Leisure Vale Assisted Living

Allegation investigated: Resident was assaulted due to staff neglect.

Licensing Program Analyst (LPA) Michael Cava conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with the administrator, Stephanie Oden, and explained the reason for the visit. During today’s visit LPA conducted a tour of the facility between 9:40am to 11:00am, interviewed Administrator and two (2) staff, between 11:00am to 12:00pm, interviewed ten (10) residents between 12:00pm to 1:00pm, reviewed and requested copies of the following documents: Resident 1 (R1) and Resident 2 (R2) physician report and needs and services plan, an incident report, resident and staff roster. Regarding allegation: Resident was assaulted due to staff neglect, it was reported that on or around 06/23/26, R1 was assaulted by R2 due to lack of supervision. Interviews with the administrator and staff Unsubstantiated deny the allegation of staff neglect. According to both administrator and staff, R1 and R2 are friends and roommates, but have a history of being aggressive towards each other. There was an incident report and SOC 341, Report of Suspected Dependent Adult/Elder Abuse, that was submitted to the licensing agency of when both these two residents had an altercation with each other. Law enforcement were also called by the administrator, who responded on the date of the incident. Law enforcement deemed that it was an argument between the two residents, but there was no mention or report of staff neglect or injuries sustained by either residents. Law enforcement suggested that the administrator separate both residents by having them in different rooms, which the administrator complied. Interviews with random residents were made, and these interviews do not confirm staff neglect or lack of supervision. Review of both R1's and R2's record reveal that both R1 and R2 are independent, alert, and have no cognitive impairment. Based on the department’s observations and interviews and record review, which were conducted, there was not enough evidence to prove that a resident was assaulted to due to staff neglect. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Aug 5, 2026 · control 31-AS-20260727182459

Allegation investigated: . Staff did not prevent the residents from engaging in inappropriate sexual behavior 2. Staff did not properly report an incident involving a resident

Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Stephanie Oden to deliver the final findings of the allegations mentioned above. The following information determined during the investigation: Allegation #1: Staff did not prevent residents from engaging in inappropriate sexual behavior. To investigate the allegation, on 12/15/2025, from 10:00 a.m. to 10:30 a.m., (LPA) interviewed the reporting party (RP) and staff from the local police department. On 12/16/2025, from 9:15 a.m. to 2:15 p.m., LPA conducted a physical plant inspection, interviewed (4) staff and (16) out of (16) residents, and obtained documents pertaining to the allegation. According to the complaint, R1's family member observed R1 engaging in inappropriate sexual behavior with another resident. Interviews with the RP and law enforcement revealed the allegation was based solely on the family member's observation. Police reported the family member was unable to provide sufficient details (Cont'd LIC9099C) Unsubstantiated regarding the identity of the alleged individual, or the specific date, time, or circumstances of the incident. The description provided did not match any current resident at the facility. Law enforcement further advised that R1 was unable to participate in an interview, and no charges were filed or further action taken. On 06/26/2026, LPA confirmed with law enforcement that the investigation had been closed without additional action. LPA made attempts to contact both R1 and the family member for additional information but was unsuccessful. The Administrator stated she had no knowledge of any inappropriate sexual behavior involving R1 and reported that neither R1 nor the family member had informed the facility of such an incident. The Administrator also reported having several conversations with the family member following R1's hospitalization, during which no concerns regarding inappropriate sexual behavior were raised. Although the complaint alleged the incident had been reported to the front desk, the receptionist denied receiving any such report. Residents interviewed stated they were unfamiliar with R1 or the individual described by the family member and had no knowledge of any inappropriate sexual behavior occurring at the facility. Based on interviews conducted, records reviewed, and information obtained from law enforcement, there is insufficient evidence to support the allegation that facility staff failed to prevent residents from engaging in inappropriate sexual behavior. Therefore, the allegation is Unsubstantiated. Allegation #2: Staff did not properly report an incident involving a resident. To investigate the allegation, on 12/15/2025, from 10:00 a.m. to 10:30 a.m., (LPA) interviewed the reporting party (RP) and staff from the local police department. On 12/16/2025, from 9:15 a.m. to 2:15 p.m., LPA interviewed four (4) staff members, including the Administrator, and obtained and reviewed facility records. According to the complaint, facility staff were notified of an incident involving alleged inappropriate sexual behavior between Resident #1 (R1) and another resident but failed to report the incident to authorities. During interviews, staff and the Administrator consistently denied having prior knowledge of any such incident involving R1. The Administrator reported that she first became aware of the allegation when law enforcement arrived at the facility to gather information related to the complaint. The Administrator further stated that neither R1, R1's family member, nor any staff member had previously reported the alleged incident to the facility. Staff interviews corroborated the Administrator's statement, and no evidence was found indicating that facility staff had prior knowledge of the alleged incident. Facility records confirmed that after becoming aware of law enforcement's involvement, the Administrator....(Cont'd LIC9099C - page 2) submitted a Special Incident Report (SIR) to the Department documenting the police contact involving R1. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that facility staff failed to properly report an incident involving a resident. Therefore, the allegation is Unsubstantiated. Exit interview conducted and copy of report provided to Administrator. (LIC9099C - page 3)the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 31-AS-20251209152204

Allegation investigated: Staff did not provide meals to resident in care in accordance with the resident's modified diet.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to investigate the above allegations. LPA met with Stephanie Oden and explained the reason for the visit. --- Staff did not provide meals to resident in care in accordance with the resident's modified diet. It was alleged that Resident #1 (R1) needs to be on a low sodium diet due to his high blood pressure, but staff have provided some foods high in sodium. R1 refused to eat some of them. To investigate the allegation on December 18, 2025, LPA requested documents at around 10:00a.m. LPA also interviewed seventeen (17) residents and four (04) staff from 11:30a.m. – 2:30p.m. A review of R1’s physician’s report states that R1 has a low fat, low sodium dietary restriction. During the physical plant tour, LPA did not observe documentation or any other available information in the kitchen regarding R1’s dietary restriction. (CONT. on LIC9099-C) Substantiated During interviews, Staff #2 (S2) stated, “When I started here there were a lot of papers all over the place, very disorganized and so I created this”. R1’s name was not on the list. During interviews, all residents stated the food meets their dietary needs. R1 did not wish to be interviewed. Based on interviews, record review and observations, there is enough information to verify the above allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued. During interviews, fifteen (15) out of seventeen (17) residents stated they are treated with respect and dignity. R1 did not wish to be interviewed. Based on interviews, there is not enough information to verify the above allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not provide housekeeping services to resident in care It was alleged that staff have refused to clean R1’s room and bathroom for the past weeks. R1 was not given an explanation why staff refuse to provide housekeeping services. To investigate the allegation on December 18, 2025, LPA requested documents at around 10:00a.m. LPA also interviewed seventeen (17) residents and four (04) staff from 11:30a.m. – 2:30p.m. A review of the staff schedule shows there are at least two (2) housekeepers per morning and afternoon shifts daily. During interviews, all staff stated resident rooms are cleaned at least two (2) times per week. Staff #3 (S3) added, residents do have the right to refuse but are unaware of R1’s refusal. During interviews with residents, five (5) out of seventeen (17) stated they are not receiving housekeeping services regularly. All other interviewed residents stated they receive housekeeping services regularly. R1 did not wish to be interviewed. Based on interviews and record review, there is not enough information to verify the above allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not safeguard resident's confidential information It was alleged that S1 told several residents that a resident had HIV and they should stay away from that person. To investigate the allegation on December 18, 2025, LPA interviewed seventeen (17) residents and four (04) staff from 11:30a.m. – 2:30p.m. During interviews all staff stated they do not disclose resident’s medical or personal information to residents and do not tell them to stay away from other residents. During interviews all residents stated they do not feel staff disclose their personal information or control who they communicate with. R1 did not want to be interviewed. Based on interviews, there is not enough information to verify the above allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No other health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 31-AS-20251210092920

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Jul 27, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This is not met as evidenced by; Based on interviews and observations, S2 was not aware of R1’s dietary restrictions and LPA did not observe any documentation.the state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: Administrator will submit proof of correction by the POC due date. Proof may be in the form of a picture showing all the residents' restrictions or proof of training. The Administrator will also submit a written statement explained they have reviewed and will adhere to Title 22 CCR 87555 General Food Requirements by the POC due date.

Allegation investigated: Resident was left outdoors for an extended period of time due to staff neglect Staff do not prevent smoking in the facility Licensee does not ensure that the facility has adequate supplies in order to adhere to infection control requirements as necessary Staff do not accord privacy to residents in care

On 07/13/26, at 8:19am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Stephanie Oden, Administrator. LPA explained the purpose of this visit was to information and deliver findings for this complaint. On 07/13/26, LPA Saucedo asked for the census, staff, and resident rosters. On 07/13/26, at 8:35am, LPA Saucedo conducted a physical tour, interviewed staff, residents and delivered findings. LIC 9099C-continued Unsubstantiated Regarding the allegation: Resident was left outdoors for an extended period of time due to staff neglect. It is alleged that a resident was abandoned outside the facility and left outdoors unattended until 1:00 AM and other residents are outside until 12:00AM. During LPA’s interview with four (4) staff, the four (4) staff confirmed that residents are allowed to come and go as they please plus there is an agency called "clipboard" along with home health and hospice that also come to help the residents so there is no staff neglect to residents. In addition, the front door can be accessed at any time of the day including nights plus there is a bell that can be rung at the front desk and there also a security guard at the front of the facility during the hours of 10:00PM-6:00AM. During LPA’s physical tour, LPA also confirmed that there is a sign in and out binder for residents at the front desk and that the front bell is working properly. LPA took a picture of the front desk binder used by residents. Furthermore, during LPA’s interview with sixteen (16) residents they confirmed that they have not been locked out of the facility and/or abandoned outside the facility at any time. Furthermore, sixteen (16) out of sixteen (16) residents confirmed that they do not feel like staff is neglecting them. Therefore, based on the interviews conducted and LPA's physical tour the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not prevent smoking in the facility. It is alleged that residents are smoking in their room creating a fire and life-safety hazard. During LPA’s physical tour, LPA did not observe any residents smoking in their room and/or inside the facility. In addition, LPA did not observe any residents smoking in front of the facility. Furthermore, LPA took pictures of the back of the outside facility where residents are permitted to smoke. LPA’s interview with four (4) staff confirmed that they regulate the smoking outside where it is permitted as much as possible and remind all residents that there is a designated smoking area and smoking is not allowed inside the facility. LPA interviewed sixteen(16) residents and they have not seen anyone smoking in the facility. Therefore, based on the interviews conducted and LPA's physical tour the allegation(s) is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Licensee does not ensure that the facility has adequate supplies in order to adhere to infection control requirements as necessary. It Is alleged that there are not enough sanitary wipes available in the building for staff to provide proper hygiene care. During LPA’s physical tour, LPA observed plenty of sanitary wipes, gloves, incontinence, and other Personal Protective Equipment (PPE). LPA took several pictures of supplies at the facility. LPA interviewed four (4) staff that confirmed adequate supplies of PPE and/or infection control items are kept in five (5) different areas of the facility. There are two (2) storage areas with supplies, the front desk, Medical Technician Room and Wellness Director Room also have supplies. Furthermore, sixteen(16) residents did not have any concerns pertaining to inadequate supplies not being used by any of the staff and/or provided at the facility to them if they need it. Therefore, based on the interviews conducted and LPA’s physical tour the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not accord privacy to residents in care. It is alleged that there are no privacy curtains available or utilized, violating the residents' fundamental right to privacy during personal care. During LPA’s physical tour, LPA observed every resident room to have bathrooms. In addition, if any resident is sharing a room they have their own privacy because the room is accommodated for two (2) people and Individual privacy is being provided in toilets, baths and shower areas. Sufficient room is also available to accommodate persons served in comfort and safety with their own dresser and bed. Furthermore, if the room is not shared then the room considered a private room. LPA interviewed sixteen(16) residents that did not have any issues with their personal privacy in accommodations, medical treatment, personal care and assistance. LPA interviewed four (4) staff that confirmed when an individual needs help they provide as much privacy to that resident as necessary. Therefore, based on the interviews conducted and LPA’s physical tour the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issue, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jul 13, 2026 · control 31-AS-20260707161238

Allegation investigated: Staff refused to provide medication to resident in care. Staff spoke inappropriately to residents in care.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with Stephanie Oden and explained the reason for the visit. --- Staff refused to provide medication to resident in care. It was alleged that Staff #1 (S1) refused to give medication to Resident #2 (R2). To investigate the allegation LPA requested documents at around 10:00a.m., interviewed four (4) staff from 11:00a.m. to 1:00p.m., and interviewed one (1) resident from 1:00p.m. to 2:00p.m. On May 14, 2026, LPA Gina Saucedo interviewed two (2) residents and three (3) staff from around 12:30p.m. to 2:30p.m. On July 3, 2026, LPA interviewed sixteen (16) residents. A review of the Department’s records revealed no incident reports involving R2 regarding any medication refusal. (CONT. on LIC9099-C) Unsubstantiated A review of R2’s Medication Administration Records indicates that all medication were given as prescribed, with exceptions for surgery and community outings. A review of the Physician’s Report states R2 is able to communicate needs, independently able to administer and store own medications with assistance. A review of R2’s Service Plan states R2 is independent and needs reminders for other activities of daily living. During interviews, Staff #1 (S1) stated they give all residents their medications as prescribed and never refuse to give residents their medications. One (1) out of four (4) staff stated they overheard S1 refusing to give R2 their medication. All other staff stated they are not aware. During interviews, Resident #1 (R1) stated they witnessed S1 refuse to give R2 their medications. All residents, including R2, stated all medications are given as prescribed. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff spoke inappropriately to residents in care. It was alleged that S1 yelled at and threatened to call Immigration and Customs Enforcement (I.C.E.) on R1 and R2. To investigate the allegation LPA requested documents at around 10:00a.m., interviewed four (4) staff from 11:00a.m. to 1:00p.m., and interviewed one (1) resident from 1:00p.m. to 2:00p.m. On May 14, 2026, LPA Gina Saucedo interviewed two (2) residents and three (3) staff from around 12:30p.m. to 2:30p.m. On July 3, 2026, LPA interviewed an sixteen (16) residents. A review of the Department’s records revealed no incident reports involving R1 regarding any altercation between staff and residents. A review of the Physician’s Report states R2 is able to communicate needs, able to leave facility unassisted, ambulatory, independently able to transfer and able to administer and store own medications with assistance. A review of R2’s Service Plan states R2 is independent, reminders only/prepare items for bathing, and standby assistance and reminders for other activities of daily living. A review of the Physician’s Report states R1 is not confused, able to follow instructions, able to communicate needs and able to leave facility unassisted. During interviews, two (2) out of four (4) staff stated they witnessed S1 being rude to R2 and not treating them with respect and dignity. All other staff, including S1, stated they treat all residents with respect and dignity. During interviews, R2 stated there are two (2) staff that tell them to take their clothes off quickly, and they can’t because they have a medical condition. R2 could not identify which staff. S1 is a MedTech and does not bathe residents. (CONT. on LIC9099-C) R1 stated S1 does not want R1 and R2 to be friends and hang out in R1’s room. R1 added that S1 yells at R2 and threatens to call I.C.E. on us. All other residents stated they are treated with respect and dignity. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 3, 2026 · control 31-AS-20260427092547

Allegation investigated: Facility increased rate without appropriate notification Licensee failed to respond promptly and appropriately to communications from the resident’s representative Staff do not safeguard resident's personal belongings Staff did not prevent a resident in care from becoming severely dehydrated Staff did not notify authorized representative of incident Staff threatened to evict resident in retaliation for filing complaints

On 06/30/26, at 7:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Stephanie Ogden, Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 04/08/26, LPA Saucedo conducted the initial complaint visit. On 06/30/26, at 8:05am, LPA Saucedo conducted a physical tour, interviewed additional staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Facility increased rate without appropriate notification. It is alleged that resident #1 (R1)’s rent has been increased since June 2025 for the amount of $ 1,464.07 instead of $ 1,444.07. During LPA’s interview with staff #1 (S1) and staff #2 (S2) R1’s rent did not increase until January 2026 in the amount of $1464.07 when their SSA-Social Security Administration benefits were increased. LPA received the copies of R1’s payments from June 2025 through January 2026 where it shows R1's Power of Attorney (POA) paid $1444.07 up to January 2026 and then paid $1464.07 for January 2026 and thereafter from the facility. Furthermore, LPA interviewed R1 and R1 did not know the amount they were paying. LPA also interviewed R1’s POA and R1’s POA stated, “they had been paying R1’s rent in the amount of $1464.07 not $1444.07 but never sent LPA their proof of receipts. Therefore, based on the record reviews, receipts received and interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Licensee failed to respond promptly and appropriately to communications from the resident’s representative. It is alleged that resident #1 (R1) RP asked Staff #1 (S1) how much the Medi Cal waiver pays towards R1’s rent and S1 refused to respond. During LPA’s interview with R1’s representative/Power of Attorney (POA) they wanted to know how much the waiver was paying towards rent but S1 refused to tell them. During LPA’s interview with Staff #1 (S1) and Staff #2 (S2) they both confirmed that the waiver pays for R1’s care not rent portion and a point system is used to determine the care. Furthermore, the waiver that the facility gets does not state form of payment for residents, it only states the tier-level of care. S1 and/or S2 would have to call the waiver program to check how much is being given for R1’s care but that doesn’t cover R1’s rent which was told to the POA. During LPA’s file review of R1, LPA observed the level of care for R1 was Tier 4 and was updated 03/2026 because their level of care had increased per the Waiver Representative and Point System used but it also did not state how much payment the facility receives for R1. LPA received a copy of the ALW-Assisted Living Waiver of 03/2026. Therefore, based on the record reviews, and interviews conducted, the allegation is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff do not safeguard resident's personal belongings. It is alleged that resident #1 (R1) personal belongings have gone missing on several occasions. During LPA’s interview with R1’s Power of Attorney (POA) they stated R1 was missing a “Jesus Hat and radio.” During LPA’s interview with R1, they stated to LPA that their “Jesus Hat” was missing. During LPA’s review of R1’s Client/Resident Personal Property and Valuables-(LIC 621) there was no radio and Jesus Hat listed. The property list had an original list dated 2022, 2024 and 2026 and there was no hat and/or radio on the list. The last update was in March 2026 signed by Staff #1 (S1) for High back wheelchair that R1 received. Prior to this update was March 06, 2024, for a Hospital Bed provided by R1’s Hospice. During LPA’s interview with S1, S1 confirmed that R1 and/or their POA did not report a radio and/or had their property list updated. Furthermore, S1 also stated that R1’s POA said that R1 had prune juice missing but that was also never confirmed. Therefore, based on the record reviews, and interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not prevent a resident in care from becoming severely dehydrated. It is alleged that resident #1 (R1) is not given water and was severely dehydrated. During LPA’s physical tour, LPA observed a jug of water on the dresser next to R1’s bed. LPA took a picture of the jug of water. During LPA’s interview with R1, R1 did confirm they get water. During LPA's observation of R1, LPA observed R1 is non-ambulatory and can reach the water. During LPA’s record review of R1, their pre-placement, resident appraisal, Physician’s Report and Service Plan confirm that R1 can feed themselves and R1 is diagnosed with kidney failure which can cause dehydration because of the constant urination. During LPA’s interview with R1’s Power of Attorney (POA), they stated, “the water is out of reach for R1 so R1 cannot get the water. Furthermore, LPA interviewed two (2) caregivers that confirm a jug of water is kept in R1’s room so R1 can always have water since R1 has kidney issues. Therefore, based on the record reviews, and interviews conducted, the allegation is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff did not notify authorized representative of incident. It is alleged that resident #1 (R1) was being transported to the hospital and that R1 had a kidney infection and the Power of Attorney (POA) learned this information from the doctor not the facility. During LPA’s interview with Staff #1 (S1), S1 stated, “I have had multiple conversations with R1’s POA about R1’s hospitalization I cannot disclose the reason for R1 going to the doctor because that is determined until they are at the hospital and the medical evaluation is made but every time R1 has been to the doctor R1’s POA is notified.” During LPA’s record review of R1, R1 has an updated Physician’s Report dated 2025 where R1 was diagnosed with acute kidney failure and in one (1) of R1’s discharge documents from the Healthcare and Wellness Center confirms that R1 had chronic kidney disease stage 3 unspecified. Furthermore, LPA received the most recent Unusual/Incident Injury Reports dated 01/06/26, 03/07/26 and 05/25/26 where it confirms the responsible party was notified. During LPA’s interview with R1’s POA, the POA confirmed that R1 went to the hospital on 03/07/26 for suicidal thoughts/Ideation and the POA did not agree with that because they stated to LPA R1 “does it for attention.” Additionally, the Unusual/Incident Injury Report for 03/07/26 says R1 called 911 themselves saying they were suicidal. Therefore, based on the record reviews, and interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff threatened to evict resident in retaliation for filing complaints. It is being alleged that resident #1 (R1)’s Power of Attorney (POA) deducted $200.00 from R1’s rent to pay for groceries and the facility threatened to evict R1. During LPA’s interview with R1, R1 did not know about an eviction notice. During LPA’s interview with R1’s POA, the POA confirmed that $200.00 was deducted from R1’s rent to pay for groceries. Furthermore, during LPA’s interviews with Staff #1 (S1) and Staff #2 (S2), R1’s POA tried to pay a portion of the rent deducting $200.00 saying the facility owed R1 because the POA spent $200.00 in groceries and that the POA was advised not threatened but advised that the entire amount of rent has to be paid and that the facility; thus R1’s rent has nothing to do with the POA buying groceries for R1. Therefore, based on the interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 31-AS-20260408081238

Allegation investigated: Staff do not assist resident with showering Staff neglect residents needs

On 06/24/26, at 8:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Stephanie Oden, Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 06/09/26, Licensing Program Analyst (LPA) Jose Tan conducted the initial, complaint visit. On 06/24/26, at 8:50am, LPA Saucedo conducted a physical tour, interviewed staff, residents and obtained documents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff do not assist resident with showering. It is alleged that resident #1 (R1) has not showered in two (2) weeks. During LPA's interview on 06/16/26 with R1, they stated they have not showered in a week because their shower schedule changed. R1 confirmed that their shower days were Wednesday and Saturday and now it is Wednesday and Sunday. During LPA's interview with staff #1 (S1) and staff #2 (S2) they confirmed that R1's shower schedule did change because R1 requested it because of their dialysis schedule. LPA confirmed with R1 on 06/24/26 that their dialysis schedule days are Tuesday, Thursday and Saturday and R1 did request their shower schedule to change from Saturdays to Sundays because of dialysis and R1 stated, "yes." LPA interviewed fourteen (14) residents that did not have an issue with their shower assistance and/or shower days. LPA obtained R1's medical assessment and service plan that does confirm that R1 needs assistance with showers and on R1's medical assessment it does confirm R1 has chronic kidney disease and their dialysis days are Tuesday, Thursday and Saturday. LPA also obtained the shower schedule. Furthermore, during LPA's physical tour on 06/24/26 which is a Wednesday, LPA observed caregiver looking for R1 for their shower. Let it be noted, R1 was outside in front of the facility. Therefore, based on the staff and resident interviews and documents obtained the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff neglect residents needs. It is alleged that resident #1 (R1) incontinence needs are not being met. During LPA's interview with R1, they stated they have not changed their diaper/pull-ups in over a week. LPA did confirm with R1 that they have a schedule. R1 stated on 06/24/26 they did not know they had a schedule. LPA obtained R1's medical assessment and service plan that does confirm that R1 has stand by assistance meaning R1 can change themselves but just needs someone to observe them changing for safety. LPA also obtained the incontinence schedule that shows stand by assistance is needed for R1. LPA interviewed two (2) caregiver staff that did confirm they provide stand by assistance for R1 but they do not change R1 because R1 can change themselves. Furthermore, during LPA's physical tour, LPA observed caregiver looking for R1 for their shower and to provide stand by assistance for their incontinence. Let it be noted, R1 was outside in front to facility. LPA also interviewed fourteen (14) residents that did not have an issue with their incontinent needs. Therefore, based on the staff and resident interviews and documents obtained the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jun 24, 2026 · control 31-AS-20260603101143

Allegation investigated: Staff are not following resident's doctors orders Staff are not administering resident's medication in a timely manner

On 06/16/26, at 8:05am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Stephanie Oden, Administrator. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 06/16/26, LPA Saucedo conducted the initial, complaint visit. At 8:15am, LPA conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff are not following resident's doctors orders. It is being alleged that the nurse practitioner changed resident #1 (R1)'s order to where they only get their suppository three (3) times per week instead of the original two (2) times per day as needed. During LPA's interview with R1, R1 stated, "yes, the nurse practitioner changed my order when I am supposed to get my suppository everyday and I need my suppository to have a bowel movement." LPA did obtain R1's prescription orders and R1's suppository order was changed by the nurse practitioner. Three (3) staff were interviewed that confirmed R1's suppository order was changed recently but they are only following the current prescription orders which cannot be over written and would have to be changed back to it's original order by a prescribed medical personnel. Therefore, based on the staff and resident interviews and pertinent documents obtained the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not administering resident's medication in a timely manner. It is being alleged that resident #1 (R1) waited one (1) time for eight (8) hours and the facility ended up calling home health to come give them their suppository. During LPA's interview with R1, R1 stated, "they do not remember if a licensed vocational nurse was on grounds but the medical technician that was on duty told them that they could not give them the suppository." R1 also stated to LPA that their original prescription of suppository was "one (1) in the morning and one (1) as needed (PRN) in the afternoon and now it is changed and they are upset." Furthermore, R1 could not remember the day they had to wait eight (8) hours for a suppository. LPA did interview three (3) staff that confirmed the suppository is supposed to be provided to R1 by a skilled professional such as a licensed vocational nurse that is on duty and furthermore, the facility has an outside agency named "Clipboard" that has licensed vocational nurse in addition to other staff when regular staff are not present. The three (3) staff did confirm that R1 now has a new prescription of suppository of it being originally everyday to now every other day. In addition, R1 does have home health services which have provided R1 their suppository before. Let it be noted, LPA did obtain R1's medication list. Therefore, based on the staff interviews and resident interview obtained the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 31-AS-20260611160903

Allegation investigated: Staff mishandled a resident's medication(s).

On 06/16/26, at 8:05am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Stephanie Oden, Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 06/09/26, Licensing Program Analyst (LPA) Jose Tan conducted the initial, complaint visit. On 06/16/26, at 8:15am, LPA Saucedo conducted a physical tour and interviewed staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff mishandled a resident's medication(s). It is being alleged that resident #1 (R1) wants to administer their own insulin. During LPA's interview with three (3) staff it was confirmed that R1 is legally blind and has Motor Impairment/Paralysis. During LPA's interview with three (3) out of three (3) staff it was determined that R1 is to be given their insulin by a skilled professional. R1 cannot administer their own insulin because of their vision and motor impairment. LPA obtained R1's medication list where R1 is to receive their insulin three (3) times under the skin subcutaneously. Furthermore, one (1) of the vocational licensed nurse tried to administer the insulin to R1 and R1 did not want to be touched and R1 then refused their insulin twice in one (1) day. Let it be noted, R1 is not currently in the facility and remains in the hospital. Furthermore, LPA spoke to one (1) of the hospital staff and R1 is being administered their medication including their insulin by medical staff. LPA received R1's Medical Assessment and Resident Appraisal where it confirms that R1 needs assistance with medication management including needing assistance with administering their own injections and Max assistance with medication. Therefore, based on the staff interviews and pertinent documents obtained the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 31-AS-20260608102458

Allegation investigated: Staff do not meet resident's incontinence care needs in a timely manner, resulting in resident sustaining multiple pressure injuries. Staff do not assist resident with repositioning Licensee does not ensure there is enough staff to meet resident's needs in a timely manner Staff do not follow resident's care plan Staff do not provide resident with bed prescribed by a physician

On 06/02/26, at 8:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Stephanie Ogden, Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 04/22/26, LPA Saucedo conducted the initial complaint visit, conducted a physical tour and interviewed residents and staff. On 06/02/26, at 9:50am, LPA Saucedo conducted another physical tour, interviewed additional staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff do not meet resident's incontinence care needs in a timely manner, resulting in resident sustaining multiple pressure injuries. It is being alleged that resident #1 (R1) waits for an hour or two (2) before a staff comes to help them and they developed pressure injuries. During LPA’s interview with R1, R1 stated, “I don’t get changed often and I am left in soiled diapers waiting for a staff.” LPA asked when do they change you and R1 stated, “only in the morning and before I go to bed.” LPA obtained a copy of incontinence residents and R1 is supposed to be changed four (4) times a day and during the nocturnal shift (NOC). During LPA’s physical tour, R1 was observed spending most of their day out of the facility. LPA conducted another interview with R1 on 05/12/26 and observed them out of their room during incontinence scheduled. When questioned as to why they are not in their bedroom and/or in the facility during the scheduled incontinence changes, R1 stated, “I don’t use the bathroom much so I just decide to stay in my diaper.” LPA asked R1 if they wanted to go to the hospital so they can get re-evaluated for all their concerns, R1 stated to LPA, “they are not going to the doctor, they are doing fine and their wound is doing much better.” LPA did obtain Home Health notes for R1 on 05/04/26 and it was determined that R1 developed a stage 3 wound on their buttocks area on 03/23/26. Furthermore, LPA interviewed one (1) of the Home Health case managers regarding R1 and they stated, “R1 did have a stage 3 in their buttocks area but it is now healed.” Let it be noted, R1’s admission to the facility was on 01/27/26 and was discharged from the health care center on 01/26/26 with no wounds. Furthermore, LPA interviewed three (3) facility staff that confirmed R1 does not like to be touched and refuses to go to the hospital for anything that they have complained about. LPA's interview with the Licensed Vocational Nurse stated, "R1’s wound now looks like a stage 1 and not a stage 3 wound anymore.” Therefore, based on the home health records of wound care and the refusal of R1 to be changed per the incontinence schedule, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff do not assist resident with repositioning. It is being alleged that resident #1 (R1) does not often get repositioned in bed so they have constant pain. During LPA’s interview with R1, R1 stated, “they have constant back pain.” LPA asked how often are you repositioned and R1 stated, “it’s not the repositioning it’s the bed that I have. I want an airbed that is on the floor and that has a black machine where I can blow up.” LPA asked how often does staff come and reposition you in bed and R1 stated, “they come and help me with bathing, changing my clothes and place me in my wheelchair.” Let it be noted, R1 is not bedridden and/or bed bound, R1 is non-ambulatory. LPA interviewed three (3) facility staff that confirmed R1 is not complaining about their repositioning they are complaining about back pain and want the same bed they had at their Home Care Center. Therefore, based on the staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Licensee does not ensure there is enough staff to meet resident's needs in a timely manner. It is being alleged that there is not enough staff in the facility, and the staff turnover is very high. LPA interviewed four (4) caregivers that have been there for a few years and the four (4) caregivers confirmed they are assigned certain rooms and residents and they do their best to accommodate the residents but it depends also what they need help with. In addition, they have an outside agency that is used for extra help. During LPA’s physical tour on multiple occasions 04/22/26, 05/12/26, 05/19/26, LPA observed several caregivers, housekeepers and medical technicians helping different residents. LPA observed R1, not to be in their room but outside of the facility on these different dates. LPA asked R1 what is their need that is not being met and R1 stated to LPA, “when I need changing in the morning they do not come fast enough for me.” LPA stated to R1, you do have a caregiver assigned to you and a housekeeper and I have seen the outside agency staff come help you when you have requested help and R1 stated, “yes, they’ll send the outside help to come help me if the facility staff is not available.” Furthermore, LPA interviewed eleven (11) other residents that confirm there is an outside agency that comes to help the facility and that facility staff is also meeting their needs. Therefore, based on the staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff do not follow resident's care plan. It is being alleged that resident #1 (R1)’s care plan is not being followed. During LPA’s file review of R1, it was determined that R1 needs help with several ADL’s-Activities of Daily Living such as bathing, dressing, toileting, transfers and repositioning. LPA obtained R1’s Pre-Placement Appraisal, Medical Assessment, Service Plan, Home Health notes for wound care, R1’s Home Care Center admission record, Incontinence Schedule, Admission Agreement and Identification and Emergency Information. During LPA’s interview with R1, R1 did confirm that they get help with bathing, dressing, toileting, changing clothes and transfers to their wheelchair. LPA asked what about repositioning and R1 stated, “yes, because they use a Hoyer lift to help me, with two (2) staff. In addition, LPA did observe a Hoyer lift in R1’s room. Let it be noted, R1 is alert and can eat and take their prescribed medication on their own. LPA interviewed three (3) facility staff that confirmed R1 does not like to have staff help them throughout the day only when in the morning when they first get up and at night when R1 is getting ready to go to bed. LPA interviewed R1 again and asked R1 if they would go to the hospital so they can get re-evaluated for all their concerns and R1 stated to LPA, “they are not going to the doctor, they are doing fine.” Therefore, based on the staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not provide resident with bed prescribed by a physician. It is being alleged that resident #1 (R1) was told they could have the airbed that their doctor ordered for them, but R1 still does not have that air bed. During LPA’s interview with R1, R1 stated, “they wanted an airbed the same airbed they had at the Health Care Center.” LPA Interviewed a Health Care Center staff whom stated “R1 had a low air loss mattress for back support.” Furthermore, LPA also interviewed two (2) facility staff who stated, “they ordered a new mattress cushion for R1 called Medical Over Lay Mattress which is a therapeutic pad placed over a standard bed to enhance comfort and prevent skin breakdown but R1 is still not happy with the mattress they have ordered and mentioned it again that they wanted the same mattress they had at the Health Care Center. Let it be noted, there was not a bed prescribed by a physician. Therefore, based on the staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 31-AS-20260416151237

Allegation investigated: Staff are in violation of resident’s personal rights. Staff confiscated resident's personal belongings.

On 6/02/2026 at approximately 9:20 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Administrator, Stephanie Oden and stated the reason for their visit. To investigate the allegation(s), at approximately 09:30 AM, LPA conducted a physical plant tour. By 10:30 AM, LPA requested pertinent documentation pertaining to the investigation. From 10:30 AM to 12:30 PM, LPA conducted interviews with one (1) resident (R1), one (1) staff member (S1), and conducted record review. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff are in violation of resident’s personal rights. It was alleged that staff have denied R1 their physician’s visits. To investigate the allegation, LPA conducted interviews with one (1) resident and one (1) staff member. LPA’s interview with R1 revealed they see the facility’s physician when needed and they haven’t needed to see the physician due to it not being, “necessary”. When questioned if staff have denied them their physician visits, R1 stated, “No”. LPA’s interview with S1 confirmed R1 is seen by the facility’s physician. Based on interviews, R1 denied the allegation and confirmed they do in fact see their physician as needed. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff confiscated resident's personal belongings. It was alleged staff entered R1’s bedroom and confiscated their medical card and home health folder. To investigate the allegation, LPA conducted interviews with one (1) resident. LPA’s interview with R1 revealed that no staff have taken any of their personal belongings. When questioned if staff entered their room and confiscated their medical card and home health folder, R1 stated, “No”. Based on interviews, R1 denied the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 31-AS-20260528133548

Allegation investigated: Staff confined resident to bedroom

Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Stephanie Oden to investigate the allegation mentioned above. The following information was obtained during the visit: It was alleged that facility staff confined residents to their bedrooms. To investigate the complaint, between 9:30 a.m. and 1:00 p.m., LPA conducted a physical plant inspection, obtained and reviewed resident and facility records, including the facility’s infection control plan and policy, and interviewed four staff members, including the Administrator. According to the information obtained, resident #1 (R1) had a skin infection that could potentially be contagious. R1 was assessed by home health and a nurse practicioner (NP), and prescribed treatment. It was confirmed R1 had a contagious skin infection. (R1) shared a room with resident #2 (R2). During R1’s isolation period, R2 was also placed on precautionary quarantine measures due to potential exposure. (Cont'd LIC9099C) Unsubstantiated Information obtained revealed that facility staff informed R2 that the temporary isolation was necessary for health and safety reasons related to infection control procedures. Records reviewed and interviews conducted confirmed that R2 remained on quarantine precautions for two days. Following hospitalization for an unrelated medical condition, R2 was discharged back to the facility and relocated to a private room, per R2's request. Based on interviews conducted, records reviewed, and the facility’s infection control procedures, as well as policy, LPA determined that the facility implemented appropriate precautionary measures consistent with infection control practices and policy. Therefore, the allegation that staff confined residents to their bedrooms is deemed Unsubstantiated. Exit interview conducted and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, May 21, 2026 · control 31-AS-20260515111926

Allegation investigated: Staff did not prevent a physical altercation between residents in care

On 05/20/26, at 9:15am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Stephanie Oden,Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 12/29/25 Licensing Program Analyst (LPA) Abeye Duguma conducted the initial complaint visit. On 05/20/26, at 9:40am, LPA Saucedo conducted a physical tour, interviewed staff and residents. LIC 9099C-continued Substantiated Regarding the allegation: Staff did not prevent a physical altercation between residents in care. It is being alleged that two (2) residents were involved in a fight in the dining hall and there was no staff present. During LPA's interview with Resident #1 (R1), R1 was asked what happened and R1 stated, "I don't remember anything." LPA asked were any staff present and R1 stated, "no." During LPA's interview with Resident #2 (R2), R2 stated, "they did not remember what happened that day." LPA asked R2 if there was any staff present during the incident and R2 stated, "no." LPA interviewed two (2) staff that were present the day of the fight and they confirmed that there were no staff present during the fight in the dining hall. Staff #1 (S1) confirmed that while they were passing by they heard a loud noise and when they looked over R1 was already on the floor. Staff #2 (S2) confirmed they responded to give R1 and R2 medical attention if they needed any but the fight had already occurred when they went to the dining hall so they did not observe anything. S2 also remembers there was no other staff present because it was a weekend day. LPA confirmed that the incident was a Sunday-12/14/25. LPA interviewed fourteen (14) other residents and out of the fourteen (14) residents two (2) remember the incident involving R1 and R2. Both residents that were present for the fight stated, "R2 pushed R1, R1 then fell hitting their head and when R1 got up they went towards R2 with a butter knife." LPA asked the two (2) residents that remember the incident if there were any staff present and they both stated, "no." The twelve (12) other residents that were interviewed did not recall the incident between R1 and R2. Therefore, based on the staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, an appeals right was provided and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, May 20, 2026 · control 31-AS-20251223171146

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 3, 2026

(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...personal rights:(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...This requirement is not met by: Based on LPA's interviews, the licensee/administrator did not comply with the section cited above by providing R1 and R2 the care and supervision they need which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: The Administrator/Licensee shall conduct an in-service training to all staff regarding care and supervision of all residents. POC 06/03/26

Allegation investigated: Staff discriminates against a resident in care. Staff did not respond to a resident's call light. Staff do not treat resident with dignity.

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced subsequent complaint visit to deliver findings on the above-mentioned allegations. LPA met with administration coordinator, Nida Mercado, and explained the reason for the visit. The investigation consisted of the following: On 10/13/2025 at 10:30 a.m., Licensing Program Analyst (LPA), Evelin Rios, conducted an initial, unannounced complaint visit. LPA met with Stephanie Oden the Administrator and explained the reason for the visit. LPA requested the resident and staff roster. At approximately 10:49 a.m., LPA initiated the physical plant tour to ensure the health and safety of the residents in care. LPA conducted call button test and reviewed a call button log in the facility’s computer. Between 11:00 a.m. and 2:00 p.m., LPA interviewed nine (9) residents, one (1) of whom declined to be interviewed, and six (6) staff members from 2:00 p.m. to 3:30 p.m. Continue to LIC 9099-C Unsubstantiated (Continued from LIC9099) LPA conducted interviews with an additional ten (10) residents and three (3) staff members. On 10/16/2026 LPA Rios conducted an interview with an additional resident. On 05/06/2026 LPA Rios requested and obtained copies of R1’s documents such as Physician’s Report (LIC602), and Resident Appraisal from the facility. The investigation revealed the following: Regarding the allegation, staff discriminate against a resident in care. It is alleged that staff treated a resident differently from other residents. LPA’s interview with sixteen (16) out of twenty (20) residents stated they had not been discriminated against by staff. Three (3) residents stated they may have experienced discrimination at some point in the past by staff but were not sure when. They reported they don’t feel that way now. One (1) resident stated they felt staff were friendlier toward other residents than toward them. The residents could not provide a timeframe, identify who was involved, or describe any specific discriminatory actions. Interviews with nine (9) staff denied any discriminatory conduct and stated they have not witnessed residents being discriminated against by other staff. Staff also reported not receiving complaints from residents related to discrimination. 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 at this time. Regarding the allegation, staff do not treat a resident with dignity. It is alleged staff ridiculed resident in care. Interviews with seventeen (17) out of twenty (20) residents stated they had not been made fun of by staff. Two (2) residents stated they believed staff talk among themselves and felt staff laugh at them but could not hear what is said. Interviews with nine (9) staff indicated they have not made jokes about residents nor witnessed other staff making jokes or inappropriate comments toward residents. Staff reported they feel comfortable bringing any concerns to management or addressing the issue directly with the staff involved. 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 at this time. Continue to LIC 9099-C Regarding the allegation, staff did not respond to a resident's call light. It is alleged staff did not respond to resident’s call light when resident needed assistance to the bathroom. Interviews with sixteen (16) residents revealed that they had pushed the call button/call light for assistance. Three (3) of which stated they were independent and did not need to call for assistance. Seven (7) out of the sixteen (16) residents stated that had called for assistance reported call-light response times were fine, while three (3) out of the sixteen (16) reported to have waited 1-3 hours and five (6) out of the sixteen (16) reported wait times varied with the longest being 30 minutes and it depended on the shift but also reported staff provided a reason for a delay on response time. Interviews with nine (9) staff reported that they typically respond within 5 minutes, stating they go straight to the room and turn off the call-light button, unless they are already assisting another resident. Staff also state they communicate with other staff if they cannot make it to the room so that someone else can assist the residents. LPA conducted a test of four (4) call buttons in 4 resident rooms and staff responded within five minutes or less. On 10/13/26, LPA reviewed the facility’s call light log and observed two rooms where call lights were tested earlier to which staff responded, continued to show the calls as active. According to the receptionist, staff may forget to turn off the call light after assisting someone or the call light might be on in error. 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 at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 13, 2026 · control 31-AS-20251003161950

Allegation investigated: Due to lack of supervision, resident eloped

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced subsequent complaint visit to deliver findings on the above-mentioned allegation. LPA met with administration coordinator, Nina Mercado, and explained the reason for the visit. The investigation consisted of the following: On 12/09/2025 at 10:30 a.m., Licensing Program Analyst, (LPA) Evelin Rios, conducted an unannounced complaint visit to investigate the above allegation. LPA met with the Administrator, Stephanie Oden and explained the reason for the visit. At 10:50 a.m., LPA initiated a physical plant tour of the facility. At 10:50 a.m., LPA Rios requested and obtained copies of the facility's resident roster and Personnel Report (LIC 500). LPA also obtained records for Resident #1 (R1) such as, Continue to LIC 9099-C Unsubstantiated but not limited to, Physician's Report (LIC 602), medication list, Assisted Living Waiver (ALW) assessment and Hospice documents. From 11:00 a.m. to 3:00 p.m., LPA Rios conducted interviews with eight (8) staff not including the administrator and seven (7) residents. The investigation revealed the following: Regarding the allegation, due to lack of supervision, resident eloped. It is alleged the facility did not provide adequate supervision, resulting in Resident #1 (R1) leaving the facility and being found wandering in the community. Interviews with two (2) out of seven (7) residents stated they have seen residents who should not leave unassisted attempt to walk out the front door, but staff had been able to redirect them back inside. Six (6) out of seven (7) residents stated there is a sign-in/sign-out log at reception. R1 was not interviewed as they were not at the facility at the time of the visit. R1 is in a skilled nursing facility (SNF) for higher level of care. Residents stated that they don’t consistently sign out or sign back in when returning from the community. Interviews with staff reported the staff are able to assist each other and redirect residents that may have been noted as not being able to leave the facility. Per the receptionist, R1 has left the facility unassisted previously and has returned. Staff also reported that residents are encouraged to sign out and sign in when leaving and returning to the facility. Interviews with nine (9) staff revealed that R1 appeared fine or no more confused than usual in the days leading up to the incident. According to staff interviews, R1 received their morning medication but was not found for their evening medication pass at approximately 3PM. The Administrator was notified, and at approximately 8:00 PM the facility was informed that R1 had been found wandering in the community and transported to the hospital. Staff denied any prior incidents of elopement involving R1. Review of R1’s Physician’s Report dated 01/25/2025 notes R1 may leave the facility unassisted and documents that R1 has some forgetfulness. Review of R1’s Individual Services Plan with start date 07/02/2024 and end date 01/02/2025 notes R1 requires reminders and redirection but does not exhibit wandering behaviors. 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 at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was provided to Nina Mercado.the state’s words, verbatim · CDSS document, May 13, 2026 · control 31-AS-20251208122238

Type of visit: Required - 1 Year

On 05/12/26, at 8:10am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. LPA met with Nilda Mercado, Administrative Service Coordinator. LPA asked for the census, resident, and staff files. There are several doors that are utilized as entrances and exits at the facility. The facility is fire cleared for one hundred ninety-nine (199) residents of which one hundred (100) may be non-ambulatory on the first floor in rooms #1-8, 25-30, 51-71 and 87-88 and 30 bedridden in rooms #72-86. The second and third floors are for ambulatory and non-ambulatory residents and the facility has a hospice waiver for thirty (30). Kitchen: Food Service/Kitchen area was sufficiently stocked with seven (07) days of perishable and seven (07) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents. LPA conducted a physical tour of the kitchen area: Against the wall of the kitchen there is a diabetic list, residents that are currently in the hospital list, an Allergy list and a list of all resident and their room number. There is a pantry filled with food and a freezer filled with food. There is a large fire extinguisher against the wall and a temperature log for the freezer. The chemicals are kept in a pantry area in the kitchen locked and inaccessible to residents. LIC 809-C-continued Staff Files: LPA reviewed eight (8) staff files. Staff records were complete and updated. Resident Files: LPA reviewed sixteen (16) resident files. Resident records were complete and updated. LPA reviewed LIC 405 for residents that receive safeguarded cash resources form the office. Due to time constraints, LPA was unable to complete today's annual inspection. LPA will return to the facility to complete physical tour of the rest of the facility and complete the annual inspection. An exit interview was conducted and a copy of this report was given to the Administrative Service Coordinator.the state’s words, verbatim · CDSS document, May 12, 2026

Allegation investigated: Staff are mismanaging resident's medication. Staff did not give resident a 60 day notice for increase in rent.

On 05/05/2026 at approximately 9:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Administrator, Stephanie Oden and stated the reason for their visit was to deliver the findings of the complaint. To investigate the allegation(s), on 1/15/2026 at approximately 10:00 AM, LPA conducted a physical plant tour. By 11:00 AM, LPA requested relevant documentation. From 11:30 AM to 3:00 PM, LPA attempted interviews with one (1) residents (R1), six (6) staff members (S1-S6) and conducted record review. (Continue to LIC 9099-C) Substantiated Regarding the allegation: Staff are mismanaging resident's medication. It was alleged that staff had mismanaged R1’s medication. To investigate the allegation, LPA conducted interviews with one (1) resident and five (5) staff members. LPA’s interview with R1 revealed that on multiple occasions, staff have not distributed their medication on time, have mixed other residents’ medication with their Medication Administrator Records (MARs) and have not refilled their medication in a timely manner. LPA’s interview with all five (5) staff members confirmed that R1’s medication is distributed on time (there is a two (2) hour window for medication pass), recorded correctly on the Medication Administration Records (MARs) and refilled in a proper time frame. All five (5) staff members confirmed that resident’s medications are administered as prescribed. However, during LPA’s record review of R1’s MARs, LPA observed on 1/15/2026 it was shown R1 was given one of their prescribed medications by S5. When LPA conducted a record review of R1’s medication, LPA observed said medication could not be found. Upon further review it was revealed that the medication was not yet available. LPA’s interview with S5 revealed they had mistakenly marked medication as taken and were planning on correcting it on the MARS. Additionally, LPA’s review of R1’s medication, LPA observed two (2) medications to be missing resulting in S1 having to go to the medication room to find said medication. S1 was able to locate one (1) of the two (2) medications during LPA’s visit. Based on interviews, record review and observations there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Regarding the allegation: Staff did not give resident a 60 day notice for increase in rent. It was alleged that staff did not provide R1 with a 60-day notice of rent increase. To investigate the allegation, LPA conducted interviews with one (1) resident and two (2) staff members. LPA’s interview with S2 revealed that R1 is under the program of Assisted Living Waiver (ALW) and receives Social Security Administration (SSA). LPA’s interview with S2 revealed that R1’s rent is paid directly to the facility by the third-party provider (SSA). S2 revealed that R1’s rent increase occurs annually which is determined by SSA and not them. S2 revealed that SSA will send notification to all residents who are SSA recipients, and the facility themselves have posted the announcement on the community bulletin. (Continue to LIC 9099-C) LPA’s interview with R1 revealed that staff never gave them their notice of rent increase nor did they receive notice from SSA. R1 stated staff had them sign a form for their room rate to increase due to them having a private room. LPA’s record review confirmed R1’s “Addendum to Residence and Care Agreement for Residents with Third-Party Payer Source” for their room rate change dated 1/01/2026. LPA's interview with S2 correlated the room rate change for R1's single room occupancy stating they, "...agreed to a single room which is a rate increase. We have the copy". Further record review of R1’s file, LPA observed R1’s notice of rent increase due to SSA benefit increases effective January 1, 2025, dated 12/1/2024, and addressed to R1. However R1’s file did not contain the new notice reflecting the rent increase of 2026 for SSA benefit increase. During LPA’s physical plant tour, LPA observed the facility’s posting of the rent increase of 2026 labeled, "New Rates for Room and Board" posted in the hallway’s passageway located near the medication room on the first floor. When LPA questioned S2 if R1 had been given a notice of their rent increase correlating with the posting LPA observed in the hallway, S2 stated, “No”. Based on interviews, record review and observations there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Citations issued, please refer to LIC 9099-D No other immediate health and safety issues observed during the day of the visit. Exit interview was conducted, appeal rights given, and a copy of this report was provided to the Administrator. Regarding the allegation: Staff did not provide resident with her records. It was alleged that staff did not provide R1 with their file upon their request. To investigate the allegation, LPA conducted interviews with one (1) resident and two (2) staff members. LPA’s interview with S1 revealed that R1 had only requested a copy of their medication list and their Admission Agreement, which was provided to them. LPA’s interview with S2 revealed that R1 only requested their Assisted Living Waiver (ALW) information, which they too provided. Both staff stated R1 did not request their entire file. LPA’s interview with R1 stated they had requested their medication information due to concerns of their medication being mismanaged. LPA observed R1 to have a copy of their medication list. When questioned how they obtained their medication list, R1 informed LPA it was provided to them by the facility staff. Based on interviews, R1 confirmed they received their medication list and LPA observed them to be of possession of said information. There is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, May 5, 2026 · control 31-AS-20260107113426

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: May 19, 2026

87465 Incidental Medical and Dental Care. (c)...facility staff designated by the licensee shall be permitted to assist the resident with self-administration...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirment was not met evidenced by: Based on interviews, record review and observations, S5 had incorrectly marked R1's MARs with a medication that was not yet available which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: The Administrator/Licensee will conduct an in service-training with staff regarding medication distribution and record keeping of the MARs which will then be emailed to LPA Segovia by POC due date: 5/19/2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(4) · Plan of correction due date: May 12, 2026

87507 Admission Agreements. (g)Admission agreements shall specify...(4) Modification conditions...at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes. This requirment was not met evidenced by Based on interviews, record review and observations, R1 was not provided with their 60 days rent increase which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: The Administrator/Licensee will review the regulation and email LPA Segovia a statement of understanding by POC due date: 5/12/2026

Allegation investigated: Staff do not keep the facility free from infestation Staff do not properly maintain the facility grounds Staff did not provide laundry services for a resident Staff do not timely address a resident's change in medical condition

On 04/29/26, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Stephanie Ogden, Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 03/10/26, LPA Saucedo conducted the initial complaint visit. On 04/29/26, at 10:10am, LPA Saucedo conducted a physical tour, interviewed additional staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not ensure the residents had running water. It is being alleged that resident #1 (R1) had no water. During LPA’s interview with R1, “they stated that they did not have running water for the weekend of 03/07/26-03/08/26 and could not take a shower.” During LPA’s physical tour on 03/10/26, LPA tested the water in R1’s bathroom and R1 had water in the shower area but not the sink/handwashing area. Also, LPA received an Unusual Incident report on 03/06/26, stating that water was going to be shut off for about thirty (30)-sixty (60) minutes but not for the entire weekend. LPA interviewed an additional fifteen (15) residents that confirmed they did not have water that weekend. LPA interviewed three (3) staff that confirmed there was no water that weekend. Therefore, based on the observation and interviews conducted, the allegation is SUBSTANTIATED at this time. Regarding the allegation: Staff did not respond to a resident's call button in a timely manner resulting in not meeting resident's medical needs. It is being alleged that resident #1 (R1) fell, used their emergency call button, and nobody came to help them, leaving R1 on the floor for hours. During LPA's interview with R1, R1 stated, "they were left on the floor for several hours because no staff responded when they pressed their pendant." During LPA’s physical tour on 03/10/26, LPA pressed the emergency call button in R1’s bathroom and no one responded. In addition, LPA pressed R1’s pendant and no staff responded. As a result, it was determined that R1's pendant and call button were not working and that was the reason for not meeting R1's medical needs. LPA interviewed three (3) caregivers that confirmed it depends how many resident's they have to care for, what they need and them communicating to another caregiver if they are currently busy prolongs the time to respond to the call buttons. Although, LPA interviewed an additional fifteen (15) residents that confirmed their pendants and call buttons work because they use it and staff respond to them the allegation is still substantiated based on R1's malfunction of equipment in their room. Therefore, based on LPA's observation of R1's pendant and call button not functioning and interviews conducted, the allegation is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, an appeals right was provided and a copy of this report was given to the Executive Director. Regarding the allegation: Staff do not keep the facility free from infestation. It is being alleged that resident #1 (R1)’s bed and room is full of roaches and bed bugs. During LPA’s physical tour on 03/10/26, LPA did not observe any roaches and/or bed bugs in R1’s room and/or bed. In addition, R1 could not find the pictures on their phone that they said had proof of roaches and bed bugs. Furthermore, ECOLAB PEST conducted a visit on 03/06/26, and there was no rodents and roaches in R1’s room. LPA received a copy of the ECOLAB PEST paperwork. Although R1 did not have bed bugs, the above facility gave R1 a new bed on 03/10/26. During another facility visit conducted on 03/18/26, LPA visited R1 and LPA observed the new bed that was given to them. LPA interviewed an additional fifteen (15) residents that confirmed they have not seen any roaches in their room, and they do not have bed bugs. LPA interviewed three (3) staff that confirmed they have not seen any roaches and/or bed bugs in R1's room and throughout the facility. Therefore, based on the observations and interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not properly maintain the facility grounds. It is being alleged that poop and other fluids are smeared on the floor. During LPA’s physical tour on 03/10/26, LPA did not observe any poop and/or other fluids smeared on the floor of the facility. In addition, LPA conducted another physical tour on 03/18/26 and 04/29/26, and again LPA did not observe, and poop and/or other fluids smeared on the floor. LPA interviewed sixteen (16) residents that confirmed they have not seen any poop and/or other fluids smeared on the floor. LPA interviewed three (3) staff that confirmed the facility is cleaned several times per day and per shift. Therefore, based on the observations and interviews conducted, the allegation is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff did not provide laundry services for a resident. It is being alleged that staff are refusing to do resident #1 (R1)’s laundry. During LPA’s interview with R1, R1 admitted, “that they did not know their scheduled laundry day before but now know that it is on Thursdays. LPA received a copy of the laundry schedule, and it was confirmed that R1’s laundry day is on Thursdays. LPA interviewed an additional fifteen (15) residents that confirmed they know their laundry day and laundry services are provided to them on a certain day. LPA interviewed three (3) staff that confirmed weekly laundry is done for residents. Therefore, based on the interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not timely address a resident's change in medical condition. It is being alleged that resident #1 (R1) had an eye infection and was not being treated. During LPA’s interview with R1, R1 did say that they had recently had an eye infection and had let the facility doctor know and an antibiotic had been ordered but it was taking too long for them to receive. During LPA's physical tour on 03/10/26, LPA did observe R1’s left eye to be a little red. During R1’s medication review, R1’s ointment was ordered on 03/09/26 and was provided to them within the next couple days following approval. During LPA’s physical tour on 03/18/26 and 04/29/26, LPA observed R1’s eye not infected anymore. Furthermore, an additional ointment was prescribed for R1 on 04/22/26. LPA interviewed an additional fifteen (15) residents that confirmed they receive their prescriptions in a timely manner and the staff address their change in medical condition. LPA interviewed two (2) medical technicians and two (2) licensed vocational nurses that confirmed R1 is getting ointment medication for their eye. Therefore, based on the observations and interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 31-AS-20260309152656

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(6) · Plan of correction due date: Apr 29, 2026

87303(e)(6) Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or non-ambulatory residents, based on the residents' needs. This requirement is not met by: Based on LPA's observation and interviews, the licensee/administrator did not comply with the section cited above when resident #1 (R1) did not have water supply/plumbing issues for a couple of days which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: The Administrator/Licensee was made aware that resident's water supply/plumbing in the bathroom had issues and they were repaired at time of visit. POC Cleared: 04/29/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 13, 2026

87468.1 (a)(2) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met by: Based on LPA's observation and interviews, the licensee/administrator did not comply with the section cited above when resident #1 (R1)'s pendant and emergency call button in the bathroom was not working which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: The Administrator/Licensee will make sure that Resident #1 (R1)'s pendant and emergency call button in the bathroom is working and will send LPA a video and/or work order that it is working. POC Cleared: 05/13/26

Allegation investigated: Staff do not prevent resident from eloping from the facility

On 04/22/26, at 8:20am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Stephanie Ogden, Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 03/18/26, LPA Saucedo conducted the initial complaint visit. On 04/22/26, at 8:50am, LPA Saucedo conducted a physical tour, interviewed additional staff and residents. LIC 9099C-continued Substantiated Regarding the allegation: Staff do not prevent resident from eloping from the facility. It is being alleged that resident #1 (R1) is currently missing and has dementia. During LPA’s file review of R1, R1 did not have an updated physician report, did not have a resident reappraisal and did not have a needs and services plan. On 12/11/23, 01/05/24 and 02/05/24, R1 had a doctor stating, "R1's Psychiatric Evaluation behavior/problem/Issue is Dementia." R1 was admitted to the above facility on 06/28/23 and R1's physician report was dated 08/30/24. R1's pre-placement Appraisal was dated 03/28/23 and under service needed states R1 needs special observation/night supervision (due to confusion, forgetfulness, wandering). R1 was also under the Assisted Living Waiver which states R1 had dementia. R1 could not be interviewed because R1 never returned to the facility after they left, instead R1 was found and taken to a hospital. R1 is now transferred to a Memory Care Facility and is no longer at the above facility. During LPA's physical tour, LPA determined that there are two (2) exit doors towards the left side of the facility that are not monitored by staff and/or do not have an auditory device and/or perimeter fence gates. LPA interviewed five (5) staff that confirmed anyone can come in and out of those exit areas. One (1) staff did confirm that “R1 had left the facility a couple years ago but did return.” Another staff stated, "R1 along with other residents are not to leave the facility and the front desk is aware of it." During LPA’s interview with the front desk staff, the front desk staff did not know and could not give the LPA a list of the residents not able to leave the facility unattended/unassisted but did state, "we have cameras." LPA took a look at the cameras and five (5) of the cameras were not working. Furthermore, LPA took a picture of the cameras not working and the two (2) side exit doors where anyone can enter and exit. LPA interviewed sixteen (16) residents. Eight (8) out of the sixteen (16) residents, were residents that cannot leave the facility unassisted/unattended. Therefore, based on the LPA's observations, file review, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, an appeals right was provided and a copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 31-AS-20260310154619

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(d) · Plan of correction due date: May 6, 2026

87705(d) Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement...This requirement is not met by: Based on LPA's observation and interviews, the licensee/administrator did not comply with the section cited above by ensuring that exit doors and cameras at the front are working properly which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: The Administrator/Licensee will send a written plan for the facility to monitor exit doors. The licensee will also need to repair the cameras at the front desk that are not working which help monitor the exit doors. POC 05/06/26

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: May 6, 2026

(a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) 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. This requirement is not met by: Based on LPA's observation and interviews, the licensee/administrator did not comply with the section cited above by ensuring that Resident #1's individual needs were met which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: The Administrator/Licensee will need to provide all staff with the names of the individuals that cannot leave unassisted/unattended and provide training. POC 05/06/26

Allegation investigated: Staff did not ensure the elevator was in disrepair Staff are inappropriately isolating resident Staff did not ensure resident had her phone appointment with care coordinator

On 04/08/26, at 8:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Executive Director, Stephanie Ogden. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 04/08/26, LPA Saucedo asked for the census, staff, and resident rosters. On 04/08/26, at 8:45am, LPA Saucedo conducted a physical tour, interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not ensure the elevator was in disrepair. It is being alleged that the elevator is still not working. LPA conducted a physical tour and the elevator was working. On 12/31/25, Woodland Hills South Regional Office (WHSRO) received an incident report stating that the elevator is out of order. Since 04/02/2026, the elevators have been working. LPA also received the Performance Elevator update and requirement of the elevators to perform properly dated 01/19/26. Staff #1 (S1) did state, "the elevator took longer to repair than usual because elevator parts had to be ordered." LPA interviewed sixteen (16) residents from the second and third floor that are ambulatory and non-ambulatory and they were able to access the stairway to go up and down without any issues. In addition, during LPA's physical tour, LPA observed an emergency evacuation chair on the second and third stairway to help residents if there was an emergency. Therefore, based on the interviews conducted the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are inappropriately isolating resident. It is being alleged that resident #1 (R1) is being isolated on the third floor. During LPA's interview with R1, LPA asked R1 if they would like to move rooms and R1 stated, "I want to stay in this room but not at the facility." LPA asked R1 if they are able to go up and down the stairway and R1 stated, "yes." Let it be noted, LPA received R1's Identification and Emergency Information and Physician's Report that states R1 is ambulatory. LPA interviewed sixteen (16) residents from the second and third floor including R1 and asked them if they are being isolated and they all stated, "no." One (1) of the sixteen (16) residents did state, "they moved me from the lobby area and I would like to go back down there to my prior room." Let it be noted, this resident is also non-ambulatory and can go up and down the elevators and stairway. Furthermore, two (2) staff confirmed that if a resident wants to move rooms they can ask and they will be accommodated if the room is available and if the room meets their needs. Therefore, based on the interviews conducted the allegation is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff did not ensure resident had their phone appointment with care coordinator. It is being alleged that resident #1 (R1) had a phone appointment and it was not provided. LPA asked R1 when did they have their phone appointment scheduled with their care coordinator and R1 did not know. LPA asked R1 if they had a cell phone and R1 stated, "it is broken." LPA asked R1 why did they not use the phone that is in the hallway to call their care coordinator but R1 stated, "I didn't know I had an appointment and I didn't know there was a phone down the hallway." In addition, LPA asked R1 if they are able to walk downstairs and R1 stated, "yes." Let it be noted, LPA received R1's Identification and Emergency Information and Physician's Report that states R1 is ambulatory. During LPA's physical tour, LPA observed a phone on every floor for residents to use. LPA also physically checked the phones to see if they were working and they were. In addition, a resident was using one (1) of the phones in the office area. During LPA's interview with two (2) staff, the two (2) staff stated, "the residents are allowed to use our cell phones but we have to know exactly when and where." One (1) staff also stated, " a care coordinator did come to see R1 on 03/30/26 and spoke to them." LPA called two (2) care coordinators and one (1) stated they couldn't come visit R1 because they lived too far and wanted to face time with R1 and the other care coordinator stated, "I am now the new care coordinator and I will be seeing R1 from now on at the facility and I did see R1 on 03/30/26 at the facility." During LPA's interview with fifteen (15) other residents they confirmed they either have their own cell phone or can use the telephone in the hallway. Therefore, based on the interviews conducted the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Apr 8, 2026 · control 31-AS-20260403085839

Allegation investigated: Facility staff are not adhering to resident care plan. Facility staff do not provide adequate care and supervision to resident in care. Facility staff are unable to communicate effectively with the residents. Facility staff do not communicate with authorized representative in a timely manner. Staff did not answer the facility phone in a timely manner.

At 12:10pm, Licensing Program Analyst (LPA), Angela Panushkina conducted a subsequent visit to deliver final findings. LPA met with the Administratove Service Coordinator and, Nilda Mercado, explained the reason for the visit. The Administrator arrived shortly after. An initial complaint visit was conducted on 08/15/25 by LPA Alvizar-Ettima. During that visit LPA requested resident and staff roster. At approximately 10:40am, LPA conducted a physical plant tour, to ensure the health and safety of the residents in care. At 11:20am, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, Centrally Stored Medication and Destruction Record (CSMDR), Medication Administration Record (MAR), Staff Training, relevant to the investigation. Continue on LIC9099-C Unsubstantiated On 11/20/2025 at 9:20am, LPA Panushkina conducted subsequent visit and interviewed with the Administrator, three (3) staff, two (2) MedTechs and fourteen (14) out of seventeen (17) residents. Allegation: Facility staff are not adhering to resident care plan It was alleged that R1 was not provided with adequate care and the staff did not follow care plan by failing to cut his/her food and provide assistance with feeding. To investigate this allegation, LPA conducted an interview with the Administrator and three (3) staff members. All parties interviewed denied the above allegation and informed LPA that they were well aware of R1’s medical condition and the care plan was always followed. However, R1 would sometimes refuse meals and request cold liquids instead, due to his/her throat cancer. Additionally, three (3) staff members informed LPA that after multiple attempts to feed R1 during each meal, the staff would no longer push and or force R1 to eat their food because they did not want to violate R1’s personal rights. Fourteen (14) residents interviewed expressed no concern regarding this allegation and confirmed that their dietary orders are always followed by the kitchen staff and their personal rights are protected by the facility staff. Lastly, during physical plant tour, LPA observed posters throughout the kitchen notifying kitchen staff of resident’s preferences/special diets. LPA also observed that effective 07/22/2024, R1’s doctor ordered No Concentrated Sweets (NCS) due to R1’s diabetes. Therefore, based on interviews, record reviews and LPA observations, this allegation is deemed Unsubstantiated at this time. Allegation: Facility staff do not provide adequate care and supervision to resident in care Interview with the Administrator revealed that prior to employment, all staff are provided with “Basic Services” training and provided with copies of training to LPA. Additionally, LPA conducted interviews with fourteen (14) out of seventeen (17) residents and all residents interviewed expressed no concern regarding this allegation. LPA was informed that the facility staff will try their best to meet everyone's needs by providing good care and to ensure residents receive adequate care and supervision. Lastly, LPA observed staff appear to demonstrate proper knowledge in the interactions of the day. Interviews with staff also confirmed that they have been trained in a variety of the mandatory training. Therefore, based on interviews, this allegation is deemed Unsubstantiated at this time. Continue on LIC9099-C Allegation: Facility staff are unable to communicate effectively with the residents It was alleged that R1 often tried to communicate with staff, but many did not understand R1’s requests due to a language barrier. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that all staff members providing care and supervision to residents communicate in English. All three (3) staff and two (2) MedTechs interviewed were able to communicate with the LPA basic knowledge and procedures in the event of an emergency. Fourteen (14) residents interviewed expressed no concern regarding this allegation. LPA was informed that the staff can effectively understand, communicate, and treat the residents with dignity and respect. LPA conducted multiple visits to this facility and did not observe residents or staff having difficulty communicating with each other. Therefore, based on interviews and LPA observation, this allegation is deemed Unsubstantiated at this time. Allegation: Facility staff do not communicate with authorized representative in a timely manner The Administrator, three (3) staff and two (2) MedTechs interviewed denied the above allegation. LPA was informed that the Wellness Director and the Administrator did communicate with R1’s responsible party, on multiple occasions, regarding R1’s changes/updates. Fourteen (14) out of seventeen (17) residents interviewed expressed no concerns regarding this allegation, and informed LPA that staff maintain their authorized representatives/significant others informed of their status at all times. Therefore, based on interviews this allegation is deemed Unsubstantiated. Allegation: Staff did not answer the facility phone in a timely manner Prior to visiting the facility, LPA called the facility multiple times, and every call was answered by the facility staff/concierge. Interview with the Administrator revealed that the facility receives enormous calls and if staff are unable to answer, it goes to voicemail. Every voicemail received is addressed promptly. Interview with the concierge confirmed the statement provided by the Administrator. LPA was also informed that the facility did not have issues with the phone lines and in the event that the phone lines are not operating properly, staff have contact information for the Technical Support Department (available 24 hours per day/7 days per week). Fourteen (14) residents interviewed expressed no concern regarding this allegation and informed LPA that the phone calls are regularly answered and staff check daily voicemail and return calls immediately. Therefore, based on interviews and observation, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 31-AS-20250814150705

Allegation investigated: Staff did not prevent a resident from accusing another resident of stealing their personal belongings Staff did not safeguard resident's personal belongings

On 03/18/26, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Executive Director, Stephanie Ogden. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 03/18/26, LPA Saucedo asked for the census, staff, and resident rosters. On 03/18/26, at 9:45am, LPA Saucedo conducted a physical tour, interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not prevent a resident from accusing another resident of stealing their personal belongings. It is being alleged that Resident #1 (R1) is being accused by Resident #2 (R2) of stealing their belongings. During LPA's interview with R1, R1 stated, "that R2 accuses them of stealing their clothes." LPA asked R1 if they have reported this to staff and/or management and R1 stated, "no." LPA asked R1 why did they move rooms and R1 stated, "I had a procedure done so they moved me then when they moved me I wasn't happy so I asked to be moved from that room and I want to move again now." During LPA's interview with R2, R2 stated, "I have never accused R1 of stealing anything from me but I have accused staff." R2 also stated, "R1 just moved in here so I don't really know them." LPA interviewed two (2) staff that confirmed R1 is requesting to be moved again because they are not happy and that R1 never reported to them that R2 was accusing R1 of stealing their clothes." LPA spoke to fifteen (15) residents that confirmed they have never had any issues with informing staff of anything at the facility and they know where to report things in the main office. Therefore, based on the interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not safeguard resident's personal belongings. It is being alleged that Resident #1 (R1) had their wheelchair and mini speaker stolen. LPA obtained R1's Client/Resident Personal Property and Valuables form that has all of R1's personal belongings. R1's personal belongings did show there is one (1) speaker but no wheelchair. When LPA interviewed R1, R1 did state, "that the wheelchair was bought from another resident but did not remember when." Also, R1 stated, "I don't have my speaker with me." R1's two (2) previous roommates stated, "R1 never had a wheelchair but they did have a walker." R1's current roommate stated, "R1 never had a wheelchair only a walker which they use daily." R1's current roommate also stated, "R1 does have a speaker because they play it loudly and they have been told to lower the volume on it." LPA spoke to three (3) staff that reported, "R1 never had a wheelchair and only observed to have a walker which they use everyday." Furthermore, Two (2) other staff confirmed that R1 was using their speaker last couple of days." LPA spoke to fifteen (15) residents that confirmed they have never had any belongings stolen and/or missing." During LPA's record review, LPA also confirmed that R1's Physician's Report shows R1 is ambulatory and does not require a wheelchair. Therefore, based on the interviews and record review conducted the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 31-AS-20260312091507

Allegation investigated: Due to lack of supervision, resident physically assaulted another resident

On 03/10/26, at 9:05am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Executive Director, Stephanie Ogden. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 03/10/26, LPA Saucedo asked for the census, staff, and resident rosters. On 03/10/26, at 9:15am, LPA Saucedo conducted a physical tour, interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Due to lack of supervision, resident physically assaulted another resident. It is being alleged that resident #1 (R1) was physically assaulted by another resident due to lack of supervision. LPA interviewed two (2) staff that were present the day of the fight between the three (3) residents. Staff #1 (S1) stated, "that R1 took Resident #2's (R2's) wallet and threw water in their face and S1 told them to stop." S1 also stated, "R1 then began to attack Resident #3 (R3) because R3 was hanging around R2." LPA also interviewed Staff # 2 (S2) whom stated, "they did not see the initial fight but said I called 911, the Glendale Police Officer then showed up and took the resident's statement." LPA interviewed R1 and R3. R1 and R3 gave a similar statements that S1 gave. R1 stated, "they saw R2 and R3 together and they got mad so they started to hit R2 and R3." R2 refused to talk to LPA about the incident. R3 stated, "their hair was pulled and their glasses were broken by R1 when they got attacked because they were hanging around R2." LPA asked both R1 and R3 if any staff were present and both stated, "yes, because the fight happened near the stairway by the dining hall." Furthermore, LPA interviewed thirteen (13) additional residents that did not witness the fight between the three (3) residents but did state, "that they feel safe at the facility because staff are always present to help them." During LPA's physical tour, LPA observed R1 in R2's room. In addition, LPA received the Unusual/Injury report that was sent to Community Care Licensing Department about the incident that happened between the three (3) residents. Therefore, based on the interviews conducted the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 31-AS-20260305084625

Allegation investigated: Staff do not ensure residents have hot running water.

On 02/24/2026 at 10:00 am Licensing Program Analyst (LPA), Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegation. LPA was greeted and granted access by staff and LPA met with the Administrator Stephanie Oden. LPA explained the reason for the visit. Entrance interview conducted. At 11:00 am, LPA conducted a physical plant tour with the Administrator to ensure the health and safety of the clients are protected. At approximately 12:00 pm, LPA requested copies of LIC500 and resident roster. LPA also requested copies of maintenance logs, receipts and any documents relevant to the investigation. At approximately 12:15 pm LPA conducted a file review of documents provided. Between 10:00 am and 01:30 pm, LPA conducted interviews with Administrator, three (3) staff and ninteen (19) out of one hundred and seventy-five (175) residents. Continued on LIC9099-C Unsubstantiated Allegation: Staff do not ensure residents have hot running water. It is reported that Resident #1 (R1) moved into a room that does not have hot running water and that R1 has been using wipes to clean themselves. It is further reported that R1 receives wipe downs twice a week on Tuesdays and Thursdays by staff. LPA attempted to interview R1 but R1 refused to be interviewed. LPA interviewed Administrator who stated that all the rooms currently have running hot water. Administrator stated that on 02/03/26 maintenance technicians reported that there was a water leak in R1’s room that was immediately repaired. On 02/05/2026 a plumber was called out due to the water heater failing and made repairs. On 02/12/26 the water heater failed again and on 02/13/26 a plumber returned to repair the ignition box in the water heater that was the source of the issue. During this time although water heater kept failing it was only for short periods of time as a plumber would come out immediately to fix it, or the maintenance technicians would relight the pilot temporarily. Administrator stated that the water was only shut off for approximately 60 minutes on 02/13/26 as the repairs were being made. Showers for residents were scheduled to be done either before or after the plumber was due to make repairs. At no point was the hot water or water in general turned off to where it would have significantly interfered with any of the residents’ grooming. LPA interviewed Maintenance Staff #1 (S1) and Staff #2 (S2), who confirmed what Administrator reported, stating that they repaired what was needed and the portion that was out of their hands was handled by a professional plumber. The repairs were done as soon as possible, however S1 and S2 stated that when it came to replacing parts, the situation was beyond what they could do and that is when the plumber was called. During the water heater failure S1 and S2 were able to temporarily reignite the water heater stating that there were no interruptions to having hot water. Both staff stated that as of 02/13/26, when the faulty part was replaced, there have been no concerns with the hot water. LPA interviewed Staff #3 (S3), who stated that R1 does not get wiped down or bedside baths but instead gets assistance with showers on Tuesdays and Thursdays, as the other days of the week R1 is not at the facility. S3 further stated that R1 has not requested additional days of assistance with showers. Continued on LIC9099-C LPA interviewed nineteen (19) out of one hundred and seventy-five (175) residents and all of them expressed that they have no concerns regarding lack of running hot water or plumbing issues, some expressed that they were not aware that the water was shut off to reflect that there was very minimal impact or interruption. LPA reviewed maintenance notes and plumbing service receipts dated back to 02/03/26 and was able to confirm the information that was provided by Administrator and staff. During facility tour, LPA checked eighteen (18) rooms for running hot water and LPA confirmed that the rooms all had running hot water measuring within regulation between 105˚F and 120˚F. LPA checked random restrooms throughout the facility and was able to confirm that they all had running hot water that was measured within regulation. Therefore, based on interviews, record reviews and observations, this allegation is deemed unsubstantiated at this time. No citations issued. Exit interview conducted. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 31-AS-20260217164251

Allegation investigated: Staff are not safeguarding resident's belongings Staff are not providing mail to resident Staff are not bathing resident as needed

On 02/24/2026 at 02:00 pm Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced subsequent visit to this facility to deliver the report for the above stated allegations. LPA spoke to the Administrator Stephanie Oden and explained the reason for the visit. On 12/17/2025, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegations mentioned above. On 12/22/2025, LPA Casillas initiated the complaint visit. LPA Casillas conducted a tour of the facility and obtained copies of pertinent information. LPA also conducted interviews with the Administrator, five (5) staff and seventeen (17) out of one hundred and sixty-seven (167) residents. Continued on LIC9099-C Unsubstantiated Allegation: Staff are not safeguarding resident's belongings It is reported that Resident #1 (R1)’s clothes and toiletries were stolen and/or missing. LPA interviewed R1 and R1 revealed that they did not say that their belongings were stolen or missing, they stated that their belongings were “not there”. LPA asked for clarification and R1 instructed LPA to check R1’s drawers to see if clothes and toiletries were present. LPA was able to locate R1’s belongings and toiletries in R1’s drawers that were half closed, allowing LPA to observe the drawers without having to open them. LPA informed R1 of what was observed and R1 simply acknowledged that it could have been a misunderstanding. LPA interviewed the Administrator who stated that there have been no reports made regarding any belongings missing for R1, denying the allegation. Administrator stated that R1 at times will alert staff that R1’s things are missing but are later located in R1’s dresser. LPA interviewed five (5) staff, and they all stated that they have not moved R1’s belongings. Two (2) of the five (5) staff interviewed work directly with R1 and they stated that R1 is constantly asking staff for their belongings and that they always show R1 that R1’s things are in the drawers. LPA interviewed seventeen (17) out of one hundred and sixty-seven (167) residents and they all stated that they have no concerns with their belongings not being safeguarded, adding that the staff are always helpful when they need assistance locating their belongings if they need it. Therefore, based on interviews and observations, this allegation is deemed unsubstantiated at this time. Allegation: Staff are not providing mail to resident. It is reported that R1 is not being provided with their mail. LPA interviewed R1 and R1 stated that they did not report this allegation. R1 clarified that they stated that the mail was delayed but never that it was not provided. LPA was able to observe a stack of unopened mail on R1’s dresser and when LPA inquired about the stack R1 restated that they never stated that it was not provided. LPA interviewed Administrator who denied the allegation that mail is not provided to residents stating that mail is taken to residents on a daily basis. Administrator added that mail is received for those residents that cannot go to their mailboxes, then it is sorted and distributed by staff. LPA interviewed five (5) staff who also denied the allegation stating that all residents get their mail, some in their mailboxes and some delivered to their rooms depending on their needs. LPA interviewed seventeen (17) out of one hundred and sixty-seven (167) residents who all stated that they have no concerns with their mail. LPA observed that some residents have mailboxes and some don’t as some repairs are being made some of the mailboxes. For residents that cannot get their own mail, or who’s mailbox is being repaired, the reception area is designated for the mail carrier to drop off mail or packages. Based on interviews and observations this allegation is deemed unsubstantiated at this time. Continued on LIC-9099C Allegation: Staff are not bathing resident as needed. It is reported that R1 is not getting enough baths. LPA interviewed R1 who stated that they only get bedside baths once a week and would like more baths. R1 states that once a week is not enough and that they have told staff that they want more baths but have been ignored. LPA interviewed Administrator who denied this allegation stating that R1 gets a bedside baths every Monday and Thursday not just once a week, furthermore Administrator states that R1 agreed to twice a week and has not expressed a desire or requested additional baths. LPA interviewed facility Wellness Coordinator Staff #1 (S1) who stated that there is a verbal agreement with R1 that R1 will have a bedside bath twice a week. S1 states that R1 has not expressed to S1 that they would like additional baths and although R1 has not refused any of the currently scheduled baths, R1 does get upset when R1 has to get up even though this is something that R1 has expressed to want. S1 stated that they are constantly working with R1, however it has been a challenge as R1 expresses that they want to improve but is reluctant to cooperate at times. LPA interviewed seventeen (17) out of one hundred and sixty-seven (167) residents who all stated that they have no concerns with getting assistance if they require it for grooming or for any other needs that they may need help with. LPA reviewed facility logs pertaining to bedside baths and could observe that R1 does receive their baths twice a week and that there has been no refusal on R1’s end, to reflect that baths take place twice a week. Therefore, based on interviews, observations and record reviews, this allegation is deemed unsubstantiated at this time. No citations issued. Exit interview conducted. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 31-AS-20251217163518

Allegation investigated: Staff did not get timely medical care for resident. Staff do not treat resident with respect. Due to lack of supervision, residents go into other resident's bedrooms at night. Staff handled resident roughly.

Licensing Program Analysts (LPA) Leslie Ngo-Castaneda conducted a subsequent complaint visit to the facility to investigate the above allegation. LPA met with the executive director (S1) and advised them about the visit. An entrance interview was conducted. To investigate the allegation, on 12.16.2025 at 10:30 AM, LPA conducted a physical plant tour to ensure the health and safety of the clients in care. LPA interviewed seventeen (17) out of one hundred sixty-seven (167) residents, the executive director, and seven (7) staff from 10:36 AM until 12:32PM. At 12:35 PM, LPA reviewed and received copies of documents related to the investigation, including the staff roster, resident roster, R1 physician report, identification and emergency information, resident appraisal, and other relevant documents. Continue to LIC 9099-C Unsubstantiated Allegation #1: Staff did not get timely medical care for resident. It was alleged that on 12/03/25, resident #1 (R1) was brought to the Emergency Department. R1 had blurred speech the day before and it was not clear why R1 was not sent to ER within the same day. LPA interviews with the Executive Director and other staff revealed that R1 was sent to the emergency department (ED) immediately when slurred speech was observed. Furthermore, staff revealed that medical assistance, such as calling 9-1-1 during an emergency, has been used for all residents when needed. Residents revealed that in addition to staff, they also have access to call 911 if they need to. A review of facility internal documents verified the information revealed from interviews. Therefore, based on LPA observations, record reviews, and interviews, this allegation is deemed Unsubstantiated. Allegation #2: Staff do not treat residents with respect. Regarding the above allegation, it is alleged that staff was rude and mean to R1 and R1 is trying not to call the police as it was going to make things worse for R1. Interviews with residents revealed that they are happy and have not experienced such treatment from staff. Interviews with staff revealed that they treat all their residents with respect and dignity. Upon review of facility records, including internal incident logs, LPA did not obtain any information to support the allegation. Based on observations, record reviews, and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation #3: Due to lack of supervision, residents go into other residents’ bedrooms at night. It was alleged that a few different men have been going in and out of R1’s room in the middle of the night. LPA interview with S1 revealed that staff would not enter the resident's bedroom unless they are called. Staff would knock first before entering their bedroom. LPA interview with residents revealed that they are happy with the night staff and were well taken care of by the staff and provided with all the care they need. A review of internal records did not provide any information to verify the a validity of the allegation. Therefore, based on the information gathered during this and prior visits, these allegations are deemed unsubstantiated at this time. Continue to LIC 9099-C Allegation #4: Staff handled resident roughly. It was alleged that R1 was slammed against the wall by "a big Hispanic guy" staff member. Interviews with staff and the S1 revealed that no staff handle residents roughly or abuse them. They have no staff matching that description. During a facility tour on 12.16.2025, LPA observed staff handling residents gently and with respect. Based on interviews and observations, there was no evidence corroborating the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to S1.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 31-AS-20251208105927

Allegation investigated: Facility is in disrepair. Facility did not follow fire regulations.

At approximately 9:22AM on 1.28.2026, Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced complaint visit. LPA met with the Executive Director (ED)/(S1) and disclosed the reason for the visit. To investigate the allegation above, prior to this visit at 8:00am, LPA reviewed the incident reports received from the facility. During licensing visit, LPA interviewed ED at approximately 9:40 AM today and toured the facility at 9:42 AM. In addition LPA spoke with 2 maintenance technicians Staff #2 (S2) and staff #3 (S3) . - Facility is in disrepair - Facility did not follow fire regulations. Continue to LIC 9099-C Unsubstantiated Regarding the allegation “Facility is in disrepair,” it was witnessed by a mandated reporter that the only elevator in the facility is out of service. The interview with the ED today confirmed that the facility elevator was out of order. ED has reported the issue in a timely manner, and they were working to fix it. Interviews with the facility maintenance technicians (S2 and S3) at 9:55 AM revealed the facility has been waiting for parts to put in a new and modernized elevator, which can take up to 4-6 weeks. On 12/31/25, Woodland Hills South Regional Office (WHSRO) received an incident report stating that the elevator is out of order. A review of facility maintenance records revealed that a new elevator will be inputted at the facility. ED reported the incident of fire safety concerns to LAFD (Los Angeles Fire Department) on 12.29.2025, on 1.3.2026 LAFD was at the facility to alleviate the concerns of residents on the upper floors. A Review of the incident report from 12.31.2025 submitted to Licensing office verified the information revealed from interviews. During this visit LPA observed that the elevator is still not working today. To accommodate residents the staff served the meals to the residents’ bedrooms as per their requests. All residents interviewed during this visit had knowledge that the elevator was not working and the parts were ordered. No one addressed any concerns, and they verified that staff is doing their best to accommodate everyone. Based on observations, interviews, and record review, it was concluded that although the elevator is not working, the facility staff reported the issue accordingly and they are taking appropriate actions to accommodate the residents and fix the elevator. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 31-AS-20260123153522

Allegation investigated: Staff did not include resident’s representative in care decisions.

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda made an initial complaint visit to investigate the above noted allegations. LPA was greeted by Executive Director (S1) and explained the purpose of this visit. It was reported that Resident #1 (R1) was transferred to Culver City Skilled Nursing Care facility from the hospital and R1’s responsible party was not involved in decision making process. Per reporting party, R1 lives in Glendale and there is no justification to send R1 far away, To investigate the allegation at 9:30am, LPA spoke with Executive Director (ED), who revealed that resident #1 (R1) is upset with the hospital arrangements. From th hospital R1 was discharge to a SNF that is not of their preference. The Facility has nothing to do with the transfer or decision-making process of the hospital. Prior to this visit on 01/23/26. LPA Ngo Castaneda spoke with R1’s responsible party, Continue to LIC 9099-C Unfounded who also stated that R1 was transferred to SNF without prior discussion with the resident or the responsible party. Overall investigation revealed that issues and concerns addressed by the complainant are unrelated to the facility. Based on the results of the investigation, it was concluded that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, is deemed UNFOUNDED at this time. This agency had investigated the complaint alleging “Staff did not include resident’s representative in care decisions”. We have found that the complaint was without a reasonable basis. We have therefore dismissed the complaint. No health and safety hazard is noted during this visit. Exit interview was conducted and copy of report was issued.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 31-AS-20260122155004

Allegation investigated: Staff did not ensure residents records were properly managed

On 01/26/26, at 9:15am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Nilda Mercado, Administrative Service Coordinator. LPA explained the purpose of this visit was to gather information and deliver findings regarding this complaint. On 01/26/26, between 9:25am-2:30pm, LPA Saucedo conducted a physical tour, conducted resident and staff interviews and delivered findings for this complaint. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not ensure residents records were properly managed. It is being alleged that Resident #1 (R1) received a bill for blood they had withdrawn at the above facility. During LPA's interview with R1, R1 confirmed that they did not have proof of a bill that they were being charged on behalf of a blood draw. LPA interviewed sixteen (16) other residents that confirmed they have had blood withdrawn at the facility but they have never received a bill. LPA interviewed five (5) staff, four (4) out of the five (5) staff did not know about how a resident gets billed, they only provide medication disbursement. One (1) staff out of the five (5) staff confirmed that residents only get blood withdrawn at the above facility if their insurance covers it. Furthermore, that same staff confirmed if a resident's insurance refused to pay the bill they would get an email saying the resident's insurance was not covering the bill. In addition, that staff also confirmed that R1 gets Medical and Medicare and should not be getting charged for anything. LPA obtained R1's Identification and Emergency Information and Admission Record that confirms R1 gets both Medical and Medicare. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Administrative Service Coordinator. Regarding the allegation: Staff does not ensure residents medications are properly managed. It is being alleged that Resident #1-(R1) received a new pain medication and it was not provided to them. LPA asked for R1's MAR-Medication Administration Record and it was determined by reviewing R1's MAR, that the pain medication was never noted in the facility's medication system and on the MAR. LPA received R1's pain medication prescription from R1's new Health Insurance and the doctor that prescribed it. R1's medication was prescribed on 01/09/26. LPA conducted a physical review of R1's medication and noticed that pain medication was in a bubble pack stored in R1's medication packet in the medical technician's cart and the following dates were missing 01/20/26-01/26/26. It is a morning medication but there was no notation that it was being provided to R1. LPA interviewed the medical technician that confirmed R1's pain medication was provided that morning (01/26/26) but they did not document it anywhere because the new pain medication was not on the MAR list. Although, LPA interviewed sixteen (16) residents that confirm they receive their medication, R1 continues to confirm that they are not receiving their pain medication. LPA interviewed five (5) staff that confirmed that R1 should have been receiving their pain medication but because there was no documentation of R1 receiving their pain medication they cannot determine if R1 ever received it. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, an appeals right was provided and a copy of this report was given to the Administrative Service Coordinator.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 31-AS-20260123142414

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(4) · Plan of correction due date: Feb 9, 2026

Personnel Requirements: All personnel shall be given on the job training or have related experience with knowledge required to safely assist with prescribed medications. This requirement was not met as evidenced by: Based on LPA's observation and interviews, the licensee/administrator did not comply with the section cited above by providing R1 their medication everyday and/or when prescribed which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: The Administrator/Licensee shall conduct an in-service training to all staff regarding medication. POC 02/09/26

Allegation investigated: Staff did not prevent resident's money getting stolen

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint visit to investigate the allegation referenced above. LPA met with Administrator Stephanie Oden, who was informed of the reason for the visit. The allegation indicated that facility staff failed to prevent a resident’s money from being stolen. Prior to the visit, LPA reviewed the complaint and attempted to contact the reporting party to obtain additional information; however, the attempt was unsuccessful. During the visit, conducted from 9:30 a.m. to 1:00 p.m., LPA obtained facility documentation and interviewed four (4) staff members and multiple residents. Based on the information reviewed, it was alleged that Resident #1 (R1)’s money may have been stolen. Unsubstantiated LPA interviewed the Administrator, who reported she was not aware of any personal items or money being stolen from R1’s room. The Administrator stated that R1 is currently hospitalized and is anticipated to be transferred to a convalescent facility for further treatment. R1 has a Power of Attorney (POA) who communicated with the Administrator via email regarding R1’s personal belongings while R1 was hospitalized. LPA reviewed the email correspondence, which did not reference any missing or stolen personal belongings. Facility staff also reported that they spoke with the POA, who did not indicate at that time that any of R1’s belongings were missing or stolen. During the visit, LPA interviewed the POA, who reported that money was missing from R1’s wallet. The POA stated she was unable to determine whether the money was missing while R1 was residing at the facility or if the loss occurred during transport with paramedics. LPA was able to communicate with R1, who confirmed that money was missing but was unable to identify when the money was taken or who may have taken it. Interviews with residents revealed that theft occasionally occurs at the facility and is typically attributed to residents failing to lock their room doors. Residents reported that when theft is reported to the Administration office, staff attempt to locate the missing item or replace it using facility funds. Facility staff reported they were not aware of any missing items or money belonging to R1. Due to inconsistent reporting, the absence of timely notification to the facility by R1 or the POA, and the inability to determine when or where the alleged loss occurred, there is insufficient evidence to substantiate that the facility or its staff were responsible for the alleged missing money. Based on interviews and documentation reviewed, although the allegation may be possible, there is insufficient evidence to support that facility staff failed to safeguard R1’s money. Therefore, the allegation is determined to be Unsubstantiated at this time. Exit interview conducted and copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 20, 2026 · control 31-AS-20260112120742

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit in conjunction with Complaint Control #31-AS-20260115084953. Based on information obtained during the visit, it was revealed that there were multiple incidents involving inappropriate behavior by resident #1 (R1) toward other female residents. According to the Administrator, staff observed R1 during nighttime hours looking through the windows of other residents’ rooms. Although incidents of inappropriate behavior involving R1 were reported to and known by the facility, the facility failed to report these incidents to Licensing as required. This failure to report poses a health and safety risk to residents in care. Citation issued, appeal rights, exit interview conducted and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Jan 20, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 3, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specificed o (A) through (D) below.. This requirement was not met, evidenced by, based on interviews, it was revealed R1 was displaying inappropriate behavior toward female residents in Oct 2025, and the facility did not submit incident reports. This poses as a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 20, 2026

Plan of correction: Administrator will submit incident reports involving R1 to LPA for year 2024 and 2025.

Allegation investigated: Staff did not provide adequate supervision resulting in an altercation between residents.

At 12:00pm, Licensing Program Analyst (LPA), Angela Panushkina and conducted a subsequent visit to deliver final report. LPA met with the Administrator and explained the reason for the visit. Initial visit was conducted on 09/23/25 and during course of the investigation, LPA requested resident and staff roster. At 09:55am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Facility's Abuse Policy, House Rules and Staff Training relevant to the investigation. At approximately 10:00am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:10am – 2:00pm, LPA conducted interviews with the Administrator, three (3) staff, two (2) MedTechs and fourteen (14) out of seventeen (17) residents. Continue on LIC9099-C Unsubstantiated Allegation: Staff did not provide adequate supervision resulting in an altercation between residents. It was alleged that on 09/10/25 R1 got slapped by R2 and staff did not provide adequate supervision. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that during the morning and afternoon shifts (from 7am – 3:00pm) the facility has six (6) to seven (7) staff members, including two (2) MedTechs. LPA was also informed that the staff is always available to redirect residents in case an altercation or any type of disagreement between the residents occurs. Interview with three (3) staff members confirmed the statement provided by the Administrator. All staff interviewed informed the LPA that no serious injury was reported during R1's and R2’s incident. This was the first time that R1 and R2 had an altercation and no previous incidents between the two had ever happened in the past. According to the R1's Physician's Report (dated on 07/13/23) and R2's (dated on 04/29/25) both residents have a history of depression. Administrator also informed LPA that R1 has a history of confusion, however, both residents have never had a history of aggression. Interviews with fourteen (14) out of seventeen (17) residents revealed that residents may occasionally argue and or disagree, however, the staff is well trained to prevent altercation and an immediate staff intervention/redirection is being provided. According to a police report (dated on 09/10/25), R2 instigated the altercation when R2 interrupted a conversation between R1 and another resident, which turned into an argument, and then R2 slapped R1 one time on the right side of the face. The two were eventually separated by the staff and no further medical attention was required or requested by both residents. Although there was an altercation between R1 and R2, that lead to R2 striking R1, there wasn't enough evidence to prove that staff did not prevent resident from hitting another resident in care, as there was staff supervision present to intervene and redirect both residents. Moreover, licensee did submit an Incident Report (IR) to the Licensing agency regarding the incident. Therefore, based on the information obtained the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 31-AS-20250915150605

Allegation investigated: Staff yell at residents Staff are mismanaging resident's medications Staff do not ensure residents are wearing adequate clothing Staff do not safeguard resident's personal belongings Staff open mail without resident's consent Staff do not provide resident's adequate food service Staff do not follow resident's activities schedule Staff are not able to communicate with resident's due to language barrier

At 10:30am Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver findings of the above noted allegations. LPA met with Nilda Mercado, Administrative Services Coordinator (ASC) Executive Director, Stephanie Oden and explained the reason for the visit. During initial visit on 07/15/2025 At 10:15a.m., LPA and ASC conducted a physical plant walk-through. Between 11:00a.m. – 12:45p.m., LPA interviewed six (06) out of one hundred and seventy-four (174) residents. At approximately 2:00p.m. LPA interviewed Director of Culinary, Administrative Services Coordinator (ASC) and asked questions relevant to the investigation. LPA request copies of the activities calendar, residents package log, menu and other pertinent documents. Prior to this visit on 10/23/2025 LPA, Alvizar-Ettima reviewed records and other documentation obtained Cont. on LIC9099-C Unsubstantiated Cont. from LIC9099 during the initial visit. Records included but were not limited to staff training information, residents’ medication administration records, activity calendar and inventory records of residents’ personal belongings. LPA interviewed eleven (11) additional residents including resident#1 (R1) via-phone. On 12/08/2025 LPA, Alvizar-Ettima interviewed Staff #1- #4 (S1- S4) via-phone and requested additional clarification to complete the investigation. During this visit at 10:50a.m. LPA and ASC conducted a physical plan tour and delivered findings. 1.) Staff yell at residents It was alleged that non kitchen workers yell at hungry residents to go away. During interview with resident #1 (R1) indicated that they have not seen staff yelling at residents. Interview with additional residents consistently stated staff are respectful and do not yell at residents. Resident #12 indicated that the services are excellent at this facility. Interviews with the Director of Culinary and ASC revealed no complaints of staff yelling at residents. Other staff reported that they are always present during meal service and have not observed staff telling at hungry residents to go away. LPA did not observe staff yelling during the visits. Based on interviews, observations, and records review, there is insufficient evidence to prove or disprove the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED. 2.) Staff are mismanaging resident's medications It was alleged that unlicensed staff distribute sleeping pills and other medication at dinner time. Interview with R1 revealed medications as prescribed are provided and had no idea of sleeping pills being distributed at dinner. Staff revealed that all Med-Tech’s are trained at administering medications at designated times. Interview with additional residents confirmed the same practice. Resident #2 (R2) indicated that they take sleeping pills and med-tech always gives them to R2 at bedtime in their room. ASC reported that all Med – Tech staff are trained and certified to administer medications. A review of facility training records verified staff competency requirements. Interviews with staff indicated that medication distribution occurs according to policy and Med-Tech staff distribute medications in the dining room only when appropriate. A review of R2’s medication records showed no discrepancies and confirmed the information that R2 provided. There were no prior complaints regarding medication errors. Cont. on LIC9099-C Cont. from LIC9099-C Based on interviews, observations, and records review, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED. 3.) Staff do not ensure residents are provided adequate clothing It was alleged that residents are often in pajamas in the common areas. Interview with R1 stated residents are provided with choices and may wear pajamas if they choose. Interviews with all additional residents revealed no concerns about clothing availability. ASC reported no prior complaints and stated staff redirect residents if they attempt to enter the dining room without proper attire. S1 confirmed the information provided by ASC. No observations during the visit indicated that residents lacked adequate clothing. Based on interviews and observations, there is insufficient information to support the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED. 4.) Staff do not safeguard resident's personal belongings It was alleged residents’ room door locks are a missing key and belongings are not secure. Interview with R1 stated they have not experienced theft and that staff assist residents in safeguarding personal items. Interviews with additional residents indicated that staff do safeguard their personal belongings and had no concerns. ASC reported that when residents misplace a key, staff issue a replacement key after confirming identification. Staff interviews confirmed that staff follow facility protocol for key replacement. A review of residents’ personal inventory records and other documents did not reveal any information to verify the allegation. Based on interviews, observations, and records review, there is insufficient evidence to support the allegation. The allegation is deemed UNSUBSTANTIATED. 5.) Staff open mail without residents’ consent It was alleged that packages mailed to resident(s) go missing or are opened by staff. Interview with R1 stated they receive the packages mailed to them. Interviews with additional residents indicated no concern about open or missing packages. R12 reported that staff are strict about properly Cont. on LIC9099-C Cont. from LIC9099-C logging packages, not opening them. ASC confirmed that packages are logged and may only be opened by the resident identified on the package. Staff explained that FedEx/USPS/UPS packages are delivered directly Based on interviews, observations, and records review, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED. 6.) Staff do not provide residents with adequate food service It was alleged that burgers served at dinner time are lukewarm. Interview with R1 reported that food is prepared fresh and heated appropriately. Interviews with additional residents reported no concerns about food service. Interview with R16 described food quality as “excellent”. ASC and the Director of Culinary confirm no prior complaints were received about food being cold or not held on a warmer, as staff prepare meals per order and within reasonable time. Observations during the visit showed proper food handling procedures. Based on interviews, observations, and records review, there is insufficient evidence to support the allegation. The allegation is deemed UNSUBSTANTIATED. 7.) Staff do not follow resident's activities schedule It was alleged that Bingo is “often unscheduled or canceled.” Interview with R1 indicated Bingo continues as scheduled. Interviews with additional residents stated they had no concerns regarding activity cancellations. ASC stated that Bingo is posted on the monthly calendar and is conducted regularly unless otherwise noted. S1 interview collaborated with ASC and indicated that Bingo is the most popular and requested activity in the facility. A review of activity schedule verified the information revealed by staff. No evidence was obtained showing inconsistency or cancelation of activities. Based on interviews, observations, and record review, the allegation is deemed UNSUBSTANTIATED. 8.) Staff are not able to communicate with resident's due to language barriers Cont. on LIC9099-C Cont. from LIC9099-C It was alleged staff “pretend to not speak English” or cannot assist residents. Interview with R1 indicated staff communicate effectively, assist residents and can call for Emergency Assistance as needed. Interviews with additional residents stated they have no concerns regarding communication. ASC reported no prior complaints and stated bilingual staff are available. Interviews with other staff confirmed they can communicate with residents in English and seek assistance from another staff member when needed. No credible evidence was found indicating staff are unable to communicate with residents. Based on interviews and observations, the allegation is deemed UNSUBSTANTIATED. No immediate health and safety issues were observed during the visit. No citations issued. Exit interview was conducted and copy of was provided.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 31-AS-20250708081539

Allegation investigated: Staff are financially abusing resident

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegation. LPA arrived, was greeted by the receptionist, and met with the Executive Director Stephanie Olden, explaining the reason for the visit. LPA requested copies of pertinent information which includes and not limited to LIC 500, and Resident Roster. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and are in compliance with Title 22 Regulations. Allegation: Staff are financially abusing resident It was alleged that facility staff used Resident #1’s (R1) bank account information and accessed R1’s funds. It was also alleged that facility staff financially exploited Resident #2 (R2) by accessing R2’s checking account to pay for placement. Interview with the Executive Director indicated that R1 had never been a resident of the facility and that R2 had only been at the facility for a week. LPA conducted a records review of R2’s file and confirmed that R2 is responsible for his/her own finances. (Continue on 9099C) Unsubstantiated Interview with Staff #2 (S2) and Staff #3 (S3), confirmed that R2 is responsible for their own financial matters and that the facility had no access to any banking information, nor had the facility charged R2 for placement. LPA also interviewed 16 residents, all of whom denied the allegation. Based on the information obtained, the allegation is deemed unsubstantiated at this time. Exit interview conducted, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 31-AS-20251201143417

Type of visit: Case Management - Deficiencies

In conjunction to the complaint 31-AS-20251201143417 Licensing Program Analyst (LPA) Mariana Agban conducted a Case Management Deficiencies Visit. During the course of investigation, it was confirmed that Executive Director did not submit Special Incident Report (LIC 624) for Resident#2(R2) hospitalization on 11/23/25 to CCL. LPA conducted a file review and didn't observe any reports on file for R2. Exit Interview Conducted. Citation issued. Appeal rights given. Report signed and delivered.the state’s words, verbatim · CDSS document, Dec 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80061(b) · Plan of correction due date: Dec 4, 2025

80061(b) Reporting Requirements. Upon the occurrence…a report shall be made to the licensing agency..., a written report ...within seven days following the occurrence of such event. This requirement was not met as evidence by: Based on file document review, the Executive Director did not comply with the section cited above. The ED didn't submit a SIR (LIC 624) report for R2's hospitalization on 11/23/25 within seven days. This poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Executive Director had provided SIR during the visit.

Allegation investigated: Staff did not assist resident with mobility needs in a timely manner. Staff did not dispense medication to resident as prescribed. Staff did not provide resident with adequate fluids.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegation. LPA met with administrator, Stephanie Oden, and explained the reason for the visit. ---Staff did not assist resident with mobility needs in a timely manner. It was alleged that facility staff leave Resident #1 (R1) lying in bed all day and do not help R1 get out of bed. To investigate the allegation, on 08/15/2025, LPA Antonia Alvizar-Ettima requested documents at 10:30 a.m. and conducted a physical plant tour. On 10/24/2025, LPA Duguma requested documents at around 10:00a.m. LPA also interviewed seventeen (17) residents and four (04) staff from 11:30a.m. – 2:30p.m. The Physician’s Report dated one (01) year prior to the incident states R1 is ambulatory. (CONT. LIC9099-C) Unsubstantiated Hospital discharge records do not indicate mobility status, only that R1 needs to be standing or sitting upright when taking medication. R1’s Service Plan states daily frequency for standby transfer assistance and care team supports R1 with safe ambulation, mobility and repositioning. A review of the staff personnel records and schedule shows that facility has eight (08) caregivers per shift providing care and supervision to eight (08) residents. During interviews with staff, all staff stated R1 was checked on frequently and assisted in and out of bed as needed. Staff added R1 was never without care and supervision. During interviews with residents, all residents stated they are checked on often and those that need transfers confirmed they receive assistance. LPA was unable to interview R1. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. ---Staff did not dispense medication to resident as prescribed. It was alleged that staff have not been giving R1 lidocaine medication that R1 should be receiving before meals. To investigate the allegation, on 08/15/2025, LPA Antonia Alvizar-Ettima requested documents at 10:30 a.m. and conducted a physical plant tour. On 10/24/2025, LPA Duguma conducted a physical plant tour and requested documents at around 10:00a.m. LPA also interviewed seventeen (17) residents and four (04) staff from 11:30a.m. – 2:30p.m. A review of the Medication Administration Records shows medications were not given as it was suspended from 08/11/2025 to 08/16/2025 per physician's orders. During interviews with staff, Staff #1 stated the medication was withheld by the physician and R1 had a liquid pain killer as a temporary substitute. All other staff stated residents are given their medications as prescribed. During interviews with residents, all residents stated they receive their medications as prescribed. LPA was unable to interview R1. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. (CONT. on LIC9099-C) ---Staff did not provide resident with adequate fluids. It was alleged that R1 is not given enough water. To investigate the allegation, on 08/15/2025, LPA Antonia Alvizar-Ettima requested documents at 10:30 a.m. and conducted a physical plant tour. On 10/24/2025, LPA Duguma conducted a physical plant tour and requested documents at around 10:00a.m. LPA also interviewed seventeen (17) residents and four (04) staff from 11:30a.m. – 2:30p.m. A review of most recent Hospital Discharge documents does not indicate resident suffered from dehydration. There are also no incident reports filed that would indicate R1 suffered from dehydration around the time in question. During the physical plant tour, LPA observed drinking water available for residents and in resident rooms. During interviews with staff, all staff stated they make water readily available for all residents and check to make sure all residents are drinking water. During interviews with residents, all residents stated they feel they have easy access to drinking water and that they are checked on often. LPA was unable to interview R1. Based on interviews, observations and record review, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 14, 2025 · control 31-AS-20250814112828

Allegation investigated: Illegal Eviction

At 10:00am, Licensing Program Analyst (LPA), Angela Panushkina conducted an initial, unannounced visit in response to the above-mentioned allegation. LPA met with the Business Office Manager and explained the reason for the visit. At 10:10am, LPA requested resident and staff roster. At 10:15am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement and Eviction Policy relevant to the investigation. At approximately 10:20am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:25am – 12:30pm, LPA conducted an interview with the Business Office Manager (BOM), two (2) staff, two (2) MedTechs, one (1) housekeeper, one (1) concierge and sixteen (16) residents. Continue on LIC909-C Unsubstantiated Allegation: Illegal Eviction It was alleged that Resident #1 (R1) was unlawfully evicted. Prior to the visit, LPA reviewed the facility’s complaint history, including complaints control (#28-AS-20230223145614 and #31-AS-20250903125435), which involved R1 with the same allegation. The 1st complaint investigation revealed that R1 allegedly refused to return to the facility following hospitalization, and R1 was reported to have relocated to another facility. Interview with BOM revealed that she started working at this facility since February 2025 and was not aware of R1 and or R1 being unlawfully/illegally evicted. However, during the 2nd complaint investigation BOM was informed that R1 was relocated from this facility over three (3) years ago. Moreover, BOM informed LPA that the last eviction was issued in August 2025 to R2 for non-payment and the facility followed all proper eviction procedures, and there are no current evictions in process or pending. Staff and residents interviewed were unable to identify R1 and had no knowledge of any recent evictions. Sixteen (16) residents interviewed expressed no concerns regarding this allegation. Lastly, LPA conducted review of resident roster and confirmed that R1 is not a current resident at this facility. Based on interviews, record reviews and information gathered, during today’s visit, this allegation is deemed Unsubstantiated at this time. No deficiency issued during today's visit. Exit interview conducted and a copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 12, 2025 · control 31-AS-20251106103910

Allegation investigated: Staff leaves resident soiled for an extended period of time.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with administrator, Stephanie Oden, and explained the reason for the visit. ---Staff leaves resident soiled for an extended period of time. It was alleged that staff left Resident #1 (R1) waiting for pull ups. R1 called the front desk for the first time and the staff said they'll bring it but still has not received the pull ups and waiting for two (02) hours and it happens frequently. To investigate the allegation, on 11/07/2025 LPA requested documents at around 10:00a.m., interviewed three (03) staff from 11:00a.m. to 12:30p.m. and sixteen (16) residents from 12:30p.m. – 3:00p.m. (CONT on LIC9099-C) Unsubstantiated A review of Residents Care assignments and Facility Staff Schedule shows facility has on average eight (08) care staff providing incontinent care to fifty-seven (57) incontinent residents. During interviews with staff, all staff stated they check on and change incontinent residents every two (02) hours or as needed. Staff added residents are not left soiled for an extended time and calls for service are answered on average within eight (08) to ten (10) minutes. Staff added each caregiver overseas on average seven (07) incontinent residents to check on residents every two (02) hours. Staff do not recall the alleged incident. During interviews with residents, one (01) resident stated they are left soiled for an extended time and finds the response time is very slow. All other residents stated they are checked on often and all incontinent residents stated they are not left soiled for an extended time. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 7, 2025 · control 31-AS-20251105122800

Allegation investigated: Facility did not ensure to have a sufficient amount of food to provide for the residents.

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Administrator Stephanie Oden and explained the reason for the visit. LPA conducted a physical plant tour at 9:34 AM, requested copies of facility documents at 10:12 AM and interviewed staff and residents between 10:30 AM to 1:30 PM. Regarding the allegation that Facility did not ensure to have a sufficient amount of food to provide for the residents, it was alleged that Resident #1 (R1) was not provided with breakfast and the facility failed to provide lunch or dinner due to the supply issue. LPA's observation during the physical plant tour at 9:34 AM revealed that the facility has sufficient stock of perishable food for two (2) days and non-perishable for seven (7) days. LPA's interview with the Culinary Director today at around 10:44 AM revealed that the food is being delivered twice a week on Mondays and Thursdays and admitted that there were some delays due to logistical issues with the Food company but it only happened about twice since the culinary director's tenure of about six (6) months. Unsubstantiated (continued from LIC 9099) LPA's interview with four (4) dietary staff today between 10:30 AM to 1:30 PM revealed that there was no time that they missed any meals (breakfast, lunch and dinner) at any time as they always have sufficient supply of foods, from cereal for breakfast to whatever is on the menu for lunch and/or dinner. Further interview also revealed that R1 goes to the day program for most of the morning and had to leave early so R1 only eat cereal with milk and coffee during the times R1 eat breakfast at the facility. R1 eats breakfast most of the time at the Day Program. LPA's record review of the facility menu and observation during visit revealed that the facility served what was written in the menu and had an alternative food in case a resident did not like what is being served at this time such as Peanut butter and Jam, Ham and Cheese and Tuna sandwich, in stock for any resident. LPA also observed that the facility is serving Hot dog sandwich, Quesadilla and Grilled Cheese sandwich during lunch at the request of some residents. LPA's interview with seventeen (17) residents or more than 10% of the current census revealed that seventeen (17) out of seventeen (17) residents interviewed stated that the food is sufficient and they never missed any meal (breakfast, lunch and dinner) at any time while staying at the facility. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 31, 2025 · control 31-AS-20251027113254

Allegation investigated: Staff mishandled a resident's personal belongings

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with administrator, Stephanie Oden and explained the reason for the visit. --- Staff mishandled a resident's personal belongings. It was alleged that staff members go through Resident #1’s (R1) room and steal belongings. R1 stated various items went missing but could not specify what items and could not provide any specific names of staff members or anyone that R1 could identify with stealing their belongings. To investigate the allegation, LPA requested documents at 11:00 a.m. and interviewed seventeen (17) residents and four (04) staff from 11:30a.m. – 2:30p.m. R1’s signed and dated Client/Resident Personal Property and Valuables log revealed that R1 declined to track personal items with the understanding of their right to begin tracking at any time. (CONT. on LIC 9099-C) Unsubstantiated During interviews with residents, R1, stated Brand new clothes and $400.00. went missing but could not identify who allegedly took the items. Resident #2 (R2) and Resident #3 (R3) stated they have had items go missing but could not identify who may have taken them. All other residents stated staff do not go through their rooms and steal belongings. During interviews with staff, all staff stated they do not go through residents’ belongings and steal things. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 16, 2025 · control 31-AS-20251008101416

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management - Deficiencies visit to this facility in conjunction to Complaint Control #31-AS-20251003161950. LPA met with the Administrator Stephanie Oden and explained the reason for the visit. During physical plant tour at 10:59 a.m., LPA observed following: During the inspection, LPA observed that bedroom number 50 had a broken window with shattered glass scattered on the ground outside. The window itself had been covered with a wooden board. According to the resident occupying the room, the damage had been present for several months without repair. In bedroom number 68, LPA observed that only one of the four light bulbs was functioning in the bathroom. The shower head was in disrepair. Additionally, one of the two bed frames in the room was broken and had been propped up using a box filled with cans. Residents staying in the room reported that these issues had been communicated to both caregivers and reception staff, with no corrective action taken for over a year. Deficiencies cited (refer to LIC809-D). Exit interview conducted. Appeal rights provided. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 13, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 31, 2025

87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above licensee did not ensure that the facility is in good repair in room 50 and 68 which possess an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 13, 2025

Plan of correction: Administrator agreed to provide a picture when window, light bulbs, bed frame and shower head are repaired and/or replaced by POC due date.

Allegation investigated: Staff did not seek medical attention to resident

At approximately 10:45 a.m. on 09/24/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. Regarding the allegation "Staff did not seek medical attention to resident" it was alleged Resident #1 (R1) had low blood sugar on the evening of 09/16/25 and did not receive staff assistance. To investigate the allegation, LPA interviewed staff and residents between 10:50 a.m. and 2:00 p.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 11:00 a.m., and toured the facility inside and out at 11:30 a.m. Interview with R1 at approximately 11:45 a.m. today revealed they were okay and free from pain. R1 stated they were asleep when Staff #1 (S1) checked on them. S1 later told R1 that they saw R1 with their eyes fluttering and looking uncomfortable. Although R1 was fine, R1 was concerned with S1’s report. R1 noted that S1 assisted them with medications as usual, and R1 received all necessary medications and medical attention. Unsubstantiated Telephonic interview with S1 at 2:00 p.m. today confirmed R1 received assistance with all necessary medications and their blood sugar level returned to normal shortly thereafter. S1 further stated that R1 reported no pain or discomfort to S1 at the time or afterwards. Interviews with four (04) out of four (04) other staff revealed staff have properly attended to R1’s medical needs. Record review of R1’s preplacement appraisal revealed they required assistance with preparing their medications. Review of R1’s medical assessment revealed they were able to communicate their needs, perform their own glucose testing, and administer their own medications. Based on interviews and record review, facility staff provided appropriate medical attention to R1 in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 31-AS-20250918094556

Allegation investigated: Staff allowed resident to sit in the hot sun while waiting for transportation Staff did not ensure resident was cleaned properly

At approximately 10:45 a.m. on 09/24/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. To investigate the allegations above, LPA interviewed staff and residents between 10:50 a.m. and 2:00 p.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 11:00 a.m., and toured the facility inside and out at 11:30 a.m. Regarding the allegation "Staff allowed resident to sit in the hot sun while waiting for transportation" it was alleged Resident #1 (R1) sits in the sun waiting for their rideshare without staff assistance. Record review of R1’s care plan revealed staff were to check on R1 every four (04) hours to ensure their safety, however R1 “has no observable safety awareness deficits”. Additionally, review of R1’s medical assessment revealed R1 was able to communicate their needs to staff. Unsubstantiated Review of the facility’s house rules revealed “Residents being picked up… [should] wait in the lobby”. Interview with Staff #1 (S1) at 11:00 a.m. today revealed R1 goes to their day program every day and waits for their rideshare without issue. R1 was yelling yesterday while waiting. S1 attended to R1 and noted everything was okay. S1 offered R1 water and shade, and R1 refused both. Interview with Staff #2 (S2) at 11:10 a.m. today confirmed R1 frequently waits for their rideshare without issues. LPA observed about five (05) residents sitting outside in the shade today at 12:00 p.m. LPA observed sufficient shaded area for residents. Interview with the receptionist, Staff #3 (S3) at approximately 1:00 p.m. today revealed R1 yells due to being impatient, but S3 has not heard R1 yelling out for help. Interview with R1 at 2:45 p.m. today revealed they receive adequate care from staff. R1 sits in the sun to ensure they do not miss their ride. Based on observations, interviews, and record review, staff provide adequate care and supervision to R1 while respecting their personal right to sit where they want. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not ensure resident was cleaned properly " it was alleged R1 had feces on their shoe and the handle of their walker. Interviews with S1 and S2 revealed they have never observed R1 to have feces on them or appearing disheveled. Interviews with S3 and Staff #4 (S4) at approximately 1:15 p.m. today revealed R1 is very particular and often asks staff how they look before leaving. S3 and S4 have also never seen R1 with feces on them. Interview with R1 revealed staff provide adequate assistance with bathing, toileting, and hygiene. Record review of R1’s file revealed staff are to provide reminders and standby assistance for R1’s grooming, dressing, and incontinence needs. LPA observed R1 at 2:45 p.m. today to be in good health and hygienic. Based on observations, interviews, and record review, there is insufficient information to determine if R1 was cleaned improperly. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 31-AS-20250924082432

Allegation investigated: Staff are mismanaging resident's medication

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced 10-day complaint visit to this facility at 10 am to investigate the above allegations. LPA met with the executive director and disclosed the reason for the visit. Staff are mismanaging resident's medication It was alleged that Resident #1 (R1) frequently doesn’t receive their medication because staff does not have it and medication is not administered as prescribed. To investigate the allegation, LPA Smith interviewed five (05) staff, fifteen (15) residents, and requested documents relevant to the investigation. A review of Resident #1’s (R1) medication records reveal multiply order changes to suppository medication with current change to be administered at 7am and 5pm. Interview with R1 reveal did not receive it or staff are a few hours late in administering suppository. During interviews with staff, two (2) of five (5) staff stated all medications are given as prescribed. Three (3) of five (5) staff state that R1 was Substantiated (Cont from 9099) not administered suppository due to an episode of loose stools and that R1 regularly changes the times they want the medications administered. Interviews with five (5) of fourteen (14) revealed they have not received their medications because their medication is not available and/or they received their medications up to 3 hours late. One (1) of fourteen (14) residents revealed witnessed R1 in pain from not receiving medication. Eight (8) of fourteen (14) residents stated they are given their medications as prescribed. Based on interviews and record review, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Aug 25, 2025 · control 31-AS-20250815105727

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 8, 2025

87465-Incidental Medical & Dental Care (c) If the resident 's physician stated in writing that the resident is able to determine his/her own prescription medications...the licensee shall be permitted to assist resident with self-administration […](2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by...staff failing to give medication at time prescribed or not at all. This poses an immediate and health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 25, 2025

Plan of correction: The Licensee shall submit in writing to the department by 09/08/25, how they will ensure that medication is order, available, and administered according to doctors order. The licensee shall provide medication training to staff and provide proof that the training was completed.

Allegation investigated: Staff forced resident in care to shower

At 10:15a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced initial visit for the above noted allegation. LPA met with the Executive Director and explained the reason for the visit. At about 10:30a.m. LPA requests and receive staff and resident rosters. At approximately 10:40a.m. LPA and Administrator Coordinator conducted a physical plant tour, interviewed randomly selected seventeen (17) residents including resident (R1) throughout the facility. In addition, at 11:20a.m., LPA requested copies of pertinent documents relevant to the investigation. LPA also reviewed the documents obtained. LPA interviewed Executive Director, Administrator Coordinator, Wellness Director, Wellness Coordinator and Caregiver that provides care to R1. LPA asked questions relevant to the nature of the complaint. Staff forcing residents to take showers. It was alleged that resident (R1) was assaulted when assisted with taking a shower. Concerns were addressed that staff assaulted R1 when assisting with taking a shower. Staff denied assaulting residents Cont. on LIC 9099-C Unsubstantiated Cont. from LIC 9099 when assisting with shower. They revealed that R1 was able to take a shower/bathe themselves they just assist if needed. During today’s interview R1 indicated that staff never assault them when taking a shower. Other residents interviewed during investigation denied being assaulted when taken a shower and had no concerns. Records verify that R1 is able bath/shower themselves. Per review of R1’s shower schedule, R1 was taking showers two (2) times per week and the staff was keeping shower schedule for R1. Based on observation, interviews, and record review there is no sufficient information to corroborate the allegation. Therefore, allegation deemed to be UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit interview is conducted and copy of report was provided to Executive Director.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 31-AS-20250813113546

Allegation investigated: Staff are not meeting residents' personal hygiene needs

On 7/30/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted a complaint investigation at the above facility to address the following allegation(s). LPA Spaeth met with the Administrator, Angela Smith. LPA explained the purpose of this visit was to gather information, interview staff and residents, and deliver findings regarding the complaint. LPA interviewed seventeen (17) out of one hundred seventy-one (171) residents (R2-R18), the Administrator, and eight (8) out of sixty-nine staff members (S1-S8) at 11:10 am until 2:00 pm. LPA reviewed residents’ documents at 2:10 pm until 2:30 pm. LPA received the resident roster, staff work schedule, and copies of residents’ files. LPA and the Administrator toured the facility at 2:45 pm until 3:00 pm. Continued on 9099-C Unsubstantiated Regarding the allegation: Staff are not meeting residents’ personal hygiene needs. It’s alleged a resident’s hair and nails are unkept and a resident’s appearance is untidy due to staff neglect. R1 was unavailable for an interview. R2-R18 stated they receive assistance from staff with their hygiene needs. LPA Spaeth observed R2-R18 were well groomed and were wearing clean clothes. S1-S8 and the Administrator denied the allegation. LPA’s review of the residents’ documentation revealed when a resident refuses assistance with their hygiene needs, the staff document the refusal. If a resident forgets to shower themselves, the staff will document each week when they encourage residents to shower. Based upon interviews and review of documentation, the allegation is unsubstantiated. Exit interview was conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 31-AS-20250723141110

Allegation investigated: Staff opens residents' mail and packages without resident's consent

On 07/07/25, at 12:40pm, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Angela Smith, Administrator. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 07/07/25, LPA Saucedo asked for the census, staff, and resident rosters. On 07/07/25, at 12:50pm, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff opens residents' mail and packages without resident's consent. It is being alleged that manager did not order keys for mailboxes and staff open mail and packages. During LPA's physical tour, LPA observed mailboxes to have key locks and are numbered by room number. LPA took a picture of the mailboxes that were against the wall on your right hand side of the entrance of the facility. LPA also took a picture of main, mailbox of the facility which is located on your left hand side of the entrance of the facility. During this visit, LPA interviewed four (4) staff. Four (4) out of the four (4) staff confirmed that when they receive the mail from the main, mailbox it is sorted out and put in the individualized mail boxes. Two (2) staff confirmed that some residents need help with their keys and they help them get their mail out of the mailbox. Also two (2) staff confirmed that residents have lost their keys in the past and a new key had to be ordered for them. One (1) staff confirmed that the main, mailbox was installed because of past issues with the post office. Fifteen (15) out of seventeen (17) residents confirmed they do not have an issue with their mail, getting their mail and/or any mail/packages being opened by staff. One (1) resident refused to speak to LPA and the other resident confirmed they have not received their social security mail from the main post office due to unknown reasons but they are checking on the status of their social security by other means. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Jul 7, 2025 · control 31-AS-20250627092504

Allegation investigated: Staff did not ensure personal proprty of resident was safely secured

At approximately 11:00 a.m. on 06/25/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA Duguma conducted an initial visit on 10/25/24 and conducted a record review at 3:00 p.m. LPA De La Cerra conducted a subsequent visit on 04/17/25 and reviewed additional records at 11:100 a.m. and interviewed staff and residents between 11:00 a.m. and 3:45 p.m. Today, LPA Reed interviewed the administrator, staff, and residents between 11:15 a.m. and 3:00 p.m., conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 11:30 a.m., and toured the facility inside and out at 12:15 p.m. Unsubstantiated Regarding the allegation "Staff did not ensure personal property of resident was safely secured" it was alleged gold coins belonging to Resident #1 (R1) were stolen by Resident #2 (R2) when R1 hired R2 to clean their closet. At the time of this visit, LPA Reed conducted additional interviews with seventeen (17) residents, including R1 and other residents who entrusted their belongings to be safeguarded by the facility. Prior to this visit, Licensing Program Manager Naira Margaryan made a phone contact and spoke with the Business Office Manager and facility Administrator. At the time of this visit, LPA Reed requested additional records including inventory records for R1, a copy of the facility theft and loss policy, and a copy of incident report pertaining to allegation. Staff interviews revealed that R1 did not include theirgold coins on their inventory sheet. On 10/27/24, R1 reported to Business Office Manager that they hired R2 to clean their closet and R2 stole the coins and other valuables from R1. R1 contacted the police on their own and provided a police report number to the Business Office Manager. The investigation was initiated by the Glendale Police Department and concluded on 06/24/25. The police investigation revealed that R2 returned R1’s gold coins to them. A review of facility records verified the information revealed from staff. As per facility Theft and Loss policy, if resident reports missing articles and valuables exceeding $100, police are contacted to investigate the theft. During interviews, R1 stated that R2 actually returned their coins months ago, and R1 had lost them again at a market. R2 denied taking R1’s money or other valuables. Other residents interviewed during this investigation by LPA Reed did not address any concerns regarding their personal belongings. Based on interviews and record review it was concluded that although the allegation may have happened, there is not enough information to verify that facility failed to safeguard R1’s personal belonging and valuables. Therefore, the allegation deemed to be UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 25, 2025 · control 31-AS-20241022132307

Allegation investigated: Staff do not communicate with responsible party regarding resident's care

At approximately 11:00 a.m. on 06/25/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA interviewed the administrator, staff, and residents between 11:15 a.m. and 3:00 p.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 11:30 a.m., and toured the facility inside and out at 12:15 p.m. Regarding the allegation "Staff do not communicate with responsible party regarding resident's care" it was alleged facility staff have not provided care updates to the responsible party (RP) of Resident #1 (R1). Record review of R1’s facility file revealed they had a different RP from November 2022 until March 2025. R1's current RP tookover and became their Power of Attorney on 03/31/25. Review of R1’s hospice records indicated their most recent care plan update occurred on 02/03/25. Unsubstantiated No changes have been to R1's care since then. Interview with the administrator today at 11:30 a.m. revealed they have communicated all aspects of R1’s care with the RP and spoke to the RP yesterday. The administrator also provided contact information of other members of R1’s care team to provide medication updates and documentation. Interview with R1 at 2:45 p.m. today revealed they are satisfied with all aspects of their care. R1 also noted they are informed of all aspects of care by the facility and care team. R1 did not know of any concerns from their RP. Interview with Staff #1 (S1) at 3:00 p.m. today revealed they have also communicated directly with the RP about R1’s care. Based on interviews and record review, the facility has communicated with R1 and their responsible person for all care updates. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 25, 2025 · control 31-AS-20250619143905

Allegation investigated: Facility staff did not seek timely medical attention for resident in care.

At 10:10 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit for the above allegation. LPA was greeted by the receptionist, and met with the Executive Director (ED) and explained the reason for the visit. At 10:20 AM, LPA requested resident and staff roster. At approximately 10:30 AM, LPA conducted a physical plant tour of the facility. At 10:45 AM, LPA requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, and etc., relevant to the investigation. Between 10:55 AM – 1:30 PM, LPA interviewed ED, Wellness Director (WD), Admission Cordinator (AC), Engagement Director, and seventeen (17) out of twenty one (21) residents who were avaliable. Continue on LIC 9099C Unsubstantiated Facility staff did not seek timely medical attention for resident in care. It is alleged that on 06/05/2025, the facility staff sent Resident #1 to the senior-program with constipation and neck pain and did not provide medical attention. To investigate this allegation LPA conducted an interview with the ED who informed LPA that R1 did not report any constipation or neck pain to the facility staff on 06/05/2025. Furthermore, LPA was informed that on 02/27/2025, R1 did report constipation issue and the facility staff immediately informed the Primary Care Physician and hospice. An immediate medical attention was provided to R1 through hospice agency. Interview with the WD and Engagement Director confirmed the information provided by ED. sixteen (16) residents interviewed express no concerns regarding the above allegation. Lastly, interview with R1 revealed that no information was provided to facility staff on 06/05/2025 and LPA was informed that once R1 went to the senior program R1 experienced discomfort and constipation. Therefore, based on information gathered during today's visit, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 10, 2025 · control 31-AS-20250609142241

Allegation investigated: Staff did not maintain the facility in a clean, safe, sanitary condition

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegation. LPA arrived, was greeted by the receptionist, and met with the Executive Director, explaining the reason for the visit. LPA requested copies of pertinent information which includes LIC 500 and Resident Roster. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and are in compliance with Title 22 Regulations. Allegation: Staff did not maintain the facility in a clean, safe, sanitary condition The complainant alleged that there is always feces on the toilets in the facility. LPA conducted phyiscal plant and observed all facility main toilets are clean and in saniatry condition. Interviews with 13 out of 175 residents denied the allegation. Interview with the Executive Director confirmed that staff are providing housekeeping services daily and weekly and as needed. Based on information obtained the allegation is deemed Unsubstantiated at this time. Unsubstantiated S2 was unable to provide documentation, as the staff notes and end-of-shift reports were inconsistent. Based on the information obtained, the allegation is deemed substantiated at this time. Exit interview conducted, citation issued, appeal rights given and copy of this report delivered.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 31-AS-20250527104046

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(B)(3) · Plan of correction due date: Jun 17, 2025

(B)General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on interviews and record reviews, the facility staff did not properly manage resident’s catheter care. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: The Executive Director will provide in-service staff training to ensure staff notes are complete and consistent. In addition to developing incontinence care plan and a catheter care plan for Resident 2 by the POC date

Allegation investigated: Facility staff did not provide a copy of admission agreement to resident

This is the addendum of the investigation report previously issued on 08/29/24. Licensing Program Analyst (LPA)Antonia Alvizar-Ettima conducted an unannounced visit to conduct additional investigation for the above noted allegation. LPA met with Administrator and explained the reason for the visit. The investigation of the above allegation was initiated by the LPA Rosaura Valenzuela on 08/29/24 at which time LPA interviewed facility staff and residents. At the time of this visit, at 10:10a.m. LPA Alvizar- Ettima and Administrator conducted facility tour. At 11:25a.m. LPA conducted interview with seventeen (17) out of one-hundred and seventy-three (173) residents. At 1:30a.m. LPA spoke with facility staff regarding R1. In addition, at 2:30p.m. LPA reviewed facility records, including, but not limited to R1’s facility admission agreement and other documents pertaining to allegation. Prior to this visit on 4/30/25 LPA Alvizar-Ettima interviewed R1 over the phone and asked questions regarding their Admission Agreement. Unsubstantiated Facility staff did not provide a copy of admission agreement to resident It was reported that facility staff did not provide a copy of the admission agreement to a resident #1 (R1). To investigate this allegation on 08/29/24, between 11:00am and 12:00pm, LPA Valenzuela initiated staff interviews. Interviews revealed that staff did provide a copy of the admission agreement to R1. However, when R1 signed their admission agreement and was given a copy, R1 refused to take a copy because they disputed the fact that they had a share of cost to pay to the facility. LPA Valenzuela was not able to speak to R1 due to being out of the community. Other residents interviewed during todays visit verified receiving copies of their admission agreements. R1 recalled writing their initial and signing many documents in the facility’s business office. R1 also recalled signing admission agreement but was unable to remember receiving a copy of it. A review of facility records, conducted on 08/29/24 and at the time of this visit, verified the information received from staff and residents. Based on interviews and records review there is not sufficient validity of the complaint, Thus, this allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 30, 2025 · control 31-AS-20240822110519

Allegation investigated: Staff failed to provide emergenvy medical servies in timely manner

This is amended copy of the report previously issue on 5/30/25 the document was amended to make the corrections. This is the addendum of the investigation report previously issued on 07/10/24. Licensing Program Analyst (LPA) Anotonia Alvizar-Ettima conducted an unannounced visit for the above noted allegation. LPA met with Administrator and explained the reason for the visit. The investigation of the above allegation was initiated by the LPA Rosaura Valenzuela on 07/10/24 at which time LPA interviewed facility staff and residents. At the time of this visit, LPA Alvizar-Ettima inspected the facility at 10:10a.m. and checked call pendants of the residents present in their rooms. While inspecting residents’ rooms and thereafter at 11:25a.m. LPA Alvizar- Ettima conducted interview with seventeen (17) out of one-hundred and seventy-three (173) residents. At 1:15p.m. LPA requested and reviewed facility records, including, but not limited to R1’s facility files, unusual incident reports,and other documents pertaining to allegation. In addition, at approximately 4:30p.m. LPA Alvizar-Ettima spoke with facility staff assisting R1. Substantiated Staff failed to provide emergency medical services in a timely manner It was reported that on 06/21/24 at approximately 7:00p.m., R1 was vomiting and not feeling well. R1’s roommate called for assistance. R1 had been food poisoned and 911 was not called until 11:00p.m. Staff revealed that on 06/21/24, R1 was taken to their room from the dining room at approximately 7:00p.m., by staff due to appearing tired. Shortly after being placed in the bed, R1 vomited and R1 fell asleep. Staff continued to frequently monitor R1 every 30 - 45 minutes until approximately 10:30p.m., when staff noticed that R1 had vomited. At approximately 11:00p.m., staff assessed R1 and due to having shortness of breath decided to call 911. A review of records revealed that on 06/21/24 R1 was not feeling well since 7:00p.m. Between 7:00p.m. to 10:30p.m. staff monitored resident and R1 had vomited at list three (3) times. Overall investigation revealed that although between 7:00p.m. and 10:30p.m. staff had knowledge that R1 was vomiting and feeling weak, they did not call 911 emergency services until 11:20p.m. Based on interviews, and record review, there is a sufficient information to verify validity of the complaint. Hence the allegation is SUBSTANTIATED at this time. No other health and safety issues noted at the time of this visit. Under Title 22, Division 6, Chapter 8 following deficiency was issued and recorded on LIC9099D. Exit interview conducted and a copy of the report was issued. Facility staff did not respond in a timely manner to resident's call pendant It was reported that on 06/21/24, staff did not respond in a timely manner to Resident #1 (R1's) call pendant. Staff interviews revealed that neither R1 or R2 pushed the call pendant. Staff indicated that they are responding to the emergency calls within ten (10) to fifteen (15) minutes. On 07/10/24, LPA Valenzuela was unable to speak with R1 as she was not present at the facility. At the time of this visit LPA Alvizar-Ettima was informed that R1 passed away on 06/22/24. Upon checking ten (10) randomly selected residents’ pendants, LPA noted that staff is responding within fourteen (14) minutes. Residents interviewed during this visit did not address any concerns regarding staff response time to the call pendants. Based on interviews and records review there is not sufficient validity of the complaint, Thus, this allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 30, 2025 · control 31-AS-20240710101309

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jun 2, 2025

87465 Incidental Medical and Dental Care; (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…. This requirement is not met as evidenced by. Licensee did not ensure to provide immediate emergency medical assistance to resident (R1), who appeared to be weak and vomiting. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: The Administrator will in service (focus training) to direct care staff regarding emergency protocol. Administrator will submit a sign in sheet and handouts of topics discussed to LPA via fax by due date.

Allegation investigated: Staff did not respond timely to a resident's emergency alerts. Staff did not provide required medical attention to a resident. Staff did not properly maintain a resident's room.

On 5/12/2025 at approximately 9:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Executive Director (ED), Angela Smith and stated the reason for their visit was to deliver the findings of the complaint. To investigate the allegation(s), on 4/23/2025 LPA and Licensing Program Manager (LPM) Troy Agard conducted a physical plant tour, requested pertinent documentation, and conducted interviews with eleven (11) residents (R1-R11) and six (6) staff members (S1-S6). (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff did not respond timely to a resident's emergency alerts. It was alleged that R1 had used their emergency alert system and staff did not respond. Interview with R1 revealed that on the night of the alleged incident, they fell and activated their alarm. R1 stated that they activated their alarm, but staff did not arrive to their room. Interview with R6 revealed that they too have used their alarm system and staff has failed to respond. However, interviews with four (4) other residents revealed that when they have activated their alarm system, staff has responded. Interviews with all six (6) staff revealed that when residents activate their alarm, staff do respond. LPA’s record review of the facility’s past call system roster showcased that both R1’s and R6’s alerts have all shown to have been arrived and completed. LPA attempted interviews with R2 and R3 but due to their inability to determine the validity of the allegation, LPA terminated the interviews. LPA attempted to interview R9-R11 but they refused to be interviewed. Based on interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not provide required medical attention to a resident. It was alleged that R1 fell from their bed and sustained a cut on their face and staff did not attend to the injury. Interview with R1 revealed that when R1 showed staff the cut they sustained, staff did help by applying medical dressing on the wound. Based on interview with R1 that staff did help attend to their wound, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not properly maintain a resident's room. It was alleged that when R1 sustained an injury resulting in their bedroom floor needing to be cleaned, the staff did not clean their room until the morning after. Interview with R1 revealed that the day of the alleged incident, they left the facility later in the morning and returned at around 10:00 AM. Upon their return, R1 mentioned that their bedroom floor had been cleaned including where the injury had occurred. Interview with six (6) residents revealed that staff clean their room daily. Interview with all six (6) staff revealed that every day the residents’ rooms are cleaned. S5 and S6 stated that not only are the rooms cleaned daily but Tuesdays and Thursdays are when deep cleaning of the residents’ rooms are performed. While conducting the physical plant tour, LPA witnessed multiple staff members throughout the facility cleaning resident’s rooms. LPA conducted random room checks where they witnessed the residents’ rooms to be clean and properly maintained. (Continue to LIC 9099-C) Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was provided to the Executive Director.the state’s words, verbatim · CDSS document, May 12, 2025 · control 31-AS-20250414152217

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with the Executive Director, Angela Smith, for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 10:30a.m. and the following was noted: There is one entrance being utilized at the facility. The facility is fire cleared for one hundred ninety-nine (199) residents of which one hundred (100) may be non-ambulatory on the first floor in rooms #1-8, 25-30, 51-71 and 87-88 and 30 bedridden in rooms #72-86. The second and third floors are for ambulatory only and the facility has a hospice waiver for thirty (30). The facility is currently occupying one hundred sixty-nine (169) residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for parking and storage. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The common and dining areas are neat and clean. The facility maintains an average comfortable temperature at 73°F. The smoke and carbon monoxide detectors are hardwired, interconnected and centralized. The alarm automatically sends a signal to the local fire department. Fire extinguishers are located throughout the facility and observed to be fully charged and last inspected 10/21/2024. (continued on LIC 809-C) The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at an average 117.8°F. Towels and washcloths are not shared. There was enough clean linen available. LPA observed medication to be inaccessible to residents. Facility maintains complete first aid kits. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Apr 16, 2025

Allegation investigated: Facility elevator is in disrepair

On 03/12/25, at 9:05am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Angela Smith, Administrator. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 03/12/25, LPA Saucedo asked for the census, staff, and resident rosters. On 03/12/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Facility elevator is in disrepair. It is being alleged that the elevator was not working and there is residents that use wheelchairs on the third floor. During LPA's physical tour, LPA observed the elevator to be working. LPA toured the second and third floor and conducted seventeen (17) interviews on the second and third floor that confirmed the elevator has been working and that they do not use wheelchairs. LPA also observed residents on the second and third floor not using any wheelchairs. LPA interviewed three (3) staff that confirmed the elevator has been working. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 31-AS-20250307125306

Allegation investigated: Staff did not follow up with resident's medical coverage.

Licensing Program Analyst (LPA) Abeye Duguma conducted an initial complaint visit to the facility to investigate the above allegations. LPAs met with Executive Director, Angela Smith, and explained the reason for the visit. --- Staff did not follow up with resident's medical coverage. It was alleged that facility did not assist with Resident #1's (R1) HMO insurance coverage. To investigate the allegation, LPA interviewed three (03) residents from around 11:00a.m. to 11:45a.m. and two (02) staff from around 11:45a.m. to 12:30p.m. During interviews with residents, R1 stated they made a mistake, and it was all a mix up, the issue was resolved immediately, they got the care they needed and wishes to remove the complaint. All other residents stated facility assists with medical appointments and transportation and are not experiencing any issues with getting assistance. (cont. on LIC9099-C) Unsubstantiated During interviews with staff, Staff #1 (S1) stated they assist residents with scheduling doctor’s appointments and transportation. S1 added that, as a courtesy, staff assist residents with applying for and managing their insurance. Staff also encourage residents to follow-up with appointments and checkups. Staff #2 (S2) stated resident does not have HMO, rather resident has MediCal-Medicare (Medi-Medi), and when at the doctor’s appointment, R1 presented their expired HMO card, and the doctor rejected them. S2 added they rescheduled the appointment for two (02) days after R1’s error and R1 has since received treatment. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 5, 2025 · control 31-AS-20250228131814

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management visit to this facility to address an incident which allegedly occurred on 10/17/2024. LPA met with Executive Director Angela Smith (ED) and explained the reason for the visit. It was alleged that Staff #1 (S1) financially abused multiple residents in the facility. According to the ED’s statements, there are currently six (06) residents involved in the alleged abuse of which three (03) filed police reports. ED stated R1 did not report anything to the facility, and only found out about anything the day after S1 was arrested and the police informed them that R1’s debit card was found on S1’s person. ED added that on 09/25/2024, Resident #2 (R2) discovered possible fraud while attempting to pay their monthly debt obligations. R2 and a representative from the facility went to the bank and confirmed there was possible financial fraud. R2 reported the suspected abuse to the Glendale Police department and a report was filed 09/26/2024. Facility also disclosed that on 10/05/2024, Resident #3’s (R3) responsible party reported to the facility that they suspected financial fraud and a week later brought a copy of the police detective’s information and police report number to let facility know they filed a report. Similarly, on 10/05/2024 Resident #4 (R4) also discovered that something was wrong when trying to pay their rent and notified the facility about filing a police report and provided the detective’s information and police report number. (CONT. on LIC 809-C) A review of the department’s records revealed that facility did not submit an incident report for the 09/25/2024 incident. During the police department’s investigation, the ED was asked about a seventh potential victim, but after reviewing the facility’s records it was determined that the person was not a current or past resident of the facility. When LPA asked about dollar amounts, the ED stated they are currently unaware as the investigation is ongoing. ED was also asked about any missing credit cards around 08/28/2024 and ED stated nothing was discovered or reported within the past six (06) months. LPA interviewed four (04) out of six (06) of the alleged victims all of which confirmed some form of financial abuse. LPA was unable to interview the other residents. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): The ED was informed that the Department may take additional action if deemed necessary. No other health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: Oct 26, 2024

Each licensee shall furnish to the.. agency.. reports…Occurrences…which threaten the welfare,...of residents.. shall be reported within 24 hours...Licensee did not meet the requirement as evidenced by submitting the incident report not until 10/24/2024...As a reminder to the licensee, as a mandated reporter…..the administrator… has knowledge of an incident that reasonably appears to be …. financial abuse….a written report shall be sent, or an Internet report... established in Welfare and Institutions Code Section 15658, within two working days.the state’s words, verbatim · CDSS document, Oct 25, 2024

Plan of correction: Licensee will submit a written letter by the POC due date stating that they have reviewed Title 22 Division 6 Chapter 8 of the CA Code of Regulations 87211 Reporting Requirements in FULL and that going forward will adhere to these regulations.

Allegation investigated: Staff did not provide adequate supervision resulting in resident eloping from facility.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above allegation. LPA met with the assistant administrator, Brandy Rangel, and explained the reason for the visit. ---Staff did not provide adequate supervision resulting in resident eloping from facility. It was alleged that Resident #1 (R1) was found lying on a sidewalk a short distance from the facility. To investigate the allegation, on 05/29/2024 LPA Rosaura Valenzuela requested pertinent documents. On 09/05/2024, LPA interviewed two (02) staff from 11:00 AM – 12:00 PM. A review of the R1’s Physician’s Report states that R1 can leave the facility unassisted. The Needs and Service Plan indicates that R1 is not a wandering and elopement risk, does not require assistance and is independent. (CONT on LIC 9099-C) Unsubstantiated During interviews with staff, all staff stated that it was an isolated incident, R1 was walking uphill and became exhausted, R1 is independent and remains able to leave and return unassisted. Based on record review and interview, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 5, 2024 · control 31-AS-20240529142935

Allegation investigated: Facility staff did not provide a copy of admission agreement to resident

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Assistant Administrator Brandy Rangel and explained the reason for the visit. It was reported that facility staff did not provide a copy of the admission agreement to a resident. Resident #1 (R1) recalls signing the admission agreement, but believes they did not receive a copy of it. To investigate this allegation on 08/29/2024, between 11:00am and 12:00pm, LPA initiated staff interviews. Inteviews revealed that staff did provide a copy of the admission agreement to R1. When R1 signed their admission agreement and was given a copy, they then disputed the fact that they had a share of cost to pay to the facility. LPA was not able to speak to R1 since they were out of the community at the time of this visit. Between 12:00pm and 1:00pm, LPA reviewed facility records. Records conirmed what staff told LPA. Based on interviews and records review there is not sufficient information to support the allegation. Thus this allegation is UNSUBSTANTIATED at this time. Unsubstantiated No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 31-AS-20240822110519

Allegation investigated: Facility staff did not respond in a timely manner to Resident's call pendant Staff failed to provide emergency medical services in a timely manner

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Assistant Administrator Brandy Rangel and explained the reason for the visit. It was reported that staff did not respond in a timely manner to Resident #1 (R1's) call pendant. To investigate this allegation on 07/10/2024, between 11:00am and 12:30pm, staff interviews were initiated. Interviews revealed that neither R1 or Resident #2 (R2) pushed the call pendant. R1 was taken to their room from the dinning room at approximately 9:00pm by staff due to appearing tired. Shortly after being placed in the bed, R1 fell asleep. Staff continued to frequently monitor R1. R1 slept until approximately 10:30pm, when staff noticed that they were grunting and had vomited. Staff immediately assessed R1 and after evaulating them decided to call 911. LPA attempted to speak to R2 but they refused to answer questions. Between 12:30pm and 1:30pm, faciliy files were reviewed. Records revealed that R1 had serveral underlying medical conditions. Continue on C-9099 Unsubstantiated Based on interviews and records review there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. It was alleged that Staff failed to provide emergency medical services in a timely manner, To investigate this allegation on 07/10/2024, between 11:00am and 12:30pm, staff interviews were initiated. Interviews revealed that R1 was in the dinning room talking to fellow residents when they were given their medication at 8:00pm, At the time that medication was dispensed, R1 did not appear to be ill or in distress. Approximately one hour later, R1 was taken to their room by staff because they looked tired. Between 9:00pm and 10:30pm, R1 was being checked on and monitored by staff. At approximately, 10:30pm, Staff #1 (S1) went to R1's room and noticed that they were grunting and had vomit. S1 called Staff #2 (S2) to assess R1 and take the vital signs. According to S2, R1's vital signs were within normal range, but they noticed that R1 was clammy .S2 called the paramedics and R1 was taken to the hospital. Between 12:30pm and 1:30pm, faciliy files were reviewed. Records revealed that R1 had several underlying medical conditions and took various medications. Based on interviews and records review there is not sufficient information to support this allegation. Hence, this allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 10, 2024 · control 31-AS-20240710101309

Allegation investigated: Staff mismanaged resident's medication Staff did not meet resident's medical needs

At 9:45 a.m. on 06/28/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the assistant administrator and disclosed the reason for the visit. To investigate the allegations above, LPA toured the facility at 10:00 a.m., interviewed four (04) staff between 10:10 a.m. and 11:45 a.m., Resident #1 (R1) at 1:45 p.m., and conducted a records review of pertinent records including but not limited to admission agreements, medical assessments, and medications records at 12:00 p.m. Regarding the allegation “Staff mismanaged resident's medication” it was alleged that the medication Ethambutol was given at too high of a dose to R1. Also, Medication Administration Records (MARs) had missing entries which may have indicated the medications were not given at all. Unsubstantiated Interview with the assistant administrator today at 11:00 a.m. revealed R1 received all medications at the proper times and dosages. The facility had poor internet connection, so they had purchased a new router. Interview with Staff #1 (S1) at 11:15 a.m. today revealed the facility followed the physician’s orders prescribed by R1’s primary physician. When the facility received information that the dosage may be incorrect, S1 contacted R1’s physician who wrote a new order for a lower dosage. The facility assisted R1 with the updated, lower dosage immediately and documented the change in their files. Interview with Staff #2 (S2) at 11:30 a.m. today revealed they properly assisted R1 with Ethambutol at the correct times and dosages that their physician prescribed. S2 documented all medications in a hand-written MAR. LPA reviewed the electronic MAR, a hand-written MAR, and the new physician order at 12:00 p.m. today. The electronic MAR showed some missing entries. The hand-written MAR showed all entries were complete. The new physician order from 06/18/24 showed a change of Ethambutol from 1,000 mg to 800 mg. LPA conducted a medication review at 1:15 p.m. today of R1’s medication Ethambutol and found all medication quantities matched the MAR. The previous container for Ethambutol 1,000 mg was destroyed and documented in the facility record. Interview with R1 at 1:45 p.m. today revealed they received all of their medications properly and felt no pain or side effects. Based on interviews and record review the facility followed all physician orders and properly assisted R1 with their medication. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not meet resident's medical needs” it was alleged the facility did not assist R1 with their required lab work. Interview with the assistant administrator and S1 revealed R1 had refused their previously scheduled lab work on 06/18/24. S1 arranged for another appointment on 06/21/24 which was completed. The facility received the results of the lab work on 06/24/24 around 11:00 a.m. S1 stated R1’s lab work looked good and R1 had no pain. Record review revealed R1’s lab work indicated no concerns. Interview with R1 confirmed they refused to go their initial appointment then agreed to a subsequent appointment. Based on interviews and record review the facility arranged for R1’s medical appointment and met their medical needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during today's visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 28, 2024 · control 31-AS-20240620150023

Allegation investigated: Staff did not prevent an altercation between residents

At 9:45 a.m. on 06/28/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the assistant administrator and disclosed the reason for the visit. To investigate the allegations above, LPA toured the facility at 10:00 a.m., interviewed three (03) residents between 10:20 a.m. and 10:45 a.m., four (04) staff between 10:10 a.m. and 11:45 a.m., and conducted a records review of pertinent records including but not limited to admission agreements, medical assessments, and service plans at 12:00 p.m. Regarding the allegation “Staff did not prevent an altercation between residents” it was alleged staff did not intervene to prevent a physical altercation between Resident #1 (R1) and Resident #2 (R2) in the dining room on 06/22/2024. Substantiated Interview with R1 at 10:20 a.m. today revealed R1 and R2 were arguing and R2 lightly hit R1 in the arm five (05) to six (06) times. R2 then called R1 a derogatory slur and R1 slapped R2. R1 stated they had not fought before and no longer intend to fight. R2 “always wants to start stuff” with R1. R1 also admitted they are confused, struggle with mental stability, and take medication for the problem. R1 could not recall if staff intervened. Interview with R2 at 10:35 a.m. today revealed they did call R1 a derogatory slur and R1 slapped R2. R2’s partner Resident #3 (R3) called the police. R2 stated R1 was always in the hallways “looking for a fight”. R2 also stated no staff intervened and they do not feel safe living at the facility. The assistant administrator held a meeting with R1 and R2 the following day and instructed the two to stay away from one another. Interview with Staff #1 (S1) at 10:45 a.m. today revealed they were in the TV room when they had heard R1 and R2 arguing in the dining room. S1 ran over and saw R1 with their hands on R2’s wheelchair and R1’s face very near R2’s face. S1 put their body in between R1 and R2. R1 then slapped R2, and R2 slapped R1. S1 separated the two residents afterwards. Interview with Staff #2 (S2) at 10:10 a.m. today revealed staff are trained to place their hands and arms between residents to break up fights. Interview with the assistant administrator revealed R2 had a history of using derogatory slurs and starting fights. During the meeting between R1 and R2 and the assistant administrator on 06/23/24, the police’s instructions for the two to stay away from each other were reiterated. The assistant administrator also stated the facility has scheduled staff training with their consultant group for all residents with known behavioral issues. It was stated that the service plans for R1 and R2 were not updated to address their arguments and altercations. Record review at 12:00 p.m. today revealed R2’s service plan noted the facility “will observe for mood changes, agitation... signs of anxiety”. R1’s service plan noted the facility “will observe client daily for mood changes, apathy, aggression, agitation". Based on interviews and record review, facility staff did not intervene in time to prevent an altercation between R1 and R2. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the attached LIC 9099-D page. No immediate health and safety risks were observed during today's visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 28, 2024 · control 31-AS-20240624134254

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 26, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in two (02) out of one hundred forty three (143) residents which poses a potential Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 28, 2024

Plan of correction: In addition to scheduling staff trainings with a consultant for residents with challenging behaviors, the licensee has agreed to update the service plans of Resident #1 (R1) and Resident #2 (R2) with instructions for staff intervention.

Allegation investigated: Staff did not safeguard residents belongings

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Nilda Mercado Business Officer Manager and explained the reason for the visit. It was reported that staff did not safeguard residents belongings. To investigate this allegation on 06/12/2024, between 12:00pm and 12:30pm, staff interviews were initiated. Interviews revealed that Resident #1 ( R1) arrived to the facility on 04/16/2024 at approximately 2:30pm and left the community at approximately 4:30pm the same day. R1 did not return to the facility to pick up their belongings or to sleep there and never signed the admissions agreement. They left the facility before the paper work was finalized. In regards to R1's personal belonings, they were placed in the facility storage. Based on interviews there is not sufficient information to support this allegation. Hence, the allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 12, 2024 · control 31-AS-20240610154955

Allegation investigated: Staff does not provide safe environment for resident.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Assistant Administrator Brany Rangel and explained the reason for the visit. It was reported that staff does not provide a safe environment for resident. Resident #1 (R1) alleged that an unknown male resident at the facility threaten and attempted to assault them. To investigate this allegation on 05/29/24, between 1:00pm and 1:30pm, staff interviews were initiated. Interviews revealed that R1 has been out of the community since 05/06/2024, due to being a danger to others and placed on a 5150. Staff are not aware of anyone in the community trying to hurt or assault R1. LPA could not speak to R1 since they out of the community at the time of this visit. Between 1:30pm and 2:00pm, facility records were reviewed. Records confirmed what staff told LPA. Based on interviews and records review there is not sufficient information to support this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Unsubstantiated No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 29, 2024 · control 31-AS-20240522125506

Allegation investigated: Lack of supervision resulting in resident being assaulted by another resident. Staff did not provide a safe environment for resident.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Assistant Administrator Brandy Rangel and explained the reason for the visit. It was reported that due to lack of supervision residents assaulted each other. It was alleged that Resident #1 (R1) was punched and pushed by Resident #2. As a result, R1 sustained a broken rib and was hospitalized. It was also alleged that Resident #3 was physically assualted by Resident #4. To investigate the allegation on 05/29/24, between 1:00pm and 2:00pm, staff interviews were initiated. Interviews revealed that R1 and R2 had a disagreement in their room that led to an altercation. R1 tried to punch R2 and fell in the process. R2 denied hitting R1. Both R1 and R2 are non-ambulatory. When staff heard the commotion, they went to the room and accessed each resident. R1 was sent to the hospital since they were complaining of pain. R1 was moved to another room and R2 will be vacating the facility at the end of this month. Moreover,R3 and R4 had a non physical altercation in their room with staff present. Staff stated that there was no physical contact between the residents and both were re-directed. LPA was not able to speak Unsubstantiated to the residents since they were not in the community at the time of this visit. R1 is at the hospital. R2 is moving to another board and care, R3 had a medical appointment, and R4 was not present at the time of this visit. Between 2:30pm and 3:00pm, LPA reviewed facility records. Records confirmed what staff told LPA. Based on interviews and records review, there is not sufficient information to support this allegation. Hence the allegation is UNSUBSTANTIATED at this time. It was alleged that staff did not provide a safe environment for residents in care. To investigate this allegation, between 1:00pm and 2:00pm, staff interviews were initiated. Interviews revealed that staff do their best to provide a safe environment to all residents in care.. The staff are constantly supervising and checking in on residents. Between 2:00pm and 3:00pm resident interviews were initiated. Interviews revealed that residents feel safe at the facility. Based on interviews there is not sufficient information to support this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 29, 2024 · control 31-AS-20240528164626

Allegation investigated: Licensee does not allow resident to have a cat

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Assistant Administrator Brandy Rangel and explained the reason for the visit. It was reported that Licensee does not allow Resident #1 (R1) to have a cat. To investigate this allegation on 05/21/2024, between 1:35pm and 2:00pm, staff interviews were initiated. Staff interviews revealed that R1's medical doctor said that R1 is not capable of caring for service animals since they can not take care of self. Moreover, staff held a meeting with R1 and their case manager to explain why they can not have a cat. Between 2:00pm and 2:30pm, LPA reviewed facility records. Facility records confirmed what staff told LPA. Based on interviews and records review, there is not sufficient information to support the allegation. Thus, this allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 21, 2024 · control 31-AS-20240517154045

Allegation investigated: Due to lack of supervision, resident was able to leave the facility unassisted

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Assistant Administrator Brandy Rangel and explained the reason for the visit. It was reported that due to lack of supervision, Resident #1 (R1) was able to leave the facility unassisted. On 04/18/2024, between 11:45am and 12:10pm, staff interviews were initiated. Interviews revealed that R1 arrived to the faciility on 4/16/2024 at approviately 2:30pm and left the community at approximately 4:30pm the same day . R1 has not returned to the facility to pick up their belongings or to sleep there and never signed the admissions agreement. They left the facility before the paper work was finalized. Between 12:15pm and 12:45pm, LPA reviewed facility records. Records confirmed what staff had told LPA. In addition, records revealed that R1 is ambulatory and is able to leave the facility unassisted. The facility is not locked down. Continue on 9099-C Unsubstantiated Based on interviews and records review, there is sufficient information to not support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 31-AS-20240417123440

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Rosaura Valenzuela and Abeye Duguma arrived at the facility on 02/22/2024 at 10:30 a.m. to conduct an announced Pre-Licensing visit and met with Administrator Aaron Khodorkovsky, Entrance interview conducted with the administrator and explained the purpose of today’s visit. Today's site visit consisted of the LPAs and administrator touring the physical plant at 10:30 a.m. inside and outside the following was observed: The facility has one main entrance being used. The facility is a three floor building. The facility temperature observed to be in the range of 72 to 76 degrees Fahrenheit. The telephone on the premises is operational and functioning. The emergency exit plan/sketch is posted on the walls throughout the building. Kitchen: At approximately 11:00 a.m. LPAs observed the kitchen area by the dining room to be clean. Appliances observed; sink and refrigerator and stove appeared to be in good repair and functional. The food is prepared at the facility. The food is then placed in large serving trays and transported in a large sealed cart and then individually served to residents at this facility. Bedrooms: At approximately 11:30 a.m. LPAs inspected fifteen (15) random bedrooms all were observed to be clean and appropriately furnished and equipped with adequate lighting, bedroom furniture and linens. LPA observed the call light system to be on the front desk. Screen doors and window coverings were observed during the time of inspection to be in good condition Bathrooms: LPA observed bathrooms located inside resident bedrooms to have non-skid shower flooring and appropriate grab bars installed in shower and around the toilet. At 11:50 a.m. hot water was tested in bathrooms and measured at 119.9*F. Continued on LIC809C Medications: At approximately 11:45 a.m. the medication room was observed to be locked and inaccessible to residents. Medications were kept locked in a medication cart. Medication records are kept in files. LPA observed the First Aid Kit and Manual stored in the medication room. Resident and Staff Records: Records are kept stored and locked in the office of facility. Common areas: LPAs observed television areas to be clean and clear of clutter. LPAs observed elevator to be operational. LPAs observed fire extinguishers through out the facility with last serviced date of 11/19/2023. LPAs observed smoke/carbon monoxide detectors to be interconnected through out the facility. Dining Area was observed clean and have enough tables and chairs to sit the capacity of the facility. Surroundings: LPAs observed the outside and surrounding area of the facility to be clean and clear from debris and obstruction. . "Pre-Licensing is complete and this facility has no deficiencies." Component III was also completed. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 22, 2024

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 199 Census (if any clients in care): 126 COMP II Participants: Aaron Khodorkovsky, Administrator Steven Atlas, Applicant Interview Method: Virtual interview (Microsoft Teams) On November 30, 2023, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Applicant and Administrator. Copy of report sent via email and informed to return sign copy to CAB by end of business day today.the state’s words, verbatim · CDSS document, Nov 30, 2023