Ivy Park at Claremont

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual inspection utilizing the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by facility staff, who were informed of the purpose of the visit. Daisy Hernandez, Administrator, arrived shortly thereafter. This facility is licensed to serve eighty-one (81) residents, age 59 and older, of whom eight (8) may be bedridden on the first floor only. The facility may retain no more than twenty (20) hospice residents. At the time of the inspection, thirteen (13) residents were receiving hospice services. The facility provides care to both Assisted Living and Memory Care residents. At the time of the inspection, the facility census was sixty-one (61) residents. Physical Plant and Environmental Safety: LPA toured the Assisted Living and Memory Care (Evergreen) areas of the community. A total of twelve (12) resident rooms were inspected. All resident rooms contained the required furniture, linens, and adequate lighting. Water temperatures in resident grooming and bathing areas measured between 105°F and 120°F. Water temperatures in public restrooms located on the first and second floors were also tested and measured within the required regulatory range of 105°F to 120°F. Public restrooms displayed postings encouraging proper handwashing, and resident bathrooms were equipped with grab bars adjacent to toilets and inside showers. Disinfectants, cleaning supplies, poisons, and other hazardous materials were observed to be secured and inaccessible to residents. Carbon monoxide detectors and smoke alarms were observed in resident bedrooms and hallways. LPA also observed evacuation chairs positioned in stairwells for emergency use. LPA observed the facility to be clean, odor-free, and maintained in good repair. Interior and exterior passageways were free of obstructions and provided safe ingress and egress for residents. Outdoor areas were furnished with appropriate seating and shade, allowing residents access to safe outdoor recreational space. (continued on 809C) Food Service: LPA toured both dining areas and the kitchens that serve the Assisted Living and Memory Care residents. LPA observed proper food storage, food preparation, and food handling practices throughout both kitchen areas. No chemicals, cleaning supplies, or other hazardous substances were observed in food preparation or food storage areas. LPA discussed with kitchen staff the process for monitoring and providing meals to residents with physician-ordered special diets. LPA observed the community’s daily and weekly menus, which were posted and available for resident review. Food menus were readily available throughout the community. The facility maintained at least a one-week supply of nonperishable food and a minimum two-day supply of perishable food. Soaps, detergents, and cleaning compounds were stored separately from food supplies. Freezers and refrigerators were clean and maintained at appropriate temperatures. Freezers measured approximately 0°F (-17.7°C), and refrigerators were maintained at or below 40°F (4.4°C). Planned Activities: LPA observed residents participating in a staff-led group exercise class. The July 2026 activity calendar was posted and included a variety of recreational activities, fitness programs, social events, and scheduled community outings. LPA observed adequate outdoor recreational space for residents, providing opportunities for outdoor activities, relaxation, and social interaction. Amenities: LPA observed that the community offers a variety of amenities for resident use, including activity rooms, an on-site beauty salon, and outdoor patio areas with beautiful scenery. These amenities provide residents with opportunities for recreation, social engagement, personal care, and enjoyment of the outdoor environment. LPA observed the amenities to be clean, well-maintained, and available for resident use. Residents Council Meeting: LPA reviewed documentation of the facility's monthly Resident Council meetings. The meetings provide residents with an opportunity to voice concerns, offer suggestions, discuss community matters, and participate in decisions affecting their living environment. Documentation reflected the facility's ongoing efforts to encourage resident participation and promote resident rights within the community. Resident Rights/Information: LPA observed the required postings displayed throughout the facility's common areas, including the Complaint Poster (PUB 475), Personal Rights, and the Nondiscrimination Notice. Internet access was also available for resident use. (continued on 809C) Health-Related Services & Records Seven (7) resident files were reviewed. Files contained current required documentation, including Admission Agreements, signed consents, Needs and Services Plans, Physician's Reports documenting TB results and ambulatory status, and signed Resident Rights acknowledgments. Residents' medications were reviewed. Medications were observed to be centrally stored in the facility's medication room in locked medication cabinets, locked medication carts, and a locked medication refrigerator. All medications observed were maintained in a secure manner and inaccessible to residents. Personnel Records & Training Five (5) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings. Administrator Certificate for Daisy Hernandez was valid through February 7, 2027. Disaster Preparedness LPA received copies of the facility's Telgian Fire Sprinkler System Inspection/Test Reports, including the required comprehensive inspection report dated June 22, 2026. Facility records reflected that the last fire and earthquake drill was conducted on May 27, 2026. Documentation of emergency drills was available for LPA's review. LPA observed that the facility's LIC 610D, Emergency Disaster Plan, was in the process of being updated. Emergency disaster supplies, including potable water, nonperishable food, flashlights, batteries, and first aid supplies, were observed and appeared sufficient to meet emergency preparedness requirements. LPA reviewed the facility's current liability insurance policy and verified that coverage is in effect through May 1, 2027. An exit interview was conducted with Daisy Hernandez, Administrator. During the inspection, the facility was observed to be following Title 22, Division 6 regulations. No deficiencies were cited at this time. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 7, 2026

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not distribute resident's medication as prescribed.

***This report supersedes the report dated 04/30/26 and was updated to correct the date of the medication incident from August 2025 to August 2024. No other changes made to the report findings remain unchanged. *** Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 04/30/2026 to deliver findings related to the above allegation. LPA met with Administrator Daisy Hernandez and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, R1’s face sheet, R1’s Physician’s Reports, medication documentation, and reimbursement documentation. LPA conducted interviews with two (2) staff members and R1. (continued on 9099C) Substantiated Allegation: Staff Did Not Distribute Resident’s Medication as Prescribed It is alleged that facility staff did not ensure that R1’s medication was properly handled and made available as prescribed. During interviews and record review, it was determined that in or around August 2024, there was an incident in which R1’s medication was received by the facility but was subsequently misplaced prior to being provided to R1. Staff acknowledged the incident and reported that corrective action was taken, including reimbursement to R1. During R1’s interview, R1 stated that his medication was delivered to the facility but was not located in his room as expected. R1 reported that he went one day without the medication, requested an overnight delivery, and subsequently received it. R1 further stated that staff provided him with $90 in cash as reimbursement for the misplaced medication. Documentation reviewed included a copy of the funds issued to R1, confirming the reimbursement. However, the Department could not confirm whether a dosage medication was missed as a result of this incident. 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 1 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, May 7, 2026 · control 28-AS-20260424080523

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 15, 2026

(a) A plan for incidental medical ... care shall be developed by each facility. The plan shall encourage routine medical care and provide assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, interviews, and record review, facility did not comply with the cited section, as R1’s prescribed medication was misplaced after being received by the facility which poses/posed an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: The facilty will ensure all medications received at the facility are properly logged and immediately provided to the resident or securely stored. A plan will be provided to LPA.

Allegation investigated: Staff did not distribute resident's medication as prescribed.

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 04/30/2026 to deliver findings related to the above allegation. LPA met with Administrator Daisy Hernandez and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, R1’s face sheet, R1’s Physician’s Reports, medication documentation, and reimbursement documentation. LPA conducted interviews with two (2) staff members and R1. (continued on 9099C) Substantiated Allegation: Staff Did Not Distribute Resident’s Medication as Prescribed It is alleged that facility staff did not ensure that R1’s medication was properly handled and made available as prescribed. During interviews and record review, it was determined that in or around August 2025, there was an incident in which R1’s medication was received by the facility but was subsequently misplaced prior to being provided to R1. Staff acknowledged the incident and reported that corrective action was taken, including reimbursement to R1. During R1’s interview, R1 stated that his medication was delivered to the facility but was not located in his room as expected. R1 reported that he went one day without the medication, requested an overnight delivery, and subsequently received it. R1 further stated that staff provided him with $90 in cash as reimbursement for the misplaced medication. Documentation reviewed included a copy of the funds issued to R1, confirming the reimbursement. However, the Department could not confirm whether a medication was missed. 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 1 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 28-AS-20260424080523

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 15, 2026

(a) A plan for incidental medical ... care shall be developed by each facility. The plan shall encourage routine medical care and provide assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, interviews, and record review, facility did not comply with the cited section, as R1’s prescribed medication was misplaced after being received by the facility which poses/posed an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: The facilty will ensure all medications received at the facility are properly logged and immediately provided to the resident or securely stored. A plan will be provided to LPA.

Allegation investigated: Staff did not follow proper eviction procedure Staff do not serve residents food of good quality Staff do not maintain facility in good repair Staff did not report incidents to appropriate parties

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 04/30/2026 to deliver findings related to the above allegation. LPA met with Administrator Daisy Hernandez and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, R1’s face sheet, R1’s Admission Agreement, Facility Notices related to reported incidents, Special Incident Reports (SIRs), and letters of concern issued to residents, maintenance logs, fire inspection reports, and documentation related to the elevator repair. LPA conducted interviews with four (4) staff members and six (6) residents. Information obtained through interviews and record review was used to assess the validity of the allegations. A facility walkthrough was conducted, including observation of resident bedrooms, common areas, the kitchen, and the overall food supply. Unsubstantiated Allegation: Staff did not follow proper eviction procedure It is alleged that the facility did not follow proper eviction procedures when issuing R1 a 30-day eviction notice. Based on record review and interviews conducted, it was determined that R1 is his own responsible party; therefore, the facility is not required to notify an additional responsible party regarding the eviction. Record review indicates that R1 signed the Resident Admission Agreement on 11/05/2021, acknowledging understanding of facility policies. Article II, “Responsibilities and Representation of the Resident,” specifies that the resident shall not engage in disruptive behavior, create unsafe conditions, or physically or verbally abuse other residents or staff. Documentation further reflects that the facility provided multiple written notices and letters of concern to R1 addressing behavioral issues and expectations prior to issuing the eviction notice. These documents demonstrate that R1 was informed of ongoing concerns and expectations for compliance with facility rules. Additionally, based on review of the eviction notice, it was determined that the notice is consistent with Title 22 requirements. Allegation: Staff do not serve residents food of good quality It is alleged that the facility does not provide residents with food of good quality, including concerns that meals may be improperly prepared or contain spoiled or moldy items. During staff interviews, all staff denied concerns regarding food quality, including any reports of spoiled or moldy food. Staff stated that meals are prepared in accordance with proper food handling procedures and that any concerns raised are addressed immediately. Staff further reported that the facility conducts regular meetings to discuss dining services and address resident feedback. Resident interviews were consistent, with the majority of residents reporting satisfaction with the food and denying any observations of mold or spoiled meals. Additionally, LPA toured the facility kitchen and observed proper food handling and storage practices. All food items appeared to be in good condition, with no visible signs of spoilage. Allegation: Staff Do Not Maintain Facility in Good Repair It is alleged that the facility is not being properly maintained in good repair, including concerns related to the elevator not functioning and other potential maintenance issues within the facility. During staff interviews, staff reported that the facility is maintained in good repair. Staff acknowledged that the elevator experienced a temporary malfunction in March 2026; however, repairs were completed as soon as the necessary part was obtained. Staff further reported that residents were notified of the repair status and were assisted as needed during the outage. Documentation reviewed indicates that Community Care Licensing (CCL) was notified of the elevator malfunction. Staff indicated that the elevator is maintained every six (6) months, and maintenance logs were provided and reviewed. Additionally, a recent fire alarm inspection was conducted with no issues identified, and copies of the inspection records were observed. LPA conducted a walkthrough of the facility and observed the elevator to be operational. The fire alarm system was not activated at the time of the visit, and no issues were observed. During interviews, R1 and other residents reported no current concerns regarding the fire alarm system. (continued on 9099C) Allegation: Staff did not report incidents to appropriate parties It is alleged that the facility failed to report incidents involving R1’s behavior to appropriate parties, including failing to document and communicate concerns as required. During staff interviews, staff reported that incidents involving R1’s behavior were documented and maintained in the resident’s file. Staff stated that notes were completed following incidents and that, when necessary, witnesses were present during interactions due to R1’s communication style. Staff also reported that multiple letters of concern were issued to R1 addressing behavioral issues and expectations. Record review corroborated staff statements, as documentation including incident notes, letters of concern, and related records were observed in the resident’s file. Additionally, it was determined that R1 is his own responsible party. Based on the investigation conducted, which included interviews with staff and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 28-AS-20260424080523

Allegation investigated: Staff are not following infection control measures Staff are not properly reporting incidents involving the residents

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced initial complaint investigation visit on 03/10/2026 regarding the above allegations. During today’s visit, LPA Trueman was greeted by Staff S1 and explained the purpose of the visit. Administrator- Daisy Hernandez arrived shortly after. The investigation consisted of the following: LPA Trueman requested and obtained copies of Resident Roster and Staff roster. Staff interviews#1-7 (S1 – S7 ) and Resident Interviews#1-6 (R1 – R6) .Administrator interviewed. Purchase Order dated 2/23/2026 for Rapid Multi Surface Disinfectant Cleaner 2/10/2026 and 2/23/2026 and 1/8/2026, was submitted along with receipts for Clorox Wipes 9/16/2025 and 3/4/2026, Purchase Orders for Super Santi Cloth Wipes 1/8/2026, 2/10/2026 were submitted. In regards to the allegation Staff are not following infection control measures, based on interviews conducted and information gathered Administrator and 7 of 7 staff all stated they washed their hands for 20 seconds, used masks and gloves. Also said that they used EPA approved Rapid Multi Surface Disinfectant Cleaner and EPA approved Clorox wipes. Unsubstantiated All stated that Housekeeping thoroughly cleaned all resident rooms and common areas with EPA approved spray and wipes. Also used sanitizer and also cleaned equipment. LPA reviewed Purchase Orders for Rapid Multi Surface Disinfectant Cleaner 2/10/2026, 2/23/2026 and 1/8/2026, which were submitted along with receipts for Clorox Wipes 9/16/2025 and 3/4/2026, Purchase Order for Super Santi Cloth Wipes 1/8/2026, 2/10/2026 was also reviewed. Staff S7 stated that the facility always had EPA approved spray and Clorox wipes and stated that there was an e-mail exchange with Department of Health Representative in which the facility stated they already have been using EPA approved wipes and spray. LPA confirmed the e-mail exchange. Interviews with Resident's R1- R6 who all stated that there was a virus going around. All stated that staff did a great job and they observed staff constantly cleaning and wiping down all areas. Stated that housekeeping were doing a good job too cleaning rooms and other areas in the facility. Said they all observed staff constantly washing their hands and staff would always tell them too to wash thier hands for 20 seconds. 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 are not properly reporting incidents involving the residents based on interviews conducted and information gathered it was revealed by the Department of Health Representative that the facility staff who handles reporting any incident did send it in immediately on Monday 2/23/2026 and that there was not a problem with reporting. Staff all stated that the incident was reported immediately by the Health Services Director. Administrator stated that it was immediately reported. It was Record ID # 116 on 2/23/2026. 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 and copies provided.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 28-AS-20260303153942

Allegation investigated: Facility does not have hot water Staff did not observe personal hygiene and sanitation practices to maintain infection control.

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 02/26/2026 to deliver findings related to the above allegation(s). LPA met with Daisy Hernandez, Administrator, and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, facility resident notices (water shutoff) and plumbing invoices for services rendered. LPA also conducted interviews with seven (7) staff members (S1–S7) and seven (7) residents (R1–R7). (continued 9099C) Unsubstantiated Allegation: Facility does not have hot water. It is alleged that the facility did not provide hot water at resident bathrooms and common area sinks, including the bathroom near the kitchen and the dining room sink, for several days. Staff consistently reported there was no complete loss of hot water at the facility. Staff reported temporary issues involving low water pressure and a required water shutoff on 2/11/2026 after approximately 8:00 p.m. to complete plumbing repairs, including replacement of a water pressure regulator and repair of a piping leak. Staff stated hot water remained available outside of the repair period, although pressure was reduced at times. Staff reported residents were notified of the temporary disruptions. Plumbing services were contacted and repairs were completed, as reflected in work orders and invoices reviewed by LPA dated 2/11/2026 and 2/17/2026. R1 reported experiencing a lack of hot water for several days, including the date of the investigation visit. R1 stated they were not notified of any water shutoffs and reported maintaining a log documenting days without hot water. During resident interviews R2–R7, Residents provided varied statements. Several residents denied experiencing issues with hot water or reported having continuous access to hot water. At the time of the visit, all residents interviewed confirmed that hot water was available. LPA verified hot water was accessible in resident rooms and common areas during the visit. During Witness One (W1) interview, W1 confirmed plumbing services were rendered at the facility and that repairs were conducted on 02/11/26 after approximately 8:00 p.m., once the kitchen was closed, in order to minimize disruption to residents in care. W1 stated that certain repairs may take several hours to complete and explained that during active plumbing repairs, water service must be shut off. W1 further stated that if a resident attempted to use water during the repair period, water may not have been available. W1 explained that for certain repairs, such as a piping rupture, initial work may be completed during daytime hours to patch the pipe, with follow-up visits occurring in the evening to complete full repairs, which require shutting off the water supply. During the facility walk through, LPA tested the dining area sink and observed hot water available. LPA documented the observation with a photograph and observed posted hand-washing guidelines. LPA toured the kitchen and observed hot water available, hand-washing signage posted throughout the kitchen, and hand sanitizer present at workstations. (continued on 9099C) LPA received Unusual Incident Reports related to both the pipe leak and the hot water pressure issue, which included notification of a temporary and slight water shutoff. LPA observed the bathroom near the dining area to be clean, with hot water accessible. LPA inspected a total of eleven (11) resident bedrooms, including R1’s room, and observed hot water available in each room, meeting regulatory temperature requirements between 105°F and 120°F. Some faucets required additional time to reach the required temperature; however, hot water was available. LPA reviewed work orders and invoices related to the water pressure regulator replacement and the piping leak repair, which reflected that the issues were addressed and corrected. Allegation: Staff did not observe personal hygiene and sanitation practices to maintain infection control. It is alleged that staff did not wash their hands using warm water and soap while performing duties. During resident R1 interview, R1 alleged that dining room staff (servers) did not consistently practice proper hand hygiene. R1 reported observing servers assist residents with walkers and then proceed to other duties without washing their hands. R1 further alleged that staff did not wash their hands using warm water and soap and stated that on the date observed, hot water was not available. During staff interviews, staff consistently reported they follow proper hand hygiene practices. Staff stated they wash their hands with soap and water, use gloves as required, and follow posted hand-washing guidelines. Kitchen and dining staff reported hands are typically washed in the kitchen area, where hand-washing supplies and signage are posted. Staff reported that hand hygiene is routinely practiced during resident care. During the facility walkthrough, LPA observed sufficient supplies of hand soap and hand sanitizer available in the kitchen, dining area, and common areas. Based on the investigation conducted, which included interviews with staff, witness, and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 28-AS-20260223122931

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Gabby Castro conducted an unannounced annual inspection visit and was greeted by Administrator Daisy Hernandez. LPA Ramirez explained the purpose of the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed non-slip coating in showers. LPA Ramirez observed seated shower chairs in bathrooms. Food Service: LPA Ramirez observed a sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. The facility employs a full-time activities director. See 809-C Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed the facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. The last documented emergency drills were conducted on 07/12/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed an emergency food supply. Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication closet and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. Staffing: Administrator Certificate for Daisy Hernandez 02/27/2027. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed the required annual training, CPR and First Aid for four (4) out of the four (4) personnel record reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel record reviewed. Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. No deficiencies were observed during this visit. Exit interview conducted. A copy of this report was provided via email. Operational Requirements: The fire clearance is approved for eighty-one (81) residents over the age of 59 years old, of which eight (8) may be bedridden on the 1st floor only. This facility may retain no more than twenty (20) hospice residents. There were twelve (12) residents on hospice during the time of inspection. Resident Records/Incident Reports: LPA reviewed resident records for four (4) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. See 809-Cthe state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management-Other regarding the correction of deficiency issued on 03/11/2025. LPA Ramirez was greeted by Business Office Director- Lachaun Gill and explained the purpose of the visit. On 03/11/2025, LPA Ramirez issued a deficiency as a result of COMPLAINT CONTROL NUMBER: 28-AS-20250304162038. During this complaint investigation, it was determined facility staff were not following proper infection control practices. On 03/27/2025, Monterey Park Adult and Senior Care Regional office received an appeal response to deficiency issued on 03/11/2025. After review of the appeal, the department granted the dismissal of the deficiency. The Department agreed the required information on the deficient practice statement was not provided. However, since it was determined there was a violation of Section 87465(a)(9) as the facility failed to follow its own infection control plan, this citation was dismissed, and a corrected citation is being issued during today’s visit. One (1) deficiency was cited today. No further action is required on behalf of the facility in connection with this deficiency. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Jun 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(9) · Plan of correction due date: Jun 20, 2025

87465 Incidental Medical and Dental Care (a) The plan shall encourage routine medical and provide for assistance in obtaining such care, by compliance with the following: (9) The licensee shall ensure that infection control practices are maintained in the facility as specified in Section 87470, Infection Control Requirements. This requirement was not med as evidenced by: The licensee did not ensure infection control practices were maintained during an active epidemic outbreak. This poses a immediate risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Jun 20, 2025

Plan of correction: **No further action is required. Deficiency was cleared on 3/17/25.** Administrator will certify plan for re-training by 3/12/2025. Proof of re-training must be completed and sent to LPA Ramirez by 3/25/2025.

Allegation investigated: Facility staff do not provide adequate food service to residents.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 04/24/2025 regarding the above allegations. During today’s visit, LPA Ramirez was greeted by Business Office Director- Lachaun Gill and explained the purpose of the visit. Administrator- Daisy Hernandez arrived shortly after to assist with tour. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff roster, Staff interviews#1-4 (S1 – S4), Resident Interviews#1-6 (R1 – R6), Copies of R1’s: Original Admission Agreement, Face Sheet, Physician’s Report (LIC 602A), Copies of: Easter Brunch Menu 2025, Easter Brunch Flyer dated 04/19/2025, Reconciliation roster of Easter Brunch meal (04/19/2025) purchased by resident’s loved ones, and physical plant tour. See 9099-C Unsubstantiated The investigation revealed the following: regarding the allegation- “Facility staff do not provide adequate food service to residents.” It is alleged staff over salted food and did not provide quality food service to residents and their families on 04/19/2025. LPA Ramirez toured kitchen area and dinning room area during visit. LPA Ramirez observed facility walk in refrigerator temperature to read 40 degrees F, which is within regulation General Food Service Requirements- 87555(b)(21). LPA Ramirez observed stored food in containers to contain labels that indicated “preparation date and use by date” on all containers with food. Food was stored away from chemicals and cleaning sinks. LPA Ramirez did not observe spoiled food while inspecting perishable foods and non-perishable foods. LPA Ramirez observed kitchen staff wearing hair nets and using gloves while handling food during today’s visit. Four (4) out of the four (4) staff interviewed did not corroborate this allegation. One (1) out of six (6) residents interviewed corroborated this 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. No violations were observed during this investigation visit. Exit interview conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 28-AS-20250422152151

Allegation investigated: Facility staff are not properly addressing pest infestation in facility. Facility staff do not provide adequate food service to residents. Facility staff do not ensure that residents are delivered hot water throughout the facility.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 04/03/2025 regarding the above allegations. LPA Ramirez identified herself to concierge desk upon entry and requested to speak with facility Administrator. LPA Ramirez was greeted by Marketing Director Heather Moore and explained the purpose of the visit. Administrator Daisy Hernandez arrived shortly after to assist with tour. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff roster, Staff#1 - 4 interviews (S1 – S4), Resident#1-5 (R1- R5), copies of R1’s: face sheet, physician’s report, physician’s orders, Ecolab pest control services contract, Ecolab service report dated 3/11/25, facility charting notes for R1, and physical plant tour. See 9099-C for continued report. Unsubstantiated The investigation revealed the following: regarding the allegation(s)- Facility staff are not properly addressing pest infestation in facility. It is alleged the facility has a mice and rodent infestation throughout the facility. Four (4) out of the four (4) staff interviewed did not corroborate this allegation. One (1) out of the five (5) residents interviewed corroborated this allegation. LPA inspected physical plant including kitchen, pantry, residents’ rooms, lobby, dining room, visitor bathrooms, memory care unit and outdoor patio. LPA did not observe any health and safety violations. LPA reviewed facility pest control contract services with Ecolab. According to pest control service contract reviewed, pest control services are performed monthly throughout the facility. LPA reviewed service report dated 3/11/25 (start time 9:38am- end time 10:56am), it revealed no rodent, no fly, no ant, and no cockroach activity was found during inspection. 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. Facility staff do not provide adequate food service to residents. It is alleged staff do not provide good quality food. Four (4) out of the four (4) staff interviewed did not corroborate this allegation. One (1) out of the five (5) residents interviewed corroborated this allegation. LPA inspected physical plant including kitchen, pantry, walk-in refrigerator, walk in freezers and dining room. LPA did not observe any health and safety violations. LPA observed kitchen staff wearing gloves while handling food and wearing hair nets. LPA observed perishable foods to contain labels that indicate discard date. LPA did not observe perishables to be spoiled or contain mold. Canned goods and dry foods stored in pantry contained labels that indicate discard dates. 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. Facility staff do not ensure that residents are delivered hot water throughout the facility. It is alleged facility staff do not maintain hot water temperatures in grooming areas, in the early morning hours. Four (4) out of the four (4) staff interviewed did not corroborate this allegation. One (1) out of the five (5) residents interviewed corroborated this allegation. LPA inspected random resident rooms to inspect, shared/visitor bathrooms throughout the facility and kitchen area. Water temperatures in grooming areas tested to be within 105 – 120 degree F. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No violations were observed or cited during this complaint investigation. Exit interview was conducted. A copy of this report was provided via email due to printer malfunction.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 28-AS-20250327102043

Allegation investigated: Staff are not following proper infection control practices at the facility.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 03/11/2025 regarding the above allegation. Staff from The California Department of Public Health joined LPA Ramirez for this investigation visit. LPA was greeted by Administrator Daisy Hernandez and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 2 interviews (S1 – S2), Interview with staff from The California Department of Public Health (CDPH), copy of facility Coronavirus/COVID-19 Preparedness and Response Plan, copy of facility Infection Control Polices, copy of County of Los Angeles Official Inspection Report dated 03/04/2025, and physical plant tour. See 9099-C Substantiated The investigation revealed the following. Regarding Allegation: Staff are not following proper infection control practices at the facility – It is alleged facility staff did not follow infection control practices during an active infectious outbreak beginning on 2/23/2025. On 02/23/2025, facility staff reported to this licensing agency and to The California Department of Public Health (CDPH), that the facility had five (5) residents that had tested positive for COVID-19. Staff interviews revealed that on 02/24/2025, CDPH placed the facility on surveillance due to an active epidemic outbreak of COVID-19. On 02/27/2025, CDPH recommended the facility suspended communal dining and activities during an outbreak. Staff interviews conducted by LPA Ramirez revealed, communal dining was not suspended but residents that tested positive, self-isolated. According to the facility’s Coronavirus/COVID-19 Preparedness and Response Plan, I. “Upon widespread market-based transmission or suspected exposure within the community the following quarantine interventions will be followed: 5. Meals will be delivered to apartments, in accordance with Culinary Virus Protocol procedures.” On 03/04/2025, CDPH issued a violation for “COVID-19 Employees Face Cover Required”. County of Los Angeles Official Inspection Report dated 03/04/2025, revealed multiple staff were observed to be unmasked while walking indoors in common areas. According to the facility’s Coronavirus/COVID-19 Preparedness and Response Plan, I. “Upon widespread market-based transmission or suspected exposure within the community the following quarantine interventions will be followed: 2. All team members will wear med-surg masks within the community.” According to the facility’s Coronavirus/COVID-19 Preparedness and Response Plan, Steps of Community Reopening Plan, Step 1: Reopen the salon and indoor visits if: Request letter to the county has been submitted and no obligations have been raised and there have been no positive COVID residents or staff at the community for at least the past 14 days. There are no residents or staff suspected with COVID-19. Step 2: Resume limited communal dining and small group activities if 14 days have passed since Step began and there have been no positive COVID residents or staff and there are no residents or staff suspected with COVID-19. Staff interviews revealed, the last resident or staff to test positive for COVID-19 was on 02/26/2026. On 03/11/2025, LPA Ramirez observed several residents utilizing the dining room for activities and dining, even though the facility is in an active epidemic outbreak. Based on interviews, observations, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One (1) type A violation was cited during this complaint investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 28-AS-20250304162038

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(9) · Plan of correction due date: Mar 12, 2025

Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (9) The licensee shall ensure that infection control practices are maintained in the facility as specified in Section 87470, Infection Control Requirements. The licensee did not meet these requirements as evidenced by:the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: The licensee did not ensure infection control practices were maintained during an active epidemic outbreak. Administrator will certify plan for re-training by 3/12/2025. Proof of re-training must be completed and sent to LPA Ramirez by 3/25/2025.

Allegation investigated: Staff does not treat resident with respect.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/22/2024 regarding the above allegation. LPA Ramirez was greeted by Business Office Director Lachaun Gill and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff roster, Staff#1 - 9 interviews (S1 – S9), Attempted interview of Staff#10 (S10), Interview of Resident#1 (R1), Attempted interview of Residents in Evergreen Unit, copies of Resident#1 (R1) Physician’s Report, Identification and Emergency Information, Copy of Staff#10 (S10) Employment Application, Copy of (S10) fingerprint clearance, three (3) written statements from facility staff, and physical plant tour. See 809-C for continuation. Substantiated The investigation revealed the following. Regarding Allegation: Staff does not treat resident with respect - It is alleged that S10 shouted and did not treat R1 with dignity on or around 8/17/2024. Five (5) out nine (9) staff verbally interviewed corroborate this allegation. LPA Ramirez observed three (3) written statements by three facility staff that corroborate this allegation. S10 was not available for interview during visit and LPA Ramirez attempted to contact S10. According to staff, S10 resigned effective 8/22/2024. One (1) out of one (1) resident interviewed deny this allegation. Residents that reside in the Evergreen unit suffer from cognitive impairments; LPA Ramirez was unable to conduct additional resident interviews. During staff interviews and records reviewed, it was revealed that on multiple occasions S10 was observed by other staff to shout and refuse to assist residents with activities of daily living. Written statements by facility staff revealed on 7/15/2024, S11 documented that S10 left R3 soiled in feces for more than 4 hours. LPA Ramirez observed a written statement by S5 that documented on or around 5/15/24 or 5/16/24, S10 raised their voice at residents’ family while searching for a resident’s shirt. Interviews with staff revealed S10 was heard redirecting residents by shouting and refusing to assist other staff reposition residents upon request. Based on interviews and and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One (1) deficiency is being cited during this investigation. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Aug 22, 2024 · control 28-AS-20240819124811

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 29, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not as evidenced by:the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: 5 out of 9 staff inteviews confirm this allegation. 3 written statments by staff confirm this allegation. S10 was observed shouting at and refusing to assist residents Licensee will retrain staff on regulation 87468.1 (a)(1) by 8/29/24 and send proof of retrainig via email.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an announced pre-licensing visit and was greeted by Administrator Daisy Hernandez. LPA Ramirez explained the purpose of the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply. Residents with Special Needs: LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. SEE 809-C for continuation. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for six (6) out of the six (6) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for six (6 ) out of the six (6) personnel records reviewed. COMP III was reviewed with Administrator Hernandez. Pre-licensing is complete and this facility has no deficiencies. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 26, 2024