Hayworth Terrace

Type of visit: Case Management - Health Checks

On August 12, 2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced health and safety inspection at the facility, LPA identified herself to Administrator Cavin Yoo. During the visit, the department observed seven staff members, including kitchen and housekeeping staff, a medication technician, and three caregivers. The facility appeared clean, odor-free, and well maintained, with clear walkways and adequate lighting. During the tour, the department observed residents watching TV, resting in their rooms, and spending time in common areas. Fire extinguishers and smoke detectors were fully charged, and carbon monoxide detectors were operational. The hot water temperature for resident personal care was within the required range of 105–120 degrees Fahrenheit. The facility had a sufficient supply of perishable food for two days and non‑perishable food for seven days. Mandated postings, including Personal Rights, were observed. There appeared to be an adequate supply of personal protective equipment (PPE). Both a functioning landline and internet service were available. During the visit, the department did not observe any health or safety concerns. An exit interview was conducted where this report was discussed and provided to Cavin Yoo-Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 12, 2026

Type of visit: Case Management - Legal/Non-compliance

On August 12, 2026, at 5:46 p.m., Licensing Program Analyst (LPA) Ernand Dabuet, Licensing Program Manager (LPM) Stephanie Cifuentes, and Regional Manager (RM) Janae Hammond conducted an unannounced Case Management Visit at the facility. LPA, LPM, and RM met with Administrator Cavin Yoo and explained the purpose of the visit. The purpose of the visit was to issue one Temporary Suspension Order (TSO). The TSO’s is effective immediately August 12, 2026. The TSO is for HAYWORTH TERRACE (HAYWORTH PROPERTIES LLC), located at 325 N. Hayworth Ave, Los Angeles, CA 90048 (#198320420). During the visit, the Department conducted a tour of the physical plant, which consists of two floors. The first floor contains resident rooms, common areas, the kitchen, staff offices, and the dining area. The second floor contains additional resident rooms. A total of 54 residents were observed in care during the visit. Residents were observed in their rooms, common areas, and dining area. The Department reviewed the TSO packet with Administrator Cavin Yoo, with Licensee Representative Mohsen Abdolsalehi participating via telephone. Administrator Yoo signed the TSO on behalf of the Licensee, and a copy was emailed to the Licensee and a copy was placed in the mail. An exit interview was conducted with Administrator Cavin Yoo. A copy of the appeal rights, (3) copies of TSO (1 copy for Cavin Yoo, 1 copy for Mohsen Abdolsalehi and 1 copy for Hayworth Properties LLC), and the licensing report were provided.the state’s words, verbatim · CDSS document, Aug 12, 2026

Type of visit: Case Management - Other

Licensing Program Analyst, (LPA) arrived on August 12, 2026, for an unannounced inspection to follow up on a substantiated allegation of complaint investigation. On May 1, 2026, the Department concluded a complaint investigation regarding the following allegations: Resident sustained multiple fractures while in care and staff did not seek timely medical attention for the resident in care. The licensee was cited for California Code of Regulations (CCR) § 87466 Observation of the Resident; CCR § 87468.1(a)(2) Personal Rights of Residents in All Facilities. At the time of the complaint visit on May 1, 2026, an immediate civil penalty of $ 500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility failing to provide appropriate care, proper assistance and supervision, implement a Plan of Care to ensure R1's safety and prevent injuries, and obtain a physician assessment for the resident prior to admission which resulted in serious bodily injury requiring hospitalization for multiple injuries [brain bleeds and fractures (rib & hip). Evaluation Report continues LIC 809-C Today, August 12, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $ 500 was previously issued on May 1, 2026, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Administrator Cavin Yoo signature on this report acknowledge receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 12, 2026

Type of visit: Case Management - Health Checks

On August 9, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced health and safety inspection at the facility, where Administrator Cavin Yoo greeted the LPA. During the visit, the LPA observed seven staff members, including kitchen and housekeeping staff, a medication technician, and two caregivers. The facility was clean, odor-free, and well-maintained, with clear walkways and adequate lighting. Fire extinguishers, smoke detectors, and carbon monoxide detectors were operational. The hot water temperature for client personal care was within the required range of 105 to 120 degrees Fahrenheit. The facility had sufficient perishable food for two days and non-perishable food for seven days. Mandated posters, such as Personal Rights, were displayed, and the supply of personal protective equipment (PPE) was adequate. Both a working landline and internet service were available. The LPA observed that the elevator in the activity room was non-operational, as confirmed by both maintenance and the administrator. It was also noted that only one caregiver was scheduled for the NOC shift, which is considered insufficient to meet residents' needs. Additionally, in room #59, the resident has a locked door equipped with a doorknob lockout device and padlock. This issue was addressed in complaint #11-AS-20260710145112.. Based on interviews, observations, and record reviews, the licensee violated the California Code of Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies were documented, and an exit interview was conducted with Cavin Yoo. A copy of this report is provided along with the appeal rights.the state’s words, verbatim · CDSS document, Aug 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 9, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interview and observation, licensee did not ensure elevator in the activity is in good repair. This violation poses/posed a potential risk to persons in care.the state’s words, verbatim · CDSS document, Aug 9, 2026

Plan of correction: Licensee will adhere to Title 22- 87303(a) and ensure that faciilty is in good repair including a operational elevator. Submit proof of correction by POC due 09/09/26 to attn: Ernand Dabuet at 424-544-1016.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(a) · Plan of correction due date: Aug 16, 2026

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers...to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required... The licensing agency may require any facility to provide additional staff whenever it determines through documentation...of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Based on interview and observation, licensee is insufficient staffing for NOC shift with only one carestaff working. This violation poses/posed a potential risk to persons in care.the state’s words, verbatim · CDSS document, Aug 9, 2026

Plan of correction: Licensee will adhere to Title 22- 87411(a) and ensure that the facility has sufficient staff to meet residents' needs for care and supervision. Submit proof of correction with updated LIC 500 to indicate another care staff member is scheduled for NOC shift by POC due 09/16/26 to attn: Ernand Dabuet at 424-544-1016.

Type of visit: Case Management - Health Checks

On August 8, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit at the facility. Upon arrival, the LPA performed a risk assessment and explained that the purpose of the visit was to conduct a health and safety inspection. Licensed Vocational Nurse Hee Yung Park and Maintenance Representative Juan Rosselle greeted the LPA. A total of 26 resident rooms on the first floor were inspected, specifically rooms #1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 14, 15, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, and 70. Additionally, 30 resident rooms on the second floor were inspected, including rooms #18, 19, 20, 21, 22, 23, 25, 26, 27, 29, 30, 31, 34, 35, 38, 40, 41, 42, 43, 49, 74, 75, 76, 77, 78, 79, 80, 82, 84, and 87. A thorough inspection of the dining room, activity room, medication room, and administrative office, along with the exterior surroundings, revealed no bodies of water or obstructions on the premises included (40) mouse bait boxes. The kitchen was found to have a sufficient supply of both perishable and non-perishable food, all of which was properly maintained. Fire extinguishers were charged, and both smoke detectors and carbon monoxide detectors were operational. The LPA noted that the Emergency Disaster Plan (LIC 610) was posted, along with the Activities Calendar. A functioning landline and internet services were also available. The LPA observed a “Public Scabies Notification Letter” dated July 22, 2026, posted on the main entrance door. During the inspection, the LPA observed several cans of insecticide and pesticide in rooms #20, #78, and #80. Room #19 contained two sharp scissors lying on the sink basin. Additionally, room #29 had powder detergent in the bathroom. (Evaluation Report continues LIc 9099-C) Based on interviews, observations, and record reviews, the licensee violated the California Code of Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies were documented, and an exit interview was conducted with Hee Kyung Park and Juan Rosselle. A copy of this report is provided along with the appeal rights.the state’s words, verbatim · CDSS document, Aug 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a)(b) · Plan of correction due date: Aug 9, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances... which could pose a danger to residents are in locked storage and are not left unattended... This requirement was not met as evidenced by: Based on interview and observation, licensee did not ensure to have hazardous toxic chemical, pesticides and scissors in locked storage area. This violation poses/posed an immediate risk to persons in care.the state’s words, verbatim · CDSS document, Aug 8, 2026

Plan of correction: Licensee will adhere to Title 22- 87309(a)(b) and ensure all residents are restricted access from hazardous, toxic chemicals. Submit proof of correction by POC due 08/09/26to attn: Ernand Dabuet at 424-544-1016. Corrected during the visit and all hazardous and toxic chemcal items were removed and stored in loced storage.

Type of visit: Case Management - Legal/Non-compliance

On August 6, 2026, at 1:00 PM, the El Segundo Adult & Senior Care Regional Office convened a Non-Compliance meeting. The primary objective of this meeting was to address concerns raised by the Regional Office regarding operational oversight, the delineation of responsibilities between the Licensee and Administrator, and ongoing non-compliance issues. This meeting was conducted virtually via Microsoft Teams. In attendance were Regional Manager Janae Hammond, Licensing Program Manager Stephanie Cifuentes, Licensing Program Analysts Ernand Dabuet and Bernadette Allen, Facility Administrator Cavin Yoo, Facility House Manager Miram Bae, and Facility Maintenance Representative Juan Roussell. The meeting could not proceed without the Licensee Representative, Mohsen Abdosalehi. The Department made multiple attempts to contact Abdosalehi via telephone and text messages to secure his participation; however, these efforts were unsuccessful, as he did not respond. Abdosalehi had been duly informed of the Non-Compliance Meeting in advance. The participants waited for Abdosalehi from 1:00 PM until 1:35 PM, at which point the meeting was adjourned. The meeting will be rescheduled by the El Segundo Adult & Senior Regional Office. An exit interview was conducted with Cavin Yoo, during which he was provided with a copy of this report.the state’s words, verbatim · CDSS document, Aug 6, 2026

Allegation investigated: Facility retained resident with prohibited health condition.

On July 19, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Cavin H. Yoo, Administrator, greeted the (LPA). (LPA) explained that the purpose of the visit was to deliver the findings for the allegation mentioned above. The investigation consisted of the following: an initial visit on June 12, 25, and a subsequent visit on June 17, 2026. During the visits, the department conducted a tour of the facility's physical plant and observed residents in care. The department obtained copies of the following documents: Personnel Report LIC 500 (dated 05/27/26), Resident Roster (dated 06/17/26), Resident #1 (R1's) Face Sheet, Identification and Emergency Information LIC 601 (dated 01/24/18 & 05/13/21) Admission Agreement (dated 01/24/18), Appraisal/Needs and Services Plan LIC 625 (dated 05/25/23) , and other pertinent records associated with this complaint. Interviews conducted with Staff #1-#5 (S1-S5) and Residents #2-#6 (R2-R6), and Witness #2-#3 (W2-W3). (R1) and (W1) were not available for interviews. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION #2: Facility retained resident with prohibited health condition. It is alleged that the facility retained Resident #1 (R1) with a prohibited health condition. There are reports expressing concern about possible neglect in care for (R1), who has been a resident at this facility since 2018. It is reported that (R1) has a deep tissue injury to the sacrum that is unstageable, as well as an unstageable open ulcer on the right hip and a severe unstageable ulcer on the left foot, which exhibits sloughing tissue. On May 8, 2025, Resident #1 (R1) was admitted to Cedars-Sinai Medical Center for a comprehensive evaluation and management of (R1's) health conditions. Upon admission, the medical team conducted a thorough wound assessment. The assessment revealed that (R1) suffered from a significant deep tissue injury located on (R1's) sacrum, which was classified as unstageable due to its severity and the absence of visible tissue layers. Additionally, (R1) presented with an open ulcer on (R1's) right hip, characterized by exposed underlying tissue and signs of infection. Furthermore, a severe ulcer was noted on (R1's) left foot, also unstageable, with sloughing tissues indicating advanced tissue damage and complicating factors that would require targeted intervention and careful monitoring throughout (R1's) treatment plan. On June 17, 2026, and June 22, 2026, between 10:37 AM and 04:10 PM, the Department interviewed staff members identified as Staff #1 through Staff #5. Five (5) out of the five (5) staff members acknowledged that (R1) was treated for pressure injuries. All staff members reported that (R1) had been a resident at Hayworth Terrace since 2018 and that (R1's)health continued to decline during this time, and (R1) has had ongoing pressure injuries "on and off" since being admitted to the facility. (R1) experienced frequent hospitalizations and was sent to skilled nursing in April 2025 due to pressure injuries, according to (S1). (S1) mentioned that (R1) was readmitted to the facility in late April 2025 at the request of (R1's) responsible party, who preferred (R1) to stay in an assisted living facility instead of skilled nursing. (S1) also disclosed that when (R1) was readmitted in April 2025, (R1) had pressure injuries and was not under hospice care. Both (S1) reported that (R1) received services from Excellent Home Health and a Wound Rescue Specialist from April 18, 2025, until June 8, 2026, up to (R1's) passing on June 9, 2026. (EVALUATION REPORT CONTINUES LIC 9009-C) INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Questionable Death. It is alleged that the death of Resident #1 (R1) is questionable. Reports indicate that (R1), who was bedbound and required assistance with activities of daily living, may have experienced neglect and a lack of proper care. (R1) was admitted to Cedars Sinai Medical Center dehydrated and with pressure injuries. On June 17, 2026, and June 22, 2026, between 10:37 AM and 04:10 PM, the Department interviewed staff members identified as Staff #1 through Staff #5. Five (5) out of the five (5) staff members could not corroborate this claim. All staff members claimed that (R1) had been a resident at the facility for a very long time since 2018 and that (R1’s) health continues to decline. (R1) was in and out of hospitals during (R1's) residency at Hayworth Terrace and was sent to skilled nursing in April 2025 and returned to the facility before (R1’s) passing, according to (S1). (S1) stated that (R1) had a history of respiratory failure with hypoxia. (S1-S2) reported that (R1) was being serviced by Excellent Home Health and Wound Rescue Specialist effective April 18, 2025, until June 08, 2026, when (R1) was admitted to Cedars Sinai Hospital. While the facility staff addressed (R1's) assisted daily living activities daily. Witness #1 identified the party responsible for (R1) as not available for an interview, as telephone calls were not returned. The Department reviewed (R1’s) County of Los Angeles Department of Public Health Certificate of Death (dated 07/25/25) indicated (R1’s) death was an immediate cause of Acute Hypoxemic Respiratory Failure with underlying cause of Septic shock, pneumonia, and Alzheimer’s Dementia. Further review of (R1’s) Face Sheet, Identification and Emergency Information LIC 601 (dated 01/24/18 & 05/13/21) Admission Agreement (dated 01/24/18), Appraisal/Needs and Services Plan LIC 625 (dated 05/25/23) Medical Assessment for Residential Care Facilities for the Elderly LIC 602A (dated 05/27/25), Consent Log (dated 05/25/23 & 07/15/23), Unusual Incident Report LIC 624 (dated 10/24/24 & 03/07/25). Based on the information gathered, there is not enough evidence to support the allegation mentioned above. (EVALUATION REPORT CONTINUES LIC 9009-C) Allegation #3: Resident's hygiene needs were not met by staff. It is alleged that Resident #1 (R1’s) hygiene needs were not met by staff. Reports indicate that (R1) was bedbound and required assistance with all hygiene needs such as toilet and incontinence care, medication administration, feeding, grooming and bathing. Reports indicate that (R1) was unclean and dehydrated. On June 17, 2026, and June 22, 2026, between 10:37 AM and 04:10 PM, the Department interviewed staff members identified as Staff #1 through Staff #5. Five (5) out of the five (5) staff members could not corroborate this claim. All staff members claimed that (R1) were being assisted adequately with hygiene care needs. (S2) stated there were no issues with (R1’s) medications and was being administered as prescribed by (R1's) primary physician. (S3-S5) reported that (R1) was being assisted with reposition, incontinence, hygiene and was given sponge bath once or twice a week. (S2-S5) claimed that (R1) was provided with liquids with every meal three times a day and as needed to stay hydrated. However, the facility staff did not maintain progress notes as part of the (R1’s) record or care documentation. On June 17, 2026, between 01:11 AM and 03:29 PM the Department interviewed residents identified as Resident #2 through #6 (R2-R6). Five (5) out of the five (5) resident members could not support this claim. (R2-R6) reported that their hygiene needs are consistently met satisfactorily by the staff, expressing no concerns regarding this aspect of care. Additionally, they all indicated that they receive adequate meals and hydration throughout the day, with none experiencing dehydration due to a lack of available liquids from the facility. Resident #1 (R1) was unavailable for an interview as resident had passed. On June 30, 2026, July 02, 2026, and July 06, 2026, between 8:30 AM and 03:27 PM, the Department interviewed the witness members identified as Witness #2 and Witness #3. Two (2) out of the two (2) witnesses could not support this claim. During wound care visits, it was consistently noted that the (R1) maintained a satisfactory level of hygiene and did not show signs of neglect in this area according to (W2 and W3). (EVALUATION REPORT CONTINUES LIC 9009-C) Witness #1 identified the party responsible for (R1) as not available for an interview, as telephone calls were not returned. A review of Personnel Report LIC 500 (dated 05/27/26), Resident Roster (dated 06/17/26), Resident #1 (R1's) Face Sheet, Identification and Emergency Information LIC 601 (dated 01/24/18 & 05/13/21) Admission Agreement (dated 01/24/18), Appraisal/Needs and Services Plan LIC 625 (dated 05/25/23) Medical Assessment for Residential Care Facilities for the Elderly LIC 602A (dated 05/27/25), Consent Log (dated 05/25/23 & 07/15/23), Unusual Incident Report LIC 624 (dated 10/24/24 & 03/07/25), and Death Report LIC 624A (dated 06/12/25). Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. An exit interview was conducted with Cavin H Yoo, and copies of the reports were provided. Excellent Home Health and the Wound Rescue Specialist coordinated their efforts, with the Wound Rescue Specialist visiting (R1) once a week. . According to (S2-S5), the staff is trained to reposition residents every two to three hours and provide hygiene and incontinence care. However, (S1) also mentioned that staff do not receive assistance with wound care, as this is left to the Wound Rescue Specialist and Excellent Home Health. (S2) stated that they are responsible for training the staff to spot pressure injuries. (S2) instructs the staff to look for signs, such as redness or blisters, on the skin before an open wound. If staff see these symptoms, they must inform the administrator. The administrator will then contact the primary physician and family representatives to obtain a referral for home health or hospice services. Additionally, (S1) could not provide any documentation from Excellent Home Health or Wound Rescue Specialist, incident reports, or wound care related to (R1's) pressure injuries. As a result, (R1) continues to experience pressure injuries due to poor circulation, having been bedbound. On June 30, 2025, July 02, 2026, and July 06, 2026, between 8:30 AM and 03:27 PM, the Department interviewed the witness members identified as Witness #2 and Witness #3. Two out of two witnesses confirmed this claim. During weekly wound care visits (W2 and W3), treatment was provided for (R1), who had pressure injuries classified as Stage 3, Stage 4, and unstageable, which are prohibited health conditions. Witness #1 identified the party responsible for (R1) as not available for an interview, as telephone calls were not returned. The Department reviewed the following records: Wound Rescue Special Records (dated 06/05/25). Notably, (R1) was assessed for (7) prohibited health conditions out of (17) wounds. · Wound 1 and 2: Left Foot Lateral - Stage 4 (8 cm x 4 cm x 0.4 cm) Total wound size: 32 cm · Wound 3: Left Foot Lateral – Stage 2 (0.5 cm x .05 cm x 0 cm) Total wound size: 0.25 · Wound 4: Left Foot Heel to Medial – Stage 4 (11 cm x 14 cm x 0.3 cm) Total wound size: 154 cm · Wound 5, 6 and 7: Right Foot Lateral Stage 1 (cm x cm x cm) Total wound size: cm2 (EVALUATION REPORT CONTINUES LIC 9009-C) · Wound 8: Right Hip – Stage 3 (3 cm x 3 cm x 0) total wound size: 9 cm2 · Wound 9: Sacrum – Stage 3 (9 cm x 10 cm x 0.3 cm) Total wound size: 90 cm2 · Wound 10: Right Buttock #1 – Stage 3 (6 cm x 5 cm x 0.3 cm) Total wound size: 30 cm2 · Wound 11 Right Buttock #2 – Stage 2 (1 cm x 1 cm x 0 cm) Total wound size: 1 cm · Wound 12: Right Buttock #3 – Stage 2 (3 cm x 2 cm x 0 cm) Total wound size: 6 cm2 · Wound 13: Back #1 – Stage 2 – (.05 c, x 0.5 c, x 0 cm) Total wound size: 0.25 cm2 · Wound 14: Back #2 – Stage 2 – (1 cm x 1 cm x 0 cm) Total wound size: 1 cm · Wound 15: Right Leg – Stage 2 – (1 cm x 5 cm x 0 cm) Total wound size: 5 cm2 · Wound 16 – Left Foot – Unstageable – (1 cm x 1 cm x 0 cm) Total wound size: 1 cm2 · Wound 17 – Left Foot 5th - Unstageable – (1 cm x 1 cm x 0 cm) total wound size: 1 cm2 A review of Personnel Report LIC 500 (dated 05/27/26), Resident Roster (dated 06/17/26), Resident #1 (R1's) Face Sheet, Identification and Emergency Information LIC 601 (dated 01/24/18 & 05/13/21) Admission Agreement (dated 01/24/18), Appraisal/Needs and Services Plan LIC 625 (dated 05/25/23) Medical Assessment for Residential Care Facilities for the Elderly LIC 602A (dated 05/27/25), Consent Log (dated 05/25/23 & 07/15/23), Unusual Incident Report LIC 624 (dated 10/24/24 & 03/07/25), and Death Report LIC 624A (dated 06/12/25). Further review of the Facility Program Description "Plan of Operation" Section B under Prohibited Health Conditions: "No resident shall be admitted or retained in a residential care facility with a prohibited health condition. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. (EVALUATION REPORT CONTINUES LIC 9009-C) California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099D). An exit interview was conducted with Cavin H Yoo, and copies of the reports and appeal rights were provided. *Immediate Civil Penalty issued* ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).the state’s words, verbatim · CDSS document, Jul 19, 2026 · control 11-AS-20250611131031

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a) · Plan of correction due date: Jul 20, 2026

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including but not limited to... shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interviews, observation, and record reviews, Licensee was aware of (R1's) pressure injuries upon readmission from SNF, retaining (R1) with (7) out of (17) wounds classified as Stage 3, Stage 4, or unstageable, which are prohibited health conditions. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 19, 2026

Plan of correction: Licensee/Administrator will review Title 22, Section 87615, and the Plan of Operation to ensure compliance. The Licensee will retrain staff on pressure injuries and submit the completed training, including staff names and completion dates, to ernand.dabuet@dss.ca.gov by the POC date of 07/20/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Jul 20, 2026

87208 Plan of Operation(a) The licensee shall... operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49... This requirement is not met as evidenced by: Based on interviews, observations, and record reviews, the licensee was aware of (R1's) history of stage 3 and 4 pressure injuries and continued to retain (R1) despite the prohibition on health. This violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 19, 2026

Plan of correction: Licensee/Administrator will review Title 22, Section 87208, and the Plan of Operation to ensure compliance. The Licensee will retrain staff on subject matter prohibited health conditions and submit the completed training, including staff names and completion dates, to ernand.dabuet@dss.ca.gov by the POC date of 07/31/26.

Type of visit: Case Management - Deficiencies

On July 17, 2026, Licensing Program Analysts (LPAs) Ernand Dabuet and Jose Anquiano conducted an unannounced case management visit to the facility regarding complaint #11-AS-20260710145112. During the visit, the LPAs met with Assistant to Administrator Terri Han and explained the purpose of the inspection. The Department determined that the facility is not in compliance with Title 22 Regulations and issued the following citations: **87468.1(a)(6)** Personal Accommodations and Services - The investigation revealed Resident #5 and Resident #6 both are bed-bound, restricted with locked doors that only staff have access to with a room key. **87309(a)(b)** Storage Space and Access - The investigation revealed Resident #1 and Resident #7 both had Raid Ant & Roach (chemical toxic spray) stored in their rooms accessible to the resident and other residents in care. **87405(d)(2)**Administrator Qualifications and Duties - The investigation revealed the administrator did have the ability to conform to the applicable laws, rules, and regulations about complaint # #11-AS-20260710145112 Based on interviews, observations, and record reviews, the licensee violated the California Code of Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies were documented, and an exit interview was conducted with Terri Han. A copy of this report is provided along with the appeal rights.the state’s words, verbatim · CDSS document, Jul 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Jul 18, 2026

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: (6) To leave or depart the facility at any time and to not be locked into any room... on facility premises by day or night... This requirement was not met as evidenced by: Based on interview and observation, licensee locked interior room doors for R5 & R6 restricting both bed bound residents in their rooms with only staff having access to a key. This violation poses/posed an immediate risk to persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: Licensee will adhere to Title 22- 87468.1 and ensure all residents restricted in locks rooms. Submit proof of correction by POC due 07/18/26 to attn: Ernand Dabuet at 424-544-1016.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a)(b) · Plan of correction due date: Jul 18, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances... which could pose a danger to residents are in locked storage and are not left unattended... This requirement was not met as evidenced by: Based on interview and observation, licensee did not ensure to have hazardous toxic chemical spray in locked storage area. This violation poses/posed an immediate risk to persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: Licensee will adhere to Title 22- 87309(a)(b) and ensure all residents are restricted access from hazardous, toxic chemicals. Submit proof of correction by POC due 07/18/26 to attn: Ernand Dabuet at 424-544-1016.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2) · Plan of correction due date: Jul 31, 2026

87405 Administrator - Qualifications and Duties (d)The administrator shall have the qualifications specified in Sections 87405(d)...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on interview and observation, licensee locked interior room doors for R5 & R6 restricting both bed bound residents in their rooms with only staff having access to a key. This violation poses/posed an immediate risk to persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: The licensee will adhere to Title 22 Section 87405. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 07/31/26 with documentation for authorizzed administrator acknowledgement and review of Title 22 Regulations.

Allegation investigated: Facility did not reveal or make records available upon request.

On 05/28/2026, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced complaint visit and met with Administrator Kevin Yoo. The investigation consisted of the following: The Department conducted interviews with four staff (S1–S4), five residents (R2–R6), and one witness (W1). Also reviewed records related to the request for former resident (R1’s) records. Records reviewed included the record request email, the facility’s response email, authorization documents, and documents related to the request for R1’s records. Staff and Resident roster. The investigation revealed the following: Regarding the allegation: Facility did not reveal or make records available upon request. It is being alleged that the facility did not provide R1’s requested records timely and did not provide all requested records. Please see (LIC9099-C) for report continuation. Substantiated Records reviewed revealed: W1 requested R1’s records from the facility on 05/01/2026 at 3:41 PM. Records reviewed also showed the facility sent records to W1 on 05/20/2026 at 12:37 PM. Interviews conducted revealed: W1 requested R1’s resident records, including billing records and other records maintained in R1’s file. W1 stated the records were not provided timely and the records later received on 05/20/26 did not include billing records. During interview, S1 acknowledged there was a delay in the facility’s response to the records request and stated the request was not completed timely. Based on interviews conducted and records reviewed, the facility did not provide R1’s requested records timely, and the records later provided did not include all requested records. Based on the evidence gathered, the preponderance of evidence standard has been met; therefore, the allegation is SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.2(a)(19). A citation is being issued on the attached LIC 9099-D. An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, May 28, 2026 · control 11-AS-20260520164129

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19 · Plan of correction due date: Jun 8, 2026

Additional Personal Rights of Residents in...(a)…facilities for the elderly shall have all of the following personal rights:(19) To have prompt access to review all of their records...records shall be provided within two (2) business days…This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, the licensee failed to provide R1’s requested records within two (2) business days. This violation poses/posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: Administrator agreed to submit a written plan of correction to LPA Jose Anguiano by due date, explaining how the facility will ensure resident record requests are processed and provided within the required timeframe. Emailed to Jose.Anguiano@dss.ca.gov

Allegation investigated: Staff did not prevent resident from harming themselves. Staff did not provide a blanket to resident in care. Staff spoke inappropriately to resident in care.

On 05/28/26, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegations. LPA met with Administrator Cavin Yoo. Investigation consisted of the following: On 05/28/26, the Department obtained Register of Residents, Personnel Report (05/27/26), Unusual Incident Report (05/14/26), and Resident #1’s Record. LPA interviewed Residents #1 - #6 (R1 – R6) and Staff #1 - #4 (S1 – S4). LPA left a voicemail for Staff #5 - #6. Note: R1 is no longer at the facility. Investigation revealed the following: Allegation: Staff did not prevent resident from harming themselves. It is alleged staff neglected Resident #1 (R1) and did not prevent R1 from harming self. Record review of R1’s medical assessment (05/05/26) revealed R1 displays expressions of frustration and does not have suicidal ideation. Continue to LIC9099-C. Unsubstantiated Review of Unusual Incident Report (05/14/26) revealed R1 acted aggressively towards the caregivers and started hurting self; thus, emergency services were called. Four out of four staff interviews (S1 – S4) indicated staff conduct rounds at least every two hours. S1 indicated staff checked on R1 often because R1 was screaming and staff went to check on R1. S3 indicated R1 had some bleeding that could have been treated with first aid but R1 would not allow staff to treat R1. S3 indicated R1 was aggressive with staff, used a cane as a weapon to keep staff away, and was commenting on suicide. Therefore, S3 called emergency services. S4 indicated R1 was aggressive and hitting people. Four out of five resident interviews (R2 – R6) indicated their care needs are met. Regarding the allegation, “Staff did not prevent resident from harming themselves,” based on record reviews and interviews, the Department found no evidence to support the above allegation. 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. Allegation: Staff did not provide a blanket to resident in care. Four out of six resident interviews (R1 – R6) indicated that have enough blankets to stay warm. Four out of four staff interviews (S1 – S4) indicated residents are provided with blankets. S1 and S3 – S4 indicated R1 had a blanket. S3 indicated R1 was throwing all of the blankets and trying to destroy all of the closet items. S4 indicated the room has heating. S2 showed the LPA multiple blankets in the residents’ closets. Regarding the allegation, “Staff did not provide a blanket to resident in care,” based on interviews and observations, the Department found no evidence to support the above allegation. 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. Continue to LIC9099-C. Allegation: Staff spoke inappropriately to resident in care. Four out of six resident interviews (R1 – R6) indicated staff has not spoken to them inappropriately. Four out of four staff interviews (S1 – S4) indicated staff has not spoken to the residents inappropriately. Regarding the allegation, “Staff spoke inappropriately to resident in care,” based on interviews, the Department found no evidence to support the above allegation. 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. An exit interview was conducted and a hard copy of this report was provided to Cavin Yoo.the state’s words, verbatim · CDSS document, May 28, 2026 · control 11-AS-20260519100831

Allegation investigated: Staff did not prevent resident from harming themselves. Staff did not provide a blanket to resident in care. Staff spoke inappropriately to resident in care.

On 05/28/26, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegations. LPA met with Administrator Cavin Yoo. Investigation consisted of the following: On 05/28/26, the Department obtained Register of Residents, Personnel Report (05/27/26), Unusual Incident Report (05/14/26), and Resident #1’s Record. LPA interviewed Residents #1 - #6 (R1 – R6) and Staff #1 - #4 (S1 – S4). LPA left a voicemail for Staff #5 - #6. Note: R1 is no longer at the facility. Investigation revealed the following: Allegation: Staff did not prevent resident from harming themselves. It is alleged staff neglected Resident #1 (R1) and did not prevent R1 from harming self. Record review of R1’s medical assessment (05/05/26) revealed R1 displays expressions of frustration and does not have suicidal ideation. Continue to LIC9099-C. Unsubstantiated Review of Unusual Incident Report (05/14/26) revealed R1 acted aggressively towards the caregivers and started hurting self; thus, emergency services were called. Four out of four staff interviews (S1 – S4) indicated staff conduct rounds at least every two hours. S1 indicated staff checked on R1 often because R1 was screaming and staff went to check on R1. S3 indicated R1 had some bleeding that could have been treated with first aid but R1 would not allow staff to treat R1. S3 indicated R1 was aggressive with staff, used a cane as a weapon to keep staff away, and was commenting on suicide. Therefore, S3 called emergency services. S4 indicated R1 was aggressive and hitting people. Four out of five resident interviews (R2 – R6) indicated their care needs are met. Regarding the allegation, “Staff did not prevent resident from harming themselves,” based on record reviews and interviews, the Department found no evidence to support the above allegation. 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. Allegation: Staff did not provide a blanket to resident in care. Four out of six resident interviews (R1 – R6) indicated that have enough blankets to stay warm. Four out of four staff interviews (S1 – S4) indicated residents are provided with blankets. S1 and S3 – S4 indicated R1 had a blanket. S3 indicated R1 was throwing all of the blankets and trying to destroy all of the closet items. S4 indicated the room has heating. S2 showed the LPA multiple blankets in the residents’ closets. Regarding the allegation, “Staff did not provide a blanket to resident in care,” based on interviews and observations, the Department found no evidence to support the above allegation. 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. Continue to LIC9099-C. Allegation: Staff spoke inappropriately to resident in care. Four out of six resident interviews (R1 – R6) indicated staff has not spoken to them inappropriately. Four out of four staff interviews (S1 – S4) indicated staff has not spoken to the residents inappropriately. Regarding the allegation, “Staff spoke inappropriately to resident in care,” based on interviews, the Department found no evidence to support the above allegation. 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. An exit interview was conducted and a hard copy of this report was provided to Cavin Yoo.the state’s words, verbatim · CDSS document, May 28, 2026 · control 11-AS-20260519100831

Type of visit: Case Management - Deficiencies

On 05/28/26, Licensing Program Analysts (LPA) Regina Cloyd conducted a case management - deficiency visit after conducting an unannounced complaint visit (11-AS-20260519100831). LPA met with the Administrator and explained the purpose of the visit. During the facility tour, LPA observed inoperable call buttons in rooms: 14, 27, 60, and 61. Manager indicated that portable call buttons are in some of the rooms but the residents do not want them or remove them from the walls. LPA only observed one portable call button in room 65. A deficiency is being cited according to California Code of Regulations. See LIC809-D page. An exit interview was conducted, plans of correction developed, and a copy of this report with appeal rights were provided to the Administrator Cavin Yoo.the state’s words, verbatim · CDSS document, May 28, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303i(1)(A)(B)(C) · Plan of correction due date: Jun 8, 2026

87303(i) (1) All facilities licensed for 16 or more... shall have a signal system which shall: (A)Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location ... loud enough to summon staff. (C) Identify the specific resident living unit. This requirement is not met as evidenced by: During the facility tour, LPA observed inoperable call buttons in rooms: 14, 27, 60, and 61, which poses a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: The Administrator will ensure all portable call buttons are installed and will talk to residents. Evidence of correction to be emailed to regina.cloyd@dss.ca.gov by the POC due date.

Allegation investigated: Resident sustained multiple fractures while in care. Staff did not to seek timely medical attention for the resident in care.

On May 1, 2026, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Licensed Vocational Nurse, Hee Kyung Park, greeted the (LPA). (LPA) explained the purpose of the visit is to deliver the findings for the allegations mentioned above. The investigation consisted of the following: The complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigator Sonia Torre. Records subpoenaed included Los Angeles Fire Department Records and 9-1-1 Audio Records (dated 12/01/25), Cedars Sinai Medical Center Records (dated 12/12/25), Olympica Convalescent Hospital Records (02/09/26), California Department of Public Health Records (dated 02/09/26), Starline Hospice Records (dated 02/18/26), Photographs taken by Facility Staff (dated 02/09/26), Patient Care Report (dated 11/09/25). Furthermore, the investigator conducted interviews with Staff #1- #8(S1-S8), Witness #1-W#2 (W1-W2), and Resident #2-#4 (R2-R4). (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Resident sustained multiple fractures while in care. It is alleged that the facility staff failed to provide adequate supervision for Resident #1 (R1), who sustained multiple fractures while in their care. Reports indicate that (R1) was admitted to the hospital following an unwitnessed fall. Further information revealed that (R1) suffered various traumatic injuries, including pneumocephalus, subdural hematoma, epidural hematoma, and a closed facial fracture, all consistent with a single fall. No additional details regarding this incident are available. Resident #1 (R1) was admitted to Hayworth Terrace on September 15, 2025, as documented in the facility’s Residential Care Admission Agreement (dated 09/15/25). On November 9, 2025, (R1) was transferred to Cedars-Sinai Hospital for treatment of injuries sustained in a fall. On January 13, 2026, February 9, 2026, February 12, 2026, February 23, 2026, between 09:40 AM and 02:50 PM, the Department interviewed staff members identified as Staff #1 through Staff #8 (S1-S8). (8) eight out of eight (8) could not corroborate this claim. On November 9, 2026, (R1) experienced a fall incident resulting in head injuries, necessitating treatment at Cedars Sinai Hospital. (S1) reported discovering (R1) lying by the exterior stairway and believed (R1) had fallen down the stairs, though the specifics of the fall—such as the number of steps—remain unclear. (S1) emphasized that (R1) requires constant supervision since (R1) frequently moves around the facility. Notably, (4) out of (8) staff members corroborated that (R1) has a history of unwitnessed falls, typically resulting in minor injuries. All staff members interviewed agreed that (R1) suffers from Major Neurocognitive Disorder (NCD) and is physically fragile. Additionally, (S7) confirmed that (R1) lacked a Physician's Report LIC 602A, or any formal medical assessment, as (R1) was categorized as a "temporary" resident. On January 13, 2026, between 10:15 AM and 12:15 PM, the Department interviewed resident members identified as Resident #2 through Resident #4 (R2-R4). Three (3) out of three (3) could not support this claim. All residents expressed they had no concerns about the level of care and supervision provided by staff. Resident #1 (R1) was unavailable for interview due to death. On November 26, 2025, and February 23, 2026, between 09:36 AM and 03:31 PM, the Department interviewed witness members identified as Witness #1 and Witness #2 (W1-W2). (Evaluation Report continues LIC 9099-C) Two (2) out of two (2) witness members were able to corroborate the claim. (W1) reported that (RI) had (NCD) but could walk independently. (R1) lost significant weight and appeared frail during (W1’s) visits. On November 9, 2025, (W1) learned that (R1) had fallen and required, but was initially stable. The next day, the hospital reported a brain bleed. After a week in the ICU, (W1) chose comfort-focused treatment. (R1) was moved to a skilled nursing facility and passed away on November 21, 2025. (W2) pointed out that the injuries exhibited by (R1) at the hospital were inconsistent with a simple ground-level fall. Notably, staff discovered (R1) lying at the foot of a stairway. (W2) emphasized that, given this context, it is entirely apparent that the injuries resulted from a fall down the stairs, which would account for the observed severity. A review of the facility's records revealed the absence of a Physician's Report, which should have included essential information on medication, medical diagnoses, and physical restrictions, to assess whether the facility could provide the appropriate level of care for Resident #1 (R1). Additionally, the Needs and Services Plan was not complete and failed to identify any of (R1's) mental, physical, or health needs. Furthermore, an examination of Cedars Sinai Medical Records (dated 12/12/25) verified that (R1) had been diagnosed with multiple severe traumatic brain injuries and facial injuries including bilateral frontal subarachnoid hematomas (8mm right, 4mm left), a bilateral frontal subarachnoid hemorrhage, and a left temporal epidural hematoma (9mm). There are also displaced fractures in the left zygomatic arch, frontal and anterior temporal bones, left orbital wall, and left maxillary sinus, as well as a nondisplaced C6 articular pillar fracture, a displaced right pubic root fracture, and a closed left fifth rib fracture. During the investigation, records were reviewed, and interviews were conducted with both residents and facility staff. An inspection also found that no surveillance cameras were installed, either inside or outside, to monitor residents. Moreover, it was noted that the stairways leading to the second floor were accessible, which posed safety risks. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. Allegation #2: Staff did not to seek timely medical attention for the resident in care. It is alleged that the facility staff failed to provide timely medical attention for Resident #1 (R1). Reports indicate that (R1) experienced an unwitnessed fall on November 9, 2025, resulting in multiple fractures and injuries. Further report indicated (R1) did not receive appropriate medical care in a timely manner and received only basic care from facility staff. No further details regarding this incident are available. On January 13, 2026, February 9, 2026, February 12, 2026, February 23, 2026, between 09:40 AM and 02:50 PM, the Department interviewed staff members identified as Staff #1 through Staff #8 (S1-S8). Eight (8) out of the eight (8) staff members confirmed that (R1) experienced an unwitnessed fall and sustained injuries early in the morning on November 9, 2026. On the morning of November 9, 2026, (R1) was found on the floor by the stairway, bleeding and injured at approximately 9:00 AM. (S1) reported that (R1) was distressing, appearing "in bad shape" and "kind of unresponsive," with visible facial injuries. (S1 and S2) helped (R1) back to (R1’s) room and provided only minimal care, such as wiping the blood and applying a bandage to (R1's) head. Neither (S1) nor (S2) reported this serious incident to management or contacted (R1's) primary physician. At around 11:30 AM, (S3) entered (R1's) room and discovered them sitting on the bed with a bandage still wrapped around (R1's) head. Observing continued bleeding, (S3) replaced the bandage. Later, around 3:00 PM, (S4) found (R1) lying on the floor of (R1’s) room, the bandage missing. (S4) noticed (R1's) eyes were shut, discolored, and swollen, which raised concerns that (R1) may have suffered another fall. (S4) immediately informed (S3) and insisted that a 9-1-1 call is necessary. (S1-S3) stated that 9-1-1 was not called after (R1) fell because staff were instructed to notify the Medication Technician for assessment and to notify management. (S1-S2) did not consider (R1) needed medical attention since (R1) was able to get up independently, despite having facial injuries and bleeding. On January 13, 2026, between 10:15 AM and 12:15 PM, the Department interviewed resident members identified as Resident #2 through Resident #4 (R2-R4). Three (3) out of three (3) could not support this claim. All residents expressed they had no concerns about the level of care and supervision provided by staff. Resident #1 (R1) was unavailable for interview due to death. On December 1, 2026, at 10:27 AM, the Department received audio calls from Emergency Medical Services (EMS) and 9-1-1. The initial 9-1-1 call was made at approximately 3:24 PM, reporting that (R1) had experienced a fall from a standing position. Units were dispatched at 3:26 PM and arrived at the facility by 3:34 PM. At 3:52 PM, (EMS) transported (R1) to Cedars Sinai Hospital. (Evaluation Report continues LIC 9099-C) The Department reviewed records consisting of: Unusual Incident Report/Injury Report (dated 11/09/26); Client/Resident Face Sheet; Identification and Emergency Information; Admissions Agreement (dated 09/15/25); Consent for Emergency Medical Treatment (dated 09/15/25); Appraisal/Needs and Services Plan; and Medication Administration Record. Further review of Los Angeles Fire Department Records (dated 12/01/25), the 9-1-1 Audio Call (dated 12/01/25), Cedars Sinai Medical Records (dated 12/12/25), and Patient Care Report (dated 11/09/25) revealed that the facility failed to provide timely medical attention to (R1), who sustained multiple fractures and head injuries during a fall. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099 D). An exit interview was conducted with Terri Han, and copies of the report and appeal rights were provided. *Immediate Civil Penalty issued* ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000). INVESTIGATION REVEALED THE FOLLOWING: Allegation #3: Staff are unable to effectively communicate with emergency response agency. It is alleged staff are unable to communicate with Emergency Response agency effectively. It is reported that the Los Angeles Fire Department was unable to communicate effectively with staff due to lack of English-speaking personnel and only spoke Korean. No further details regarding this incident are available. Reports indicate that Resident #1(R1) was admitted to the hospital following an unwitnessed fall. Further information revealed that (R1) was transported by Emergency Medical Services (EMS) on November 9, 2025, to Cedars Sinai Medical Center Hospital. On May 1, 2026, 9:30 AM and 12:30 PM the Department interviewed staff member identified as Staff #6 through Staff #9 (S6-S9). Four (4) out of the four (4) staff members could not support this claim. (S6) claimed that there is always an English-speaking staff to assist with residents, visitors and agencies. (S1) claimed that (6) out of (26) personnel staff member are fluent English communicators. While the other personnel staff are fluent in Korean or Spanish. (S9) who was present during the incident on November 9, 2025, with (R1) assisted with communications with (EMS) and stated there were no issues with communications with the (EMS) authorities. On January 13, 2026, and May 1, 2026, between 10:15 AM and 01:30 PM, the Department interviewed residents identified as Resident #2 through Resident #8 (R2-R8). Eight (8) out of three (8) could not corroborate this claim. Residents are satisfied with the care and supervision of the staff, noting that communication effectively meets their needs. (R5-R8) values the diverse language support, which enables smooth, uninterrupted care for residents. An analysis review of the Facility Resident Roster (dated 05/01/26) shows diversity among residents: 31% primarily communicate in Korean, and 69% primarily communicate in English. A further analysis of the Personnel Staff Roster (dated 05/01/26) shows that only 4.3% of the staff are proficient in English, whereas 95.7% are fluent in either Korean or Spanish. The staffing is designed to effectively meet the needs of their predominantly Korean-speaking residents, ensuring better communication and care. Based on the information gathered from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. 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. An exit interview was conducted with Terri Han and copies were provided.the state’s words, verbatim · CDSS document, May 1, 2026 · control 11-AS-20251110142021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 2, 2026

87466 – Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance...observation reveals unmet needs… brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidence by Based on interviews and record reviews, the facility did not ensure that (R1) received timely medical attention after a fall, allowing more than 6 hours to pass before seeking emergency services. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 1, 2026

Plan of correction: Licensee has agreed to a (POC). The facility will provide in-service training to all staff regarding the cited regulation. Additionally, the facility will develop a plan for residents identified as at risk of falling and submit it to the assigned LPA by May 2, 2026.

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

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... This requirement is not met as evidence by Based on interviews and record reviews, the facility did not ensure that (R1) was free from neglect and received safe accommodations after a fall. As a result of this failure, the resident sustained multiple fractures and injuries. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 1, 2026

Plan of correction: Licensee has agreed to a (POC). The facility will provide in-service training to all staff regarding the cited regulation. Additionally, the facility will develop a plan for residents identified as at risk of falling and submit it to the assigned LPA by May 2, 2026.

Type of visit: Case Management - Deficiencies

On May 1, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit to the facility in connection with complaint #11-AS-20251110142021. The LPA met with Assistant to the Administrator Terri Han and House Manager Miran Bae and explained the purpose of the visit. The Department determined the facility is not in compliance with Title 22 Regulations and is cited as follows: 87458 Medical Assessment(a)(b). The investigation revealed that the facility did not comply with Title 22 regulations. LPA identified that there was no current medical assessment for Resident #1 (R1), and (LIC 602 or equivalent) must be completed before admission and kept updated. No assessment included the resident’s diagnoses, functional capacity, and care needs. The resident’s Physician’s Report is missing, and or any formal medical assessment. Based on interviews, observation, and record reviews, the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies are issued, and an exit interview is conducted with Terri Han. A copy of this report is provided along with the appeal rights.the state’s words, verbatim · CDSS document, May 1, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a)(b) · Plan of correction due date: May 15, 2026

87458 Medical Assessment -(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment... to be kept in the resident's record.(b)The licensee shall obtain an updated medical assessment when required by the Department. This requirement is not met as evidence by: Based on record review, the licensee did not ensure that (R1) had a current medical assessment, as required by Title 22. The resident’s Physician’s Report (LIC 602) was not obtained and maintained in the resident’s record. This failure poses a potential health and safety risk to residents in care,the state’s words, verbatim · CDSS document, May 1, 2026

Plan of correction: Licensee will obtain a current Physician’s Report (LIC 602) for each resident, ensure all records have a current medical assessment, retrain admissions staff on documentation, and submit (POC) by 05/15/26.

Type of visit: Required - 1 Year

On January 22, 2026, Licensing Program Analyst (LPAs) Ernand Dabuet, Lizeth Villegas, Sparkle Day and Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with Executive Director Cavin Yoo. LPA explained the purpose of today’s visit. The facility is licensed to serve (111) non-ambulatory elderly adults ages 60 and above. The facility is approved for (25) hospice residents. Currently, the facility has (12) residents on hospice care. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (81) resident bedrooms. Each room has a bathroom in the unit. The facility houses an activity room, dining area, kitchen, administrative offices, and outside patio area. LPA Dabuet toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #18; #20; #22; #40; #48; #74; #86; #62, #65 and #49. The water temperature range from 95.0 - 121.5 degrees F. and room temperature range from 66 - 70 degrees F. and smoke and carbon monoxide are all in operating condition. LPA Dabuet observed the facility to be sanitary and appropriately 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 there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged. A review of Fire Drills were completed 12/19/25 . Several working landline phones are available on-site. A review of Medication Administration Records found to be in order and accurate. Evaluation Report continues on LIC 809C 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, including the Activities Calendar and Food Menu, were posted. An audit of resident's service records for resident #1-#6 (R1-R6) and staff personnel records for staff #1-#6 (S1-S6). The facility is current on Community Care Licensing annual fees. The facility has a current administrator certificate on file for Cavin Yoo #6078367740 09/12/2025 through 09/11/2027 RCFE. The facility has a Liability Insurance Certificate valid with policy # HOO76K0023601 effective 11/26/25 through 11/26/26. Deficiencies: The emergency call button is non-operational in the following rooms: #49, #20, #22, and #86. There is no emergency call button available in rooms #62 and #18. The toilet seat cover is missing in room #22. Disinfectant and toxic chemical sprays were observed in rooms #17 and #65. Scissors and other hazardous objects were found in room #18. Staff members #2, #3, and #5 do not have CPR/First Aid certifications on file. There is no Appraisal/Needs Service Plan LIC 625 on record for residents #1, #2, #3, and #5. Staff members #4 and #6 do not have TB Test and Health Screening results on file. Residents in rooms #18 and #65 have prescribed medications stored in their rooms, but they are unable to handle medications according to LIC 602A guidelines. The hot water temperature measured between 95°F and 97°F in rooms #18, #20, and #2. An exit interview was conducted, and a copy of this report and appeal rights were provided to Cavin Yoo.the state’s words, verbatim · CDSS document, Jan 22, 2026

Type of visit: Case Management - Deficiencies

On December 04, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit to the facility in connection with complaint #11-AS-20250624090908. The LPA met with assistant to the administrator Terri Han and administrator Cavin Yoo and explained the purpose of the visit. The Department determined the facility is not in compliance with Title 22 Regulations and is cited as follows: 87465(e)(1-4) Incidental Medical and Dental Care.The investigation revealed that the facility did not comply with Title 22 regulations. LPA identified that care staff were providing over-the-counter medications to Resident #1 (R1) without a physician's written authorization, prescription, or other documentation indicating the name of the medication, the dosage, and the reason for administration. The Department determined the facility is not in compliance with Title 22 Regulation and is cited as follows: 87405(a) Administrator - Qualifications and Duties. The facility has Staff #1 (S1) identified as the administrator since October 2025, and requests for the required documents for an RCFE Administrator have not been provided to the Department. Based on interviews, observation, and record reviews, the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies are issued, and an exit interview is conducted with Cavin Yoo. A copy of this report is provided along with the appeal rights.the state’s words, verbatim · CDSS document, Dec 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Dec 18, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidence by: Based on record review and interview the licensee fail to provide the require proof that the administrator qualifications by submission of required RCFE documentations. This violation poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licensee will adhere to Tittle 22 87405 regulations at all times. As plan of correction, licensee will provide the required documentation indication that facility has administrator on duty to the regional office before the POC due date at ernand.dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(e)(1-4) · Plan of correction due date: Dec 18, 2025

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file... Both the physician's order and the label shall contain at least all of the following information. This requirement was not met as evidence by: Based on record review and interview the licensee fail to provide did not comply with Title 22 regulations. LPA identified that care staff were providing over-the-counter medications to Resident #1 (R1) without a physician's written authorization, prescription, or other documentation and the reason for administration.This violation poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licensee will adhere to Tittle 22 87465 regulations at all times. As plan of correction, licensee will provide a staff training on medication administration to the regional office before the POC due date at ernand.dabuet@dss.ca.gov

Allegation investigated: Staff had inappropriate interaction with resident. Staff did not provide resident with assistance in a timely manner. Staff did not meet resident's needs while in care.

On November 16, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Yun Ji Kim Registered Nurse/Med-Tech, greeted the (LPA). (LPA) explained the purpose of the visit is to investigate the allegations mentioned above. The investigation included interviews, a collection of records, and an observation of the facility. The Department obtained several documents, including the Facility Staff Roster (dated 11/10/25), the Resident Roster (dated 11/10/25) and other pertinent records associated with this complaint. Interviews were conducted with Resident #1-#6 (R1-R6)'s and Staff #1- #5 (S1-S5). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff had inappropriate interaction with resident. The complaint alleges that the staff interacted inappropriately with Resident #1 (R1). Reports indicate that a staff member engaged in inappropriate behavior when (R1) requested water. Specifically, it was reported that the staff member threw water in (R1's) face after only one day at the facility. No further information has been provided regarding this situation. On November 6, 2025, between 12:40 PM and 01:10 PM, the Department interviewed resident member identified as Resident #1 (R1). During the interview with (R1), several inconsistencies were noted in (R1’s) statements regarding the incident with Staff #1 (S1). (R1) initially stated that the incident occurred several weeks earlier, on October 8, 2025, before (R1's) admission to Hayworth Terrace on October 22, 2025. (R1) confirmed that the incident happened only once and expressed that (R1) perceived (S1's) behavior as inappropriate when (S1) threw water in (R1's) face. Additionally, (R1) expressed dissatisfaction with the facility, particularly regarding the incident with (S1). When asked about possible witnesses, (R1) pressed for more details but ultimately refused to provide additional information. On November 10, 2025, between 10:30 AM and 11:45 AM, the Department interviewed resident members identified as Resident #2 through Resident #6 (R2-R6). Five (5) out of the five (5) resident members were unable to support this claim. (R2-R6) provided positive feedback about the staff, noting their professionalism in interactions. They all reported interacting with Staff #1 (S1), who was described as reliable, dependable, and proficient. On November 10, 2025, between 10:30 AM and 04:59 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members were able to validate the incident between Resident #1 (R1) and Staff #1 (S1). It was confirmed by (S1-S5) that no staff members misbehaved towards residents in care. (S2-S3) verified that (R1) was a patient at Martin Luther King, Jr. Community Hospital and was transferred to Hayworth Terrace on October 22, 2025. According to (S2), (R1) was at the facility for only one night when (R1) called 9-1-1 and was subsequently admitted to Cedar Sinai Hospital later that day, October 23, 2025, and did not have further information to disclose regarding (R1). (Evaluation Report continues LIC 9099-C) (S1) denied making any inappropriate remarks or exhibiting poor behavior toward (R1). (S1) asserted that (S1) did not throw water at (R1), emphasizing that this accusation is entirely unfounded. (S1) explained that (R1) was upset and wanted to leave the facility after staying at Martin Luther King, Jr. Community Hospital on October 22, 2025. In a moment of high emotion, (R1) threatened to call 9-1-1 and strongly objected to staying at Hayworth Terrace. The Department made several attempts to contact (R1's) family representative, Witness #1 (W1), but the calls went unanswered. The Department reviewed medical records from Martin Luther King, Jr. Community Hospital (dated 10/22/25), and the Unusual Incident Report (LIC 624) (dated 11/10/25) along with Centrally Stored Medication and Destruction Record LIC 622 (dated 10/22/25). The records show that (15) medications are prescribed, with (11) of these causing side effects such as confusion, agitation, depression, restlessness, dizziness, and vision or memory impairment (ref: National Institutes of Health). The medical records presented (R1) with a history of challenging situation faced with incidents involving a staff member at board and care facilities. Additional review of Staff Training revealed all staff have completed training in topics in Resident’s Rights, Abuse & Neglect, House Rules, Positive Behavior Support, and Positive Case Support. During the investigation on November 10, 2025, the Department observed staff members interacting with residents and noted that their conduct was appropriate. The Department found that the facility upholds the rights of its residents. Posters detailing Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Allegation #2: Staff did not provide resident with assistance in a timely manner. Allegation #3: Staff did not meet resident's needs while in care. The complaint claims that the staff did not promptly assist Resident #1 (R1) or meet (R1's) needs while in care. Reports indicate that (R1) received incontinence care only two hours later and that staff also failed to reposition (R1) as needed. No further information has been provided regarding this situation. (Evaluation Report continues LIC 9099-C) On November 6, 2025, between 12:40 PM and 01:10 PM, the Department interviewed resident member identified as Resident #1 (R1). During the interview with (R1), the Department noticed some inconsistencies in (R1's) account of the incident involving Staff #1 (S1). (R1) shared that the incident took place on October 8, 2025, before (R1) was admitted to Hayworth Terrace on October 22, 2025. (R1) expressed the challenges of being bed-bound and needing assistance with repositioning and diaper changes while under hospice care. (R1) felt that (S1) refused to help and purposely delayed assisting (R1) with these essential needs. When asked for more details, (R1) chose to end the discussion. On November 10, 2025, between 10:30 AM and 11:45 AM, the Department interviewed resident members identified as Resident #2 through Resident #6 (R2-R6). Five (5) out of the five (5) resident members could not corroborate these claims. (R2-R6) provided affirmative feedback regarding the staff's responsiveness to their care and needs. They reported multiple interactions with (S1), during which assistance was consistently prompt and their individual needs were effectively addressed. On November 10, 2025, between 10:30 AM and 04:59 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members were able to validate these claims between Resident #1 (R1) and Staff #1 (S2-S3) verified that (R1) was a patient at Martin Luther King, Jr. Community Hospital and was transferred to Hayworth Terrace on October 22, 2025, and was on under hospice care with Comforter Hospice. According to (S2), (R1) was at the facility for only one night when (R1) who contacted 9-1-1 and wanted to be off hospice care. (S2-S3) stated (R1) was released from (MLK) hospital at 5:30 PM and was sent over to our facility and was admitted at Hayworth Terrace approximately at 7:00 PM. (R1) was in a private room overnight and the facility did not really abundance of time to fully attend to (R1’s) needs as (R1) admitted self to Cedar’s Sinai by contacting 9-1-1 the less than 24 hours. In an interview, (S1) denied the allegations, saying they are not true. (S1) mentioned that (R1) was resentful and did not want to receive hospice care. (R1) threatened to call 9-1-1 and was firmly against staying at Hayworth Terrace. According to (S1), (R1) had (R1's) diapers changed twice during the evening and was repositioned twice before paramedics took (R1) to Cedar Sinai Hospital on October 23, 2025. The Department made several attempts to contact (R1's) family representative, Witness #1 (W1), but the calls went unanswered. (Evaluation Report continues LIC 9099-C) The Department reviewed medical records from Martin Luther King, Jr. Community Hospital (dated 10/22/25), and the Unusual Incident Report (LIC 624) (dated 11/10/25) along with Centrally Stored Medication and Destruction Record LIC 622 (dated 10/22/25). The records show that (15) medications are prescribed, with (11) of these causing side effects such as confusion, agitation, depression, restlessness, dizziness, and vision or memory impairment (ref: National Institutes of Health). The medical records presented (R1) with a history of challenging situation faced with incidents involving a staff member at board and care facilities. A review of all staff indicates that they have completed their training in the following areas: Basic Care, Health and Safety, Specialized Care, Dementia and Alzheimer’s Care, and Documentation and Reporting. Based on the information collected, there is not enough evidence to support the allegations mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. An exit interview was conducted with Yun Ji Kim and copies were provided.the state’s words, verbatim · CDSS document, Nov 16, 2025 · control 11-AS-20251105091914

Allegation investigated: Staff do not meet a resident's diabetic needs. Staff mishandle a resident's medication. Staff do not communicate effectively. Staff are isolating a resident. Staff do not provide adequate food service to a resident.

On 11/10/25, at 9:30am, the department conducted an initial complaint visit to the facility and was greeted by Terri Han, Administrator’s Assistant. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegation(s) mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S3) and residents (R1-R6). The department received the following facility documents: Resident Roster (Date: No Date), Staff Roster (Dated: 05/23/2025), Hayworth Food Menu (Dated: November 2025), Identification and Emergency Information (Dated: 07/09/25,10/12/21,02/15/25), Physician Report LIC 602A (Dated: 10/12/24 & 02/13/25), Appraisal and Needs Service Plan (Dated: 07/29/25,10/12/21, 02/15/25), and Medication Administration Record (Dated: 11/01/25-11/30/25), from the facility. Report Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Staff do not meet a resident's diabetic needs. The details of the complaint alleged that the facility is not checking the residents’ blood sugar levels properly throughout the day, which is important for managing and preventing further complications of the disease. On 11/10/2025, from 9:30am-2:00pm, the department interviewed staff (S1-S3) and residents (R1-R6) regarding the allegation. 3 of 3 staff denied the allegation that Staff do not meet a resident's diabetic needs. All staff stated that the residents who are diabetic are independent and handle their own diabetic medications. Staff also stated that the nurse and med-techs monitor the residents to make sure they are taking their medication. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that the staff does assist them with their medication when needed. Residents also stated that the staff does monitor their glucose levels throughout the day. The department reviewed the Physician Report LIC 602A (Dated: 10/12/24 & 02/13/25), Appraisal and Needs Service Plan (Dated: 07/29/25,10/12/21, 02/15/25), and Medication Administration Record (Dated: 11/01/25-11/30/25) for the residents and did not observe any discrepancies. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not meet a resident's diabetic needs. 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. Allegation #2- Staff mishandled a resident's medication. The details of the complaint alleged that the resident is supposed to receive insulin three times a day along with their eight other medications yet, at Hayworth, they have been lax at checking the resident’s blood sugar levels or providing the resident with their insulin and other medications. On 11/10/2025, from 9:30am-2:00pm, the department interviewed staff (S1-S3) and residents (R1-R6) regarding the allegation. 3 of 3 staff denied the allegation that Staff mishandled a resident's medication. All staff stated that the residents’ medication is never mishandled and those who need their diabetic medication are given it. They also stated that their blood sugar levels are monitored and checked before and after each meal. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that their medication has never been mishandled by the staff. The department reviewed the Appraisal and Needs Service Plan (Dated: 07/29/25,10/12/21, 02/15/25), and Medication Administration Record (Dated: 11/01/25-11/30/25) and did not observe any discrepancies. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff mishandled a resident's medication. 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. Report Continued on LIC9099-C Allegation #3- Staff do not communicate effectively. The details of the complaint alleged that the majority of the staff at the facility mostly speak Korean, and the resident speaks only English making it hard to communicate effectively. On 11/10/2025, from 9:30am-2:00pm, the department interviewed staff (S1-S3) and residents (R1-R6) regarding the allegation. 3 of 3 staff denied the allegation that Staff do not communicate effectively. All staff stated that the facility has three main languages that are Korean, English, and Spanish. They stated that they work as a team to translate for those who need it, so that they can serve their entire community of residents. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that they don’t have a problem communicating with the staff and are provided with translators if they need it. Based on interviews, there is insufficient evidence to support the allegation that Staff do not communicate effectively. 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. Allegation #4- Staff are isolating a resident. The details of the complaint alleged that most of the staff at the facility speak Korean and the television stations are all set to Korean stations, making the resident feel isolated and have no way of interacting with other residents. On 11/10/2025, from 9:30am-2:00pm, the department interviewed staff (S1-S3) and residents (R1-R6) regarding the allegation. 3 of 3 staff denied the allegation that Staff are isolating a resident. All staff stated that the main televisions in the recreational are set to English and Korean. The staff also stated that residents have an individual television in their room so that they can watch whatever program they would like. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that the televisions are set to different languages and that they have a television in their own room. Residents that were interviewed also stated that they do not feel isolated and do interact with the other residents in the facility. The department took a tour of the facility and observed that the residents do have their own televisions in their room. Based on observation and interviews, there is insufficient evidence to support the allegation that Staff are isolating a resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued on LIC9099-C Allegation #5- Staff do not provide adequate food service to a resident. The details of the complaint alleged that the facility is only giving the resident Korean meals which they do not like. Thus, making it difficult for them to eat and keep their blood sugar levels within range to avoid complications of the disease. On 11/10/2025, from 9:30am-2:00pm, the department interviewed staff (S1-S3) and residents (R1-R6) regarding the allegation. 3 of 3 staff denied the allegation that Staff do not provide adequate food service to a resident. All staff stated that they do provide adequate food service for the residents. They stated that they serve a Korean, American, and Kosher foods for their residents. They also stated that sometimes they order other foods for the residents if they want something different. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that the facility does serve Korean food, along with American. They also stated that they serve a kosher meal for a resident as well. Most residents also stated that they were able to order their own food for extra variety but said they were satisfied with the food provided. The department reviewed the facility’s menu and took a tour of the kitchen and verified that they do serve a variety of American and Korean meals for their residents. Based on observation, interviews, and records reviewed, there is insufficient evidence to support the allegation that Staff do not provide adequate food service to a resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued. An exit interview was conducted with Terri Han, Administrator’s Assistant, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Nov 10, 2025 · control 11-AS-20251103124148

Allegation investigated: Staff did not seek timely medical attention for resident leading to hospitalization. Staff refused to call 9-1-1 for resident.

On November 08, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Licensed Vocational Nurse, Hee Kyung Park, greeted the (LPA). (LPA) explained the purpose of the visit is to deliver the findings for the allegations mentioned above. The investigation consisted of the following: On June 25, 2025, the department conducted an initial visit and met with House Manager Miran Bae (S2). A subsequent visit was completed by the department on November 08, 2025. During the initial visit, the department conducted a tour of the facility's physical plant and observed residents in care. The department obtained copies of the following documents: Resident Roster (dated: 06/25/25), Staff Roster (dated: 06/25/25), (R1's) Physicians Report LIC 602A (dated12/23/24), and Home Health Care Medical Records (dated 01/24/25), Besht Wellness Center (dated 06/13/25), Hollywood Presbyterian Medical Records (dated 07/08/25) and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Substantiated This complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigator Christine Ferris. As part of the investigation, Investigator Ferris subpoenaed medical progress notes from Besht Wellness Center (dated 06/13/25), Hollywood Presbyterian Medical Records (dated 07/08/25), Home Health Care Medical Records (dated 01/24/25), Behst Wellness Center Medical Records (dated 06/01/25) Besht Wellness Center (dated 07/01/25) Besht Wellness Progress Notes (dated 05/14/25), ALSO Home Health Care, Inc (dated 01/09/25), Professional Care Home Health, Inc (dated 05/10/25) and Besht Wellness Center Progress Notes (dated 06/15/25). Furthermore, the investigator conducted interviews with Staff #1- #4(S1-S4), Witness #1-W#2 (W1-W2), and Resident #1-#2 (R1-R2). INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION #1: Staff did not seek timely medical attention for resident leading to hospitalization. ALLEGATION #2: Staff refused to call 911 for resident. It has been alleged that Resident #1 (R1) did not receive timely medical attention, which ultimately resulted in hospitalization. Additionally, staff allegedly refused to call 911 when needed. Between June 1, 2025, and June 3, 2025, it was noted that (R1) was in pain and was being treated with pain patches and pain pills. During this time, the facility was contacted several times, but no one was available to respond to the calls. On June 14, 2025, a request was made for (R1) to receive hospital treatment for the right arm, but staff again refused to call 911. The facility maintains that it is not responsible for transporting the resident to the hospital, even with a doctor's correspondence for medical treatment in place. Staff indicated they needed a physician's referral before contacting 911 for hospitalization, and it was clear they were unwilling to call for emergency assistance. On July 09, 2025, at 11:30 AM, the Department interviewed Resident #1 (R1). (R1) reported to have been living at Hayworth Terrace for about six months (date of placement 12/18/24). (R1) expressed (R1) fell out of bed and informed staff about the fall. (R1) advised staff (R1) was in pain “every day”, and the staff gave (R1) “pain pill”, and place “pain patch” on (R1’s) arm. (R1) added that “No one thought I was hurt”. (Evaluation Report continue LIC 9099-C) On July 09, 2025, and August 11, 2025, between 11:30 AM and 02:00PM, staff members interviewed identified as Staff #1 through Staff #4 (S1-S4) all denied both allegations. (S1-S4) stated they were unaware of any fall involving (R1) and that (R1) never notified them about it. However, (3) out of the (4) staff members were aware or made aware of (R1) being provided with pain pills and pain patches for (R1’s) shoulder pain for several days less or a week. (S1-S4) claimed that (R1’s) pain to the back and right shoulder was due to being “elderly” and had carried a “heavy bag” so complaining was not unusual. (S1-S3) claimed to have no documentation of over-the-counter medications or incidents of falls for (R1). Regarding the procedure for contacting emergency services, (S1) stated that Besht Wellness Center has instructed its staff to call 911 and arrange for Non-Emergency Medical Transportation (NEMT) when necessary. According to (S2), policy dictates that if a resident falls and sustains an injury, 911 should be called or the resident should be taken to see a doctor. On July 07, 2025, at 11:00 AM, the Department interviewed Witness #1 (W1). According to (W1), on May 22, 2025, (W1) was informed about (R1's) bed fall, and the facility cannot contact 911 without a doctor's approval. On July 31, 2025, at 03:00 PM, the Department interviewed Witness #2 (W2). (W2) reported that an X-ray order was sent to Besht Wellness Center on May 2, 2025, by (S4). (R1) had been experiencing moderate pain for seven days. The X-rays were performed on May 8, 2025. (W2) confirmed that (R1's) shoulder issue was classified as “chronic” because treatment did not start until May 14, 2025, despite the pain being reported on May 2, 2025. This delay contributed to the chronic classification. On July 30, 2025, and September 17, 2025, between 01:00 PM and 04:00 PM resident members interviewed identified as Resident #2 to Resident #5 (R2-R5). Four (4) of the (4) claimed they were unable to support the staff's refusal-to-contact-911 allegation. (R2-R5) were unaware of any harm and denied knowing about the staff's refusal to provide timely medical assistance with 911. The Department reviewed medical progress notes from Besht Wellness Center (dated 06/13/25), which indicated that attempts to reach the facility regarding (R1’s) fracture were unsuccessful. “Attempted to contact the facility multiple times using all phone numbers on file; no answer and disconnected.” Transfer orders were sent to the facility by fax on May 13, 2025, due to a lack of response. (Evaluation Report continues LIC 9099-C) Besht Wellness Center sent an email to the facility stating (R1’s) X-Ray shows a fracture-dislocation of the proximal humerus and advised (R1) to be transported to the emergency department for treatment via (NEMT). Further review of the Hollywood Presbyterian Medical Center medical records (dated 07/08/25) reported an inability to reach the facility, as noted in the documents, “Multiple attempts were made to reach staff at the assisted living facility with no success.” Medical records revealed (R1) notable for an obvious deformity,” and “it is possible that since the shoulder might have been out for up to a week, reduction is no longer possible.” The Department reviewed the California Department of Social Services Provider Information Notice (PIN) 25-06-ASC, dated June 24, 2025. The notice states that it is best practice for the licensee to immediately call 9-1-1 if a resident is experiencing serious injuries, such as “obvious broken bones”, or if they have “falls with complaint of pain or loss of range of motion.” Based on the gathered information, the facility showed no urgency in following up on June 6, 2025, X-ray results, despite staff knowing that (R1) was in "severe pain," according to (S4) and medical records. Hollywood Presbyterian Medical Center indicated (R1's) fracture required surgery, likely due to the delayed medical attention. The staff noted that (R1) had significant pain for a week, relying on over-the-counter medications for relief. However, there was a lack of communication about arranging Non-Emergency Medical Transportation (NEMT) to meet (R1's) needs. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099D). *Immediate Civil Penalty issued* An exit interview was conducted with , and copies of the reports were provided. This complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigator Christine Ferris. As part of the investigation, Investigator Ferris subpoenaed medical progress notes from Besht Wellness Center (dated 06/13/25), Hollywood Presbyterian Medical Records (dated 07/08/25), Home Health Care Medical Records (dated 01/24/25), Behst Wellness Center Medical Records (dated 06/01/25) Besht Wellness Center (dated 07/01/25) Besht Wellness Progress Notes (dated 05/14/25), ALSO Home Health Care, Inc (dated 01/09/25), Professional Care Home Health, Inc (dated 05/10/25) and Besht Wellness Center Progress Notes (dated 06/15/25). Furthermore, the investigator conducted interviews with Staff #1- #4(S1-S4), Witness #1-W#2 (W1-W2), and Resident #1-#2 (R1-R2). INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION #3: The resident suffered a dislocated shoulder due to staff negligence. It is alleged that Resident #1 (R1) suffered a dislocated shoulder due to staff negligence. On May 22, 2025, (R1) was observed with their right arm hanging limp and dragging, and (R1) complained of pain. When this was reported to the facility staff who stated that the hanging arm was due to old age and was not a concern. Additionally, it was noted that facility management was unable to provide clarification on the matter during multiple inquiries. No further details about this incident were provided. On July 09, 2025, at 11:30 AM, the Department interviewed Resident #1 (R1). (R1) reported to have been living at Hayworth Terrace for about six months (date of placement 12/18/24). (R1) expressed (R1) fell out of bed and injured the shoulder. (R1) did not call for assistance prior to or after the fall and is able to lift self from the floor, which (R1) did after the fall. The facility had no documentation of (R1) notifying them of a fall and denied any know of a fall. On July 09, 2025, and August 11, 2025, between 11:30 AM and 02:00PM, staff members interviewed identified as Staff #1 through Staff #4 (S1-S4) who are unable to support this claim. (S1-S4) stated they were unaware of any fall involving (R1) and that (R1) never notified them about it. Additionally, there was no documentation from the facility indicating any notification from (R1) regarding the fall. (Evaluation Report continues LIC 9099-C) On July 07, 2025, at 11:00 AM, the Department interviewed witness member identified as Witness #1 (W1). (W1) was not aware of (R1's) fall or fractured shoulder until (R1) disclosed the injury on May 22, 2025. During this conversation, (R1) mentioned that (R1) had fallen out of bed and was experiencing pain in the right shoulder. According to (W1), no one at the facility had notified (W1) about the fall. The Department reviewed medical progress notes from Besht Wellness Center (dated 06/13/25) where (R1) denied any recent falls but per Hollywood Presbyterian Medical Records (dated 07/08/25) (R1) reported (R1) fell out of bed but did not not know when it occurred. Further review of the Physicians Report LIC 602A (dated12/23/24), and Home Health Care Medical Records (dated 01/24/25). Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. 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. An exit interview was conducted with the Licensed Vocational Nurse, Hee Kyung Park, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Nov 8, 2025 · control 11-AS-20250624090908

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Nov 10, 2025

87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided... when such observation reveals unmet... When changes such as... deterioration of mental ability or a physical health condition... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician. This requirement is not met as evidenced by: Based on interviews, observation, and record reviews, the Licensee was aware of (R1's) the Licensee knew R1 had significant pain for a week but didn't seek medical attention, leading to hospitalization and surgery for fracture. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 8, 2025

Plan of correction: Licensee/Administrator will review Title 22 87466 Observation of Resident. Licensee will provide staff with training on observation of the residents. Licensee will provide copies of training materials and sign-in sheet to CCL by POC 11/10/25 and submit to ernand.dabuet@dss.ca.gov *Immediate Civil Penalty*

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Nov 22, 2025

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement is not met as evidenced by: Based on interviews, observation, and record reviews,(R1) experienced significant pain for a week, but there was inadequate communication about arranging Non-Emergency Medical Transportation (NEMT). This violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 8, 2025

Plan of correction: Licensee/Administrator must submit a written statement outlining staff protocols for addressing injured residents in emergencies and non-emergencies, including the provision of medical attention. Review PIN 25-06 ASC and 87465 Title 22 regulations and submit the protocol by 11/22/25 to ernand.dabuet@dss.ca.gov.

Type of visit: Case Management - Deficiencies

On September 17, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit to the facility in connection with complaint # 11-AS-20250909112019. The LPA met with the Assistant to the Administrator Terri Han and explained the purpose of the visit. The Department determined the facility was not incompliance with Title 22 Regulations and were cited as follows: · 82711(a)(1)(D) - Reporting Requirements · 87405(a) - Administrator - Qualifications and Duties The investigation revealed that the facility did not comply with Title 22 regulations, with no reporting of incidents that occurred on September 1, 2025, associated with complaint # 11-AS-20250909112019. The facility does not have a qualified Administrator, which pertains to 87405(a) Administrator Qualifications and Duties. Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies are issued and an exit interview is conducted with Terri Han. A copy of this report is provided along with the appeal rights.the state’s words, verbatim · CDSS document, Sep 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Oct 1, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidence by: Based on observation and interview the licensee fail to provide the require proof that the administrator on duty is meeting the qualifications of hours spent at the facility. This violation poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: Licensee will adhere to Tittle 22 regulations at all times. As plan of correction, licensee will provide the required documentation indication that facility has administrator on duty to meet the qualified hours spent at the facility to the regional office before the POC due date at ernand.dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Oct 1, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...of the occurrence of any of the events... (D) Any incident which threatens the welfare, safety or health of any resident...,or unexplained absence of any resident. This requirement was not met as evidence by: Based on LPA's interviews conducted and record reviews, the Licensee failed to report incident (R1's) A/C system not working 09/01/25. This violation poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: Licensee agrees that a Plan of Correction will be submitted to CCLD by 10/01/25 with Unusual Incident Reports LIC 624 involving (R1) incident 09/01/25 to (CCL). POC must be fax to 424-544-1016.

Allegation investigated: Staff did not ensure residents' air conditioner was working properly.

On September 10, 2025, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Terri Han, Assistant to the Administrator, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, a collection of records, and a tour of the facility. Interviews were conducted with Staff #1 and Staff #2 (S1-S2). The Department reviewed several documents, including the Facility Resident Roster (dated 09/10/25), Facility Personnel Roster (dated 09/10/25), Air Conditioning Invoice #0383770 (dated 09/04/25), and (R1's) Physicians Report LIC 602A (dated 11/15/22), as well as other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not ensure the residents’ air conditioner was working properly. The complaint alleges that the staff at the facility did not ensure that Resident #1 (R1's) air conditioner was functioning correctly. It has been reported that the air conditioner in the middle hallway on the second floor is either broken or malfunctioning, while the rest of the floor below is operating correctly and remains cool. No additional information about this situation was provided. On September 10, 2025, between 10:00 AM and 12:00 PM, the Department interviewed staff members identified as Staff #1 and Staff #2. Two (2) of the two (2) staff members were unable to validate this claim. (S1) stated that the air conditioning (AC) unit in room #45 is functioning correctly for Resident #1 (R1). In contrast, (S2), who has been closely monitoring service records for (R1), has not reported any issues with the air conditioning system. (S1) mentioned that (R1) informed about the AC system's malfunction on August 27, 2025. (S1) inspected the thermostat unit that controls rooms #33, #41, #42, #45, and #46. The thermostat, located in the second-floor hallway, is securely enclosed in a clear plastic lockbox. However, it had been tampered with and turned off. (S1) explained that residents often attempt to adjust the thermostat in the middle of the night without access to the key, leading them to tamper with the lockbox. To resolve the issue, (S1) had to reset the circuit breaker panel located on the rooftop where the Central Air Conditioner Condenser unit for rooms #33, #41, #42, #45, and #46 is situated. According to (S1), the AC was operational for several days but failed on September 1, 2025, due to a malfunction in the compressor. (S1) noted that compressors can fail due to electrical issues, blocked coils, overheating, contamination from dirt or moisture, and imbalanced refrigerant levels. (S1) reported compressor part was immediately ordered and on September 4, 2025, the new part was installed by AC specialist and AC was in working condition. (S1) indicated that (R1) received an oscillating tower fan to cool the entire room while awaiting part replacement. On September 10, 2025, the Department conducted an inspection of the thermostats on the second floor, focusing on the thermostat unit for room #45, which is designated as (R1’s) private room. All thermostats were found to be functioning correctly. Furthermore, rooms #33, #41, #42, #45, and #46 were also inspected, and it was observed that the air conditioning units in these rooms were operational. (Evaluation Report continues LIC 9099-C) The inspection covered the common areas on the first floor, which included the lobby, activity rooms, and dining area. All of these areas are equipped with functioning air conditioning units. Additionally, the Department inspected the rooftop circuit breaker panel connected to the Central Air Conditioner Condenser unit that serves rooms #33, #41, #42, #45, and #46, confirming that it was in working condition. An oscillating tower fan located in room (R1) was also found to be functioning correctly. The temperature in (R1’s) room ranged from 68°F to 74°F, which is compliant with Title 22 regulations. A review of the Air Conditioning Invoice #0383770 (dated 09/04/25) confirmed that the ordered part was replaced promptly, and the labor involved was verified. Additionally, an examination of (R1’s) Physician’s Report LIC 602A (dated 11/15/22) and the Appraisal/Needs Service Plan LIC 625 (dated 06/28/22) indicated that (R1) did not have respiratory or cardiovascular conditions that could present physical or mental conditions with improper room temperature (ref: National Institute of Health NIH). Resident #1 (R1) was unavailable for an interview during the investigation. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. 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. An exit interview was conducted with Terri Han, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 11-AS-20250909112019

Allegation investigated: Staff did not seek timely medical attention for resident. Staff mismanaged residents’ medication. Staff dispensed medication not prescribed to resident.

On 09/04/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to deliver amended report for the allegations mentioned above. LPA met with Admission Assistant, Terri Han, and the purpose of the visit was explained. LPA was granted entrance to the facility. **This report supersedes the report created and delivered on 07/02/25. This report is to clarify findings. On 06/18/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to further investigate the allegations mentioned above and deliver findings. LPA met with Manager, Miran Bae, and the purpose of the visit was explained. LPA was granted entrance to the facility. Continued on LIC9099-C Unsubstantiated The investigation consisted of the following: On 05/19/25, LPA requested the staff and resident rosters. LPA collected and reviewed the following records for resident #1 (R1): Resident Assessment, Individual Service Plan, Physician’s Report, Identification and Emergency Information, Face Sheet, and Medical Administration Record (MAR) (dated: 03/01/25-03/31/25). LPA conducted interviews with staff #1-#3 (S1-S3) and residents #2-#6 (R2-R6) and was unable to interview R1. Additionally, LPA and Aldo Apostol conducted a tour of the facility. The investigation revealed the following: Allegation: Staff did not seek timely medical attention for a resident. It is being alleged that a resident had rashes, edema, and was limping, and despite the reports, staff did not seek timely medical attention for the resident. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of 3 staff interviewed stated that staff did not fail to seek medical attention for a resident, and 1 out of 3 staff interviewed stated they did not know if staff did not seek timely medical attention for a resident in the past. 2 out of 3 staff interviewed stated that a resident never reported needing medical attention to staff. 3 out of 3 staff interviewed stated that staff ensures to seek medical attention for residents in a timely manner when they need it. On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R2-R6. Based on interviews conducted, 5 out of 6 residents stated that they don’t know if staff have failed to seek medical attention for a resident in a timely manner. 5 out of 6 residents stated that staff do seek medical attention for residents when they need it. 5 out of 6 residents stated that they did not know if a resident ever reported needing medical attention to staff. 5 out of 6 residents stated that they are satisfied with the services being provided to them. A review of records revealed that R1s family member emailed Dr. Whiteman on 11/01/23 letting the doctor know that R1 had swelling in their right leg, below the knee, for over two months. Continued on LIC9099-C Email also stated that R1 had a corn on their right pinky toe, and that R1 reported a 7 out of 10 on the pain scale. On 04/05/24, R1’s family member emailed Dr. Whiteman advising that R1 had an urgent care visit for leg swelling and skin lesions. Medical records from Cedars-Sinai Medica Network dated 11/02/23, revealed that R1’s family member took R1 to the hospital, and was seen for age-related osteoporosis without current hyperlipidemia, mixed hyperlipidemia, major neurocognitive disorder (HCC), leg swelling, corn, primary hypertension. Medical records from Cedars-Sinai Medica Network dated 11/03/23, revealed that R1’s family member took R1 to the hospital, and was seen for toe pain, bilateral and tyloma. Medical records from Cedars-Sinai Medica Network dated 04/04/24, revealed that R1’s family member took R1 to the hospital, and was seen for a follow up podiatry evaluation, bilateral lower extremity edema/stasis dermatitis, mycotic toenail changes, bilateral feet and painful tylomas, bilateral 5th toes. Medical records from Cedars-Sinai Medica Network dated 07/12/24, revealed that R1’s family member took R1 to the hospital, and was seen for bilateral lower extremity edema/stasis dermatitis, mycotic toenail changes, bilateral feet and painful tylomas, bilateral 5th toes. Medical records from Cedars-Sinai Medica Network dated 12/13/24, revealed that R1’s family member took R1 to the hospital, and was seen for age-related osteoporosis without current pathological fracture, rash, mixed hyperlipidemia, and primary hypertension. Although records reviewed revealed that R1 was seen on several occasions at Cedars-Sinai Medical Network for health-related issues. There is not enough evidence to support the allegation that the facility did not seek timely medical attention for the resident. Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff mismanaged residents’ medication. It is being alleged that a staff administered Alendronate 70mg to a resident, despite never having been prescribed. It is also alleged that no explanation was given as to how a prescription never prescribed could have been administered. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of staff interviewed stated that staff has not mismanaged a resident’s medication. 3 out of 3 staff interviewed stated that staff dispenses resident’s medication(s) on time and as prescribed by their physician. On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R2-R6. Based on interviews conducted, 5 out of 6 residents stated that staff dispenses their medications on time and as prescribed by their physician. 5 out of 6 residents stated that staff has not mismanaged their medication. 5 out of 6 residents stated that they did not know if staff mismanaged a resident’s medication in the past. 5 out of 6 residents stated that staff administer their medication on time and as prescribed by their physician. 5 out of 6 residents stated that they are satisfied with the services being provided to them. On 05/19/25, LPA Gonzalez reviewed the Medication Administration Record (MAR) (dated: 03/01/25-03/31/25) for R1 and did not observe any discrepancies. Facility did not provide LPA with MAR’s for previous months for review. Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff dispensed medication not prescribed to resident. It is being alleged that staff administered Alendronate 70mg despite never having been prescribed to a resident. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of 3 staff interviewed stated that they did not know if staff administered Alendronate 70 mg to a resident in the past. An interview conducted with S2 revealed that they did not know of this allegation and denied ever confirming this allegation with a resident’s responsible party. On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R2-R6. Based on interviews conducted, 5 out of 6 residents stated that they did not know if staff dispensed medication(s) not prescribed to a resident in the past. 5 out of 6 residents interviewed stated that staff administer their medication to them on time and as prescribed by their physician. 5 out of 6 residents stated that they are satisfied with the services being provided to them. On 05/19/25, LPA Gonzalez reviewed the Medication Administration Record (MAR) (dated: 03/01/25-03/31/25) for R1 and did not observe any discrepancies. LPA was not able to obtain MAR’s for previous months for review. Continued on LIC9099-C Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Terry Han, Admission Assistant.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 11-AS-20250514114905

Allegation investigated: Facility staff can not effectively communicate with resident in care. Facility staff do not provide resident with activities. Facility staff are not assisting with soiled diapering in a timely manner. The resident's grooming needs are not being met. Facility staff did not maintain a comfortable temperature for residents.

This report serves to clarify the investigation narrative and is created to supersede the LIC 9099 and LIC 9099C reports dated June 5, 2025. Although this report supersedes the previous report, the complaint investigation findings remain the same. On July 23, 2025, LPA conducted a subsequent complaint visit. LPA Richard met with Manager Miran Bae, Assistand Administrator Terri Han and explained the purpose of the visit. The investigation included the following steps: On March 27, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted an initial unannounced complaint visit. The investigation involved interviews, the collection of records, and a tour of the facility. LPA Richard interviewed three staff members #1-3 (S1, S2, and S3), the Administrator (A1), Hien Hwang, and four residents #2-6 (R2 to R6). and attempted ot interviewe resident #1 (R1). Several documents were reviewed and obtained during the visit, including the Facility Staff Roster, Resident Roster, Identification and Emergency Information for Resident #1 (R1), Medical Consent Form, Appraisal/Needs and Service Plan, Personal Rights, Medication Administration Records, Physician's Report, scheduled activities, and appointments with the foot doctor, along with other relevant records related to the complaint. Unsubstantiated Allegation #1: Facility staff cannot effectively communicate with residents in care. The complaint alleges that the staff speak Korean, and the residents speak Japanese, which often results in the residents being left alone. On March 27, 2025, LPA Richard interviewed Administrator Hien Hwang (A1), who denied the allegation. A1 stated that the caregiver does speak English and assists all residents with their daily needs. Between 10:00 AM and 12:30 PM on the same day, LPA Richard interviewed four Residents, 2-5 (R2-R6). Four out of the four residents denied the allegation and indicated that they had no problems communicating with the staff, even though they primarily speak Korean. Additionally, between 10:00 AM and 12:30 PM, LPA Richard interviewed three staff members #1-3 (S1-S3). All three staff members denied the allegation, asserting that everyone who works there speaks English and is fully capable of assisting the residents in their care. During the visit, LPA observed the staff communicating effectively in English with both LPA and the residents without any difficulty. On March 27, 2025 LPA observed R1 sitting in the activities room with other residents, laughing. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the assistance of an interpreter; however, R1 was unable to communicate due to R1 experiencing cognitive impairment. Based on information gathered and interviews, LPA did not find sufficient evidence to support the allegation “Facility staff cannot effectively communicate with residents in care.” Therefore, the allegation is unsubstantiated. Allegation #2: Facility staff do not provide a resident with activities. The complaint alleges that the resident was frequently left alone in her wheelchair at a table without any activities to engage in, such as reading a book or watching TV. On March 27, 2025, LPA Richard interviewed Administrator Hien Hwang (A1), who denied the allegation. A1 stated that all residents have a TV in their rooms, allowing them to watch any show in any language they choose. Additionally, there is a large screen TV in the activities room, and daily activities are scheduled for all residents to participate in if they wish. Between 10:00 AM and 12:30 PM on the same day, LPA Richard interviewed four Resident #2-6 (R2-R6). Four out of the four residents denied the allegations and expressed a preference for watching TV in their rooms. They also indicated that the facility provided them with daily activities. Additionally, between 10:00 AM and 12:30 PM, LPA Richard interviewed three Staff members, 1-3 (S1-S3). All three staff members denied the allegations and stated that the facility has seven days of activities scheduled for all residents. On March 27, 2025, during a review of the activities schedule, LPA Richard confirmed that the facility offers activities every day from 9:00 AM to 3:00 PM. Furthermore, on the same day, LPA Richard observed R1 sitting in the activity room with other residents playing some kind of card games, coloring papers, while other residents were watching their favorite show on TV. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the assistance of an interpreter; however, R1 was unable to communicate due to R1 experiencing cognitive impairment. Based on the information gathered and interviews, LPA Richard did not find sufficient evidence to support the allegation that “facility staff do not provide residents with activities.” Therefore, the allegation is deemed unsubstantiated. Allegation #3: Facility staff are not helping residents with soiled diapering quickly enough. This complaint claims that residents are often left in dirty diapers for long periods without being changed. On March 27, 2025, between 10:00 AM and 12:30 PM, LPA Richard interviewed four residents (R2-R6). All four residents denied the allegation and stated that they are changed every one to two hours each day. On the same day and during the same time, LPA observed R1 being cleaned, and the caregiver (S2) was checking to see if R1 needed a diaper change. LPA Richard also interviewed three staff members (S1-S3), all of whom denied the allegation and reported that residents are changed every two hours or sooner if an accident occurs before or shortly after the scheduled change. The Administrator (A1) confirmed that residents are checked every one to two hours. A review of the changing schedule from February 1, 2025, to March 30, 2025, showed a list of residents who wear diapers along with their scheduled change times. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the help of an interpreter; however, R1 was unable to communicate due to experiencing cognitive impairment. Based on the information gathered and interviews, LPA Richard did not find sufficient evidence to support the allegation that “facility staff are not assisting with soiled diapering in a timely manner.” Therefore, the allegation is deemed unsubstantiated Allegation #4: The resident’s grooming needs are not being met. The complaint alleges that the resident’s toenails are often not trimmed. On March 27, 2025, between 10:00 AM and 12:30 PM, Licensing Program Analyst (LPA) Richard interviewed the Administrator, who denied the allegation. The Administrator stated that the facility has a podiatrist who visits every month to provide podiatry services to the residents. During the same period, LPA Richard interviewed four residents (R2 to R6). All four residents denied the allegation, stating that a pedicurist comes every month to assist them with their nails and toes. Additionally, on March 27, 2025, LPA Richard observed that Resident 1 (R1) had well-maintained feet and toenails and noted that R1 was included in the facility's monthly pedicurist schedule. Additionally, LPA interviewed three staff members (S1-S3) on March 27, 2025, between 12:30 PM and 1:30 PM. They also denied the allegation and confirmed that a podiatrist visits the facility each month to service the residents' nails and toes. Records reviewed by LPA, including the facility's foot doctor schedule dated February 13, 2025, indicated that residents receive podiatric services regularly. Furthermore, LPA observed that most residents' feet were well-trimmed and clean. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the help of an interpreter; however, R1 was unable to communicate due to R1 experiencing cognitive impairment. Based on the information gathered and interviews, LPA Richard did not find sufficient evidence to support the allegation that the resident’s grooming needs were not being met. Therefore, the allegation is deemed unsubstantiated. Allegation #5: Facility staff did not maintain a comfortable temperature for residents. The complaint alleges that the resident's room is covered with wallpaper, preventing proper heat flow, which keeps the resident's room cold. On March 27, 2025, between 10:00 AM and 12:30 PM, the Licensing Program Analyst (LPA) interviewed A1, who denied the allegations. A1 stated that each room is equipped with a heat control system that allows residents to adjust the temperature themselves. During the same time frame, LPA Richard interviewed four residents (R2-R6), all of whom denied the allegations. They reported that their rooms were comfortable and that they could turn the heater on or off as needed. Additionally, on March 27, 2025, between 10:00 AM and 12:30 PM, LPA Richard interviewed three staff members (S1-S3), who also denied the allegations. Additionally, the Licensing Program Analyst (LPA) visited the rooms of five residents and requested that the heaters be turned on during each visit. The rooms were not cold, and the heaters were functioning properly, providing warm air. During a tour of Room #1 (R1), the LPA noted that the room was warm. When the heater was turned on, it also worked correctly in R1’s room. At 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the assistance of an interpreter; however, R1 was unable to communicate due to cognitive impairment. Based on the information gathered and interviews, LPA Richard did not find sufficient evidence to support the allegation that the resident’s grooming needs were not being met. Therefore, the allegation is deemed unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Assistant Administrator Terri Han.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 11-AS-20250321122706

Allegation investigated: Resident sustained an unexplained injury while in care.

On 7/16/25, at 09:00am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced subsequent complaint visit to further investigate the allegation mentioned above and deliver findings. LPA met with Assistant Manager, Terri Han, and explained the purpose of this visit is to gather information about the complaint, interview staff and residents, and deliver findings for the allegation mentioned above. The investigation consisted of the following: An initial complaint visit was conducted by the department on 10/23/2024 and subsequently on 04/17/2025. The department investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S5), witness (W1), and residents (R1-R5) from 9:00am-02:00pm. The department received the following documents: Resident Roster (Dated: 10/23/2024), Staff Roster (Dated: 10/23/2024), Admission Agreement (Dated: 07/23/2024), ID Emergency Information (Dated: 7/23/2024), Physicians Report (Dated: 07/22/2024), Resident Appraisal Information (Dated:07/22/2024), Unusual Incident/Injury Reports (Dated: 10/14/2024), Admission Record (Dated: 07/01/2024), Tiny Oasis Hospice, INC Medication List (Dated: 10/02/2024), and So Cal Hospital at Hollywood Medical Record (Dated: 10/28/2024) for R1 from the facility. Report Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation- Resident sustained an unexplained injury while in care. The details of the complaint alleged that the resident (R1) sustained an unexplained injury while in care. It was reported that the resident had a fall and fractured their hip. On 07/16/25, from 9:00am-02:00pm, the department interviewed staff (S1-S5) witness (W1), and residents (R1-R5) about the allegation. 4 of 5 staff denied the allegation that Resident sustained an unexplained injury while in care. The majority of the staff stated that the resident was non-ambulatory and had a fall trying to get out of their wheelchair. S3 stated that they found R1 on the floor and asked what happened? S3 stated that R1 said they tried to get out of the chair and fell. S3 stated that they asked if R1 was in pain, and R1 said yes, so they sent R1 to the emergency room. Staff stated that the resident did not have a history of falling in the facility. The department interviewed witness (W1) and residents (R1-R5) about the allegation. Witness (W1) stated that they were concerned because R1 had a fall but did not know what happened and was concerned for their safety while living at the facility. 4 of 5 residents that were interviewed stated that they have never sustained any injuries at the facility and did not witness or experience any physical abuse from the staff. They further stated that they did not have any concerns about living in the facility and felt safe with the staff. The department reviewed the Physicians Report (Dated: 07/22/2024), Resident Appraisal Information (Dated:07/22/2024), Unusual Incident/Injury Reports (Dated: 10/14/2024) and observed that there was no history of falling at the facility. The department also reviewed the So Cal Hospital at Hollywood Medical Record (Dated: 10/28/2024) and observed that R1 was admitted for right hip pain from fall transferring from wheelchair. The department did not observe any other medical records or appraisals that would suggest R1 was a fall risk. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Resident sustained an unexplained injury while in care. 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 because of neglect, therefore the allegation is Unsubstantiated. No citations were issued. An exit interview was conducted with Terri Han, Assistant Manager, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jul 16, 2025 · control 11-AS-20241015121546

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

**This report supersedes the report created and delivered on 06/18/25. This report is to clarify findings. On 06/18/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to further investigate the allegations mentioned above and deliver findings. LPA met with Manager, Miran Bae, and the purpose of the visit was explained. LPA was granted entrance to the facility. The investigation consisted of the following: On 05/19/25, LPA requested the staff and resident rosters. LPA collected and reviewed the following records for resident #1 (R1): Resident Assessment, Individual Service Plan, Physician’s Report, Identification and Emergency Information, Face Sheet, and Medical Administration Record (MAR) (dated: 03/01/25-03/31/25). LPA conducted interviews with staff #1-#3 (S1-S3) and residents #2-#6 (R2-R6) and was unable to interview R1. Additionally, LPA and Aldo Apostol conducted a tour of the facility. Substantiated The investigation revealed the following: Allegation: Staff did not seek timely medical attention for a resident. It is being alleged that a resident had rashes, edema, and was limping, and despite the reports, staff did not seek timely medical attention for the resident. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of 3 staff interviewed stated that staff did not fail to seek medical attention for a resident, and 1 out of 3 staff interviewed stated they did not know if staff did not seek timely medical attention for a resident in the past. 2 out of 3 staff interviewed stated that a resident never reported needing medical attention to staff. 3 out of 3 staff interviewed stated that staff ensures to seek medical attention for residents in a timely manner when they need it. On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R2-R6. Based on interviews conducted, 5 out of 6 residents stated that they don’t know if staff have failed to seek medical attention for a resident in a timely manner. 5 out of 6 residents stated that staff do seek medical attention for residents when they need it. 5 out of 6 residents stated that they did not know if a resident ever reported needing medical attention to staff. 5 out of 6 residents stated that they are satisfied with the services being provided to them. A review of records revealed that R1s daughter (F1) emailed Dr. Whiteman on 11/01/23 letting the doctor know that her mother had swelling in her right leg, below the knee, for over two months. She also sated that her mother had a corn on her right pinky toe, and that her mother reported a 7 out of 10 on the pain scale. On 04/05/24, F1 emailed Dr. Whiteman advising that R1 had an urgent care visit for leg swelling and skin lesions. Medical records from Cedars-Sinai Medica Network dated 11/02/23, revealed that F1 took R1 to the hospital, and was seen for age-related osteoporosis without current hyperlipidemia, mixed hyperlipidemia, major neurocognitive disorder (HCC), leg swelling, corn, primary hypertension. Medical records from Cedars-Sinai Medica Network dated 11/03/23, revealed that F1 took R1 to the hospital, and was seen for toe pain, bilateral and tyloma. Medical records from Cedars-Sinai Medica Network dated 04/04/24, revealed that F1 took R1 to the hospital, and was seen for a follow up podiatry evaluation, bilateral lower extremity edema/stasis dermatitis, mycotic toenail changes, bilateral feet and painful tylomas, bilateral 5th toes. Continued on LIC9099-C Medical records from Cedars-Sinai Medica Network dated 07/12/24, revealed that F1 took R1 to the hospital, and was seen for bilateral lower extremity edema/stasis dermatitis, mycotic toenail changes, bilateral feet and painful tylomas, bilateral 5th toes. Medical records from Cedars-Sinai Medica Network dated 12/13/24, revealed that F1 took R1 to the hospital, and was seen for age-related osteoporosis without current pathological fracture, rash, mixed hyperlipidemia, and primary hypertension. Although staff interviewed stated that they did not fail to seek medical attention for R1, records reviewed revealed that R1 was seen on several occasions at Cedars-Sinai Medica Network for health-related issues. Based on record review, and interviews conducted, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited, please see the attached LIC 9099-D. Exit interview conducted. Appeal rights and a copy of this report was provided to Manager, Miran Bae. The investigation revealed the following: Allegation: Staff mismanaged residents’ medication. It is being alleged that a staff administered Alendronate 70mg to a resident, despite never having been prescribed. It is also alleged that no explanation was given as to how a prescription never prescribed could have been administered. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of staff interviewed stated that staff has not mismanaged a resident’s medication. 3 out of 3 staff interviewed stated that staff dispenses resident’s medication(s) on time and as prescribed by their physician. On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R2-R6. Based on interviews conducted, 5 out of 6 residents stated that staff dispenses their medications on time and as prescribed by their physician. 5 out of 6 residents stated that staff has not mismanaged their medication. 5 out of 6 residents stated that they did not know if staff mismanaged a resident’s medication in the past. 5 out of 6 residents stated that staff administer their medication on time and as prescribed by their physician. 5 out of 6 residents stated that they are satisfied with the services being provided to them. Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff dispensed medication not prescribed to resident. It is being alleged that staff administered Alendronate 70mg despite never having been prescribed to a resident. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of 3 staff interviewed stated that they did not know if staff administered Alendronate 70 mg to a resident in the past. An interview conducted with S2 revealed that they did not know of this allegation and denied ever confirming this allegation with a resident’s responsible party. Continued on LIC9099-C On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R2-R6. Based on interviews conducted, 5 out of 6 residents stated that they did not know if staff dispensed medication(s) not prescribed to a resident in the past. 5 out of 6 residents interviewed stated that staff administer their medication to them on time and as prescribed by their physician. 5 out of 6 residents stated that they are satisfied with the services being provided to them. Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted. Appeal rights and a copy of this report was provided to Terry Han, Admission Assistant.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 11-AS-20250514114905

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

On 06/18/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to further investigate the allegations mentioned above and deliver findings. LPA met with Manager, Miran Bae, and the purpose of the visit was explained. LPA was granted entrance to the facility. The investigation consisted of the following: On 05/19/25, LPA requested the staff and resident rosters. LPA collected and reviewed the following records for resident #1 (R1): Resident Assessment, Individual Service Plan, Physician’s Report, Identification and Emergency Information, Face Sheet, and Medical Administration Record (MAR) (dated: 03/01/25-03/31/25). LPA conducted interviews with staff #1-#3 (S1-S3) and residents #1-#5 (R1-R5). Additionally, LPA and Aldo Apostol conducted a tour of the facility. Continued on LIC9099-C Substantiated The investigation revealed the following: Allegation: Staff did not seek timely medical attention for a resident. It is being alleged that a resident had rashes, edema, and was limping, and despite the reports, staff did not seek timely medical attention for the resident. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of 3 staff interviewed stated that staff did not fail to seek medical attention for a resident, and 1 out of 3 staff interviewed stated they did not know if staff did not seek timely medical attention for a resident in the past. 2 out of 3 staff interviewed stated that a resident never reported needing medical attention to staff. 3 out of 3 staff interviewed stated that staff ensures to seek medical attention for residents in a timely manner when they need it. On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R1-R5. Based on interviews conducted, 5 out of 5 residents interviewed stated that they don’t know if staff have failed to seek medical attention for a resident in a timely manner. 5 out of 5 residents interviewed stated that staff do seek medical attention for residents when they need it. 5 out of 5 residents interviewed stated that they did not know if a resident ever reported needing medical attention to staff. 5 out of 5 residents interviewed stated that they are satisfied with the services being provided to them. A review of records revealed that R1s daughter (F1) emailed Dr. Whiteman on 11/01/23 letting the doctor know that her mother had swelling in her right leg, below the knee, for over two months. She also sated that her mother had a corn on her right pinky toe, and that her mother reported a 7 out of 10 on the pain scale. On 04/05/24, F1 emailed Dr. Whiteman advising that R1 had an urgent care visit for leg swelling and skin lesions. Medical records from Cedars-Sinai Medica Network dated 11/02/23, revealed that F1 took R1 to the hospital, and was seen for age-related osteoporosis without current hyperlipidemia, mixed hyperlipidemia, major neurocognitive disorder (HCC), leg swelling, corn, primary hypertension. Medical records from Cedars-Sinai Medica Network dated 11/03/23, revealed that F1 took R1 to the hospital, and was seen for toe pain, bilateral and tyloma. Medical records from Cedars-Sinai Medica Network dated 04/04/24, revealed that F1 took R1 to the hospital, and was seen for a follow up podiatry evaluation, bilateral lower extremity edema/stasis dermatitis, mycotic toenail changes, bilateral feet and painful tylomas, bilateral 5th toes. Continued on LIC9099-C Medical records from Cedars-Sinai Medica Network dated 07/12/24, revealed that F1 took R1 to the hospital, and was seen for bilateral lower extremity edema/stasis dermatitis, mycotic toenail changes, bilateral feet and painful tylomas, bilateral 5th toes. Medical records from Cedars-Sinai Medica Network dated 12/13/24, revealed that F1 took R1 to the hospital, and was seen for age-related osteoporosis without current pathological fracture, rash, mixed hyperlipidemia, and primary hypertension. Although staff interviewed stated that they did not fail to seek medical attention for R1, records reviewed revealed that R1 was seen on several occasions at Cedars-Sinai Medica Network for health-related issues. Based on record review, and interviews conducted, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited, please see the attached LIC 9099-D. Exit interview conducted. Appeal rights and a copy of this report was provided to Manager, Miran Bae. The investigation revealed the following: Allegation: Staff mismanaged residents’ medication. It is being alleged that a staff administered Alendronate 70mg to a resident, despite never having been prescribed. It is also alleged that no explanation was given as to how a prescription never prescribed could have been administered. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of staff interviewed stated that staff has not mismanaged a resident’s medication. 3 out of 3 staff interviewed stated that staff dispenses resident’s medication(s) on time and as prescribed by their physician. On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R1-R5. Based on interviews conducted, 5 out of 5 residents interviewed stated that staff dispenses their medications on time and as prescribed by their physician. 5 out of 5 residents interviewed stated that staff has not mismanaged their medication. 5 out of 5 residents interviewed stated that they did not know if staff mismanaged a resident’s medication in the past. 5 out of 5 residents interviewed stated that they are satisfied with the services being provided to them. Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff dispensed medication not prescribed to resident. It is being alleged that staff administered Alendronate 70mg despite never having been prescribed to a resident. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of 3 staff interviewed stated that they did not know if staff administered Alendronate 70 mg to a resident in the past. An interview conducted with S2 revealed that they did not know of this allegation and denied ever confirming this allegation with a resident’s responsible party. Continued on LIC9099-C On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R1-R5. Based on interviews conducted, 5 out of 5 residents interviewed stated that they did not know if staff dispensed medication(s) not prescribed to a resident in the past. 5 out of 5 residents interviewed stated that. 5 out of 5 residents interviewed stated that they are satisfied with the services being provided to them. Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted. Appeal rights and a copy of this report was provided to Manager, Miran Bae.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 11-AS-20250514114905

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jun 25, 2025

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not as evidenced by: Records reviewed revealed that R1 was seen on several occasions at Cedars-Sinai Medica Network for health-related issues. This poses a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: Licensee shall ensure that staff seeks medical attention for residents in a timely manner. Licensee to conduct In-service training with staff. Licensee will submit proof of training and a statement aknowledging they reviewed regulation and understood. Licensee to submit POC to LPA Gonzalez by POC due date.

Allegation investigated: Facility staff can not effectively communicate with resident in care. Facility staff do not provide resident with activities. Facility staff are not assisting with soiled diapering in a timely manner. The resident's grooming needs are not being met. Facility staff did not maintain a comfortable temperature for residents.

On 06/05/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent visit regarding the above allegations. LPA met with the Manager Miran Bae and the purpose of the visit was explained. The investigation included the following steps: On March 27, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted an initial unannounced complaint visit. The investigation involved interviews, the collection of records, and a tour of the facility. LPA Richard interviewed three staff members #1-3 (S1, S2, and S3), the Administrator (A1), Hien Hwang, and five residents #1-5 (R1 to R5). Several documents were reviewed and obtained during the visit, including the Facility Staff Roster, Resident Roster, Identification and Emergency Information for Resident #1 (R1), Medical Consent Form, Appraisal/Needs and Service Plan, Personal Rights, Medication Administration Records, Physician's Report, scheduled activities, and appointments with the foot doctor, along with other relevant records related to the complaint. Unsubstantiated Allegation #1: Facility staff cannot effectively communicate with resident in care. The complaint alleges that the staff speak Korean, and the residents speak Japanese, which often results in the residents being left alone. On March 27, 2025, LPA Richard interviewed Administrator Hien Hwang (A1), who denied the allegation. Hien stated that the caregiver does speak English and assists all residents with their daily needs. Between 10:00 AM and 12:30 PM on the same day, LPA Richard interviewed five Residents, #1-5 (R1-R5). Four out of the five residents denied the allegation and indicated that they had no problems communicating with the staff, even though they primarily speak Korean. Additionally, between 10:00 AM and 12:30 PM, LPA Richard interviewed three staff members #1-3 (S1-S3). All three staff members denied the allegation, asserting that everyone who works there speaks English and is fully capable of assisting the residents in their care. During the visit, LPA observed the staff communicating effectively in English with both LPA and the residents without any difficulty. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the assistance of an interpreter; however, R1 was unable to answer the questions posed. Based on information gathered and interviews, LPA did not find sufficient evidence to support the allegation “Facility staff cannot effectively communicate with residents in care”, therefore, the allegation is unsubstantiated. Allegation #2: Facility staff do not provide a resident with activities. The complaint alleges that the resident was frequently left alone in her wheelchair at a table without any activities to engage in, such as reading a book or watching TV. On March 27, 2025, LPA Richard interviewed Administrator Hien Hwang (A1), who denied the allegation. Hwang stated that all residents have a TV in their rooms, allowing them to watch any show in any language they choose. Additionally, there is a large screen TV in the activities room, and daily activities are scheduled for all residents to participate in if they wish. Between 10:00 AM and 12:30 PM on the same day, LPA Richard interviewed five Resident #1-5 (R1-R5). Four out of the five residents denied the allegations and expressed a preference for watching TV in their rooms. They also indicated that the facility provided them with daily activities. Additionally, between 10:00 AM and 12:30 PM, LPA Richard interviewed three Staff members, #1-3 (S1-S3). All three staff members denied the allegations and stated that the facility has seven days of activities scheduled for all residents. On March 27, 2025, during a review of the activities schedule, LPA Richard confirmed that the facility offers activities every day from 9:00 AM to 3:00 PM. Furthermore, on the same day, LPA Richard observed staff and residents participating in current events activities in the activity room. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the assistance of an interpreter; however, R1 was unable to answer the questions posed. Based on the information gathered and interviews, LPA Richard did not find sufficient evidence to support the allegation that “facility staff do not provide residents with activities,” therefore, the allegation is deemed unsubstantiated. Allegation #3: Facility staff are not assisting with soiled diapering in a timely manner. This complaint alleges that residents are often left in soiled diapers for extended periods without being changed. On March 27, 2025, between 10:00 AM and 12:30 PM, LPA Richard interviewed five residents (R1-R5). Four out of the five residents denied the allegation and stated that they are changed every one to two hours each day. LPA Richard also interviewed three staff members (S1-S3), all of whom denied the allegation and reported that residents are changed every two hours, or sooner if an accident occurs before or shortly after the scheduled change. The Administrator (A1) confirmed that residents are checked every one to two hours. A review of the changing schedule from February 1, 2025, to March 30, 2025, showed a list of residents who wear diapers along with the times they are scheduled to be changed. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the help of an interpreter; however, R1 was unable to answer the questions asked. Based on the information gathered and interviews, LPA Richard did not find sufficient evidence to support the allegation that “facility staff are not assisting with soiled diapering in a timely manner,” therefore, the allegation is deemed unsubstantiated. Allegation #4: The resident’s grooming needs are not being met. The complaint alleges that the resident’s toenails are often not trimmed. On March 27, 2025, between 10:00 AM and 12:30 PM, LPA Richard interviewed the Administrator, who denied the allegation. The Administrator stated that the facility has a podiatrist who visits every month to provide podiatry services to the residents. During the same time frame, LPA Richard interviewed five residents (R1-R5). Four out of the five residents denied the allegation, stating that a pedicurist comes every month to assist them with their nails and toes. Additionally, LPA interviewed three staff members (S1-S3) on March 27, 2025, between 10:00 AM and 12:30 PM. They also denied the allegation and confirmed that a podiatrist visits the facility each month to service the residents' nails and toes. Records reviewed by LPA, including the facility's foot doctor schedule dated February 13, 2025, indicated that residents receive podiatric services regularly. Furthermore, LPA observed that most residents' feet were well-trimmed and clean. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the help of an interpreter; however, R1 was unable to answer the questions asked. Based on the information gathered and interviews, LPA Richard did not find sufficient evidence to support the allegation that the resident’s grooming needs were not being met. Therefore, the allegation is deemed unsubstantiated. Allegation #5: Facility staff did not maintain a comfortable temperature for residents. The complaint alleges that the resident's room is covered with wallpaper, preventing proper heat flow, which keeps the resident's room cold. On March 27, 2025, between 10:00 AM and 12:30 PM, the Licensing Program Analyst (LPA) interviewed A1, who denied the allegations. A1 stated that each room is equipped with a heat control system that allows residents to adjust the temperature themselves. During the same time frame, LPA Richard interviewed five residents residents (R1-R5). Four out of the five residents denied the allegations, indicating that their rooms were comfortable and that they could turn the heater on or off as needed. Additionally, the LPA interviewed three staff members (S1-S3) on March 27, 2025, between 10:00 AM and 12:30 PM, and they also denied the allegations. Furthermore, LPA visited five residents' rooms and requested to turn on the heaters during each visit. The rooms were not cold, and the hot air from the heaters was functioning properly. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the help of an interpreter; however, R1 was unable to answer the questions asked. Based on the information gathered and interviews, LPA Richard did not find sufficient evidence to support the allegation that the resident’s grooming needs were not being met. Therefore, the allegation is deemed unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Manager Miran Bae.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 11-AS-20250321122706

Type of visit: Case Management - Deficiencies

On 05/19/25, Licensing Program Analyst (LPA) conducted a case management - deficiency visit at this facility during an unrelated complaint visit. LPA met with Assistant Administrator, Aldo Apostol. While conducting an interview with staff, LPA met with (S1) who is not associated with the facility. S1 stated they began working today 05/19/25 and is planning on conducting their live scan today as well. Based on LPA's interviews with Aldo Apostol, S1 will conduct their live scan and not return to work at the facility until they receive the clearance letter. Apostol confirmed S1 started working at this facility today. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Civil penalties assessed. Exit interview conducted. Appeal rights and a copy of this report was provided to Assistant Administrator, Aldo Apostol.the state’s words, verbatim · CDSS document, May 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355 · Plan of correction due date: May 20, 2025

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: This has not been met as evidenced by: Based on [(observation) (interview) (record review)], the facility has allowed one (1), uncleared, staff member to be employed at the facility.the state’s words, verbatim · CDSS document, May 19, 2025

Plan of correction: Licensee has agreed that prior to returning to work at this care facility, the uncleared staff will have conducted a fingerprint clearance through Care Provider Management Bureau (CPMB) on, or before, the POC due date as 05/20/25.

Allegation investigated: Staff are unable to effectively communicate with resident to ensure their needs are met Staff do not ensure that resident is adequately fed Staff do not treat resident with dignity or respect

On 05/15/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unannounced, complaint visit at the facility. LPA was met by staff four, Miran Bae Manager (S4), and the purpose of the visit was explained. The investigation consisted of the following: On 12/20/24 LPA requested and reviewed facility documents; including resident and staff roster, three (3) resident physician's report and emergency ID's, three (3) staff training's history and toured the facility. LPA interviewed five (5) out of fifty (50) residents and three (3) out of thirty-one (31) staff. On 05/15/25 LPA requested resident and staff roster (dated 03/25), reviewed two (2) monthly menu's, resident's discharge paperwork of the date in question and facilities' verification a resident is no longer residing at the facility. LPA interviewed two (2) residents and two (2) staff. The investigation revealed the following: Regarding the allegation “Staff are unable to effectively communicate with resident to ensure their needs are met”, it has been alleged that the facility is Korean owned, and run, which makes it difficult for the residents who do not speak Korean. Report continues, see LIC9099-C. Unsubstantiated Interviews revealed that four (4) out of seven (7) residents and all five (5) staff do not agree the allegation has taken place. LPA observations revealed that, during 12/20/24 and 05/15/25 visits, three (3) out of five (5) staff speak English. On 05/15/25 LPA observed the following: two (2) staff displayed the ability to understand resident's needs in English, along with body-language, and provide the resident assistance as requested through practice sessions. Record reviews have shown three (3) staff files to be current and staff training's regarding resident care has been met. Based on record reviews, LPA observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff do not ensure that resident is adequately fed”, it has been alleged that a resident was not offered any food upon their discharge back to the facility. Record reviews revealed that there is a menu that is kept current, which also display the alternative options available if a resident does not want to eat the current menu item. During LPA's visit on 12/20/24, LPA observed a black-bean and rice porridge with drinks for lunch. On 05/15/25, LPA observed a hamburger with pickled vegetables on the side with drinks for lunch. Interviews revealed that four (4) out of seven (7) residents and all five (5) staff do not agree the allegation has taken place. Based on record reviews, LPA observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation "Staff do not treat resident with dignity or respect.", it has been alleged that a resident does not feel their level of dignity or respect are being met. Interviews revealed that five (5) out of seven (7) residents and all five (5) staff disagree with the allegation. Record reviews revealed that three (3) staff files to be current and staff training's regarding resident care has been met. Based on record reviews, LPA observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. During today's visit, there have been zero (0) citations provided. An exit interview was held with staff four, Miran Bae Manager (S4), and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 15, 2025 · control 11-AS-20241212132109

Type of visit: Office

On May 12, 2025, at 10:00 AM, an office meeting was held with Administrator Erik Doan, Licensee Mohsen Abdosalehi, Designee Miran Bae, and Administrator Assistant Grace Hwang. Abdosalehi participated by telephone, alongside Clyde Kwon, the Focus Language Interpreter. In attendance were Regional Manager (RM) Benita Yates, Licensing Program Manager (LPM) Janae Hammond, and Licensing Program Analysts (LPAs) Ernand Dabuet and Saknah Madyun. The purpose of this meeting was to discuss noncompliance issues. During the meeting, RM Benita Yates provided an overview of the terms and conditions, the deficiencies and citations, and a plan of action to address the noncompliance issues. Additionally, a timeframe was agreed upon for the current licensee and administrator to submit the documents listed on page three of LIC 911. An exit interview was conducted with Erik Doan, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 12, 2025

Allegation investigated: Staff accessed resident's cell phone without permission. Staff did not respect resident's rights. Staff served cold food to a resident in care. Staff opened resident's mail.

On May 10, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Hee Kyung Park, the Licensed Vocational Nurse, greeted the (LPA). (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above. The investigation included interviews, a collection of records, and an observation of the facility. Interviews were conducted with residents #1- #6 (R1-R6) and staff #1- #5 (S1-S5). The Department reviewed several documents, including the Facility Staff Roster (dated 04/14/25), Resident Roster (dated 04/14/25), Resident #1 (R1)'s service records, Facility Menu (dated 04/01/25 through 04/30/25), and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff accessed resident's cell phone without permission. The complaint alleged that Resident #1 (R1)’s cell phone was accessed without permission by staff. It was reported that (R1) had left the cell phone with staff while (R1) was being treated at the hospital, and staff had operated the phone and deleted applications and photos. No further information has been provided relating to this allegation. On April 23, 2025, between 10:15 AM and 12:00 PM, the Department interviewed staff members, identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members claimed that this claim is false. (S1) stated that (R1) left the cell phone for safekeeping in the office while (R1) was treated at the hospital, and no one had tampered with or operated (R1)’s phone. (S1-S2) stated that although we had (R1)’s phone in safekeeping, the staff could not manage it as it required a pass code. (S1-S2) noted that the phone was returned to (R1) after the hospital visit, and the staff did not tamper with the phone. On April 23, 2025, between 10:30 AM and 01:15 PM, the Department interviewed resident members identified as Resident #2 through Resident #6. Five (5) out of the five (5) resident members have never experienced this situation and cannot corroborate this claim. On April 7, 2025, between 1:30 PM and 02:45 PM, the Department interviewed the resident member identified as Resident #1 (R1). (R1) claimed that while being treated at a hospital for several days, the office staff had kept (R1)’s phone for safekeeping and had access without permission. Personal photos and applications were deleted from the phone. The office staff had access to the phone since it had no passcode. Additional details could not be provided because it was merely speculation. The Department audited (R1)’s service file, which included a Personal Rights LIC 613C (dated 08/26/24) and Physician Report LIC 602A (dated 08/26/24), revealed that (R1) is visually impaired. (R1) did not have the required document, Resident Personal Property & Valuables LIC 621. During investigation visits on April 14, 2025, and April 23, 2025, the Department observed that mandated posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. Based on the gathered information, insufficient evidence supports the stated allegation. (Evaluation Report continues LIC 9099-C) Allegation #2: Staff did not respect resident's rights. The complaint alleged that staff did not accord Resident #1 (R1) the resident’s rights. A recent report indicated that (R1) was compelled to engage in activities in the dining room despite expressing a lack of interest in participating. No further information has been provided relating to this allegation. On April 23, 2025, between 10:15 AM and 12:00 PM, the Department interviewed staff members, identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members stated they could not support this claim. (S1-S5) noted that no residents are forced to participate in activities, whether eating meals or engaging in social activities. The staff is fully aware of the importance of personal rights, emphasizing respect for individuals and ensuring comfortable living conditions. (R1) was often granted the right to stay in the room with meals and did not want to participate with other residents during mealtime, according to (S1). On April 23, 2025, between 10:30 AM and 01:15 PM, the Department interviewed resident members identified as Resident #2 through Resident #6. Five (5) out of the five (5) resident members expressed that the facility allowed them to choose whether to eat their meals in the dining area or in their room. Participation in activities or meals is voluntary; no one is obligated to participate. On April 7, 2025, between 1:30 PM and 2:45 PM, the Department interviewed the resident identified as Resident #1 (R1). During the interview, (R1) reported that they were forced to go into the dining room against their will and were taken there by staff members. However, (R1) could not provide specific details about when the incident occurred or the staff member's name. The Department reviewed staff training records and verified that staff had completed Workplace Sensitivity Training Courses, including ADLs, Resident Behaviors, and Resident Rights. During investigation visits on April 14, 2025, and April 23, 2025, the Department observed that mandated posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. Based on the gathered information, insufficient evidence corroborates the allegation. (Evaluation Report continues LIC 9099-C) Allegation #3: Staff served cold food to a resident in care. It is alleged that the staff served cold food to Resident #1 (R1). Observations suggest that (R1) was repeatedly served food at an unsatisfactory temperature. No further information has been provided relating to this allegation. On April 23, 2025, between 10:15 AM and 12:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members reported that they could not validate the claim regarding food temperature. According to Staff #5 (S5), no residents are served food at an unsatisfactory temperature. (S5) explained that the kitchen has a food thermometer used during cooking to ensure food is maintained at safe holding temperatures. Specifically, hot foods should be held above 135 degrees Fahrenheit. (S5) also noted that residents often socialize before eating, which can cause the food to lose heat and become less hot when ready to eat. Additionally, (S5) indicated that residents are encouraged to express dissatisfaction with their food's temperature, and staff will either prepare a new serving or reheat the meal upon request. On April 23, 2025, between 10:30 AM and 01:15 PM, the Department interviewed resident members identified as Resident #2 through Resident #6 (R2-R6). Five (5) of the five (5) resident members claimed to have no issues or concerns with the meals. All of them expressed that their meals had been served at the proper temperature. On April 7, 2025, between 1:30 PM and 2:45 PM, the Department interviewed a resident member identified as Resident #1 (R1). During the interview, (R1) expressed that there have been occasions when the meals served were not at the proper temperature and were served cold. It appears that (R1) could not provide further insights on this matter. A review of the facility's Monthly Menu for April 2025 (from April 1 to April 30) included a comprehensive list of all breakfast, lunch, and dinner meals and alternative options. Additionally, an evaluation of staff training for the kitchen showed that personnel completed courses on Food Safety, Kitchen Safety, Appearance Guidelines, Customer Expectations, and Special Diet Considerations. Furthermore, a review of (R1) 's Physician's Report LIC 602A (dated 08/26/24) revealed that (R1) is capable of self-feeding and is not on any special diet. (Evaluation Report continues LIC 9099-C) During investigation visits on April 14, 2025, and April 23, 2025, the Department observed that residents were served lunch soup, pasta, vegetables, salad, and fruit in trays and taken to eat at the table. An observation of trays being served from the kitchen to the table was made in several minutes. An observation of some residents immediately ate the food while others spent leisure time socializing along with their meals. The Department surveyed six residents, and all reported that the food was of good quality and at an adequate temperature. Based on the gathered information, insufficient evidence corroborates the allegation. Allegation #4: Staff opened resident mail. The details of this complaint alleged that staff opened Resident #1 (R1)’s mail. According to the report, staff opened (R1)’s mail without permission. No further information has been provided relating to this allegation. On April 23, 2025, between 10:15 AM and 12:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) the staff members denied this accusation. (S1-S2) claimed that this accusation is false and that the office staff oversees incoming mail delivery and distribution to residents. (S1-S2) expressed a firm belief that there is no justification for opening residents' mail. They know that such actions violate residents' rights and constitute a federal offense, given that tampering with mail intended for someone else is against the law. On April 23, 2025, between 10:30 AM and 01:15 PM, the Department interviewed resident members identified as Resident #2 through Resident #6 (R2-R6). Five (5) of the five (5) resident members have never encountered any issues with mail tampering while living at this facility. Residents have reported that the office staff is responsible for distributing their mail and confirmed that it remains unopened upon receipt. On April 7, 2025, between 1:30 PM and 2:45 PM, the Department interviewed a resident member identified as Resident #1 (R1). (R1) mentioned that staff opened their mail, but the Department lacked evidence to confirm the exact date or details surrounding this occurrence. (Evaluation Report continues LIC 9099-C) The Department audited the service file of (R1), which included a Personal Rights LIC 613C (dated 08/26/24). Staff training records for staff members had completed Workplace Sensitivity Training Courses that covered Activities of Daily Living (ADLs), Resident Behaviors, and Resident Rights. During investigation visits on April 14, 2025, and April 23, 2025, the Department noted that mandated posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. Based on the information collected, insufficient evidence supports the stated allegation. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted with the Licensed Vocational Nurse, Hee Kyung Park, and copies of the reports were provided.the state’s words, verbatim · CDSS document, May 10, 2025 · control 11-AS-20250407115705

Allegation investigated: Staff left resident in dirty clothes for a period of time. Staff not providing resident with nutritious meals. Staff tied up resident.

On 5/9/2025 LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Miran Bae / Manager. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#3) and Resident’s interviews (R#1-R#5) and Witness 1 (W#1). LPA obtained and reviewed the following documents: Resident Roster (dated May/2025), staff roster (dated March/25),(R#1)’s Identification and Emergency Information or LIC 601 dated:3/22/20, (R#1)’s Physicians Report for residential Care Facilities for the Elderly (RCFE) or LIC 602A dated:3/19/25, (R#1)’s Admission Agreement dated:3/22/20, use of the interpreter line (760-640-0562), a Health and Safety check of the facility’s kitchen and Facility’s Annual Training dated:1/26/25. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff left resident in dirty clothes for a period of time. The details of the complaint alleged that (R#1) has been left in dirty clothes for an extended time. On May 9, 2025, at approximately 1:00 PM, during the records review, LPA Iniguez observed (R#1)’s Admission Agreement dated:3/22/20, in the agreement it is written that the (R#1) can be assisted with their Activities of Daily Living (ADL’s) when necessary. In addition, LPA Iniguez observed facility’s Annal Training dated:1/16/25, LPA Iniguez observed that one of the annual topics is Residents Rights. On May 9, 2025, at approximately 9:00 AM, during an Interview with the Administrator (A#1), she stated that she knows the resident’s personal rights. In addition, (A#1) stated that (R#1) has never been left in dirty clothes for an extended period. On May 9, 2025, at approximately 10:00 AM, during an interview with (R#1) using the interpreter line (Focus Interpreter with interpreter Miza#bb249), LPA Iniguez requested the interpreter to ask (R#1) if they could hear. The interpreter posed the question in Japanese, but (R#1) responded, “I don’t know.” LPA Iniguez then asked the interpreter to inquire if (R#1) knew what day it was. The interpreter relayed the question, and (R#1) answered, “I don’t know.” Following this, LPA Iniguez concluded the telephone call. In addition, LPA Iniguez observed that (R#1) was wearing clean clothes and not dirty. On May 9, 2025, at approximately 10:30 AM, during interviews with residents (R#2-R#5), (4) out of (4) stated that they are treated with dignity and respect. In addition, (4) out of (4) residents stated that they have never been left in dirty clothes for an extended period. On May 9, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#3), (3) out of (3) stated they know the resident’s rights. In addition, (3) out of (3) facility staff stated that (R#1) has never been left in dirty clothes for an extended period. Evaluation Report continues LIC 9099-C On May 9, 2025, at approximately 12:00 PM, during an interview with witness 1 (W#1), they stated that in the times they came and visited (R#1), they had never observed (R#1) with dirty clothes on. Allegation: Staff not providing resident with nutritious meals. The details of the complaint alleged that facility is not providing nutritious meals to (R#1). On May 9, 2025, at approximately 11:00 AM, during a Health and Safety Check of the facility’s kitchen, LPA Iniguez observed that the facility’s food meets the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. On May 9, 2025, at approximately 9:00 AM, during an Interview with the Administrator (A#1), she stated that the food the facility serves to (R#1) and other residents in care is nutritious. On May 9, 2025, at approximately 10:00 AM, during an interview with (R#1) using the interpreter line (Focus Interpreter with interpreter Miza#bb249), LPA Iniguez requested the interpreter to ask (R#1) if they could hear. The interpreter posed the question in Japanese, but (R#1) responded, “I don’t know.” LPA Iniguez then asked the interpreter to inquire if (R#1) knew what day it was. The interpreter relayed the question, and (R#1) answered, “I don’t know.” Following this, LPA Iniguez concluded the telephone call. On May 9, 2025, at approximately 10:30 AM, during interviews with residents (R#2-R#5), (4) out of (4) stated that the food the facility serves is nutritious. On March 9, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#3), (3) out of (3) stated that the food the facility serves to (R#1) and other residents in care is nutritious. Evaluation Report continues LIC 9099-C On May 9, 2025, at approximately 12:00 PM, during an interview with witness 1 (W#1), they stated that the food they served to (R#1) is nutritious for the most part. Allegation: Staff tied up resident. The details of the complaint alleged that (R#1) has been tied to their wheelchair. On May 9, 2025, at approximately 9:00 AM, during an Interview with the Administrator (A#1), she stated that (R#1) had not been tied to their wheelchair. On May 9, 2025, at approximately 10:00 AM, during an interview with (R#1) using the interpreter line (Focus Interpreter with interpreter Miza#bb249), LPA Iniguez requested the interpreter to ask (R#1) if they could hear. The interpreter posed the question in Japanese, but (R#1) responded, “I don’t know.” LPA Iniguez then asked the interpreter to inquire if (R#1) knew what day it was. The interpreter relayed the question, and (R#1) answered, “I don’t know.” Following this, LPA Iniguez concluded the telephone call. In addition, LPA Iniguez observed (R#1) is not tied up on their wheelchair. On May 9, 2025, at approximately 10:30 AM, during interviews with residents (R#2-R#5), (4) out of (4) stated that they have never been tied to their wheelchairs by facility staff. On May 9, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#3), (3) out of (3) stated that they do not tie (R#1) to their wheelchair. On May 9, 2025, at approximately 12:00 PM, during an interview with witness 1 (W#1), they stated that the times they come and visit (R#1), they have never seen (R#1) tied to their wheelchair. Evaluation Report continues LIC 9099-C During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be 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. An exit interview was conducted, and a copy of the Complaint Report was given to Miran Bae / Manager.the state’s words, verbatim · CDSS document, May 9, 2025 · control 11-AS-20250324165545

Allegation investigated: Staff did not allow resident to have a visitor Staff are preventing resident from moving out of facility

On 4/30/25, Licensing Program Analyst (LPA) Felisa Shirley conducted a subsequent unannounced visit to this facility. LPA was met by Assistant Manager, Grace Hwang and explained the purpose of the visit is to investigate the allegations mentioned above and deliver findings. LPA was granted access to the facility. The investigation consisted of the following: On 04/3/25 LPA Felisa Shirley requested, received and reviewed copies of the following records: Staff Roster, Resident Roster, March Visitor Log, and Rent Payment for Resident. LPA Felisa Shirley interviewed facility Assistant Manager, reviewed facility records and interviewed Staff 1 through Staff 4 and Resident 2 through Resident 5. R-1 was not available due to diagnosis. The investigation revealed the following: Con'd on 9099-C Substantiated Allegation: Staff did not allow resident to have a visitor On 4/3/25, LPA Shirley reviewed facility records that does not show a visitor for R1 on 3/26/25. Per communication with W1, they went to Hayworth Terrace for an assessment and requested to be taken to R1’s room but S1 hesitated and stated that family needs to contact staff first if they want to move R1 out as R1 had payment delinquency. W1 wanted to avoid confrontation with S1, so they left. Per interview on 4/3/25, S1 denied entrance of W1 who was there to conduct an assessment of R1 for relocation due to outstanding rent payment. Per S1, W1 left and said that they would return. LPA Shirley interviewed staff-1 thru staff-4 (S-1 thru S-4). LPA asked, if staff allow residents to have visitors. Of those interviewed, 4 out of 4 staff answered yes. LPA interviewed Resident-2 thru Resident-5 (R-2 thru R-5). LPA asked residents, if staff allows them to have visitors. Of those interviewed, 4 out of 4 answered yes. During this investigation, LPA found sufficient evidence to support the above-mentioned allegation. Based on records reviewed and interviews conducted the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be substantiated. Allegation: Staff are preventing resident from moving out of a facility The details of the complaint allege that facility staff is not allowing resident to move due to an outstanding balance. On 4/3/25, LPA Shirley reviewed Rent Payment History record Con'd on 9099-C provided by facility staff. Per record reviewed, R1 owes this facility outstanding rent. Per interview with S1, S1 told W1 that R1 has a payment delinquency and then denied entrance to conduct an assessment. Per communication with W1, S1 stated the family needs to contact staff first if they want to move R1 out. LPA Shirley interviewed staff-1 thru staff-4 (S-1 thru S-4). LPA asked, if staff prevented residents from moving out of the facility. Of those interviewed, 4 out of 4 denied the allegation. LPA interviewed Resident-2 thru Resident-5 (R-2 thru R-5). LPA asked residents, if staff prevented them from moving from this facility. Of those interviewed, 2 out of 4 answered no and 2 residents did not know. During this investigation, LPA found sufficient evidence to support the above-mentioned allegation. Based on records reviewed and interviews conducted the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be substantiated. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. An exit interview was conducted, and a copy of this report was provided to Assistant Administrator Grace Huang.the state’s words, verbatim · CDSS document, Apr 30, 2025 · control 11-AS-20250327082253

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: May 14, 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: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not as evidenced by: Based on interview, S1 admitted denying W1 entrance to facility. This poses a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2025

Plan of correction: Administrators shall review regulation and train all staff on accepting visitors for all residents. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 5/14/25, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: May 14, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement is not as evidenced by: Based on interview, S1 divulged confidential information and did not agree to release R1. This poses a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2025

Plan of correction: Administrators shall review regulation and train all staff. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 5/14/25, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.

Type of visit: POC

On April 23, 2025, between 10:13 AM and 2:30 PM, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Plan of Correction (POC) visit to the above facility regarding a deficiency issued on March 19, 2025, and April 1, 2025, during a complaint investigation visit. LPA met with Miran Bae and explained the purpose of the visit. During today's visit, LPA Dabuet reviewed the plan of correction cited on March 19, 2025, and April 1, 2025. The Licensee was to make corrections for the following citations. On March 19, 2025, visit, Title 22 Regulation 87217(a)(1) Incidental and Medical and Dental Care and Title 22 Regulation 87217(b) Safeguards for Resident Cash Personal Property and Valuables were issued, with correction due on April 9, 2025. On the April 1, 2025 visit, Title 22 Regulation Administrator Qualification and Duties 97405(a) was issued as a citation with a due date of April 07, 2025. As of April 23, 2025, the Licensee failed to provide the required documents for corrections. Civil penalties of $3,700.00 are assessed at $100 per day for all three (3) citations from April 10, 2025, through April 23, 2025, beginning after the Plan of Correction was due. Civil Penalties were assessed, and an exit interview was conducted with Miran Bae. “The licensee was provided a copy of their appeal rights, and a signature on this form acknowledges receipt of these rights.”the state’s words, verbatim · CDSS document, Apr 23, 2025

Type of visit: POC

On April 14, 2025, at 12:21 PM, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Plan of Correction (POC) visit to the above facility regarding a deficiency issued on April 1, 2025, during a complaint investigation visit. LPA met with Assistant Administrator Grace Hwang and explained the purpose of the visit. During today's visit, LPA Dabuet reviewed the plan of correction cited on April 1, 2025. The Licensee will was requested on March 25, 2025, by LPA Dabuet via email for Eric Doan, the current administrator, to submit the required documentation to update the facility administrator on record. On the April 1, 2025 visit, LPA Alfonso Iniguez observed the facility had failed to provide the necessary documentation to the department to update the administrator on record and cited the facility with Title 22 Regulations Administrator - Qualification and Duties 87405(a). As of April 14, 2025, the Licensee failed to provide the required documents to change the administrator on record. The (POC) due date was April 7, 2025. A civil penalty of $800 is assessed at $100 per day from April 7, 2025 through April 14, 2025, beginning the day after the Plan of Correction was due. Civil Penalties assessed and an exit interview was conducted with Miran Bae. “The licensee was provided a copy of their appeal rights and a signature on this form acknowledges receipt of these rights.”the state’s words, verbatim · CDSS document, Apr 14, 2025

Type of visit: Case Management - Deficiencies

On 4/1/2025 at approximately 10:30 AM, LPA Alfonso Iniguez conducted an unannounced Case Management visit. LPA Iniguez met with Grace Hwang / Assistant Administrator. LPA Iniguez explained the purpose of this visit. On 3/25/25, LPA Dabuet emailed Erick Doan, the current administrator, the required documentation to update the facility administrator in the system. On 4/1/25, during an initial complaint visit, LPA Iniguez found out the facility had failed to provide the required documentation to the department to update the facility’s administrator. Based on this information, LPA Iniguez rendered a citation. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -Failed to provide information to the department to update facility administrator. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Miran Bae/Manager.the state’s words, verbatim · CDSS document, Apr 1, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Apr 7, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirenment was not met by: Based on observation and interview the licensee fail to provide the require documents to the regional office to update administrator in the system. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Apr 1, 2025

Plan of correction: Licensee will adhere to Tittle 22 regulations at all times. As plan of correction, licensee will provide the required documentation to the regional office before the POC due date.

Allegation investigated: The resident's medical and dental needs are not being met. Staff are not safeguarding resident’s personal belongings.

On March 19, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Grace Hwang, the assistant administrator, greeted the (LPA). (LPA) explained the purpose of this visit was to investigate the allegations mentioned above. The investigation included interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #2 (S1-S2), resident members #1 to -#5 (R1-R5), and witnesses #1 to #2 (W1-W2). The Department reviewed several documents, including the Facility Staff Roster (dated 03/13/25), the Resident Roster (dated 03/13/25), Resident #1 (R1)'s Residential Care Admission Agreement (dated 03/22/2020), Physicians Report LIC 602A (dated 03/22/23), Appraisal/Needs and Services Plan LIC 625 (dated 03/22/20, and 03/10/23), and other pertinent records associated with this complaint. Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff are not allowing resident to leave the facility. The complaint details alleged that the facility staff were not allowing Resident #1 (R1) to leave the facility. It was reported that it is customary for (R1) to participate in social activities outside the facility, but on March 6, 2025, (R1) was not permitted to leave. On March 13, 2025, between 9:15 AM and 10:00 AM, the Department interviewed staff members, identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the (2) two staff members denied the claim. (S1) explained that (R1) does not have a conservator, power of attorney, or public guardian representing them. (R1) frequently receives visits from close personal friends at the facility. However, on March 6, 2025, (R1) had a visitor whom (S1) did not recognize. (S1) asked the visitor questions, but the individual refused to provide identification and did not want to sign the visitor log or follow the facility's proper guidelines. (S1-S2) reported that visitation with residents is encouraged at any time, but visitors are expected to respect the other residents, staff, and guests on the facility's premises. (S1) described the visitor as uncooperative, so authorization for the visitor to leave the facility with (R1) was denied. (S1) emphasized that the facility is responsible for ensuring the well-being and safety of residents both inside and outside the facility and returning safely. On March 13, 2025, between 10:30 AM and 02:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #5. Four (4) out of the five (5) residents claimed to have no issues or concerns with family and friends visits at the facility. Although they know they have the right to leave the facility, most visits have been only inside the facility. On March 13, 2025, between 1:30 PM and 02:45 PM, the Department interviewed witness members and identified Witness #1 and Witness #2 (W1-W2). Two (2) out of the two (2) witnesses who claimed to have never had any issues with their visits to the facility. (W1-W2) were identified as guests of (R1) who followed the rules, signed the visitor's log, and announced the purpose of their visits. The Department reviewed the Residential Care Admission Agreement (dated March 22, 2020) and revealed a signed agreement by (R1) on page 11 under the section Visitation and Communication, the guidelines for visitation with residents. (Evaluation Report continues LIC 9099-C) In addition, a review of (R1's) Identification and Emergency Information LIC 601 (dated March 22, 2020) showed that (R1) did not have an authorized guardian, conservator, or power of attorney assigned. After reviewing the facility's visitor log from January 1, 2025, to March 2025, it was confirmed that (R1) 's guest did not sign in during the visit on March 6, 2025, supporting (S1) 's statement. Resident #1 (R1) was interviewed on March 13, 2025, with the help of an interpreter. However, (R1) was unable to participate in the interview due to (R1)'s health condition. Based on the gathered information, insufficient evidence supports the stated allegation. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted with Grace Hwang, and copies of the reports were provided. INVESTIGATION REVEALED THE FOLLOWING: Allegation #2: The resident's medical and dental needs are not being met. The complaint details allege Resident #1 (R1)’s medical and dental needs are unmet. It was reported that (R1) has been at the facility for several years and has not received proper routine medical and dental care. No further information has been provided relating to this allegation. On March 13, 2025, between 9:15 AM and 10:00 AM, the Department interviewed staff members, identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the two (2) staff members claimed that (R1) has received routine medical care. (R1) was admitted at Hayworth on March 22, 2020, and had several changes with the primary physicians throughout the years. (S1) stated (R1)’s medical needs are serviced by an internal primary physician who visits the physical facility monthly. However, (R1) has not received dental care since (R1)’s admission. (S2) stated that visits to medical physicians and psychiatric services are monthly. The podiatry services are every two months, and vision care services are every six months. On March 13, 2025, between 10:30 AM and 02:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #5. Four (4) out of the five (5) residents claimed to receive medical and dental care with the internal primary physician regularly and did not present any concerns or issues with the care provided. On March 13, 2025, between 1:30 PM and 02:45 PM, the Department interviewed witness members and identified as Witness #1 and Witness #2 (W1-W2), Two (2) out of the (2) witnesses who echoed the same concerns that (R1) doesn’t seem to be getting routine medical needs or assistance. (W1-W2) during their visitations, (R1) has never been observed being medically assessed by any medical professional at the facility. The Department audited (R1)’s service files and discovered (R1) had only one Physicians Report LIC 602A (dated March 03, 2023), two Appraisal/Needs and Services Plan LIC 625 (dated March 22, 2020 and March 10, 2023). Despite facility staff's claims that (R1) is receiving routine medical care services, no current medical assessments or records of medical or dental care are included in (R1)’s service file. The Department attempted to verify (R1)’s medical care by contacting (R1)'s current primary physician, but calls were not returned. Based on the gathered information, sufficient evidence supports the stated allegation. (Evaluation Report continues LIC 9099-C) Allegation #3: Staff are not safeguarding resident’s personal belongings. The complaint details that staff are failing to safeguard the personal property of Resident #1 (R1). It has been reported that (R1’s) belongings, including dentures, socks, and fresh flowers, are frequently missing, and theft of items is common at this facility. Furthermore, the staff has not tried to assist (R1) in replacing these lost items. On March 13, 2025, between 9:15 AM and 10:00 AM, the Department interviewed staff members, identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the (2) staff members claimed that (R1) lost some property valuables in the past. (S1) stated that (R1) routinely will misplace or lose (R1)'s dentures. (S1) said the facility does its best to safeguard the resident's property valuables by doing routine room checks through supervision. On March 13, 2025, between 10:30 AM and 02:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #5. Four (4) out of the five (5) residents claimed they had all been victims of theft at the facility. Individuals R2-R5 reported that money, hygiene products, clothing, and small electronics were stolen or lost. On March 13, 2025, between 1:30 PM and 02:45 PM, the Department interviewed witness members and identified Witness #1 and Witness #2 (W1-W2). Two (2) out of the (2) witnesses who claimed to have provided (R1) with blankets, hygiene supplies, and clothing and have never seen again. No explanation is provided for the missing or lost items. The Department reviewed various documents related to (R1), including Physicians Report LIC 602A (dated March 03, 2023), two Appraisal/Needs and Services Plan LIC 625 (dated March 22, 2020, and March 10, 2023), Identification and Emergency Information LIC 601 (dated March 22, 2020), Face Sheet (dated March 22, 2020), Medication Administration Record (dated March 01, 2025, through March 31, 2025), Residential Care Admission Agreement (dated March 22, 2020), Personal Right LIC 613C (dated March 22, 2020), Consent for Emergency Medical Treatment (dated March 22, 2020), it revealed that (R1) did not have the required document, Resident Personal Property & Valuables LIC 621 on record. Resident #1 (R1) was interviewed on March 13, 2025, with the help of an interpreter. However, (R1) was unable to participate in the interview due to (R1)'s health condition. Based on the gathered information, sufficient evidence supports the stated allegation. (Evaluation Report continues LIC 9099-C) Based on observations, interviews, and record reviews, the preponderance of evidence standard for NEGLECT and LACK OF CARE AND SUPERVISION" has been met. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted with Grace Hwang, the assistant administrator. During the interview, a hard copy of the report and information on appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 11-AS-20250307091106

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(a)(1) · Plan of correction due date: Apr 9, 2025

(a) A plan for incidental medical and dental care shall... encourage routine medical and dental care and provide for assistance in obtaining such care... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidence: Based on interviews and record reviews, the licensee did not comply with the section. (S1) admitted (R1) has been neglected with dental care and medical care needs were being provided routinely but failed to provide medical records as evidence that medical care are being met. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2025

Plan of correction: Licensee will adhere to Title 22 87217 and ensure that (R1) will receive a current medical assessment LIC 602A and dental care by POC due date. LIcensee will send proof of correction to LPA Dabuet at ernand.dabuet@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Apr 9, 2025

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b)Every facility shall take appropriate measures to safeguard residents' ..., personal property and valuables which have been entrusted to the licensee or facility staff. This requirement was not met as evidence. Based on interviews and record reviews, the licensee did not comply with the section. Interviews with R2-R5 indicated loss of property and facility did not have LIC 621 for R1. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2025

Plan of correction: Licensee will submit a plan to the LPA explaining how the facility will safeguard resident's personal property and send an completed LIC 621 to LPA Dabuet by POC due date at ernand.dabuet@dss.ca.gov

Type of visit: POC

On February 6, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Proof of Correction (POC) visit. LPA Dabuet met with Assistant Administrator Grace Hwang and informed the staff that the purpose of this visit was to ensure that the Type B deficiencies cited during the Annual Inspection on January 16, 2025, were corrected as required and if the facility is now in compliance with Title 22 Regulations. The deficiencies initially cited on January 16, 2025, were 87412(a), 87507(b), and 87506(b)(16). All proof of correction that was due by January 30, 2025, remained uncorrected. Civil penalties have been issued. An exit interview was conducted with Grace Hwang, and a copy of this report was provided. Note: *Citations that are not cleared by the due date will incur a $100 fine for each citation until they are resolved. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared.*the state’s words, verbatim · CDSS document, Feb 6, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Sparkle Day, Ernand Dabuet, Lizeth Villegas and Alfonso Iniguez conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Grace Hwang, Assistant Manager and the purpose of the visit was discussed. During this visit Erik Doan , Administrator arrived and assisted with the visit. The facility is licensed to serve 111 non- ambulatory residents age 60 and over . The facility has an approved hospice waiver for 25 residents. Current census is 49 The facility does not handle any of the residents’ money. Currently there are 4 residents receiving hospice services and 20 residents receiving home health services. The facility is a two-story structure located in a residential neighborhood. It consists of the following: (72) resident bedrooms and (77) bathrooms. There is a administrative office, an activity area, dining area, kitchen, medication room, and an outside patio. LPA observed all walkways around the building to be clean, clear, and free of obstructions, debris, and hazards. LPA did not observe any bodies of water on the premises. LPA inspected eleven (11) resident rooms with restrooms, including 1, 3, 4, 33, 46, 65,72, 74, 86, and 87 . LPA observed all rooms to be properly furnished with a bed, dresser, night stand, chair, and storage space for resident’s personal belongings. LPAs toured the dining room, kitchen, Activity room and medication room. The facility had required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew.. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPAs observed the following deficiencies and issued citations. * Kitchen :Stoves in kitchen ( 2 isles not working) on 1 stove (oven not working) * Dining room : 3 window panes cracked * Back entrance door window pane cracked *Physical Plant :Gate chained *Personnel records * Resident records * personnel training Exit interview conducted with Erik Doan, Administrator and Appeals Rights were explained. A copy of this report was providedthe state’s words, verbatim · CDSS document, Jan 16, 2025

Allegation investigated: Staff did not safeguard resident's personal belongings. Staff did not administer resident's medications as prescribed. Staff force resident to bed.

On 12/19/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Assistant Manager, Grace Hwang and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 12/19/24 LPA Felisa Shirley requested, received and reviewed copies of the following records: Staff Roster and Resident Rosters. LPA Shirley requested the following records for R-1: Medication Administration Log (MAR) and physician’s report. LPA also interviewed staff 1 thru staff 5 and resident 1 thru resident 5. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Staff did not safeguard resident's personal belongings. It was reported that R-1 is missing all of their clothing. LPA Shirley conducted a search of residents clothing and did not find the 4 articles of clothing that resident states was missing. LPA observed the clothing in R-1’s closet and counted the overcoats mentioned in complaint and other articles of clothing and women’s outfits, which LPA described to the resident. LPA Shirley toured the facility and went to 7 different storage rooms and did not find the clothing. LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, does staff safeguard residents personal belongings. Of those interviewed, 5 out of 5 staff answered yes. LPA interviewed Resident-1 thru Resident-5 (R-1 thru R-5). LPA asked residents, does staff safeguard all of your belongings. Of those interviewed, 4 out of 5 answered yes, 1 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not safeguard resident’s personal belongings,” therefore the allegation is unsubstantiated. Allegation: Staff did not administer resident's medications as prescribed. It was reported that R-1 has not been administered their medications. LPA requested and reviewed R-1’s Medication administration Record (MAR) and observed that all prescribed medications were administered as prescribed since day of admission. R-1 stated that staff gives her the medications in a little plastic bag. Staff watches her take the Con'd on 9099-C medication and then leaves. R-1 states that staff does not tell her what medication she is taking. LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, does staff administer resident’s medications as prescribed. Of those interviewed, 4 out of 5 staff answered yes and 1 answered I don’t know. LPA interviewed Resident-1 thru Resident-5 (R-1 thru R-5). LPA asked residents, do you receive your medications as prescribed. Of those interviewed, 5 out of 5 answered yes. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not administer resident’s medication as prescribed,” therefore the allegation is unsubstantiated. Allegation: Staff force resident to bed. It was reported that R-1 was made to go to bed when they were not ready to go to sleep. R-1 stated that staff pushed her shoulders down towards the bed and she kept telling them no. During interviews, S-5 stated there is no bedtime, but the residents are observed by caregivers as it gets closer to 10 to see if they are sleeping or looking tired and are encouraged to return to their rooms so as to not be roaming around the facility. LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, if there is an assigned bedtime for residents. Of those interviewed, 3 out of 5 staff answered no, 1 Con'd on 9099-C stated 7pm and 1 answered I don’t know. LPA interviewed Resident-1 thru Resident-5 (R-1 thru R-5). LPA asked residents, are you forced to go to bed when you are not ready. Of those interviewed, 4 out of 5 answered no, 1 stated, somedays they just push my shoulders and say go to bed. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff force residents to bed,” therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the LIC 9099 report was provided to the Assistant Manager, Grace Hwang.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 11-AS-20241216104340

Type of visit: Case Management - Deficiencies

On 12/29/24, Licensing Program Analyst (LPA) Felisa Shirley visited this facility to investigate a complaint and upon investigating, LPA Shirley learned that this facility does not have an Administrator with a valid Administrators Certificate. The LPA met with Grace Hwang, and the purpose was discussed. LPA Shirley interviewed 5 staff members and 5 residents. Deficiencies cited under California Code of Regulations Title 22 Exit Interview Conducted with Grace Hwang, Assistant Manager.the state’s words, verbatim · CDSS document, Dec 19, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jan 9, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidenced by: Based on records review and interview, the licensee did not comply with the section cited above in which not having a qualified and certified administrator could pose a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Please submit proof that this facility has a certified Administrator by Plan of Correction date of 1/9/25 to LPA Felisa Shirley by email to felisa.shirley@dss.ca.gov or fax to 424-544-1016.

Allegation investigated: Staff did not properly secure the residents medications Staff did not keep the facility free from an insect

On 01/31/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with Facility Manager/Med Tech, Bella Lee, and the purpose of the visit was explained. During today’s visit LPA toured the facility, interviewed Staff (S1-S5), interviewed Residents (R1-R6), and received documents pertinent to the investigation. The documents include Staff Roster, Resident Roster, staff In-Service logs, and receipts OK Exterminators. The investigation revealed the following: Continued on LIC9099-C Unsubstantiated Allegation: Staff did not properly secure the residents medication. The allegation alleges the medication room was left open, unsupervised, the medication carts were unlocked, and accessible to residents. During today’s visit, LPA observed staff in the medication room when the door was open. When Staff was dispensing medications to residents, LPA observed Staff close and lock the door. While LPA was in the medication room, LPA observed the medication cart to be closed and locked. LPA did not observe the medication left unattended at any time during today's visit. During interviews with Staff (S1-S5), five (5) out of five (5) stated that when staff leave the medication room it is closed and locked every time. During interviews with S2 and S5, two (2) out of two (2) stated they have seen the medication left open and unattended during an emergency when the Med Tech went to evaluate a resident but they have not seen that for a while and since the training. LPA received and reviewed the In-Service Training that consisted of Medication Training and Medication Room must be Locked at all times training conducted on 01/08/24. During interviews with Residents (R1-R6), six (6) out of six (6) stated the medication room is closed and locked when staff are not in there, and they do not have access to the medications. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated Continued on LIC9099-C Allegation: Staff did not keep the facility free from an insect. The allegation alleges an insect was observed in the facility kitchen. During the tour, LPA observed a total of four (4) dead insects in vacant rooms 3, 38, and 43. During the inspection of the kitchen, LPA observed it to be clean and sanitary. LPA did not observe insects in the kitchen or the dining room. LPA received and reviewed receipts for OK Exterminators who provide monthly treatments for cockroaches, bed bugs, and rats. During interviews with Staff (S1-S5), five (5) out of five (5) stated they have not seen insects in the facility for a while. During an interview with S2 stated an exterminator comes out monthly to treat the facility. LPA reviewed In-Service Training conducted on 01/08/24, which consisted of housekeeping and pest control. During interviews with Residents (R1-R6), six (6) out of six (6) stated they have no concerns regarding insects in the facility. During an interviews with Resident (R4 and R6) stated we like the back doors open for fresh air and sometimes a bug will fly in. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated An exit interview was conducted with Manager/Med Tech Bella Lee, and a copy of this was providedthe state’s words, verbatim · CDSS document, Jan 31, 2024 · control 11-AS-20240126143235

Type of visit: Prelicensing

On 01/03/2024 Licensing Program Analyst (LPA's) Villegas and Dabuet conducted a case management pre licensing visit to inspect corrections dated 12/18/23 during the pre licensing inspection. LPAs met with house manager Bella Lee and maintenance supervisor Juan Rossell as the purpose of the visit was explained. During the inspection visit LPA's reviewed the inspections for the following: Smoke Detectors: · Smoke detectors in room #68 is not attached properly to the ceiling. - corrected 01/03/24 Physical Plant: · Rooms #13; #19, #44, #64, #66 and #80 cluttered - corrected: 01/03/24 · Room #29, #61 (being used as storage) - corrected: 01/03/24 · Room #23, #36, #43, #46, #73 and #83 no linens - corrected: 01/03/24 · Room #23, #35, #7, #59 no furnishings - corrected: 01/03/24 · Room #30 locked no key accessibility.- corrected: 01/03/24 · Room #31 exposed hazardous chemical spray - corrected: 12/18/23 · Room#11 obstruction bed blocking access to closet - corrected: 12/18/23 · Room #35 no hot water faucet not operable - corrected: 12/27/23 · Rooms #46, #83 and #84 window screens missing. corrected: 12/28/23 · Room #39 no doorknob - corrected: 12/28/23 · Room #25 and #34 molds along the wall surfaces - corrected: 12/28/23 Pest Control: · Room #20 (roaches) - corrected: 12/28/23 ·Room #21 (roaches) - corrected: 12/28/23 · Room #22 (roaches) - corrected: 12/28/23 Room #24 (roaches) - corrected: 12/28/23 Pest Control · Room #25 (roaches) - corrected: 12/28/23 · Room #34 (roaches) - corrected: 12/28/23 · Room #35 (roaches) - corrected: 12/28/23 · Room #36 (roaches) - corrected: 12/28/23 · Room #85 (roaches) - corrected: 12/28/23 Staff Records: · Fingerprint Clearances Exceptions - (S2), (S3), (S7) - corrected: 01/03/24 · Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders - (S3), (S4), (S5), (S7) - corrected: 01/03/24 · Criminal Statement - (S3), (S7) - corrected: 01/03/24 · Health Screening - (S3) - corrected: 01/03/24 · TB Test - (S3) - corrected: 01/03/24 · Education Verification - (S2), (S3), (S5) and (S7) - corrected: 01/03/24 · Employee Rights - (S4), (S7) - corrected: 01/03/24 Resident Records: · Consent Forms - (R3), (R5) - corrected: 01/03/24 · Safeguard for Property/Valuables - (R2), (R3), and (R4) - corrected 01/04/24 · Personal Rights (R3) - corrected: 01/03/24 An exit interview was conducted with House Manager Bella Lee, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Jan 3, 2024

Type of visit: Prelicensing

On 12/18/23 Licensing Program Analysts (LPAs) Villegas,Gibbs, Dabuet and Iniguez conducted a pre-licensing evaluation for an RCFE (Residential Care Facility for the Elderly) Change of Ownership (CHOW). Today’s pre-licensing evaluation was conducted with House Manager Bella Lee. The licensee has applied for a license to serve (111) age range 60 and over adults. The fire clearance is approved for (111) non-ambulatory. Waiver/Granted for Hospice Care for (25). Liability insurance is active. LPA’s Villegas and Gibbs toured facility kitchen, dining Room, lounge areas, (72) Bedrooms, (77) bathrooms, basement, patios with shaded area and medication room. LPA’s observed the following during this visit: MEDICATIONS- There is a locked centralized storage area for Resident medications. PHYSICAL PLANT- LPA observed Indoor and outdoor passageways, stairways, open areas, and other areas of potential hazard are free of obstructions. The facility temperature is between 68° degrees and 85° degrees. BEDROOMS- No client bedroom is a passageway to another room, bath, or toilet. There is a bed for each client with a mattress, mattress pad, bedsprings. There is dresser and closet space for each client that includes at least two (2) drawers of dresser space per client. BATHROOMS- There are plenty of toilets and washbasins for clients, family, and personnel. There are plenty of showers for clients, family, and personnel. The hot water temperature is between 105°-120° degrees Fahrenheit. Bathrooms are located inside client bedrooms and common areas. FOOD SERVICE- The dining room is near the kitchen. The refrigerator and freezer are clean and have the capacity to store at least two (2) days of perishable foods. There is storage for a seven (7) day supply of non-perishable food. There are enough tableware, tables, dishes, and utensils. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. RECORDS- There is confidential storage for personnel records at the facility. There is storage for Resident confidential information and records at the facility. ADMINISTRATION- The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. A Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES- There is an outdoor activity space with a shaded area and furnished for outdoor use. There are at least 3 common areas available to clients for visitors. There are activities scheduled during the current month. 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. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. CORRECTIONS: Smoke Detectors: Smoke detectors in room #68 is not attached properly to the ceiling. Physical Plant: Room #31 exposed hazardous chemical spray Room#11 obstruction bed blocking access to closet Room #35 no hot water Rooms #46, #83 and #84 window screens missing. Rooms #13; #19, #44, 64, #66 and #80 cluttered Room #29, #61 (being used as storage) Room #23, #36, #43, #46, #73 and #83 no linens Room #23, #35, #7, #59 no furnishings Room #39 no doorknob Room #25 and #34 molds along the wall surfaces Room #30 locked no key accessibility. Pest Control: Roaches Room #20, Room #21, Room #22, Room #24, Room #25, Room #35 Room #34, Room #35, Room #36, Room #85 Staff Records: Fingerprint Clearances Exceptions (S2), (S3), (S7) Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders (S3), (S4), (S5), (S7) Criminal Statement (S3), (S7) Health Screening (S3) TB Test (S3) Education Verification (S2), (S3), (S5), (S7) Employee Rights (S4), (S7) Missing File (S1), (S8) Clients Records: Consent Forms (R3), (R5) Safeguard for Property/Valuables (R2), (R3), (R4) Personal Rights (R3) An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Dec 18, 2023

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership Capacity: 111 Census (if any clients in care): Unknown COMP II Participants: Man Park, Mohsen Abdolsalehi Interview Method: Telephone interview On December 13, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Dec 13, 2023