Ivy Park at Playa Vista

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the facility annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met Health Service Director Malia Hatem and explained reason for visit. Administrator Olga Rayo arrived shortly. There are currently 83 elderly residents, 60 years and older, residing in the facility. The facility is licensed for (102) residents with age range 60 and over. 102 non-ambulatory, of which four (4) may be bedridden. Hospice waiver granted for twenty (20). The facility has six (6) floors which consists of: rooms 123-124, 127, 133-135, private dining, restaurant, bistro, kitchen, lobby, two (2) living rooms, lounge, laundry room, and three (3) solariums. The second floor consists of: rooms 208-213, 215-216, 218-222, 224-227, activity studio, outdoor terrace, salon, hydro spa, and laundry room. The third floor (memory care) consists of: rooms 308-313, 315-316, 318-322, 324-327, living room, dining room, outdoor terrace, kitchen, laundry room, activity room, and storage. The fourth floor (memory care) consists of: rooms 408-413, 415-416, 418-422, 424-427, living room, kitchen, dining room, outdoor terrace, laundry room, activity lounge, and storage. The fifth floor consists of: rooms 505, 508-509, 511 – 515, 517-518, 520 – 522, activity studio, two (2) storages, and laundry room. The sixth floor consists of: rooms 603, 605-606, 609-612, 614-615, 617, and one storage. SEE LIC 809C LPA toured the entire building and observed the following: First floor has boxes that were left from a delivery in hallway floor that could be a tripping hazard to residents. Administrator instructed maintenance to move boxes at time of visit. Resident bedrooms were randomly chosen for review on each floor 1st floor (R# 135 and R# 134) 2nd floor (R#219 and R#224) 3rd floor (R#310 and R#318) 4th floor (R3 422 and R#425),5th floor (R#514 and R#517) and 6th floor (R#610 and R#617). Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The residents’ bathrooms have the required grabs bars and non-skid mat. The hot water was between 102.2-134.6 degrees, which is not within the required 105 - 120 degrees. Fire extinguishers were observed throughout the facility. Cleaning supplies and toxic substances are inaccessible to residents. Kitchen was inspected and there is a sufficient supply of 2-day perishable and 7-day non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the activity room, dining room, and living room. These areas are clean and have the required furniture. There are no firearms or weapons stored at the facility. Evacuation chairs were observed at each stairwell. All required postings were observed throughout the facility. The facility does not have a swimming pool or bodies of water on the premises. LPA checked first aid kit that included all of the required items along with the manual. Six (6) staff files were reviewed and included Criminal clearance record, and health screening with TB. Six (6) residents files were reviewed and included physicians report with TB clearance. R3 needed updated 602 TV was given. Last fire/earthquake drill was conducted in March of 2026 deficiency given. Infectious control plan was reviewed. Random resident medications were reviewed. Medications are centrally stored and locked. No errors were observed. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit will be documented on LIC809-D. Exit interview was held and a copy of the report with appeal rights was given to Administrator Olga Rayo. .the state’s words, verbatim · CDSS document, Aug 23, 2026

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

Allegation investigated: Staff do not answer resident's calls for assistance timely. Staff gave resident incorrect medications.

On 12/12/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Executive Director Dina Davis and the purpose of the visit was explained. Investigation consisted of the following: On 11/06/2025, LPA obtained Personnel Report, Register of Residents (Updated 11/05/25), R1 – R3’s Admission Agreement, Resident Assessment, Individualized Service Plan, Staff Assignment (November 2025), R1 – R3 and R7’s Medication Administration Record (05/2025 – 10/2025), Signal Call Logs (05/04/25 – 05/11/25, 06/29/25 – 07/01/25, 09/11/25 – 09/13/25, 10/19/25 – 10/23/25,10/27/25 – 10/28/25), reviewed seven resident records (R1 – R7), and Physician’s Orders (R1 – R2). LPA interviewed Staff #2 – 7 and Residents 1 – 2, 8, 9, 10, 11, 12. On 11/07/25, LPA received work schedule (05/10/25 – 05/11/25,06/29/25, 10/20/25 – 10/23/25, 10/27/25 – 10/28/25). On 12/11/25, LPA received R1’s August 2025 ledger. On 12/11/25, LPA interviewed Staff #2, #3, #8, and #9 and reviewed R1’s Physician’s Orders and staff work schedule. Continue to LIC9099-C. Unsubstantiated On 12/12/25, LPA interview Staff #2, #10, and reviewed R1’s Physician’s Orders and Hospitalization Discharge Records. Regarding the allegation, “Staff do not answer resident's calls for assistance timely,” it is being alleged Resident #1 (R1) did not get timely assistance between 05/04/25 – 05/11/25, 06/29/25 – 07/01/25, 09/11/25 – 09/13/25, 10/19/25 – 10/23/25, and 10/27/25 – 10/28/25. It is also alleged that the October delays resulted in R1 urinating on self. Record review of R1’s assessment (06/12/25) revealed R1 requires toileting schedule with stand-by assistance for incontinence episodes. Full care. Record review of R1’s call system (05/09/25) revealed zero out of three calls were responded to after 15 minutes. Record review of R1’s call system (05/10/25) revealed one out of seven calls were responded to after 15 minutes. Record review of R1’s call system (05/11/25) revealed two out of four calls were responded to after 15 minutes. Record review of R1’s call system (06/29/25) revealed three out of eighteen calls were responded to after 15 minutes. One call was “forced complete”. Record review of R1’s call system (06/30/25) revealed one out of thirteen calls were responded to after 15 minutes. Record review of R1’s call system (07/01/25) revealed four out of fourteen calls were responded to after 15 minutes. Record review of R1’s call system (09/12/25) revealed zero out of four calls were responded to after 15 minutes. Three calls were “forced complete”. Record review of R1’s call system (09/13/25) revealed zero out of five calls were responded to after 15 minutes. Three calls were “forced complete”. Record review of R1’s call system (10/19/25) revealed one out of five calls were responded to after 15 minutes. Two calls were “forced complete”. Record review of R1’s call system (10/20/25) revealed two out of eleven calls were responded to after 15 minutes. Four calls were “forced complete”. Record review of R1’s call system (10/21/25) revealed one out of tens calls were responded to after 15 minutes. Two calls were “forced complete”. Record review of R1’s call system (10/22/25) revealed one out of eight calls were responded to after 15 minutes. Seven calls were “forced complete”. Record review of R1’s call system (10/23/25) revealed one out of six calls were responded to after 15 minutes. Four calls were “forced complete”. Record review of R1’s call system (10/27/25) revealed four out of eight calls were responded to within 15 minutes. Four of the calls were “forced complete”. Record review of R1’s call system (10/28/25) revealed three out of five calls were responded to after 15 minutes. Continue to LIC9099-C. Staff #5 indicated that “force complete” occurs when a care staff is having technical issues with resetting the call button and the front desk completes the call. Five out of five staff interviews (S2 – S5, S7) indicated staff responds to calls within 5 – 15 minutes. S2 provided explanation for the calls answered after 15 minutes. Staff shortage on 05/10/25 – 05/11/25. Staff was delivering tray services and R1 was in the dining room waiting to be escorted upstairs (07/01/25 8:51 AM). Staff was delivering tray services and R1 was waiting to come downstairs for lunch (07/01/25 11:56 AM). Care Providers were providing care to other residents (10/22/25 1:38 PM). R1 called during the middle of crossover in which Care Providers and Medtechs meet to give resident updates (10/23/25 1:51 PM and 1:54 PM). R1 made a pendant call and it was not cleared because some staff do not have a pendant or the internet signal was not strong. Thus, staff waited for the concierge to clear the call (10/21/25 and 10/28/25 7:13 AM). S2 indicated that none of the delays resulted in R1 urinating on self. R1 indicated that it can take 10 – 40 minutes for staff to respond to calls. R1 indicated that the morning shift is the longest. Four out of five residents indicated (R2, R8 – R11) that staff responds after 15 minutes. R12 has not used the call system. Regarding the allegation, “Staff do not answer resident's calls for assistance timely,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff gave resident incorrect medications Record review of Medication Administration Records (June – October 2025) do not reveal that R1 was given incorrect medication. Two out of two staff interviews (S4, S7) indicated there has not been any medication errors nor complaints. S3 and S5 indicated that staff has been issuing R1’s medication according to the physician’s order on file. S2 indicated R1 has not made medication complaints but refuses one specific medication. R1 indicated that R1 is taking too much medication. R9 and R11 manages own medication. Four out of four residents indicated (R2, R8, R10, R12) that medication is given according to physician’s orders. Continue to LIC9099-C. Regarding the allegation, “Staff gave resident incorrect medications,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to the Executive Director Dina Davis.the state’s words, verbatim · CDSS document, Dec 12, 2025 · control 11-AS-20251028145616

Allegation investigated: Staff did not ensure resident received meals. Staff did not ensure resident was getting showers.

On 12/11/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Executive Director Dina Davis and the purpose of the visit was explained. Investigation consisted of the following: On 11/06/2025, LPA obtained Personnel Report, Register of Residents (Updated 11/05/25), R1 – R3’s Admission Agreement, Resident Assessment, Individualized Service Plan, Staff Assignment (November 2025), R1 – R3 and R7’s Medication Administration Record (05/2025 – 10/2025), Signal Call Logs (05/04/25 – 05/11/25, 06/29/25 – 07/01/25, 09/11/25 – 09/13/25, 10/19/25 – 10/23/25,10/27/25 – 10/28/25), reviewed seven resident records (R1 – R7), and Physician’s Orders (R1 – R2). LPA interviewed Staff #2 – 7 and Residents 1 – 2, 8, 9, 10, 11, 12. On 11/07/25, LPA received work schedule (05/10/25 – 05/11/25,06/29/25, 10/20/25 – 10/23/25, 10/27/25 – 10/28/25). On 12/11/25, LPA received R1’s August 2025 ledger. On 12/11/25, LPA interviewed Staff #2, #3, #8, and #9 and reviewed R1’s Physician’s Orders and staff work schedule. Unsubstantiated Regarding the allegation, “Staff did not ensure resident received meals,” it is being alleged that Resident #1 (R1) meals were delayed or missed in August 2025. Record review of R1’s August 2025 ledger revealed tray services charges from 08/01/25 – 08/08/25. Three out of three staff interviews (S2 – S4) indicated that the care staff monitor that resident receive their meals. Interview with the Executive Chef (S6) indicated that R1 has not made any complaints. Staff #7 indicated R1 has not had tray service complaints and has meals downstairs. S2 indicated R1 received tray services a couple of times due to illness but usually eats downstairs by the second day. R1 has also complained about it not arriving on time but tray services are delivered to the first, second, fifth, and sixth floors respectively. R1 indicated that R1 eats downstairs but has received tray services. R1 indicated that the food quality for tray services was not very good. Five out of five residents indicated (R8 – R12) that eats downstairs. Resident #2 indicated that tray services were received on time. Regarding the allegation, “Staff did not ensure resident received meals,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Regarding the allegation, “Staff did not ensure resident was getting showers,” it is being alleged Resident #1 (R1) did not receive showers according to the plan of care in August 2025 and between 10/22/25 – 10/23/25. It is alleged that R1 is on an every-other-day shower schedule. Record review of R1’s Resident Assessment (06/12/25) revealed R1 requires total assistance for all showering/bathing needs 4x/week. Record review of R1’s Resident Assessment (10/31/25) revealed R1 requires total assistance for all showering/bathing needs 1-2x/week. Four out of four staff interviews (S4 - S7) indicated there has not been any shower complaints. S2 indicated that R1’s showers increased from twice per week to four times per week (Sunday, Tuesday, Thursday, and Friday). Executive Director indicated that R1 is receiving four showers at the standard rate (two showers). R1 indicated that showers are given according to the agreement; however, there were issues in the past because staff did not want to give showers to R1. R1 indicated that things got better. Two out of two residents indicated (R2, R11) that showers are given according to agreement. R8 – R10, R12 are independent. Regarding the allegation, “Staff did not ensure resident was getting showers,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Continue to LIC9099-C. 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, as a result, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to Dina Davis.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 11-AS-20251028145616

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are not meeting resident's needs due to lack of staff. Staff do not seek medical attention for residents. Staff leave residents soiled for extended periods of time. Staff did not ensure facility's plumbing was in good repair.

On 07/30/25, at 09:50am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Johanna Dejoya Bellomo, Business Office Director. LPA explained the purpose of this visit is to gather information about the complaint, gather facility files, interview staff/residents, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S7) and residents (R1-R7) from 10:00am-03:00pm. The department received the following: Resident Roster (Dated: 01/08/2025) Personnel Roster (Dated: 06/03/2025), ID/Emergency Information (Dated: 05/14/2025, 02/28/2025, 07/30/2025), Physicians Report (Dated: 06/26/2025, 04/14/2025, 02/28/2025) Appraisal/Needs and Service Plan (Dated: 09/08/2024, 04/14/2025, 02/28/2025), Maintenance Notes/Invoice (Dated: 01/28/2025, 01/13/2025, 01/23/2025) and Incident/Injury Reports (Dated: 07/22/2025, 06/13/2025, 06/16/2025,07/05/2025) from the facility. Report Continued On LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Staff are not meeting resident's needs due to lack of staff. The details of the complaint alleged that residents are not getting proper care due to the lack of staff in the facility. It was reported that residents are not being bathed and that meals are not served in a timely manner. On 7/30/25, from 10:00am-3:00pm, the department interviewed staff (S1-S7) and residents (R1-R7) regarding the allegation. 5 of 7 staff denied the allegation that the Staff are not meeting resident's needs due to lack of staff. The majority of the staff interviewed stated that the staff were providing enough care to meet the needs of the residents. They stated that each resident has a service plan in place that provides different dates to bathe or shower the residents. They also stated that there haven’t been any complaints of residents not getting their meals in a timely manner. The department interviewed residents (R1-R7) about the allegation and 5 of 7 residents that were interviewed stated that there is enough staff to meet their needs. They also state that they do receive their meals in a timely manner and that staff does assist them with their ADLs when needed. The department reviewed the Personnel Roster (Dated: 06/03/2025) and observed that there is sufficient staff the meet the needs of the residents. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not meeting resident's needs due to lack of staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #2- Staff do not seek medical attention for residents. The details of the complaint alleged that staff would avoid calling 911 when a resident might need medical attention, such as when they may fall in the facility, to avoid any issues. On 7/30/25, from 10:00am-3:00pm, the department interviewed staff (S1-S7) and residents (R1-R7) regarding the allegation. 7 of 7 staff denied the allegation that Staff do not seek medical attention for residents. All staff (S1-S7) that were interviewed stated that whenever a resident needs medical assistance or needs to go to the hospital, emergency medical services are provided. They also state that any of the staff can call 911 for assistance if the resident needs emergency services, no one is denied the right to have emergency services come out to the facility. Staff stated that at no time has anyone been told not to call 911 for help. Report Continued On LIC9099-C The department interviewed residents (R1-R7) about the allegation and 7 of 7 residents that were interviewed stated that staff does call 911 for residents if they need assistance and that they are satisfied with the care and supervision provided by the staff. The Department reviewed Incident/Injury Reports (Dated: 07/22/2025,06/13/2025, 06/16/2025, 07/05/2025) and observed that the facility has consistently reported incidents in the facility and requested emergency services to come out to the facility to assist with residents’ injuries. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not seek medical attention for residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3- Staff leave residents soiled for extended periods of time. The details of the complaint alleged that due to lack of staffing, the residents that are incontinent, are not being changed timely and are left in soiled briefs for an extended period of time. On 7/30/25, from 10:00am-3:00pm, the department interviewed staff (S1-S7) and residents (R1-R7) regarding the allegation. 7 of 7 staff denied the allegation that Staff leave residents soiled for extended periods of time. All staff (S1-S7) interviewed stated that they have not observed any residents who were not changed or were left in soiled briefs because of a lack of staffing. They state that they have enough staff to meet the needs of the residents and that their resident census has decreased. They state that they have two care givers and one med-tech per floor to care for the residents. The department interviewed residents (R1-R7) about the allegation and 7 of 7 residents that were interviewed stated that they had no knowledge of any resident who were left in soiled briefs for an extended period of time. They also stated that they were satisfied with the care and supervision provided by the staff. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff leave residents soiled for extended periods of time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued On LIC9099-C Allegation #4- Staff did not ensure facility's plumbing was in good repair. The details of the complaint alleged that the facility has plumbing issues that leave the residents without drinking water. It was reported that plumbers are always at the facility fixing something. On 7/30/25, from 10:00am-3:00pm, the department interviewed staff (S1-S7) and residents (R1-R7) regarding the allegation. 7 of 7 staff denied the allegation that the Staff did not ensure facility's plumbing was in good repair. All staff (S1-S7) interviewed stated that at no time has there been an issue where residents could not receive drinking water. They state that residents have access to bottled water throughout the building as well as drinkable tap water, if needed. Staff also stated that on January 28, 2025, there was an issue with the plumbing that needed the Department of Water and Power to come out for essential maintenance and repairs to maintain a backflow prevention device. They stated that the repair took place between 6am -11pm and the residents and their family members were notified on January 15th and January 23rd of the pending repairs. They stated that at no time were the residents impacted by the repairs. The department interviewed residents (R1-R7) about the allegation and 7 of 7 residents that were interviewed stated that they have never been without drinking water. They also state that they see plumbers around fixing things, but it hasn’t impacted their care. The Department reviewed the Maintenance Notes/Invoice (Dated: 01/28/2025, 01/13/2025, 01/23/2025) and observed that the facility alerted the residents to the pending repairs that would take place on January 28, 2025. The department also observed that the repair was completed on January 28, 2025. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not ensure facility's plumbing was in good repair. 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 deficiencies were cited. An exit interview was conducted with Johanna Dejoya Bellomo, Business Office Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 11-AS-20250722124554

Type of visit: Prelicensing

On 05/29/25, Licensing Program Analysts (LPAs), Regina Cloyd and Jose Anguiano, conducted an announced visit to the facility for purpose of a prelicensing evaluation. On 05/30/25, Licensing Program Analysts (LPAs), Regina Cloyd and Alfonso Iniguez, conducted an announced visit to the facility for purpose of a prelicensing evaluation continuation. An application was submitted to Community Care Licensing Division (CCLD) for a change of ownership for a Residential Care Facility for the Elderly to serve the Elderly for 60 years and older. The requested capacity is for 102 residents of which 98 may be non-ambulatory and 4 may be bedridden. Any rooms on the first and second floor may be used for bedridden residents. Structure: The facility has six (6) floors which consists of: rooms 123-124, 127, 133-135, private dining, restaurant, bistro, kitchen, lobby, two (2) living rooms, lounge, laundry room, and three (3) solariums. Continue to LIC809-C. The second floor consists of: rooms 208-213, 215-216, 218-222, 224-227, activity studio, outdoor terrace, salon, hydro spa, and laundry room. The third floor (memory care) consists of: rooms 308-313, 315-316, 318-322, 324-327, living room, dining room, outdoor terrace, laundry room, kitchen, activity room, and storage. The fourth floor (memory care) consists of: rooms 408-413, 415-416, 418-422, 424-427, living room, kitchen, dining room, outdoor terrace, laundry room, activity lounge, and storage. The fifth floor consists of: rooms 505, 508-509, 511 – 515, 517-518, 520 – 522, activity studio, two (2) storages, and laundry room. The sixth floor consists of: rooms 603, 605-606, 609-612, 614-615, 617, and one storage. Bedrooms: LPAs inspected rooms 127, 135, 210, 213, 220, 225, 310, 313, 325, 410, 413, 419, 424, 505,5 15, 518, 522, 606, 610, 614, and 617 and each had bed(s), chair(s), night stand(s), chest of drawer(s)/closet space, and a lamp(s) or lights sufficient for reading. Bathrooms were inspected. Water temperature was tested in rooms 127, 135, 210, 213, 220, 225, 313, 413, 505, 515, 518, 522, and 610 and ranged between 105 to 120 degree F. Bathrooms have a working toilet, wash basin, and step-in shower. Bathrooms will accommodate non-ambulatory residents in a wheelchair. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Continue to LIC809-C. Adequate supply of linen stored in the laundry room on the fourth and sixth floors and are provided to residents, if necessary. Emergency Phone Numbers, Exit Plan & Menu: The facility has a working landline and an after-hours phone line. There are fire extinguishers located on all floors. Evacuation chairs are in stairway #1 on the first, second, and fourth through sixth floors. Evacuation chairs are in stairway #2 on the fifth and sixth floors only. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a secured kitchen on the first floor. The server door on the first floor contains a lock. Sharp kitchen utensils are also locked in cupboards on the third and fourth floor. Food supply adequate stored in the kitchen area and refrigerator and consists of the following: canned goods, fruit, meat, and vegetables. Emergency food supplies is located in a storage section behind the kitchen area. Smoke Detectors & Carbon Monoxide Detector: Los Angeles Fire Department conducted a fire protection equipment performance report on 08/02/2024. The test results revealed passed. Continue to LIC809-C. Appliances: The facility is equipped with central air and heat and may be individually adjusted in residents’ room. Toxins: Locked/stored outside in a box near generator and in the laundry room near the kitchen area. Medications, First-Aid Kit & Book: A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, and gauze, which are stored in the copy room (first floor), Med rooms (second and fourth floors) and are available for staff use but inaccessible to residents. Reading Material, Games, Equipment & Materials: In addition to a monthly activity schedule, the facility has board games, books, arts and crafts, and puzzles for the residents' use, commensurate with the plan of operation. Pool/Jacuzzi & Pets: Some residents have pets in their apartments. Continue to LIC809-C. Fire clearance: Fire Clearance with the following special conditions: rooms approved for non-ambulatory/bedridden and approval of delayed egress/secured (locked) perimeter was approved on 11/07/2024. During the facility tour, the delayed egress was tested on the third and fourth floors. Record Review Seven (7) staff records were reviewed, 7 out of 7 staff records had required criminal record clearances or criminal record exemptions. Seven (7) resident records and medications were reviewed. Infection Control Plan and Emergency Disaster Plan (LIC610E) were reviewed. Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance. During the prelicensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA by 06/17/2025. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction. Continue to LIC809-C. 1. During record review, LPA did not observe an Infection Control Plan (last reviewed 04/01/2023) that addressed the initial training requirements for new facility staff, ongoing training requirements for all facility staff, and a description of initial and ongoing training requirements. 2. During record review, LPA did not observe updated CCLD phone numbers, temporary shelter locations, and assignments during an emergency or disaster on the Emergency Disaster Plan (LIC610E). Also, LPA did not observe a key for identifying hospice residents on the register of residents as stated in the LIC610E lasted reviewed 05/04/2023. 3. During facility tour, LPA did not observe a current edition of a first aid manual. 4. During facility tour, LPA did not observe evacuation maps with assembly points. 5. During record review, LPA did not observe an emergency and disaster plan that addresses fire safety precautions specific to evacuation of residents who are bedridden in the event of an emergency or disaster. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to the applicant. An exit interview was conducted, and a copy of this report has been furnished to the applicant.the state’s words, verbatim · CDSS document, May 30, 2025

Type of visit: Prelicensing

On 05/29/25, Licensing Program Analysts (LPAs), Regina Cloyd and Jose Anguiano, conducted an announced visit to the facility for purpose of a prelicensing evaluation. An application was submitted to Community Care Licensing Division for a change of ownership for a Residential Care Facility for the Elderly to serve the Elderly for 60 years and older. The requested capacity is for 102 residents of which 98 may be non-ambulatory and 4 may be bedridden. Any rooms on the 1st and 2nd floor may be used for bedridden residents. The facility has six (6) floors which consists of: rooms 123-124, 127, 133-135, private dining, restaurant, bistro, kitchen, lobby, two (2) living rooms, lounge, laundry room, and three (3) solariums. The second floor consists of: rooms 208-213, 215-216, 218-222, 224-227, activity studio, outdoor terrace, salon, hydro spa, and laundry room. The third floor (memory care) consists of: rooms 308-313, 315-316, 318-322, 324-327, living room, dining room, outdoor terrace, kitchen, laundry room, activity room, and storage. The fourth floor (memory care) consists of: rooms 408-413, 415-416, 418-422, 424-427, living room, kitchen, dining room, outdoor terrace, laundry room, activity lounge, and storage. The fifth floor consists of: rooms 505, 508-509, 511 – 515, 517-518, 520 – 522, activity studio, two (2) storages, and laundry room. The sixth floor consists of: rooms 603, 605-606, 609-612, 614-615, 617, and one storage. LPAs inspected several rooms on each floor, including the kitchen(s) and common areas, tested delayed egress and smoke detectors, measured water temperature, and reviewed nine resident records and medications. Due to insufficient time, a pre-license inspection continuation is required. A copy of this report was reviewed, discussed, and provided to the Executive Director Nestor Mendez.the state’s words, verbatim · CDSS document, May 29, 2025