Ivy Park at West Hills

Allegation investigated: Staff are not mitigating the spread of infectious outbreaks in the facility

On 7/23/2026 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted subsequent complaint visit to investigate the above allegation and to deliver the final findings. Upon arrival, LPA met with the Executive Director (ED) Lidia Cauchi and explained the reason for the visit. During the initial complaint visit conducted by LPA Khurshudyan on 4/4/2025, LPA requested copies of resident and staff roster. LPA also requested copies of pertinent information which include, but not limited to Admission Agreement, Appraisal Needs and Services, Physician Report, Unusual Incident Reports, copy of Medication Administration Record (MAR), copy of staff training, copy of Department of Public Health summary, and other documents relevant to the investigation. At approximately 09:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Continue on LIC9099-C Unsubstantiated Between 10:00am – 3:30pm, LPA conducted interviews with the Executive Director, Memory Care Director, Health Care Director, three (3) staff/caregivers, six (6) out of forty-five (45) residents residing at Assisted Living, two (2) family members of residents residing at Memory Care unit and attempted to speak with six (6) out of 15 residents residing at Memory Care unit. During today’s visit, at approximately 2:15pm, LPA Khurshudyan requested residents and staff rosters. LPA also conducted a physical plant tour to ensure health and safety of the residents are protected. No health and safety hazards noted during the visit. Allegation: Staff are not mitigating the spread of infectious outbreaks in the facility. It was reported that Resident 1 (R1), who resides in the facility’s Memory Care “Evergreen” Unit, developed skin rash in September 2024 and was subsequently diagnosed with scabies by primary care physician. R1 received treatment, and the rash resolved. However, the rash and itching recurred in January 2025, and R1 received a second course of treatment. At the time of the investigation, R1 was symptom free, however, there was a concern that the rash could recur. To investigate the allegation, LPA interviewed the Executive Director (ED), Memory Care Director (MCD), Health Care Director - HCD, staff, residents, and family members/witnesses. Interviews with ED, MCD, Staff, and two family members, confirmed that two (2) residents in the Memory Care Unit experienced skin rash and itching consistent with scabies. Staff reported that responsible parties were promptly notified regarding the residents’ skin condition, and the affected residents were evaluated by their primary care physicians, who prescribed appropriate treatment. Additionally, ED and MCD confirmed that the facility implemented Universal Precautions on a daily basis to reduce the risk of an outbreak throughout the facility. Interview with residents residing in the Assisted Livening denied having any skin issues, rash or itching. LPA reviewed the Incident Reports submitted to Community Care Licensing Division CCLD, physician documents, treatment records, and the facility’s infection control and Universal Precaution policies. Documentation confirmed that the facility promptly reported the residents’ skin condition to CCLD, notified responsible parties, and reported the outbreak to the Los Angeles Couty Department of Public Health. The facility received recommendations outlining corrective measures to immediately address and contain the outbreak and implemented those recommendations. According to the ED, the facility temporarily closed new admissions and residents’ transfers, placed affected residents on contact isolation precautions, removed affected staff members from work duties until they were symptoms free and medically cleared to return to work. Continue on LIC9099-C Facilities also conducted enhanced environmental cleaning and disinfection of affected areas, provided daily treatment and hygiene care to affected residents in accordance with physician’s orders, and closely monitored residents and staff for any additional signs or symptoms of infection. Based on interviews conducted, records reviewed, and documentation obtained during the course of investigation, LPA confirmed that although some residents were diagnosed with scabies, sufficient evidence demonstrated that the facility promptly implemented appropriate infection prevention and control measures to mitigate the spread of the outbreak. The facility followed physician recommendations, complied with public health and safety of residents and staff. Therefore, the allegation is deemed Unsubstantiated at this time. No Deficiency issued during today's visit. Exit interview conducted and copy of this report delivered.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 31-AS-20250326120738

Allegation investigated: Staff’s medication administration error led to a resident’s hospitalization.

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced initial complaint visit. LPA Smith met with the regional operations specialist and executive director trainees and disclosed the reason for the visit. Staff’s medication administration error led to a resident’s hospitalization It was alleged that Resident #1 (R1) experienced symptoms of an overdose requiring hospitalization due to R1 being administered the wrong medication and/or dosage. To investigate the allegation LPA Smith interviewed three (3) staff from 11:00am - at 12:20 pm, requested documents relevant to the investigation during interviews and reviewed facility records at 12:35 pm. Interviews with three (3) of three (3) staff reveal the following: R1 was sent to Kaiser on 04/12/26 due to receiving improper medication, was observed to be drowsy and not at baseline. Review of Kaiser discharge records reveal Substantiated (Cont from 9099) that R1 was admitted on 4/12/26 for drug overdose. R1 was given Supratherapeutic Lorazepam at 2 mg instead of 0.5 mg PRN and Clozapine 25 mg which was no longer prescribed with multiple dose over 1-2 days leading to progressive sedation. Staff acknowledged responsibility for the medication error, and the staff member involved was subsequently terminated; therefore, no further interviews were conducted. Based on interviews and record review, the allegation is deemed SUBSTANTIATED at this time. Deficiency cited on 9099D Exit interview conducted/copy of report giventhe state’s words, verbatim · CDSS document, Apr 29, 2026 · control 31-AS-20260420122935

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Apr 30, 2026

87465 (c)(2) Incidental Medical and Dental Care [...] Once ordered by the physician the medication is given according to the physician's directions. This requirments has not been met: Based on interviews and record review licensee failed to ensure medication procedures were followed which led to R1 being hospitalized for drug overdose, which is an imediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Vendored medication training sugested. Proof of registration and/or training due by POC date POC date: 04/30/26

Allegation investigated: Staff’s medication administration error led to a resident’s hospitalization.

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced initial complaint visit. LPA Smith met with the regional operations specialist and executive director trainees and disclosed the reason for the visit. Staff’s medication administration error led to a resident’s hospitalization It was alleged that Resident #1 (R1) experienced symptoms of an overdose requiring hospitalization due to R1 being administered the wrong medication and/or dosage. To investigate the allegation LPA Smith interviewed three (3) staff from 11:00am - at 12:20 pm, requested documents relevant to the investigation during interviews and reviewed facility records at 12:35 pm. Interviews with three (3) of three (3) staff reveal the following: R1 was sent to Kaiser on 04/12/26 due to receiving improper medication, was observed to be drowsy and not at baseline. Review of Kaiser discharge records reveal Substantiated (Cont from 9099) that R1 was admitted on 4/12/26 for drug overdose. R1 was given Supratherapeutic Lorazepam at 2 mg instead of 0.5 mg PRN and Clozapine 25 mg which was no longer prescribed with multiple dose over 1-2 days leading to progressive sedation. Staff acknowledged responsibility for the medication error, and the staff member involved was subsequently terminated; therefore, no further interviews were conducted. Based on interviews and record review, the allegation is deemed SUBSTANTIATED at this time. Deficiency cited on 9099D Exit interview conducted/copy of report giventhe state’s words, verbatim · CDSS document, Apr 29, 2026 · control 31-AS-20260420122935

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Apr 30, 2026

87465 (c)(2) Incidental Medical and Dental Care [...] Once ordered by the physician the medication is given according to the physician's directions. This requirments has not been met: Based on interviews and record review licensee failed to ensure medication procedures were followed which led to R1 being hospitalized for drug overdose, which is an imediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Vendored medication training sugested. Proof of registration and/or training due by POC date POC date: 04/30/26

Allegation investigated: Staff restricted residents from accessing their mobility devices. Staff fell asleep while on their shift. Staff handled residents forcefully while changing residents.

On 4/16/2026 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted subsequent complaint visit to investigate the above allegations. Upon arrival, LPA met with the Regional Memory Care Specialist Alma Fuentes and explained the reason for the visit. During the initial complaint visit conducted by LPA Khurshudyan on 4/9/2025, LPA requested copies of pertinent information which include but are not limited to the copies staff training, staff shift schedules, and other relevant documents, and conducted interviews with the Executive Director, Memory Care Director, six (6) staff members, (2) family members/witnesses, and attempted to speak with seven (7) out of 15 residents residing at Memory Care unit. During today’s visit, at approximately 3:30pm, LPA Khurshudyan requested residents and staff rosters. LPA also conducted a physical plant tour to ensure health and safety of the residents are protected. No health and safety hazards noted during the visit. Continue on LIC9099-C Unsubstantiated Allegation: Staff restricted residents from accessing their mobility devices. It was reported that staff #1 (S1) restricted residents from accessing their mobility devices. The reporting party alleged that night shift caregiver S1 took wheelchairs and walkers and placed them out of residence reach during the NOC shift. The reporting party did not provide the names of any specific residents allegedly affected. During the course of investigation, LPA conducted interviews with seven (7) out of fifteen (15) residents residing in the Memory Care Unit. All residents interviewed denied that staff took away their mobility devices and stated that they are always able to access their wheelchairs and walkers as needed and did not report concerns related to staff interfering with their mobility equipment. Residents also added that even during nighttime, their mobility devices are next to their beds for easy access. During the visit, LPA also observed that all residents had wheelchairs or walkers next to them and by their beds. LPA also interviewed staff members, who denied witnessing or hearing of any staff restricting residents’ mobility devices and stated that residents’ mobility equipment is kept available at all times. Furthermore, staff added that they would immediately notify supervisors if they observed any conduct that interfered with residents’ care or residents’ rights. Staff consistently stated that residents are provided with care and supervision in a professional manner. LPA interviewed the Executive Director (ED) and Memory Care Director (MCD), who informed that this issue was brought to their attention with anonymously written letters and they both conducted their internal investigation by conducting surprise night visits to the facility to ensure residents are receiving appropriate care and supervision. ED and MCD further stated that staff receive regular in-service training and are expected to maintain residents’ personal rights and dignity. Based on interviews and observations, because no specific resident was identified and no corroborating evidence was obtained, the allegations that staff restricted the resident from accessing their mobility devices is Unsubstantiated at this time. Continue on LIC9099-C Allegation: Staff fell asleep while on their shift. It was alleged that staff #1 (S1) working for NOC shift fell asleep while on shift. It was reported that on 4/6/25, Staff #3 (S3) found (S1) asleep in a recliner in room 117. During the investigation, LPA interviewed seven (7) residents. All residents interviewed denied observing staff asleep while on duty stated they have no concerns regarding night shift staff. Residents stated that staff is always available when needed and did not indicate any lack of supervision during nighttime hours. LPA interviewed staff members regarding the allegation, staff denied seeing S1 or any other staff sleeping while on duty. Staff also added that during the NOC shift staff get breaks and during their break time they rest. Staff stated they had not heard neither staff nor residents complain about S1 sleeping during the shift and reported that if such behavior observed, it would be immediately reported to supervisors. Staff also stated that all caregivers are expected to remain awake and attentive during their schedule shift to provide appropriate care. LPA intervied Executive Director and Memory Care Director, both of whom denied staff sleeping while on shift. Both reported that they conduct ongoing oversight of night staff, including surprise visits, to ensure staff are awake and providing sufficient care and supervision. Based on interviews, and no evidence to support the allegation that staff fell asleep while on their shift is Unsubstantiated at this time. Allegation: Staff handled residents forcefully while changing residents. It was reported that night shift caregiver Staff #2 (S2) pulled and shoved residents onto their beds while preparing to change their clothing and that residents were heard exclaiming “you're hurting me”. There were no specific names provided by reporting boarding. During the investigation, LPA interviewed seven (7) residents. Residents interviewed denied that staff handled them roughly during care or while assisting with dressing or changing. Residents did not report staff pulling, shoving, or hurting them during personal care assistance. LPA interviewed staff who denied witnessing or hearing S2, or any other staff member, handling residents in a forceful or inappropriate manner. Staff stated that residents are provided assistance with daily living in a respectful and professional manner. Continue on LIC9099-C Staff also added that they are mandatory reporters and would report immediately to management if observed neglect to residents. LPA interviewed the Executive Director and Memory Care Director, who denied receiving any confirmed reports that NOC shift forcefully handled residents during care. They stated they routinely supervise and monitor staff performance, including during night shift, to ensure residents are treated with dignity and respect. ED and MCD also added that staff receive regular training regarding resident care and personal rights. Based on interviews conducted, and because no specific residents were identified, the allegation that staff handled residents forcefully while changing is Unsubstantiated at this time. No deficiencies issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 16, 2026 · control 31-AS-20250407160344

Allegation investigated: Staff locked residents in their rooms. Staff did not change residents in care.

At 9:00am Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina conducted a subsequent visit to deliver final findings. Upon arrival, LPAs met with the Executive Director (ED) Lidia Cauchi and explained the reason for the visit. During the initial visit conducted on 04/18/2025, at 09:05am, LPAs requested residents and staff rosters. LPAs also requested copies of pertinent information which include, but not limited to Mandated Reporting policy, Staff training log, Incontinent Plan of Operation, Staff work schedule for one week, Staff work daily log for one month. At approximately 09:25am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 9:30am – 11:10am, LPAs conducted interviews with the Executive Director, Memory Care Director, three (3) out of six (6) staff/caregivers, nine (9) out of ten (10) residents who were able to communicate and one (1) witness. Also, while interviewing a sample of ten (10) residents, LPAs also inspected four (4) resident door locks in a Memory Care Unit. Continue on LIC9099-C Unsubstantiated Allegation: Staff locked residents in their rooms. It was alleged that residents in a Memory Care Unit are kept locked in their rooms. To investigate this allegation, LPAs conducted an interview with the Administrator and Memory Care Director. Both parties denied ever witnessing or hearing residents being locked in their rooms. LPAs were informed that the doors can only be locked from inside by the residents. However, all staff members have a master key and can easily gain access. Interview with three (3) staff members revealed that a Memory Care Unit currently has two (2) wandering residents. LPAs were also informed that when residents are out in common areas all residents’ doors are kept closed but not locked to prevent wandering residents from entering. Interview with staff also revealed that all Memory Care Unit residents’ doors are always unlocked when the resident is in the room, and the staff checks on them every hour. LPA visited four (4) random rooms and observed that the doors have no auto lock and can easily be opened. However, if the door is locked from the outside only a staff member with master key can gain access. Therefore, based on interviews, observation and record reviews, this allegation is deemed Unsubstantiated at this time. Allegation: Staff did not change residents in care To investigate this allegation, LPAs conducted an interview with the Administrator and Memory Care Director. Both parties denied the above allegation and informed LPAs that all incontinent residents are scheduled to be changed every two (2) hours or as needed. Three (3) staff members interviewed corroborated with the information provided by the Administrator and Memory Care Director. Additionally, LPAs conducted an interview with one (1) witness, who also denied the above allegation and stated that they visit their loved one twice a week and always witnessed staff changing residents frequently. Lastly, nine (9) out ten (10) residents interviewed also expressed no concern regarding the above allegations. During LPA's tour of the facility, there were no noticeable odors of incontinence and all residents were appropriately dressed and well taken care of. Based on information obtained through interviews and LPAs observation this allegation is deemed Unsubstantiated at this time. No deficiency issued during today's visit. Exit interview conducted, appeal rights explained and copy of this report delivered.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 31-AS-20250411152240

Type of visit: Required - 1 Year

On 9/5/2025, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a required Annual Inspection. Upon arrival the LPA introduced herself by showing her department badge, was greeted by the Assistant Executive Director (AED) Dina Davis, and was informed that due to medical issues the current Executive Director Lidia Cauchi will be off for a couple of days. LPA explained the reason for the visit and requested staff and residents’ rosters for review. LPA Khurshudyan reviewed the required postings on a wall and used the inspection tool to complete today's visit. A tour of the physical plant was conducted at around 11:00am and the following was noted: The facility is fire cleared for ninety (90) Non-Ambulatory residents, of which eight (8) may be Bedridden. Bedridden residents may be housed in any bedrooms on ground floor, and a hospice waiver for fifteen (15). The facility is currently occupying sixty-six (66) residents. There is one main entrance being utilized at the facility. The facility is two-story building and has one elevator which operates properly. The facility has two (2) wings: Assisted living with private rooms for all residents. And Memory Care Unit with private and/or shared bedrooms. Continue on LIC809-C LPA observed four (4) common bathrooms throughout the facility, all four bathrooms appeared clean and were functional. The kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. LPA observed walk in refrigerator and freezer stocked with adequate amount of frozen and fresh foods wrapped and stored appropriately. Food storage and preparation areas were clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. A dietitian visits the facility quarterly. The daily menus were posted on the wall next to the dining area. A restricted diet menu was also available for residents requiring special diets. The kitchen closes at 7:00pm and reopens at 7:00am. The common and dining room are neat and clean. The activity room and TV room were nicely furnished. The monthly activity schedule was posted and available for residents. The facility maintains a comfortable temperature at 74°F. The smoke and carbon monoxide detectors are hardwired, interconnected and centralized with automatic dispatch to the Los Angeles Fire Department. Fire extinguishers were located throughout the facility and observed to be fully charged and last inspected on 08/07/2025. LPA observed at least thirteen (13) fire extinguishers throughout the facility. LPA toured a random selection of resident rooms. All bedrooms were properly furnished and had appropriate bedding, linens and a lighting system. The call signal system was tested and functioned properly. Hallways are well lit. Residents have enough personal hygiene products. The bathrooms were checked for cleanliness and proper operations. Towels and washcloths are not shared. There was enough clean linen available in each resident room. Hot water temperature measured between 115.4 and 119.5 degrees Fahrenheit. There is a medication room for assisted living and a medication room for memory care unit. LPA observed properly labeled medications and residents’ medical files to be locked and inaccessible to residents in care. The facility maintains a complete first aid kit. The facility has three (3) laundry rooms, of which one is for the Memory Care unit. The Laundry rooms observed to be locked. There is a resident laundry room on the second floor of assisted living. Cleaning supplies, chemicals and detergents are stored inside the locked closets and inaccessible to residents. The facility has nice outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. All pathways are clear of obstruction. Continue on LIC-809C Between 12:30pm -2:55pm LPA conducted records review of eight (8) staff files and eight (8) residents records. Files were complete and updated. LPA collected LIC500, LIC9020, and Certificate of Liability Insurance – Exp Date 5/1/2026. No health and safety hazards noted during today’s visit. No citations issued during today's visit. Exit interview conducted. Copy of this report provided.the state’s words, verbatim · CDSS document, Sep 8, 2025

Type of visit: Case Management - Other

At 10:15 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced case management-other vist to the above facility. LPA met with the front desk receptionist Susan Danzig and later with the Business Office Director Marilu Mampell. LPA explained the reason for the visit. LPA was informed that Resident #1 (R1) who have been relocated from Santa Clarita Hills Senior Living is currently residing in the above facility. At 10:20 AM, LPA requested resident’s roster and reviewed which confirmed that R1 is residing at the facility as of 03/17/2025. No deficiencies issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 5, 2025

Allegation investigated: Staff do not ensure that hazardous items are inaccessible to residents in care.

On 5/1/2025 at approximately 1:00pm, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan made an unannounced subsequent visit to this facility to deliver final findings. LPA met with the Executive Director Lidia Cauchi and explained the reason for the visit. Initial visit was conducted by LPAs Perchui Milena Khurshudyan and Angela Panushkina on 4/9/2025, and during the initial course of investigation, LPAs requested client and staff rosters. At 10:25am, LPAs requested pertinent documentation which include, but not limited to Admission Agreement, Appraisal Needs and Services, Physician Report, Unusual Incident Reports, copy of R1's Assesment report, copy of facility Plan of Operation, copy of staff training, copy of staff shift schedules, copy of staff files, copy of facility internal investigation summary, copy of staff suspension summary, etc. relevant to the investigation. At approximately 10:45am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected, and the facility is in compliance the Title 22 regulations. Continue on LIC9099-C Substantiated Between 11:00am – 1:00pm, LPAs conducted interviews with the Executive Director, Memory Care Director, Health Care Director, three (3) staff/caregivers, six (6) out of forty-five (45) residents residing at Assisted Living, two (2) family members of residents residing at Memory Care unit and attempted to speak with six (6) out of 15 residents residing at Memory Care unit. Allegation: Staff do not ensure that hazardous items are inaccessible to residents in care. It was alleged that on 4/6/2025, R1 who resides in the Memory Care unit ingested dishwashing soap that was left on the kitchen counter. To investigate this allegation, LPAs conducted interviews with Executive Director and Memory Care Director and both parties interviewed confirmed that S1 diluted dishwashing soap “Dawn” in water and placed the container in the memory care unit kitchen counter unsupervised. During investigation, LPAs reviewed R1’s Physician’s Report (dated on 10/21/2024), where indicated (in Mental Condition section) Confused/Disoriented, Wondering Behavior and At Risk if Allowed Direct Access to Personal Grooming and Hygiene Items due to Dementia. ED and MCD also confirmed that R1 had several episodes of wondering around the MCU during the nighttime. Although, no witnesses were present during the incident, the ED stated that when R1 was taken to the hospital on 4/6/2025 and discharged on the same day, both ED and MCD witnessed that R1 vomited soap like solution that was similar to bubbles. Moreover, during the interview with S1, S1 admitted that because he/she had to do scheduled residents check-up rounds, the mix of dishwashing soap “Dawn” and water was left unattended and accessible to R1. Review of the facility Incident Report revealed that R1 ingested unknown substance consisting of dishwashing soap and water, 911 was immediately contacted and R1 was transferred to the hospital. Lastly, review of Plan of Operation for Dementia Care specifies on page 13, under Safety and Storage of Hazardous Materials: "The materials that may pose a risk to residents, whether through contact or ingestion, are stored securely in locked areas and remain inaccessible to residents. This includes, but not limited to: Laundry and cleaning supplies...". Review of "Dawn" detergent, the Warning label specifies the following, " Warning: Causes eye irritation, do not get in eyes. Keep out of reach of children. Rinse hands throughout after handling. First Aid treatment contains anionic and nonionic surfactants. If in eyes: Rinse cautiously with water for several minutes. Remove contact lenses if present and easy to do. Continue rinsing for 15 minutes. If eye irritation persists: Get medical attention. If swallowed, drink a glass of water to dilute". Also, review of training records confirmed that Hazardous Chemicals course was provided and completed by S1 on 12/23/2024. Therefore, based on interviews and records review this allegation is Substantiated. Exit interview conducted and copy of this report delivered.the state’s words, verbatim · CDSS document, May 1, 2025 · control 31-AS-20250407131128

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a)(2)(A)(B) · Plan of correction due date: May 2, 2025

Storage Space and Access: (a)Disinfectants, cleaning solutions...shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based interviews and record review, the licensee did not comply with the section cited above. R1 ingested a chemical detergent left by S1 on the counter in a MCU. This posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 1, 2025

Plan of correction: Executive Director agreed to conduct all staff training regarding this Section. POC cleared immediately as the proof of training got provided to LPA on the day of the visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 2, 2025

Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on LPA’s observation, interview and records review, the licensee did not comply with the section cited above as R1 diagnosed as having dementia, and documented instances of wandering nighttime in the MCU, was left unsupervised. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 1, 2025

Plan of correction: Executive Direcot (ED) shall review regulations regarding supervision and dementia care. ED shall provide trainings to staff and submit plans to ensure residents do not left unsupervised. POC cleared immediately as the proof of training got provided to LPA on the day of the visit.

Allegation investigated: Staff does not allow residents to possess personal belongings. Staff does not ensure that residents' incontinence needs are met. Staff confines residents to bedrooms. Staff does not answer residents' call buttons in a timely manner. Staff does not ensure that resident is afforded a comfortable accommodation. Staff speaks inappropriately to residents.

At 09:30am, Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina conducted an initial visit to investigate the above allegations. LPAs met with the Memory Care Director (MCD) and explained the reason for the visit. During course of the investigation, interviews and record review were made. At 9:35am, LPAs requested resident and staff roster. At 09:40am, LPAs requested copies of pertinent information which include, but not limited to Policy and Procedures for an Emergency Response System, Emergency Call Log, etc., relevant to the investigation. At approximately 9:50am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:00am – 1:00pm, LPAs conducted interviews with the Memory Care Director (MCD), four (4) staff members, one (1) MedTech, six (6) residents and one (1) witness. Also, while interviewing a sample of six (6) residents, LPAs randomly tested resident’s emergency pull cords in rooms and bathrooms. Continue on LIC9099-C Unsubstantiated Allegation: Staff does not allow residents to possess personal belongings It was alleged that on 12/14/2024, 12/15/2024 and 12/16/2024, S1 took Memory Care Unit (MCU) residents' wheelchairs and walkers and placed them far away from residents, so that the residents didn't get out of bed. To investigate this allegation, LPAs conducted an interview with a Memory Care Director, four (4) staff and one (1) MedTech and all parties interviewed denied the above allegation. Moreover, LPAs conducted interviews with six (6) residents and one witness. LPAs were informed that all facility staff members provide an excellent care with dignity and respect. In addition, all residents and a witness interviewed expressed no concerns regarding this allegation. Therefore, based on interviews this allegation is deemed Unsubstantiated, at this time. Allegation: Staff does not ensure that residents' incontinence needs are met It was alleged that S1 does not change residents' diapers during the shift. To investigate this allegation, LPAs conducted interviews with the Memory Care Director (MCD) and were informed that their current census in a Memory Care Unit (MCU) is thirteen and during the morning (6:00am-2:00pm) and afternoon (2:00pm-10:00pm) shifts the MCU has three (3) staff members and one (1) MedTech and during the night shift (10:00pm-6:00am), the facility has two (2) staff members and one (1) MedTech available. LPAs were also informed that all incontinent residents are being changed at least three (3) times per shift and/or as needed. Four (4) staff members interviewed corroborated with the statement provided by the MCD. In addition, LPAs conducted interviews with three (3) residents and one witness from the Memory Care Unit and three (3) residents from the Assisted Living. All parties interviewed expressed no concerns regarding this allegation. Therefore, based on interviews and LPAs observations, this allegation is deemed Unsubstantiated, at this time. Allegation: Staff confines residents to bedrooms It was alleged that the S1 abuses residents during his/her work shift. To investigate this allegation, LPAs conducted an interview with a Memory Care Director (MCD) and were informed that this issue was brought up to her attention about two (2) weeks ago and she conducted her own investigation by interviewing with two (2) night shift staff members and made unannounced visits during the night shift to observe the staff and make sure that the health and safety of the residents are protected. During todays’ visit, LPAs contacted three (3) night shift staff members, who denied the above allegation. Moreover, three (3) residents from the MCU informed LPAs that they really like S1 and the care provided by S1 and expressed no concerns regarding this allegation. Therefore, based on interviews this allegation deemed Unsubstantiated, at this time. Continue on LIC9099-C Allegation: Staff does not answer residents' call buttons in a timely manner To investigate this allegation while interviewing a sample of six (6) residents, LPAs randomly tested resident’s emergency call buttons in their rooms and bathrooms. LPAs conducted a random inspection of five (5) emergency call buttons, and staff responded within a reasonable time. Interview with the Memory Care Director revealed that the facility’s expectation for response time is three (3) minutes. Moreover, interviews with four (4) staff members revealed that they respond to residents' call buttons immediately and if, for any reason, a staff member is not available to assist, they communicate with each other to make sure the call/page is being taking care of right away. In addition, interviews with six (6) residents revealed that the staff always response immediately and expressed no concerns about the above allegation. Based on interviews, LPAs observation and review of the information received, this allegation is deemed Unsubstantiated at this time. Allegation: Staff does not ensure that resident is afforded a comfortable accommodation It was alleged that S1 placed the residents' pillows and blankets on the floor, then placed the residents on the floor to sleep, so that the residents couldn't get up. To investigate this allegation, LPAs conducted an interview with the Memory Care Director (MCD) who denied the above allegation and informed LPAs that no such approach towards residents were brought up to her attention. LPAs were also informed in the month of November S1 was recognized as an “Employee of the Month” for being so kind, caring, and favorite to residents. In addition, LPAs conducted an interview with S1 who also denied this allegation and informed LPAs that he/she always provides care to all residents with dignity and respect. Moreover, four (4) staff and six (6) residents interviewed, expressed no concerns regarding this allegation. Therefore, based on interviews this allegation deemed Unsubstantiated, at this time. Allegation: Staff speaks inappropriately to residents It was alleged that S1 yells at residents when the residents try to leave their rooms. To investigate this allegation, LPAs conducted an interview with the Memory Care Director, six (6) staff and one (1) MedTech. All parties interviewed denied the above allegation and informed LPAs that they haven’t witness nor heard S1 yelling and or inappropriately speaking with the residents. Moreover, interviews with three (3) residents and one (1) witness from a Memory Care Unit expressed no concerns regarding this allegation. Therefore, based on interviews this allegation deemed Unsubstantiated, at this time. No deficiency cited during today's visit. Exit interview conducted and copy of this report signed and deliveredthe state’s words, verbatim · CDSS document, Dec 26, 2024 · control 31-AS-20241220102450

Allegation investigated: Staff did not utilize universal precautions to care for residents affected with scabies.

This is an Amendment to the original report issued on 12/26/2024. Additional information was added to clarify the investigation. On 11/25/2024, during the initial ten-day complaint visit conducted by LPA Khurshudyan, LPA obtained copies of the staff and resident rosters and requested ten (10) resident files. At 11:45am, LPA conducted a physical plant tour including the Memory Care Unit to ensure health and safety of the residents are protected. In addition, between 12:30pm and 3:30pm LPA reviewed files and interviewed eight (8) out of seventy-one (71) residents who were able to communicate; four (4) from the Assisted Living, four (4) from Memory Care Unit, and total of five (5) staff members including Executive Director, and four (4) caregivers/Med-Techs. Interviews with the Executive Director (ED) and staff revealed that residents at Memory Care unit had some type of rash and itching on their skin for the past few months. Continue on LIC9099-C Substantiated During the subsequent visit conducted on 12/26/24, LPA Khurshudyan collected staff and resident rosters, toured the physical plant at 10:00am and interviewed Memory Care Director Alma Fuentes. Review of medical records confirmed that two (2) residents were seen by their primary physicians and diagnosed with scabies on 11/15/24 and 11/21/2024. Topical medication was prescribed for treatment. Additionally, three (3) staff members reported having skin irritation and itching during the same time frame. Records review showed that the first Incident Report submitted to CCL regarding a resident with body itching was received on 9/5/2024 and per SIR an anti-itch powder applied. Further interviews with staff members confirmed that the skin rash issue started about five (5) months ago, and almost every resident in Memory Care unit had rash and itchy skin. Documentation review indicated that although the facility was aware of two (2) confirmed scabies diagnosis, and at least seven (7) residents with skin rash problems, staff did not follow Universal Precautions at the facility. The facility failed to immediately notify all staff of the confirmed scabies cases and did not ensure that appropriate infection control measures were implemented throughout the affected unit. Interviews with the Memory Care Director revealed that the facility relied solely on the facility’s doctor’s evaluation and did not implement preventive measures as required by Universal Precautions reporting to Department of Public Health on time. Based on interviews, records review, and observations, there is sufficient evidence to support that staff did not utilize universal precautions while caring for residents affected with skin rash which posed rash epidemic within the Memory Care unit. Therefore, the allegation is substantiated. Deficiency issued on LIC9099-D. Exit interview conducted, appeal rights explained and copy of this report delivered.the state’s words, verbatim · CDSS document, Dec 26, 2024 · control 31-AS-20241119092225

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b)(1)(A) · Plan of correction due date: Dec 11, 2025

Infection Control Req's. (b)when 1 or more residents in the facility are diagnosed with a contagious disease... (1)assigned staff...shall be required to perform enhanced environmental cleaning and... (A)The licensee shall consult with a medical professional... This requirement was not meet as evidenced by: Based on interviews and record review the Licensee did not comply with the section cited above, by not following Universal Precaution which resulted spread of rashes/scabies within Memory Care Unit, which poses an immediate health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Dec 26, 2024

Plan of correction: The Executive Director agreed to conduct In-service training with all staff regarding this Section. Training materials will be submitted to LPA.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20241119092225. LPAs met with the Memory Care Director (MCD) Alma Fuentes and explained the reason for the visit. During the visit, LPAs interviewed Health Care Director who confirmed that they were unaware that incident with scabies were reportable. LPAs conducted review of Incident Reports and did not observe the facility submitted nor notified the Community Care Licensing (CCL) the above incident. Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the MCD that all staff members are mandated reporters and they are all responsible for reporting. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Dec 26, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Dec 30, 2024

87211(a)(2) Reporting Requirements. Within 24 hours the licensee shall notify the licensing agency... if an epidemic outbreak, poisoning, catastrophe, or major accident which threatens the welfare, safety, or health of residents. This requirement was not meet as evidenced by: Based on interviews and record review the Executive Director did not comply with the section cited above by not reporting to CCL about the outbreak within the specified time, which poses/posed a potential health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Dec 26, 2024

Plan of correction: Executive Director will complete and submit Incident Reports to CCL Regional Office by POC date 12/30/2024.

Type of visit: Prelicensing

On 06/18/24, 9:15 AM Licensing Program Analyst (LPA) Raymond Comer, conducted a scheduled pre-licensing inspection of the Facility. LPA met with Administrator, Matt Ryan. Facility is licensed as a two-story building with resident bedrooms, private bathrooms, and multiple public bathrooms. Fire clearance approved for (75) non-ambulatory, and an additional fifteen (15) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, there are fifty-two (52) Ambulatory residents, eight (8) Non-Ambulatory residents, none of which are bedridden, and seven (7) residents receiving hospice care services. LPA and the Administrator toured the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main doors are the primary entry/exit access point, with three (3) emergency exits being located off the dining room area, and two stairwells. Emergency exit routes are clear of obstructions. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Facility is separated into Assisted Living and Memory Care floors. LPA observed the delayed egress system working properly. Room temperature is comfortable; wall thermostat displays a setting of 73°F., within the required range. The facility maintains required Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 5/30/2024. [LIC 809C-Continued] Fire Safety: Fire Detection/Protection system is present in the facility. Multiple smoke and carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire system back up and tests are completed and documented, in house, on a monthly basis. Fire drill last conducted 5/30/2024. Fire extinguishers were observed throughout the facility on all floors. All extinguishers were last serviced on 11/08/2023. Evacuation chairs were observed in each stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Kitchen: LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. Resident food allergy info/reports are disseminated to Staff. No pesticides, nor poisons were observed near any food areas. Medications: Medications were locked in rolling medication carts located on the second floor. Medications are properly labeled, stored and inaccessible to residents. Medication documentation and implementation appeared to be complete. First aid kits were observed on each medication cart and stocked with required supplies. Laundry: At 11:25 AM, LPA observed laundry rooms located on the first and second floor. Residents in the assisted living wing of the facility have access to do their own laundry. Laundry area is clean and clear from obstruction. Cleaning supplies, and other toxins, are securely stored and inaccessible to residents. The Laundry room located in the memory care wing was observed as locked and inaccessible to residents. Commons: LPA observed multiple common areas upstairs, and downstairs. Activity rooms, movie theaters, dining rooms, and library rooms observed to be clean and furnishings to be in good condition. No obstructions, nor tripping hazards observed. [LIC 809C-Continued] Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Random resident rooms were inspected and observed to maintain required furnishing and sufficient lighting, linens, blankets, closet space and dressers. All bedrooms were observed to be clean and clear of obstructions. Signaling system is present in all bedrooms to request staff assistance. LPA activated the signaling system in a randomly inspected bedroom and staff responded promptly. (Response time was within two (2) minutes) Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 115°F. Within the required range. Outdoor: Courtyard areas observed to have a shaded patio, with tables with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. Resident records: Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current. Staff records: Staff files were reviewed. Criminal record clearances, Health Screening, Employee Rights records were present, and Staff are associated to this facility. Staff records appear to be complete and current. At 2:00 PM, LPA conducted the COMP III presentation with the Administrator and Assistant Administrator, and completed at 2:25 PM There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility Administrator.the state’s words, verbatim · CDSS document, Jun 18, 2024