Garden Crest

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Allegation investigated: Staff are leaving resident unattended for extended periods of time

Licensing Program Analysts (LPA) Luis De Leon conducted an initial unannounced complaint investigation visit for the allegation listed above. LPA met with Administrator Mary Ann De Jesus Villegas and explained the reason for the visit. Regarding allegation: Staff are leaving resident unattended for extended periods of time It is alleged that are leaving residents unattended for extended periods of time which has led to residents feeling neglected. Investigation consisted of interviews with staff, residents, and review of R1 facility file, including admission agreement, physician’s report, needs and service plan, and progress notes. The investigation reveals the following: Interview with residents revealed that four (4) out of six (6) residents stated that staff are responsive to residents’ needs and residents are not left unattended for long period of time. Residents stated that staff encourage residents to participate in activities with other residents. (Report continues on page LIC-9099C...) Unsubstantiated R1 stated that R1 chooses not to get out of room for fear that R1’s belonging may be lost. LPA observed that R1’s belongings were on R1’s bed next to R1. LPA observed that R1 has a dresser next to bed with a lock, but R1 stated that R1 cannot reach the drawer/lock. R1 stated that R1 also prefers to stay in bed because of fear of falling. R1 stated that a wheelchair doesn’t help because staff do not stay next to R1 all the time. Interview with staff revealed that six (6) out of six (6) staff stated that residents are not left unattended for long period of time. Administrator stated that there is no way that a resident will be left unattended for a long period of time. There are staff interacting with residents throughout the day including caregivers, activity staff, administrators, and housekeepers. Administrator explained that R1’s expectation of care to be the same as the skill nursing home where R1 came from. However, Administrator explained that such level of care is not possible in an assisted living home. Administrator stated that R1 preference is to stay in bed and not participate in activities with other residents. Staff have encouraged R1 to get out of bed, but R1 prefers not to. Staff encourage residents to get out of room to participate in various activities at the facility. Records review revealed the facility logs show staff interacting with R1 throughout the day. LPA observations revealed that residents are encouraged to participate in various activities and activity staff reminds residents of the daily activities available for residents to participate. LPA observed three (3) out of four (4) bedbound residents in the common areas engaged in some facility activities. Based upon the investigation, resident and staff interviews, document review, and LPA observations, there is insufficient evidence to support the allegation that staff are leaving residents unattended for extended periods of time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was held with Administrator Mary Ann De Jesus Villegas. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 17, 2026 · control 28-AS-20260710153258

Allegation investigated: Staff handled resident in a rough manner.

Licensing Program Analyst (LPA) Luis De Leon conducted an announced visit on 6/15/2026, regarding the above allegations in order to deliver a superseded licensing report with no changes to initial investigation finding. On 06/02/2026, LPA De Leon conducted an unannounced initial complaint investigation and delivered findings. During today’s office visit, LPA De Leon met with Administrator Waynn Romero and explained the purpose of today’s meeting. The investigation consisted of the following: On today’s visit, LPA De Leon toured the physical plant with Facility Administrator and obtained the current resident and staff roster. Relevant copies of resident (R1's) file documents were reviewed and obtained, along with admission agreement, physician’s report, needs and service plan, MARs log and facility training for transferring techniques. (Report continues on page LIC-9099C...) Unsubstantiated Regarding allegation: Staff handled resident in a rough manner. It is alleged that residents are handled in a rough manner when staff assist residents with transferring from bed to chair. Investigation consisted of interviews with staff, residents, and review of R1 facility file, including admission agreement, physician’s report, needs and service plan, and MARs logs. The investigation reveals the following: interview with residents revealed that six (6) out of seven (7) residents stated that staff does not treat residents rough while assisting residents with activities of daily living, including bed transferring. Interview with R1 revealed that R1 was not able to describe an incident where staff was rough when providing assistance to R1. R1 stated that two guys have hurt R1 when transferring, but R1 was not able to provide names or times of incidents. LPA’s interview with R1 revealed that R1 was not able to provide consistent answers to LPA’s questions. Interview with staff revealed that six (6) out of six (6) staff stated not to be aware of staff treating residents in a rough manner. Three (3) out of three (3) staff providing direct care to residents denied handling residents in a rough manner or knowing any other staff treating residents in a rough manner. S3 confirmed providing transferring assistance to R1, but denied treating R1 in a rough manner. Administrator stated that staff is trained as much as possible with transferring techniques. Based upon the investigation, resident and staff interviews, document review, and LPA observations, there was insufficient evidence to corroborate the allegation that staff treats residents in a rough manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was held with Administrator Waynn Romero. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 15, 2026 · control 28-AS-20260528091814

Allegation investigated: Staff handled resident in a rough manner.

Licensing Program Analysts (LPA) Luis De Leon conducted an initial unannounced complaint investigation visit for the allegation listed above. LPA met with the Administrator Waynn Romero and explained the reason for the visit. The investigation consisted of the following: On today’s visit, LPA De Leon toured the physical plant with Facility Administrator and obtained the current resident and staff roster. Relevant copies of resident (R1's) file documents were reviewed and obtained, along with admission agreement, physician’s report, needs and service plan, MARs log and facility training for transferring techniques. Regarding allegation: Staff handled resident in a rough manner. It is alleged that residents are handled in a rough manner when staff assist residents with transferring from bed to chair. Investigation consisted of interviews with staff, residents, and review of R1 facility file, including admission agreement, physician’s report, needs and service plan, and MARs logs. (Report continues on page LIC-9099C...) Unsubstantiated The investigation reveals the following: interview with residents revealed that six (6) out of seven (7) residents stated that staff does not treat residents rough while assisting residents with activities of daily living, including bed transferring. Interview with R1 revealed that R1 was not able to describe an incident where staff was rough when providing assistance to R1. R1 stated that two guys have hurt R1 when transferring, but R1 was not able to provide names or times of incidents. LPA’s interview with R1 revealed that R1 was not able to provide consistent answers to LPA’s questions. Interview with staff revealed that six (6) out of six (6) staff stated not to be aware of staff treating residents in a rough manner. Three (3) out of three (3) staff providing direct care to residents denied handling residents in a rough manner or knowing any other staff treating residents in a rough manner. S3 confirmed providing transferring assistance to R1, but denied treating R1 in a rough manner. Administrator stated that staff is trained as much as possible with transferring techniques. Based upon the investigation, resident and staff interviews, document review, and LPA observations, there was insufficient evidence to corroborate the allegation that staff treats residents in a rough manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was held with Administrator Waynn Romero. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 28-AS-20260528091814

Allegation investigated: Staff neglect resulted in pressure injuries to a resident in care.

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 02/19/2026 to deliver findings related to the above allegation. LPA met with Administrator Waynn Romero and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, resident face sheets, physician’s reports, medication orders and progress notes. In addition, LPA reviewed documentation related to home health services involved in R1’s care. LPA also conducted interviews with four (4) staff members (S1–S4), two (2) witnesses (W1–W2), and five (5) residents (R1–R5). (continued 9099C) Unsubstantiated Allegation: Staff neglect resulted in pressure injuries to a resident in care. It is alleged that staff failed to reposition R1 as required, resulting in the development of possible pressure ulcers/bedsores. During staff interviews, staff reported that their duties include providing direct care to residents, assisting with activities of daily living, repositioning, incontinence care, housekeeping tasks, meal assistance, and medication administration. Staff consistently stated that facility procedure requires repositioning residents every two hours and that caregivers collectively share responsibility for ensuring repositioning is completed. During R1 interview, R1 stated she is changed approximately every three hours but is not consistently repositioned and reported that her pressure sores developed after admission to the facility. During resident interviews (R2–R5), residents reported being satisfied with the care provided by staff. Residents stated that staff assist with repositioning or provide help when needed and reported that staff are kind and responsive. One resident reported occasional delays in assistance, particularly for restroom needs, while the remaining residents reported no concerns regarding care. During witness interview (W1), W1 reported concerns regarding the development of R1’s pressure-related skin issues following admission. W1 described notifying R1’s physician, requesting increased repositioning from facility staff, and expressed uncertainty regarding the consistency of repositioning practices. W1 also reported encouraging R1 to participate in her own care when possible. During witness interview, W2 provided information regarding home health services for R1. W2 was contacted by telephone and reported that a home health nurse visits R1 three (3) times per week to assist with care. W2 confirmed they are currently treating one (1) wound only. W2 confirmed they will be emailing the facility all skilled nursing visit notes from start of care 12/25/25 to date. (continued on 9099C) LPA observed a Physician’s Report dated 12/15/25 indicating that R1 was admitted to the facility with a healing Stage Two sacral wound. R1’s admission date was 12/22/25. Based on Home Health notes, R1 began receiving services on 12/25/25. Per a Home Health note dated 01/28/26, nurse documented that the wound continued to show signs of healing. A wound assessment completed on 02/02/26 noted the wound had improved to Stage One. Home Health notes dated 12/31/25 to present reflect consistent care and continuous progress in wound healing. Based on the investigation conducted, which included interviews with staff, witnesses, and residents, as well as a review of relevant records, there was insufficient evidence to support 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 was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 28-AS-20260129121605

Type of visit: Required - 1 Year

License Program Analysts (LPA) Luis De Leon conducted an unannounced annual required visit. LPA met with Administrator Mary Anne Villegas. The purpose of today’s visit was explained. The facility is licensed to serve 44 residents over the age of 60, 18 residents may be non-ambulatory. The facility is approved for 4 hospice waivers, and 6 bedridden in assigned rooms. The LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows: FACILITY PHYSICAL PLANT The facility is a two-story building located in Los Angeles, CA. A tour of the facility includes: Upstairs (2nd Floor): 9 resident rooms (with private bathrooms), lobby/TV room, kitchen, dining/activity room, 2 public restrooms, janitor closet and linen closet. Downstair (1st Floor): 13 resident rooms, 2 common shower rooms, beauty shop, library/laundry room, 2 common shower rooms, 2 staff bathrooms, nurse station (medication room), janitor closet and linen closet. REVIEW OF FILES Client record review consisted of Admission Agreements, Identification and Emergency Info, Physicians Report, Consent Report, Need and Service Plans, Personal Rights, and Centrally Store Medication. Client’s P&I money were reviewed for 2 clients. Staff record review consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, Training, and CPR. Report continues on page LIC-809C... Observations during facility tour: Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for clients. Signal System was observed in the bedroom and the bathroom. LPA tested the signal system and caregivers responded in a timely manner. Wall and floors are in good repair. Hallways and stairwells were clean and free of obstructions. Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area. Weekly food menu is posted at the facility. The kitchen staff has modified diets posted for residents that require modified diets. Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean. The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees. The LPA did not observe any sharps accessible to clients in their rooms or in the common areas. Also, disinfectants and cleaning supplies are locked and secured inaccessible to clients. Smoke detectors were observed in all bedrooms and common areas. Carbon monoxide detectors were observed in the hallway on both floors leading to residents’ rooms. Three (3) fire extinguishers were observed and were fully charged with last inspection on 01/13/2025. Last fire drill, earthquake, and disaster drill was conducted on 7/15/2025. There are shaded areas in front of the facility for residents to enjoy. The medications are centrally stored and locked in the nurse room. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all four (4) residents. LPA conducted interviews with one staff. One client interview was conducted while second client was out in the community. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided to administrator Mary Anne Villegas.the state’s words, verbatim · CDSS document, Sep 29, 2025

Allegation investigated: Staff did not safeguard resident’s personal belongings Facility failed to address resident’s medical needs

Licensing Program Analysts (LPA) Luis De Leon conducted an initial unannounced 10-day complaint investigation visit for the allegations listed above. LPA met with the Activities Director Waynn-Nietzle Romero and explained the reason for the visit. Ms. Romero contacted Administrator Mary Ann De Jesus Villegas to inform of today’s visit. The administrator joined the visit at 9:30 AM. The investigation consisted of the following: On today’s visit, LPA De Leon interviewed the Administrator and obtained staff, resident rosters and discharge roster. Both resident roster and discharge roster reveal that the individual #1 (I1) does not currently reside and/or was never a resident at the facility. The interview with administrator De Jesus Villegas confirmed that the individual has not resided at the facility. This agency has investigated the complaint alleging staff did not safeguard resident’s personal belongings, and that facility failed to address resident’s medical needs. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened, and/or are without a reasonable basis. We therefore dismissed the complaint. An exit interview was conducted, and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Aug 21, 2025 · control 28-AS-20250815143343

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) S Vaid conducted the required annual inspection. LPA arrived unannounced and met with Lorra Ghazarian (Administrator) and explained the purpose of today’s visit. The facility is licensed to serve 44 residents over the age of 60 of which up to 18 may be non-ambulatory residents, is approved for 4 hospice waivers, and 6 bedridden in assigned rooms. The facility is a two story building located in Los Angeles, CA. A tour of the facility includes: First Floor: 13 resident rooms, tv room, 2 public restrooms, 2 shower rooms, janitor closet and linen closet. Second Floor: lobby / tv room, kitchen, dining/activity room, library/ laundry room, 2 common shower rooms, 2 staff bathrooms, 9 resident rooms (with private bathrooms), nurse station (medication room), janitor closet and linen closet. Facility has multiple fire extinguishers and carbon monoxide detectors with a sprinkler fire system throughout the facility. LPA interviewed five (5) staff and four (4) residents on today’s visit. LPA utilized the Compliance and Regulatory Enforcement tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and there is an Infection Control Plan on file. Operational Requirements: The facility maintains a plan of operation and has the required liability insurance on file. Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance. Bathrooms are clean and operational. Residents’ bedrooms were observed to have reasonable accommodations each clients comfort was available. Nonskid mats were observed in shower rooms and residents’ private bathrooms. The outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees. (Continued on 809-C) All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a secured/locked area and inaccessible to residents. The last Fire/Emergency Drill was conducted on 8/13/24 and 08/19/24 respectively. The fire extinguisher was observed and is fully charged. Facility has telephone service on premises. Staffing: There appears to be sufficient staffing at all times in the facility with at least one CPR trained employee on the premises at all times. Administrator Edwin Villanueva certificate expires 12/17/2025. Personnel Records-Training: Staff has criminal record clearance, current first aid and CPR, and ongoing training. Staff files are maintained at the facility and kept in the Nurse Station. During todays visit LPA observed 4 staff files with no issues. Resident Records-Incident Reports: Resident files are kept in a secure location within the Nurse Station and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA observed 4 resident files during todays visit with no issues. Resident Rights-Information: Complaint and Personal Rights posters were observed in hall-way. Residents are provided with telephone and internet at the facility. Planned Activities: There is an activity schedule posted outside the activity/dining room, LPA observed residents engaging in a exercise activity during today’s visit. There are board games and books readily available for residents in the library. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: All medications for residents are kept locked and inaccessible to other residents. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed 4 residents’ medication no issues were observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The facility does have evacuation chair at each stairwell. Residents with Special Health Need: “No smoking oxygen In Use” signs are properly posted. There are no bedridden or residents or residents with postural supports at this facility. No deficiencies were noted on today's visit, copy of this report was left with Karla Yumal (Interim Administrator/ Business Office Manager).the state’s words, verbatim · CDSS document, Aug 27, 2024