Ivy Park at Palos Verdes

Type of visit: Required - 1 Year

Licensing Program Analyst, Mayra Cota, conducted an unannounced annual visit today. LPA met with Markeith McGrew, Memory Care Director and Brenda Myers, Executive Director and the reason for the visit was explained. The facility is licensed to serve 115 non-ambulatory residents aged 60 and over, of which 8 may be bedridden. The facility has an approved hospice waiver for 20. The facility is a five-story structure located in a commercial neighborhood in Torrance and consists of car park, entrance and lobby, the first and second floor is Assisted Living (AL) and the third and fourth floor is Memory Care (MC). There is a total of 37 resident rooms in the AL units and 61 in MC. The building as a whole has common bathrooms, beauty salon, 2 areas with a TV, computer area, dining rooms, bistro area, industrial kitchen, kitchenettes, laundry rooms, offices, staff break room, activity room/theater room, wellness center, janitorial closets, storage rooms, shaded outdoor patios and sensory rooms. During today’s visit, LPA inspected (14) resident rooms at random. Resident rooms have the required furniture and sufficient lighting. Bathrooms were observed clean and water measured between 113.3 – 117.6 degrees F which is within compliance range. Bathrooms are kept clean and sanitary. Showers have safety grab bars and anti-slip surfaces. Bathing equipment was also observed to be in good repair. Call buttons in resident rooms were tested and observed to be working properly. The facility’s main kitchen was inspected and observed to be clean for the preparation and storage of food. Refrigerators and freezers were also observed clean, and food is kept properly stored. The facility has sufficient 2-day perishable and 7-day non-perishable food supply. Food preparation areas are kept clean and food is properly stored. ***Continues on LIC 809-C*** Common areas have sufficient seating and furniture throughout the facility is in good repair. Passageways, walkways, ramps and exits are kept clear and free of obstructions. Storage rooms are kept locked and inaccessible to residents. The facility is equipped with fire extinguishers which are kept charged and operational. The facility also has a sprinkler system and smoke alarms which are tested yearly. Last inspection was conducted on 9/26/2025. The facility’s back-up generator is also tested and serviced routinely. Last inspection was conducted on 6/18/2026. Safety drills are conducted quarterly. Last drill was conducted on 6/30/2026. Emergency and Disaster Plan is current. Carbon monoxide detectors were also tested throughout the building and were working properly. Six (6) resident and (7) staff files were reviewed. Files contained all documents required to maintain regulatory compliance. No deficiencies noted during today’s visit. Exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 22, 2026

Allegation investigated: Staff locks residents in rooms. Staff did not communicate with resident's responsible party. Staff engaged in a verbal altercation in the presence of another resident. Staff is not allowing resident to have visitations.

On 07/17/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Executive Director, Brenda Myers, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA interviewed Staff S4, interviewed Residents R4-10, interviewed W2, and received and reviewed the Durable Power of Attorney (dated 02/22/2017) and the Advance Health Care Directive (dated 02/22/2017). During initial visit conducted on 06/03/2026, LPA inspected the facility, interviewed Staff S1-S3, S5-S6, interviewed Residents R1-R3, interviewed Witnesses W1-W2, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed, Staff Roster, Resident Information Form, Resident Roster, Admission Agreement, House Rules, email communication, Staff Statement, Witness Statements, Plan of Operation For Dementia Special Care, and City of Torrance Police Department case number 260020612. The investigation revealed the following: Unsubstantiated Allegation: Staff locks residents in rooms. The allegation alleges residents’ rooms are locked, residents are not able to exit their room, and visitors cannot enter the room without a key. LPA observed resident doors have a keyhole to lock and unlock their door from the hallway. There were no deadbolts, latches or chains observed on the residents doors to keep them inside. LPA tested the doors during the visit. A care provider locked a resident’s door from the outside, and the LPA was able to exit the room by pushing down on the door handle, which also unlocks the door. Additionally, LPA observed the resident doors are fire doors. During Record Review, LPA received and reviewed the Plan of Operation for Dementia Special Care that on page 3, section H. Physical Environment, states “Each room has a lockable door to the hallway which can be opened easily from the inside by the residents by pushing down on the handle. Staff keys are available at all times.” Additionally, in Appendix E, under House Rules states, “Always lock your door when you leave you apartment.” Additionally, LPA received a City of Torrance Police Department, case number 260020612, for two officers who visited the community after receiving a call that residents are being locked in their room. According to S1 the two officers came, walked through, and left with no concerns. During interviews with Staff S1-S6, were asked if staff lock residents in their room in the Memory Care Unit, six (6) out of six (6) stated resident’s rooms are locked when they are not in their rooms and can go to their rooms at any time and they lock the door once the resident is assisted back to their room and they exit the room and residents can exit at any time. During interviews with Residents R1-R10, were asked if they have been locked in their room by staff, ten (10) out of ten (10) stated no they have not been locked in their rooms. During interviews with Witness W1 and W2, were asked if they have seen staff lock residents in their rooms, two (2) out of two (2) stated no, they have not seen staff lock residents in their rooms. Allegation: Staff did not communicate with resident’s responsible party. The allegation alleges facility staff refused to provide information to resident’s family member due to not being the Power of Attorney. During the facility inspection, LPA observed a resident’s family member ask a care provider a question regarding a resident’s care and medication, the care provider referred the family member to go and speak with the Health Service Coordinator because they are unable to provide that information. During record review, LPA received and reviewed a Durable Power of Attorney dated 02/22/2017 and an Advance Health Care Directive dated 02/22/2017 for Resident R1 and confirmed who the facility can provide information to. During interviews with Staff S1-S6, were asked if there were any issues with communication between the staff and residents responsible party, two (2) out of six (6) stated there have been no issues with communicating with Resident responsible party and if they have a question they refer them to the Health Services Director. Four (4) out of six (6) stated they had an issue communicating with a Residents family member because the person was asking questions about the resident’s assistance and they are not the Power of Attorney, and they were getting upset due to their policy and procedure that had been implemented. Additionally, Staff S1-S6 were asked who they can communicate with regarding the resident, six (6) out of six (6) stated the Power of Attorney, conservator, or designated Responsible Party. During interviews with Residents R1-R10, were asked if there have been any issues with communication between the staff and them or their responsible party, ten (10) out of ten (10) stated no, there has been no issues with the communication with staff. During interviews with Witness W1 and W2, were asked if there have been any issues with communicating with staff, two (2) out of two (2) stated no, they have not experienced any issues with communicating with staff. Allegation: Staff engaged in a verbal altercation in the presence of another resident The allegation alleges that staff had a verbal altercation with resident’s family member in front of resident. During Record Review, LPA received and reviewed an incident report submitted to the department regarding a verbal altercation between staff and a residents family member. According to the report, the resident’s family member was yelling at staff and getting in their face. LPA reviewed statements from the staff and a visitor who witnessed the altercation. Upon review of the Admission Agreement, dated 04/24/2024, on page 12, section 8. Visits and Communication, states “Visitors are welcome at any time provided that they respect the rights of other residents and staff and abide by visitation policies.” Additionally, LPA observed on Appendix , page 2, House Rules that states, “Disruptive or abusive behavior by employes, residents, and resident’s families or guest is not acceptable or permitted.” During interviews with Staff S1-S6, were asked if there was verbal altercation between staff and a resident’s family, four (4) out of six (6) stated yes there was an altercation with a resident’s family member who was yelling at staff members. During interviews with Residents R1-R10, were asked if they observed a verbal altercation in their presences, ten (10) out of ten (10) stated no, they have not observed a verbal altercation between a staff member and residents family member. During interviews with W1 and W2, were asked if they have observed a verbal altercation between staff and a family member, one (1) out of two (2) stated yes, they observed a resident’s family member yelling at staff, getting in their face, and pointing their face. They additionally stated Staff did not yell, tried to de-escalate the situation, asked them to step back because they were feeling threatened, and the staff remained professional. They stated they stepped in and asked if this was the appropriate place or time for this, and the person continued to yell. Allegation: Staff is not allowing resident to have visitations The allegation alleges that a resident’s family member received a call from facility staff informing them they were no longer allowed to visit resident. During the facility inspection, LPA observed visitors coming and going, in and out of the facility. During Record Review, LPA received and reviewed the Admission Agreement, dated 04/24/2024, on page 12, section 8. Visits and Communication, states “Visitors are welcome at any time provided that they respect the rights of other residents and staff and abide by visitation policies.” Additionally, LPA observed on Appendix , page 2, House Rules that states, “Disruptive or abusive behavior by employes, residents, and resident’s families or guest is not acceptable or permitted.” During interviews with Staff S1-S6, were asked if a resident’s family member has been informed, they cannot visit a resident in the facility, two (2) out of six (6) stated yes, pending an investigation of an incident that occurred between staff and a residents family member who became aggressive with staff. During interviews with Residents R1-R10, were asked if any of their visitors had been denied entry into the facility, ten (10) out of ten (10) stated no, their visitors have not been denied entry into the facility. During interviews with Witnesses W1 and W2, were asked if they have been denied entry into the facility, two (2) out of two (2) stated no, they have not been denied entry into the facility. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Brenda Myers, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 17, 2026 · control 11-AS-20260527142624

Allegation investigated: Staff does not ensure residents' behavioral needs are being met.

On 11/05/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent Complaint Visit to the facility listed above. LPA met with Executive Director, Brenda Myer, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today's visit, LPA inspected the facility, interviewed Staff S2 a second time, received a Physician’s Report (01/09/2025), Physician’s Fax Report (09/22/2025), Resident R1 and R2 Charting notes, Staff In-Service Logs, and Staff Relias training logs. During a subsequent visit conducted on 10/17/2025, LPA inspected the facility, interviewed Staff S1, S3-S7, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Reports, Physician’s Fax Report (03/25/2025), and Optum Referral (dated 03/04/2025). During the initial visit on 10/15/2025, the LPA inspected the facility, interviewed Staff S2, interviewed Residents R1-R8 and received and reviewed documents pertinent to the investigation. The following Unsubstantiated documents were received and reviewed Staff Roster, Resident Roster, Resident Alert Charting Logs, Shift Report (dated 10/01/25 through 10/14/25), Incident Reports for R1 (dated 09/17/25 and 09/18/25), copies of text messages from med techs, Resident Assessment, and Individualized Service Plan. The investigation revealed the following: Allegation: Staff does not ensure resident’s behavioral needs are being met. The allegation alleges that residents are expressing aggressive and inappropriate behavior, and the facility staff are not addressing it. During record review, LPA observed Incident Reports dated 09/17/2025 and 09/18/2025 regarding an incident that occurred between Resident R1 and staff where the resident was upset and yelling at the staff. According to Staff who witnessed the incident, reported that the resident did not threaten, intimidate, or touch the Staff, but was in the staff’s face expressing their frustration. LPA did observe a Physician’s Fax Report, dated 09/22/2025, that was sent to R1’s primary care physician (PCP) informing them of the incident and behavior. LPA reviewed Resident R1’s Physician’s Report, dated 01/09/2025, that address R1’s behavioral expression. During record review, LPA observed in R2’s Physician’s Reports, dated 07/23/2024 and 10/25/2023, that indicates R2 does not express inappropriate or aggressive behavior. LPA did observe in R2’s Charting Notes there were eleven (11) instances of confusion documented since 01/01/2025. LPA reviewed Resident R2’s Healthcare Provider Communication forms that indicate R2 is seen regularly by their physician, home health nurse, and physical therapist. LPA received and reviewed staff in-service logs for Behavior Expression, Redirection and Dementia vs. MCI conducted on 05/29/2025. LPA received and reviewed seven (7) staff Relias training that include Managing Challenging Behaviors, Psychosocial Needs, Communication, and Recognizing Change of Condition. During interviews with Staff S1-S7, were asked if management follow-up with incidents of behavioral expression, seven (7) out of seven (7) stated when it is reported that a resident is experiencing behavioral expression the residents Primary Care Physician and responsible party is notified. During an interview with S2 stated if a resident is exhibiting behavioral expression, they will request a urinalysis and/or psych evaluation when speaking with the PCP. During interviews with Residents R1-R8, were asked if staff address any change of condition/behavior exhibited by them or other residents, eight (8) out of eight (8) stated yes, staff address any changes they see immediately. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Brenda Myers, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 11-AS-20251008205238

Allegation investigated: Facility staff are mismanaging resident's medications.

On 10/15/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Executive Director, Nestor Eligio and Breanda Myers, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit LPA interviewed Residents R1-R8. During the initial visit conducted on 10/09/2025, LPA inspected the facility, interviewed Staff S1-S9, conducted a medication review, narcotic count and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, staff Learner Status Report, Staff Relias Transcript, Physician’s Report, Physician’s Orders, Centrally Stored Medications, Medication Destruction Logs, and Medication Administration Records (MAR). The investigation revealed the following: Substantiated Allegation: Facility staff are mismanaging resident’s medications. The allegation alleges that they have witnessed incidents of medication mismanagement and staff have destroyed narcotic records. During the facility inspection and file review, LPA participated in a narcotic count for nineteen (19) residents. LPA observed nineteen (19) out of nineteen (19) residents narcotic medications are consistent with properly documented records. Additionally, LPA reviewed Centrally Stored medication and the Medication Administration Record (MAR) for eight (8) residents. LPA observed seven (7) out of eight (8) residents Centrally Stored Medications are not consistent with documented records. LPA did not observe notations of missed or refused medications, or resident out of community. During record review, LPA received and review the training logs for Medication Technicians (Med Tech), and observed they have all completed 32 hours of shadowing and 8 hours of medication instruction provided on Relias. During interviews with Staff S1-S9, were asked if residents receive their medications as prescribed, nine (9) out of nine (9) stated yes residents are provided with their medications as prescribed. Additionally, Staff S1-S9, were asked if they have knowledge of medication mismanagement, nine (9) out of nine (9) stated they have no knowledge of medication mismanagement. During interviews with Residents R1-R8, were asked if they receive their medications as prescribed, eight (8) out of eight (8) stated yes, they receive their medications as prescribed. Additionally, Residents R1-R8 were asked if there was a time they did not receive their medications, three (3) out of eight (8) stated yes, there have been times they did not receive their prescribed medication. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director, Nestor Eligio and Brenda Myers , and a copy of this report ant the appeals rights were providedthe state’s words, verbatim · CDSS document, Oct 15, 2025 · control 11-AS-20250930101557

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 25, 2025

87465 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: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by record review, observation, and interviews, Residents R1-R7 have a total of 13 medication errors that were observed during medication review.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: Administrator will conduct an In-service of medication destruction and logging it properly, and to properly ducment missed medications and the reason why. Administrator will email logs for the in-service and handout to LPA by POC.

Type of visit: Required - 1 Year

On 07/24/25, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Business Office Director, Amber Lambert, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve 115 non-ambulatory residents aged 60 and over, of which 8 may be bedridden. The facility has an approved hospice waiver for 20. Physical Plant/Structure The facility is a five-story structure located in a commercial neighborhood. The ground floor is the car park and entrance, the first and second floors are Assisted Living, the third floor is Memory Care, and the fourth floor is Memory Care. There is a total of 37 Assisted Living units and 61 Memory Care units, each unit contains a bathroom. On the first floor there are 3 common bathrooms, beauty salon, 2 common areas with a TV, computer area, dining area, bistro area, industrial kitchen, storage rooms, laundry room, offices, and staff break room. The second floor consists of an activity room/theater room, bistro, wellness center, laundry room, staff offices, and storage rooms. The third and fourth floor consist of a kitchen, dining room, activity room, TV room, shaded outdoor patio, staff offices, storage room, and laundry room. During the tour, LPA did not observe any bodies of water on the premises. The outside patio/garden area has a shaded area with tables and chairs. The gates exiting the patio are egressed, and work properly. All outside walkways were observed to be clean, clear, and free of obstructions, debris, and hazards. All windows, screens, curtains, and blinds were observed to be in good repair and operate properly. Rooms LPA inspected eight (8) resident rooms, 117, 125, 204, 215, 304, 321, 403, and 412 and observed them to be clean and in good repair. LPAs observed the rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. Residents have the option to furnish their room, or the facility has furniture available if residents require it. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Residents do have the option to use their personal linens, or the facility has a supply available. LPA observed an additional supply of linens in a storage room. All linens and mattresses were observed in good condition. All rooms were observed to have ample lighting. Bathrooms LPA observed all bathrooms to be operable and within Title 22 regulations. The toilet, facets, and shower work properly. The bathrooms were observed clean. The showers were observed with secured safety handrails, nonskid mats, and a shower chair. The showers were observed to be free of mold and mildew. LPA observed storage space for residents’ hygiene products. LPA observed an ample supply of towels and hygiene products available for residents or residents have the option to supply their own. The water temperature in rooms inspected and bathrooms in common areas measured between 108-degrees and 115.4-degrees Fahrenheit. Kitchen LPAs observed the industrial kitchen to be clean and sanitary during the time of visit. LPA observed all appliances to be operable and in good repair. LPA observed an ample supply of cookware, dishware, and cutlery. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods were observed properly dated, labeled, packaged, and stored. The freezer temperature measured 0-degrees Fahrenheit, and the refrigerator temperature measured 45-degrees Fahrenheit. LPA observed knives and sharps to be secured and are inaccessible to residents. LPA observed a menu posted in the dining room. The menu and kitchen were last reviewed and inspected by a dietitian on 06/25/2025. The third and fourth floor kitchens were observed to be clean and sanitary. LPA observed a supply of snacks and drinks available for residents at any time LPA observed cleaning supplies and sharps to be secured in a locked storage room and are inaccessible to residents. All trash cans were observed with tight fitting covers. Common Rooms LPA observed the facility was appropriately furnished during the time of the visit. LPA observed all common rooms to have ample seating to accommodate residents. LPAs observed all dining rooms to have ample seating to accommodate residents. In the activity room, LPA observed arts, crafts, games, puzzles, and reading material available for residents. LPA observed a daily and monthly activity schedule. All walkways, hallways, and stairs in the facility were observed to be clean, clear, and free of hazards and obstructions. The facility was kept at a comfortable temperature of 72-degrees Fahrenheit. All rooms and hallways were observed to have ample lighting. Files LPAs observed resident files secured in the locked wellness room and are inaccessible to residents. LPA reviewed the files for eight (8) residents and observed they have the required documents. The staff files are secured in the business office and are inaccessible to residents. LPA reviewed the file for the the Administrator and six (6) staff and observed they have the required documents, certification, clearance, and training. LPA Observed the administrators Administrator Certificate is valid till 08/02/2025. LPA informed Business Office Manager that Licensing fees are due on 07/24/2025 and provided the PIN. Safety LPA obseved smoke detectors on each floor and carbon monoxide detectors in each resident unit and found them to be operable. When smoke detectors are triggered they close. LPA observed multiple fully charged fire extinguisher last serviced on 12/03/2024, throughout the facility. The last Fire Prevention Inspection was conducted on 05/07/2025. The last emergency drill was conducted on 06/27/2025. LPA observed evacuation chairs at each staircase. The facility has a working landline telephone. LPA observed the facility’s Emergency and Disaster Plan posted and last updated on 03/31/2025. LPA observed all required posting, posted throughout the facility. LPA received and reviewed a copy of the liability insurance through Acord valid till 05/01/2026. Medications LPA observed medications secured in locked medication carts, secured in locked medication rooms. Medications are inaccessible to residents. LPA observed medications to be in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR) for six (6) residents. LPA observed six (6) out of six (6) resident’s medications are consistent with properly documented records. LPA observed a fully stocked First Aid kit with a current manual, in the wellness room. LPA observed additional First Aid supply secured in a storage room. Infection Control LPA observed a sanitizing station upon entry, in the restrooms, and throughout the facility. LPA observed required infection control signs posted throughout the facility. LPA observed a 30-day supply of Personal Protective Equipment (PPE). During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Business Office Director, Amber Lambert, and Regional Health Services Director, Jennifer Frost, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 24, 2025

Allegation investigated: Licensee does not ensure that there are enough staff to meet the needs of residents in care.

On 05/16/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Administrator, Joe Saldana, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit LPA, interviewed Staff S3, interviewed Residents R2-R8, interviewed Residents Responsible Party W2, and received documents pertinent to the investigation. The following documents were received and reviewed Physician’s Reports for five (5) residents, Individualized Service Plan for five (5) residents, and Assessments for five (5) residents. During a subsequent visit conducted on 05/09/2025 LPA inspected the facility, interviewed Staff S1, S2, and S4-S11, interviewed a residents Responsible Party W1, and received documents pertinent to the investigation. The following documents were received and reviewed: Staff Roster, Staff Schedule, Resident Roster, Admission Policies, Plan of Operation for dementia Special Care, Job Descriptions, Positions/Work Hours/Shifts, Senior Living Resident Assessment Detail, and Resident Admission Agreement. Unsubstantiated The investigation revealed the following: Allegation: Licensee does not ensure that there are enough staff to meet the needs of residents in care. The allegation alleges that staff have left and there are not enough staff to meet the needs of residents. During the facility inspection, LPA observed four (4) care providers, and the Activity Director working in the fourth floor Memory Care Unit, four (4) care providers working in the third floor Memory Care Unit, and four (4) care providers working on the Assisted Living floors. Additionally, LPA observed two (2) medication technicians working. LPA observed staff assisting residents to the rest room, during activities, escorting to meals, and assisting with eating. During record review, LPA received and reviewed the facility’s Staff Schedule from April 27, 2025, through May 17, 2025. LPA observed on the AM shifts, 6 AM to 2 PM, there are 4 Care Providers in Assisted Living, 3 Care Providers in the Memory Care Unit on the 3rd floor, 4 Care Providers in the Memory Care Unit on the 4th floor, 2 Med Techs, and 1 LVN. LPA observed on the PM shifts, 2 PM to 10 PM, there are 4 Care Providers in Assisted Living, 3 Care Providers in the Memory Care Unit on the 3rd floor, 4 Care Providers in the Memory Care Unit on the 4th floor, 2 Med Techs, and 1 LVN. LPA observed on the NOC shifts, 10 PM to 6 PM, there are 2 Care Provider in Assisted Living, 2 Care Providers in Memory Care 3rd floor, 2 Care Providers in Memory Care 4th floor, and 1 Med Tech. The Health Service Director (S3), who is an LVN, is scheduled to work Sunday through Thursdays from 9 AM to 5 PM. During review of the Positions/Work Hours/Shifts, LPA observed The Health Service Director is on call and available 24/7. During interviews with Staff S1-S11, were asked if they feel there are enough staff on each shift to meet the needs of residents, eleven (11) out of eleven (11), stated yes there is enough staff to meet the needs of residents. Additionally, Staff S1-S11 were asked how many resident’s care providers are assigned to assist during their shift, ten (10) out of eleven (11) stated care providers are assigned five (5) to seven (7) residents to assist. During interviews with Residents R2-R8, were asked if they feel there is enough staff on each shift to assist residents with care needs, six (6) out of seven (7) stated yes, there is enough staff on each shift to assist residents with care needs. Additionally, during interviews with Residents R2-R8, were asked if they receive assistance when needed, seven (7) out of seven (7) stated yes, they received assistance when needed. During interviews with Resident’s R9 and R10’s Responsible Party W1 and W2, were asked if there is enough staff on each shift to meet the needs of residents, two (2) out of two (2) stated yes, there is enough staff to meet the needs of residents. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Joe Saldana, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 16, 2025 · control 11-AS-20250502132635

Type of visit: Case Management - Incident

On 05/01/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Case Management Visit to the facility listed above. LPA met with Administrator, Joe Saldana, and the purpose of the visit was explained. LPA was granted entry into the facility. LPA conducted a Case Management Visit to follow up on a Special Incident Report (SIR), submitted on 04/18/2025 and a Death Report submitted on 04/24/2025 for Resident R1. LPA received an incident report on 04/18/25, informing the department R1 had a witnessed fall on 04/12/25. R1 was transferred to Kaiser Harbor City Emergency Room for further evaluation and treatment due to hitting their head. LPA received a Death Report on 04/24/25 for R1 who passed on 04/22/25 while at Kaiser Harbor City Hospital. On the Death Report it was indicated under the Cause of Death that R1 was transferred on 04/12/24 due to a fall. Under the section Conditions Prior to or Contributing to Death, R1 had a hip surgery. During today’s visit, LPA inspected the fourth (4th) floor, checked all hallways, walkways, common rooms, and resident R1’s room. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. All common rooms and Resident R1’s room was observed clean, clear, and free of hazards. All rooms were observed with ample lighting. Additionally, during today’s visit, LPA interviewed Staff S1-S4, received, and reviewed documents pertinent to visit. LPA received and reviewed the following documents Staff Roster, Resident Roster, Resident Information Sheet, Admission Agreement, Physician’s Report (dated 02/15/25, 02/10/22, 05/28/21, and 10/06/20), Pre-Placement Appraisal Information (dated 12/10/20), Physician’s Fax Report of Fall (dated 04/13/25, 12/25/24, 08/23/24, 08/28/24, and 11/25/23). During interviews, R1 was considered a fall risk due to their diagnosis. Additionally, during interviews, LPA was informed R1’s passing was not related to the fall. During today’s visit, LPA did not observe any Health and Safety violations. An exit interview was conducted exit interview with Administrator, Joe Saldana, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 1, 2025

Allegation investigated: Staff do not respond to residents calls for assistance in timely manner resulting in resident falls

On 03/13/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced complaint visit to the facility listed above. The department met with Executive Director, Jose Saladana, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA received additional Device Activity Reports for resident pendants, Incident Reports, Healthcare Provider Communication, Resident R11 Charting Notes, and incontinent supply review. During a subsequent visit on 03/05/2025, LPA toured the facility, tested resident’s pendants, and interviewed Residents R2-R9. During the initial visit conducted on 02/20/2025, LPA toured the facility, interviewed Staff S1-S10, interviewed Residents Responsible Party W1, and received documents pertinent to the investigations. The following documents were received and reviewed, Staff Roster, Resident Roster, Preplacement Appraisal Information, Physician’s Report, Assessment Summary, Charting Notes, Centrally Stored Medications, Needs and Substantiated Service Plan, Healthcare Provider Communication, pendant Device Activity Report, and Staff Training Logs. The investigation revealed the following: Allegation: Staff did not respond to residents calls for assistance in a timely manner resulting in resident falls The allegation alleges that a Resident pressed their call button for assistance and when staff did not come the resident got up and had a fall. LPA received and reviewed pendant Device Activity Report and observed on 02/08/2025 at 11:07:21PM R1 pressed their pendant, it was cleared at 11:31:54AM, taking staff a total of 24 minutes and 33 seconds to respond. Additionally, LPA observed R1 pressed their pendant at 2:37:13AM, that was cleared at 3:00:25AM, taking staff a total of 23 minutes and 12 seconds to respond to the call. R1’s arrival to the Emergency Room was on 02/09/2025, at 3:46AM. Additionally, LPA reviewed a Special Incident Report (SIR) for Resident R11, that states R11 had a fall on 02/14/2025. LPA reviewed the Device Activity Report and observed on 02/14/2025 at 8:57:29AM R11 pressed their pendant, it was cleared at 9:27:52AM, taking staff a total of 30 minutes and 23 seconds to respond. LPA received and reviewed staff Charting Notes for R11 that states on 02/14/2025 Resident had an unwitnessed fall approximately around 9:15AM and Resident was found on the floor. During interviews with Staff S1-S10, were asked if any residents experienced a fall while waiting for assistance, two (2) out of ten (10) Staff stated residents have experienced a fall while waiting for assistance. During interviews with Residents R2-R9, were asked if they experienced a fall due to lack of assistance, five (5) out of eight (8) stated they have not experienced a fall due to lack of assistance. During interviews with Witnesses (W1 and W2), were asked if a resident experienced a fall due to lack of assistance, one (1) out of two (2) stated a resident experienced a fall due to lack of assistance. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director, Jose Saladana, and a copy of this report and the Appeals Rights was provided. Service Plan, Healthcare Provider Communication, pendant Device Activity Report, and Staff Training Logs. The investigation revealed the following: Allegation: Staff are taking resident’s incontinent supplies. The allegation alleges a staff member came into a resident’s room and left with a trash bag full of their incontinent supplies and supplies are needing to be replaced more frequent. LPA received and reviewed the list of residents who receive incontinent assistance and have supplies delivered, brought in, or supplied by the facility. During the facility tour, LPA observed an ample supply of incontinent supplies to be used for residents if they run out of their supply of incontinent products. During interviews with Staff S1-S10, were asked if staff take other residents incontinent supplies to use for other residents, ten (10) out of ten (10) stated they do not take other resident’s incontinent products to use on other residents. During interviews with Residents R2-R9, were asked if staff have taken their incontinent products from their room to use on other residents, one (1) out of eight (8) stated they have seen staff take their incontinent products from their room. During interviews with Witnesses W1 and W2, were asked if any of their resident’s incontinent products were taken to use on other residents, one (1) out of two (2) indicated their resident said staff has taken their incontinent products from their room. Allegation: Staff do not check on resident every 2 hours. The allegation alleges staff do not check on resident every 2 hours. During file review, LPA received and reviewed Healthcare Provider Communication, for Resident R1, on 12/05/2024 LPA observed the provider from Torrance Memorial Medical Center indicates the Outcome of Visit: “Check in every 2 – 3 hours for toileting. LPA received and reviewed Resident R1’s Assessment Summary that indicates R1 “is at moderate risk for falling according to the Fall Risk Assessment.” LPA received and reviewed Resident R1’s Care Plan dated 01/10/2023, indicates R1 has had a fall with injury in the past, the Goal is to minimize fall risk by “supervision, not leaving me unattended”, and the Intervention is to “Check on me at frequent intervals to see if I need any assistance.” During interviews with Staff S1-S10, were asked how often they check on residents, five (5) out of ten (10) stated they check residents every hour, three (3) out of ten (10) stated they check every 2 hours, and two (2) out of ten (10) stated they check every 30 minutes. Additionally, during interviews, four (4) out of ten (10) stated for residents who are a fall risk they check on them every 30 minutes. During interviews with Residents R2-R9, was asked if staff come and check if they need assistance throughout the day, eight (8) out of eight (8) stated staff check on them a few times a day. During the course of the investigation, LPA was unable to find evidence to support the allegations. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director, Jose Saladana, and a copy of this report was providedthe state’s words, verbatim · CDSS document, Mar 13, 2025 · control 11-AS-20250212160256

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 24, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in all Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) to to care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on record review R1 and R11 experienced a fall after pressing their pendants and waiting an extened period of time for assistance.the state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: Administrator will develop a plan, conduct an in-service with Care staff, e-mail LPA with plan and in-service conducted by POC.

Allegation investigated: Facility did not refund preadmission fees. Facility did not provide copies of admission agreement.

On 12/03/2024, the department conducted a subsequent unannounced complaint visit to the facility listed above. LPA met with Regional Operations Specialist, Kathleen Olson, and the purpose of today’s visit was explained. During a previous visit conducted on 11/21/24, the department toured the facility, interview Staff S1-S5, interviewed Residents R2-R8, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Resident Admission Agreement, Resident Billing Statement, Physician orders, Physician’s Report, Healthcare Provider Communication, MC Assessment and Service Plan, Hospice IDG Comprehensive Assessment and Plan of Care Report, and emails between R1’ family and the facility staff. The investigation revealed the following: Unsubstantiated to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegations: Facility did not provide copies of admission agreement. The complaint allegation alleges the family of R1 requested a copy of the admission agreement and despite the request they did not receive a copy. During record review, the department received and reviewed a copy of R1’s admission agreement. During interviews with Staff S1-S5, were asked if a responsible party asks for a copy of their residents Admission Agreement how long the process takes them to receive it, five (5) out of five (5) stated once it is confirmed the responsible party has the authority to receive documents it will be provided as soon as possible. Additionally, during interviews with Staff S1-S5, was asked if a copy of the admission agreement is provided to the resident or family once signed, five (5) out of five (5) stated they are provided with a copy at the time of signing. During interviews with Residents R2-R8, were asked if they received their admission agreement after signing, seven (7) out of seven (7) stated they received a copy of their Admission Agreement before moving in. Additionally, during interview with Residents R2-R8, were asked if they or their family have requested copies of documents from the facility and did not receive them, seven (7) out of seven (7) stated they had no issues or problems getting a copy of documents requested. Allegation: Facility did not refund preadmission fees. The complaint allegation alleges resident R1 moved out of the facility due to staff being unable to provide proper care for them and they were not refunded a percentage of their preadmission fees for not being there a full 90-days. During record review, the department received and reviewed a copy of R1’s Admission Agreement that states on page 8, section E. Termination, 1. Termination by Resident, that states “If You move out without providing thirty (30) days’ notice, You will be responsible for the amount of you Monthly Fee through the date You move plus one full month’s fees.” Additionally, in the Admission Agreement on page 6, section B. Fees, 1. Community Fee, states “The length of stay, for purposes of determining the amount of the refund, begins on the day Monthly Fees starts and ends on the day Monthly Fees cease.” R1 moved out on 10/25/24 without providing a 30-day notice, per the Admission Agreement R1 is responsible for a full month’s fees from the date R1 moved out, which will be 11/23/24. During an interview with Staff S3, stated R1’s monthly fees started when R1 took possession of the room on 08/05/24 and monthly fees cease on 11/23/24. During an interview with Staff S2, they were asked if they met with R1’s family regarding R1’s care, S2 stated they had a phone conversation with R1’s daughter regarding 1 on 1 care for R1. Additionally, during interviews with S1 and S2, stated they did not tell R1's family they could not provide care. During the course of the investigation, the department was unable to find evidence During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. During today's visit the department did not observe or cite any deficiencies. An exit interview was conducted with Regional Operations Specialist, Kathleen Olson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 11-AS-20241113145950

Allegation investigated: Staff threatened a resident with eviction. Staff do not properly maintain the facility. Staff do not provide adequate food service.

On 11/26/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Kristal Jenkins/Interim Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#6) and Resident’s interviews (R#1-R#6). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#6) Identification and Emergency Information, (R#1-R#6) Admissions agreements, Copies of facility menu (6 weeks) and a Health and safety check of the facility. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff threatened a resident with eviction. The details of the complaint alleged that administrator threatened a resident with eviction. During the records review, LPA Iniguez reviewed the Special Incident Report (SRI) or LIC 624 on the completed file. LPA observed that there have been no eviction notices in the past two months. During an Interview with the Administrator (A#1), she stated that she has never been hostile toward a resident’s family, PO, or representative and has never threatened to evict a resident in care. During interviews with residents (R#1-R#6), (6) out of (6) stated that they have never been treated with hostility by the facility administrator toward them and their family members, POA, and representatives, and they have never been threatened with eviction. During interviews with staff (S#1-S#6), (6) out (6) stated that the facility administrator has never been hostile towards the resident’s family, POA, or representatives, and she has never threatened a resident with eviction. Allegation: Staff do not properly maintain the facility. The details of the complaint alleged that facility is not properly maintained by staff. Evaluation Report continues LIC 9099-C During the records review, LPA Iniguez reviewed the Special Incident Report (SRI) or LIC 624 on the completed file. LPA observed that there have been no eviction notices in the past two months. During an Interview with the Administrator (A#1), she stated that she has never been hostile toward a resident’s family, PO, or representative and has never threatened to evict a resident in care. During interviews with residents (R#1-R#6), (6) out of (6) stated that they have never been treated with hostility by the facility administrator toward them and their family members, POA, and representatives, and they have never been threatened with eviction. During interviews with staff (S#1-S#6), (6) out (6) stated that the facility administrator has never been hostile towards the resident’s family, POA, or representatives, and she has never threatened a resident with eviction. Allegation: Staff do not properly maintain the facility. The details of the complaint alleged that facility is not properly maintained by staff. During a health and safety check of the facility, LPA Iniguez toured all the facility floors and randomly selected (4) residents’ rooms. LPA observed that the facility and resident rooms were clean and sanitary. During an Interview with the Administrator (A#1), she stated that the facility is clean and sanitary. During interviews with residents (R#1-R#6), (6) out of (6) stated that the facility is clean and sanitary. During interviews with staff (S#1-S#6), (6) out (6) stated that the facility is clean and sanitary. Evaluation Report continues LIC 9099-C Allegation: Staff do not provide adequate food service. The details of the complaint alleged that facility staff do not provide adequate food service to residents in care. During the records review, LPA Iniguez observed seven weeks of the facility menu. The menu offers a variety of meals throughout the day, such as breakfast, soup of the day, lunch special, lunch side, dinner special, starch, vegetables, and dessert. During a health and safety check of the facility, LPA observed the kitchen with enough perishable and non-personal food for the residents in care for at least seven days. During an Interview with the Administrator (A#1), she stated that the facility provides adequate food for residents in care. During interviews with residents (R#1-R#6), (6) out of (6) stated that the facility provides adequate food for them and the rest of the residents. During interviews with staff (S#1-S#6), (6) out (6) stated that the facility provides adequate food for the residents in care. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Evaluation Report continues LIC 9099-C Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Kristal Jenkins /Interim Executive Director.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 11-AS-20241118102021

Type of visit: Case Management - Incident

On 09/13/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced case management visit for an incident reported. LPA met with Regional Operations Specialist, Krystal Jenkins, and the purpose of today’s visit was explained. LPA conducted a case management due to two Special Incident Reports (SIR) regarding resident falls one submitted to Community Care Licensing (CCL) on 08/30/24 and the other on 09/02/24. Resident R1 experienced a fall on 08/27/24 resulting in a right distal radius other type extraarticular fracture. Resident R2 experienced a fall on 08/28/24 resulting in a right subtrochanteric fracture requiring surgery. During today’s visit, LPA toured the facility, checked all hallways, walkways, common rooms, and resident R1 and R2’s room. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. All common rooms and Resident R1 and R2’s room was observed clean, clear, and free of hazards. All rooms was observed with ample lighting. LPA reviewed resident R1’s Physician’s Report (Exam on 12/27/23), Preplacement Appraisal Information, Needs and Service Plan (updated 05/3/23), hospital discharge paperwork, Internal Incident Report and Progress Notes. LPA observed R1 has a minimal history of falls. When LPA conducted a follow-up call the Health Service Director, stated R1 does not have a fall plan. LPA reviewed resident R2’s Physician’s Report, Resident Care Assessment, MC Assessment, Progress Notes, and Internal Incident Report. When LPA conducted a follow-up call the Health Service Director, stated R2 is considered a fall risk due to their medical diagnosis. During today’s visit, LPA did not observe any Health and Safety violations. An exit interview was conducted exit interview with Regional Ops Specialist, Krystal Jenkins, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 13, 2024

Type of visit: Prelicensing

On 07/02/24, Licensing Program Analysts (LPA), Wendy Gibbs and Perry Scott, conducted an announced pre-licensing visit to the facility listed above. LPAs met with Administrator, Kelley Koul, and the purpose of today’s visit was explained. There were 77 clients at the facility during the time of visit. An application was submitted to CCLD on 10/20/23 for a change of ownership. The facility is a Residential Care Facility for the Elderly serving residents aged 60 and over, of which 107 can be non-ambulatory and 8 can be bedridden. Physical Plant/Structure The facility is a five-story structure located in a commercial neighborhood. The ground floor is the parking and entrance, the first and second floors are Assisted Living, the third floor is Memory Care and the fourth floor is Memory Care. There is a total of 37 Assisted Living units and 61 Memory Care units, each unit contains a bathroom. On the first floor there are 3 common bathrooms, beauty salon, 2 common areas with a TV, computer room, dining room, bistro area, industrial kitchen, storage rooms, laundry room, offices, and staff break room. The second floor consist of an activity room/theater room, bistro, wellness center, laundry room, staff offices, and storage rooms. The third and fourth floor consist of a kitchen, dining room, activity room, TV room, shaded outdoor patio, staff offices, storage room, and laundry room. During the tour, LPA did not observe any bodies of water on the premises. The outside patio/garden area has a shaded area with tables and chairs. The gates exiting the patio are egressed, and work properly. All outside walkways were observed to be clean, clear, and free of obstructions, debris, and hazards. All windows, screens, curtains, and blinds were observed to be in good repair and operate properly. Rooms LPAs inspected all resident rooms and observed them to be clean and in good repair. LPAs observed the rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. Residents have the option to furnish the rooms how they would like, or the facility has furniture available if residents need it. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Residents do have the option to use their personal linens, or the facility has a supply. LPAs observed an additional supply of linens in a storage room. All linens and mattress were observed in good condition. All rooms were observed to have ample lighting. Bathrooms LPAs observed all bathrooms to be operable and within Title 22 regulations. The toilet, facets, and shower work properly. The bathrooms were observed clean. The showers were observed with secured safety handrails, nonskid mats, and a shower chair. The showers were observed to be free of mold and mildew. LPA observed storage space for residents’ hygiene products. LPAs observed an ample supply of towels and hygiene products available for residents or residents have the option to supply their own. The water temperature measured between 113.3-degrees and 117.5-degrees Fahrenheit. Kitchen LPAs observed the industrial kitchen to be clean and sanitary during time of visit. LPAs observed all appliances to be operable and in good repair. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods were observed properly dated, labeled, packaged, and stored. The freezer temperature measured 0-degrees Fahrenheit, and the refrigerator temperature measured 45-degrees Fahrenheit. LPA observed knives and sharps to be secured and are inaccessible to residents. LPA observed a menu posted in the dining room. The third and fourth floor kitchens were observed to be clean and sanitary. LPA observed a supply of snacks and drinks available for residents at any time LPA observed cleaning supplies and sharps to be secured in a locked storage room and are inaccessible to residents. All trash cans were observed with tight fitting covers. Common Rooms LPAs observed all common rooms to have ample seating to accommodate residents. LPAs observed all dining rooms to have ample seating to accommodate residents. In the activity room, LPAs observed arts, crafts, games, puzzles, and reading material available for residents. LPAs observed a daily and monthly activity schedule. LPAs observed laundry rooms, that are available to residents, to be clean and in good repair. All walkways, hallways, and stairs in the facility were observed to be clean, clear, and free of hazards and obstructions. The facility was kept at a comfortable temperature of 72-degrees Fahrenheit. All rooms and hallways were observed to have ample lighting. Files LPAs observed resident files secured in the locked wellness room and are inaccessible to residents. The facility does not handle resident’s finances. The staff files are secured in the business office and are inaccessible to residents. Safety LPAs tested smoke detectors on each floor and carbon monoxide detectors in each resident unit and found them to be operable. When smoke detectors were triggered, fire doors on each floor operated properly. LPA observed multiple fully charged fire extinguisher last serviced on 05/17/24, throughout the facility. The Fire Safety Inspection was conducted on 05/14/24. The last emergency drill was conducted on 06/28/24. LPAs observed an evacuation chair at each staircase. The facility has a working landline telephone. LPAs observed the facility’s Emergency and Disaster Plan posted. LPAs observed all required posting, posted throughout the facility. LPAs tested the signal system in residents’ rooms and in common bathrooms. LPAs received and reviewed a copy of the liability insurance through Acord. Medications LPAs observed medications secured in locked medication cart on each floor. Medications are inaccessible to residents. LPAs observed medications to be in their original packaging. LPAs observed a fully stocked First Aid kit with a current manual, in the wellness room. LPAs observed additional First Aid supply secured in a storage room. LPAs and Administrator reviewed and discussed Component III. During today's visit, LPA did not observe any issues requiring corrections. LPAs will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application. An exit interview was conducted with Administrator, Kelley Koul, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 2, 2024