Ivy Park at Cerritos

Allegation investigated: Staff interacts inappropriately with resident Staff speaks inappropriately to resident

On 05/05/2026, Licensing Program Analyst (LPA) Jewel Baptiste conducted an initial complaint visit in conjunction with an annual inspection. Upon arrival, LPA met the Maintenance Director, Maria Gallegos. The Administrator, Mark Padilla, arrived at 9:30 a.m., and the LPA explained the purpose of the visit. During the visit, LPA interviewed the Administrator and a total of five (5) staff members, who shall be referred to as Staff #1 through #5 (S1-S5). LPA also interviewed a total of fourteen (14) residents, who shall be referred to as residents #1-14 (R1-R14). LPA Baptiste obtained the staff roster, the resident roster, R1’s physician’s report, preplacement appraisal information, and the Resident Information Form. Report continued on 9099c Unsubstantiated The investigation reveals the following: Regarding “Staff interacts inappropriately with residents”. It is alleged that staff were taunting R1”. It was found that R1 was referring to the private staff they hired, not the facility staff. The administrator and all staff denied taunting the residents and further stated that none of the residents complained about staff taunting. All residents interviewed denied the allegation. R1 stated that the issues they are having are with the private care staff they hired. The investigation reveals the following: Regarding “Staff speaks inappropriately to resident”. It is alleged that the staff was making fun of and calling R1 names. The administrator and all staff members denied making fun of or calling the residents names. All residents denied the allegation, stating that the staff is wonderful. R1 stated the facility staff is not the issue, but their private care staff is the problem. Based on LPA's interviews, the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Mark Padilla, and a copy of this record was provided.the state’s words, verbatim · CDSS document, May 5, 2026 · control 28-AS-20260428090637

Type of visit: Required - 1 Year

On 05/05/2026, Licensing Program Analyst (LPA) Jewel Baptiste conducted an initial complaint visit in conjunction with an annual inspection. Upon arrival, LPA met the Maintenance Director, Maria Gallegos. The Administrator, Mark Padilla, arrived at 9:30 a.m., and the LPA explained the purpose of the visit. The facility is licensed for the age range 60 and over and 163 non-ambulatory residents. Hospice approved for 25. All (8) bedridden on the first-floor ground level, only apartments #101, 102, 103, 132, 136, 138, 139, 141, are designated for bedridden. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control Plan: The facility staff are practicing appropriate hand hygiene and wearing gloves when assisting residents. Staff is cleaning and disinfecting once a day and more often for high-touch surfaces. The facility has sufficient PPE supplies and has an Infection Control Plan in place. Physical Plant and Environmental Safety: LPA toured the facility with the Executive Director, Mark Padilla. This property is comprised of one large two-story building on 5.5 acres and contains (90) studio apartments, (42) - 1-bedroom apartments, (12) 2- bedroom apartments, first floor; Lobby/Front desk reception area, administrative offices, Computer room, Salon, Coffee Lounge, Dining room, Kitchen, Community Laundry room, Housekeeping Storage closet, Men/Women restroom, (2) utility rooms. Second floor: Program Director's office, Director of Nursing's office, Staffing Coordinator's office, Medication room, Library, Fitness Center, Theater/Multipurpose room, Men's/Women's restroom, (4) utility rooms, Storage room (emergency food supplies), and (PPE supplies). The outdoor grounds contained bodies of water in a fountain, Report Continued on 809C Physical Plant and Environmental Safety [Cont.]: East Wing Courtyard, West Wing Courtyard, and the community park. Passageways, walkways, and patios are free from obstructions and hazards. The facility is equipped with central heating and air conditioning. LPA inspected 14 residents' rooms, and each resident's bedroom had the required furniture, including bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, a walk-in shower with a grab bar, skid mat/strips, and a shower chair. The temperature measured was between 111.4 and 118.8 degrees F, which is within Title 22 regulations. Resident Rights-Information: LPA observed that the required posters were posted in the facility, including the Long-Term Care Ombudsman poster on the second floor next to the resident's laundry room and the Community Care Licensing Complaint and Personal Rights Poster on the first floor near the resident's mailbox. The residents also have internet service for at least one device, enabling them to communicate with their family members or physicians. Planned Activity: The facility has sufficient space to accommodate indoor and outdoor activities. LPA also observed the weekly activity calendar, and it's posted in the facility. The facility does not have an active Resident Council. Food Service: The facility has an ample supply of perishable food for 2 days and non-perishable food for 7 days. The facility also has emergency food supplies and water located on the first floor. All the food is stored properly. The kitchen was toured and contained working appliances: refrigerator, stove, and oven, as well as dishware, cups, plates, utensils, pots, and pans, with knives secured and locked. Walls and floors, cabinets and counters were clean and sanitary throughout the facility. Disaster Preparedness: The facility has an updated LIC610E Emergency Disaster Plan. The facility has two alternative shelter locations for emergencies. The last fire /disaster drill was conducted on 2/19/2026. LPA also observed the evacuation chair at each stairwell. Due to time constraints, LPA will return at a later date to complete five (5) CARE Tool domains. An exit interview was conducted and a copy of the report was provided to the Executive Director, Mark Padilla.the state’s words, verbatim · CDSS document, May 5, 2026

Allegation investigated: Staff mismanaged resident's medications. Staff did not communicate with resident's responsible party of medication changes.

On 04/01/2026 at 08:00 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an initial complaint visit to investigate the above allegations. Upon arrival, LPA met the Maintenance Director, Maria Gallegos. The Administrator, Mark Padilla, arrived at 9:00 a.m., and the LPA explained the purpose of the visit. During the visit, LPA interviewed the Administrator and a total of two (2) staff members, who shall be referred to as Staff #1 and #2 (S1-S2). LPA interviewed the nurse practitioner, who shall be referred to as Witness #1 (W1). LPA also interviewed a total of fourteen (14) residents, who shall be referred to as residents #1-14 (R1-R14). LPA Baptiste obtained the staff roster, the resident roster, R1’s physician’s report, R1’s Consonsus pharmacy provider waiver, preplacement appraisal information, Resident information form, R1 PRN medication ability determination, medication clarification form, charting notes, and a copy of R1’s physician’s orders. A file review and medication review were conducted for R1. Prior to the visit, LPA Baptiste attempted to contact R1’s physician and left a message. Report continued on 9099c Unsubstantiated The investigation reveals the following: Regarding “Staff mismanaged resident's medications”. It is alleged that the facility removed R1’s prescribed Omeprazole and replaced it with a facility-provided version of the medication. It was found that R1 began receiving Omeprazole from the facility pharmacy after the Omeprazole they had moved in with ran out. This caused a change in the manufacturer and the medication's color, which alerted R1. During the file review, LPA determined that R1 consented to using the facilities' pharmacy rather than the pharmacy they had before moving in. R1 stated they don’t want to make any changes to the medication and will continue taking the medication provided by the facility. The administrator and 2 out of 2 staff stated they have given the medication as prescribed and can use another pharmacy if this is what R1 wants. W1 stated that both forms of Omeprazole have the same effect and that they have educated R1 on the topic. 13 out of 14 residents stated they either receive assistance with their medication or take it independently and have no issues with the facility. The investigation reveals the following: Regarding “Staff did not communicate with the resident's responsible party of medication changes”. It is alleged that the facility has been providing the resident with a facility version of their prescribed medication without notifying the resident's responsible party. The administrator and both staff members stated that R1 does not have a Power of Attorney and that they are their own responsible party. They further stated there were no changes in the medication. R1 stated they were not informed of the medication change. File review confirmed that R1 is their own responsible party and that there were no changes to the medication. LPA also confirmed that R1 consented to using the facility pharmacy. 13 of 14 residents stated that the facility always updates them on any changes to their care. Based on LPA's interviews, the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator Mark Padilla, and a copy of this record was provided.the state’s words, verbatim · CDSS document, Apr 2, 2026 · control 28-AS-20260325164747

Allegation investigated: Unlawful Eviction

Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent unannounced complaint visit to deliver finding to the above-mentioned allegation. LPA met with Executive Director and explained the reason for visit. The investigation consisted of the following: During the visits LPA obtained copies of Staff & Residents rosters, Interviewed Interim Executive Director, Staff 1 (S1), Staff 2 S (2), Staff 3(S3), Current Executive Director, Resident 1 to Resident 11 (R1 to R11). LPA reviewed and collected documents related to R1. Continue 9099C Substantiated Investigation revealed the following: in regards to the allegation “Unlawful Eviction”. It was alleged that R1 received 30-day notice and feels R1 is being retaliated against due to complaining about the facility. Interviewed Interim Executive Director stated that Resident 1 (R1) was served an eviction notice due to multiple incidents over the years involving disrespectful behavior toward staff and other residents. Interviewed current Executive Director stated that they joined the Facility on 10/3/25 and was made aware that R1 had been served an Eviction Notice due to behavioral concerns and the concerns had reached a level that the previous leadership felt R1 needed to be removed from the community. However, the Executive Director stated they have developed a positive relationship with R1 and consider R1’s behavior to be manageable. They further indicated that through communication and ongoing relationship-building, the concerns have improved, and the eviction notice was rescinded on 12/01/2025. Interviewed S1 stated they were aware of process of R1’s eviction but new Executive Director established a rapport with R1 and believed he effectively manage R1’s behaviors. Interviewed S2 stated in the past, sometimes R1 could make a comment to the staff and residents, which made them feel uncomfortable. However, under new management, R1 significantly improved and there were no major recent issues. Interviewed S3 stated that R1 is nice, and they didn’t see any behavior from R1 that would make them or others uncomfortable. LPA interviewed 11 residents. R1 denied making negative or disrespectful comments and stated that the incidents listed in the eviction notice were either exaggerated or did not occur. R1 also expressed that the eviction notice may have been issued in response to their raising concerns to administration, such as ensuring doors are locked after hours and maintaining comfortable facility temperatures. (5) out of (10) Interviewed residents stated that they don’t know R1. (5) out of (10) residents stated that they don’t have any issues with R1. Review of the Eviction notice dated 06/25/2025 indicated R1 was served Eviction notice for noncompliance with community policies and house rules regarding disruptive or abusive behavior. Continue 9099C The notice referenced a few incidents between 2022 and 2025 involving alleged negative or disrespectful comments. However, upon review of R1’s file, house rules, and eviction documentation, as well as observations and interviews conducted, the LPA did not find sufficient evidence that R1 engaged in behavior that disrupted the facility’s calm, peaceful environment or violated house rules to the extent described, and that R1’s actions violate general facility policies created for the purpose of making it possible for residents to live together as stated under regulation 87224(a)(3). Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was held, and a copy of this report, appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 28-AS-20250711081001

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(3) · Plan of correction due date: Mar 19, 2026

The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5).Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).(3)Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement. This requirement is not met as evidenced by: Eviction Notice dated 06/25/25 does not indicate how R1's actions violate general facility policies created for the purpose of making it possible for residents to live together.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Cleared during visit. Eviction notice was rescinded on 12/01/25.

Allegation investigated: Staff does not ensure to keep resident's information confidential. Staff takes photographs of residents without resident's consent. Staff is not background cleared.

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced initial complaint visit to address the allegations listed above. LPA met with Administrator Mark Padilla and explained the purpose of the visit. The investigation consisted of the following: LPA interviewed Residents R1 - R12, Staff S2 and Staff S3. Administrator Mark Padilla was interviewed. Also Interviewed telephonically Vice President of Human Resources Representative. Obtained the staff and resident rosters. In regards to the allegations Staff does not ensure to keep resident's information confidential. Staff takes photographs of residents without resident's consent and Staff is not background cleared based on interviews conducted and information gathered it was revealed by Vice President of Human Resources Representative that Staff S1 has never worked at this facility for at least the last 7 years. Staff S2 and Staff S3 who have both worked at this facility for over 20 years both stated that there has never Unfounded had anyone working here by the name of Staff S1. Facility Personnel Report does not have the name of Staff S1 listed as having criminal clearance. Staff S2, Staff S3 and Administrator are all listed on the Facility Personnel Report as cleared and associated. Interview with Resident's R1-R12 also stated that no staff have ever taken pictures of them. Based on the information gathered during this visit, the allegation(s) are deemed UNFOUNDED. A finding of UNFOUNDED means that the allegations are either false, could not have happened, and/or are without a reasonable basis. LPA conducted an exit interview with Administrator and a copy of the licensing report was provided during visit.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 28-AS-20260120161028

Allegation investigated: Staff does not ensure to keep resident's information confidential. Staff takes photographs of residents without resident's consent. Staff is not background cleared.

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced initial complaint visit to address the allegations listed above. LPA met with Administrator Mark Padilla and explained the purpose of the visit. The investigation consisted of the following: LPA interviewed Residents R1 - R12, Staff S2 and Staff S3. Administrator Mark Padilla was interviewed. Also Interviewed telephonically Vice President of Human Resources Representative. Obtained the staff and resident rosters. In regards to the allegations Staff does not ensure to keep resident's information confidential. Staff takes photographs of residents without resident's consent and Staff is not background cleared based on interviews conducted and information gathered it was revealed by Vice President of Human Resources Representative that Staff S1 has never worked at this facility for at least the last 7 years. Staff S2 and Staff S3 who have both worked at this facility for over 20 years both stated that there has never Unfounded had anyone working here by the name of Staff S1. Facility Personnel Report does not have the name of Staff S1 listed as having criminal clearance. Staff S2, Staff S3 and Administrator are all listed on the Facility Personnel Report as cleared and associated. Interview with Resident's R1-R12 also stated that no staff have ever taken pictures of them. Based on the information gathered during this visit, the allegation(s) are deemed UNFOUNDED. A finding of UNFOUNDED means that the allegations are either false, could not have happened, and/or are without a reasonable basis. LPA conducted an exit interview with Administrator and a copy of the licensing report was provided during visit.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 28-AS-20260120161028

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Daniel Konishi conducted the unannounced required annual inspection. LPA met with the Business Office Manager, Carmen Hernandez and the purpose for the visit was explained. The facility is licensed for the age range 60 and over and 163 non-ambulatory residents. Currently, the facility has six (6) hospice waiver residents and seven (7) home health residents. The initial annual visit was conducted on 07/29/2025. During the initial visit the following eight (7) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant Environmental Safety, Resident Rights-Information, Planned Activities, Food Services, Incidental Medical and Dental, Disaster Preparedness. During today’s annual visit, the following five (5) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Operational Requirements, Staffing, Personnel Records-Training, Resident Records-Personnel Reports, Resident with Special Health Needs. Operational Requirement: The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 25 residents is approved. A fire clearance approved for 163 non-ambulatory residents. Based on record review, LPA observed that the facility has valid Liability Insurance in place. However, based on record review and observation, the facility has one (1) resident that is bedridden. Staffing: Facility has sufficient staffing for care and supervision for the residents. Personnel Record-Training: LPA observed ten (10) staff files which include: health screening, TB test results, personnel records, criminal record clearance, current First-Aid training certificates, medication assistance training, and other ongoing training. Administrator’s certificate expires on 3/3/2027. The Administrator has all the required training hours and staff has the required training hours annually. Based on record review, LPA observed that Staff #3 (S3), Staff #4 (S4), Staff #5 (S5) and Staff #6 (S6) did not have valid first aid training in file. Based on record review, LPA observed that Staff #1 (S1’s) file did not have an TB test result Resident Record-Incident Reports: LPA inspected fourteen resident files and they all have the required documents in file which include: Face sheet, Identification and Emergency Information, Pre-admission appraisal, admission agreement, recent medical assessment, ambulatory status, TB test result, appraisal/services and needs plan, and personal rights. Based on record review, LPA observed that Resident #6 (R6’s) file with Dementia did not have an updated medical assessment. Residents with Special Health Needs: Six (6) residents are receiving hospice services. Seven (7) residents receive home health services. No resident in the facility is on any postural support. No residents have prohibited health conditions. Immediate Civil Penalties is issued on today’s visit in the amount of $500.00 due to facility retaining one (1) bedridden resident (R13). Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the as provided to the Business Office Manager, Carmen Hernandez.the state’s words, verbatim · CDSS document, Jul 31, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted the unannounced required annual inspection. LPA met with the Business Office Manager, Carmen Hernandez and the purpose for the visit was explained. The facility is licensed for the age range 60 and over and 163 non-ambulatory residents. Currently, the facility has six (6) hospice waiver residents and seven (7) home health residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control Plan: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan in place. Physical Plant and Environmental Safety: LPA toured the facility with the Business Office Manager, Carmen Rodriguez. This property is comprised of one large two-story building on 5.5 acres and contains (90) studio apartments, (42) - 1-bedroom apartments, (12) 2- bedroom apartments, first floor; Lobby/Front desk reception area, administrative offices, Computer room, Salon, Coffee Lounge, Dining room, Kitchen, Community Laundry room, Housekeeping Storage closet, Men/Women restroom, (2) utility rooms. Second floor; Program Director office, Director of Nursing office, Staffing Coordinator office, Medication room, Library, Fitness Center, Theater/Multipurpose room, Men/Women restroom, (4) utility rooms, Storage room (emergency food supplies) and (PPE supplies). The outdoor grounds contained bodies of water in a fountain, Physical Plant and Environmental Safety [Cont.]: East Wing Courtyard, West Wing Courtyard and community park. Passageways, walkways, and patios are free from obstructions and hazards. The facility is equipped with central air and heat. LPA inspected 14 residents' rooms and each resident bedroom has the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid matt/strips and shower chair. The temperature measured between 110.0 and 117.0-degrees F which is within the Title 22 regulation. The carbon monoxide detectors and smoke detectors are interconnected and all tested and they are all working well. Fire Extinguishers are fully charged. Resident Rights-Information: LPA observed the required posters posted in the facility which include Long Term Care Ombudsman located on the second floor next to the resident's laundry room, and the Community Care Licensing Complaint and Personal Right Poster are located on the first floor near the resident's mailbox. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physicians. Planned Activity: Facility has sufficient space to accommodate for indoor and outdoor activity. LPA also observed the weekly activity calendar and it's posted in the facility. The facility does have an active Resident Council. Food Service: Currently the facility has about three (3) residents who are required to go on modified diet and LPA reviewed and observed the doctor's order. The facility has an ample supply for two days perishable and seven days non-perishable food supply. The facility also has emergency food supplies and water located on the first floor. All the food are stored properly. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked. Walls and floors, cabinets and counters were clean and sanitary throughout the facility. Incidental Medical and Dental: LPA reviewed 14 centrally stored resident medications; containing a 30-day supply of medications and no issues were observed. Medical and dental transportation is provided if needed. Disaster Preparedness: The facility has an updated LIC610E Emergency Disaster Plan. The facility has two alternative shelter location for emergencies. The last fire /disaster drill was conducted on 7/23/2025. LPA also observed the evacuation chair at each stairwell. Due to time constraints, LPA will return at a later date to complete five (5) CARE Tool domains. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. An exit interview was conducted and a copy of the report was provided to the Business Office Manager, Carmen Hernandez.the state’s words, verbatim · CDSS document, Jul 29, 2025

Allegation investigated: Staff does not respond to resident’s call button in a timely manner Facility did not issue refund to resident's responsible party

Licensing Program Analysts (LPAs) Erik Zaragoza and Gabriela Castro conducted an unannounced initial complaint visit to address the allegations listed above. LPAs met with Martha Altamina, Resident Care Director for the facility, and explained the purpose of the visit. Administrator Dina Davis arrived shortly thereafter. The investigation consisted of the following: LPAs interviewed Residents #2 - 13 (R2 - R13), Staff #1 - 7 (S1 - S7), toured the facility, tested a call light in a room, and obtained the staff and resident rosters, the physician's report for Resident #1 (R1), the most recent reassessment of R1, the pendant activity report for R1, the admissions agreement for R1, along with serious incident reports (SIRs) for R1 dating from April of 2025 - 7/7/2025. Unsubstantiated In regards to the allegation that "Staff does not respond to resident’s call button in a timely manner," it is alleged that staff take a long time to assist residents when they use their call pendant. During interviews with the residents, eleven (11) out of twelve (12) interviewed did not corroborate the allegation. One residents stated that the staff are all very responsive to when they use their call signal. Another resident stated that staff do respond to her pendant requests for assistance in a timely manner. During staff interviews, none of them corroborated the allegation. One of the staff interviewed explained that the facility utilized pages, tablets, and radios to respond to the pendant requests. Another explained that if one caregiver is busy assisting a resident, then another caregiver is called to address the resident pendant requests. During record review of the activity report for R1, on 6/30/2025 there was a eighteen (18) minute delay from when the resident used their pendant and when the pendant was cleared, and on 6/29/2025 there was a twenty-four (24) minute delay from the time the resident used the pendant and when it was cleared. All other records of R1's pendant use between 6/24/2025 through 7/3/2025 were fifteen (15) minutes or under. Staff stated that the incident on 6/30/2025 was caused by staff assisting R1 immediately and completely before clearing the pendant on their system. On 6/29/2025 they stated that R1 didn't allow staff to clear the pendant. In regards to the allegation that "Facility did not issue refund to resident's responsible party," it's alleged that R1's family was not provided a refund for the monthly fee of July 2025 when they were discharged from the facility on 7/9/2025 because he needed a higher level of care. During interviews with the residents, none of them corroborated the allegation. Most residents interviewed stated they never had to request a refund from the facility. During interviews with staff, none of them corroborated the allegation. One staff interviewed stated that R1 did not require a higher level of care, and that the facility would be able to retain him, and therefore the residents authorized representative needed to issue a thirty (30) day notice of the termination to receive a refund, as indicated on the admissions agreement. Another staff interviewed also stated that R1 was never taken to a Skilled Nursing Facility or Rehabilitation Center, and was taken to a Board and Care facility that houses residents of similar needs. The staff stated the family will still receive a refund of $628.10. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 28-AS-20250715122553

Allegation investigated: Staff retaliates against resident.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Interim Executive Director Dina Davis. The investigation consisted of: A physical plant tour of the interior and exterior, record review, and interviews with residents (R1- R11), and staff (S1- S8) was completed. Copies of resident (R1's) Identification and Emegency Information, Admission Agreement, Eviction Notice (6/25/25), Physician's Report (2/8/2022), Health and Service Evaluation, Resident Assessment, House Rules, LIC 500 Personnel Report, and resident roster were obtained. *See next page for narrative. Unsubstantiated Allegation: Staff retaliates against resident. It is alleged that on June 25, 2025 resident (R1) received a 30-day eviction notice because they expressed concerns regarding the facility to the city council about facility safety. It is also alleged that the licensee has not been responsive to safety concerns such as, unlocked empty rooms and main entrance doors kept unlocked by staff late at night. According to information obtained, when their was a change in ownership the licensee told residents that town hall meetings would be ongoing, and their concerns would be addressed. One (1) out of 11 residents stated administration staff retaliates if residents complain. The majority of the residents had no knowledge of the eviction notice issued to resident (R1). Staff interviews revealed that the eviction notice was issued on June 25, 2025, because in recent months there have been numerous incidents where R1 has become aggressive towards other residents and staff. According to staff, resident (R1) has exhibited unsafe behaviors and broken facility House Rules. Staff denied the allegation. Based on record review, the findings indicate that from April 202 5- to present there have been five incidents of aggressive behavior towards resident and staff. Per House Rules, "Disruptive or abusive behavior by employees, residents, and resident's families or guests is not acceptable or permitted." Therefore, there is insufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to Interim Executive Director Dina Davis.the state’s words, verbatim · CDSS document, Jul 3, 2025 · control 28-AS-20250626151034

Allegation investigated: Staff do not observe residents for change in condition Staff do not assist a resident with grooming Staff do not answer residents' call buttons in a timely manner Staff did not provide resident with housekeeping services Staff did not safeguard a resident's personal belongings

Licensing Program Analyst (LPA) Jose Villalobos conducted an initial unnanounced complaint investigation visit for the allegation(s) listed above. LPA met with Administrator Laura Rodriguez and the purpose of the visit was discuseed. During todays visit, LPA conducted the following: Interviewed Staff #1-7 (S1-S7), interviewed residents #1-10 (R1-R10), LPA toured the physical plants which included rooms #'s 160, 173, 177, 203, 234, 264, 275, and 281. LPA also collected and reviewed documents from R1 and R2's files, collected copies of the staff and client roster as well as reviewed and collected records of call button response times. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Staff do not observe residents for change in condition", it is alleged that R1 has had changes in their condition not observed and addressed by staff. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Staff interviewed stated that R1 and all residents are observed by staff daily. If there are any concerns of changes in their conditions, it is addressed with medical staff. If needed, individual service plans are also updated. Staff interviewed stated that R1's service plan is current and address their needs and services. R1 was not able to express having any issues with their needs and services. Residents interviewed stated that staff are observant of any health issues regarding the residents. File review of R1's needs and services plan shows to have been last updated on 12/7/24. Based on LPA's interviews, observations, and file review the investigation revealed that ; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff do not assist a resident with grooming" it is alleged that there is a resident who walks around in diapers because staff are not meeting their grooming needs. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews did not show there being a resident who walks around the facility in their diaper. Staff interviewed stated that all residents who need grooming assistance will receive it from staff. LPA was not provided further information about any resident who walks around the facility in a diaper. Based on LPA's interviews, observations, and file review the investigation revealed that ; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff do not answer residents' call buttons in a timely manner" it is alleged that staff take 30 to 50 minutes to assist R2 when they press their call button. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Staff interviewed stated that R2 is listed as a 2-person assist, meaning there needs to be 2 caregivers available for assisting with mobility when needed. In some instances it may take longer than 10 minutes to get 2 caregivers into R2's room when there are other residents who need assistance as well but it does not take longer than 30 minutes. Residents interviewed did not have issues with the response times of the staff and stated that they arrive in a timely manner. interview with R2 did not state they had issues with the staff response times either. LPA reviewed the call button response times for R2 and observed an average response time of 11 minutes. Based on LPA's interviews, observations, and file review the investigation revealed that ; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continued on LIC 9099-C In regards to the allegation "Staff did not provide resident with housekeeping services" it is alleged that staff are not cleaning R2's room. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Staff stated that it is facility policy to provide housekeeping services to residents. Rooms are cleaned weekly and any additional assistance can always be requested by the residents. Residents interviewed stated that staff do provide housekeeping services and have no issues with the services. LPA observed housekeeping staff going through residents rooms during the time of the visit. LPA entered R2's room along with other rooms while touring the physical plant and did not observed unattended messes. The facility was clean and in good repair. Based on LPA's interviews, observations, and file review the investigation revealed that ; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff did not safeguard a resident's personal belongings" it is alleged that a resident had 70 dollars taken from their room due to lack of supervision. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. LPA was not provided with specific information regarding who was the resident who had money missing or who could have taken it. Interviews with staff and residents did not provide any names of an individual having 70 dollars taken from them by either staff or another resident. Interviews with staff stated that any reports of missing or stolen items are investigated and local police is contacted. Based on LPA's interviews, observations, and file review the investigation revealed that ; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Administrator Laura Rodriguez and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 28-AS-20250108095853

Type of visit: Case Management - Incident

On 9/24/2024, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced case management visit to follow up on the incident report submitted by the licensee dated 09/16/2024 regarding a staff and a resident. LPA met with Laura Rodriguez, Executive Director and explained the reason for the visit. During the visit, LPA interviewed the Executive Director, Resident #1 (R1) and R1’s responsible party. LPA also obtained copy of residents' census and staff roster. LPA was also informed that Staff #1 was terminated due to the staff #1 actions that did not follow company protocols. The facility has plans of conducting in-service training for current staff. No deficiencies cited during today's visit. Additional follow up may follow. Executive Director Laura Rodriguez was advised, and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 24, 2024

Allegation investigated: Resident was sexually abused while in care Staff did not ensure resident had privacy

On 09/16/2024, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced subsequent complaint investigation regarding the above allegation(s). The complaint was also investigated by IB investigator Dennis Douglas. LPA met with Laura Rodriguez, Executive Director (ED) and explained the reason for the visit. During the visit on 08/01/2024, LPA Baptiste conducted a tour of the facility. The following documents were also obtained for R1: Face Sheet, Physician Report, Level of Care Assessment, Physician’s Order’s, SOC 341, Individualized Service Plan, Admissions Agreement, and Identification and Emergency Information. LPA Baptiste also obtained Staff Roster, Resident During todays visit LPA Baptiste interviewed a total of 9 resident who shall be referred to as R3 through R11. R1 and R2 was interviewed by IB investigator Dennis Douglas. LPA also interviewed the Administrator and a total of 2 staff who shall be referred too as S1 and S2. LPA obtained a copy of the staff roster and resident roster. (Report Continued on 9099c) Unsubstantiated The investigation reveals the following: Regarding “Resident was sexually abused while in care”. It is alleged that R1 was sexually assaulted by R2. The Executive Director (ED) stated this is the second time R1 has made this allegation, and it is during the times the facility has construction. The ED further stated R1 claims R2 lives about their room but R2 lives on the other side of the building. 2 out of 2 staff stated R1 and R2 were friends when R2 first moved in. When R2 started to distance themselves from R1 they noticed R1 started making allegations against R2. Staff further stated that there were other allegations R1 made against R2 but R2 was not around R1. 5 out of 11 residents stated R2 is a nice and respectful person. 4 out of 11 residents stated they don’t know R1 or R2. R1 stated in their interviews with IB investigator that someone in the facility is trying to hurt them but would not elaborate. R2 denied the allegation. LPA reviewed IB’s report from Cerritos College Police department. While the police visited there were thumping noises coming from the ceiling and stated R1 stated R2 was in the room because of those noises. R1 also told the police they were assaulted 3-4 times in the past 4 years but R1 was not living in the facility for 4 years at the time. LPA reviewed R1’s medical records and observed R1 has a diagnosis and a history of dementia and confusion. R1 has since relocated to another facility, needing a higher level of care. The investigation reveals the following: Regarding “Staff did not ensure resident had privacy”. It is alleged that R2 sprays themselves through R1’s vent and is listening in on R1’s phone conversation. The Executive Director (ED) denied the allegation stating the residents have their privacy and R2 lives on the other side of the building. The ED further stated staff knocks and wait for acknowledgment 3 times before entering the resident’s rooms. 2 out of 2 staff confirmed the ED’s statement. 10 out 11 residents stated they have enough privacy while living in the facility. Based on LPA's interviews, observation, and file review the investigation revealed that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Laura Rodriguez Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 16, 2024 · control 28-AS-20240801132548

Type of visit: Case Management - Incident

On 8/12/2024, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced case management visit to follow up on the incident report and SOC 341 submitted by the Executive Director(ED) Laura Rodriguez dated 8/2/2024, regarding a resident and resident altercation. During the visit, LPA interviewed the Executive Director. According to SOC 341 and Incident report, it is alleged that on 8/02/2024, R1 exhibited aggressive behavior towards R2 and R3. R1 tried to sit on the couch between R2 and R3. R2 and R3 tried to tell R1 to hold on so they can make some space. R1 then proceeded grabbed R2 by the arm and let a scratch. Staff was contacted and helped R1 to the room. The ambulance or police was not contacted for the incident. Per ED R1 was had a move out date prior to the incident and the family has opted to move R1 to facility requiring a higher level of care. The facility stated there are no issues at this time. Additional follow up may follow. Executive Director Laura Rodriguez was advised, and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Wong conducted the Unannounced required annual inspection. LPA arrived unannounced and met with Administrator Laura Rodriguez and assisted with the visit. The purpose for the visit was explained. The facility is licensed for age range 60 and over and 163 non-ambulatory residents. Currently, the facility has 9 hospice waiver residents and 8 home health residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control Plan: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan in place. LPA reviewed staff files and observed two staff does not have chest x ray result and one staff does not have health screening in file. 2. Operational Requirement: The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 25 residents is approved. A fire clearance approved for 163 non-ambulatory residents. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($10,000,000) is in place. 3. Physical Plant and Environmental Safety: LPA toured the facility with the Executive Director Laura Rodriguez. This property is comprised of one large two story building on 5.5 acres and contains (90) studio apartments, (42) - 1-bedroom apartments, (12) 2- bedroom apartments, first floor; Lobby/Front desk reception area, administrative offices, Computer room, Salon, Coffee Lounge, Dining room, Kitchen, Community Laundry room, Housekeeping Storage closet, Men/Women restroom, (2) utility rooms. Second floor; Program Director office, Director of Nursing office, Staffing Coordinator office, Medication room, Library, Fitness Center, Theater/Multipurpose room, Men/Women restroom, (4) utility rooms, Storage room (emergency food supplies) and (PPE supplies). The outdoor grounds contained body of water in a fountain, East Wing Courtyard, West Wing Courtyard and community park. Passageways, walkways, and patios are free from obstructions and hazards. The facility is equipped with central air and heat. LPA inspected 10 residents' rooms and each resident bedroom has the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid matt/strips and shower chair. The temperature measured between 107.6 and 116.4 degrees F which is with in the Title 22 regulation. The carbon monoxide detectors and smoke detectors are interconnected and all tested and they are all working well. 4: Staffing: Facility has sufficient staffing for care and supervision to the residents. All the staff in the facility are over 18 years old, background clearance and associated with the facility. The administrator is Laura Rodriguez and her administrator certificate is effective through 3/3/25 and she has all the required training hours and staff has the required training hours annually. 5. Personnel Record-Training : LPA reviewed staff files and they have the required documents included employee application and they have at least one person has the required CPR training certificate 6. Resident Right Information: LPA observed the required posters posted in the facility which include Long Term Care Ombudsman located on the second floor next to the resident's laundry room, and the Community Care Licensing Complaint and Personal Right Poster are located on the first floor nearby the resident's mailbox. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician. 7. Planned Activity: Facility has sufficient space to accommodate for indoor and outdoor activity. LPA also observed the weekly activity calendar and it's posted in the facility. The facility does have an active Resident Council. 8. Food Service: Currently the facility has about 5 residents who are required the modified diet and LPA reviewed and observed the doctor's order. The facility has ample supply for two days perishable and seven days non-perishable food supply. The facility also has emergency food supplies and water located on the first floor. All the food are stored properly. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked. Walls and floors, cabinets and counters were clean and sanitary throughout the facility. 9. Incidental Medical and Dental: Nine (9) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided if needed. 10. Resident Record-Incident Reports: LPA inspected 10 resident files and they all have the required documents in file which include: Identification and Emergency Information, Pre-admission appraisal, admission agreement, recent medical assessment and TB test result, medical consent and medication record. 11. Disaster Preparedness: The facility has an updated LIC610E Emergency Disaster Plan. The facility has two alternative shelter location for emergency. The last fire /disaster drill was conducted on 5/15/24. LPA also observed the evacuation chair at each stairwell. Records of resident Appraisal and Needs services plans are part of Emergency training. 12. Residents with Special Health Needs: Night (9) residents are receiving hospice services. Eight (8) residents receive home health services. No resident in the facility is on any postural support. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Executive Director Laura Rodrigeuz. A copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jul 26, 2024

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure that residents were served food free from contamination.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit regarding the above allegation. LPA met with Martha Altamira (Resident Care Director) and explained the reason for the visit. The investigation consisted of the following: On 04/18/2024, LPA obtained copies of staff & resident rosters, a Public Health list with names of all residents and staff that got sick, and interviewed Resident Care Director, Staff 1 (S1), and Department of Public Health representatives, and conducted a tour of the kitchen. During today's visit, LPA interviewed Staff 2 - Staff 4 (S2 - S4) and Resident 1 - Resident 12 (R1 - R12), and conducted a tour of the kitchen. Regarding the allegation: "staff did not ensure that residents were served food free from contamination”, it is alleged that over twenty residents and three staff became sick after they consumed breakfast, lunch and dinner meals served from the facility's kitchen. (Continued to LIC 9099-C) Unsubstantiated Administrator believes that residents and staff did not get sick from facility's food. She stated that there was an outbreak and LA County Public Health got involved. LA County Public Health determined that there was a norovirus outbreak based on some stool collected and tested. Administrator stated that their first case was Resident 1 (R1). Resident 1 (R1) vomited in the dining room on 04/08/2024. After this incident, many residents and staff started getting sick. Administrator stated R1 was not showing any symptoms until R1 vomited in the dining room. Administrator believes this incident might have been the beginning of the norovirus outbreak, but LA County Public Health was not able to determined the cause of the norovirus. LPA reviewed the LA County Public Health list of all the residents and staff that got sick and observed a total of 32 residents and 18 staff. R1's date of onset illness was 04/08/2024 and everyone else is either 04/10/2024 or after. The LA County Public Health Nurse assigned to this outbreak stated that the case was assigned to her on 04/11/2024 and it was determined that it was a norovirus outbreak based on test results from some stools they collected. The nurse also stated that unfortunately they were not able to determined the source of this outbreak and this case was closed on 04/25/2024. LPA conducted a tour of the kitchen on 04/18/2024 and today, and did not observed any concerns with the food. Staff interviewed believe they got sick from providing care to the residents that were sick and not from eating the facility's food. Residents interviewed did not provide any information that indicated that the facility's food was the cause of the sickness. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, May 16, 2024 · control 28-AS-20240417083844

Allegation investigated: Staff did not follow resident's care plan resulting in resident obtaining a prohibited health condition.

**Please note: This licensing report has been amended to remove confidential information. However, the findings of this report will not change.** Licensing Program Analysts (LPA's) V. Maldonado and Tyler Reyes made an unannounced subsequent visit to the facility, for the purpose of delivering the amended report. LPA met with Executive Director, Laura Rodriguez, and explained the reason for the visit. On 04/19/24, LPA Maldonado made an unannnounced visit to the facility to deliver findings regarding the above-mentioned allegation. LPA Maldonado met with staff, Kris Schero, and explained the purpose for the visit. On 01/31/23, LPA Ashley Calderon conducted a health and safety inspection. The visit consisted of the following: A tour of the physical plant with Carmen, residents rooms# 103,109,126,136, 279, 204 and 205, and common areas. LPA also observed food supplies, and obtained a copy of the staff and resident rosters, and the following documents for Resident #1: Admission agreement, Emergency Identification, previous and current Physicians Report, Resident Assessment, Physician Orders/Medication List, Dignity Palliative Hospice Care Reports, Hospice Plan of Care, Progress Notes, Outside Provider Communication Logs, Resident Care Notes, Recent Doctor visit reports, Indicent Reports, Individualized Service Plan and the Appraisal/Pre Appraisal Needs and Services Plan. LPA observed facility and residents in care and did not observe there to be any health and safety concerns. (Report Continued on LIC9090-C...) Substantiated On 04/04/24, LPA Maldonado made a subsequent visit and met with Executive Director, Laura Rodriguez. During the visit, LPA obtained a copy of the resident and staff rosters, and conducted interviews with Staff# 8-14 (S8-S14), and Residents# 2-7 (R2-R7). LPA also obtained copies of the following documents for R2-R7: Facesheet, Physician's Report, and Needs and Services Plan. LPA was unable to interview Resident#1 (R1) due to R1 deceased. The investigation for the above-mentioned allegation was conducted by the department. The investigation consisted of the following: Interviews conducted with Staff#1-7 (S1-S7) and Witness# 1-2 (W1-W2), and obtained the following records for R1: Facility Service Plan, Resident Assessment, Individualized Service Plan, facility Assessment Notes dated: 08/08/22, 09/12/22, and 11/25/22, facility shift reports, facility Communication notes from Hospice, Hospice Care Notes, Transfer/Discharge report from Skilled Nursing facility, Hospital records dated 12/14/22. R1 was not interviewed due to R1 deceased. The investigation revealed the following: Staff did not follow resident's care plan resulting in resident obtaining a prohibited health condition. It is alleged that per R1's care plan, R1 was required to be repositioned every (2) hours, however staff did not follow the care plan, which lead R1's Stage I pressure wound to become a Stage III pressure wound. Per the investigation, R1 sustained a fall at the facility in November 2022 which resulted in a hip fracture. Following surgery from the fracture, R1 was at a skilled nursing facility where R1 developed a Stage I pressure wound on the buttocks due to R1 becoming bedridden. Per R1's updated facility service plan, dated: 11/25/22, R1 had a change in condition which required R1 with hands on assistance for repositioning in bed due to becoming bedridden. Per staff interviews, (7) of (7) staff stated that R1 was repositioned as per R1's care plan. However, R1 was repositioning self onto R1's back after being repositioned by staff. Per records review, it was discovered that the facility did not update R1's care plan to address R1 repositioning self back after being repositioned by facility staff, which led to R1's Stage I pressure wound becoming a Stage III pressure wound. Therefore, this allegation is Substantiated. Based on observation and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on LIC9099-D. Immediate Civil Penalties in the amount of $500 will also be issued. An exit interview was conducted and a copy of this report, and appeal rights were provided. The following allegation was investigated by the department: Resident in care sustained multiple falls resulting in a hip fracture while in care. The investigation consisted of the following: Interviews conducted with Staff#1-7 (S1-S7) and Witness# 1-2 (W1-W2), and obtained the following records for R1: Facility Service Plan, Resident Assessment, Individualized Service Plan, facility Assessment Notes dated: 08/08/22, 09/12/22, and 11/25/22, facility shift reports, facility Communication notes from Hospice, Hospice Care Notes, Transfer/Discharge report from Skilled Nursing facility, Hospital records dated 12/14/22. R1 was not interviewed due to R1 deceased. The investigation revealed the following: Regarding allegation: Resident in care sustained multiple falls resulting in a hip fracture while in care. It is alleged that R1 had multiple falls while in care at the facility, which resulted in R1 sustaining a hip fracture that required surgery. Per the investigation, R1's first documented fall occurred in November 2022. The fall that occurred at that time resulted in R1 sustaining a hip fracture. Per R1's Pre-Placement appraisal and Individualized Service Plan, R1 was not a fall risk at this time. R1 returned to the facility on 12/09/22 and was placed on hospice to receive wound care due to R1 being bed bound and sustaining wounds while in a skilled nursing facility, following recovery from the hip surgery. Per R1's hospice records dated 1/20/23, 1/30/23, and facility shift reports dated 1/20/23 and 1/26/23, it was noted that R1 was found by caregivers on the floor, tangled in R1's blankets with no visible injuries. From 2/07/23 through 2/10/23, R1's family hired a private caregiver through a home health company to provide 1:1 care to R1 during the night, as it was noted that R1 was getting up at night and sustaining more frequent falls. Per staff interviews, (7) of (7) staff stated they did not witness R1's falls. R1 was found on the floor during their regular status checks. Staff also stated that due to R1's falls were becoming more frequent due to R1's progression of R1's cognitive impairment. The allegation suggests that the multiple falls culminated in the resident sustaining a hip fracture. There was no evidence to prove that R1 was a fall risk prior to the fall that resulted in a hip fracture. Therefore, this allegation is Unsubstantiated. On 04/04/24, LPA Maldonado made a subsequent visit and met with Executive Director, Laura Rodriguez. During the visit, LPA obtained a copy of the resident and staff rosters, and conducted interviews with Staff# 8-14 (S8-S14), and Residents# 2-7 (R2-R7). LPA also obtained copies of the following documents for R2-R7: Facesheet, Physician's Report, and Needs and Services Plan. LPA was unable to interview Resident#1 (R1) due to R1 deceased. (Report Continued on LIC9099-C...) During the visit, LPA Maldonado investigated the following allegations: Resident fell and was left unattended on the floor for an extended period of time. Resident is not being transferred out of bed by staff on routine basis. Staff are not assisting resident with oral hygienes & dressing. Regarding allegation: Resident fell and was left unattended on the floor for an extended period of time. It is alleged that on 1/19/23, R1 fell out of bed and was found on the floor by facility staff about (3) to (4) hours later, on 1/20/23. Per incident reports dated 1/20/23, R1 was found on the floor at 1:45AM during status check rounds conducted by facility staff. It was noted that R1was assessed for injuries and assisted back into bed. At 4:45AM, during status check rounds, facility staff found R1 on the floor again. R1 was assessed for injuries again and was assisted back into bed by staff. Per staff interviews, (7) of (7) staff denied the allegation. Staff stated that R1 was getting up at night more frequently, so R1 was placed on status checks every (2) hours. There is insufficient evidence to prove the amount of time R1 was on the floor for before staff found R1 while conducting their status checks. (6) of (6) residents interviewed could not corroborate the allegation. Regarding allegation: Resident is not being transferred out of bed by staff on routine basis. It is alleged that R1 is not being transferred out of bed on a routine basis and as a result, R1 is becoming more contracted. Per hospice records dated 2/04/23, R1 was to be assisted with repositioning every (2) hours due to a pressure ulcer on R1's coccyx and R1 being bedbound, and required assistance with transferring out of bed/chair. Per medical and hospice records, there is no indication that R1 was contracted. (7) of (7) staff interviewed denied the allegation. Staff stated that residents who require repositioning and assistance with transfers are assisted as required and as needed, based on their care plans. During interview with R2, R2 reported that staff come in frequently to assist with repositioning and transferring, as they require it. (5) of (6) residents interviewed could not corroborate the allegation. Regarding allegation: Staff are not assisting resident with oral hygienes & dressing. It is alleged that the facility is charging R1 an excessive amount of fees to provide services that R1 is not receiving, such as providing oral hygiene twice a day and assisting R1 with changing clothes daily, as R1 was found in only a shirt and briefs during the fall incident on 1/20/23. (7) of (7) staff interviewed denied the allegation and stated that R1 and other residents who require assistance with oral hygiene are assisted (2) to (3) times a day. (Report continued on LIC9099-C...) Staff stated sometimes residents may deny the care, however they will attempt at a later time and encourage them to complete the care. If residents continue to deny, it is charted and communicated to the staff on the incoming shift so that they may offer residents the care again. During interview with R2, R2 stated that staff assist R2 with oral hygiene care, changing clothes, and incontinence care frequently. (5) of (6) residents interviewed could not corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 19, 2024 · control 28-AS-20230130161858

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a)(3) · Plan of correction due date: Apr 20, 2024

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...(3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This requirement was not met as evidenced by: Based on interviews and record review, the Licensee failed to update R1's appraisal to document that R1 was repositioning R1's self after staff were repositioning R1 that led to R1 sustaining a Stage III ulcer while in care, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 19, 2024

Plan of correction: Licensee will submit a plan in writing on how facility will esnure to document all resident changes in condition to prevent prohibited health conditions.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of citing deficiencies. LPA Maldonado met with and explained the purpose for the visit. During the investigation conducted for a complaint, dated: 1/30/23, it was discovered that in November 2022, Resident#1 (R1) sustained a fall at the facility that resulted in a hip fracture and required surgery. At the time of the incident, R1 was not deemed a fall risk. After surgery, R1 was transferred to a skilled nursing facility to recuperate from the surgery, and returned to the facility on 12/09/22. Per facility shift report dated 1/18/23, R1 was to have status checks during night shifts every (2) hours. Per facility incident reports dated 1/20/23 and 1/30/23, it was documented that R1 sustained (2) falls on 1/20/23 at 1:45AM and 4:30AM, and (1) fall on 1/30/23 at 11:20PM. Upon being notified of more frequent falls, R1's family decided to hire a private caregiver to provide 1:1 night supervision to R1 to keep R1 from falling out of bed. Per staff interviews conducted during the investigation of the complaint, (7) of (7) staff admitted to having knowledge of R1 becoming more agitated at night and trying to get up out of bed, which resulted in frequent falls. Staff stated this was due to R1's progression of R1's cognitive impairment. After review of R1's updated facility service plan, dated: 11/25/22, R1 had a change in condition which required R1 to have hands on assistance for repositioning in bed due to becoming bedridden. Following the incident reports of falls sustained by R1, there was no update to R1's service plan/plan of care to reflect that R1 was now a fall risk. The facility failed to put a plan in place to prevent R1 from sustaining continued falls, while in care. Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC809-D page. Exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 19, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(5)(A) · Plan of correction due date: Apr 26, 2024

87705 Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment…and a reappraisal done…(A)When…observation indicates that the resident’s needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement was not met as evidenced by: Based on record review and interviews, the Licensee failed to update R1's Physician's Report and Appraisal to indicate that R1 was now a fall risk, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 19, 2024

Plan of correction: Licensee will submit a plan in writting on how they will ensure to update resident records as needed, especially if a change in condition is observed. Plan to be emailed to LPA by POC due date.

Allegation investigated: Licensee did not ensure pre-admission appraisal was done correctly Facility did not issue the correct refund amount

Licensing Program Analyst (LPA) Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. LPA met with Staff #1 Randyl Lowe (Receptionist) who allowed entry into the facility and was later met by Administrator Laura Rodriguez who assisted with the visit. The investigation consisted of the following: On 12/20/22, LPA Wong interviewed the administrator, 4 staff (S1-S4) and 13 residents (R2-R14) and obtained the current staff roster and resident roster. On 6/28/2022, Licensing Program Manager (LPM) Sicairos conducted an initial 10-day complaint and obtained copies of Staff & Resident Rosters, reviewed Former Resident #1 (FR1) file, and obtained copies of Identification and Emergency Information Sheet, Physician's Report, Admission Agreement, Service Plan, Progress Notes, Resident Appraisal, Admission Orders, and Resident Detail Ledger. LPA interviewed Ms. Mosalla and Staff #1 (S1). (See LIC 9099C for continuation) Unsubstantiated The investigation revealed of the following: Allegation#1 “Licensee did not ensure pre-admission appraisal was done correctly.” It is alleged that the facility told R1's family that R1 requires more care than the facility can provide and the facility told R1's family to hire an outside agency to provide additional care while the family is looking for a new care home for R1. LPA interviewed 13 residents and all denied the allegation and indicated the facility is able to provide the assistance that residents required and needed. LPA interviewed the staff and denied the allegation and stated before resident move in to the facility, the facility would complete a pre-appraisal assessment along with the primary care physician report and review resident’s medication and also see if resident is under fall risk or not. They would also complete a 30-day assessment after resident move in and communicate with the families and see if the resident required full assistance. Based on the documents reviewed, the facility completed the resident’s appraisal and a comprehensive health and service evaluation with needs and service plan for R1. The facility also assessed R1’s fall risk and the level of care. In addition, the facility tried to accommodate residents’ needs and let R1’s family stay with the resident during the transition period. Allegation#2 "Facility did not issue the correct refund amount." It is alleged that R1 should have been refunded more than what the facility provided upon leaving the facility. LPA reviewed R1's financial records and conducted interviews with staff. R1's record review revealed that the facility charges a $3500 community fee. However, R1 received promotional offer which waived $2000 of that initial fee, therefore R1's family only paid a $1500 community fee upon moving in on 05/07/2022. The monthly charges for May 2022 was scheduled to be $3207, however R1 only lived at the facility for two weeks, therefore paid a prorated amount of $2762 for the month instead. Per the Admission Agreement signed by R1's family, they were entitled to an 80% refund of the community fee which equaled to $1193. In addition the facility agreed to provide a "miscellaneous fee" in the amount of $310 to R1's family which was not required per the Admission Agreement. In conclusion, R1's paid a total of $6707 but was refunded $4265. There was no evidence obtained during the investigation indicating that R1's family should have received a larger refund. Based on statements and interviews conducted with staff and residents and documents reviewed, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit Interview Conducted. A copy of the report was provided to the Executive Director Laura Rodriguez.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 28-AS-20220623080038

Allegation investigated: Staff do not maintain facility at a comfortable temperature for resident

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced subsequent complaint investigation regarding the above allegation. LPA met with Laura Rodriguez Executive Director and explained the reason for the visit. During the visit, LPA Lopez conducted a tour of the facility with Executive Director Laura Rodriguez. LPA Lopez interviewed Executive Director S1, 4 staff S2 through S5 and total of thirteen (13) residents who shall be referred to as R1 through R13. LPA Lopez obtained staff roster, resident roster, one (1) month of work orders, Report from specialty A/C and heat dated 12/01/2023 R1’s physician report, referral for R1 to Physician dated 12/23/2023. LPA took photos of the thermostats in the facility common areas and random rooms. (Continued on 9099C) Unsubstantiated The investigation revealed: Allegation: Staff do not maintain facility at a comfortable temperature for resident. It is alleged that resident did not have heat for over a week, that it is 69 degrees F in R1 room. LPA interviewed 5 total staff including 2 maintenance technicians and 5 of 5 staff denied the allegation. The technicians stated that the have had many work orders due to R1 complaining about the temperature in R1 room and that after inspecting the room, it has been confirmed that R1 thermostat is functioning properly. The facility also provided 2 portable heaters to provide R1 with alternative heat due to R1 insisting that R1 room heat is not working and alleging that is it blowing cold air. LPA was in R1 room for some time measuring the temperature in R1 room. The temperature was 82 degrees at the time of measurement and felt warmer than that to LPA. LPA did not notice or feel any cold air coming from the vent as alleged. LPA checked temperatures throughout the facility, and it measured 72.8 degrees in the facility sample room #145. It was 75.3 degrees in hallway adjacent to room 117. LPA along with Laura Rodriguez Executive Director checked the temperatures in rooms 116, 117,119,123, 125, 120, 127, 129, and 246 and they measured between 73.9 degrees F to 78.0 degrees F which is within regulatory range. LPA interviewed 13 residents and 13 of 13 could not collaborate the allegation. Mostly all the residents stated that the temperature in the rooms are comfortable, and they have no complaints. 2 residents stated that the cold goes through the window in their rooms, but stated the room is comfortable. One resident stated the heat goes through the window in room. LPA suggested to Laura Rodriguez Executive Director to follow up with the 3 residents’ window issues to check if windows have failed. LPA tested the thermostat in R1 room, and it was operating properly. R1 had stated that one of R1 portable heaters was not working. LPA, Laura Rodriguez Executive Director, and S2 verified that it was working and S2 instructed R1 on how to operate it. On initial visit on 12/22/2023, LPA suggested that facility make R1 physician aware of R1 concerns about feeling very cold most of the time while in R1 room. Facility did follow-up with R1 physician right away and tests were order and results pending. LPA obtained invoice from Specialty A/C that confirms that the A/C-Heating unit in room 117 is working properly. Facility has also offered to move R1 but R1 refused. LPA did not find any evidence to substantiate the allegation. Based on LPA's interviews, observation, and file review the investigation revealed that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Laura Rodriguez Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 18, 2024 · control 28-AS-20231219092627

Allegation investigated: Staff are not maintaining a comfortable room temperature for resident.

On 12/04/2023 at 08:00 a.m., Licensing Program Analyst(s) (LPA) Jewel Baptiste and Sanjay Vaid conducted an unannounced subsequent complaint investigation regarding the above allegation(s). LPAs met with Laura Rodriguez Executive Director and explained the reason for the visit. During the visit on 11/30/2023, LPA Baptiste conducted a tour of the facility. LPA checked the thermostat in rooms #117,163,179,201, 210, 219, and 227 with Executive Director Laura Rodriguez. LPA Baptiste interviewed Executive Director and a total of five (5) residents who shall be referred to as R1 through R5. LPA Baptiste obtained staff roster, resident roster, one (1) month of work orders, Ontario Refrigeration dated 6/9/2023, Report from specialty A/C and heat dated 11/28/2023, R1’s physician report, and photos from Executive Director regarding the thermostat in room#117. LPA took photos of the thermostats in the facility common areas. Report Continued on 9099c Unsubstantiated The investigation reveals the following: Regarding “Staff are not maintaining a comfortable room temperature for resident”. It is alleged that R1’s room is very hot in the summer and very cold during the winter. The Executive Director denied the allegation stating each resident have an individual unit that they can control, if the A/C unit is not working the resident can put in a work order and received a portable unit if needed. The Executive Director further stated R1’s A/C unit is operational and has been inspected by two (2) A/C companies who found no issues. 2 out of 2 staff denied the allegation stating all the A/C units work and they respond right away. 10 out of 13 residents stated their system work and they call for assistance whenever they want to change it. 1 out of 13 residents stated their A/C unit is not working but was given portable A/C unit until the repairs are made. 1 out of 13 residents stated their A/C unit is not operational. LPA’s reviewed A/C invoices and confirmed the A/C units are operating normally. Based on LPA's interviews, observation, and file review the investigation revealed that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Laura Rodriguez Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 4, 2023 · control 28-AS-20231121100332

Allegation investigated: Facility failed to provide a safe environment for residents Facility failed to provide a comfortable temperature for residents

On 10/10/23 at 8:34 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted two unannounced complaint visits in-conjunction. Upon arrival LPA was greeted by receptionist and activites director Chelsea Vandueck. The Executive Director Laura Rodriguez arrive at 9:50 and LPA explained the purpose of the visit. During the initial investigation on 3/14/2023: A physical plant tour and interviews with staff (S1-S2), and resident (R1-R3). The following documents were obtained: Photo of the thermostats, Staff schedule, admissions agreement, Evacuation order, LIC 500 Personnel Report, and resident roster. Report continued on 9099c Unsubstantiated During today’s visit LPA interviewed seven (7) Residents who shall be referred to as R4 through R10. The investigation reveals the following: Regarding "Facility has insufficient staffing to meet residents’ needs.”. It is alleged that the facility has a high turnover rate, which led to residents waiting more than an hour for food. The Executive Director at the Time (Lilit Charparyan) denied the allegation stating it has never taken a 1 ½ hours for the residents to receive their food. 2 out of 2 staff denied the allegation. 8 out of 10 residents stated due to the lack of staff they have had to wait an hour or more for their food. 2 out of 10 residents stated they don't eat at the facility or they get there food in 10-15 minutes. Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met,therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D. Exit Interview Conducted with Executive Director/ Appeal Rights Provided / A Copy of the Report Issued. During today’s visit LPA interviewed Eecutive Director Laura Rodriguez and seven (7) Residents who shall be referred to as R4 through R10. The investigation reveals the following: Regarding Facility failed to provide a safe environment for residents". It is alleged that the facility staff leaves the back door unsecured. Executive Director Laura Roriguez denied the allegation stating the staff ensure they provide a safe environment to the residents and secures the perimeter. The former Executive Director (Lilit Charparyan) denied the allegation stating the facility secures the door after hours. 9 out of 10 residents denied the allegation stating they feel safe. 1 out of 10 residents stated the facility never secures the doors. 2 out of 2 staff denied the allegation stating the back doors are always secured after hours. The investigation reveals the following: Regarding “Facility failed to provide a comfortable temperature for residents ". It is alleged that the facility is always cold. The Executive Director Laura Rodriguez stated the residents have individual thermostats and staff assists if the residents do not know how to operate the device. The former Executive Director (Lilit Charparyan) denied the allegation, stating residents have individual thermostats in their room that they can adjust themselves. 2 out of 2 staff denied the allegation, stating that the thermostats can be adjusted by the residents. 7 out of 10 residents stated they are fine with the temperature. 1 out of 10 residents stated the facility doesn’t turn on the heating system and the facility is extremely cold. 2 out of 10 residents stated the thermostat was broken and has been repaired. LPA toured the facility and observed the temperature was 77 degrees. LPA also toured residents’ bedrooms and observed their thermostat was between 77-78 degrees. Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Laura Rodriguez and a copy of this record provided.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 28-AS-20230307090726

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 31, 2023

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidence by: Based on interviews 8 out of 10 residents stated due to the lack of staff they have had to wait an hour or more for their food, which poses an potential health,safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: The facility will ensure there are sufficent staffing in the kitchen to provide residents meals in a timely manner. Facility Administrator stated they are working on stream lining the kitchen services and hired new kitchen staff. The facility will provide training to all kitchen staff and send training to LPA by POC due date.

Allegation investigated: Staff did not assist resident with ADLs Staff did not meet resident's needs

On 10/10/23 at 8:34 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted two unannounced complaint visits in-conjunction. Upon arrival LPA was greeted by receptionist and activites director Chelsea Vandueck. The Executive Director Laura Rodriguez arrive at 9:50 and LPA explained the purpose of the visit. During the initial investigation on 10/03/2023: LPA obtained resident roster, staff roster, R1 admissions agreement, R1’s physicians report, R1’s Hospice plan of care, R1’s resident assessment, R1’s resident information form, R1’s hospice treatment plan, R1’s physicians orders from hospice agency. LPA interviewed: The residential care director and (1) staff who shall be referred to as S1. LPA interviewed a total of ten (10) residents who shall be referred to as: R2 through R11. LPA also interviewed a former resident who shall be referred to as R1. LPA interviewed resident family members and hospice agency who shall be referred to as witness #1 (W1) and witness #2 (W2). LPA is currently waiting on additional documents from an outside agency. Report continued on 9099C Unsubstantiated During today’s visit LPA interviewed Executive Director Laura Rodriguez and delivered findings for the investigation. The investigation reveals the following: Regarding " Staff did not assist resident with ADLs.”. It is alleged that the facility does not assist with the residents’ activities of daily living (ADL). LPA interviewed Executive director Laura Rodriguez and Resident Care Director, Martha Altamira, who denied the allegation stating the facility assist’s residents with ADLs. They further stated residents are reassessed every resident quarterly to ensure their needs are met. 1 out of 1 staff stated the facility assists residents with their ADL’s. 8 out of 10 residents stated the facility helps them with their activities of daily living or they do not need assistance with their activities of daily living. 1 out 10 residents stated the facility was not assisting with their activities of daily living. 1 out of 10 residents stated the facility was not assisting ADL’s. The investigation reveals the following: Regarding " Staff did not meet resident's needs.”. It is alleged that the facility is not meeting the needs of the residents. LPA interviewed Executive Director Laura Rodriguez and Resident Care Director, Martha Altamira, who denied the allegation stating the facility has always met the needs of the residents. 8 out of 10 residents denied the allegation stating the facility has always met their needs. 2 out of 10 residents stated the facility was not able to meet their needs. Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Laura Rodriguez and a copy of this record provided.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 28-AS-20230925081542