Everest at Walnut Valley Senior Living

Allegation investigated: Staff does not ensure resident is allowed to be readmitted to the facility.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint investigation regarding the above mentioned allegation. LPA met with Donghyun Moon, administrator and explained the reason for the visit. The investigation consisted of the following: LPA obtained a copy of the staff & resident rosters, SNF Admission record, Walnut Police report (SEAR 06/09/2026), Resident #1 (R1) files such as Identification and Emergency Information (Face sheet), Admission agreement, Pre admission appraisal, Medical Assessment, Appraisals Needs and services plan, Medication administration record (MAR) for May 2026 and Physician's reassessment letter (06/09/2026). LPA interviewed Staff #1 (S1) - Staff #3 (S3) and Resident 2 (R2) – Resident #9 (R9). Resident #1 (R1) was not interviewed because they are in a Skilled Nursing Facility (SNF). *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: Allegation: Staff does not ensure resident is allowed to be readmitted to the facility. It is alleged that on 06/09/2026, facility is refusing to readmit R1 from SNF due to care needs unless they are placed on hospice care. All staff interviewed denied the allegation. Staff stated that R1 was transferred to SNF on 05/19/2026 due to worsening respiratory conditions. Prior to R1's release at SNF, S3 re-assessed R1 on 06/10/2026 to ensure that their needs are met upon their return. However, S3 determined that R1's condition has changed requiring a higher level of care that the facility was unable to provide. R1 also has a highly communicable condition that poses a high risk of infection to both staff and the current residents if readmitted. Staff informed R1's family about the decision and facility will provide a 30-day eviction notice to terminate the residency agreement. Staff also added that they are prepared to assist in finding appropriate alternative placement for R1. (5) of (8) residents stated that the facility readmitted them to the facility after being hospitalized, without any issues. All (8) residents stated that staff provide the care and assistance they need. LPA reviewed R1’s physician reassessment which confirmed that R1 requires a higher level of care due to their complex healthcare needs, chronic comorbidities and high risk of antibiotic resistance. In addition, physician stated that the facility is unable to provide services suitable for R1. Documentation reviewed and interviews conducted do not corroborate this allegation. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Donghyun Moon, Administrator.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 28-AS-20260609142602

Allegation investigated: Resident sustained bruises, due to staff neglect.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit regarding the above-mentioned allegation. LPA met with Donghyun Moon, Administrator and explained the reason for the visit. The investigation consisted of the following: LPA conducted a tour of the facility, obtained copies of the Staff and Resident rosters, Staff in-service training log on Mandated reporting, Personal rights and Gait mobility/Repositioning of residents, Staff 72-hour log notes and Resident #1 (R1)'s files such as: Face sheet/Identification and Emergency Information, Physician's Report, Medication list, Hospice care plan and notes, Unusual Injury/Incident Report/SIR, photo of R1's arm, LPA also interviewed Staff #1 (S1) - Staff #5 (S5), Resident #1 (R1) - Resident #8 (R8) and Hospice Nurse #1 (N1). The investigation revealed the following: Regarding the allegation: "Resident sustained bruises, due to staff neglect." It is alleged that a large bruise was observed on R1's left arm while being given a shower. In addition, R1 has been observed to have bruises several times in the past. *****CONTINUED ON LIC9099-C***** Unsubstantiated Interviews conducted with staff members indicated they have seen R1's bruise on the left arm but denied it was caused by neglect. Staff members interviewed indicated they have never physically abused or handled R1 or any of the residents in a rough manner, nor have they seen it happen. Staff members also stated that they have received the necessary training on how to transfer the residents and how to reposition them. S5 stated that R1 has had the bruise on her arm since December 2025 and has taken actions and interventions to prevent the bruising. S5 also indicated that aging causes R1 to have thinner or fragile skin and that the bruise on R1 may have been caused by medication side effects. Some staff stated that on either March 6 or March 7, 2026, the police came to conduct a welfare check on R1 but did not have any information nor contact details provided to them. Documents reviewed revealed that the facility has sufficient staffing and that the staff members have the proper documentation and notes. Moreover, the photos of R1's bruise appeared to be consistent with R1's thin skin and possible medication side effects. During the visit, LPA observed S3 and N1 assisting and transferring R1 from wheelchair to bed. Interviews conducted with (8) residents indicated they have not been hit or handled aggressively by any of the staff. All residents interviewed indicated that staff are well trained, helpful and nice to them. Interview with R1 revealed that the staff are nice to them and they had not been hurt nor injured by any staff. Additionally, R1 does not have a roommate and there were no witnesses, surveillance footage, or evidence obtained during the investigation to corroborate with the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Donghyun Moon, Administrator.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 28-AS-20260306101319

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by Christina Matsumoto, Executive Director and explained the purpose of the visit. The facility is licensed to serve for a capacity of (120) non ambulatory residents, age range 60 and over, of which (10) may be bedridden. Rooms 129-145 and all 1st floor rooms approved for bedridden except for room 101, 103, 105, 107, 109, and 111. Exterior gates approved for delayed egress. Hospice waiver for (20) has been approved. The facility has a new management, Walnut Silver Town effective 10/15/2025. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathrooms have hygiene items such as paper towel, hand soap and toilet paper. Staff are adhering to infection control requirements. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan. The facility has a dementia care plan to accept or retain residents with dementia. Facility maintains the required liability insurance which expires on 12/22/2025. Facility does not handle residents cash resources. Physical Plant/Environment Safety: The facility is a 2 story building with resident rooms on both floors. The main floor consists of the main lobby, administrative offices, activity room, dining room, kitchen, resident rooms, laundry room and the memory care unit. The 2nd floor consists mainly of resident rooms, medication room, office, laundry room and activity rooms. LPA selected random rooms in the 1st and 2nd floors to inspect. They are clean and have the required furnishings. There are no items obstructing the walkways. The fireplace is adequately screened. There are multiple carbon monoxide detectors in each hallway and fire sprinklers throughout the facility. There are shaded areas with outdoor furniture in the Memory Care unit and Assisted Living unit provided to the residents. There are no pools or large bodies of water. Facility has sufficient space to accommodate indoor and outdoor activities. There are planned activities daily. There are sufficient food supplies of 2-day perishable and a week of non-perishable items as well as water supply. The foods are properly stored in the refrigerator. There are no security bars or weapons on the premises. The facility has central air and heating accommodations. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. Storage areas for cleaning solutions, toxic, knives, and hazardous items were inaccessible to residents. The fire extinguishers were observed to be fully charged. *****CONTINUED ON LIC809-C***** Staffing: A total of 62 staff members including the Administrator provide care and supervision to the residents. There is sufficient staffing for each shift. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records-Training: The Administrator's certificate expires on 07/25/2027. Staff have criminal background clearance and training. (7) staff files were reviewed. There is at least one staff with CPR & First Aid training on each shift. Proof of staff training, health clearance and 1st Aid/CPR training are current. Resident Rights-Information: A total of (10) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, Individual Needs/Service Plans, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records, RCFE complaint poster and Personal rights were observed posted in the lobby. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in the lobby and the elevator. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Incidental Medical and Dental: Residents medications were reviewed containing 30-day supply of medications to confirm medication is given as prescribed and is documented properly. The facility uses the Quick Medication Administration Record (MAR) log to document medications given. Medications are centrally stored and locked in the medication room. Facility uses medical carts. Medications are administered as prescribed. Medical and dental transportation is provided. First aid is available and stored in each medical cart. Resident Records-Incident Reports: Resident files are kept in a secured location and have the following documents in their files: Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers. Facility conducts fire drill at least quarterly for each shift. Last fire drill was conducted on 09/29/2025. Residents with Special Health Needs: (2) residents who are utilizing oxygen tanks have signs posted at the front door. There are (10) residents receiving hospice care in the facility. Staff provide support care and supervision appropriate to meet the need of the residents receiving care from a Hospice agency. No deficiencies cited. An exit interview was conducted, and a copy of this report was provided to Christina Matsumoto, Executive Director.the state’s words, verbatim · CDSS document, Dec 16, 2025

Allegation investigated: Staff mismanaging resident’s medication(s). Staff misplaced resident’s medication(s). Staff billing resident for medication not administered.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with Christina Matsumoto/S-1 and discussed the purpose of today's visit. During the initial visit (02/18/25), LPA obtained a copy of the staff and resident rosters, interviewed Staff #1 (S-1)/Facility Administrator and reviewed Resident #1 (R-1) file and obtained relevant documentation. During the course of this investigation, LPA also interviewed Staff #2 (S-2) through Staff #4 (S-4) and Resident #1 (R-1) through Resident #7 (R-7). Refer to LIC 9099C for the continuation of this report. Unsubstantiated Staff mismanaging resident’s medication(s). It has been alleged that staff are mismanaging R-1’s sodium chloride medication. Staff interviews revealed that staff made numerous attempts to contact R-1’s physician to have R-1’s sodium chloride medication discontinued (per R-1’s authorized representative request) and were unsuccessful. Interviewed staff indicated that R-1’s authorized representative was successful in reaching R-1’s physician and obtained an order to discontinue the sodium chloride medication in which facility staff discontinued administering since receiving this new order (discontinued on 01/24/25). Resident interviews revealed that staff do not mismanage medications. Interviewed residents indicated that staff provide their medication as prescribed. Interviewed residents indicated they have not heard anyone complain nor have any concerns pertaining to this matter. Interviews do not corroborate this allegation. Staff misplaced resident’s medication(s). It has been alleged that Atenolol medication for R-1 was provided to a med tech “last September” and it was misplaced. Interviewed staff indicated that staff do not misplace residents’ medications. Staff interviews revealed that Atenolol medication for R-1 was not received from R-1’s authorized representative. Resident interviews revealed that staff do not misplace residents’ medications. Interviewed residents indicated they have not heard anyone complain nor have any concerns pertaining to this matter. Interviews do not corroborate this allegation. Staff billing resident for medication not administered. It has been alleged that staff are billing R-1 for medication that is not administered. Interviewed staff indicated that the staff nor this facility are not involved with billing for medications as the billing comes directly from the pharmacy. Interviewed staff indicated that residents and/or authorized representatives are responsible for paying any medical/pharmacy co-pays directly to those entities and not to this facility. Interviewed staff indicated that the medication billed and received by the pharmacy is administered as prescribed. Staff interviews revealed they have not received any complaints pertaining to this matter. Resident interviews revealed that residents pay their own co-pays for medical and medication services directly to the providers and not this facility. Interviewed residents indicated they have not heard anyone complain nor have any concerns pertaining to this matter. Interviews do not corroborate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, appeals rights and a copy of this report was provided to Christina Matsumoto/S-1/Administrator.the state’s words, verbatim · CDSS document, Apr 11, 2025 · control 28-AS-20250212113650

Allegation investigated: Staff administered felony drugs to resident. Resident sustained an unexplained head injury.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the investigation on the allegations listed above. LPA met with Administrator, Christina Matsumoto, and explained the purpose of the visit. On 1/23/25, LPA Chan conducted the initial visit and toured the physical plant. LPA obtained copies of the staff and resident rosters and collected documents for Resident #1. No health and safety concerns were observed. During the visit today, LPA interviewed the Administrator, Staff #1 - #6, and Residents #1 - #8. The investigation revealed the following: Allegation – Staff administered felony drugs to resident. It is alleged that Resident #1 (R1) tested positive for cocaine and PCP. LPA obtained medication records for R1 and were reviewed by the Department of Social Services clinical consultant nurse. Unsubstantiated There was no indication that the medications R1 is taking can produce false positives for cocaine and PCP. However, the hospital medical records showed that R1 was tested positive for felony drugs. The administrator and Staff were interviewed regarding this allegation. Per the administrator, no felony drugs were given to the resident. Staff interviewed denied giving R1 any illegal drugs and did not notice any signs of drug use. R1 did not behave differently prior to being hospitalized. The med techs stated they only administer medications that are prescribed by the physician, and they are careful in distributing the medications. LPA interviewed R1 who did not remember how resident fell but stated there was no usual item given by staff or visitors. Although R1 tested positive for cocaine and PCP, there is no evidence that the facility staff gave the drugs. Therefore, the allegation is unsubstantiated. Allegation - Resident sustained an unexplained head injury. LPA interviewed the administrator, Staff, and Residents on this allegation. The facility submitted an incident report to Licensing regarding Resident #1's fall in January. Resident #1 (R1) had a fall on 1/17/25 at approximately 2 a.m. and sustained a head injury. Per the administrator, R1 resided in the assisted living side at the time of the fall. Staff indicated R1 does not like to ask for assistance and would go to the restroom on own. For this reason, staff would ensure that the assistive devices are moved closer to the resident, and nothing is obstructing the walkway. Staff interviewed stated they check on R1 at least every 2 hours and remind resident to press the pendant if assistance is needed. R1’s son was aware of the resident's falls and was in communication with the administrator to move R1 to the memory care unit prior to the last fall. LPA interviewed 8 residents during today’s visit. All the residents stated staff check on them and will assist if needed. Although the resident sustained a head injury, there is no sufficient evidence to show that there is a lack of care/supervision. Therefore, the allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with the administrator. A copy of this report along with the appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 25, 2025 · control 28-AS-20250121093142

Allegation investigated: Staff are discriminating against resident. Staff are not safeguarding residents belongings.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegations listed above. LPA arrived unannounced and met with Executive Director, Christina Matsumoto. LPA obtained copies of the staff and resident rosters, reviewed file for Resident #1, and interviewed the administrator, 4 Staff members, and 9 Residents. For allegation – Staff are discriminating against resident. LPA interviewed staff and residents regarding this allegation. Staff stated they do not discriminate against residents. They provide reasonable accommodation if needed and treat residents fairly. For the incident in the dining room, the administrator stated she had explained and kindly asked the resident to move from the seat one time because it had been another resident’s daily seating. The resident got upset but got up to move on own. Unsubstantiated Staff indicated that the resident occasionally comes out to the dining room to eat and had moved from table to table due to preference. They do not tell the resident that they cannot sit at a particular spot but would let the resident know of available spots. LPA interviewed 9 residents, and 8 out of the 9 feel that the staff are kind and respectful. They have not felt discriminated by staff or have seen them discriminate against others. Allegation – Staff do not safeguard resident’s belongings. The administrator stated they try their best to safeguard belongings. The residents have their keys to their rooms and staff would only go in to do housekeeping or provide assistance. Staff interviewed do not touch or move residents' belongings without their consent. Staff stated that when a resident reports something missing/stolen, they would look for it right away. Sometimes the reported items were found misplaced in their rooms. LPA interviewed 9 residents. 3 out of the 9 residents have reported some of their belongings or money were stolen from their rooms. One of the residents stated their belongings were recovered after looking in the room. The rest of the residents did not have any missing or stolen items. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted. A copy of this report along with the appeal rights was provided to the administrator.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 28-AS-20250131144725

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection on 11/8/24. LPA arrived unannounced and met with the Executive Director, Christina Matsumoto. The facility is licensed to serve 120 non-ambulatory residents, ages 60 and over, of which 10 may be bedridden. Rooms #129 - #145 and all first floor rooms (except for rooms #101, #103, #105, #107, #109, and #111) are approved for bedridden. The 3 exterior gates are approved for delayed egress. There is a hospice waiver for 20 residents. LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tools. The facility is a 2 story building with resident rooms on both floors. The main floor consists of the main lobby, dining room, kitchen, resident rooms, and the memory care unit. The 2nd floor consists mainly of resident rooms and activity rooms. There is no swimming pool on the premises. LPA selected 8 random rooms (#112, #141, #143, #156, #215, #225, #226, and #238) to inspect. The rooms have non-skid mats and the hot water temperature was measured within range of 105-120 degrees F. There are multiple carbon monoxide detectors in each hallway. The fireplace is adequately screened. Facility has sufficient space to accommodate indoor and outdoor activities. There are planned activities daily. There are sufficient food supplies of 2-day perishable and a week of non-perishable items as well as water supply. The foods are properly stored in the refrigerator. The facility has a dementia care plan to accept or retain residents with dementia. Residents utilizing oxygen tanks have signs posted at the front door. Facility is continuing to follow their infection control plan and using appropriate hand hygiene. Gloves are worn by staff while assisting residents with some of the activities of daily living. The liability insurance is still current for the coverage of $1 million (per occurrence) and $3 million (total annual aggregate). Per the administrator, there is sufficient staffing for each shift. There is at least one staff with CPR & First Aid training on each shift. LPA reviewed 5 personnel files. The Administrator's certificate expires on 7/25/25. The staff files have the required documents and have fingerprint clearance. Staff are receiving the appropriate training for dementia care. LPA reviewed 8 resident files. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, and pre-appraisal form. Medications are centrally stored in a locked cart in the med room. The medications were checked for 6 out of the 8 residents and there were no discrepancies found. Information for appropriate reporting agencies are posted at the facility. The facility has the updated Emergency Disaster Plan and is receiving unannounced fire drills/disaster drills training from a specialist for all shifts. There were no deficiencies issued today. An exit interview was held and a copy of this report was given to Administrator Matsumoto.the state’s words, verbatim · CDSS document, Nov 8, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to finish the annual inspection. LPA met with Administrator, Christina Matsumoto, to explained the reason for the visit. LPA continued the inspection using the CARE tools. The following domains were reviewed: Staffing: The facility has sufficient staffing to meet the needs of the residents. There are awake staff providing night supervision in both assisted living side and the memory care unit. Personnel Records-Training: LPA reviewed 5 Staff files. The administrator's (Christina Matsumoto) certificate expires on 7/25/25. Staff have fingerprint clearance and associated to the facility. Staff have appropriate dementia care training and ongoing training. Resident Records-Incident Reports: LPA reviewed 5 resident files. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, and pre-appraisal form. Resident Rights-Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff. Incidental Medical & Dental: The medications are centrally stored in the wellness office. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed 5 residents' medication and they are being administered as prescribed by the physician. Residents with Special Health Needs: Facility accepts and retain residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. No smoking-Oxygen in use signs are posted where appropriate. The facility has approved delayed egress on 3 of the exterior gates. No deficiencies are issued today. A technical violation is provided on the LIC9102 form. An exit interview was held and a copy of this report was given to Administrator Matsumoto.the state’s words, verbatim · CDSS document, Nov 30, 2023

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.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Cynthia Chan and Sanjay Vaid conducted the required annual inspection. LPA met with Administrator, Christina Matsumoto, and explained the purpose of the visit. The facility is licensed for a capacity of 120 residents ages 60 and over, of which 10 may be bedridden. Rooms #129 - #145 and all first floor rooms (except for rooms #101, #103, #105, #107, #109, and #111) are approved for bedridden. The 3 exterior gates are approved for delayed egress. There is a hospice waiver approved for 20 residents. LPAs conducted the inspection using the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff continue to clean and disinfect daily. Facility has sufficient PPE supplies and the Infection Control Plan in place. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. Residents utilizing oxygen tanks have signs posted at the front door. Physical Plant & Environment Safety: The facility is a 2 story building with resident rooms on both floors. The main floor consists of the main lobby, dining room, kitchen, resident rooms, and the memory care unit. The 2nd floor consists mainly of resident rooms and activity rooms. There are no swimming pool or bodies of water on the premises. LPA selected 8 random rooms - (rooms #143, #137, #116, #104, #234, #239, #218, #202) to inspect. The rooms have non-skid mats and the hot water temperature was measured within range of 105-120 degrees F. There are multiple carbon monoxide detectors in each hallway. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are planned daily activities and are posted on the monitor. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. There are no deficiencies observed during the visit today. An exit interview was held and a copy of this report was given to administrator Matsumoto.the state’s words, verbatim · CDSS document, Nov 28, 2023