is not enough information to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time No hazards observed in common areas at time of visit Exit interview conducted/copy of report giventhe state’s words, verbatim · CDSS document, Aug 24, 2026 · control 31-AS-20260821081655

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

Type of visit: Case Management - Other

This case management visit was conducted by LPM Naira Margaryan and LPA Nicholas Reed to discuss the citations previously issued to the facility during licensing visit conducted on 04/08/26. Initially on 02/26/2026, LPM Margaryan and LPA Smith visited the facility and conducted complete inspection of the entire facility. LPM and LPA noted that the facility is operating in substantial noncompliance of Title 22 Regulations. Some of the noted deficiencies were addressed as a part of complaint investigations. Other issues and concerns were addressed under the Case Management visit. LPM Margaryan and LPA Smith had extensive discussions about noted issues and concerns with the Licensee and VP of operation, who arrived to the facility few hours later. Licensing representatives were notified that noted issues required immediate attention and corrections. The topics of discussion included but not limited to the following deficiencies: 1. The facility did not have sufficient support staff and sufficient number of qualified personnel to assist residents. 2.The facility’s Emergency Plan of Operation was reviewed, and it was noted that the plan does not address how the facility personnel will assist non-ambulatory residents to bring them down from the upper floors. Non-ambulatory residents were observed on the 2nd and 3rd floor, and it was not clear how staff would assist them during an emergency. 3. Residents’ records were incomplete and/or outdated. 4. Physician reports and other records were not updated as required. Licensee indicated that all noted issues will be addressed, and written documentation will be submitted to Licensing Office informing how the Licensee will correct noted deficiencies. Licensee was advised that no deficiencies will be cited during the visit with expectations that noted issues will be corrected as soon as possible. Between 02/26/26 and 04/08/26 LPA Smith made numerous Licensing Visit to the facility, and no documentation was provided to the LPA explaining the steps that facility is taking to correct noted issues and bring facility to compliance. · No updated emergency plan has been submitted to the Licensing office for review and approval. · No documentation was submitted to explain how the facility is addressing staffing shortage. · No written notification was provided to the Licensing office verifying that all resident records had been updated and corrected. Due to failure to submitting required documents, on 04/08/2026, LPA Smith visited the facility and noted that the issues discussed during Licensing visit on 02/26/26 were not corrected as discussed. Therefore, LPA had another discussion with the Administrator and issued citation for the noted deficiencies. Up to date facility failed to submit plan of corrections to clear the citations. Furthermore, during licensing visits LPA was informed that the facility is unable to maintain required staffing. The staff that they were hiring or planning to hire either quit or did not complete hiring process. The issue regarding updates for emergency disaster plan was discussed and Licensing representatives were informed that the facility will use evacuation chairs to bring residents down from the upper floors during evacuation. At the time of this visit LPM and LPA were informed that the facility has 3 evacuation chairs. The plan will be updated to identify the assistance with evacuation chairs.the state’s words, verbatim · CDSS document, Jun 9, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Tihesha Smith was conducting a complaint investigation (31-AS-20260205155546) at the facility when Los Angeles Police Department (LAPD) arrived at approximately 2:10 pm. LPA Smith was with staff #1 (S1) on the elevator returning to front lobby when staff mentioned they sent several incidents reports to licensing on 06/05/26, however the elopement was not directly mentioned until law enforcement arrived. Law enforcement toured R1, room and spoke with neighboring residents, and will follow-up with report. Per S1 R1 was last seen on on 04:30 pm on 06/05/26, check room on 06/06/26 7/8 am, didn't see R1 downstairs then contacted law enforcement around 11:30 -1200 pm. LPA Smith reviewed, requested and obtained documents relevant to the incident to include but not limited to physician's report and contact information for LAPD officers. This is the second incident of elopement, missing resident, or a resident leaving the facility without staff awareness within the past six months. Deficiencies are cited on LIC 809D. Exit Interview conducted. Appeal Rights explained. Copy of report issued.the state’s words, verbatim · CDSS document, Jun 6, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(4) · Plan of correction due date: Jun 7, 2026

Additional Personal Rights To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interview and records review licensee did not comply with the section cited above. Facility failed to provide adequate supervision to prevent R1 from leaving the facility unsupervised. This poses an immediate health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Jun 6, 2026

Plan of correction: Licensee/Administrator to conducted in service training for all staff. Staff attendance sheet will be submitted to LPA by 06/08/26. In addition, Licensee/administrator will update R1's Appraisal Needs/services plan and send to LPA by POC due date: 06/08/26.

Allegation investigated: Staff gave resident medications twice

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at 10:15 a.m. LPA met with staff and disclosed the reason for the visit. Staff gave resident medications twice It was alleged that Staff #1 (S1) administered medications twice to Resident #1 (R1). To investigate the allegation on 09/11/25, LPA Smith interviewed the executive director and requested copies of facility documents relevant to the investigation and on 10/17/25 LPA Smith conducted interviews with staff and residents. The administrator revealed the following:R1 had an early morning medical appointment and requested to have their morning medications dispensed ahead of time so they could take them with them. (S1) dispensed R1’s medications and placed them in a plastic bag for R1 to take to the appointment. The administrator stated that R1 did not attend the appointment. Substantiated (Cont from 9099) Later that same morning, during routine medication rounds, R1 requested their medications again and became verbally aggressive to S1 by yelling and screaming, and due to the escalating behavior, S1 re-dispensed the same morning medications to R1. During interview, R1 revealed S1 told them they had to take their medications again. R1 revealed they felt scared and intimidated, so they accepted the medications but did not ingest them. R1 acknowledged raising their voice but denied screaming at S1. LPA was unable to confirm whether the medications dispensed were the same medications due to the facility’s inability to retrieve the electronic records from a system that is no longer used. Interviews with residents revealed the following: five (5) residents received medications as prescribed and two (2) residents revealed they didn’t receive their medications. However, the administrator confirmed that S1 acknowledged dispensing the same medications twice to R1. S1 was not available for interview during licensing visits. Based on the information obtained, there is enough information to verify the allegation. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency cited on 809D Exit interview conducted/Appeal rights/copy of report given. (cont from 9099A) On 09/10/25, R2 told R1 in a firm voice to stop yelling at the staff. Staff intervened before anything escalated. Administrator revealed she arrived later but staff were present in dining room providing supervision. Based on the information obtained there is insufficient evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted/copy of report given.the state’s words, verbatim · CDSS document, Apr 18, 2026 · control 31-AS-20250910141622

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Apr 24, 2026

Incidental Medical and Dental Care Services. [...]Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met base on information obtained during investigation: Staff #1 dispensed R1’s morning medications twice.This duplicate medication administration posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Apr 18, 2026

Plan of correction: All Med Techs will receive refresher training on proper dispensing, verifying prior administration, documentation, and de escalation. POC:04/24/26

Type of visit: Case Management - Incident

This case management visit conducted by Licensing Program Analyst (LPA) Tihesha Smith at 10:35 am. During the visit an incident was brought to the attention of the LPA Smith. Resident #1 (R1) approached LPA Smith and revealed that they had not received any notification from the facility that their personal belongings were going to be moved, relocated, or placed into storage. LPA Smith asked R1 where they were currently residing, and R1 stated they are still temporarily admitted at a skilled nursing facility but came here because another resident called and said their belongings were being thrown in the trash. An interview with the Executive Director revealed no notice or consent was provided to R1 prior to staff packing and moving the resident’s belongings to the onsite storage area at Encino Terrace Senior Living not to the trash. The Executive Director further confirmed that there is no signed documentation indicating that R1 relinquished their room, nor is there an eviction notice on file for the resident. Interview with staff #2 revealed spoiled food left in refrigerator was thrown away. The Executive Director also stated that R1 has not paid rent since December 2025 and reported that she will be issuing proper written notification to R1 regarding the outstanding balance, along with warning notices related to nonpayment. (Cont from 809) LPA Smith asked R1 if they would be returning to the facility after the SNF but R1 revealed may not since having this issue at the facility and R1 also revealed the facility where they are temporarily residing will help with find another place to live. Deficiencies cited on 809D Exit interview conducted Copy of report given.the state’s words, verbatim · CDSS document, Apr 10, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1)(3) · Plan of correction due date: Apr 24, 2026

87468.1 (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff, […](3)to be free from […] actions of a punitive nature […] This requirement has not been met based on resident did not give consent to touch/move belongings which poses a potential risk on residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2026

Plan of correction: All staff will receive immediate training on Personal Rights (87468) and Safeguarding Resident Property (87218), with emphasis on obtaining resident or responsible person consent before touching/moving belongings. POC Due Date: 05/01/26

Type of visit: Case Management - Deficiencies

This case management visit conducted by Licensing Program Analyst (LPA) Tihesha Smith and Licensing Program Manager (LPM) Naira Margaryan due to increased complaint volume, prior issues observed to include but not limited to insufficient staffing. Upon arrival, licensing representatives observed the following: · The facility did not have sufficient support staff. · LPA Smith and LPM Margaryan observed no front desk staff present. They remained at the front desk for approximately 20–30 minutes before a maintenance worker arrived to assist. · On 04/06/2026, LPM Margaryan conducted a follow-up call with the Executive Director (ED), who confirmed that the facility does not currently have an employee assigned to the front desk. · The facility continued to lack adequate staffing to meet residents’ needs. During the licensing visit on 02/27/2026, LPA Smith and LPM Margaryan detected a strong urine odor in the elevator, third-floor hallways, and common areas. They observed a resident in a wheelchair who was wet and emitting an odor of urine, and/or feces. On the third floor and throughout the facility, only one caregiver was on duty to provide care and supervision for all residents. (cont from 809C) Based on observations and interviews with residents and staff, nine residents required extensive care. Three residents in wheelchairs, who required escort assistance, were left without supervision. At least one resident required a two-person assist for transfers in and out of bed/chairs/toileting and/or showering. Emergency Plan Review · The facility’s Emergency Plan of Operation was reviewed and requires updates. · Non-ambulatory residents were observed on the third (3rd) floor, and it was not clear how staff would assist them during an emergency. · To date, no updated emergency plan has been submitted to the Licensing office for review and approval. Resident Records Review · Residents’ records were incomplete and/or outdated. · At least one (1) resident assessment contained conflicting information regarding the level of care required (e.g., bathing, toileting, dressing) when compared to medical assessments. · At least one (1) resident file did not contain the Administrator’s/Director’s signature and date on required documents, including Resident Appraisals and Needs and Services Plans. · No written notification was provided to the Licensing office verifying that all resident records had been updated and corrected. Deficiencies cited on the LIC 809D. Exit interview conducted, appeal rights discussed, copy of the report giventhe state’s words, verbatim · CDSS document, Apr 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 8, 2026

87411 Personnel Requirements – General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care [...] Additional staff shall be employed as necessary to perform office work[...]The licensing agency may require any facility to provide additional staff whenever it determines [...]the needs of particular residents This requirement was not met based on licensing staff observation at time of visit which poses risk for residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: Licensee/Administrator will provide hiring plan to LPA POC: 04/09/26

From the deficiency page — Deficiency type: Type A · Section cited: CCR87212(a)2(A) · Plan of correction due date: Apr 8, 2026

87212 Emergency Disaster Plan. (a)Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available. (2) Plan for evacuation including: (A) Fire safety plan This requirement was not met based on licensing staff observation at time of visit which poses risk for residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: Licensee/Administrator will provide Emergency disaster plan to LPA POC: 04/09/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506 · Plan of correction due date: Apr 17, 2026

87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available[..] to licensing agency staff This requirement was not met based on licensing staff observation at time of visit which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: Licensee/Administrator will submit plan on how to ensure resident records update and readily available for review POC: 04/17/26

Allegation investigated: Unlawful eviciton Insufficient staffing to meet the needs of incontinant residents

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility to deliver findings. LPA met with staff and disclosed the reason for the visit. Unlawful eviction In regard to the above allegation, this allegation is the same allegations to previous complaint number: 31-AS-20250902094715 which has already been investigated and substantiated. To investigate this allegation, on 09/11/2025, LPA Smith interviewed staff and requested copies of facility documents relevant to the investigation from approximately 2:35 pm - 3:30 pm. LPA Smith briefly observed facility grounds. During the course of the investigation the records of R1 were reviewed to include but not limited to admission agreement, physician report, and medication administration record. Substantiated Record review reveals R1’s last physician report was completed 10/31/23 to 11/22/23 clear of any declining health or behavioral changes noted. There is a notification of incident or change of condition document on 04/16/24 and 04/17/24 regarding aggressive language and behavior disturbance however no assessments for the resident were completed following those incidents. Two (2) of two (2) staff reveal R1 sending numerous email messages and are not taking their medication. Interviews with the executive director reveal that there are not any current year reappraisals for R1 documenting any changes in behavior, non-compliance with medication including no written warnings or notices to R1 noting any failure to comply with state, local law or any violations of community rules. Additional interview conducted today with executive director reveal no new evictions for R1 exist for year 2026. Additional interview with R1 states has not received a new eviction for this year but didn’t remember receiving the results of the investigation. Based on record review and interviews there is sufficient evidence to support the allegation of unlawful eviction. Therefore, the allegation is deemed Substantiated at this time. Insufficient staffing to meet the needs of incontinent residents In regard to the above allegation this allegation is the same or similar allegation to previous complaint number: 31-AS-20250806114836 which has already been investigated and substantiated. To investigate the allegation: LPA Smith conducted interviews with staff and R1 from approximately 11:10 am 12:00 pm. Interview conducted with executive director revealed she is still having issues finding and retaining competent caregivers as the hired staff will either quit within the same day or a week starting the position and some of the applicants do not continue with the hiring process. Although hiring process is still on going, observation by licensing staff on previous visits to the facility has observed staff shortage. Based on interviews and observation there is enough information to verify the allegation. Therefore, the allegation is deemed SUBSTANTIATED at this timethe state’s words, verbatim · CDSS document, Apr 1, 2026 · control 31-AS-20260323103456

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Apr 10, 2026

Eviction Notification (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5).[...]This is evidenced by: The Administrator failed to have R1 reassessed and failed to provide any warning notices or documentation that R1 is out of medical compliance, has any current behavior changes and/or is not following community rules.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: Administrator will need to provide current reappraisal for R1, review Title 22 regarding Eviction process, provide plan on how to ensure residents that are not enrolled in facility managed care program remain compliant to include medically compliant. POC: 04/10/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 10, 2026

Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement has not been met based on Interviews and executive director admission hiring more staff which poses health and safety risk to the residents in carethe state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: Licensee will ensure additional staff is hired if required. The staff schedule and written information must be provided explaining the steps taken by the Administrator. POC:04/10/26

Allegation investigated: Unlawful eviciton Insufficient staffing to meet the needs of incontinant residents

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility to deliver findings. LPA met with staff and disclosed the reason for the visit. Unlawful eviction In regard to the above allegation, this allegation is the same allegations to previous complaint number: 31-AS-20250902094715 which has already been investigated and substantiated. To investigate this allegation, on 09/11/2025, LPA Smith interviewed staff and requested copies of facility documents relevant to the investigation from approximately 2:35 pm - 3:30 pm. LPA Smith briefly observed facility grounds. During the course of the investigation the records of R1 were reviewed to include but not limited to admission agreement, physician report, and medication administration record. Substantiated Record review reveals R1’s last physician report was completed 10/31/23 to 11/22/23 clear of any declining health or behavioral changes noted. There is a notification of incident or change of condition document on 04/16/24 and 04/17/24 regarding aggressive language and behavior disturbance however no assessments for the resident were completed following those incidents. Two (2) of two (2) staff reveal R1 sending numerous email messages and are not taking their medication. Interviews with the executive director reveal that there are not any current year reappraisals for R1 documenting any changes in behavior, non-compliance with medication including no written warnings or notices to R1 noting any failure to comply with state, local law or any violations of community rules. Additional interview conducted today with executive director reveal no new evictions for R1 exist for year 2026. Additional interview with R1 states has not received a new eviction for this year but didn’t remember receiving the results of the investigation. Based on record review and interviews there is sufficient evidence to support the allegation of unlawful eviction. Therefore, the allegation is deemed Substantiated at this time. Insufficient staffing to meet the needs of incontinent residents In regard to the above allegation this allegation is the same or similar allegation to previous complaint number: 31-AS-20250806114836 which has already been investigated and substantiated. To investigate the allegation: LPA Smith conducted interviews with staff and R1 from approximately 11:10 am 12:00 pm. Interview conducted with executive director revealed she is still having issues finding and retaining competent caregivers as the hired staff will either quit within the same day or a week starting the position and some of the applicants do not continue with the hiring process. Although hiring process is still on going, observation by licensing staff on previous visits to the facility has observed staff shortage. Based on interviews and observation there is enough information to verify the allegation. Therefore, the allegation is deemed SUBSTANTIATED at this timethe state’s words, verbatim · CDSS document, Apr 1, 2026 · control 31-AS-20260323103456

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Apr 10, 2026

Eviction Notification (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5).[...]This is evidenced by: The Administrator failed to have R1 reassessed and failed to provide any warning notices or documentation that R1 is out of medical compliance, has any current behavior changes and/or is not following community rules.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: Administrator will need to provide current reappraisal for R1, review Title 22 regarding Eviction process, provide plan on how to ensure residents that are not enrolled in facility managed care program remain compliant to include medically compliant. POC: 04/10/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 10, 2026

Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement has not been met based on Interviews and executive director admission hiring more staff which poses health and safety risk to the residents in carethe state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: Licensee will ensure additional staff is hired if required. The staff schedule and written information must be provided explaining the steps taken by the Administrator. POC:04/10/26

Allegation investigated: Administrator intimidated resident Staff allowed for a resident to expose themself indecently to others Resident wandered out of the facility unsupervised Staff allowed for a resident to shout obscenities at other residents Staff did not assist a resident with an injury

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced subsequent complaint visit to deliver findings. LPA Smith was greeted by staff. and LPA Smith disclosed the purpose of the visit. On 09/22/25, LPA Smith delivered findings for one allegation. On August 15, 2025, LPA Smith interviewed three (3) staff members, reviewed records, and requested copies of facility documents relevant to the investigation from approximately 10:25 a.m. to 2:10 p.m. Allegation: Administrator intimidated resident It was alleged that staff intimidated Resident#1 (R1) into signing paperwork by using threats or coercive behavior. To investigate this allegation, LPA interview staff #1 (S1) and Staff #2 (S2), who both denied forcing or intimidating R1 and stated facility documentation for medication program was explained to (R1) in order for R1 to be compliant with medical care/medications. (cont to 9099C) Unsubstantiated (Cont from 9099) During the interview with R1 on 12/04/25, R1 was asked about the identity of the unknown male who allegedly intimidated them. R1 indicated they did not know what male was being referenced and did not provide any explanation related to the allegation. When asked whether they had any safety concerns within the community and/or with staff, R1 stated they did not. They reported enjoying living in the community, participating in games and activities, and feeling safe in the facility. They did note, however, that some staff lack appropriate training for their roles. Interviews with five (5) of (6) six residents indicated they had never been intimidated by staff and had never observed staff intimidating other residents. Based on the information obtained during the course of this investigation, there is insufficient evidence to support the allegation Administrator intimidated 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 deemed UNSUBSTANTIATED at this time. Staff allowed for a resident to expose themself indecently to others It was alleged that staff allowed a resident to expose themself indecently to others. To investigate the allegations on 8/13/25, LPA Smith conducted a 10-day visit at which time LPA Smith requested documents relevant to the investigation, interviewed with the administrator and three (3) residents. Interview with S2 reveal was assisting resident #3 (R3) in their room when resident #2 (R2) opened door by accident and immediately apologized for opening the wrong door. Staff revealed that R3 did not get into R3 bed and/or expose themself indecently to others nor did R3 scream and run out of their room. Interview with administrator revealed follow-up was conducted with R2 who admitted to having a beverage containing alcohol prior to coming back to the facility and heading to their room. Interview with R2 revealed that they opened the wrong door on the way to their room but denied getting into R3’s bed and denied exposing themselves indecently to anyone. LPA was unable to interview R3 as residents no longer reside at the facility. Based on the information obtained during course of investigation, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Continue to (9099C) (Cont from 9099C) Resident wandered out of the facility unsupervised Regarding the allegation above, interview with the ED (executive director) revealed that Resident #8 (R8) is not a resident of Encino Terrace Senior Living but of North Lake Villa and does not maintain any records on the resident additionally are no longer providing temporary location services for Northlake Villa residents as of 12/31/25. Per review of dept internal notes and/or incident reports R8 eloped from facility on 08/16/25. However, information received from staff #8 (S8) by licensing staff on 08/18/25 reveal that all relevant parties were contacted and due to R8 having good mental status, they were able to leave the facility unattended. Based on the information obtained during course of investigation, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time Staff allowed for a resident to shout obscenities at other residents It was alleged that Staff allowed for a resident to shout obscenities at other residents. Interview with staff revealed that did not allow resident to shout obscenities however, (R3) has history of psychological issues and having behavior episodes so was sent to the hospital on 08/26/25 and then transferred to a skilled nursing facility (SNF). S1 revealed they took appropriate action to address behavioral issues with R3. LPA Smith was unable to interview R3 as residents no longer reside at the facility. Based on the information obtained during course of investigation, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time Staff did not assist a resident with an injury It was alleged staff did not assist a resident with an injury. Per interview with S1, resident # 9 (R9) has various repetitive soothing behaviors to include rocking, laughing, and putting tissue or straws in nostrils and S1 denies R9 have any injuries that required medical aid or treatment. Review of R9 physician’s report on 03/06/26 reveal R9 has multiple diagnoses to include but not limited to anxiety disorder and schizophrenia. LPA Smith attempted to interview R9 but R9 did not respond to any questions. During previous licensing visits LPA Smith observed R9 removing tissue from nostrils with no blood present on tissues with staff (cont from 9099C) attempting to assist R9. Based on the information obtained during course of investigation, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time No hazards observed during visit. Exit interview /conducted copy of report sent.the state’s words, verbatim · CDSS document, Mar 6, 2026 · control 31-AS-20250825092249

Allegation investigated: Staff did not protect a cognitively impaired resident from repeated inappropriate contact by another resident Staff does not ensure residents are treated with dignity and respect in their personal relationships with other residents Staff did not ensure reporting requirements were followed

Licensing Program Analyst (LPA) Tihesha Smith and Licensing Program Manager (LPM) Naira Margaryan conducted unannounced subsequent complaint visit to the facility to complete an investigation for the above noted allegations. The Executive Director (ED) or the designee was not available during the visit. After waiting in the lobby for about 20 min, licensing staff met with the maintenance supervisor, who contacted the Licensee representative over the phone. The Licensee Representative and Vice President of Operation (VPO) arrived later. During initial visit LPA Smith interviewed two (2) staff and three (3) residents from 10:45 AM to 3:15 PM. LPA Smith toured the facility at approximately 12:15 PM between interviews and requested copies of facility documents relevant to the investigation to include but not limited to personnel report, client register, physician reports at approximately 1:10 PM. Prior to this visit during other licensing visits, LPA Smith interviewed four (04) additional residents and on 12/26/25 LPA spoke with party relevant to the investigation over the phone. On 02/13/26, LPA Smith reviewed records obtained from the facility. Staff did not protect a cogitively impaired resident from repeated inappropriate contact by another resident Unsubstantiated (cont from 9099) Staff did not protect a cognitively impaired resident from repeated inappropriate contact by another resident It was alleged that Resident #1 (R1), who has cognitive impairment, was taken advantage of in a sexual manner by Resident #2 (R2), who does not have cognitive impairment. Staff revealed that they had no knowledge of any incidents of inappropriate or sexual contact made by R2 towards R1. R2 denied taking advantage of R1. LPA Smith attempted to interview R1, but they were unable to respond to the questions. Residents denied seeing inappropriate interactions between R1 and R2 or between other residents. Interview with party relevant to the investigation did not provide any concrete and verifiable information to support the allegation. A review of facility records did not reveal any information to verify the allegation. Based on interviews and record review, there is insufficient evidence to support the allegation 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 deemed UNSUBSTANTIATED at this time. Staff does not ensure residents are treated with dignity and respect in their personal relationships with other residents Concerns were addressed that Resident #3 (R3) was attempting to report incidents at the facility and was ignored by staff. The ED and staff denied ignoring or any untoward behavior toward residents. They revealed that they are all respectful to all residents and no resident came to report any incident(s) to them regarding the allegations. R3 was interviewed and was unable to clarify staff they reported incident(s) to, and which staff were ignoring them. The residents interviewed indicated that they are being treated with dignity and respect. Review of licensing records and facility incident reports did not reveal any information to support the allegation. Based on interviews and record review, there is insufficient evidence to support the allegation 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 deemed UNSUBSTANTIATED at this time. (cont from 9099C) Staff did not ensure reporting requirements were followed Regarding the allegation above, It was reported that R3 made several attempts to report incidents concerning R1 and R2. Staff failed to report the incident so R3 reported it. During interviews, ED and facility staff indicated that no one reported an incident involving R1 and R2 and did not observe any untoward behavior between R1 and R2. Therefore, there was nothing to report to R1 and R2s responsible parties, doctors or to appropriate agencies. During interview, R3 was unable to clarify who they reported an incident to at the facility. Other residents stated that they are able to communicate with staff and will report any emergencies or issues to staff, including going to front desk reception to report issues that require immediate attention. During today’s visit licensing staff witnessed a resident reporting an issue regarding their emergency pendant. No records were available to verify an incident involving R1 and R2. Based on interviews and record review, there is insufficient evidence to support the allegation 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 deemed UNSUBSTANTIATED at this time. No issues/hazards observed during brief visit to deliver report. Exit interview conducted/Copy of report sent.the state’s words, verbatim · CDSS document, Feb 28, 2026 · control 31-AS-20251125160009

Type of visit: Case Management - Other

This case management visit conducted by Licensing Program Analyst (LPA) Tihesha Smith and Licensing Program Manager (LPM) Naira Margaryan visit due to complaint volume, issues observed during previous licensing visits to include but not limited to insufficient staffing to provide care and supervision. Upon arrival, licensing representatives observed the following: No manning at front desk reception. Residents unable to open door to go to break area Residents with strong urine odor Strong urine odor in elevator/and third floor hallways, common areas One caregiver is on duty to provide care and supervision for 9 residents requiring extensive care 3 residents observed in wheelchairs, requiring escort assistance, left without supervision. *There were non-ambulatory clients on the 3rd floor, and it was not clear how the staff would assist them during emergencies. Emergency plan of operation was reviewed and required updates. At least one (1) or more residents require a 2 person assist in transferring in/out of bed/chair At least one (1) or more resident assessments have conflicting information regarding level of care needed (Bathing/independent/toileting/dressing) compared to medical assessments At least one (1) or more resident documents do not have Administrators/Directors signature/date (Resident Appraisals/Needs and Services plans) Due to time constraints deficiencies will be addressed during a later visit. Exit interview conducted/copy of report giventhe state’s words, verbatim · CDSS document, Feb 27, 2026

Allegation investigated: Staff did not safeguard resident's belongings Resident was retaliated against for filing a complaint with the Ombudsman.

Licensing analyst (LPA ) Tihesha Smith conduct an unannounced subsequent complaint visit to this facility. LPA Smith was greeted by staff and disclosed the reason for the visit. The administrator was present at the facility. Staff did not safeguard resident's belongings It was alleged that staff did not safeguard a residents’ belongings, specifically Resident #1’s (R1’s) shoes and glasses were thrown away or broken by staff. To investigate the allegation on 11/19/25 LPA Smith interviewed two (2) staff from approximately 12:55 pm AM to 1:45 pm and requested copies of facility documents relevant to the investigation at approximately 01:10 pm to include but not limited to personnel report and resident roster. On 12/04/25, during interview, R1 did not name any staff in regard to staff breaking their glasses. R1 also revealed they believe their roommate may have taken shoes but did not witness roommate or staff touching their belongings nor did they ask roommate or staff about their shoes or glasses. Unsubstantiated (cont frrom 9099) Interviews conducted during the course of the investigation revealed the following: five (5) of five (5) staff revealed that they have not taken or stolen R1’s belongings or any residents’ belongings. Interviews with five (5) of six (6) residents revealed they have not had or noticed any personal belongings missing or stolen by staff. Review of R1’s personal property and valuables form does not include an entry for any shoes or glasses. Interview with Staff #1 (S1) revealed that no staff at the facility would steal any residents’ belongings and that due to R1 maintaining sunglasses fell and broke on facility grounds they have purchased replacement for the sunglasses but were not aware of any issues with R1 shoes. LPA Smith observed new sunglasses still in packaging. Based on the information obtained during the course of this investigation, there is insufficient evidence to support the allegation Staff did not safeguard resident's belongings. 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 at this time. Resident was retaliated against for filing a complaint with the Ombudsman In regard to this allegation, R1 was not able to provide any illegal actions that have been carried out against them by the administrator and receives all meals, housekeeping and medical treatment. R1 also revealed is looking to move. Interview with the administrator revealed they and facility staff have not and would never retaliate against any resident who files a complaint with any agency and also reveal that information is normally confidential and residents don’t normally disclose to them that they are filing a complaint. The administrator also revealed R1 does not have an eviction notice on file. Based on the information obtained during the course of this investigation, there is insufficient evidence to support the allegation Resident was retaliated against for filing a complaint with the Ombudsman. 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 at this time. Exit interview conducted/Copy of report given.the state’s words, verbatim · CDSS document, Feb 13, 2026 · control 31-AS-20251117115117

Allegation investigated: Staff do not ensure facility is free of tripping hazards

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility to deliver findings. LPA Smith was greeted by staff and disclosed the purpose of the visit. At 10:35 am on 10/08/25, LPA Smith interviewed six (6) residents and two (2) staff from 10:40 am-2:35 pm. LPA Smith also requested copies of facility documents relevant to the investigation during and after interviews from approximately 10:35 am - 1:10 pm. LPA Smith briefly observed facility grounds during interview transitions. Staff do not ensure facility is free of tripping hazards It was alleged that staff do not ensure the facility is free of tripping hazards. Interview with the executive director revealed they have not observed any items on the floors that would be a potential hazard. Interview with R1 revealed that flooring in their room is uneven, to include other areas on the third floor. Substantiated (cont. from 9099) LPA observed the floors in R1's room and floors on the 3rd floor and noted the following: R1’s room floors have an incline to a degree from sink to patio door and in bathroom. The areas in common walkway and near the elevator have an unevenness and is more apparent when R1 is using walker to ambulate over the areas and when individuals with wheelchairs are entering the elevator. LPA briefly discussed the floors with Staff #2 (S2) who mentioned the cost would be significant to have the floors leveled. Based on interviews and observation there is information to verify the allegation. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency cited on 9099D Exit interview conducted/Appeals Rights /Copy of report printed (cont from 9099A) Additionally, R1 was informed that emergencies services can be called for their own care, but staff should be contacted first in order to assess residents and verify if 911 services are needed. The executive director also revealed that staff do not prevent 911 calls from being made and would never threaten a resident, nor have they threatened R1 with any eviction notice for doing so. Interview with R1 it was revealed that a resident was having a medical emergency and therefore R1 contacted 911. R1 was not available to provide reason for not alerting staff but noted it is their right to contact 911. LPA asked R1 if they recalled speaking with the executive director regarding contacting 911 services and R1 states wasn’t clear what was said and requested to go to the executive director’s office. While in the executive director's office R1 asked if they were able to contact 911 and the executive director reiterated that R1 can call for self but need to contact staff for other residents. R1 noted their understanding by nodding head and saying ok. Based on the information received during the investigation, there is not enough information to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Staff yelled at a resident LPA interview with executive director and staff revealed the following: executive director refutes this allegation, revealing has not received any notice from R1 regarding yelling or mistreatment from any staff and that staff maintain a professional demeanor and has not heard or witnessed any staff yelling at any residents in care. LPA conducted interview with R1 who revealed that the staff that yelled at them worked at the facility in 2024 but no longer works at the facility, and does not recall when the left. LPA interviews six (6) out of seven (7) residents revealed they have not witnessed any staff yelling at R1 or any residents in care and staff has not yelled at them. Based on the information received during the investigation, there is not enough information to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Staff do not ensure resident receive their mail Staff do not ensure resident have access to their personal records In regard to these two allegations: It was alleged that staff do not ensure residents receive their mail and staff do not ensure residents have access to their personal records. Interview with the executive director revealed the following: when mall is delivered by post office, the mail is held at the front desk, the residents are notified by concierge/front desk and residents stop by front desk and ask if they have mail. (cont from 9099C) The executive director deny they or any staff has withheld mail from R1 or any resident in care. The executive director also revealed that any request for records from residents must be written and should include what documents they are requesting such as admission agreements or copy of medical assessment and have not received a written request for records from R1. Interview with R1 revealed that these issues are not a concern and would like to cancel or close these issues to focus on a big concern. R1 revealed they are receiving mail. R1 also revealed they wanted a copy of their medical file kept at the facility but was told to submit a written request. LPA informed R1 that if there is a rule/policy in place for a written request to receive the documents then R1 will need to follow that rule or policy. Based on the information received during the investigation, there is not enough information to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Feb 8, 2026 · control 31-AS-20250929131634

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80087(a) · Plan of correction due date: Feb 9, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement has not been met as evidenced by: Based on interviews and observation the floors in the facility (R1 room/3rd floor) are uneven which pose an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 8, 2026

Plan of correction: The Licensee will obtain an inspection for the facility floors (carpeted) and provide a plan to repair/correct uneven floors within the facility POC: 02/09/26.

Allegation investigated: Licensee does not ensure facility has sufficient staffing to meet the care needs of residents

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced complaint visit to this facility to deliver findings. LPA Smith was greeted by staff and disclosed the purpose of the visit. At 10:10 am on 01/07/26, LPA Smith requested documents relevant to the investigation to include but not limited to a copy of admissions agreement, Personnel Report, Staff schedule, Resident roster. LPA Smith conducted interviews with the administrator and three (3) residents from approximately 11:10 am -1:10 pm. Licensee does not ensure facility has sufficient staffing to meet the care needs of residents In regard to staffing, interviews with the administrator revealed does not agree with the allegation and revealed the same number of caregivers have been employed at the facility for several years. Review of personnel report shows 20 resident assistants/coordinators that assist residents and Substantiated (Cont from 9099A) Interview with S2 reveal was assisting resident #3 (R3) in their room when resident #2 (R2) opened door by accident and immediately apologized for opening the wrong door. Staff reveal R3 did not get into R3 bed nor did R3 scream and run out of their room. Interview with administrator revealed follow-up was conducted with R2 who admitted to having a beverage containing alcohol prior to coming back to the facility and heading to their room. Administrator also stated supervision is not one-on-one, but staff are present in facility providing supervision. Interview with R3 revealed that they opened the wrong door on the way to their room but denied getting into R3’s bed. LPA was unable to interview R3 as residents no longer reside at the facility. A review of R3’s physician’s report notes mild cognitive impairment however R3 assessment notes independent and ambulates independently. Based on the information obtained from interviews and record review, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. Staff do not observe changes in resident health conditions It is alleged that staff do not observe changes in resident health. Interview with administrator revealed that residents are observed by staff during regular interactions and medical attention is provided when requested or needed. Administrator also revealed that R3 no longer resides at the facility due to them experiencing various changes in behavior and/or health and required higher level of care. Interviews with three (3) out of three (3) staff reveal records are noted and LIC 624’s are sent to Licensing when changes occur in the residents’ health/behavior, or they require hospital transport. Review of LIC 624s verify that staff are documenting and observing changes in residents. LPA Smith observed staff checking on resident in lobby. Based on interviews, record review, and observation, this allegation is deemed Unsubstantiated at this time. Exit Interview conducted/Copy of report given. (cont from 9099) and staff schedule reveal the following: Three (3) caregivers on the AM shift (6:00 - 2:00 pm), three (3) caregivers on the PM shift (2:00 - 10:00 pm), and three (3) caregivers on the NOC shift (1000 pm - 6:00 am) Review of personnel report dated from July 2025 shows a total of 10 caregivers assigned and personnel report from Aug 2025 shows a total of 11 caregivers. According to the administrator, they currently have a staffing ratio of 4 caregivers on the AM shift, 3 caregivers on the PM shift and 3 caregivers on the NOC shift. However during complaint visit on 01/11/26 there were only two (2) staff available to provide assistance to residents and at least one (1) resident requires a two (2) person assistance with Activities of Daily Living (ADLs), such as bathing and toileting. Interview with two (2) staff reveal have informed licensee of additional staff needs. Based on the information obtained, there is enough information to verify the allegation, therefore the allegation is SUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 31-AS-20250804081258

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 17, 1984

Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement has not been met based on: Interviews staff informed licensee need more staff/only two staff on Sunday Pm for resident assistance which poses health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Feb 6, 2026

Plan of correction: Licensee will ensure additional staff is hiired if required. The staff schedule and written information must be provided explaining the steps taken by the Administrator. POC:02/20/26

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tihesha Smith conducted a case management visit at this facility in conjunction with complaint # 31-AS-20260127135209. LPA Smith was greeted by staff and LPA Smith disclosed the reason for the visit. During interview with Resident #1 (R1) LPA observed resident with severe wound on left leg/foot. Resident was self applying first aid to the area. The room had an odor and residents bedroom window was open. R1 was in a wheel chair during the interview and revealed was doing well. Executive Director revealed R1 has refused treatment/transfer to hospital. Due to time constraints a follow-up visit may be conducted at a later date No deficiencies cited.the state’s words, verbatim · CDSS document, Feb 2, 2026

Allegation investigated: Staff do not ensure resident is provided with transferring assistance

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at 845 a.m. LPA met with staff and disclosed the reason for the visit. Staff do not ensure resident is provided with transfer assistance It was alleged that staff do not ensure residents are provided with transfer assistance and alleging that staff leave them in their bed all day and won't assist them with transferring to their chair. To investigate the allegations on 8/13/25, LPA Smith conducted a 10-day visit at which time LPA Smith requested documents relevant to the investigation, interviewed staff, residents and toured random resident rooms. On 11/05/25, LPA Smith delivered findings for one (1) of the five (5) remaining allegations. During interviews with staff, five (5) of five (5) staff denied the above allegation and/or revealed it is not true. Interview with five (5) of six (6) residents reveal they receive transferring or mobility assistance if requested or if staff observes them in the common areas. Unsubstantiated (Continued from 9099) On 11/05/25, LPA Smith asked Resident#1 (R1) if they receive assistance with transferring to wheelchair for interview but R1 didn’t provide an answer. LPA has made various visits to the facility and observed R1 going to and from first floor break area accessible through the subterranean parking which is inconsistent to being in bed all day. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jan 11, 2026 · control 31-AS-20250806114836

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

Allegation investigated: Staff do not ensure a safe environment for residents in care

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at 845 a.m. LPA met with staff and disclosed the reason for the visit. On 10/17/25, LPA Smith conducted a 10-day complaint and interviewed staff and residents from 10:20 AM to 12:50 PM, and requested copies of facility documents relevant to the investigation at 11:25 am. Staff do not ensure a safe environment for residents in care It was alleged that Staff do not ensure a safe environment for residents in care. Interviews with staff reveal they help the residents as needed and help keep the facility safe and clean for the residents. Interviews with three (3) of three (3) staff revealed they have never witnessed Resident #1 (R1) and Resident # (R2) in any physical fight. Per interviews with five (5) staff and six (6) residents R1 is constantly yelling and demanding service. Then on 09/10/25, R2 told R1 in a firm voice to stop yelling at the staff. Staff intervened before anything escalated. Unsubstantiated (continued from 9099) Administrator notes that during those incidents they were not present. Administrator revealed law enforcement was contacted by R1 however, R1 did not come downstairs to meet with them, so the officers left with no statement taken at the facility. During interviews R1 was unable to provide copy of police reports or police report number. On 10/10/25 staff revealed both residents were downstairs and R1 made a comment to R2 in Spanish and R2 replied by stating do talk to me but neither resident touched one another. R2 reveals denies any allegation of fighting or bothering R1. Five (5) of six (6) residents revealed they like living at the facility and do not have any concerns regarding the allegation. Therefore, based on interviews, the above allegation is deemed unsubstantiated at this time. No hazards observed at time of visit. Exit interview conducted/Copy of report giventhe state’s words, verbatim · CDSS document, Jan 11, 2026 · control 31-AS-20251010123155

Allegation investigated: Staff do not ensure residents are accorded right to choose their own health care providers Staff did not ensure resident was admitted with complete medical records upon entry to the facility

Licensing Program Analysts (LPA) Tihesha Smith made a subsequent unannounced complaint visit to the facility,met with the administrator and disclosed the purpose of the visit. During initial visit, on 08/13/2025, LPA Smith requested documents relevant to the investigation to include but not limited to a copy of admissions agreement, Personnel Report, Staff schedule, Resident roster. LPA Smith conducted interviews with the administrator and three (3) residents from approximately 11:10 am -1:10 pm. Regarding Allegation: Staff do not ensure residents are accorded right to choose their own health care providers. Interview with the administrator revealed that the facility contracts with physicians and informs residents and/or their representatives of the option to use these providers during admission. In R1’s case, contracted physician services were offered due to concerns about the lack of consistent medical updates from R1’s private doctor. The administrator stated that R1 was not pressured or required to use the facility’s physicians Unsubstantiated Review of R1’s physician report confirmed care by a private doctor, but the documentation was outdated. Interviews with five (5) of six (6) residents revealed they had a choice in choosing their own provider and were not forced to choose the facility doctor. R1 revealed that they didn’t have the right to choose their own healthcare provider but when LPA Smith asked when they started receiving medical care from the facility doctor R1 revealed they have their own doctor and didn’t choose to sign up to use the facility doctor. Based on the information obtained, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. Staff did not ensure residents were admitted with complete medical records upon entry to the facility In regard to the allegation, it was alleged that staff did not ensure residents were admitted with complete medical records upon entry to the facility specifically without their medication. Interview with administrator revealed that complete medical records are not a requirement for entry into the facility as in California residential care facilities for the elderly (RCFE) are non-medical facilities, so the admission does not require a complete medical record. Administrator also revealed that each resident does need a physician’s report completed and signed by a licensed physician with in 12 months prior to admission, preappraisal, current TB test or risk assessment, and appraisal/needs and services plan. Administrator states that medication is either brought with the resident or they may have to coordinate with residents’ private pharmacy or new admission will elect to use facility medication program. LPA reviewed Resident #4 (R4) records to include admissions agreement, physician’s report, controlled medication record. R4 elected to use facility medication program and medications dispensed to R4 has been logged since 7/13/2025. Based on the information obtained, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. Exit interview conducted copy of report giventhe state’s words, verbatim · CDSS document, Dec 4, 2025 · control 31-AS-20250804081258

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility. LPA was greeted by the administrator and disclosed the purpose of the visit. LPA conducted a tour of the physical plant to ensure there are no health and safety hazards, and the facility is following Title 22 Regulations. There is main entrance at the front of the building and another entry through the subterranean parking garage. The facility has a total of seventy-three (73) bedrooms with private bathrooms, and four (4) public restrooms. Showroom and resident rooms were observed to be appropriately furnished. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas observed to be clean. Sharps observed to be locked and inaccessible to residents. The dining areas observed to be clean, free of hazards, and have adequate sitting. are neat and clean. Laundry room appliances on each floor were observed to be functional. The smoke and carbon monoxide detectors are hardwired and interconnected. Fire extinguishers are located throughout the facility and observed to be fully charged. Toxins stored in storage closet on 2nd floor observed to be locked and inaccessible to residents. The residents' rooms have appropriate lighting and are adequately furnished. Hallways are well lit. Hygiene products are provided by the licensee. The public bathroom’s hot water temperature was measured at 113.9°F -115.3. There is an adequate supply of clean linen available to residents. LPA observed medication room to be locked and inaccessible to residents. Facility maintains a complete first aid kit in medication room and in business manager office. Liability insurance policy valid from 01/01/2025 to 01/01/2026. At approximately 11:40 am to 1:45 pm, LPA reviewed four (4) random staff files and seven (7) resident files. Staff files had the appropriate training courses to include first aid and CPR. Resident files included admissions agreements and functional appraisals. Deficiency noted on 809D. Technical advisory noted for Fire clearance issue. A case management visit may follow to address fire clearance and flooring on 3rd floor. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Nov 24, 2025

Allegation investigated: Staff do not ensure medications are dispensed as prescribed to resident in care

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced subsequent complaint visit to this facility to investigate the allegations above. LPA Smith was greeted by staff and LPA Smith disclosed the purpose of the visit. At approximately 10:35 am, LPA Smith requested copies of facility documents relevant to the investigation from approximately 10:35 am, interviewed six (6) residents and six (6) staff from 11:15-4:17pm. LPA Smith also toured facility grounds at 1:28 pm and 3:05 pm. LPA Smith conducted an initial investigation on 08/13/25. Staff do not ensure medications are dispensed as prescribed to resident in care It was alleged that Resident #1 (R1) is not receiving thier medications twice a day. Interview with the administrator on revealed 08/13/25 revealed that the medication staff use Caring data to dispense the medication and deny validity of the allegation. Unsubstantiated Three (3) staff interviewed revealed they or staff dispensing medication follow proper medication administration and deny the allegation. Interview with R1 revealed they do not have an issue with the dispensing of their medication. Based on the information obtained, there is not enough evidence to prove that Staff do not ensure medications are dispensed as prescribed to resident in care. Therefore, the allegation is deemed Unsubstantiated. Exit interview conducted, Copy of report given.the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 31-AS-20250806114836

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

Allegation investigated: Staff did not treat resident with respect

Staff did not treat resident with respect It was alleged that staff do not treat Resident #1(R1) with respect. On 9/10/25, R1 clarified that most staff do treat them with respect, but states there are one (1) to three (3) staff who did not treat them with respect. LPA Smith asked R1 to provide clarification on how those staff failed to treat them with respect. R1 revealed that when they are requesting food at mealtimes, the staff would yell at them and tell them to wait. Interview with four (4) staff revealed they have never yelled at, treated R1 or any other residents in a bad way or not respect them. All staff interviewed describe R1 as rude and yells at staff when R1 does not get their way. Interview with six(6) of six (6) residents revealed they have not been treated disrespectfully by staff. However (3) of six (6) residents reveal they have witnessed R1 being disrespectful to staff and other residents during mealtime in the dining room. Three (3) of six (6) residents state that R1 is aggressive and is a bully. Based on the information obtained during the interviews, there is insufficient information to verify the allegation.Therefore the allegation is UNSUBSTANTIATED at this time Exit interview conducted/copy of report given. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 17, 2025 · control 31-AS-20250910141622

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: There is no qualified administrator or back up administrator on duty during weekends.

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced complaint visit to this facility to investigate the allegations above. LPA Smith was greeted by staff. and LPA Smith disclosed the purpose of the visit. There is no qualified administrator or back up administrator on duty during weekends. It was alleged that there is no qualified administrator or back up administrator on duty during weekends. To investigate the allegation, on 08/28/25, LPA Smith interviewed three (3) staff, reviewed records and requested copies of facility documents relevant to the investigation from approximately 10:25 am - 2:10 pm. LPA Smith briefly observed facility grounds during interview transitions. The interview with the Executive Director revealed that although it is not required to have a backup administrator, there is a qualified designee available to oversee the facility if they are not available to be present. Unsubstantiated (cont from 9099) The executive director also revealed they are on call during the weekends in addition to staff being trained in reporting procedures. LPA review of staff roster and personnel records verified the information revealed from interviews. Interview with Business Office manager revealed is in charge of facility in the Executive Directors absence as in any other designee. Interviews with six (6) residents revealed they have no concern about this allegation as they have seen management staff or designee present in the facility during the weekend. Based on interviews and review of records there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Sep 22, 2025 · control 31-AS-20250825092249

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

Allegation investigated: Unlawful Eviction

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced complaint visit to this facility to deliver findings. LPA Smith was greeted by staff and disclosed the purpose of the visit. Allegation: Unlawful Eviction To investigate this allegation, on 09/11/2025, LPA Smith interviewed staff and requested copies of facility documents relevant to the investigation from approximately 2:35 pm - 3:30 pm. LPA Smith briefly observed facility grounds. During the course of the investigation the records of R1 were reviewed to include but not limited to admission agreement, physician report, and medication administration record. Record review reveals R1’s last physician report was completed 10/31/23 to 11/22/23 clear of any declining health or behavioral changes noted. Substantiated (Cont from 9099) There is a notification of incident or change of condition document on 04/16/24 and 04/17/24 regarding aggressive language and behavior disturbance however no assessments for the resident were completed following those incidents. Two (2) of two (2) staff reveal R1 sending numerous email messages and are not taking their medication. Interviews with the executive director reveal that there are not any current year reappraisals for R1 documenting any changes in behavior, non-compliance with medication including no written warnings or notices to R1 noting any failure to comply with state, local law or any violations of community rules. Based on record review and interviews there is sufficient evidence to support the allegation of unlawful eviction. Therefore, the allegation is deemed Substantiated at this time.the state’s words, verbatim · CDSS document, Sep 17, 2025 · control 31-AS-20250902094715

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Oct 1, 2025

Eviction Notification (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5).[...]This is evidenced by: The Administrator failed to have R1 reassessed and failed to provide any warning notices or documentation that R1 is out of medical compliance, has any current behavior changes and/or is not following community rules.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: Administrator will need to provide current reappraisal for R1, review Title 22 regarding Eviction process, provide plan on how to ensure residents that are not enrolled in facility managed care program remain compliant to include medically compliant. POC: 10/01/25

Allegation investigated: Staff did not provide adequate food service to resident in care Staff are unable to communicate with resident in care

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced complaint visit to this facility to investigate the allegations above. LPA Smith was greeted by staff. The administrator was present at the facility and LPA Smith disclosed the purpose of the visit. Allegation #1 Staff did not provide adequate food service to residents in care To investigate this allegation, on 09/15/2025, from approximately 10:35 a.m. - 3:45 p.m. LPA Smith conducted interviews with the Administrator, staff, and residents, and reviewed facility files relevant to the investigation. During record review Resident #2 (R2) records did not have any notes, assessments, service plan or doctors’ instructions requiring food to be served cut up. Interviews with staff reveal no instructions for R2 foods to be cut up. During the interview with R2, they communicated by hand gesture and shaking head in response to needing food cut up. Unsubstantiated (Cont from 9099) The sample population of residents interviewed revealed they do not have an issue with the food service, the food is good, staff are timely with food service and do their best in providing prompt services and any food services needed. LPA also observed staff delivering food to residents who prefer to dine in their room, observed fresh food being served and menu available. Based on record review, observations, and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation #2 Staff unable to effectively communicate with residents while in care LPA Smith conducted interviews with the Administrator, staff, and residents, and reviewed facility files relevant to the investigation. During interviews staff revealed they don’t have issues communicating with residents although staff may need to take time or talk slowly or louder with some clients due to hearing aids or residents that speak another language. During today’s visit, LPA observed that Resident #1 (R1) does not speak English and required some assistance to speak with the LPA, however LPA and staff were able to communicate with resident using short phrases, single words, and gestures. According to Title 22 Regulations, staff must be able to communicate with residents but are not required to speak the residents’ language. Per interview with staff: Resident #2 (R2) speaks Spanish and most facility staff including kitchen staff are able to communicate in Spanish. Interview with R2 (with the assistance of staff providing translation) R2 states does not have any issues communicating with staff. The sample population interviewed revealed they do not have any issues concerning communicating with staff and/or ordering food. Based on interviews, observation and Title 22 Regulations this allegation is unsubstantiated. No health and safety hazards noted during the visit. Exit interview conducted/Copy of report given.the state’s words, verbatim · CDSS document, Sep 15, 2025 · control 31-AS-20250912151449

Allegation investigated: Facility has no activities director. Facility does not have an administrator. Licensee has not conducted emergecy drills.

Licensing Program Analyst (LPA) Leslie Ngo Castaneda conducted unannounced subsequent complaint visit to the facility. LPA met Rose Yousefian who is the executive director and explained the purpose of this visit. The investigation was initiated on 04/23/2025 at which time at 10:15 AM, LPA conducted a physical plant tour. At 10:30 AM LPA requested facility documents relevant to the investigation which include but not limited to staff roster, resident roster, physician report, admission agreement, and other relevant document. LPA interviewed twelve (12) residents out of fifty-eight (58) and eight (8) staff between 10:53 AM to 2:50 PM. LPA reviewed records of staff between 2:50PM to 3:30 PM. Prior to this visit LPA Ngo Castaneda reviewed additional records previously gathered at the facility. Continue to LIC 9099-C Unsubstantiated Allegation#1: Facility has no activities director. It was alleged that the facility has no activities director. Interviews with the facility staff including executive director (S1), business director (S2), and activities director (S3) and other facility staff revealed that the current activities director has held the position since November 2024. A review of staff roster and personnel files for the last few months and of the staff list confirmed S3 has been the activity director. Interview with S3 at 2:20 PM on 4.23.2025 confirmed they are and have been the activity director. Residents interviewed during investigation also verified that the facility has activity director. A review of S3’s personnel record verified the information revealed from interviews. Based on observation, interviews and record review, the facility has an activity director. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Allegation #2: Facility does not have an administrator. It was alleged that the facility administrator was fired and no facility representatives from management were available to report to. During investigation LPA observed Executive Director (ED) (S1) and other administrative personnel present and available in the facility. Interview with S1 and S2 at 2:47 PM on 04/23/25 revealed that they were hired 3 days ago. Prior to hiring of new ED, Business Office manager (S2) was acting Executive Director and has been in charge of the facility. Interviews with Resident Service Coordinator (S8) and other facility personnel revealed that in the absence of ED, there are always someone designated to act as an Administrator. All staff including administrative personnel were trained to report any concerns and incidents to S2 or other designee. Interviews with eleven (11) out of fifty-eight (58) residents revealed that management is always seen at the facility assisting staff and residents as needed. A review of staff roster and personnel records verified the information revealed from interviews. Based on observation, interviews and record review, although the ED is not always present at the facility, the facility ensured that a qualified designee is always present and available to manage facility staff and assist families and residents as needed. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Continue to LIC 9099-C Allegation #3: Licensee has not conducted emergency drills. It was alleged that the facility has not conducted an emergency drill ever. ED and other managers indicated they have a contract with the Southwest Fire Life Safety and Security and just conducted the emergency fire drill on 04/23/25 in the morning. Staff stated there are always one to two full-time staff members who will work with the agency staff in the overnight shift. When they have any fire or disaster drills, the facility staff on the shift and temporary agency staff present in the facility are participating during the drill. In the event of any emergency, staff know where to obtain the emergency contact numbers and LIC610E Emergency Disaster Plan. During facility inspection LPA observed the emergency disaster plan posted and a Fire and Disaster Guidelines binder by the S2 office. Residents interviewed during investigation did not address any concerns regarding emergency disaster drill. Residents feel that there are sufficient well trained staff to assist residents during emergencies. A review of the facility records verified that facility is conducting quarterly emergency drills as required. Based on observation, interviews, and record review, there is no sufficient information to verify validity of the complaint. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit Interview conducted. Copy of report provided to ED.the state’s words, verbatim · CDSS document, Aug 19, 2025 · control 31-AS-20250414131655

Allegation investigated: Staff does not ensure the food is of good quality Staff do not ensure residents room is kept in clean/sanitary conditions

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced complaint visit to this facility to investigate the allegations above at 9:45 am. LPA Smith was greeted by Laurie Fernando, Regional Manager. The administrator was present at the facility and LPA Smith disclosed the purpose of the visit. At 10:10 am LPA Smith requested documents relevant to the investigation to include but not limited to a copy of admissions agreement, Personnel Report, Staff schedule, Resident roster. LPA Smith conducted interviews with the administrator and five (5) residents, and toured 4-6 random rooms from approximately 11:10 am -3:45 pm. The allegation: Staff does not ensure the food is of good quality It was alleged that Staff does not ensure the food is of good quality, specifically the food is terrible. LPA Smith interview with the administrator revealed the facility provides a menu for food being served Unsubstantiated (cont from 9099) each day and the food is fresh and prepared properly. The administrator also revealed she does eat meals that are prepared at the facility just as the residents do and notes the food is of good quality. Interviews with five (05) out of five (05) residents interviewed revealed the food is of good quality and/or okay. Based on the information obtained, there is not enough evidence to prove that staff do not ensure the food is of good quality. Therefore, the allegation is deemed Unsubstantiated. Staff do not ensure residents room is kept in clean/sanitary condition Interview wit the administrator revealed each room is cleaned by housekeeping and has not received any notices that a resident has refused any housekeeping services. Interviews with five (5) of five (5) residents revealed housekeeping does clean room and they are well kept. During the the tour of the resident rooms LPA observed rooms to be clean and sanitary. Furniture in rooms were in good repair and floors were free of obstruction. Based on the information obtained, there is not enough evidence to prove that Staff do not ensure residents room is kept clean/sanitary condition. Therefore, the allegation is deemed Unsubstantiated. Exit Interview conducted/Copy of report given.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 31-AS-20250806114836

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

Allegation investigated: Licensee did not ensure passageways were maintained free of hazards Licensee did not ensure elevators were maintained in working condition Facility does not have Evacuation Plan

On 04/07/25, at 9:05am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Business Manager, Katia Arriaga. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 04/07/25, LPA Saucedo asked for the census, staff, and resident rosters. On 04/07/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Substantiated Regarding the allegation: Licensee did not ensure passageways were maintained free of hazards. It is being alleged that because there is construction being conducted there is debris such as piles of carpet, lumber, tiles and shards of glass leaning against the wall creating a hazardous passageway. During LPA’s physical tour, LPA observed construction being conducted on the first and second floor. There was debris such as paint buckets, piles of lumber and fiber glass, ladders, exposed electrical wires and electrical outlets in the passageways, dining hall area and patio area creating a hazardous environment to both residents and staff. LPA interviewed four (4) residents and four (4) staff that confirmed there has been construction being conducted for several weeks now. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. Regarding the allegation: Licensee did not ensure elevators were maintained in working condition. It is being alleged that the elevator was not working for two (2) days. Although, the elevator is properly working now, it was confirmed by four (4) residents and four (4) staff that the elevator was not previously working. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. Regarding the allegation: Facility does not have Evacuation Plan. It is being alleged that there is no emergency exiting plans posted and there is no emergency evacuation plan. During LPA's physical tour, LPA did not observe any emergency exiting plans or/and sketches of the facility on the first or second floor during construction. There is an emergency evacuation plan that is available upon request of the resident and/or resident's family member but the emergency evacuation plan was not provided to the resident and/or resident's family when it was asked to be seen. Resident #1 (R1) and their family member confirmed they have not seen the emergency evacuation plan that they requested. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued and the appeal rights were given and a copy of this report was given to the Business Manager.the state’s words, verbatim · CDSS document, Apr 7, 2025 · control 31-AS-20250401113558

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 28, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met by: Based on the observations, the administrator/licensee did not comply with the section cited above in the areas of the elevator not working which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 7, 2025

Plan of correction: The Administration/Licensee will need to keep the elevator in good repair at all times. POC Cleared at time of visit: 04/07/25

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Apr 21, 2025

87468.1 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 acc...This requirement is not met by: Based on the observations, the administrator/licensee did not comply with the section cited above in the areas of construction/ passageways were not free of hazards, exposing of electrical wires/outlets which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 7, 2025

Plan of correction: The Administration/Licensee will need to keep the passageways, electrical outlets covered, electrical wires not being exposed and send a picture to the LPA when the project/construction is completed. POC Due Date:04/21/25

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(g) · Plan of correction due date: Apr 28, 2025

HSC1569.695- Emergency Plans(g) A facility shall make the plan available upon request to residents onsite, any responsible party for a resident, the local long-term care ombudsman, and local emergency responders...This requirement is not met by: Based on the observations, the administrator/licensee did not comply with the section cited above in the areas of the Emergency Plan not being available upon request which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 7, 2025

Plan of correction: The Administration/Licensee will need to have the Emergency Plan available upon request: POC Due Date: 04/28/25

Allegation investigated: Licensee is financially abusing former resident. Facility did not adhere to resident's Admissions Agreement. Facility staff did not accurately assess resident's needs.

Licensing Program Analyst (LPA) Abeye Duguma conducted a subsequent complaint visit to the facility to investigate the above allegations. LPA met with Vartan Stepanian and explained the reason for the visit. --- Licensee is financially abusing former resident. --- Facility did not adhere to resident's Admissions Agreement. It was alleged that facility intimidated and extracted funds from Resident #1 (R1) in an unethical way and enticed R1 into the residency agreement with a one (01) bedroom apartment, and then billed it as two (02) studio apartments. To investigate the allegations, on 03/04/2024 LPA Tihesha Smith conducted a physical plant tour, requested documents and interviewed one (01) staff from around 01:45p.m. to 02:50p.m. On 03/09/2025 LPA Duguma conducted a physical plant tour at around 10:00a.m., reviewed documents at around 11:30a.m. to 12:15p.m., interviewed three (03) staff from 12:15p.m. to 1:30p.m. (CONT on LIC9099-C) Unsubstantiated On 03/29/2025 LPA Duguma reviewed all forwarded documents from around 10:00a.m. to 11:00a.m. A review of all forwarded documents revealed that R1’s Admission’s Agreement was not amongst the dossier, however, one letter shows that in a final attempt to collect a debt, the facility offered R1 a fifty percent (50%) discount. During interviews with staff, all staff stated they do not entice their residents into making any financial decisions and that all residents have a choice. Staff #1 (S1) added, R1 moved out and did not provide proper notification. Staff #2 (S2) stated facility is under new ownership and unable to provide requested documents. During interviews with residents, all residents stated they do not feel facility tries to intimidate them or extract funds from them by not following the admissions agreement. LPA Duguma made several attempts to reach the other parties by phone but to no avail. Based on interviews and a review of available records, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility staff did not accurately assess resident's needs. It was alleged that a staff member’s review of facility’s residents and resources indicated facility was not able to properly care for residents like R1. To investigate the allegations, on 03/04/2024 LPA Tihesha Smith conducted a physical plant tour, requested documents and interviewed one (01) staff from around 01:45p.m. to 02:50p.m. On 03/09/2025 LPA Duguma conducted a physical plant tour at around 10:00a.m., reviewed documents at around 11:30a.m. to 12:15p.m., interviewed three (03) staff from 12:15p.m. to 1:30p.m. On 03/29/2025 LPA Duguma reviewed all forwarded documents from around 10:00a.m. to 11:00a.m. A review of all available documents do not indicate that R1 had a prohibited health condition, a restricted health condition or any other condition that may have hinder the facility’s ability to provide the necessary care and supervision. During interviews with staff, all staff stated they do not admit residents they cannot properly care for. During interviews with residents, all residents stated they feel facility has the resources to be able to properly care for them. Based on interviews and a review of available records, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 29, 2025 · control 31-AS-20240227123807

Allegation investigated: Cluttered room created an unsafe environment for resident. Resident sustained a fall due to clutter in the room.

Licensing Program Analyst (LPA) Abeye Duguma conducted a subsequent complaint visit to the facility to investigate the above allegations. LPA met with Katia Arriaga and explained the reason for the visit. --- Cluttered room created an unsafe environment for resident. --- Resident sustained a fall due to clutter in the room. It was alleged that Resident #1’s (R1) room is cluttered and unsafe and contributed to a fall injury in September 2023. To investigate the allegations, on 03/04/2024 at around LPA Tihesha Smith conducted a physical plant tour and interviewed one (01) staff from around 01:45p.m. to 02:50p.m. On 03/09/2025 LPA Duguma conducted a physical plant tour at around 10:00a.m., reviewed documents at around 11:30a.m. to 12:15p.m., interviewed three (03) staff from 12:15p.m. to 1:30p.m. and six (06) residents from around 1:30p.m. to 3:00p.m. (CONT. on LIC9099) Unsubstantiated During the physical plant tour, LPAs did not observe any clutter. A review of the department’s incident report records revealed R1 did not have a fall reported during the month in question. During interviews with staff on 03/09/2025, all staff stated they do not know R1 and are unfamiliar with their room or if they had a fall as they were all hired after the change of ownership and R1 was not a resident at the time of purchase. Staff #2 added, former owners have all files for R1. During interviews with residents, all residents stated they get housekeeping services one (01) to two (02) times a week and do not feel their room is an unsafe environment. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 9, 2025 · control 31-AS-20240227123807

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

Allegation investigated: Staff did not prevent resident from causing injuries to another resident in care

At 10:15a.m. Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced initial visit to investigate the above stated allegation. LPA met with the VPO and explained the reason for the visit. At 10:30a.m. LPA Alvizar-Ettima requested the staff, and facility residents’ roster, as well as the rosters for residents that temporarily were relocated in this facility due to Eaton Fire. At 10:45a.m.LPA Alvizar-Ettima and VPO conducted physical plant tour. Between 10:50a.m. – 11:20a.m. LPA conducted interviews with VPO and staff. LPA asked questions relevant to the nature of the complaint. In addition, at 11:53a.m. LPA reviewed available rosters for facility residents and temporality relocated residents. Staff did not prevent resident from causing injuries to another resident in care. It was alleged that the resident #1 (R1) has been seen with a cut on their arm and multiple bruises on body,caused by resident #2 (R2). Cont. LIC 9099C Unsubstantiated LPAs interviews with administrative personnel, Caregivers and Med-Tech revealed they have not seen a resident with a cut and multiple bruises. R1 and R2 are not resident of the facility. They maybe residents that were temporarily relocated at this facility due to Eaton Fire. At the time of this visit, LPA attempt to interview temporarily relocated residents. However, they were no longer at the facility. During investigation, LPA did not observe residents with a cut and multiple bruises on body in the facility. LPA reviewed facility resident roster, temporarily relocated resident roster and R1, and R2’s names were not there. Based on observation, interviews and record review it was concluded that although the allegation may have happened, there is no pertinent information to verify validity of the complaint. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit Interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 17, 2025 · control 31-AS-20250116132313

Allegation investigated: Due to lack of supervision, resident was restrained by another resident causing injuries

At 10:15a.m. Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced initial visit to investigate the above stated allegation. LPA met with the VPO and explained the reason for the visit. At 10:30a.m. LPA Alvizar-Ettima requested the staff, and facility residents’ roster, as well as the rosters for residents that temporarily were relocated in this facility due to Eaton Fire. At 10:45a.m. LPA Alvizar-Ettima and VPO conducted physical plant tour. Between 10:50a.m. – 11:20a.m. LPA conducted interviews with VPO and staff. LPA Alvizar- Ettima asked questions relevant to the nature of the complaint. In addition, at 11:53a.m. LPA reviewed available rosters for facility residents and temporality relocated residents. Due to lack of supervision, resident was restrained by another resident causing injuries. Cont. LIC 9099C Unsubstantiated It was alleged that resident #1 (R1) allegedly was seen tied up to a chair with a blanket by resident #2 (R2). Interviews with Administrative personnel, caregiver and Med-Tech. revealed that they have not witnessed R1, or any other resident restrained/tied to a chair. Staff indicated that R1 and R2 are not resident of the facility and may have been residents temporarily living at the facility due to Eaton Fire. At the time of this visit, LPA attempt to interview temporarily relocated residents. However, residents were no longer at the facility. During investigation, LPA did not observe residents restrained/tied to a chair in the facility. LPA Alvizar - Ettima reviewed facility and Eaton residents rosters and noted that R1 was a temporarily relocated resident. R2’s name was not on the list. Based on observation, interviews, and record review there is no pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit Interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 17, 2025 · control 31-AS-20250116144714

Type of visit: Collateral

At approximately 11:55 a.m. on 01/17/2025 Licensing Program Analyst (LPA) Antonia Alvizar-Etitma conducted an unannounced case management visit. LPA met with VPO and disclosed the reason for the visit. Today’s case management visit was conducted to ensure the safety and welfare of evacuees from the RCFE North Like Villas (LIC# 197603823), due to Eaton Fire. LPA interviewed the Vice President of Operations and staff at about 12:05 p.m., and toured the facility. LPA was not able to conduct interviews, due to Residents’ having lunch. Currently, twenty-four (24) residents from North Lake Villas Inc. # 197603823 facility are present. LPA observed all residents in good condition; well kept, clean and groomed. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 17, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Cava conducted an unannounced Case Management (CM) visit to the facility. LPA met with the Business Office Manager (BOM), Katia Arriage, and advised the BOM of the reason for the visit. Today’s CM visit was conducted to ensure the safety and welfare of evacuees from the Eaton Fire who were relocated temporarily to this facility. The CM visit composed of interviews with the BOM, the Charge Nurse and Director of Nursing from both Skilled Nursing Facilities (SNF), and random residents that were evacuated to this facility. A physical plant inspections was also made to insure the health and safety of the residents in care. The following information was obtained during the visit: SNF #1 has one (1) RN, three (3) LVNs, and four (4) CNAs daily, round the clock for 24 hour coverage. They are awaiting instructions from the Department of Health Service for clearance to return back to their SNF. Care and supervision only provided by their staff and not staff from Encino Terrace. SNF #2 has 6-8 nurses (CNAs & RNs combined) daily, round the clock for 24 hour coverage. Return to the SNF is indefinite for now. Charge nurse is in communication with the health department for instruction. Care and supervision only provided by their staff and not staff from Encino Terrace. SNF #1 has a census of 12. SNF #2 has a census of 29. Facility has a census of 35. Total in building 76. All residents were in good condition and feel safe. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Katia Arriaga for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 9:30 AM and the following was noted: There is one entrance being utilized at the facility. The facility has a total of seventy-three (73) bedrooms each with its own restroom. and four (04) public restrooms. The facility is fire cleared for eighty-four (84) non-ambulatory and a hospice waiver for eight (08). The facility is currently occupying thirty-two (32) residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 74°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located throughout the facility and observed to be fully charged and last inspected 12/19/2023. (continued on LIC 809-C) The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 110.6°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. Liability insurance policy expires 01/01/2025. LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 24, 2024

Allegation investigated: Staff speaks inappropriately to residents in care. Staff hit resident in care. Food services are inadequate.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above allegation. LPA met with Katia Arriaga and explained the reason for the visit. ---Staff speaks inappropriately to residents in care. ---Staff hit resident in care. It was alleged that resident was spoken to inappropriately, bullied and sucker punched by staff. To investigate the allegation, on 10/02/2024 LPA conducted a physical plant tour at around 11:00a.m., interviewed four (04) staff from 12:00p.m. to 1:30pm and interviewed six (06) residents from 1:30p.m. to 2:45p.m. During the physical plant tour, LPA observed that residents were clean, well-groomed with no signs of abuse. During interviews with staff, all staff stated they have never hit or bullied a resident and treat all residents with dignity and respect. (CONT. on LIC9099-C) Unsubstantiated During interviews with residents, five (05) out of six (06) residents stated they have never experienced or witnessed any bullying or hitting by staff and are treated with respect and dignity. One (01) out of six (06) residents stated one (01) staff who is no longer employed pointed their finger at them while speaking, did not treat them with dignity and respect but did not physically assault them. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Food services are inadequate. It was alleged that there are food issues, and that the food is bad. To investigate the allegation, on 10/02/2024 LPA conducted a physical plant tour at around 11:00a.m., interviewed four (04) staff from 12:00p.m. to 1:30pm and interviewed six (06) residents from 1:30p.m. to 2:45p.m. During the physical plant tour, LPA also observed a full and well-balanced menu with options. During a tour of the kitchen and dining area, LPA observed fresh and nutritious foods being prepared and served. A review of the menu shows that there are a variety of nutritious and well-balanced meals served daily. During interviews with staff, all staff stated residents are served fresh and nutritious foods daily. During interviews with resident, all residents stated they are served fresh, well-balanced and nutritious breakfast, lunch and dinners daily. Based on observations, record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 31-AS-20240417171008

Allegation investigated: Staff did not seek timely medical attention for a resident

On 10/02/2024, Licensing Program Analyst (LPA) Abeye Duguma visited the facility to deliver findings. On Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at approximately 11:25 am. LPA Smith met the administrator and disclosed the purpose of the visit. Staff did not seek timely medical attention for a resident On 11/07/2023, during the initial complaint visit, LPA Tihesha Smith conducted interview with the Business Director and staff. From approximately 12:10 pm to 2:50 pm, LPA Smith toured Resident #1(R1) room, requested and reviewed copies of documents relevant to the investigation. (CONT. on LIC 9099-C) Unsubstantiated These documents included, but were not limited to, R1 admissions agreement, transport document and hospital admission and discharge documents. LPA Smith was unable to interview R1 as they were not present at the facility during time of visit. Interviews with three (3) of three (3) staff revealed that R1 refused to be taken to the hospital when 911 was contact on 10/30/2023 Two (2) of three (3) staff revealed when residents refuse medical service and or transport, the paramedic staff are not happy and express their disapproval. The next day on 10/31/2023, R1 began to experience pain from leg injury and wanted to be taken to hospital. Facility staff called for transport and R1 was taken to the hospital on 10/31/2023. During interviews with residents, six(6) out of six (6) residents stated they feel staff seek medical attention timely. LPA Smith reviewed R1 records which included daily notes, transport documents, medical documents, and incident reports. Records reveal 911 was contacted for R1 and R1 was taken to the hospital by ambulance in a timely manner. Based on interviews and record review there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 31-AS-20231031161113

Allegation investigated: Staff is refusing to accept a resident back into the faciltiy

Licensing program analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility to deliver findings. The administrator was present at the facility and LPA Smith met with the administrator and disclosed the purpose of the visit. Staff is refusing to accept a resident back into the facility It was alleged that the facility refused to accept Resident #1 (R1) back at the facility. To investigate this allegation, during initial visit on 10/02/23, LPA Smith conducted interviews and requested copy of facility documents between 11:35 am-2:20 pm. On 10/17/23, LPA Smith made a subsequent visit and conducted interviews and requested additional documents between 10:12 am -11:48 am. (R1) passed away on 9/26/23. LPA's interview with staff revealed that R1 was never refused to be accepted back into the facility. R1 arrived without notice from the hospital on 9/22/23 and was allowed to return to the facility. Further interviews revealed that the concern was the facility staff was not notified Unsubstantiated (cont from 9099) by the hospital of R1’s discharge and return back to the facility and the administrator was not afforded time to conduct a reassessment for R1 prior to R1s discharge from the hospital. Based on interviews there is insufficient information to support the allegation, therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 31-AS-20230922124025

Allegation investigated: Staff did not provide authorized representative with resident's 30-days notice of eviction.

On 09/17/24 Licensing Program Analyst (LPA) Nicholas Reed visited the facility to deliver amended document for the visit previously conducted on 05/25/2023. The report was amended to add additional information to support final findings. On 05/25/2023 Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at approximately 11:25 am. LPA Smith met the administrator and disclosed the purpose of the visit. Staff did not provide authorized representative with resident's 30-day’s notice of eviction On 05/30/2023, during the initial complaint visit, LPA Tihesha Smith conducted interviews with the Director and other facility staff. From approximately 12:40 pm to 1:10 pm, LPA Smith requested and reviewed copies of documents relevant to the investigation. Unsubstantiated (cont from 9099) These documents included, but were not limited to, R1’s admission agreement, R1’s account payment summary, a copy of the 30-day eviction notice, and other relevant records. LPA was unable to interview Resident #1 (R1) as they no longer reside at the facility. Interviews two (2) of two (2) staff revealed that Resident 1 (R1) was self-responsible and did not have a Power of Attorney (POA) on file. One (1) of two (2) staff revealed R1’s friend was in the process of obtaining a POA. The Administrator disclosed that R1 had an overdue balance, which initiated the eviction process. Despite previous discussions about the default balance, R1 made no attempts to settle the unpaid amount. On 02/24/23 a second 30-day eviction notice was issued to R1 due to non-payment. A brief discussion with the interested party on 04/18/2024 revealed that they started the process of obtaining a POA in May of 2023 which was after R1 received 30-day Eviction Notices on 9/22/2022 and 02/24/2023. LPA Smith reviewed R1’s file and it did not contain any POA records for R1. Records confirmed that R1 was self-responsible, and that the eviction notice was served to R1 in accordance with the policy outlined in the admissions agreement. Additionally, records showed that information and/or communication regarding default and/or return payment was discussed with R1. The resident moved out of the facility on 02/15/2024 with a pending outstanding balance at the facility. Based on record review and interviews there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 31-AS-20230525140558

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 11:25 am. LPA was greeted at concierge desk. The administrator was present at the facility and LPA disclosed the purpose of the visit to the administrator. LPA conducted a tour of the physical plant at approximately 12:05 pm to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The common areas were observed for the ability to safely serve the needs residents. The following areas were observed: Gym-three (3) activity areas, dining/private dining room, library, and two (2) patio areas. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be sanitary and furnished appropriately. The facility has a total of seventy-three (73) bedrooms including private bathroom in each and four (04) public restrooms for both residents and staff use. Due to time constraints this required annual will be completed at a later time. Exit interview conducted/Copy of report giventhe state’s words, verbatim · CDSS document, Apr 18, 2024