Generations of Los Angeles Assisted Lvng. Facility

Allegation investigated: Staff left resident soiled for an extended period Staff handled resident in a rough manner Staff did not ensure resident received physical therapy

On 08/20/2026 at approximately 9:00AM Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced subsequent visit to deliver findings. LPA met with Administrator Kathleen Tamondong and the purpose of the visit was explained. Investigation consisted of the following: On 12/04/2025 at approximately 9:00 AM, the Department conducted interviews with eight (8) staff members (S1–S8) and nine (9) residents (R1–R9). The Department also reviewed staff and resident rosters, the caregiver staff schedule, R1’s routine check logs, the December staff assignment log, staff in-service and orientation training records, and the facility’s admission agreement. On 08/17/2026 at 12:00Pm, The Department reviewed R1's Routine Check documentation dated 11/24/2025 through 11/25/2025; Application for Assessment/Evaluation and 72-Hour Detention dated 11/24/2025; Southern California Hospital at Culver City Wound Care Initial Assessment and Physician History and Physical- Please see report continuation on (LIC9099-C). Unsubstantiated dated 11/27/2025; and R1's Individual Service Plan by Concise Care Group. On 01/09/2026 at 9:00AM, The Department conducted additional interviews with five (5) residents (R10–R14)[JA1.1]. The investigation revealed the following: Regarding the allegation “Staff left resident soiled for an extended period” It is being alleged that staff left the resident sitting in urine for an extended period before providing assistance. The Department was unable to observe R1 because R1 was not present at the facility during the visits. During the visit, the department did not observe any other residents being treated in the manner alleged. Interviews conducted revealed the following: The Department interviewed eleven (11) residents (R1-R11). The Department found 1 of 11 residents (R1), agreed with the allegation 10 of 11 residents (R2-R11) disagreed with the allegation and 3 additional residents (R12-R14) were unable or unwilling to corroborate information. Interview with R1 revealed inconsistent information; R1 appeared confused, had difficulty staying on topic, and incorrectly identified current location. Interviews with eight (8) staff members (S1–S8) disagreed with the allegation. Records reviewed revealed the following: Routine Check Log for (R1) dated 11/15/2025 to 11/26/2025 indicated staff documented multiple diaper checks and changes, as well as several occasions when R1 refused diaper changes or asked staff to leave. A 72-hour Detention for Evaluation and Treatment document dated 11/24/2025 at 5:20PM, also indicated that (R1) was refusing care from staff. The Facility Resident Appraisal documented R1’s mental condition as having slight confusion. Based on interviews and records reviewed, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Regarding the allegation “Staff handled resident in a rough manner. It is being alleged that staff handled the resident in a rough and inappropriate manner while providing assistance. The Department did not observe conditions or staff interactions with residents that corroborated the allegation. Interviews conducted revealed the following: The Department interviewed eleven (11) residents (R1-R11). The Department found 1 of 11 residents (R1), agreed with the allegation 10 of 11 residents (R2-R11) disagreed with the allegation and 3 additional residents (R12-R14) were unable or unwilling to corroborate information. Interviews with eight (8) staff members (S1–S8) disagreed with the allegation. Records reviewed revealed the following: Southern California Hospital record dated 11/27/2025 did not contain medical documentation corroborating an injury resulting from staff handling R1 in the manner alleged. Please see report continuation (LIC9099-C) Based on interviews and records reviewed, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. “Staff did not ensure resident received physical therapy” It is being alleged that staff failed to ensure R1 received prescribed physical therapy services. The Department did not observe conditions or staff interactions that corroborated the allegation. Interviews conducted revealed the following: The Department interviewed eleven (11) residents (R1-R11). The Department found 1 of 11 residents (R1), agreed with the allegation 10 of 11 residents (R2-R11) disagreed with the allegation and 3 additional residents (R12-R14) were unable or unwilling to corroborate information. Interviews with eight (8) staff members (S1–S8) disagreed with the allegation. Records reviewed revealed the following: Individual Service Plan by Concise Care Group dated 06/10/2025 did not indicate that Physical Therapy (PT) was prescribed, required, or supported by an active physician order or referral prior to R1’s admission to the facility. Southern California Hospital – Physical Therapy Initial Evaluation, dated 11/29/2025, indicates (PT) was ordered and treatment was initiated during R1’s hospitalization. The record does not indicate that Generations had previously received an active PT order or failed to arrange therapy. Additional information from Hospital record dated 12/04/2025, states R1 received a trial of (PT) but made no measurable progress and was discharged from further skilled PT, with a Hoyer lift and custodial assistance recommended. Based on interviews and records reviewed, although the allegations 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 allegations are UNSUBSTANTIATED. No deficiencies were cited regarding the above allegations, and an exit interview was conducted with the Administrator.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 11-AS-20251125153143

Type of visit: Required - 1 Year

On 07/21/2026 Licensing Program Analysts (LPAs) Villegas and Brown conducted an annual required unannounced visit using the CARE Inspection Tool. LPA met with Jennifer Rivas as the purpose of the visit was explained. The facility is licensed to serve 178 ages residents ages 60 and over, 108 ambulatory and 70 non- ambulatory. The 1st floor is approved for delayed egress dementia only, the 2nd floor is approved for ambulatory only. There is an approved hospice waiver for 10 residents. Facility fees are current, surety bond active (Western surety agency 72644951), Liability insurance is active (00168885-0 Exp: 04/01/27). The facility is a Two story building that consist of the following: The facility has 92 resident bedrooms, 94 bathrooms, 2 atriums, 1 lounge, 3 offices, 1 doctors office, 1 conference room, 1 activity room, 1 industrial kitchen, 2 dining rooms, 1 library, 1 business office, 1 TV room, 1 staff break room, 1 facility laundry room, 1 resident laundry room, 3 emergency stairwells, 1 stairway, 2 lobbies, and 1 elevator. Indoor and outdoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. LPAs conducted a records review of 10 staff records, 10 client records, 10 medication administration records, and 10 P&I ledgers. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 06/14/26, 17 fire extinguishers fully charged are located throughout the facility, carbon monoxide and smoke detectors are interconnected and operational. Bay Alarm Company South Bay conducted annual fire alarm and emergency communication system inspection and testing on 11/12/25. 10 resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, non-slip mats and handrails observed, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knives were stored and inaccessible to residents. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 21, 2026

Allegation investigated: Staff inappropriately handled resident. Staff yell at resident. Staff did not provide water to resident.

On July 16, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced follow-up complaint visit. The LPA met with the Administrator (A1), Jennifer Rivas, and the Assistant Administrator (AA) Mangune Diosdado and explained the purpose of the visit. The investigation involved collecting records and touring the facility. On January 22, 2026, the Department initiated a complaint investigation and gathered documents, including the Personnel Report (LIC 500) dated February 26, 2026, and the Client Roster dated March 29, 2026. On July 16, 2026, the Department conducted a follow-up visit and collected documents related to resident #1 (R1). These included the Admission Agreement, the Physician's Report, the Medical Assessment, an unusual incident report dated January 13, 2026, R1's death report dated March 22, 2026, and the facility's water cooler log. During the investigation, the Department interviewed the Administrator (A1), five staff members (S1-S5), ten residents (R2-R11), and a witness (W). Unfortunately, the Department was unable to interview resident R1 because R1 passed away on March 22, 2026. Unsubstantiated Allegation #1: Staff inappropriately handled resident. The complaint alleged that the staff argued with resident R1 and then placed their hands on R1, resulting in R1 being hospitalized. On July 16, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that it was actually a resident, not a staff member, who was arguing with R1. The facility provided in-service training to all staff on de-escalating situations involving residents who are arguing or fighting. A1 also mentioned that R1 had been hospitalized several times due to R1's medical condition. On the same day, the department interviewed five staff members (S1-S5), all of whom denied the allegation, stating that no staff member at the facility would ever put their hands on any residents. They emphasized that they are trained in de-escalation techniques and maintain a high level of patience when dealing with residents. Additionally, the department interviewed 10 residents (R2-R11), all of whom reported that no staff member had ever mishandled them. The department also spoke with a witness (W) who denied witnessing any staff mishandling R1 during visits to the facility. Furthermore, the department reviewed the Unusual Incident Report dated January 13, 2026, which the facility submitted. This report indicated that R1 was involved in an argument with another resident that day. The department was not able to examine the facility note for that day because there were no records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur; therefore, the allegation is unsubstantiated. Allegation #2: Staff yell at resident. The complaint alleged that staff yelled at a resident, R1. On July 16, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that the facility provided in-service training on clients' personal rights and ensured that no staff member would yell at a resident, including R1, for any reason. During the same investigation, the department interviewed five staff members (S1-S5), all of whom denied the allegation and stated that they had never witnessed any staff member yelling at residents. Furthermore, none of the staff members reported that residents, including R1, had indicated any instances of being yelled at. The department also interviewed ten residents (R2-R11), all of whom denied being yelled at by any staff member. In fact, some residents jokingly said they were the ones who tended to yell at the staff. Additionally, the department spoke with a witness (W), who also denied witnessing any staff members yelling at R1 or hearing R1 complaints about it. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur; therefore, the allegation is unsubstantiated. Allegation #3: Staff did not provide water for resident. The complaint claimed that resident R1 requested water but that the staff never provided it. On July 16, 2026, the department interviewed the Administrator (A1), who denied the allegation. A1 stated that the facility has a water cooler on each floor, stocked with ice water and disposable cups for residents. Additionally, A1 mentioned that the caregiver refills the water cooler every two hours to ensure residents have plenty of water to drink. On the same day, the department also interviewed five staff members (S1-S5), all of whom denied the allegation. They confirmed that the facility has ice water coolers providing water to residents. Furthermore, they stated that the caregiver goes around each floor every two hours to deliver ice water and juice to all residents. On July 16, 2026, during the facility tour, the department noted that each floor was equipped with an ice cooler filled with ice water and provided disposable cups for residents. The department also reviewed the facility records regarding the schedule for filling the water coolers, including the specific dates and initial fill dates and times. The department also interviewed a witness (W) who denied the allegation and stated that the facility does provide R1 with plenty of water. There is ice water on each floor of the facility. (W) also stated that R1 never complained to (W) about not having had any water to drink. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur; therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to Administrator Jennifer Rivas.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 11-AS-20260115155033

Type of visit: Case Management - Deficiencies

On 02/24/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Case Management – Deficiency visit, to document two deficiencies observed during a complaint investigation control number 11-AS-20260223121758 at this facility. LPA met with Administrator, Jennifer Rivas, and the purpose of the visit was explained. LPA was allowed entrance to the facility. The following deficiencies were observed: Time-Delay-Egress-Doors not opening within 15 to 30 seconds in the Memory Care Unit. LPA pressed on the first-floor north side memory care unit door, which is a time-delay-egress-door, for 52.20 seconds when the door opened. LPA recorded the time on their Iphone stopwatch. Staff 1 was a witness to the event. LPA pressed on the first-floor south side memory care unit door, which is a time-delay-egress-door, for 49.88 seconds when the door opened. LPA recorded the time on their Iphone stopwatch. Staff 1 was a witness to the event. Outdoor and Indoor passageways were not kept free of obstructions. Large white double doors in between the front lobby and the residents’ living quarters, residents were unable to open the doors from the living quarters side to the front lobby. On 02/24/2026 around 9:00 AM, LPA was able to push the large white double doors open from the front lobby to the residents’ living quarters. LPA attempted to push the doors open from the residents’ living quarters to the front lobby but LPA was unable to open the doors (LPA took pictures and video footage of LPA attempting to open the doors – footage was submitted to the department for review). On 02/24/2026 around 10:00 AM, the facility installed door handles on the large white double doors on the residents’ living quarter side. LPA observed a resident on a wheelchair attempt to open the large white double doors but was unable to open the doors. Interviews conducted with staff and residents revealed the following: residents and staff indicated that the large white double doors were installed more than 5 months ago. Residents indicated that they are unable to open the doors and residents are not allowed in the front lobby of the facility. Deficiencies are being cited from Title 22 Regulations please see LIC809-D. An exit interview was conducted, and a plan of correction was developed. Appeal Rights and a hard copy of this report were provided to Administrator, Jennifer Rivas.the state’s words, verbatim · CDSS document, Feb 24, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.699(a)(4) · Plan of correction due date: Mar 9, 2026

1569.699 Exit doors; egress-control devices of time-delay type; fences (a) When approved by the person responsible for enforcement, as described in Section 13146, exit doors in facilities classified as Group R, Division 2 facilities under the California Building Standards Code, licensed as residential care facilities for the elderly, and housing clients with Alzheimer’s disease or major neurocognitive disorder, may be equipped with approved listed special egress-control devices of the time-delay type, provided the building is protected throughout by an approved automatic sprinkler system and an approved automatic smoke-detection system. The devices shall conform to all of the following requirements: (4) Initiate an irreversible process that will deactivate the egress-control device whenever a manual force of not more than 15 pounds (66.72?N) is applied for two seconds to the panic bar or other door-latching hardware. The egress-control device shall deactivate within an approved time period not to exceed a total of 15 seconds, except that the person responsible for enforcement, as described in Section 13146, may approve a delay not to exceed 30 seconds in residential care facilities for the elderly serving patients with Alzheimer’s disease. The time delay established for each egress-control device shall not be field adjustable. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in time-delay-egress-doors did not open after 30 seconds of having manual force pressing on the door latching hardware; during the health and safety tour of the facility, the first-floor north side memory care unit door, which is a time-delay-egress-door was manually pushed on the door latching hardware for 52.20 seconds when the door finally opened; the first-floor south side memory care unit door, which is a time-delay-egress-door was manually pushed on the door latching hardware for 49.88 seconds when the door finally opened; which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: The Administrator has agreed to test out the delay-egreess-doors with the Delta fire company and if the timer is off she will have them adjust the timer. Adminstrator will submit proof of correction via email to Socorro.Leandro@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: Feb 25, 2026

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above in, adding large white double doors in the front entrance in-between the front lobby and the residents living quarters without residents being able to open the doors from the residents living quarters; staff and resident interviews indicated that doors were installed more than 5 months ago; resident indicated that residents are not able to open the doors and residents are not allowed to go into the facility’s front lobby; LPA attempted to open the double doors from the residents living quarters but was unable to open the door, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: The Administrator has agreed to create a plan to verify that all outdoor and indoor passageways are free of obstruction, for example, all residents including residents with mobility devices have the ability to move through passageways and doorways without the assistance of others. Email Plan to: Socorro.Leandro@dss.ca.gov

Allegation investigated: Staff are not answering facility phones

On 01/09/2026, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent unannounced complaint visit regarding the allegation mentioned above and met with Facility Manager Giovanni Espinoza. Investigation consisted of the following: On 10/23/2025 at approximately 9:00 AM, LPA conducted an unannounced complaint visit to initiate an investigation regarding the allegation that staff are not answering facility phones and met with the facility Administrator, Denise Gilroy. The investigation included interviews with staff (S1–S4), residents, and family witnesses from both the Assisted Living and Memory Care units (R1–R2) and (W1–W9), as well as a review of staff and resident rosters, house rules, two signed “Employee Phone Responsibility Acknowledgement” forms, receipts for newly purchased cordless phones, and identification face sheets for residents who primarily use the facility phone. The investigation revealed the following: Please see (LIC9099-C) for report continuation. Substantiated Regarding the allegation “Staff are not answering facility phones,” it is being alleged that residents families are not able to get a hold of the residents in the facility. Records review revealed the following: Although records show that the facility has implemented improvements, including installing a better phone system and conducting staff training with signed acknowledgment forms, residents’ families are still having trouble reaching their loved ones by the facility phone. Observations revealed: On 10/23/2025, LPA observed staff answering calls but noted limited knowledge of transferring calls to the Memory Care unit and no documented training on the new phone system. While calls were observed being answered during the visit, evidence indicates that prior to corrective actions, staff were not consistently able to answer or properly route calls, which negatively impacted residents’ ability to maintain personal relationships and receive calls from family members or emergency contacts. As a result, a Type B deficiency was cited under Title 22 §87468.1(a)(2) (see LIC809 & LIC809-D). On 01/09/2026, additional interviews were conducted and revealed the following: Staff interviews (S1–S9) revealed that nine staff disagreed with the allegation while two staff (S10-S11) agreed. Resident and family witness interviews revealed mixed feedback, with the majority agreeing that calls were not consistently answered. Two residents (R1–R2) and six family witnesses (W1–W6) reported difficulty reaching staff, while five family witnesses (W7–W11) reported no issues. One family member stated that in 2024, reaching staff was a “huge problem,” and although conditions improved in 2025, issues persisted intermittently. Although the facility has taken corrective actions to improve phone accessibility, residents’ families continue to report difficulty reaching their loved ones. Based on the evidence gathered, records reviewed, observations, and interviews conducted, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is being issued on the attached (LIC-9099D). An exit interview, a copy of this report, and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 9, 2026 · control 11-AS-20251014163601

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 16, 2026

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodation, furnishings and equipment. This requirement is not met as evidenced by: Based on observations and interviews, the licensee failed to ensure that residents were afforded their personal rights to maintain communication with family and others by not consistently answering the facility phone or properly routing calls intended for residents. Which poses a potential risk to the health, safety and personal rights of the residents in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: The Administrator agrees to implement the Plan of Correction, including staff training and monitoring phone accessibility, and will submit proof of correction by the due date via email to Jose.Anguiano@dss.ca.gov.

Allegation investigated: Staff do not treat resident with dignity and respect.

On 12/18/2025, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced complaint investigation and delivered findings regarding the allegation mentioned above. LPA met with Facility Services Manager Giovani Espinoza. The investigation consisted of the following: On 12/18/2025, LPA conducted a tour of the facility, including resident rooms. LPA interviewed 11 staff members (S1–S11) and 11 residents (R1–R11). LPA also reviewed relevant records, including the personnel report, in-service training records dated 12/01/2025 regarding resident rights (which included a quiz and certificate of completion), and the current resident roster. Investigation revealed the following: Regarding the allegation that “Staff do not treat resident with dignity and respect,” it is being alleged that staff yelled at a resident and made verbal threats. No staff were observed yelling at residents during the visit. Training records confirmed instruction on resident rights and respectful care. Please see LIC 9099-C for report continuation. Unsubstantiated Records reviewed showed multiple in-service trainings reminding staff to treat residents with dignity and respect. Interviews revealed that 11 staff denied the allegation. Among residents, 8 disagreed with the allegation, and 3 agreed. It is noted that 2 of the residents who agreed were hard of hearing, which may have impacted their perception of the incident. Although the allegation may have occurred, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 11-AS-20251212120156

Type of visit: Case Management - Deficiencies

On 12/04/2025, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced Case Management – Deficiency visit to document a deficiency observed during a complaint investigation at this facility. LPA met with Administrator Kyle Watanabe. During the complaint investigation, LPA requested the admission agreement for Resident 1 (R1), who is the reporting party for the complaint. The licensee was unable to provide a copy of the admission agreement at the time of the visit. Per Title 22, California Code of Regulations, Section 87506(a)(b)(15), the licensee shall ensure that a separate, complete, and current record is maintained for each resident, and that each resident’s record shall contain, at minimum, the admission agreement and pre-admission appraisal. The failure to maintain and make available this required documentation is a violation of resident recordkeeping requirements. Deficiencies are being cited from Title 22 Regulations please see LIC809-D. An exit interview was conducted, and a plan of correction was developed. Appeal Rights and a hard copy of this report were provided to Administrator Kyle Watanabe.the state’s words, verbatim · CDSS document, Dec 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a)(b)(15) · Plan of correction due date: Dec 11, 2025

87506...The licensee shall ensure that a…complete, and current record is maintained for each resident in the facility…to licensing agency staff. (b) Each resident’s record…The admission agreement…specified in... 87507…This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee failed to comply with the section cited above by failing to maintain and make available the admission agreement for Resident 1 (R1), who is the reporting party for a complaint investigation conducted on 12/04/2025.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licensee agreed to provide more oversight on the admision process to ensure that all forms are signed and sent to LPA Anguiano by Due date. jose.anguiano@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 10/23/2025 at approximately 9:00AM, Licensing Program Analyst (LPA) Jose Anguiano conducted a case management visit. LPA observed that staff were answering incoming calls during the visit. However, interviews with staff revealed that they had not received training on how to operate the newly implemented cordless phones, including how to transfer calls to the memory care unit line. Although two staff had signed the “Employee Phone Responsibility Acknowledgement” form, they were unable to demonstrate knowledge of how to use the phone system. The facility was unable to provide documentation showing that staff had been trained on the specific procedures for transferring calls or assisting residents with phone use. As a result, calls intended for residents in the memory care unit may not be properly routed, potentially affecting residents’ ability to receive calls from family members or emergency contacts. This lack of training and procedural clarity impacts the facility’s ability to provide comfortable accommodations and equipment as required under Title 22 regulations. A Type B deficiency is being cited under Tittle 22 regulations section 87468.1(a) (2) for failure to ensure residents are accorded dignity in their personal relationships and provided with safe, healthful, and comfortable accommodations and equipment. An exit interview was conducted with the Administrator. A copy of this report, along with the LIC 809D and appeal rights, were provided.the state’s words, verbatim · CDSS document, Oct 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 30, 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 accommodations, furnishings and equipment. Based on observation and staff interviews, the licensee did not comply with the section cited above as staff were not trained to transfer calls to the memory care unit which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: LPA Jose Anguiano collaborated with the Administrator during the visit. The Administrator agreed to develop a plan to ensure that staff are trained on how to transfer calls to the memory care unit and to submit the plan via email to jose.anguiano@dss.ca.gov by the due date.

Allegation investigated: Staff did not safeguard residents belongings Staff did not treat resident with dignity and respect

On 09/18/2025 at approximately 8:00 AM, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent visit to deliver findings regarding the above allegation and met with the facility Administrator Denise Gilroy. The investigation consisted of the following: On 08/22/2025, around 8:00AM LPA Anguiano toured the facility, interviewed (8) staff members (S1–S8), interviewed (10) residents (R1-R10) and conducted record reviews. The investigation revealed the following: Regarding allegation “Staff did not safeguard resident’s belongings”, it is being alleged that staff did not respond to residents concerns regarding their personal belongings. Records reviewed revealed the following: The facilities incident report dated 08/31/2025 indicates that on 08/23/2025 a resident was missing their personal belongings, staff assisted the resident in calling the police department and the residents placement agency was also notified. The police report dated 09/10/2025 indicates that on 08/23/2025 police went to the facility to conduct interviews. Please see LIC 9099-C (Continuation Page) for additional information. Unsubstantiated A review of the residents’ LIC 621 (Personal Property and Valuables) did not include the items reported by the resident. Observations revealed the following: On 08/22/2025 and 09/18/2025, LPA observed staff interacting with residents in a respectful and professional manner. Interviews conducted revealed the following: LPA interviewed 11 residents. Eight (8) residents denied the allegation and reported no issues with staff safeguarding their belongings. Three (3) residents agreed with the allegation. LPA also interviewed eight (8) staff members. All staff denied the allegation. Staff #2 (S2) stated that when incidents involving residents’ belongings occur, residents are assisted in documenting and reporting the issue appropriately. Regarding allegation “Staff did not safeguard residents’ belongings”: although the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. Investigation consisted of the following: Regarding allegation” Staff did not treat resident with dignity and respect” It is being alleged that staff threatened to evict the resident. Observations revealed the following: On 08/22/2025 and 09/18/2025, LPA observed staff interacting with residents in a respectful and professional manner. No concerns were observed regarding staff conduct. Interviews conducted revealed the following: Ten (10) out of eleven (11) residents denied the allegation and reported that staff treat residents with dignity and respect. One (1) resident agreed with the allegation. All eight (8) staff members denied the allegation. Staff #2 (S2) stated not witnessing or hearing of any staff treating residents disrespectfully. Records reviewed revealed the following: LPA reviewed staff training records on Personal Rights conducted in May, June, and August 2025, with sign-in sheets confirming staff participation. Facility’s incident report dated 08/31/2025 stated no eviction notice was issued verbally or in writing. The facility also notified the residents’ placement agency and the Department. No documentation or witness statements were found to support the allegation that staff took the residents’ belongings or threatened eviction. Although the allegation that staff did not treat a resident with dignity and respect may have occurred, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 11-AS-20250815141833

Type of visit: Case Management - Deficiencies

On 08/22/2025, around 2:00PM Licensing Program Analyst (LPA) Jose Anguiano conducted a case management visit to the facility to address concerns related to the call system in the dementia care unit. During the visit, LPA observed that the resident call system was not functioning in multiple rooms within the secured dementia area. LPA interviewed staff and the Administrator, who confirmed that the call system had been inoperable in those rooms. Staff stated that the issue had been reported to maintenance and that repairs were pending. No alternative system or interim measures (e.g., increased staff rounds or temporary relocation) were in place at the time of the visit. Residents in the dementia unit may be unable to independently seek help or verbalize their needs. A non-functioning call system poses a potential health and safety risk by delaying staff response in the event of an emergency or resident need. California Code of Regulations (Title 22, Division 6, Chapter 1), the above-mentioned Deficiency was cited. Please see LIC809-D for details. An exit interview was conducted, and a copy of the report and Appeal Rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 22, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 5, 2025

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times…This requirement was not met as evidence by: Based on observation during the health and safety tour of the facility, the resident call system in multiple rooms within the dementia care unit was not functioning. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 22, 2025

Plan of correction: Effective 08/23/2025, the facility will implement hourly check-ins in the dementia care unit, with staff maintaining communication and documentation logs. As a long-term solution, the facility is upgrading to a new call system. Proof of correction, including interim logs and system update status, will be submitted to LPA Jose Anguiano at Jose.Anguiano@dss.ca.gov by 09/05/2025.

Type of visit: Required - 1 Year

On 07/03/2025 at around 8AM Licensing Program Analyst (LPA) Jose Anguiano conducted an annual required unannounced visit using the CARE Inspection Tool. LPA met with Administrator Camarin Johnson and explained the purpose of the visit. The residents served range from 60 years of age and over. The facility is approved for 108 ambulatory and 70 non- ambulatory.The second floor is approved for ambulatory only. 1st floor approved for delayed egress dementia only. Waiver/granted for hospice. There are currently 94 residents in total at the facility at the time of the visit. The facility consists of the following: Two-story building, 2 activity rooms, 1 kitchen area, 1 laundry, and 2 backyard patio areas with shaded seating. LPA toured the physical plant. There were no bodies of water on the premises. The rooms that were inspected, Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The call buttons were pressed and staff responded promptly. Bathrooms were operational with hot water temperature measured at 109 degrees F on both floors. A comfortable temperature was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and 3 days supplies perishable, and 7 days non-perishable food was maintained along with enough food for 94 residents. Fire extinguishers were charged and are due for maintenance on September 2025. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu. LPA conducted an audit of 5 resident records, and 5 personnel records. The facility is current in CCLD annual license fees. The facility has a valid Liability Insurance Certificate. Advisory - Technical Assistance was provided (Please see LIC 9102’s) No deficiencies were cited during today’s visit. An exit interview was conducted with Administrator Camarin Johnson and a copy of the report is provided.the state’s words, verbatim · CDSS document, Jul 3, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Unknown adult grabbed resident roughly causing injury Staff did not get timely medical care for resident

Community Care Licensing Division (CCLD) conducted an unannounced visit to Generations of Los Angeles Assisted Living Facility on 12/10/2024 and was greeted by Administrator Camarin Johnson (S1). CCLD staff explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: CCLD staff interviewed Administrator (S1), staff (S1-S4), residents (R1-R8). CCLD staff requested and reviewed copies of the following: Physician Report (dated 09/23/2024), incident report (dated 12/02/2024), Needs and Service plan (dated 10/01/2024), pre-placement appraisal (date 09/23/2024). CCLD staff toured the facility with S1. The investigation revealed the following: Unsubstantiated Regarding Allegation #1: Unknown adult grabbed resident roughly causing injury. It is being alleged that R2 grabbed R1 shoulder and dislocated R1 right shoulder. CCLD staff toured the facility and noted R1 did not appear to have a dislocated right shoulder. R1 was moving both arms with no issues. CCLD staff reviewed pre-placement appraisal (date 09/23/2024), physician report (date 09/25/2024), needs and service plan (date 10/01/2024), incident report (date 12/02/2024) for R1. R1 has health issues and claims chronic shoulder pain. CCLD staff reviewed incident report for 12/02/2024, there is no claim of any injury to either resident. CCLD staff and S1 spoke to R1. S1 offered to take R1 to the hospital for the supposed dislocated shoulder, R1 refused. 4 out of 4 staff indicate that R1 and R2 yelled at each other and R2 never grabbed R1 shoulder. R1 indicates that R2 grabbed R1 right shoulder and dislocated R1 right shoulder. 7 out of 8 residents indicate that R2 never grabbed R1 shoulder. Regarding Allegation #2: Staff did not get timely medical care for resident. It is being alleged that staff did not get timely medical care for R1. CCLD staff toured the facility and noted R1 did not appear to have a dislocated right shoulder. R1 was moving both arms with no issues. CCLD staff reviewed pre-placement appraisal (date 09/23/2024), physician report (date 09/25/2024), needs and service plan (date 10/01/2024), incident report (date 12/02/2024) for R1. R1 has health issues and claims chronic shoulder pain. CCLD staff reviewed incident report for 12/02/2024, there is no claim of any injury to either resident. CCLD staff and S1 spoke to R1. S1 offered to take R1 to the hospital for the supposed dislocated shoulder, R1 refused. 4 out of 4 staff indicate that R1 never advised staff that R1 had a dislocated right shoulder on 12/02/2024 incident. S1 and S2 came to the incident scene and spoke to R1 and R2. Staff indicate that R1 or R2 claim any injury from the 12/02/2024 incident and if R1 had claimed R1 was injured staff would have called 911. R1 indicates that R2 grabbed R1 right shoulder and dislocated R1 right shoulder. R1 indicates that staff refused to take R1 to the hospital. 7 out of 8 residents indicate that R1 never advised them of any injury. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “Unknown adult grabbed resident roughly causing injury”, “staff did not get timely medical care for resident” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Camarin Johnson S1.the state’s words, verbatim · CDSS document, Dec 10, 2024 · control 11-AS-20241204113346

Allegation investigated: Facility staff do not intervene when residents engage in physical altercations.

On 11/04/24 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to the facility listed above to investigate the allegation listed above. LPA was met by Administrator Camarin Johnson, and the purpose of today’s visit was explained. Investigation consisted of the following: LPA Gonzalez interviewed Administrator (A1) and staff #1-#4 (S1-S4) and residents #1-#6 (R1-R6). Reviewed records and obtained the following documents: resident and staff rosters, Physician’s Report, Appraisal & Needs and Services Plan, Identification and Emergency Information, Preplacement Appraisal Information, discharge paperwork from Norwalk Community Hospital and an incident report dated 10/26/24, and photographs for R1. Additionally, LPA Gonzalez conducted a tour of the facility grounds. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Facility staff do not intervene when residents engage in physical altercations. It is alleged that a resident was hit in the face by another resident. A review of records revealed that a photograph was taken on 10/24/24 of R1 because they were observed with swelling under their left eye. An Unusual Incident Report (dated: 10/26/24) was submitted to the department reporting that on 10/25/24 R1 was taken to the hospital due to watered filled pockets that developed around R1 left eye. According to records from Norwalk Community Hospital, R1 was discharged on 10/30/24 with discharge information listing facial trauma, fall reported, and failure to thrive (FTT). Additionally, a follow up photograph was taken on 10/30/24 of R1’s eye when they returned from the hospital. An interview conducted with the Administrator Camarin Johnson (A1) revealed that a physical altercation between R1 and R2 was never reported, not by the residents or staff. Johnson denies the above allegation ever happened. She stated that R1 has never had any issues with their roommate. Johnson stated that staff observed R1 with swelling, and fluid filled pockets under their eye on 10/24/24. She stated that they were advised by R1’s doctor to monitor and apply warm compress on the affected area, but after they noticed that wasn’t working, they decided to take R1 to the hospital for further evaluation. LPA conducted interviews with S1-S4, and 4 out of 4 staff interviewed denied the above allegation ever happened. 4 out of 4 staff interviewed stated that R1 was taken to the hospital because swelling was observed on R1’s under eye. LPA conducted interviews with R1-R6, and 5 out of 6 residents interviewed stated that they are not aware of R1 being hit in the face. 5 out of 6 residents interviewed stated that they are satisfied with the services being provided, and that they love it here at this facility. Based on interviews, and records reviewed, LPA did not find sufficient evidence to support the allegation, Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with Administrator Camarin Johnson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 4, 2024 · control 11-AS-20241029094715

Type of visit: Collateral

On 10/04/2024 at around 8:00 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced collateral visit regarding the former Licensee (Vista Veranda Assisted Living). LPA was met by Administrator Camarin Johnson and explained the purpose of the visit. LPA interviewed former residents and staff from Vista Veranda Assisted Living; LPA interviewed 7 residents and 6 staff. An exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 4, 2024

Type of visit: Case Management - Other

On 09/06/2024 at around 1:26 pm Licensing Program Analyst (LPA) Hollie Enriquez conducted an unannounced Case Management – Other Visit. LPA met with Administrator Camarin Johnson and explained the purpose of the visit. The facility is licensed to serve adults ages 55 and above. This facility has a capacity for 108 ambulatory residents and 70 non-ambulatory residents making it a total capacity of 178 residents. There are currently 60 residents total in care at facility at the time of the visit. There are 24 residents in Memory Care and 36 residents in the Assisted Living. At 1:36pm Administrator toured LPA through the interior of the facility. Kitchen was clean and fully stocked with additional 3 days emergency supply available. Medication Room, Activities Room, Dining Hall were observed. Common shower on the first floor was clean and sanitary.Delayed egress doors for the first floor Memory Care unit were tested and operational. LPA toured second floor with Administrator who reported that the second floor delayed egress door to the potential Memory Care unit does not work and has not been repaired or replaced. LPA observed that door does not function with delayed egress or sound. LPA observed wall area near room 186 has been repaired and painted. No citations were issued at this visit. A copy of the report and an Advisory Note - Technical violation has been provided to the Administrator Johnson.the state’s words, verbatim · CDSS document, Sep 6, 2024

Allegation investigated: Staff did not ensure supervision was provided resulting in resident sustaining an unexplained injury while in care

On 08/142024 at around 9:40 AM Licensing Program Analyst (LPA) Leandro conducted a complaint investigation regarding the allegation listed above. LPA met with the Administrator Camarin Johnson and the purpose of the visit was explained. The investigation consisted of the following: During today’s investigation LPA and Administrator toured Resident 1s (R1) bedroom. LPA interviewed 4 out of 38 staff and attempted to interview R1. LPA reviewed facility records and R1’s records. Substantiated The investigation revealed the following: Regarding the allegation “Staff did not ensure supervision was provided resulting in resident sustaining an unexplained injury while in care” it is being alleged that R1 has a history of falls and head traumas; and the licensee has not created fall prevention plan for R1 and has not assisted R1 in attaining Durable Medical Equipment (DME) for example walkers, wheelchairs, devices that assist residents in their daily activities. Record review of R1’s medical history indicate that R1 fell on: 7/7/21, 10/19/21, 10/31/22, 12/3/22, 9/9/23, 6/8/23, 6/13/24, and 8/8/24. R1's medical history shows a history of head tramas due to falls. R1 was receiving physical therapy for the month of 09/2023 and medical documentation indicates “assistive device is needed” for example, “FWW” (front-wheeled walker) and that R1 is a fall risk. LPA did not observe a fall prevention plan for R1. R1’s Appraisal/Needs and Services Plan does not include fall prevention. Interviews conducted reveal the following: R1 does not have an assistive walking device and R1 does not have a fall prevention plan. Observations reveal the following: LPA did not observe durable medical equipment in R1’s bedroom but LPA did observe handrails in R1’s bathroom. Regarding the allegation “Staff did not ensure supervision was provided resulting in resident sustaining an unexplained injury while in care,” the preponderance of the evidence standard has been met therefore the allegation is substantiated. Deficiencies cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report was left with the Administrator along with their appeal rights.the state’s words, verbatim · CDSS document, Aug 14, 2024 · control 11-AS-20240812153534

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a)(1)(3) · Plan of correction due date: Sep 3, 2024

Reappraisal (a) The pre-admission appraisal shall be updated...to keep the appraisal accurate...Significant changes shall include...limited to: (1) A physical trauma..(3) Any..trauma, or change in the health care needs of the resident... This requirement is not met as evidenced by: Based on record review and interviews conducted the licensee did not comply with the section cited above in not having an updated Reappraisail and Needs and Services Plan to include R1's Fall Risk Prevention Plan which poses a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Aug 14, 2024

Plan of correction: The Licensee will create a plan to update R1's Reappraisal, Appraisal/Needs And Services Plan to include a Fall Prevention Plan for R1. The LIcensee will also create a plan to assist R1 with attaining Durable Medical Equipment (DME) for example walkers, wheelchairs, devices that assist residents in their daily activities. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Type of visit: Case Management - Other

On 08/08/2024 at 1:30 pm Licensing Program Analyst Hollie Enriquez (LPA) and Licensing Program Manager Ulysses Coronel (LPM) conducted an unannouced Case Management-Other visit and met with Administrator, Camarin Johnson. LPM explained the purpose of the visit and the Administrator accompanied LPA and LPM on the physical tour of the facility interior. This facility is licensed to serve adults ages 55 and above. This facility has a capacity for 108 ambulatory residents and 70 non-ambulatory residents making it a total capacity of 178 residents. There are 58 residents in care at facility at the time of the visit. At 1:45 pm, Administrator accompanied LPA and LPM on a tour of the facility interior. The second floor delayed egress door to the Memory Care unit was tested and did not delay exit, opened immediately and did not have any alarm sound to signal staff. Memory Care unit on the second floor is fully vacant and has no residents in care. LPA and LPM observed on the second floor by room 186 an area of open dry wall exposing a pipe. Linen closet was fully stocked and second floor stairwell chairs observed. First floor kitchen was toured. Kitchen was sanitary and stocked. LPA and LPM reviewed five (5) resident files. LPM and LPA observed that one (1) out of five (5) Admissions Agreements, pages 3-4 under section Monthly Rental did not indicate an actual monetary amount under the monthly SSI/SSP rate. Only "SSI" was indicated. No citations were issued at this visit. A copy of the report and Advisory Notes - Technical violations have been provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 8, 2024

Type of visit: Post Licensing

On 07/18/2024 at around 10:50 AM, Licensing Program Analyst (LPA), Leandro conducted an unannounced Required Post-Licensing Inspection to the above-named facility and met with Administrator, Camarin Johnson. LPA explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection. This facility is licensed to serve adults ages 55 and above. This facility has a capacity for 108 ambulatory residents and 70 non-ambulatory residents making it a total capacity of 178 residents. A total of 59 residents are currently residing in this facility. The facility is a two-story building located on a main street. The facility has a memory care unit and an assisted living unit. The facility has 92 resident bedrooms, 94 bathrooms, 2 atriums, 1 lounge, 3 offices, several closets, 1 doctors office, 1 conference room, 1 activity room, 1 industrial kitchen, 2 dining rooms, 1 library, 1 business office, 1 tv room, 1 staff break room, 1 facility laundry room, 1 resident laundry room, 3 emergency stairwells, 1 stairway, 2 lobbies, and 1 elevator. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. There are several fire extinguishers around the facility. 5 staff records were reviewed, 5 out of 5 staff records had required documentation. 5 resident records were reviewed and, 5 out of 5 resident records had required documentation. LPA reviewed Client 1’s (C1) blood sugar summary for the month of July 2024. C1 had missing blood sugar checks on 7/1, 7/2, 7/5, 7/15, and 7/16. LPA interviewed C1, and C1 explained that she checks her blood sugar every day with the assistance of staff. Once C1 checks her blood sugar she then proceeds to inject herself with insulin. LPA followed up on items numbered 1 through 9 below. 1. bedrooms 142, 145, 144, 149, 154, and 158 are missing beds. – LPA observed beds in these bedrooms. 2. There is an insufficient supply of clean linens to permit weekly changing or more of residents’ top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers for 178 residents. – LPA observed enough linen for facility residents. 3. Window blinds and screen doors are not in good repair throughout the first and second floor bedrooms including bedrooms 31, 33, 37, 142, 145, 147, 156, 185, and 191. – LPA observed blinds and screen doors in good repair. 4. Closet door are not in good repair throughout bedrooms 23, 25, 26, 27, 33, 37, and 12. – LPA observed closet doors in good repair. 5. Bathroom sink and shower faucet drips in bedroom 31. – LPA observed sink and shower faucet in good repair. 6. There are cracks and/or holes in bedroom bathrooms 2, 10, 25, 27, 31, and 34. – LPA observed bathroom walls in good repair. 7. LPM observed water stains throughout the second-floor ceiling and must be repaired and re-painted. – LPA observed fresh paint on the ceiling of the second floor. 8. North stairwell is missing an evacuation chair. – LPA observed an evacuation chair. 9. First floor memory care unit egress door is in disrepair because it does not open after 15 seconds. – LPA observed first-floor south egress door in good repair. LPA observed north egress door not opening after 15 seconds. LPA observed documentation confirming that technicians came on 5/28/2024 to fix egress doors. On 06/07/2024, LPA observed video conforming that the north egress door was in good repair. Technicians will be coming tomorrow, 07/19/2024, to fix the north egress door. No deficiencies were cited. There is one technical violation which is the first-floor north egress door not opening after 15 seconds. And a technical advisory which is the documentation of blood sugar checks for people with diabetes. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Jul 18, 2024

Type of visit: Prelicensing

On 05/24/2024 Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Socorro Leandro conducted an announced visit to the facility for purpose of a pre-licensing evaluation. On 03/20/2024 an application was submitted to CCLD, for Initial license for a Residential Care Facility for the Elderly to serve adults ages 60 and over. The requested capacity is for 108 ambulatory residents and 70 non-ambulatory residents making it a total capacity of 178 residents. The facility is a two-story building located on a main street. The facility has a memory care unit and an assisted living unit. The facility has 92 resident bedrooms, 94 bathrooms, 2 atriums, 1 lounge, 3 offices, several closets, 1 doctors office, 1 conference room, 1 activity room, 1 industrial kitchen, 2 dining rooms, 1 library, 1 business office, 1 tv room, 1 staff break room, 1 facility laundry room, 1 resident laundry room, 3 emergency stairwells, 1 stairway, 2 lobbies, and 1 elevator. LPM and LPA conducted a review of the Physical Plant, Bedrooms, Bathrooms, Supplies, Food Service, Medications, Records, Administration, Activities, Pe-Licensing Checklist and Component III Orientation. MEDICATIONS There is a locked centralized storage area for resident medications. PHYSICAL PLANT Facility is clean and sanitary. Protective devices are in place to include nonslip material on rugs. Indoor and outdoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. Pools and bodies of water have fencing of at least five (5) feet high with self-closing, self-latching gates, or locked covers that can support the weight of an adult. All window screens are clean and in good repair. Facility temperature is around 74 degrees. Stairways, inclines, ramps, open porches, and areas of potential hazard are well-lit and equipped with sturdy hand railings. For facilities of 16 or more capacity there is a private office for the administrator, a reception area, and bathroom for visitors. For facilities of 16 or more capacity and facilities having separate floors or buildings without full time staff, there are signal systems in place. Fire Alarms and Smoke alarms operate properly. Carbon monoxide detectors operate properly. BEDROOMS Halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings are not being used as resident bedrooms. Resident bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. No resident bedroom is a passageway to another room, bath or toilet. There is dresser and closet space for each resident that includes at least two (2) drawers or eight (8) cubic feet of dresser space per resident. There is a chair and lamp for each resident and at least one (1) nightstand per two (2) residents. BATHROOMS There is at least one (1) toilet and washbasin per six (6) residents, family, and personnel. There is at least one (1) shower or bathtub per ten (10) residents, family, and personnel. Hot water temperature is between 105-120 degrees Fahrenheit. Bathroom is located near resident bedrooms. SUPPLIES There are resident personal hygiene supplies to include feminine napkins, soap, toothpaste, toilet paper, and comb. FOOD SERVICE Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0 degrees Fahrenheit. Refrigerator is a maximum of 45 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. RECORDS There is confidential storage of personnel records at the facility. There is confidential storage of resident records at the facility. ADMINISTRATION The emergency exiting plan and emergency phone numbers are posted. Resident Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES For facilities of seven (7) or more capacity, an activities calendar is posted. There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to residents for visitors. There are activity supplies to include newspapers, magazines, and a variety of reading material. MISCELLANEOUS There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. For facilities of 16 or more capacity, there is a designated laundry space. There is an operating telephone available to residents. Emergency lighting and supplies to include flashlights with batteries. Vehicles used to transport residents are in safe operating condition. PRE-LICENSING CHECKLIST Completed by licensee and reviewed by LPM and LPA. COMPONENT III Information was provided about how to operate the facility within substantial compliance. During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA by 06/07/2024. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction. 1. bedrooms 142, 145, 144, 149, 154, and 158 are missing beds. 2. There is an insufficient supply of clean linens to permit weekly changing or more of residents top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers for 178 residents. 3. Window blinds and screen doors are not in good repair throughout the first and second floor bedrooms including bedrooms 31, 33, 37, 142, 145, 147, 156, 185, and 191. 4. Closet door are not in good repair throughout bedrooms 23, 25, 26, 27, 33, 37, and 12. 5. Bathroom sink and shower faucet drips in bedroom 31. 6. There are cracks and/or holes in bedroom bathrooms 2, 10, 25, 27, 31, and 34. 7. LPM observed water stains throughout the second-floor ceiling and must be repaired and re-painted. 8. North stairwell is missing an evacuation chair. 9. First floor memory care unit egress door is in disrepair because it does not open after 15 seconds. An exit interview was conducted, and a hard copy of this report has been provided to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to the applicant.the state’s words, verbatim · CDSS document, May 24, 2024