Inn at the Park Ventura

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Quoc Huynh arrived on September 1, 2026, for an unannounced inspection to follow up on the substantiated allegations of a complaint investigation. On November 21, 2024, the Department concluded a complaint investigation regarding the following allegation: “Neglect/Lack of Care and Supervision – Facility failed to seek timely medical attention when Resident #1 (R1) developed an illness (clostridium difficile colitis) while in care of the facility.” The licensee was cited for California Code of Regulations (CCR) 87465(g) Incidental Medical and Dental Care. At the time of the complaint visit on November 21, 2024, 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(e) and 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by the facility did not provide proper care, supervision, or timely medical attention that resulted in the resident’s recurrence of clostridium difficile colitis (C-diff) which resulted in death from septic shock. Report Continued on LIC 809-C Today September 1, 2026, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(e) for a violation that the Department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on November 21, 2024, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report was issued. Appeal Rights provided. The Administrator Rose Anguiano and signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Sep 1, 2026

Allegation investigated: Staff did not prevent a resident from threatening another resident

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA arrived at 1:47PM and met with the Administrator Rose Anguiano. Entrance interview conducted. On 07/14/2026, the LPA conducted an initial visit Between 1:57PM and 3:06PM, the LPA conducted a physical plant tour, interviewed three (3) residents and the Administrator and Assistant Administrator, and reviewed and obtained pertinent documents. On 08/11/2026, the LPA conducted a subsequent visit. Between 10:31AM and 2:20PM, the LPA conducted a physical plant tour and interviewed three (3) staff. Report Continued on LIC 9099-C Unsubstantiated During today’s visit, the LPA and Administrator conducted a physical plant tour at 1:50PM, and no immediate concerns were observed. The following was then determined: Allegation: “Staff did not prevent a resident from threatening another resident” It was reported that facility staff did not prevent Resident #1 (R1) from verbally harassing and threatening other residents, despite having prior knowledge of the behavior. On 06/26/2026, the Department also received an incident report from the facility stating that R1 and Resident #2 (R2) engaged in a verbal conflict in the hallway. According to the report, both residents exchanged insulting comments, and staff quickly intervened and redirected the residents. R1 confirmed the incident and stated that the conflict began after R2 bent over and exposed themself in the hallway. R1 reported that they generally get along with all residents except R2, who R1 believes frequently instigates issues. R2 reported that R1 often makes “nasty” comments and death threats toward them. R2 stated they do not cause issues unless provoked; however, they confront R1 because they will not tolerate insults or threats. R2 confirmed that conflicts occur primarily in the hallway during passing interactions and stated that staff respond by redirecting and separating residents. Interviews with staff revealed that the statements provided by R1 and R2 about the 06/26/2026 incident were inconsistent, and the facility issued R1 a warning regarding house rules. Staff reported that R2 frequently instigates conflict among residents and that R1 and R2 often exchange insults. Staff denied additional issues involving other residents or reports of R1 making threats. Report Continued on LIC 9099-C A review of R1’s Appraisal/Needs and Services Plan dated 03/06/2026 showed no concerns related to socialization, emotional, or mental health needs. R2’s Appraisal/Needs and Services Plan dated 06/13/2026 documented a pattern of instigating problems among residents, a history of outbursts toward residents and staff, and frequent claims of harassment without providing additional details. Based on interview and record review, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur; therefore, the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 29-AS-20260708103856

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced for a required annual visit. The LPA arrived at 10:05AM and met with the Administrator Rose Anguiano. Entrance interview conducted. At 10:31AM, the LPA and Assistant Administrator Alexander Solorio toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a two (2) story building. The following was observed: RESIDENT ROOMS: The LPA observed fifteen (15) randomly selected rooms on the first and second floors and no immediate health or safety hazards were observed. Appropriate furniture was observed in the units including clean linens and sufficient lighting. Restrooms were clean, with grab-bars in resident bathrooms and non-skid strips in shower tubs. Water temperature was tested throughout the units and measured between 112.6 degrees F and 121.6 degrees F. The LPA advised the Maintenance team to lower the hot water temperature. The LPA additionally observed approximately nine (9) resident room windows without a screen. Report Continued on LIC 809-C COMMON AREAS: On the first floor there was a lobby/reception area, administrative offices, medication room, laundry room, hair salon, dining room and kitchen, courtyard, smoking area, and movie and activity rooms. On the second floor there was an activity room, game room, and secured memory care unit with it’s own activity and dining room. LPA Huynh observed all common areas to be clean, clear of obstructions, and furniture were in good condition. Required postings were observed on the first floor hallway and no bodies of water were observed. KITCHEN/DINING ROOM: The main kitchen is located on the first floor and attached to the dining room. Facility dining room and kitchen were inspected and found to be in compliance with Title 22 regulations. There was a sufficient supply of perishable and non-perishable food. The LPA observed the refrigerators and freezers with food to be of good quality and labeled with expiration dates. MEDICATION: Medication review began at 11:47AM. The LPA reviewed medications for five (5) residents. Medications were maintained locked inaccessible to residents on the first floor. Resident medications reviewed were documented and stored in compliance with regulation at this time. RECORDS: Resident records were reviewed at 12:05PM. LPA Huynh reviewed ten (10) files for, but not limited to admissions agreements, medical assessment, appraisals, and consent forms. Resident records reviewed were in order at this time. The LPA reviewed ten (10) personnel records for, but not limited to job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and appropriate trainings. Staff files reviewed were in compliance with regulation at this time. Report Continued on LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER: The LPA reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPA noted that the facility is in compliance with regulation with both plans reviewed annually. The facility conducts emergency disaster drills as required, with the last drill documented on 07/29/2026. Fire extinguishers were observed throughout the facility and last serviced on 01/27/2026. Fire systems are inspected annually with the last inspection on 04/16/2026 by Valley Public Safety. Emergency food was observed in a storage closet located on the first floor and emergency water stored in a storage closet located in the garage. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 11, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide adequate supervision resulting in resident inappropriately touching another resident in care.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation findings. LPA met with staff Martin Zepeda. The reason for the visit was explained. On 04/02/2026, Community Care Licensing Division (CCLD) received information regarding the above allegations. On 04/03/2026, an initial 10-day complaint visit was conducted by LPA Chochian. During the visit, LPA conducted a tour of the physical plant tour at approximately 10 a.m. During the tour, LPA observed the common areas, and random resident rooms. During the tour, LPA also met with and interviewed three (3) residents; additional residents were interviewed in the facility office. Total of twelve (12) random residents were interviewed from approximately 10:45 a.m.-12:15 p.m. LPA also conducted interviews with six (6) staff from approximately 12:30 p.m.-1:30 p.m. Records relevant to the investigation were reviewed at approximately 1:40 p.m. and copies were obtained. This case was referred to the Department’s Investigation Branch. The Department conducted additional interviews on 04/07/2026 with Resident #1 (R1) and facility staff. (Continue to 9099C) Unsubstantiated Resident #2 (R2) was interviewed on 04/14/2026 and R1’s Responsible Party was interviewed on 04/20/2026. Furthermore, potential witnesses were interviewed, and follow-up interviews were conducted with R1, R1’s Responsible Party, R2, and facility staff from 04/24/2026 to 04/30/206 and from 05/04/2026 to 05/08/2026. Following is the summary of the allegations and investigation finding: Regarding allegation “Staff did not provide adequate supervision resulting in resident inappropriately touching another resident in care”: Information was received that R1 was sexually assaulted by previous roommate, R2, during the first week of March 2026. A specific date was not disclosed. It was further reported that during the night R1’s roommate approached R1 while in bed and asked R1 to cover self-up with a blanket. The roommate pretended to try and help R1 and then started to touch R1's bare stomach. The roommate then proceeded to touch R1's breasts and other parts of the body. R1 asked the roommate to stop but they didn't listen. R1 stated they were too weak to stop the roommate. Records reviewed revealed that R1, who has dementia, moved to the facility on 3/05/2026 and was placed in a shared room with R2, who also has dementia. Facility staff interviewed denied having any knowledge that R2 could sexually assault another client. Records reviewed indicated residents are checked every two hours around the clock as required by the facility. R1 confirmed that caregivers were checking on them regularly. Staff interviews revealed that they first learned of the incident that R2 touched R1’s chest when fixing R1’s blanket on 3/11/2026 from R1’s responsible person and that R1 did not feel comfortable being in the same room with R2. Therefore, R1 was relocated to another room the following day (3/12/2026). Staff interviews revealed that when R1’s family reported the incident they did not report any type of abuse. However, R1’s family provided inconsistent statements that staff were informed of the alleged inappropriate behavior on 03/08/2026. Staff denied having any knowledge about R1 being inappropriately touched until 03/11/2026. Staff explained that they did not know that the touching was intentional or that included touching other parts of R1’s body other than R1’s chest. Therefore, there was no abuse report filed until it was alleged by R1’s family that R2 intentionally touched R1 inappropriately. Law Enforcement made a site visit on 04/01/2026 and 04/06/2026; R1 and R2 were interviewed and because of both residents’ confusion and memory loss, the officers took an incident report for documentation purposes and advised that because this was an injury report and not a crime report, detectives will not be investigating the matter. (Continue to LIC9099C). The investigation could not prove that the facility knew or should have known about the abuse before 3/11/2026, and that the severity of the touching is unclear, the allegation that R2 sexually abused R1 as a result of facility neglect could not be proven. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation, “Staff did not provide adequate supervision resulting in resident inappropriately touching another resident in care” is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 8, 2026 · control 29-AS-20260402113333

Allegation investigated: Due to lack of supervision, resident sexually abused another resident in care. Due to lack of supervision, resident physically assaulted another resident in care.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation findings for the above listed allegations. LPA met with staff Martin Zepeda. Staff contacted Assistant Administrator Alexander Solorio. LPA spoke with Mr. Solorio at approximately 1PM. Reason for the visit was explained. Allegation findings were discussed with Mr. Solorio and it was approved for staff Martin Zepeda to sign the report. On 04/10/2026, Community Care Licensing Division (CCLDs) received information alleging that “Due to lack of supervision resident sexually and physically abused another resident in care”. Information was provided that Resident #2 (R2) is raping and hitting Resident #1 (R1). Reporting party (RP) stated that R1 had a black eye and when asked what happened R1 said they fell. RP stated that they know that’s not true and believes R2 hit R1 and caused the black eye. The case was referred to CCLD Investigation Branch (IB) as an assignment to conduct interviews. (Continue to LIC9099c) Unsubstantiated Following is the summary of the investigation findings: On 04/13/2026, LPA Chochian conducted an initial 10-day complaint visit was conducted. During the visit a physical plant tour was conducted with staff. During the tour, LPA observed the common areas, and random resident rooms. During the tour LPA met with and interviewed seven (7) residents between 12pm-1:30pm. LPA also requested and reviewed resident records from approximately 1:40pm - 2:30pm. On 04/13/2026, IB Investigator conducted an unannounced site visit to this facility. Investigator conducted interviews with R1 at approximately 12:56 P.M. and R2 at approximately 2:22P.M. In addition, Executive Director (ED) Rose Anguiano was interviewed on 05/08/2026 at approximately 2:58P.M. and records were reviewed. Information gathered reflected that R1 denied allegations of being sexually or physically abused by R2. Per R1 reported they felt safe and loved living at the facility. R1 reported that they sustained a fall in their room which resulted in R1s black eye. R1 confirmed they were friends with R2 and reported no inappropriate contact between each other. Additionally, R2 also denied any inappropriate contact or sexual contact with R1. ED denied the allegations and provided the Unusual Incident Report (UIR) documenting R1’s unwitnessed fall in room and sustained a small laceration above left eyebrow. UIR indicated staff responded with first aid and R1 was later transported to the hospital for further evaluation. Interview with RP revealed that RP did not witness any physical or sexual assault between R1 and R2. Other random residents interviewed did not report witnessing any inappropriate behavior by R2. Random residents interviewed reported feeling safe at the facility. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Due to lack of supervision resident sexually abused another resident in care.” And “Due to lack of supervision resident physically assaulted another resident in care” are deemed Unsubstantiated at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 27, 2026 · control 29-AS-20260410094024

Allegation investigated: Staff did not ensure resident's dietary needs were met.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Administrator Rose A. and assistant Administrator Alex S. The reason for the visit was explained. On 12/23/2025, Community Care Licensing Division received information alleging that the facility is serving foods high in fat, salt, sugars, and carbs, which resident cannot eat due to having diabetes. It was also mentioned that facility prepares meats that covered in sauce, which residents’ cannot eat due to excess sugar, fats, and salt. According to the reporting party Administrator Rose A. stated that the facility cannot cater to individual needs when it comes to preference. On 12/30/2025, LPA conducted the initial complaint visit and the allegation was discussed with the Administrator. A physical plant tour was conducted. Also during initial visit LPA interviewed four (4) residents and two (2) staff from approximately 1:15pm-2:45pm. Unsubstantiated Copies of records relevant to the investigation was requested and reviewed. On 01/15/2026, a subsequent visit was conducted, and additional residents (6) were interviewed from approximately 12pm-1pm. Residents were observed in the dining room as well. LPA toured the kitchen at approximately 2:45pm. Following is a summary of the investigation finding: Regarding allegation “Staff did not ensure resident's dietary needs were met.”: LPA interviewed Administrator, staff, and resident #1 (R1). LPA also interviewed other residents, reviewed R1’s records and facility menu. R1 confirmed that they do manage their own medications and diet. R1 reported that the facility does not have a variety of options for diabetics. R1 reported that they have had five hospital visits in recent months due to high blood sugar levels. Interview conducted with R1, staff and records reviewed revealed that R1 is alert/oriented x3 and able to make own decisions. R1 was hospitalized once on June 9th, 2025, and once on December 6th, 2025, due to dizziness and nausea. R1 does have type 2 diabetes, however, does not have a prescribed diet to be followed at this time. R1 stated that they are currently working on changing physicians. R1 stated that the facility offers sugar free snacks, however R1 does not like the options. R1 did confirm that the facility offers alternative meals however they are tired of eating steamed vegetables, salad with protein or sandwiches. Administrator reported that R1 is independent and able to manage own medications and diet. Administrator confirmed that R1 does not have a prescribed diet at this time. Administrator recalled an incident discussed with R1 on or around 12/22/2025, where kitchen staff made a mistake and served R1 meat covered in sauce. Administrator informed kitchen staff to provide all sauces on the side moving forward. According to the cook and administrator, alternative items such as a salad with/protein, vegetables or a sandwich is always available, and regular meals can also be served with or without sauce when requested a head of time by residents. Random residents interviewed reported being satisfied with the facility food service at this time. Based on the above information gathered, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not ensure resident's dietary needs were met” is deemed unsubstantiated at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 29-AS-20251223091758

Allegation investigated: Facility staff are not preventing a resident from making threats towards another resident

Licensing Program Analyst (LPA) Zabel Chochian conducted a complaint visit regarding above allegation. LPA met with Administrator Rose Anguiano. The reason for the visit was explained. On 01/13/2026, Community Care Licensing Division received the above allegation. It was alleged that resident was threatened by the roommate and when staff were informed, they didn't do anything about it. Information was provided that the roommate stays up all night and is "mentally unstable". Resident feels threatened living with their roommate. During todays visit, allegation was discussed with Administrator at approximately 11:15am. Administrator explained that resident #1 (R1) reported to staff on Monday, 1/12/2026 about having an issue with the roommate on Saturday, 01/10/2026, which R1 felt threatened. No altercation was reported or observed. Administrators met with R1 and R2. R2 agreed to be transferred to another room. Staff interviewed did not observe any incident involving R1 and R2. (Continue to LIC9099c) Unsubstantiated Staff stated that R1 did not report any previous threats or report feeling unsafe prior to 01/12/2026. LPA conducted random resident interviews from approximately 12pm-1pm. R1 declined to be interviewed. R1 would not allow LPA to enter room and screamed out to LPA who was standing outside R1’s door “everything is ok leave me alone”. LPA and assistant administrator walked away and continued with other resident interviews. LPA conducted interview with R2 and was informed that they agreed to be transferred to a different room since they were not getting along with their roommate. R2 confirmed being satisfied with the new room and roommate. Other random residents interviewed stated that they feel safe. Random residents reported that anytime there is a physical or verbal altercation staff are present and either redirect or contact law enforcement. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility staff are not preventing a resident from making threats towards another resident” is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 29-AS-20260113100622

Allegation investigated: Illegal eviction Staff allow residents to smoke in undesignated areas

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit regarding allegations above. Upon arrival LPA met with Administrator Rose A. and assistant Administrator Alex S. The reason for the visit was explained. On 12/22/2025, Community Care Licensing Division received information alleging that facility is illegally evicting resident #1. It was also reported that residents smoke marijuana in their room and the staff do not do anything. On 12/30/2025, LPA conducted the initial complaint visit and the allegations were discussed with the Administrator. LPA interviewed two residents and two staff from approximately 1:15pm-2:45pm. Copies of records relevant to the investigation was requested. On 01/15/2026, a subsequent visit was conducted and additional seven (6) residents and two (2) staff were interviewed regarding above allegations from approximately 12pm-1pm. Following is a summary of the investigation findings: (continue to LIC9099c) Unsubstantiated Regarding allegation “Illegal Eviction”: LPA conducted interview with Administrator and resident #1 (R1) as well as reviewed records which included the eviction notice, residents’ admission agreement, pet policy, and facility notes. Based on the interviews and records reviewed, Administrator had several meetings with R1 about the resident’s dog. The Administrator stated that R1’s dog is very big now and residents, staff and visitors are afraid of the dog. The dog attacked a visitor who fell and sustained injury; the dog attempted to bite other residents. Administrator stated that the facility does have a “no pet policy” however they made an exception for the resident when dog was little. Administrator stated that the dog is big and unpredictable, staff, residents and visitors are scared. According to Administrator, several notices were given to R1 however R1 does not want to give up the dog. Therefore an eviction notice was issued to R1. The notice was also sent to Community Care Licensing Division on 12/15/2025. LPA reviewed the eviction notice and confirmed the notice does contain the required language, contact information for the required parties, as well as referrals for alternate care, per regulation. The notice was served on 12/16/2025 to resident. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Therefore the allegation “Illegal eviction” is deemed Unsubstantiated at this time. Regarding allegation “Staff allow residents to smoke in undesignated areas”: Investigation into this allegation consist of resident and staff interviews. Seven (7) out of the eight (8) residents interviewed denied allegation and reported that they have not observed any resident smoke in the hallways. Staff interviewed denied the allegation and reported that if they do witness any resident smoking in the facility they would report it to the administrator and residents would receive a written warning. According to the staff and administrator smoking in the facility is prohibited and if staff observe or have been notified of any issues they immediately address the issue with the resident and report to the administrator. According to Administrator residents have been found smoking in their room or balcony and have received warnings about breaking the house rules. If residents continue to ignore the house rules, then they are subject to receive an eviction notice. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation “Staff allow residents to smoke in undesignated areas” is deemed Unsubstantiated at this time. Exit conducted and copy of report provide.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 29-AS-20251222115912

Allegation investigated: Staff do not prevent the residents from using illicit drugs Staff do not keep the facility free from bug infestation Staff do not properly maintain a resident's sink

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation findings. Upon arrival LPA met with Resident Care Coorinator Tina Hernandez and Assistant Administrator Alexander Solorio. The reason for the visit was explained. On 10/17/2025, The Department received information alleging that there is an issue with residents at the facility engaging in alcohol consumption and doing illicit drugs. Also, it was alleged that there is an issue with bed bug infestations at the facility and staff, administrator, and assistant administrator, are not addressing the issue. In addition, it was alleged that Resident #1 (R1) reported having a clogged sink for 1 and a 1/2 months and it has not been fixed. On 10/20/2025, LPA conducted the initial complaint visit and the allegations were discussed with the Administrator. A physical plant tour was conducted at approximately 10 a.m. During the tour, seven (7) resident rooms were inspected, and residents were interviewed. (Continue to LIC9099c) Unsubstantiated LPA also interviewed three (3) staff beginning at approximately 11a.m. Additionally, records relevant to the investigation were reviewed at approximately 12 p.m. and copies were obtained. The Case was referred to Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Jasmine Thomas. On 11/06/2025, IB Investigator, Jasmine Thomas, conducted an unannounced site visit to this facility. Investigator conducted interview with R1 at approximately 11:51 a.m.; reviewed R1’s records and interviewed the ED at approximately 12:45 p.m. Following is a summary of the investigation findings: Regarding allegation “Staff do not prevent the residents from using illicit drugs”: Investigation into this allegation consisted of record review, resident and staff interviews conducted by LPA Chochian and IB Investigator Jasmine Thomas. All seven (7) residents interviewed denied allegation and reported that they have not observed any drug use at the facility, nor have they seen anyone drinking alcohol. Residents reported feeling safe at the facility. Staff interviews reflected that there have been incidents where residents were intoxicated, smoking in rooms and were using illicit drugs however, immediate action was taken, and residents were issued warnings. Administrator further stated that intoxication, smoking in bedrooms and the use of illicit drugs are prohibited in the facility and residents are issued written warnings and law enforcement is contacted, if needed. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff do not prevent the residents from using illicit drugs” is deemed Unsubstantiated at this time. Regarding allegation “Staff do not keep the facility free from bug infestation”, Investigation consisted of resident room checks, interviews with random residents and staff. One (1) out of seven (7) residents interviewed reported that they have bed bug activity in their room. R1 confirmed that their room was sprayed for bugs approximately one month ago, however the bug issue did not resolve. R1 confirmed that management agreed to have the room sprayed again. During the tour, both LPA and IB Investigator observed R1’s room to be unkempt. Interview with staff and pest control invoices observed R1’s room was sprayed a month ago for bed bug prevention and it was recently inspected by facility staff and pest control for any bed bug activity. No bed bug activity was found. (Continue to LIC9099c) R1 confirmed that facility provides cleaning services, however R1 prefers to clean their own room. Staff reported that R1 refuses cleaning service, however it was explained and agreed with R1 to have housekeeping staff assist with cleaning to prevent bug infestation in the room. Furthermore, records reviewed revealed that the facility is contracted for monthly general exterior/interior pest control for various bugs; bed bug treatment is provided on call bases. According to the Administrator, R1’s room was inspected by facility staff and pest control company, and no bed bug activity was found. The Administrator provided invoices from Hydrogen Pest Control for the month of October confirming general pest control treatment and bed bug inspection for R1’s room. Based on information gathered during the course of the investigation, the Department does not have sufficient evidence to support that the staff did not keep the facility free from bed bug infestation, therefore, the above allegation, “Staff do not keep the facility free from bug infestation” is deemed unsubstantiated at this time. It was further alleged that “Staff do not properly maintain a resident's sink”. Investigation consisted of resident room checks, interviews with random residents and staff. Interviews revealed that R1 did not report the sink issue to management and attempted to fix it on own; however, R1 was unsuccessful. R1 confirmed that when they finally reported the clogged sink to staff, it was fixed. Other random residents interviewed regarding maintenance and housekeeping expressed being satisfied with the services at this time. Based on information gathered during the course of the investigation, the Department does not have sufficient evidence to support the fact that staff did not properly maintain the residents’ sink, therefore, the above allegation is deemed unsubstantiated at this time. Exit interview conducted/No citations issued/A copy of report provided.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 29-AS-20251017100345

Allegation investigated: Facility staff did not ensure resident's incontinence care needs were met Resident was locked in their room

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to this facility today regarding above allegations. Upon arrival LPA met with Resident Care Coordinator Tina Hernandez and Assistant Administrator Alex Solorio. Reason for the visit was explained. On 10/06/2025, Community Care Licensing Division received the above allegations. Information was received that resident #1 (R1) was locked in their room; and when staff opened the door resident was observed in bed with soiled diaper. On 10/10/2025, LPA conducted the initial complaint visit and toured the facility's memory care unit which consists of 21 resident rooms, and common areas at approximately 11:30 A.M. LPA attempted to interview five (5) random residents in the memory care. One out of five residents was able to communicate and respond to questions asked. LPA also conducted interview with three staff, ED and Assistant Administrator beginning at approximately 11:30 A.M. and from 12:30 P.M - 2:30 P.M. At the time of the visit memory care resident observed in the activity/dining area. Residents observed dry/not soiled at the time of visit. (Continue to LIC9099c) Unsubstantiated Random rooms toured in the memory care were odor free at the time of visit. One residents who was able to communicate was interviewed and expressed being satisfied with care service. Resident #1’s (R1) records were reviewed and revealed that R1 is non-ambulatory, nonverbal, requires transfer assistance and is incontinent with folly catheter. R1 observed to be nonverbal and did not understand English. R1 was able to communicate needs and responded through hand movements and facial expressions. R1 was interviewed by LPA with staff assistance. R1 expressed being satisfied with care and staff. R1 was asked how often staff check in on resident (30min, 1hour, not more than 2 hours), and R1 gestured with thumbs up to all. R1 was asked if they are able to transfer out of bed and R1 shook there head from left to right (no). R1 was observed to be following staff command when asked to demonstrate sitting up which R1 is able to do without staff assistance. Staff reported that R1 is assisted with incontinent care according to care needs. Staff also reported that they make sure folly catheter is maintained accordingly as well. According to staff on 10/05/2025 paramedics were called for R1 as a result of R1 pulling out folly catheter. Staff stated that they cleaned R1 and called paramedics. Staff explained that when paramedics arrived R1 had a bowl movement therefore needed to be changed again. Staff reported that all memory care resident are checked at least every 2 hours due to cognitive abilities and incontinent care needs. Staff reported that resident are never left sitting or laying in soiled clothing. Other potential witness interviewed shared that the residents are observed clean and dry. Regarding allegation "Resident was locked in their room". Staff interviewed reported that the memory care units do not lock. According to staff R1's door was stuck and would not open the day paramedics were called and arrived to the facility for R1. Staff explained that the door was closed and would not open because it was stuck and not because it was locked. Staff reported that the locking mechanism on the door knobs are not functional and you can not lock the doors. Staff stated that they used a random key that day in attempt to unstuck R1's room door. During the tour LPA observed all resident room doors. Door knobs were tested and LPA observed some resident doors to have a key whole on the door knob, however the locking mechanism was tested and observed non-functional. Door knob's observed with a key whole were disabled locks which are unable to be locked. ED reported that all the door knobs that have a key which is non-functional will be replaced with regular door knobs. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations “Resident was locked in their room” is deemed unsubstantiated at this time. Exit interview held. Copy of report provide.the state’s words, verbatim · CDSS document, Nov 12, 2025 · control 29-AS-20251006104545

Allegation investigated: Illegal Eviction

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding for the above allegation. LPA met with Executive Director (ED) Rose Anguiano and the allegation finding was discussed. On 8/18/2025, between 4pm - 6pm, LPA interviewed the ED, staff and reviewed facility records relevant to the investigation. Copies of pertinent documents relevant to the investigation was obtained. Regarding allegation of “illegal eviction”, information was reported that on 08/15/2025 the facility Social Worker reported that they will not be accepting resident #1 (R1) back due to being a high fall risk. R1 has lived at the facility for five years. According to the reporting party, R1 was evicted and not provided an eviction notice. According to the ED and the facility social worker R1 was never evicted and therefore an eviction notice was not issued. Staff reported that they never stated that R1 cannot return to the facility. ED and staff reported that R1 was hospitalized on 07/29/2025 post fall and later transferred to Stoney Point Health Care Center on 08/04/2025 for rehabilitation. (Continue to LIC9099c) Unsubstantiated According to ED and staff they communicated with the rehab facility and were waiting to reassess R1 when ready for discharge. Staff confirmed that they communicated with R1’s responsible person and informed them that R1 will be reassessed by the facility prior to discharge from Stoney Point and if R1 requires a higher level of care they will not be able to meet the needs of R1. Both the ED and staff reported that R1 was not ready for discharge from the rehab facility and that R1 was picked up by family from Stoney Point on 08/18/2026. It was confirmed with Stoney Point Health Care Center that R1 was discharged against medical advice to family on 08/18/2025; R1 was dropped off at the facility by family without any notice. ED and staff expressed that they are aware of the eviction procedures and therefore would follow through with the eviction process accordingly when necessary. Based on the interviews, and facility records review revealed that R1 was never issued an eviction notice and R1 was never told they cannot return to the facility. R1 currently resides in the memory care unit and was unable to be interviewed. Attempts made to contact R1’s family on 08/19/2025 at approximately 9am, 11:15am and 2pm were unsuccessful. Based on information gathered during this visit, the department does not have sufficient evidence to determine that facility illegally evicted resident. Therefore the allegation is Unsubstantiated at this time. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 29-AS-20250818130840

Allegation investigated: Staff is abusing resident Staff are not addressing pests at facility

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation findings. Upon arrival LPA met with Executive Director (ED) Rose Anguiano. The reason for the visit was explained. On 08/13/2025, Community Care Licensing Division received information alleging “Staff is abusing resident” and “Staff are not addressing pests at facility”. Information was provided that a resident (name unknown) is being abused by the “administrator” and that there is a bed bug infestation in a room (room number not provided) at the facility. No other information was provided by the reporting party. Several attempts made to reach the reporting party was unsuccessful. On 08/18/2025, LPA conducted the initial complaint visit and the allegations were discussed with the ED. LPA toured the facility common areas and resident rooms. LPA conducted an interview with three residents and two staff. Pertinent documents relevant to the investigation obtained. (Continue to LIC9099c) Unsubstantiated During today’s visit, an additional five residents and three staff were interviewed. Following is a summary of the investigation findings: Regarding allegation “Staff is abusing resident”: Investigation into this allegation consist of random resident interviews and staff interviews. Eight of eight residents denied any abuse from facility ED and reported that they never observed the facility ED to speak inappropriately or be abusive towards any resident. Staff interviewed denied the allegation and reported that they have not witnessed the ED to be abusive towards any resident. Several attempts made to reach the reporting party for details/supporting information was unsuccessful. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff is abusing resident” is deemed Unsubstantiated at this time. Regarding allegation “Staff are not addressing pests at facility”: Investigation into this allegation consist of interview with random residents and staff; tour of the facility common areas and resident rooms. LPA interviewed eight residents and five staff. Residents interviewed reported no bed bug activity. Residents reported that if any bug activity is observed they report to the staff and either the facility maintenance or pest control company provides treatment to the rooms. Residents expressed being satisfied at this time with the procedures in place for pest control at the facility. Records reviewed revealed that the facility is contracted for monthly general exterior/interior pest control for various bugs; bed bug treatment is provided on call bases. ED stated that at this time only one resident reported bed bug activity in room (237). According to the ED room was inspected by facility staff and no bed bug activity was found. The ED also reported that the pest control company was contacted and inspected room 237 multiple times and no bed bug activity was found. The ED provided invoices from Hydrogen Pest Control for the month of July and August confirming general pest control treatment and bed bug inspection for room 237. Records reviewed revealed the facility is contracted for monthly general exterior/interior pest control for various bugs and for bed bug treatment they are on call bases. An invoice dated 08/06/2025 from the pest control company noted no bed bug activity was found in room 237, however treatment was provided. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff is abusing resident” is deemed Unsubstantiated at this time. Exit interview held/Copy of report issued.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 29-AS-20250813130227

Allegation investigated: Staff did not prevent resident from attacking another resident in care

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Rose Anguiano. The reason for the visit was explained. On 07/30/2025, Community Care Licensing Division received the above allegation. On 07/09/2025, LPA conducted the initial complaint visit and allegation was discussed with Administrator. LPA toured the facility and met with approximately seven (7) residents. Pertinent documents relevant to the investigation was obtained. On 7/30/2025 during a subsequent complaint visit LPA attempted to interview resident #1 (R1). Interview was conducted with five (5) staff members. Following is a summary of the allegation and investigation finding: Allegation “Staff did not prevent resident from attacking another resident in care”: Information was provided that R1 was attacked by another resident on Sunday June 15, 2025 (time unknown). (Continue to LIC9099c) Unsubstantiated It was also reported that the alleged physical abuse was not reported to facility staff. Staff interviewed did not observe any incident involving R1. Staff stated that R1 did not report any physical abuse. Records reviewed revealed that R1 was admitted to the facility on 2/23/2024; medical assessment dated 2/03/2025 indicates R1’s cognitive abilities is limited; R1 lived in the facility memory unit. Staff interviewed reported that R1 is currently in rehab for post fall treatment. R1 was unable to be interviewed. Information was received that R1 requires a higher level of care and will not be returning to the facility. Random residents interviewed in the assisted living units expressed satisfaction with the staff. Residents reported that anytime there is a physical or verbal altercation staff are present and either redirect or contact law enforcement. LPA attempted to interview residents in the memory care unit however it was unsuccessful. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not prevent resident from attacking another resident in care” is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 29-AS-20250703114209

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Zabel Chochian conduct a required annual visit at this facility. Upon arrival, the LPA was greeted by staff and also the Administrator, Rose Anguiano. Reason for the visit was stated. Entrance interview conducted with Administrator. LPA confirmed that the facility is operating according to the original facility plan of operation submitted and no changes have been made since licensure. Administrator acknowledged understanding that no changes can be made to the facility plan of operation unless it is approved by LPA/the department. - following updated records request were requested and obtained: facility residents and staff roster; fire and smoke alarm tests; dieticians report; facility's current liability insurance; Emergency and disaster plan. LPA, staff and the Administrator toured the physical plant areas inside and outside to ensure facility is in compliance with Title 22 Regulations from approximately 10:45am-12:45pm. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors are tested and maintain operational. The fire extinguishers observed fully charged and were last serviced 01/23/2025. The LPA observed required postings throughout the common space. The LPA observed five (5) stairwells; each have an emergency evacuation chair on the 2nd floor. RESIDENT BEDROOMS & RESTROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. At approximately 11:22am, Room 110 floor observed discolored; room 107 restroom cabinet in disrepair (not closing properly); room 212, window shades not closing and non skid strips peeling off in bath tub; room 215 missing screen and torn shower curtain; room 259, window shades missing; (inactive) wiring observed in the bathroom near the wall and towel rack; room 263, shower head not secured to wall; room 272, no hot water; no window shades; night stand drawer observed broken; Memory care common shower room shower head needs to be secured to the wall. (Continue to LIC809c). Resident restrooms observed stocked with sufficient supply of toiletries; towels and hygiene items for each resident (towels and wash clothes are not shared). Restrooms observed with grab bars and non-skid surfaces. KITCHEN: The kitchen/food service area and emergency food/water supply was checked at approximately 1pm-1:45pm; Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable items for at least 2 days and non-perishable food items for at least 7 days. Facility also has an emergency food and water supply which is rotated out accordingly. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE), and is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. According to Administrator and staff the facility infection control policy and procedures are followed accordingly. MEDICATIONS: Medications reviewed from approximately 2pm-3pm. The medications are centrally stored in the medication room on the first floor. Medications are labeled and stored inaccessible. Random sample of (four) 4 residents medications reviewed revealed that staff are not properly documenting the expiration and fill dates on the centrally stored medication and destruction log/record. Also the preprinted centrally stored medication records that the facility receives from the pharmacy observed with inaccurate expiration dates recorded on the centrally stored log/record. Due to time constraints the annual inspection will continue to a later date. LPA will return at a later date to review resident records, staff files and training records. The following deficiencies observed during today's visit are cited (see 809D) from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Aug 12, 2025

Allegation investigated: Reporting requirements not met.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Rose Anguiano. The reason for the visit was explained. On 02/14/2025, Community Care Licensing Division received the above allegation. On 02/18/2025, LPA conducted the initial complaint visit and allegation above was discussed with Administrator. Between 10:30am - 11:45am, LPA reviewed and obtained copies of pertinent documents relevant to the investigation. Allegation - “Reporting requirements not met”: Information was received that facility did not report R1’s fall. During the course of investigation it was revealed that incident which involved R1 on 10/20/2024 was not reported. Three (3) staff confirmed an incident report should have been completed for the unwitnessed fall R1 sustained outside the facility on 10/20/2024. LPA confirmed the incident was not reported/received. Administrator was unable provided proof that this incident was reported. Based on the above information gathered, there is sufficient evidence to support the allegation that a violation occurred; therefore, the allegation “Reporting requirements not met” is deemed substantiated at this time. Exit interview conducted. A copy of the report was provided. Substantiated Regarding allegations “Staff did not provide adequate supervision resulting in resident falling and sustaining a fracture and Staff did not seek medical attention to resident”: It was reported that Resident #1 (R1) is a fall risk and facility does not provide adequate supervision. On 10/21/2024, R1 was transported to dialysis appointment, and it was observed that R1 was not able to transfer from wheelchair to the chair for dialysis chair for treatment. It was revealed that R1 had a fall at the facility on 10/20/2024 and facility did not seek medical attention for R1. The clinic called an ambulance and R1 was taken to Hospital. It was determined that R1 sustained a fracture. During the course of the investigation, records were reviewed, and interviews were conducted with residents and staff. The review of the facility records revealed R1 was independent and able to leave facility unassisted. The interview with staff revealed 911 was called on 10/20/2024 for R1 due to unwitnessed fall outside the facility. Staff further stated R1 refused medical attention when the paramedics arrived and was subsequently monitored by staff for signs of a change in condition. The review of the LA City Fire Department records confirmed that on 10/20/2024 at approximately 12:17pm, facility staff called 911 for R1 post fall incident outside the facility and R1 refused medical attention. Staff reported that R1 was monitored and complained of pain during the night but refused medical attention. On the morning of 10/21/2024, R1 went to scheduled dialysis appointment. At the appointment R1 was unable to transfer self onto treatment chair at the clinic and disclosed fall incident. Staff from the dialysis clinic called 911. R1 was transferred to the hospital due to complaint of right hip/leg pain from the mechanical fall R1 sustained the day prior. R1 was diagnosed with a closed fracture of the right pubic ramus. The interview of facility staff and records reviewed revealed that, on 10/20/2024, 911 was called immediately after becoming aware R1 sustained an unwitnessed fall. In addition, R1 was monitored by facility staff after refusing medical attention from paramedics, and staff did not observe a change in condition the following morning as R1 was still able to transfer (unassisted) onto wheelchair. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not provide adequate supervision resulting in resident falling and sustaining a fracture and Staff did not seek medical attention to resident” is deemed UNSUBSTANTIATED at this time. Regarding Allegation “Staff does not ensure resident's medical needs are being met”: It was reported that R1 requires maximum assistance in transferring and assistant device to transfer resident from wheelchair to clinic chair for treatment session for dialysis. Interview conducted with staff and records reviewed revealed that R1 had a mechanical fall and therefore had difficulty in transferring. R1 was hospitalized and returned from the hospital on 01/01/2025 with no changes. R1’s service plan was updated on 01/06/2025. R1’s diagnosis included congestive heart failure, gastroesophageal reflux disease; coronary artery disease, renal failure and hypothyroidism. R1 is non-ambulatory wheelchair dependent who was able to perform all ADLs independently except for showers. R1 wore a prosthesis on right leg and had bladder impairment. R1 was noted as being able to respond to verbal commands, follow instructions, manage own incontinent care needs, able to make decisions and leave facility unassisted. According to staff R1’s medical needs are met. R1 expressed being satisfied with the facility. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff does not ensure resident's medical needs are being met” is deemed UNSUBSTANTIATED at this time. Regarding allegation “Staff does not ensure resident is being transferred to medical appointments in a timely manner”: It was reported that R1’s dialysis schedule is Monday, Wednesday and Friday from 7:30am-10:45am. It is alleged that R1 has been late multiple times to the appointments and therefore R1 receives partial treatment. Staff interviews and records reviewed revealed that R1 was late to a couple appointments due to the transportation company running late. Facility staff made changes and arrangement was made with a different transportation company. R1 confirmed the change and expressed that they are satisfied with accommodations made by facility staff in regard to the scheduling and meeting transportation needs. Random residents interviewed did not report any issues or concerns with transportation arrangements made by facility. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff does not ensure resident is being transferred to medical appointments in a timely manner” is deemed UNSUBSTANTIATED at this time. Regarding allegation “Staff left resident soiled”: It was reported that R1 was left in soiled clothing and sent out to scheduled medical appointment. Staff interviews and records reviewed revealed that R1 is able to meet own toileting needs and if need staff assist. If R1 requires any assistance with ADLs R1 would alert staff for assistance. Staff reported the for the most part R1 is still able to toilet self. R1 confirmed being independent and able to handle own ADLs. According to staff R1 leaves the facility for scheduled medical appointments in dry clean clothing. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff left resident soiled” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report issued.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 29-AS-20250214131031

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 17, 2025

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of.. the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.the state’s words, verbatim · CDSS document, Jun 13, 2025

Plan of correction: Administrator stated that staff are reminded of the reporting requirements and moving forward all incidents will be reported timely. Administrator agreed to provide a self-certification letter to CCL by POC due date.

Allegation investigated: Licensee is retaining a resident with a higher level of care need. Staff do not ensure that resident is administered their correct medication(s). Facility has bed bugs. Staff neglect resulting in resident developing recurring UTI's. Staff do not ensure that resident attends their medical appointments as necessary.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Rose Anguiano. The reason for the visit was explained. On 02/26/2025, Community Care Licensing Division received the above allegations. On 02/28/2025, LPA conducted the initial complaint visit. Allegations above were discussed with Administrator. At approximately 11:25, LPA toured the physical with staff. During the tour LPA interviewed residents who were available and in their respectful rooms. Between 11:30am - 12pm, interviews were conducted with three (3) residents. On 5/21/2025, a subsequent visit was conducted and resident records were requested and reviewed at approximately 10:45am. Between 11am-11:45am, LPA interviewed four (4) residents. From approximately 12pm-1:15pm, LPA reviewed resident medications and conducted interview with medtechs. Attempts made to reach reporting party (02/28/2025; 3/13/2025; 4/22/2025) was unsuccessful. Following is a summary of the allegations and investigation finding: (Continue to LIC9099c). Unsubstantiated Regarding allegations - Licensee retained a resident with a higher level of care need, Staff do not ensure that resident is administered their correct medication(s), and Staff neglect resulting in resident developing recurring UTI's. It was reported that the facility has not been able to care for Resident #1 (R1) affectively – R1 is in a depressive episode, does not eat for days at a time. It was also reported that facility has given R1 the wrong medications (unknown what medication; date/time). In addition it was reported that R1 gets regular UTI’s leading to emergency room visits, which may have been avoided with proper care by staff. Interview with staff, R1 and records reviewed revealed that R1 is independent with all ADLs, facility manages R1’s medication and provides daily checks. Physician report dated 8/15/2024 indicates R1 is ambulatory, able to perform ADLs, able to leave facility unassisted, communicate needs, able to follow instruction, R1 is not confused/disoriented. Additional records reviewed confirmed R1 was hospitalized on 1/13/2025 and 2/2/2025, 3/17/2025 and 5/13/2025. R1 returned to the facility the same day following each hospitalization with no new orders; facility completed a needs and services plan following each hospitalization. Staff interviewed reported that R1 is coherent, able to make decisions, and manage own ADLs. Staff reported that if needed R1 is able to alert staff for any assistance with ADLs. R1 confirmed that if needed staff are there to assist with ADLs. Staff reported that currently R1 is appropriate for the facility and does not require higher level of care; R1 is monitored every 2 hours since discharge from hospital. No issues reported by R1. Regarding R1’s medication R1 did not report any issues with receiving medication; did not recall any errors. Staff reported that R1 receives medications daily with no noted errors/issues. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegations or that a violation occurred; therefore, the allegations “Licensee retained a resident with a higher level of care need, Staff do not ensure that resident is administered their correct medication(s), and Staff neglect resulting in resident developing recurring UTI's” is deemed unsubstantiated this time. Regarding allegations – “Staff do not ensure that resident attends their medical appointments as necessary”: It was reported that facility has not been able to keep up with R1’s medical needs and medical appointments in the past, despite agreement with these tasks. Information was provided that R1 was seen at Kaiser geriatric clinic on 2/18/2025 and was driven there by facility driver. R1 wandered off for about 15 minutes before being found. Interview with staff and records reviewed revealed that R1 is able to manage own medical appointments with the assistants of family and if needed facility staff. According to staff R1 is independent and manages own ADLs; family also is assisting with arranging medical appointment for R1. Facility staff reported that when needed facility staff also assists R1 with these tasks. R1 did not report any issues regarding staff assistance. Attempts made to reach R1's family on 3/13/2025; 4/22/2025, and 05/21/2025 was unsuccessful. Regarding allegation “Facility has bed bugs”: Information was provided that R1’s room was invested with bedbugs a few years ago, and it’s believed that bed bugs have likely returned. On 02/05/2025, LPA Chochian conducted another complaint visit regarding issues with bed bugs. From 10am-11am, LPA and Administrator toured the facility and LPA interviewed ten (10) residents. Residents reported no bed bug activity. R1 denied any bed bug activity in room. Administrator provide records and invoices from Hydrogen Pest Control for the last three months confirming general pest and bed bug prevention treatment conducted. On 2/28/2025 and 05/21/2025, LPA conducted a total of eight random resident interviews, and all reported that at this time there is no issue; residents reported if they observe any bed bugs they reported to staff and management. Currently no issues of bed bugs was reported by residents interviewed. Based on the above information gathered, there is insufficient evidence to support the allegation; therefore, allegation "Facility has bed bugs" is deemed unsubstantiated at this time. Exit interview held copy of report provided.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 29-AS-20250226163350

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with Rose Anguiano and explained the reason for the visit. On 02/06/2025, the Department received a Report of Suspected Dependent Adult/Elder Abuse and an incident report from the facility. The report advised that on 01/13/2025, Resident #1 (R1) reported to the administrator that on 01/10/2025 Staff #1 (S1) inappropriately touched R1’s private area during incontinent care. The Department referred the case to the Community Care Licensing (CCL) Investigations Branch (IB). The case was assigned to Investigator Dennis Seng to conduct the investigation in reference to the allegation. On 02/07/2025, from 10:45am to 1:15pm, Licensing Program Analyst Zabel Chochian conducted an unannounced Case Management - Incident visit at the facility. Upon arrival LPA Chochian met with Administrator Rose Anguiano. The purpose of the visit was to review records and obtain copies of facility records pertaining to a self-reported incident of alleged sexual abuse received by Community Care Licensing (CCL). It was alleged that on 01/10/2025, facility Staff #1 (S1) sexually abused Resident #1 (R1) by inappropriately touching R1’s private area during incontinent care. During the visit LPA conducted an interview with Administrator, reviewed R1 and S1 records and obtained copies of pertinent documents. Administrator was informed that a referral was made to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Dennis Seng for further investigation. (Continue to LIC809c) On 02/18/2025, from approximately 2:02pm to 3:55pm, Investigator Seng conducted interviews with Administrator, R1, R1’s resident representative, resident, and staff; on 02/19/2025, at approximately 4:06pm, with R1’s roommate; on 04/15/2025, at approximately 1:16pm, with Los Angeles Police Department (LAPD) Topanga Station Detective Brigitta Shapiro; on 04/22/2025, at approximately 3:34pm, with S1; on 04/24/2025, at approximately 4:13pm, with staff; on 05/05/2025, from approximately 12:06pm to 12:43pm, with staff and residents; and on 05/07/2025, at approximately 12:42pm, with Administrator. In addition, Investigator Seng reviewed LAPD Injury Report #25015768 and facility file documents related to the investigation. A review of facility file documents reveals R1 was admitted to the facility on 07/06/2023. R1’s Physician Report, dated 07/01/2023, lists diagnosis of metabolic encephalopathy and nontraumatic subarachnoid hemorrhage. R1 needs assistance with bathing, dressing and toileting; not able to independently transfer to and from bed, non-ambulatory. A review of psychiatric progress notes indicated R1 was seen for routine monthly visits and prescribed medication for major depressive disorder and generalized anxiety disorder. R1’s Appraisal Needs and Service Plan, updated 06/21/2024, documents that “R1 frequently voices wanting to return to Skilled Care. R1 requested a Hoyer lift to transfer and bed rails. Easily becomes upset and anxious, can express rude, mean words to staff. Verbally abusive towards staff, threatening to call Ombudsman and Licensing. Accuses staff of neglect or poor care delivery. Staff reports, R1 can be very disrespectful and will make racist comments”. Based on file reviews and interviews conducted, there was insufficient evidence to prove that the facility was responsible for Sexual Abuse leading to S1 to have an inappropriate sexual contact with R1 while R1 was at the facility. R1’s roommate, facility staff, and S1 denied any sexual abuse occurring with R1 at any time. R1’s roommate stated that S1 was a good caregiver who never acted inappropriately with any residents. S1 stated that they only went into R1’s room to clean R1 as R1 had fecal matter on R1’s vagina. S1 asked R1 for permission to clean R1’s vagina, and R1 consented. S1 added that the contact with R1 was only for to clean R1 and non-sexual in nature. Based on the evidence and interviews conducted, the allegation of “Sexual Abuse: Resident #1 (R1) was sexually abused by Staff #1 (S1)” is deemed Unsubstantiated at this time. Exit interview, copy of report given.the state’s words, verbatim · CDSS document, Jun 13, 2025

Allegation investigated: Lack of supervision resulting in resident being physically and verbally abused by another resident.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Tina Hernandez. The reason for the visit was explained. On 04/22/2025, Community Care Licensing Division received the above allegation. On 04/30/2025, LPA conducted the initial complaint visit and allegation was discussed with Administrator. LPA toured the facility and met with approximately four (4) residents. Pertinent documents relevant to the investigation was obtained. On 4/22/2025 during a subsequent complaint visit for another complaint LPA interviewed Resident #1 (R1). R1 did express wanting to move out; denied to state reason for move-out. R1 did express feeling safe at the facility and able to take care of self. R1 did not report any physical abuse with any other resident. LPA attempted to ask detailed questions regarding allegation however R1 expressed increasing agitation and refused to answer any further questions. (Continue to LIC9099c). Unsubstantiated On 5/21/2025, LPA conducted additional interviews with four (4) resident and three (3) staff from approximately 1:30pm 2:30pm. Following is a summary of the allegation and investigation finding: Allegation “Lack of supervision resulting in resident being physically and verbally abused by another resident.”: Information was provided that R2 has been verbally and physically abusive towards R1. It is reported that this has been ongoing for the past few months. Attempt was made to gather additional information about the reported verbal and physical abuse from the reporting party (RP). It was indicated that R2 had “laid hands on R1”. There were no reports of any related injuries, and it was not disclosed what R2 had said to R1. R1 denied being physically abused. R2 denied ever being physically or verbally abusive with R1 or any other resident. R2 expressed that R1 is very aggressive and is verbally abusive towards the residents and staff. R2 recalled an incident happening outside the facility last month with R1 and denied that there was any physical or verbal abuse. Staff interviewed denied the allegation. Staff stated that R1 did report having a verbal altercation with R2 on 04/22/2025 and 04/20/2025 outside the facility. According to staff no physical abuse was reported between R1 and R2. According to staff, R1 has some cognitive impairments and is easily agitated. Staff reported that R1 is usually aggressive and verbal abusive towards staff and other residents. Random residents interviewed did not observe any physical or verbal abuse between R1 and R2. Residents interviewed reported that anytime there is a physical or verbal altercation staff are present and either redirect or contact law enforcement. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Lack of supervision resulting in resident being physically and verbally abused by another resident” is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 21, 2025 · control 29-AS-20250422113340

Allegation investigated: Staff allowed resident to leave the facility without proper supervision Staff did not ensure resident's hygiene care needs are properly met

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Administrator Rose Anguiano. The reason for the visit was explained. On 02/04/2025, Community Care Licensing Division received the above allegations. On 02/05/2025, LPA conducted the initial complaint visit and toured the facility which included random resident rooms, and common areas. Between 10am-11am, during the tour, LPA conducted interview with ten (10) residents and three (3) staff. LPA also requested copies of resident #1’s (R1) records. Following is a summary of the allegations and investigation finding: Regarding allegation - Staff allowed resident to leave the facility without proper supervision: It was reported that staff do not properly supervise R1; R1 continues to leave facility without signing in and out at various times during the night and early mornings. (Continue to LIC9099c.) Unsubstantiated It was also reported that R1 is allowed out unsupervised and that R1 panhandles outside the facility. Interviews conducted with staff and R1 revealed that although R1 is non-ambulatory, R1 ambulates with a wheelchair and is able to leave facility unassisted. R1 confirmed that facility does have a book at the front desk for guests and residents to sign in/out. R1 confirmed that leaving the facility without signing out and does not sign in when returned. R1 stated that staff do their rounds and know that R1 is back in the facility therefore R1 does not use the sign in/out book. R1 denied falling while out of the facility. Records reviewed on 4/21/2025, revealed that R1 is able to leave facility unassisted and does not require staff supervision. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff allowed resident to leave the facility without proper supervision” is deemed unsubstantiated at this time. Regarding Allegations - Staff did not ensure resident's hygiene care needs are properly met: It was reported that staff allow R1 to miss scheduled showers and therefore R1 lacks good hygiene. Also, staff do not ensure R1 does not use incontinent briefs routinely. R1 was interviewed and did not recall how often staff provide shower assistance. Facility’s Resident bathing schedule reviewed showed that R1 is scheduled for 2 showers a week. According to staff R1 leaves the facility often and refuses staff assistance with showers. R1 confirmed refusing staff assistance with showering. R1 expressed that when requested staff help; however R1 expressed not needing any help from anyone. Staff interviews revealed that R1 refuses assistance and staff only assist when R1 is willing to accept assistance from staff. Random residents were interviewed. All residents interviewed reported no issues with showers and other hygiene care service. Residents expressed that staff provide care services as needed. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not ensure resident's hygiene care needs are properly met“ is deemed unsubstantiated at this time. Exit interview held, appeal rights discussed and copy of report provided.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 29-AS-20250204095956

Allegation investigated: Staff are not ensuring that resident's special diet is adhered to while in care. Licensee retained a resident with a higher level of care need.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Administrator Rose Anguiano. The reason for the visit was explained. On 02/12/2025, Community Care Licensing Division received the above allegations. On 02/18/2025, LPA conducted the initial complaint visit. Between 10:30am - 11:45am, LPA reviewed and obtained copies of pertinent documents relevant to the investigation. At approximately 1pm-2pm, interviews were conducted with eight (8) residents. At approximately 2:30pm LPA conducted interview with staff. Attempts made to reach the reporting party on 02/18/2025, 02/20/205 and 04/21/2025. Following is a summary of the allegations and investigation finding: Regarding allegation - Staff are not ensuring that resident's special diet is adhered to while in care. It was reported that resident #1 (R1) is diabetic and the facility is serving regular meals; not ensuring R1 is provided a diabetic diet.(Cont.LIC9099c) Unsubstantiated Interview conducted with R1, staff and records reviewed confirmed that R1 is alert x3 and able to make own decisions; records reviewed noted that R1 is T2DM; physical report indicates R1 should follow special diet for T2DM. R1 confirmed being able to monitor and check own glucose level. R1 confirmed facility offers diabetic meals however R1 does not like it therefore, is not consistent with maintaining a diabetic diet. Staff interviewed confirmed R1 is able to handle own medications and make decisions for all ADLs at this time. Random residents interviewed reported being satisfied with the facility food service at this time. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff are not ensuring that resident's special diet is adhered to while in care” is deemed unsubstantiated at this time. Regarding Allegations - Licensee retained a resident with a higher level of care need.: It was reported that R1’s glucose was not checked and facility staff reported that as an assisted living facility, they do not follow medical recommendations, and they are not equipped to check glucose. Interview with staff, R1 and records reviewed revealed that R1 manages own medications and is also able to check own glucose if needed. R1 confirmed that if needed staff are there to assist with medications however at this time R1 manages own medications. Staff interviewed confirmed that at this time R1 handles own meds however will be re-evaluated at the next assessment date to confirm continued med-management by R1 is appropriate. R1 expressed that as result of having too many medications R1 is considering being on facility med-management program. Random resident interviewed expressed that staff provide care services and manage medication accordingly. No issues reported by residents. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Licensee retained a resident with a higher level of care need“ is deemed unsubstantiated at this time. Exit interview held, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 29-AS-20250212142037

Allegation investigated: Staff do not ensure entrance door is in good repair Staff do not ensure residents are spoken to in an appropriate manner Facility does not ensure sufficient night staff is on duty for residents in care

At 11:55 A.M. Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit with the purpose of delivering findings for the above listed allegations. Upon arrival, LPA met with front desk staff, Martin Zepeda, who informed Resident Services Coordinator (RSC), Tina Hernadez, of LPA’s visit. RSC contacted administrator via phone. Administrator was unavailable during today's visit, but authorized RSC to sign today's reports. Entrance interview conducted. The following was determined. During today’s visit, the LPA conducted an interview with RSC, conducted a brief physical plant tour, to ensure there are no health and safety concerns. LPAs Conway and Balisi conducted an initial complaint visit on 07/23/2024. During that visit, LPAs conducted a tour of the physical plant, obtained copy of the resident and staff roster and obtained pertinent information relevant to the investigation. Continued on LIC 9099-C Substantiated Continued from LIC 9099 LPAs also conducted resident and staff interviews between 10:00 A.M, and 3:00 P.M. Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted telephonic interviews with additional credible witnesses and other relevant parties. The following was then determined: Regarding allegation “Staff do not ensure entrance door is in good repair” it was alleged that the main front door is broken and does not open and close correctly and residents using mobility devices such as wheelchairs and scooters have trouble going in and out of the facility. LPAs conducted interviews with residents including those who rely on electric scooters and wheelchairs as well as ambulatory residents. Residents who do not use mobility devices reported that the door closes quickly, and, on occasion, slams shut. Those using mobility devices stated that entering and exiting the facility is extremely difficult due to the door’s weight explaining that to exit, residents must push the door open using their scooters or wheelchairs while re-entering requires significant effort, often leading to struggles in maneuvering through the doorway without getting caught between the door and the frame. In many instances, residents must rely on the receptionist for assistance in opening the door. Several residents suggested ADA-compliant automatic system as a solution. Additionally, LPAs observed that the main entrance door is not properly maintained by having a missing safety spring door closer, which causes the door to close without control behind individuals as they enter and/or exit. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation that “Staff do not ensure entrance door is in good repair” therefore, the allegation is deemed SUBSTANTIATED at this time. Regarding allegation “Staff do not ensure residents are spoken to in an appropriate manner” it was alleged that management and caregivers are being hostile toward residents. Administrator stated that residents have not reported instances of caregivers being rude or yelling. Interviews with staff revealed that they are unaware of occasions where residents have felt disrespected. Some caregivers reported that in certain cases, they have experienced disrespectful behavior from residents. However, during interviews conducted by LPA Conway, eight (8) out of fourteen (14) residents expressed concerns that the Administrator and caregivers are unfriendly and sometimes speak to them in an aggressive manner. Continued on LIC 9099-C Continued from LIC 9099-C Residents stated they have felt disrespected by staff or witnessed staff be rude or mean to other residents. Others felt that their concerns were ignored by the Administrator or that raising complaints would not lead to any meaningful changes. Some residents reported being afraid to bring up facility-related issues due to perceived threats of eviction or disciplinary action. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation that “Staff do not ensure residents are spoken to in an appropriate manner” therefore, the allegation is deemed SUBSTANTIATED at this time. Regarding allegation “Facility does not ensure sufficient night staff is on duty for residents in care”. It was alleged that caregiver(s) exited the facility during the NOC shift (Nocturnal-10pm-6am), potentially leaving residents unattended. Administrator stated that the NOC shift in Assisted Living and Memory Care normally consists of 2 caregivers. Additionally, Administrator indicated that no complaints have been received regarding NOC caregivers leaving the facility during their shifts. To support that statement, Administrator provided documentation where caregivers manually write their names and their signature every 30 minutes after completing a walk-through of the facility. LPA Conway reviewed and compared the facility’s sign-in sheets, timecards and caregiver’s schedule from 07/13/2024 through 07/23/2024. During this review LPA discovered that Staff #1 (S#1) on 7/17/2024, Staff #2 (S2) on 7/18/2024, and Staff #3 (S3) on 7/20/2024 were documented as working on the walk-through sheet, however, a review of timecards and schedules confirmed that S1, S2 and S3 did not work on those dates. LPA requested video footage, however, on 07/23/24 the Administrator stated that cameras are not in working conditions at the time. Interviews conducted with staff reported concerns regarding the NOC shift caregivers leaving the facility and sleeping in their cars while on duty. Additionally, residents interview revealed that the number of caregivers available during the NOC shift is not sufficient to meet residents’ need in a timely manner. Reporting that wait times range between 45 minutes to an hour, and that residents with urinary incontinence are not checked or changed during the late-night hours. Continued on LIC 9099-C Continued from LIC 9099 Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted additional telephonic interviews with credible witnesses and other relevant parties. The following was then determined: Regarding allegation “Staff do not ensure residents special dietary plan is being followed”. It was alleged by Resident #2 (R2), that staff are not following their special dietary restriction, requiring them to use their own money to purchase food. Interview with Administrator revealed that the facility accommodates multiple residents with prescribed modified diets. Clarifying that for cognitively capable resident who can make independent decisions, the facility provides a variety of menu items and suitable substitutes that align with their dietary restrictions or needs. However, for residents with dementia, the facility cook prepares meals that comply with their prescribed dietary plans. Furthermore, Administrator explained that the facility offers three (3) meals a day and snacks to all residents in care. Also, they stated that residents who are able to leave the facility unsupervised have the right to purchase outside food at their own discretion. However, the facility is not responsible for monitoring whether those food choices align with their prescribed diet. Interviews with staff revealed that the kitchen maintains a list of residents with dietary restrictions, which is accessible to caregivers to ensure awareness. Staff also noted that residents have the right to choose meals that may not follow their prescribed diet. In such cases, caregivers may suggest alternative meal options, but ultimately, residents retain the right to make their own food choices, including additional servings. Resident interviews further confirmed that the facility offers a menu with a variety of meal options, and if a meal does not fit a resident’s dietary needs, a substitute dish or salad is offered as an alternative. During the course of the investigation, the LPA obtained copies of the facility’s menu and alternative menu, as well as R2’s physician’s report (LIC 602) and care plan. These documents confirm that R2, a cognitive capable Assisted Living (AL) resident, has a special diet but is able to self-manage their dietary needs and feed themselves. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred. Therefore, the allegation “Staff do not ensure residents special dietary plan is being followed” is deemed UNSUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C Regarding allegation “Facility does not ensure staff have ability to communicate with residents”. It was alleged that several staff don’t speak or understand English. Information gathered during the course of the investigation reflected that some caregivers, servers and housekeeping staff have limited English proficiency. LPA interviewed 17 residents, 13 residents did not speak Spanish, 2 were bilingual and 2 spoke only Spanish. According to fourteen (14) out of seventeen (17) residents interviewed stated that they had no concerns communicating with staff. Those residents who do not speak Spanish acknowledged that communication with some staff can be challenging at times due to language barriers. However, they adapt by using hand gestures, point at objects, or using phone translation apps to facilitate understanding. LPA conducted interviews with seven (7) staff members. Two (2) out of seven (7) staff members stated that their English is limited and preferred to be interviewed in Spanish. Spanish-speaking staff confirmed that if they have any questions or need clarification, they seek assistance from other caregivers to ensure residents’ needs are met. Despite some staff having basic English skills, any concerns or issues can be promptly addressed by other caregivers, Med-Tech or the Administrator as needed. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Facility does not ensure staff have ability to communicate with residents” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued. Continued on LIC 9099-C Further concerns were raised by Resident #1 (R1), an independent resident able to leave facility unsupervised. R1 explained that for security reasons, the main door is locked after hours and can only be opened by caregivers. R1 reported an incident where upon returning from an outing around midnight, they had to wait approximately 35 minutes outside before a caregiver unlocked the door to allow them entry. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation that “Facility does not ensure sufficient night staff is on duty for residents in care”. Therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 29-AS-20240715081958

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 2, 2025

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... require additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the section cited above by not having a sufficient number of caregivers on duty during the NOC shift. This poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Administrator agrees to submit a written plan to ensure that NOC staff are supervised and accountable during working hours. This can be a new hired checking that the job is getting done and that staff are not leaving the facility during their shift leaving residents unattended and submit to LPA by 04/02/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 10, 2025

87468.1(a)(1) Personal Rights of Residents in All Facilities (a)Residents in all residential care...facilities... personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews and observations, the license did not comply with the section above when residents were not treated with dignity and respect, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Administrator agrees to hold personal rights from a third-party vendor for all staff including the Administrator and submit proof of completion to LPA by 04/10/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 10, 2025

87303 (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... This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above as the main door was missing the safety spring door closer which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Licensee will submit proof of completed repairs to the main door to LPA and submit proof of completion by 04/10/2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Case Management - Incident visit at the facility today. Upon arrival LPA met with Administrator Rose Anguiano. The purpose of today's visit was to review records and obtain pertinent copies of facility records pertaining to a self reported incident of alleged sexual abuse received by Community Care Licensing (CCL). It is alleged that on 01/10/2025, facility staff (S1) sexually abused client #1 (C1). During today's visit LPA conducted interview with Administrator, reviewed C1's and S1's records and obtained copies of pertinent documents. Administrator was informed that a referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB) on 02/06/2025; the case was excepted and assigned to Investigator Dennis Seng. Further investigation is needed regarding the alleged sexual abuse. Exit interview held. Copy of report provided.the state’s words, verbatim · CDSS document, Feb 7, 2025

Allegation investigated: Staff inappropriately spoke to resident

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding.Upon arrival LPA met with Administrator Rose A. and reason for visit was explained. On 12/06/2024, Community Care Licensing Division received the above allegation. It was alleged that a male staff (name unknown) inappropriately spoke to resident #1. Furthermore, it was stated that this same staff entered resident #1’s room without knocking and questioned resident about another resident's (name unknown) personal item. On 12/16/2024, LPA imitated complaint visit to investigated the allegation; between 11:45am-1:30pm, LPA conducted interview with ten (10) residents and three staff. Staff interviewed denied the allegation and stated that some residents do speak inappropriately with staff however staff do not retaliate and treat all residents with respect. Resident interviewed expressed that they like the facility and are treated well by staff. Resident #1 did not want to be interviewed however LPA did ask Resident #1 if they are being mistreated in anyway by staff and resident #1 stated "no". Based on the above information gathered, there is insufficient evidence to support the allegation; therefore, allegation is deemed unsubstantiated at this time. Exit interview held copy of report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 5, 2025 · control 29-AS-20241206094839

Allegation investigated: Staff are not ensuring the facility is free from pests

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Administrator Rose Anguiano. On 12/16/2024, Community Care Licensing Division received the above allegation. It was reported that resident #1 had bed bugs at one time (unknown date) and bed bug issue continues; no response or improvement was made by staff. On 12/20/2024, Licensing Program Analyst (LPA) Brian Balisi conducted a complaint visit to investigate the allegation listed above. At approx. 10:50 a.m., LPA Balisi conducted physical plant, interviewed staff, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 02/05/2025, LPA Chochian conducted a subsequent visit. From 10am-11am, LPA and Administrator toured the facility and LPA interviewed ten (10) residents. Residents reported no bed bug activity. Resident #1 denied any bed bug activity in room. Administrator provide records and invoices from Hydrogen Pest Control for the last three months confirming general pest and bed bug prevention treatment conducted. Based on the above information gathered, there is insufficient evidence to support the allegation; therefore, allegation is deemed unsubstantiated at this time. Exit interview held copy of report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 5, 2025 · control 29-AS-20241216151032

Allegation investigated: Staff mismanages resident's medications. Resident does not receive medication as prescribed.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Tina Hernandez. The reason for the visit was explained. On 08/21/2024, Community Care Licensing Division received the above allegations. On 08/29/2024, LPA conducted the initial complaint visit and allegations were discussed with Administrator. Copy of medication records were requested and reviewed. A subsequent complaint visit was conducted on 12/16/2024, LPA conducted interview with the med-tech staff and reviewed the centrally stored medications and records at approximately 1:30pm. Following is a summary of the allegations and investigation finding: Allegations “Staff mismanages resident’s medications” and “Resident does not receive medications as prescribed”: (Continue to LIC9099c) Unsubstantiated It was reported that resident #1 (R1) had severe fecal impaction and when requested the PRN medication “Bisacodyl” on 08/4/2024 an 08/05/2024, facility staff could not locate the medication. According to reporting party, the “Bisacodyl” was finally located on 08/07/2024. A review of R1’s centrally stored medication records and medication on hand was conducted and found no discrepancies with this PRN medication. There was a supply of this PRN medication from the last refill dated of 4/18/2024 and a new order filled 08/15/2024. During the medications review it was confirmed that staff did have a supply of the “Bisacodyl” on hand in the month of August 2024. R1 reported that it was late in the day when medication was requested on 08/04/2024 and 08/05/2024. R1 could not recall the name of the staff. R1 stated that it was not “Raul the med-tech it was another staff in the med-room”. Staff interviewed denied the allegations. According to staff R1 did not request this specific medication on dates indicated above from the med-techs. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff mismanages resident's medications and Resident does not receive medication as prescribed” is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2025 · control 29-AS-20240821151342

Allegation investigated: Resident sustained falls resulting in injury due to lack of staff supervision while in care

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegation listed above. During today’s visit, LPA met with Executive Director Rose Anguiano and explained the reason for the visit. On 11/20/2023, the initial complaint visit was conducted by LPA between approximately 10:30 a.m. - 12:30 p.m. During the visit, LPA conducted a tour of the physical plant, interviewed staff, residents, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 01/11/2024, between 10:30 a.m. – 03:30 p.m., LPA conducted interviews with twelve (12) residents while on site for a complaint visit on a separate investigation. On 12/18/2024, LPA reviewed medical records from Skirball Hospice. Continued on 9099-C Substantiated Continued from 9099 It was reported that "Resident sustained falls resulting in injury due to lack of staff supervision while in care" as it was alleged that Resident #1 (R1) sustained multiple falls due to lack of staff supervision. A review of facility records shows that Resident #1 (R1) was admitted to the facility on 01/02/2020 and began receiving hospice services from Skirball Hospice on 08/25/2023. A Level of Care assessment dated 08/26/2023, and an Appraisal/Needs and Services Plan dated 08/24/2023, indicate that R1 is ambulatory and does not use assistive walking devices. However, R1 is at risk of falling due to poor balance and has no safety awareness or ability to follow safety instructions. R1 requires supervision and standby assistance. A review of Skirball Hospice records, covering six visits between 10/09/2023, and 11/10/2023 confirms that R1 is a high fall risk due to poor safety judgment and an unsteady gait, and can only walk with assistance or supervision. Interviews and record review indicated that on 11/14/2023, at approximately 9:30 a.m., R1 was in the dining room, attempted to get up from a chair, lost their balance, and fell. Staff #1 (S1) approached R1 to ensure their comfort and contacted Staff# 2 (S2), who assessed R1 on the floor and called 911. Emergency Medical Services (EMS) arrived approximately 10 minutes later and transported R1 to a local hospital. R1 returned to the facility at 09:30 p.m. On 11/15/2023, R1 was visited by Skirball Hospice RN and the following was observed: “(2) stitches on left brow, Bruise present over left eye / brow. No dressing needed at this time. No other injuries reported. No nonverbal s/s of pain, discomfort, or respiratory distress noted. All needs are met”. On 11/16/2023, at approximately 6:30 p.m., R1 was again in the dining room, stood up from a chair, took a few steps, and tripped on a chair. Caregivers attempted to prevent the fall but were unsuccessful. As a result, R1 sustained an open wound on their head. Staff #3 (S3) was contacted and assessed R1 in the dining room, provided first aid, called 911, and R1 was transported to a local hospital. On 11/17/2023, R1 returned to the community. Skirball Hospice RN conducted a visit and notated that there were no signs of pain or any distress. Facility records reviewed did not reflect that the facility completed or conducted a reappraisal or updated the residents needs and services after the falls to ensure the R1s needs were met. Continued on 9099-C Continued form 9099-C Based on information gathered during the investigation the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation "Resident sustained falls resulting in injury due to lack of staff supervision while in care" has been Substantiated at this time. A $500 immediate civil penalty is assessed today. The Executive Director was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. Continued from 9099-A It was reported that "Staff did not provide assistance to resident as needed while in care" as it was alleged that on 11/16/2023, when Emergency Medical Services (EMS) arrived on site to attend to R1, that R1 was found on the floor and staff did not make any attempts to assist R1 or clean up blood. Interviews and record reviews revealed that Staff #3 (S3) provided immediate first aid to Resident 1 (R1) by applying gauze to the head injury and ensuring R1 was in a stable and comfortable position until Emergency Medical Services (EMS) arrived. S3 confirmed that there was blood on the floor, but the dining room was cleared, and no one was at risk of slipping. After R1 was transported by EMS, the blood was promptly cleaned up. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff did not provide assistance to resident as need while in care” is deemed Unsubstantiated at this time. It was reported that "Facility is odiferous" as it was alleged that the facility had a strong smell of marijuana. LPAs interview with twelve (12) residents revealed that nine (9) residents have not detected the smell of marijuana inside the facility. The remaining three (3) residents reported having smelled marijuana in the halls at some point, but they are unsure if anyone is smoking inside the facility or if the smell came from marijuana smoked outside the facility. These three (3) residents could not recall the specific time or date when they noticed the smell. In addition, interviews with six (6) staff members, all confirmed that smoking is not permitted in resident rooms, and none have ever smelled marijuana in the common areas due to a resident smoking. However, all (6) staff members acknowledged that some residents smoke marijuana and may return to the facility with the smell of marijuana on their clothing. Staff reminded residents to be mindful of the scent to avoid disturbing others. During a walk-through of the facility, the LPA did not observe any marijuana use or detect the smell of marijuana. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Facility is odiferous” is deemed Unsubstantiated at this time. It was reported that "Staff did not ensure resident's toileting needs were met while in care" as it was alleged that when R1 was being observed by emergency personnel during the fall that occurred on 11/16/2023, they observed R1 had soiled themselves and there was a strong odor of urine and feces. Continued from 9099-C Interviews conducted revealed that before the fall around 6:30 p.m., R1 did not appear visibly soiled or have a strong odor of urine or feces. Residents are typically checked for incontinence every three (3) hours and before meals. If R1 had been visibly soiled before being brought to the dining room, staff would have provided incontinence care. Additionally, during interviews with S3 and S4, they stated they do not remember if R1 was visibly soiled or had an odor of urine or feces after the fall. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff did not ensure resident's toileting needs were met while in care” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Dec 20, 2024 · control 29-AS-20231117153705

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 23, 2024

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents...(4) To care, supervision...sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cite above as facility staff did not properly supervise R1 as per their care plan, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: Licensee will submit a plan on how they will ensure staff will monitor and supervise residents in a timely manner. Licensee will provide plan to LPA via email by COB 12/23/2024

Allegation investigated: Neglect/Lack of Care and Supervision – Facility failed to seek timely medical attention when Resident #1 (R1) developed an illness (clostridium difficile colitis) while in care of the facility. Staff did not communicate with resident's responsible party. Facility failed to follow proper infection control guidelines.

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Executive Director Rose Anguiano and explained the reason for the visit. On 03/06/2024, the Department received a complaint report regarding a neglect/lack of supervision allegation. The complaint alleged that facility failed to seek medical attention in a timely manner when Resident #1 (R1) developed an illness while in care. In addition, the complaint alleged staff did not communicate with resident's responsible party (resident representative). The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Sonia Sandoval. The Department also conducted a Program Clinical Consultant (PCC) review of the information obtained during the investigation. On 03/07/2024, from 10:30 a.m. to 2:45 p.m., LPA B. Balisi conducted an unannounced initial 10-day complaint visit. Upon arrival LPA Balisi met with Rose Anguiano, administrator, and explained the reason for the visit. Substantiated Continued from 9099 At approximately 10:30 a.m., the LPA toured the physical plant, interviewed staff, and reviewed and obtained pertinent documents relevant to the investigation. On 03/25/2024, at approximately 4:18 p.m., Investigator Sandoval conducted interviews with R1’s resident representative; on 04/16/2024, from approximately 12:00 p.m. to 2:45 p.m., with staff, administrator, and residents; on 06/17/2024, at approximately 2:54 p.m., with R1’s resident representative; and on 06/18/2024, from approximately 8:13 a.m. to 10:09 a.m., with Valley’s Best Hospice Registered Nurse, and R1’s telemedicine doctor. In addition, Investigator Sandoval reviewed Providence Tarzana Medical Center medical records, Southern California Hospital at Hollywood medical records, Los Angeles City Fire Department (LACFD) Emergency Medical Services (EMS) records, Valley’s Best Hospice medical records, County of Los Angeles Registrar-Recorder / County Clerk death certificate, and other facility file documents related to R1. A review of R1’s facility file documents revealed that R1 was admitted to the facility on 06/09/2022. The Admissions Agreement’s basic services at minimum indicated continuous care and supervision, observation for changes in condition and notification to the resident’s family, physician, and other appropriate person/agency. The facility would assist with planning, arranging and or providing transportation to medical and dental appointments. Additional basic services that were checked off included “Assistance making and follow up on routine appointments…obtaining emergency care as needed.” The physician’s report dated 11/26/2023, listed R1’s primary diagnosis as dementia and secondary diagnoses were listed as hypertension, testicular cancer. The report documented bowel and bladder impairment, confused/disoriented, and wandering behavior. R1 was noted to be able to follow instructions and communicate needs. R1 was noted as being able to feed self but unable to leave the facility unassisted, unable to bathe, dress or groom. According to R1’s appraisal needs and services plan, updated on 12/06/2023, R1 was noted to have difficulties with physical development and poor health habits. R1 required assistance with all activities of daily living (ADLs) and potential for weight loss which required reminders to eat and drink fluids. According to the Southern California Hospital at Hollywood medical records, on 01/21/2024, at approximately 5:41 p.m., R1 presented to the emergency department for abdominal pain. The records noted R1 had three (3) days of abdominal pain and diarrhea. The CT scan of abdominal and pelvis revealed diverticulosis with sigmoid diverticulitis. On 01/22/2024, at approximately 10:26 a.m., R1 was admitted to the hospital for IV antibiotics for a diagnosis which included acute rectosigmoid diverticulitis, significant leukocytosis, left lower quadrant abdominal pain, electrolyte imbalance with hypokalemia, dehydration, and dementia. Continued from 9099-C On 01/30/2024, the clinical update noted R1 tested positive for C. difficile colitis (C-diff). On 01/31/2024, R1 was discharged to the facility with a new medication of Vancomycin and a follow-up with primary care provided after two weeks. In addition, R1 was advised to go to the nearest emergency room if symptoms returned or worsened. A review of the facility Medication Assistance Record (MARs) revealed no indication the new prescription for Vancomycin was administered as directed by the hospital. The interview with R1’s resident representative revealed the facility did not notify them of the hospital discharge instructions. R1’s resident representative was notified by staff that R1 had terrible diarrhea and R1 was going to be transported to Hollywood Hospital but was not transported until three to four days later 01/21/2024. R1’s resident representative stated they called daily for an update and the staff would tell them they were still waiting for R1 to be transported. R1’s resident representative indicated they told staff they were going to call 911 to have R1 transported and not until then was R1 transported to the hospital. In addition, due to the delay in medical attention in January 2024, R1’s resident representative stated when the facility informed them in February 2024 that R1 was having episodes of diarrhea again (recurrent), R1’s representative decided to have R1 assessed for hospice. The interviews with the facility staff revealed two staff stated the week prior to R1’s departure from the facility R1 was no longer observed in the common areas which was unusual for R1 and were informed by other staff that R1 was ill in R1’s room. There was no evidence found that the facility communicated with the staff regarding R1’s change of condition. Further, the facility did not provide staff training regarding how to care and monitor R1 with a contagious C-diff infection. A review of the Valley’s Best Hospice records revealed R1 was on hospice for one day on 02/27/2024. The hospice assessment visit noted R1 was reportedly able to walk ten days prior and at the time of the assessment was bedbound, unable to stand on their own with episodes of diarrhea and no food intake for a few days. The interview of the hospice nurse revealed they were not expecting R1 to be in such bad condition and immediately contacted R1’s resident representative who was unaware of the change in condition. A review of the medical records for the second hospitalization at Providence Tarzana Medical Center on 02/27/2024 revealed R1 was admitted to the hospital for dehydration and the final diagnosis included sepsis, unspecified severe protein-calorie malnutrition, and enterocolitis due to clostridium difficile (recurrent). Continued from 9099-C R1 was prescribed Vancomycin for the C-diff however was unable to pass a swallow test. Therefore, the Vancomycin was held given R1’s aspiration risk. Palliative care and code status were discussed with R1’s resident representative who elected comfort care measures only and R1 passed away on 02/29/2024. The interview of R1’s telemedicine doctor revealed the facility never notified them of a change in condition in R1 and stated if R1 had been medically assessed in a timely manner, the recurrent C-diff condition may have been resolved. The review of the death certificate revealed septic shock, gastrointestinal bleeding and C-diff listed as conditions leading to the cause of death. The Department conducted a Program Clinical Consultant (PCC) review of the information obtained during the investigation. Based on the review of the medical records, the Departments’ investigative findings, and other miscellaneous documents, the PCC review determined the facility failed to provide proper care and supervision that resulted in R1’s death from Septic shock and the recurrence of C-diff. Based on the information gathered during the investigation, the facility failed to seek timely medical attention for R1 who developed a recurrent illness while in care, failed to notify R1’s resident representative or physician with R1’s change of condition, and failed to train the staff on R1’s contagious C-diff infection. Therefore, the allegations “Neglect/Lack of Care and Supervision – Facility failed to seek timely medical attention when Resident #1 (R1) developed an illness (clostridium difficile colitis) while in care of the facility” and “Staff did not communicate with resident's responsible party” and “Facility failed to follow proper infection control guidelines” are deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The Executive Director was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 29-AS-20240306081830

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Nov 22, 2024

(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 and records review, the licensee did not comply with the section cited above. Facility staff did not seek timely medical care when R1 had C-diff and recurring symptoms, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: Licensee agreed to submit a plan how you will ensure residents receive timely medical care. Submit to CCL by due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Nov 22, 2024

The licensee shall ensure that residents are regularly observed for changes…or a physical health condition are observed, the licensee shall ensure... resident's physician and the resident's responsible person…This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above. Facility staff did not notify R1’s representative or physician when R1 had a change in physical health condition, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: Licensee agreed to submit a plan how you will ensure residents responsible party and physician are notified of changes in condition. Submit to CCL by due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b)(2)(C) · Plan of correction due date: Nov 22, 2024

(b) In addition to subsection (a), when one or more residents…. Are diagnosed with a contagious disease, the following shall apply:...are trained in the proper use of all required PPE... quarantine or isolation, from others.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. The facility failed to provide the staff training regarding how to care and monitor the resident with a C-diff infection, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: Licensee agreed to submit a plan how you will ensure staff receive training on infection control as necessary and annually. Submit to CCL by due date

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240306081830). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Upon arrival LPA met with Rose Anguiano and explained the reason for the visit. During the Department’s investigation, the following deficiencies were observed: On 01/21/2024, at approximately 5:41 p.m., Resident #1 (R1) presented to the emergency department for abdominal pain. The records noted R1 had three days of abdominal pain and diarrhea. On 01/30/2024, the clinical update noted R1 tested positive for C. difficile colitis (C-diff). On 01/31/2024, R1 was discharged from the hospital to the facility with a new medication of Vancomycin to treat the C-diff infection. A review of the facility Medication Assistance Record (MARs) revealed no indication the new prescription for Vancomycin was administered as directed by the hospital. The facility did not submit a Special Incident Report (SIR) to Community Care Licensing (CCL) to notify that R1 tested positive for C. difficile colitis (C-diff). Additionally, the facility did not submit an exception request for a prohibited health condition, when R1 tested positive for C. difficile colitis (C-diff). R1’s Needs and Services Plan dated 12/26/2023 was not updated to reflect R1’s change in condition and develop a plan of care to meet R1’s needs. Based on the numerous deficiencies noted during the course of the investigation of complaint 29-AS-20240306081830, the administrator did not demonstrate knowledge of the requirements of Title 22 Regulations, including care and supervision of residents. Citations issued, exit interview conducted and , appeal rights given.the state’s words, verbatim · CDSS document, Nov 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 22, 2024

(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with section cited above as the Medication Assistance Record (MAR) revealed no indication that Vancomycin was administered as prescribed which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: The licensee agreed to submit a plan describing how you will ensure medications are given as prescribed. Submit proof to CCL by due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87615(a)(4) · Plan of correction due date: Nov 22, 2024

(a) Persons who require health services... shall not be admitted or retained in a residential care facility for the elderly: (4) Staphylococcus aureus ("staph") infection or other serious infection. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. Licensee did not submit an exception request for a prohibited health condition when R1 tested positive for C. difficile colitis (C-diff), which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: The licensee agreed to submit a plan to ensure exception requests will be submitted for residents who have Prohibited Health Conditions. Submit proof to CCL by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Nov 29, 2024

(a)Each licensee shall furnish to the licensing agency such reports...Any serious injury as determined... by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. Licensee did not submit an incident report when R1 tested positive for C. difficile colitis (C-diff), which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: The licensee agreed to submit a plan describing how you will ensure reporting requirements are followed. Submit proof to CCL by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a)(3) · Plan of correction due date: Nov 29, 2024

The pre-admission appraisal shall be updated, in writing as frequently as necessary ...(3)Any illness... that results in a circumstance or condition specified in... Prohibited Health Conditions.This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. Licensee did not update R1’s needs and services plan to reflect R1’s change in condition and develop a plan of care to meet R1’s needs, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: The licensee agreed to submit a plan how you will ensure the residents’ needs and services plans are updated when there is a change of condition. Submit proof to CCL by due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(1)(2) · Plan of correction due date: Nov 29, 2024

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. The administrator did not demonstrate knowledge of the requirements of Title 22 Regulations, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: The licensee agreed to submit a plan how you will ensure the facility has a qualified administrator. Submit proof to CCL by due date.

Allegation investigated: Facility staff not assisting resident with ambulating as needed Facility staff not meeting resident’s showering needs Facility staff not meeting resident’s need for clean clothing Facility staff not meeting resident’s grooming needs Facility staff not ensuring resident’s diabetic needs are met Facility staff not seeking appropriate medical attention for resident Facility staff not maintaining the facility free of odor Facility staff not maintaining passageways free of obstruction Facility staff not maintaining the facility clean

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit. The purpose of the visit is to deliver final findings to a complaint initiated by LPA Z. Chochian on 08/06/2024. Upon arrival LPA met with Rose Anguiano and the reason for the visit was explained. On 08/06/2024, LPA Z. Chochian conducted an initial 10-day complaint visit and conducted a physical plant tour which included random resident rooms, common areas, and laundry rooms. From approximately (approx.)11 a.m. - 2:30 p.m., LPA interviewed fifteen (15) residents and three (3) staff. Between 2:45 p.m.-3:45 p.m. LPA reviewed four (4) resident records and conducted interview with med-tech staff. Following is a summary of the allegations and investigation finding: Regarding allegation “Facility staff not assisting resident with ambulating as needed”: It was reported that facility staff are not assisting resident #1 (R1) with ambulating Unsubstantiated Continued from 9099 Interviews conducted with staff and R1 revealed that although R1 is partially blind, R1 ambulates with a walker and can leave facility unassisted. R1 confirmed being able to ambulate without staff assistance however reported R1 could benefit from staff assistance to prevent falls. Records reviewed revealed that R1 was recently admitted to the facility and the preadmission appraisal and assessment conducted by facility staff did not indicate that R1 requires assistance in ambulating. Furthermore, records reviewed and interview with R1 revealed that R1 did not sustain any falls since admission. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility staff not assisting resident with ambulating as needed” is deemed UNSUBSTANTIATED at this time. Regarding Allegations “Facility staff not meeting resident’s showering needs, Facility staff not meeting resident’s need for clean clothing, and Facility staff not meeting resident’s grooming needs”: It was reported that R1 is supposed to get help bathing several times a week but reported that R1 only gets a shower from the facility every two weeks. It was also reported that R1 was observed wearing dirty clothes and had long nails. R1 was interviewed and did not recall how often staff provide bathing assistance. Facility’s Resident bathing schedule reviewed showed that R1 is scheduled for 2 showers a week. According to Administrator and staff showers provided are not documented however if a resident refuses to shower it is documented. No record of R1 refusing showers. Regarding staff not meeting resident need for clean clothing. R1 was interviewed and did not express any concern with laundry services. R1’s was observed in clean clothing during visit; no dirty laundry observed in room. Staff reported that laundry is picked up daily from resident. Allegations was discussed with administrator and staff. In addition, random residents were interviewed. All residents interviewed stated there is sufficient staffing to meet their needs. Residents expressed that they are independent and don’t need assistance from staff. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility staff not meeting resident’s showering needs, Facility staff not meeting resident’s need for clean clothing, and Facility staff not meeting resident’s grooming needs is deemed UNSUBSTANTIATED at this time. Continued from 9099-C Regarding allegation “Facility staff not ensuring resident’s diabetic needs are met”: It was reported that R1 is a diabetic, however staff are not ensuring that his blood sugar levels are checked. Interview conducted with R1 revealed that they are not diabetic however would like their blood sugar tested to ensure glucose levels are normal. It was explained to R1 that facility staff are not allowed to do glucose checks and only a skilled professional or resident may conduct the glucose testing if needed. Staff interviewed and records reviewed did not reveal any order for glucose testing for R1. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility staff not ensuring resident diabetic needs are met” is deemed UNSUBSTANTIATED at this time. Regarding allegation “Facility staff not seeking appropriate medical attention for resident”: It was reported that that R2 has been coughing up blood and refuses to see a doctor. It was also reported that the staff at the facility has offered to take R2 to the hospital, but the R2 refuses to go get treated. Interview was conducted with R2. R2 denied ever coughing up blood. R2 confirmed hospitalization was due to nosebleed (a week ago). R2 did not report any issues with the facility and expressed that staff are very attentive. R2 expressed that everything is well and feels safe at facility. No other medical issue reported by R2. Staff interviews revealed that R2 did have a nosebleed a week ago and was sent out to the hospital for evaluation. R2 returned the same day with no new orders. Interview with staff and records reviewed revealed that R2 was TB cleared prior to admission and recently retested with a negative result. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility staff not seeking appropriate medical attention for resident” is deemed UNSUBSTANTIATED at this time. Regarding allegations “Facility staff not maintaining the facility free of odor, Facility staff not maintaining passageways free of obstruction and Facility staff not maintaining the facility clean”: It was reported that several rooms had a strong urine smell and trash next to the entry way of several rooms, one of which blocked a resident from exiting their room. During the initial visit, LPA toured the facility physical plant which included the hallways, random resident rooms, and common areas. Continued from 9099-C Also, during the initial visit, LPA conducted interview with 15 residents. Hallways and resident rooms toured observed clean and odor free during visit. All passageways and exits observed free of obstruction. Residents interviewed did not report any issues with passageways being obstructed, facility cleanliness or any bad odor. Staff reported that if a resident has an accident in their room housekeeping is immediately called to clean. Staff stated that passageways are never obstructed, resident rooms are kept clean, and trash is picked up daily. Administrator expressed that it is a challenge with some residents who have a lot of items in their room. However, they offer to assist resident with organizing things in the room so that housekeeping can clean and have room free of any hazards and maintain room odor free. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegations or that a violation occurred; therefore, the allegations “Facility staff not maintaining the facility free of odor, Facility staff not maintaining passageways free of obstruction and Facility staff not maintaining the facility clean” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 29-AS-20240801124831

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Zabel Chochian conduct a required annual visit at this facility. Upon arrival, the LPA was greeted by staff and also the Administrator, Rose Anguiano. Reason for the visit was stated. Entrance interview conducted with Administrator - following updated records request were requested and obtained: facility residents and staff roster; fire and smoke alarm tests; dieticians report; facility's current liability insurance; Emergency and disaster plan. Administrator confirmed that they are operating according to the original facility plan of operation submitted and no changes have been made. The LPA, staff and the Administrator toured the physical plant areas inside and outside to ensure facility is in compliance with Title 22 Regulations. KITCHEN: The LPA began the inspection in the kitchen/food service area at approximately 10:45am; Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At approximately 11am LPA observed several food items in the refrigerator and freezer not sealed properly and not dated. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors are tested and maintain operational. The fire extinguishers observed fully charged and were last serviced 10/20/2023. The LPA observed required postings throughout the common space. The LPA observed five (5) stairwells; each have an emergency evacuation chair at the 2nd floor. At approximately 11:35am one stairwell wall was observed in disrepair. RESIDENT BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. At 11:53am, Room 259 window shades observed missing; room 259 and 267 floor tiles missing; Memory Care Hallway floor strips observed peeling off. The LPA did observe resident restrooms stocked with sufficient supply of toiletries; towels and hygiene items. RESTROOMS: Resident restrooms all observed with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and towels ( towels and washcloths are not shared). Room 112 and 212 had very low water flow from the faucet; room 220 restroom observed in unsanitary condition; and restroom drawer observed missing in room 259. The hot water temperature was measured in random resident rooms through out the building from the first floor to the second floor and the temperature measured between 105 - 119 degrees Fahrenheit. RECORDS: LPA reviewed ten (10) Resident Records at approximately 1:45pm-3pm. Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, personal rights form, preplacement, reappraisal and current needs and services plan. All records were in order. MEDICATIONS: Medications review began at 3:30pm. The medications are centrally stored in the medication room on the first floor. Medications are labeled and stored inaccessible; medication review revealed that resident medications are not properly documented on the centrally stored medications and destruction log/record. It was revealed that the facility is working with different pharmacies where one pharmacy is providing a printed copy of the centrally stored medication record and others are not. In review of the medication records for random residents it was observed that prescription/non-prescription medications for residents stored at the facility are not recorded on the centrally stored log with all required information (missing expiration dates; fill dates and start dates). INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate. Due to time constraints the annual inspection will continue to a later date. LPA will return at a later date to review staff files and training records. The following deficiencies observed during today's visit are cited (see 809D) from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Aug 13, 2024

Allegation investigated: Facility staff mismanged residents medication Staff member yells at resident(s) in care. Staff do not ensure that facility is clean. Staff do not ensure that fire exits are free of obstruction.

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to continue investigation for the above allegations. During today’s visit, LPA met with Rose Anguiano and explained the reason for the visit. During the visit Rose had to leave due to an appointment, but stated Tina can sign in their place. On 01/24/2024, the initial complaint visit was conducted by LPA Brian Balisi between approximately 09:45 a.m. - 3:00 p.m. During the visit, LPA’s conducted physical plant, interviewed staff, residents, medication audit as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 07/23/2024, LPA interviewed residents while conducting a visit on a separate investigation. It was reported that facility staff mismanaged resident’s medication, as it was alleged some residents are being over medicated. Unsubstantiated continued from 9099 LPA's medication audit of Medication Administration Records (MAR) for eight (8) randomly selected residents indicated that medications for the residents were administered as prescribed at this time. LPA also checked resident medications for expiration dates and instructions and the LPA uncovered minimal discrepancies.The LPA reviewed facility incident reports, and the LPA was unable to uncover incident reports as it related to known medication errors. Interviews with five (5) staff revealed that staff did not recall specific occurrences where medication errors occurred. LPA's Interview with ten (10) residents in care revealed they did not express any concerns as it related to receiving their medications. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “staff mismanaged resident’s medication” is deemed Unsubstantiated at this time. It was reported that “Staff member yells at resident(s) in care”, as it was alleged that the Executive Director yells at residents and ignores their concerns. Interviews conducted with ten (10) residents revealed that nine (9) out of (10) residents interviewed have never observed the Executive Director to speak inappropriately to any resident or ignore their concerns . One (1) resident stated they have heard the Executive Director raise their voice attempting to redirect a resident who was yelling at the Executive Director. LPA’s interview with eight (8) staff revealed that each staff have not witnessed any staff yell at any resident or ignore any concerns of the residents in care. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff member yells at resident(s) in care” is deemed Unsubstantiated at this time. It was reported that "Staff do not ensure that facility is clean" as it was alleged that the facility is roach infested, unkept and there is a bad smell throughout the hallways. Interviews conducted with ten (10) residents revealed that all (10) have not observed roaches in the facility , have never observed a foul order in the facility and have observed dedicated housekeeping staff cleaning throughout the day. Continued from 9099-C Interviews with eight (8) staff revealed that all staff have not observed roaches in the facility. Two (2) out of the (8) staff interviewed stated that the facility may be malodors when staff are cleaning sheets of residents who had a heavy bladder or bowel movement, but staff are quick to remove the foul linen so the smell does not linger for too long. In addition, records review revealed, that the pest control conducts general treatment of rooms and commons areas at least every other week. Since May 2024, there have been ten (10) visits conducted by pest control company with one (1) visit in May the pest control company discovered a minor activity of roaches under a sink in the kitchen. Since May there has not been another visit where roach activity was found. Records review of daily room cleaning assignment logs revealed that trash containers are emptied and floors are mopped every day. Then twice a week the furniture is dusted, mirrors are cleaned, windows are cleaned, towels are replaced, and bathrooms are cleaned. During physical plant, LPA did not observe any foul odors or roaches. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation "Staff do not ensure that facility is clean" is deemed Unsubstantiated at this time. It was reported that “Staff do not ensure that fire exits are free of obstruction” as it was alleged that fire exits are always blocked by wheelchairs and walkers. Interviews conducted with ten (10) residents revealed that all (10) residents have never observed fire exists blocked by wheelchairs, walkers or any other objects. Interview eight (8) staff revealed that six (6) out of the (8) staff interviewed have never observed any exits obstructed by any object. Two (2) out of the (8) staff interviewed that when medications are passed out residents line up outside of the medication room and there are multiple residents with wheelchairs and walkers, but there is always a clear path to walk to the nearest exits in the event of an emergency. During physical plants, LPA did not observe any exits obstructed by wheelchairs, walkers or other objects. . Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation " Staff do not ensure that fire exits are free of obstruction " is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 29-AS-20240122102959

Allegation investigated: Staff did not prevent unknown individual from stealing resident's personal belongings Staff did not prevent unknown individual from trespassing into facility premises

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to continue investigation for the above allegations. During today’s visit, LPA met with Rose Anguiano and explained the reason for the visit. During the visit Rose had to leave due to an appointment, but stated Tina can sign in their place. On 3/01/2024, the initial complaint visit was conducted by LPA Brian Balisi between approximately 09:45 a.m. - 3:00 p.m. During the visit, LPA’s conducted physical plant, interviewed staff, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 07/24/2024, LPA interviewed Staff #1 (S1). It was reported that “Staff did not prevent unknown individual from stealing resident’s personal belongings” and “staff did not prevent unknown individual from trespassing into facility premises”, as it was alleged that a houseless person entered Resident #1 (R1)’s room and slept on their bathroom floor. Substantiated Continued from 9099 Interviews conducted and records review reflected that on 02/09/2024, at approx. 02:30am, S1 and Staff #2 (S2) were making their rounds and noticed R1’s room closed, and the lights were turned off. During the night R1’s room is typically slightly open with a light on. S1 entered the room and observed R1 to be agitated and informed S1 to check their bathroom. S1 opened the bathroom door and observed a houseless person sleeping on the bathroom floor. 911 was called immediately and came to the facility within 5 minutes. Police took houseless person into custody and exited the facility. During search of the body of the houseless person, police officers recovered a glasses case, a pair of reading glasses and a debit card with R1’s name on it. Interviews with staff further revealed the houseless person is a known trespasser in the surrounding area and they believe the person was able to enter the facility due to one of the exterior doors not being closed and monitored properly. Since this incident occurred the facility has established direct line of communication with local authorities for extra support and added additional staffing during the NOC shift to sufficiently monitor the property. No trespassing incidents have been reported since. Based on information gathered over the course of the investigation, the Department has sufficient evidence to determine the allegations occurred. Therefore, the allegations that “Staff did not prevent unknown individual from stealing resident’s personal belongings” and Staff did not prevent unknown individual from trespassing into facility premises” has been deemed Substantiated at this time. Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 6, the following deficiencies were observed and cited (9099-D) during the visit. Exit Interview Conducted / Appeal Rights discussed and a copy of this report has been issued.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 29-AS-20240229131712

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(2) · Plan of correction due date: Jul 31, 2024

87464(f)(2)- Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above section by failing to protect a resident from an unwanted intruder entering a private room, which posed an immediate health , safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2024

Plan of correction: Licensee agreed to review section cited and provide a statement of understanding as well as a written plan to monitor building during NOC shift to CCL via email by COB 7/31/2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(25) · Plan of correction due date: Aug 9, 2024

87468.2 (25) - To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as multiple personal items of R1 were in possession of a houseless person who entered R1’s room while in care, which posed a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2024

Plan of correction: Licensee agreed to review section cited and provide a statement of understanding to CCL via email by COB 08/09/2024.

Allegation investigated: Staff stealing resident’s personal belongings. Staff not providing resident with adequate food service. Staff opens resident’s packages. Staff disrupting resident’s sleep. Staff allowing resident’s to smoke in non-designated smoking areas of facility.

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings of the allegation listed above. During today’s visit, LPA met with Executive Director Rose Anguiano and explained the reason for the visit. On 10/10/2023, from 02:30 p.m. – 4:20 p.m., LPA Brian Balisi initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPAs toured the physical plant, interviewed staff, residents and reviewed and obtained pertinent documents relevant to the investigation. On 01/11/2024, LPA interviewed twelve (12) residents while conducting a subsequent visit on a separate investigation. It was reported that “Staff stealing resident’s personal belongings”, as it was alleged that staff were taking Resident #1 (R1)’s hair wraps, earrings, DVD player and pillow cases. Interviews conducted and records review revealed that R1 declined to have their personal items inventoried. Continued on 9099-C Unsubstantiated Continued from 9099 Interview with sixteen (16) residents revealed that all (16) residents have never observed staff take any of their personal belongings. Each resident did not express any immediate or potential concerns for any staff taking their personal belongings. LPA’s interview with five (5) staff revealed that all (5) have never observed any staff take the personal belongings of any resident. Each staff interviewed did not express any immediate or potential concerns for any staff taking the personal belongings of residents in care. Records review revealed R1 declined to have personal items inventoried.Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff stealing resident’s personal belongings” is deemed Unsubstantiated at this time. It was reported that “Staff not providing resident with adequate food service”, as it was alleged that food is not cooked properly and fruits are not ripe. Interviews conducted with sixteen (16) residents revealed that fourteen (14) out of (16) residents interviewed stated that they have not observed any food that appeared to not have been cooked to the proper temperature. These residents continued to state they are frequently provided with a variety of fruits and vegetables, and they have not observed any produce that was not safe to eat. Two (2) out of the (16) residents interviewed stated that the food was observed to be cooked properly, but the food could use more flavoring such as additional salt, pepper or other seasonings. LPA records review of Nutritionist report dated 10/14/2023, notated that the overall kitchen maintenance and cleanliness met compliance and the facilities 5-week cycle menu was reviewed and no suggestions were provided. During physical plant in the kitchen, LPA observed a sufficient number of fruits, produce, breads, pasta, and non-perishable items properly stored. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff not providing resident with adequate food service” is deemed Unsubstantiated at this time. It was reported that “ Staff opens resident’s packages, as it was alleged that whenever residents receive packages it comes to them already opened. Interviews conducted with sixteen (16) residents revealed that twelve (12) residents have never received a package that had been opened prior to them receiving it from staff. Continued from 9099-C Two (2) out of the (12) residents interviewed stated they don’t receive packages in the facility while the other (2) residents stated they have received packages that appeared to be opened and repackaged, but they feel it may have been more likely due to being damaged from the courier service. LPA’s interview with four (4) staff revealed that typically packages get received by the front desk, then staff inform the resident of the package, and they either retrieve it from the front desk or staff deliver it directly to them. Each staff continued to state there would be no protocol in which, staff have to open the residents’ package before handing it over to the resident. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff opens resident’s packages” is deemed Unsubstantiated at this time. It was reported that staff are disrupting resident’s sleep, as it was alleged that staff are entering R1’s room while they are sleeping at night. Interviews conducted with sixteen (16) residents revealed that all (16) residents have not been woken up by staff during the night. Each resident continued to state they are okay with wellness checks during the night to ensure the health and safety of the residents. LPA’s interview with four (4) staff revealed that when a resident has a change of condition or suffers a fall / injury, staff conduct wellness checks on resident throughout the day and during the NOC shift. NOC shift staff are instructed to open the door slightly and take a peek inside room to ensure the health and safety of the residents. Residents are allowed to opt out of having wellness checks conducted as well. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “staff are disrupting resident’s sleep “is deemed Unsubstantiated at this time. It was reported that staff are allowing residents to smoke in non-designated smoking areas of facility, as it was alleged that some residents are smoking in their rooms. LPA’s interview conducted with sixteen (16) residents revealed that thirteen (13) out of the (16) residents interviewed have not observed any resident smoking in their room. These residents also did not express any immediate or potential concerns of residents smoking in their room and that they typically observe the same group of residents smoking smoking in the rear of the facility in the designated smoking area. Three (3) out of the (16) residents interviewed stated residents smoking in their rooms used to be an issue in previous years, Continued from 9099-C but they have not smelled any evidence of smoke in their unit or common areas lately. During physical plant, LPA did not observe any evidence of residents smoking in the resident’s room and LPA also observed a large group of residents smoking in the designated smoking area. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff are allowing residents to smoke in non-designated smoking areas of facility”is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Apr 5, 2024 · control 29-AS-20231009145534

Allegation investigated: Staff does not ensure facility is free of pests for residents in care

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with Executive Director Rose Anguiano and explained the reason for the visit. On 01/11/2024, from 10:30am – 03:30 p.m., LPA Brian Balisi initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPAs toured the physical plant, interviewed staff, residents and reviewed and obtained pertinent documents relevant to the investigation. Today LPA conducted physical plant, interviewed staff and reviewed and obtained copies of additional pertinent documentation relevant to the investigation. It was reported that Staff does not ensure facility is free of pests for residents in care, as it was alleged that residents have observed bed bugs, mosquitos and other bug infestations in their room. LPA’s interview with twelve (12) residents revealed that seven (7) out of the (12) residents interviewed have either observed bed bugs in their room or have heard of other residents observing bed bugs in their rooms. Substantiated Continued from 9099 The other five (5) residents revealed they have not observed any bed bugs in their room or heard of other residents have a bed bug infestation. All (12) residents interviewed stated they have not observed mosquitos or other bug infestations in their room or around the facility. For any bug issues facility staff/management is alerted and pest control is scheduled to have each identified room/area with bed bug issue serviced accordingly and immediately. LPA’s records review of Hydrogen Pest Control invoices reflected that since 01/25/2024 the pest control company has conducted seven (7) visits for ongoing treatments in select rooms and common areas. No bed bug activity has been observed, however on 03/11/2024 it was notated that a “minor roach infestation” was observed in kitchen and treated during the visit. Based on information gathered over the course of the investigation, the Department has sufficient evidence to determine this allegation occurred. Therefore, the allegation that “Licensee does not ensure facility is free from bed bugs” has been deemed Substantiated at this time. Although the allegation as Substantiated, the allegation was cited on a separate report from a separate complaint investigation Complaint Control #29-AS-20230831162522 Exit Interview Conducted and a copy of this report has been issued. Continued from 9099-A Interviews conducted and records review revealed the Administrator was informed of a mosquito infestation on 12/15/2023 in Resident #1 (R1)’s bedroom. Hydrogen Pest Control conducted a visit on 12/18/2023 and their inspection notes indicated that there were no evidence of bed bugs or general pest activity found at the time of their inspection. LPA’s interview with twelve (12) residents revealed that all (12) residents did not express any immediate or potential concerns of staff not addressing their concerns if a pest infestation were to arise. LPA’s records review of Hydrogen Pest Control invoices reflected that since 01/25/2024 the pest control company has conducted seven (7) visits for ongoing treatments in select rooms and common areas. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff does not ensure pest issue is being properly addressed for residents in care” is deemed Unsubstantiated at this time. It was reported that “Administrator does not treat resident with dignity and respect”, as it was alleged that resident’s concerns are ignored by the Administrator. LPA’s interview with twelve (12) residents revealed that ten (10) out of the (12) residents interviewed stated they speak with the Administrator often and they have not felt like their needs or concerns were ignored by the Administrator. Two (2) out of the ten (10) residents interviewed stated they don’t speak to the Administrator often enough to form an opinion, but each did not express any immediate or potential concerns that the Administrator would ignore their requests or concerns. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Administrator does not treat resident with dignity and respect” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Apr 5, 2024 · control 29-AS-20240104092147

Allegation investigated: Resident was financially abused while in care

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings of the allegation listed above. During today’s visit, LPA met with Executive Director Rose Anguiano and explained the reason for the visit. On 02/15/2024, from 01:50pm – 03:30 p.m., LPA Brian Balisi initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPAs toured the physical plant, interviewed staff, residents and reviewed and obtained pertinent documents relevant to the investigation. On 03/01/2024, LPA interviewed Resident #1 (R1) during a subsequent visit on a separate investigation. It was reported that R1 was financially abused while in care , as it was alleged that someone at the facility used R1’s credit card without authorization. Interviews conducted and records reviewed revealed that from 01/23/2024 to 02/08/2024 multiple orders were purchased on Doordash with use of R1’s credit card. Unsubstantiated Continued from 9099 LPA’s interview with R1 stated they informed Staff #1 (S1) to make orders on Doordash and authorized S1 to use their credit card. R1 continued to state they only made purchases for themselves and not for any staff. LPA’s interview with S1 stated R1 does not have a phone and R1 would typically write down what they wanted to order on an index card and provide it to S1 to order through Doordash. S1 does not keep R1's credit card info on their phone and they do not order through Doordash for any other resident in care. LPA records review of R1’s Physicians’ Report indicated that R1 is able to manage own cash resources. LPA’s interview with four (4) residents who often get food delivered, revealed that all (4) residents have never had staff purchase anything for them with their own credit card. Each resident also have not witnessed any staff use any residents credit card to make purchases. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “R1 was financially abused while in care", is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Apr 5, 2024 · control 29-AS-20240213163305

Allegation investigated: Staff threatened resident. Staff spoke inappropriately to resident. Staff hit resident.

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings of the allegation listed above. During today’s visit, LPA met with Executive Director Rose Anguiano and explained the reason for the visit. On 09/07/2023, from 09:30 a.m. – 4:00 p.m., LPA’s Martha Arroyo and Brian Balisi initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPAs toured the physical plant, interviewed staff, residents and reviewed and obtained pertinent documents relevant to the investigation. It was reported that staff threatened resident, as it was alleged that staff have threatened to relocate Residents. Interviews conducted with thirteen (13) residents revealed that twelve (12) out of the (13) residents interviewed have never witnessed any staff threaten to relocate any resident. One (1) resident declined to answer. LPA’s interview with five (5) staff revealed that each staff have not witnessed any staff threaten any resident in care. Unsubstantiated Continued from 9099 Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff threatened resident” is deemed Unsubstantiated at this time. It was reported that staff spoke inappropriately to resident, as it was alleged that the Executive Director speaks inappropriately to residents. Interviews conducted with thirteen (13) residents revealed that eleven (11) out of (13) residents interviewed have never observed the Executive Director speak inappropriately to any residents. One (1) resident declined to answer and one (1) resident stated a staff was rude on one occasion , but they could not recall the name of staff or when the incident occurred. In addition, that resident stated it occurred when they were first admitted into the facility over one year ago and they have not experienced any staff speaking inappropriately to any resident since. LPA’s interview with five (5) staff revealed that each staff have not witnessed any staff threaten any resident in care. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff spoke inappropriately to resident” is deemed Unsubstantiated at this time. It was reported that Staff hit resident, as it was alleged a resident informed their family / responsible party they were hit by a staff. Exact dates or names of staff were not provided. Interviews conducted and records reviewed reflected that at the time of the complaint there were no incidents that occurred that involved a staff hitting a resident. LPA’s interview with thirteen (13) residents revealed that all (13) have not witnessed any staff hit a resident in care. LPA’s interview with five (5) staff revealed that each staff have not witnessed any staff hit a resident in care. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff hit resident” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 29-AS-20230829112438

Allegation investigated: Staff do not respond to resident's call button in a timely manner.

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings of the allegation listed above. During today’s visit, LPA met with Administrator Rose Anguiano and explained the reason for the visit. On 11/20/2023, from 10:30 a.m. – 12:30 p.m., LPA conducted an unannounced complaint investigation for the allegations listed above. During the visit, LPAs toured the physical plant, interviewed staff, and reviewed and obtained pertinent documents relevant to the investigation. It was reported Staff do not respond to resident's call button in a timely manner, as it was alleged that residents have to wait for long periods of time before they receive assistance. Interviews with twelve (12) residents revealed that all twelve residents did not express any immediate or potential concerns with the timeliness of staff responding when assistance is requested. Unsubstantiated Continued from 9099 Most residents stated that the most they've had to wait is approximately 10 - 12 minutes. LPA's interview with four (4) staff revealed when a resident requests service either by pulling their emergency cord in their unit or calling the front desk, their goal is to arrive to their unit within 5 to 10 minutes. LPA' records review of facilities response log, Tek-Care report , which logs response times when a resident pulls an emergency cord, the average response time for staff since Jan 01/04/2024 is 05 min and 52 seconds. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff do not respond to resident’s call button in a timely manner” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Mar 1, 2024 · control 29-AS-20231116084346

Allegation investigated: Staff did not provide adequate supervision resulting in resident wandering away from facility.

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate allegation listed above. During today’s visit, LPA met with Administrator Rose Anguiano and explained the reason for the visit. On 12/22/2023, from 10:30 a.m. – 12:00 p.m., LPA conducted an unannounced complaint investigation for the allegation listed above. During the visit, LPAs toured the physical plant, interviewed staff, and reviewed and obtained pertinent documents relevant to the investigation. It was reported that staff did not provide adequate supervision resulting in Resident #1 (R1) wandering away from facility. On 12-16-2023, it was reported that R1 left the facility then was admitted into a local hospital after having a medical emergency at a store located near the facility. Interviews conducted and records review reflected that according to R1's LIC 602 (Physician's Report), they are "able to leave the facility unassisted" and is independent with activities of daily living. Unsubstantiated Continued from 9099 R1 is also self-responsible.R1 has a history of walking around the nearby community and was often out running errands. LPA's records review and observations revealed residents are required to sign in and out upon leaving the facility as it is in the admissions agreement and there is signage by the front desk. R1 would not often abide by those rules. Records review of staff schedule further revealed there were six (6) caregivers and a med tech on shift. LPA's interviews with five (5) staff revealed that before any resident exits the building they are reminded to sign out and most residents comply. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff did not provide adequate supervision resulting in R1 wandering away from facility” is deemed Unsubstantiated at this time. Exit interview conducted/No citations issues/ A copy of report was provided.the state’s words, verbatim · CDSS document, Mar 1, 2024 · control 29-AS-20231218082642

Allegation investigated: Licensee does not ensure facility is free from bed bugs.

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to investigate the allegations listed above. Upon arrival LPA met with Administrator Rose Anguinao and explained the reason for the visit. During the investigation, LPA's Martha Arroyo and Brian Balisi initiated the 10 day initial visit on 09/07/2023 between 9:30 a.m. - 4 p.m. LPA's toured the physical plant, interviewed fourteen (14) residents, three (3) staff and reviewed and obtained copies of pertinent documents relevant to the investigation. Today LPA conducted physical plant and reviewed and obtained additional documentation. It was reported that the “Licensee does not ensure facility is free from bed bugs ”, as it was alleged that the facility has an ongoing issue of bed bugs. Interviews conducted with fourteen (14) residents revealed that eight (8) out of fourteen (14) residents interviewed have either observed bed bugs in their room or have heard of other residents observing bed bugs in their rooms. Substantiated Continued from 9099 The other six (6) residents interviewed revealed they have not observed any bed bugs in their room or heard of other residents having a bed bug infestation. For any bed bug issues facility staff/management is alerted and pest control is scheduled to have each identified room/area with bed bug issue serviced accordingly and immediately. LPA’s records review of Hydrogen Pest Control invoices reflected that from 06/19/2023 to 08/29/2023 the pest control company conducted nine (9) appointments where evidence of bedbugs were observed during their visit. Based on information gathered over the course of the investigation, the Department has sufficient evidence to determine this allegation occurred. Therefore, the allegation that “Licensee does not ensure facility is free from bed bugs” has been deemed Substantiated at this time. Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 6, the following deficiencies were observed and cited (9099-D) during the visit. Exit Interview Conducted / Appeal Rights discussed and a copy of this report has been issued.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 29-AS-20230831162522

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 19, 2024

87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times...safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by Based on interviews and records review, the licensee failed to comply with the section cited above as bed bugs were observed by multiple residents in multiple bedrooms, which poses a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: The Administrator agreed to review section cited and provide a statement of understanding to LPA via email by 01/19/2024 COB. In addition Admin agreed to speak with pest control company regarding options for possible additional preventative measures to limit bed bug infestations.

Allegation investigated: Illegal drugs on the premises (meth, fentanyl) Inadequate supervision resulted in resident overdose

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver final findings of the allegations listed above. Upon arrival LPA met with Rose Anguiano and explained the reason for the visit. On 09/06/2023, the Department received a complaint regarding two (2) allegations of Neglect/Lack of Care. It was alleged that Staff failed to provide an adequate level of care resulting in Resident #1 (R1) overdosing and staff failed to provide care resulting in illegal drugs being present on the premises. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Christine Ferris. On 09/07/2023, between 09:30 a.m. and 4:00 p.m., LPAs Brian Balisi and Martha Arroyo conducted an unannounced complaint visit. During the visit, the LPA’s conducted a physical plant tour, interviewed staff, residents and obtained copies of pertinent documents relevant to the investigation. Unsubstantiated Continued from 9099 Investigator Ferris conducted interviews on 10/03/2023 with the Executive Director/Administrator, R1, other residents and staff. Additional interviews with staff were also conducted on 10/23/2023. On 09/27/2023, Investigator Ferris reviewed Los Angeles County Fire Department report incident #0801 and on 10/17/2023, Investigator Ferris reviewed medical records from Providence Tarzana Medical Center. The Investigation revealed that on 09/03/2023, R1 pulled the emergency cord in their bathroom. Staff #(S1) arrived to R1’s unit to find R1 unconscious. S1 requested assistance from Staff #2 (S2) and Staff #3(S3). 9-1-1 was called while S2 was on their way to R1’s unit. As both S1 and S2 attempted to relocate R1 to the floor, Paramedics arrived and began to conduct Cardiopulmonary Resuscitation (CPR). S3 entered the unit as Paramedics arrived. Interviews with S1, S2, S3 and records review revealed that S1, S2, S3 and Paramedics each stated they did not observe any drug paraphernalia present near R1. Interviews conducted and records review of R1’s resident records further reflected that R1 is independent and comes and goes from the facility without assistance. R1 stated they “found” a foil package containing a “substance” while outside of the facility and brought the foil package and substance into the facility. R1 said without anyone’s knowledge, R1 decided to “smoke” what was in the foil package. Per R1, staff did not know R1 found the foil package containing a substance, did not know R1 brought a substance into the facility, and did not know R1 intended to smoke what R1 found. Per Administrator Rose Anguiano, R1 is independent, does not have 1:1 care, leaves the facility unassisted and no resident is searched upon entering the facility after leaving. Rose stated they had no knowledge R1 was in possession of any substances or going to use any substances, though via the resident’s contracts, it is against the rules to have any illegal substances on the premises. Per staff interviewed, they denied having any knowledge that R1 was in possession of any substances or that R1 was going to use any substances. R1 also did not advise anyone they had any illegal substances. Per Providence Cedar-Sinai Tarzana Medical Center records, R1 tested positive for cannabinoids and fentanyl. Based on information obtained, the investigation did not provide sufficient evidence to substantiate neglect/lack of care against Administrator Rose Anguiano. Therefore, the above allegations, “staff failed to provide an adequate level of care resulting in R1 overdosing” and “staff failed to provide care resulting in illegal drugs being present on the premises” have been Unsubstantiated at this time. Exit interview conducted and a copy of report issued.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 29-AS-20230906162620

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management visit - Other. Upon arrival LPA met with Administrator Rose Anguiano and explained the reason for the visit. On 11/14/2023, the Regional Office (RO) received information that this facility will have to be on 24 hour fire watch due to a fire alarm trouble on their fire alarm panel. The Administrator stated Los Angeles Fire Department (LAFD) instructed them to have administrative staff, management, or a caregiver to conduct fire watch every 30 mins until their fire alarm panel is fully functional. Administrator continued to state that only management will be conducting the fire watch patrol. During the visit, LPA contacted LAFD and confirmed these instructions. At 9 a.m. LPA toured the physical plant and conducted the fire watch patrol with Resident Services Coordinator Tina Hernandez. LPA also interviewed staff and reviewed and obtained pertinent documents relevant to the visit. According to Rose fire alarm devices are still fully operational, but if one device goes into alarm mode the panel can't indicate where the alarm is in the building at this time. Administrator confirmed an appointment with the fire alarm company for Friday to troubleshoot their alarm panel. Administrator was advised of the severity of the situation and to keep LPA updated with the repair process. LPA did not observe any immediate health and safety concerns during the visit. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 15, 2023