Merrill Gardens at Rolling Hills Estates

Allegation investigated: Staff did not dispense medications as prescribed

On 2/25/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced continuation complaint investigation visit regarding the allegation listed above. LPA met with the General Manager, Tracey Mallaret, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 1/22/2026, Witness 1 (W1) was interviewed. On 1/26/2026, interviews were conducted, medications along with Medication Administration Records (MARs) were reviewed, and records were gathered. Staff 1 (S1) to Staff 5 (S5) were interviewed. Facility records were gathered which consisted of Resident Roster dated 1/23/2026, Personnel Report dated 1/26/2026, Staff Trainings, MARs, Unusual Incident/Injury Reports (UIRs) and other pertinent records were provided. On 2/25/2026, interviews were conducted, medications along with MARs were reviewed, and records were reviewed. Staff 2 (S2), S5, Staff 6 (S6), and Staff 7 (S7) were interviewed. Substantiated Investigation revealed the following Allegation: “Staff did not dispense medications as prescribed”, it is being alleged that the facility has made medication errors. Interviews conducted with S1 to S7 revealed the following: 7 out of 7 staff agreed with the allegation. Interviews conducted with W1 revealed the following: 1 out of 1 witness agreed with the allegation. UIRs for Resident 1 (R1) and Resident 2 (R2) revealed the following: On 1/3/2026, R1 received R2’s medication in error; R2 did not receive their noon medication as prescribed; the facility contacted R1’s and R2’s responsible party, physician, hospice, facility staff, and retrained staff who committed medication error. Progress Notes for R1 and R2 revealed the following: On 1/3/2026, facility staff conducted an investigation and found that R1 was provided with two medication tablets that belong to R2 during noon time, and R2 did not receive their scheduled noon medication. Staff trainings revealed the following: The staff who committed the medication error was retrained on “Skills Evaluation-Medication Assistance” dated 1/7/2026. The facility retrained staff on “Annual Medication Training” on 1/21/2026. Substantiated: Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, and a plan of correction was developed. Appeal Rights and a hard copy of this report were provided to General Manager, Tracey Mallaret.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 11-AS-20260120120410

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 25, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records review and interviews conducted, the licensee did not comply with the section cited above in not providing Resident 1 and Resident 2 with medications as prescribed on 01/03/2026, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 25, 2026

Plan of correction: The facility informed R1’s & R2’s responsible party, physicians, hospice, facility staff, retrained staff, and submitted Unusual Incident Reports to the Department. The facility retrained staff on Medication Administration on 1/21/2026. Copies of POCs have been provided to LPA Socorro Leandro.

Allegation investigated: Facility does not employ sufficient staff to meet residents needs. Staff does not ensure that resident's hygiene needs are being met. Staff does not ensure that resident's dental hygiene needs are being met.

On 01/13/26 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the facility. LPA was met by staff one, Tracey Mallaret - General Manager (S1) and the purpose of the visit was explained. The investigation consisted of the following: On 10/08/25 LPA requested and received the following documents: resident and staff rosters, staff schedule for the months of September and October of 2025 (09/25 & 10/25). LPA also requested six (6) resident documents (R1-R6), listed as follows: face sheets (emergency ID) (dated: varioius), physician reports (LIC602a) (dated:various), needs and services plan (dated: various) and care logs of 6 residents in care. LPA interviewed six (6) residents (R1 through R4 & R6), R5 is non-verbal and therefore LPA was unable to interview R5, and two (2) staff (S1-S2). On 01/13/26 LPA interviewed three (3) staff (S3-S5) and conducted further record review. Report continues, please see LIC 9099-C. Unsubstantiated The investigation revealed the following: Regarding the allegation "Facility does not employ sufficient staff to meet residents needs.", it has been alleged that there is only one (1) caregiver per twenty (20) residents. Interviews revealed that all five staff (S1-S5) and all five residents (R1-R5) have not agreed the allegation has taken place. Record reviews revealed staff coverage for residents in care, between the months of September and October of 2025 (09/25 & 10/25), are within Title 22 regulation. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation "Staff does not ensure that resident's hygiene needs are being met.", it has been alleged that staff are not assisting residents with their Activities of Daily Living (ADL). Interviews revealed that all five staff (S1-S5) and all five residents (R1-R5) have not agreed the allegation has taken place. Record reviews revealed that residents' care plan and service logs align and no discrepancies were observed. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation "Staff does not ensure that resident's dental hygiene needs are being met.", it has been alleged that a resident suffered from tooth decay, resulting in a broken tooth. Interviews revealed that all five staff (S1-S5) and all five residents (R1-R5) have not agreed the allegation has taken place. Record reviews revealed that for residents' care plan indicating full-assist with brushing teeth do match their service logs. Furthermore, staff have indicated that they can easily tell those who have not brushed their teeth and when noticed, prompting and assisting with brushing has become the normal pattern. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff one, Tracey Mallaret - General Managerthe state’s words, verbatim · CDSS document, Jan 13, 2026 · control 11-AS-20251002131508

Allegation investigated: Staff did not meet resident's hygiene care needs resulting in a unknown skin condition to resident in care Staff did not meet resident's dental hygiene care needs Staff left resident in soiled clothing

On 01/13/26 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the facility. LPA was met by staff one, Tracey Mallaret - General Manager (S1) and the purpose of the visit was explained. The investigation consisted of the following: On 10/08/25 LPA requested and received the following documents: resident and staff rosters, staff schedule for the months of September and October of 2025 (09/25 & 10/25). LPA also requested six (6) resident documents (R1-R6), listed as follows: face sheets (emergency ID) (dated: varioius), physician reports (LIC602a) (dated:various), needs and services plan (dated: various) and care logs of these 6 residents in care. LPA interviewed six (6) residents (R1 through R4 & R6), R5 is non-verbal and therefore LPA was unable to interview R5, and two (2) staff (S1-S2). On 01/13/26 LPA interviewed three (3) staff (S3-S5) and conducted further record review. Report continues, please see LIC 9099-C. Unsubstantiated Regarding the allegation "Staff did not meet resident's hygiene care needs resulting in a unknown skin condition to resident in care.", it is being alleged that a resident is suffering from a "burn and peel" on their face. Interviews revealed that all five staff (S1-S5) and all five residents (R1-R5) have not agreed the allegation has taken place. Record reviews revealed that residents' care plan and service logs align and no discrepancies were observed. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation "Staff does not ensure that resident's dental hygiene needs are being met.", it has been alleged that a resident was observed with dirty teeth. Interviews revealed that all five staff (S1-S5) and all five residents (R1-R5) have not agreed the allegation has taken place. Record reviews revealed that for residents' care plan indicating full-assist with brushing teeth do match their service logs. Futhermore, staff have indicated that they can easily tell those who have not brushed their teeth and when noticed, prompting and assisting with brushing has become the normal pattern. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation "Staff left resident in soiled clothing.", it is being alleged that a resident was observed in dirty clothing on multiple occasions. Interviews revealed that all five staff (S1-S5) and all five residents (R1-R5) have not agreed the allegation has taken place. Furthermore, staff three (S3) stated, "If we see a resident wearing anything soiled, we make sure to swap their clothing." Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Tracey Mallaret and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jan 13, 2026 · control 11-AS-20251003084145

Type of visit: Required - 1 Year

On 10/22/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Tracey Holder/Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (150) non-ambulatory elderly adults ages 60 and above of which (15) may be bedridden. Facility has an approved hospice waiver for (15). The facility is a three-story structure located in a residential/commercial neighborhood. It consists of (114) bedrooms, (124) bathrooms, garage level floor- Lobby, reception area, administrators’ offices, lounge, computer area, Theater, Activity room and office, Discovery room, Soiled room and laundry room, storage room, Prep-Kitchen, Wellness room, Med room, Beauty salon, Refuge room, discovery room, 1st floor- Open Kitchen, Private dining room, Dining room. 2nd - Floor - lounge, refuge room. 3rd Floor - Refuge and housekeeping closet. Garden House (Memory Care Unit) - laundry room, medication room, kitchen, dining room, and living room. Shaded back patio and underground parking. LPA Iniguez and the Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (9) bedrooms and (9) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 105.0°F to 116. °F, and the room temperature ranged from 76°F to 78°F.During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 9/26/25. A review of (5) residents' service files and (5) staff personnel files was maintained in order. LPA reviewed (5) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Tracy E Holder / Executive Director.the state’s words, verbatim · CDSS document, Oct 22, 2025

Type of visit: Case Management - Other

On 05/15/25 Licensing Program Analyst conducted an unannounced case management visit (CMV) at the facility. LPA was met by staff one, Lauren Amaya Resident Care Director (S1), and the purpose of the visit was explained. LPA and S1 toured the facility to test and observe two (2) delayed egress exits; located in the patio at Merrill Gardens, Garden House (memory care area). LPA requested resident and staff rosters, in-service training regarding elopement and an email thread of the repair process(es). This CMV was conducted in order to verify that the facilities' delayed egress exits are back in working order. LPA and S1 both observed two (2) delayed egress exits in working order, located in the patio section of the Garden House. LPA timed two (2) delayed egress exit door(s) and found each exit to have an open-release of around 20 seconds prior to allowing a person, or resident, from departing the patio. LPA has verified that both two (2) delayed egress exits are in working order and LPA observed both exits notifying the Garden House staff as well as the front desk. LPA then observed the front desk contacting all staff of the delayed egress alarm(s) via two-way radio. There have been zero deficiencies cited during today's visit. An exit interview was held with staff one, Lauren Amaya Resident Care Director (S1), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, May 14, 2025

Type of visit: Required - 1 Year

On 09/14/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the General Manager Tracey Holder. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (150) non-ambulatory elderly adults of which (15) may be bedridden ages 60 and above. Currently, the facility has (93) residents and (9) in hospice care. The facility is approved for (15) hospice residents. The facility is a four-story structure located in a commercial neighborhood. It consists of the following: (114) resident bedrooms, (115) resident bathrooms and (7) public restrooms, staff lounge, staff restroom, (2) dining rooms, a movie theater, activity rooms, a Wellness room, a laundry room, business offices, a kitchen, outdoor patio, (62) parking spaces, and a Beauty Salon operated by a third party. The Garden House is the memory care unit. LPA Dabuet and General Manager Holder toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #101, #108, #119, #133, #211, #223, #310, #320 and #322, All call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.2 – 107.9 degrees F. A comfortable temperature was maintained in the facility at 72 - 74 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. The facility conducted monthly fire drills. The last fire drill was on 08/15/24. Evaluation Report continues LIC 809-C Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu. LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#7 (S1-S7) personnel files were in order and complete. The facility is current in CCLD annual fees. The facility has a current administrator certificate for Tracey Holder # 7020086740 valid through 01/22/2025. The facility has a Liability Insurance Certificate valid 07/01/24 through 07/01/25. No deficiencies during this visit. An exit interview conducted with the General Manager Tracey Holder, and a copy of the report is provided.the state’s words, verbatim · CDSS document, Sep 14, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff does not serve food of good quality

On 09/03/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Tracey Mallaret, General Manager (S1) and the purpose of the visit was explained. S1 and LPA toured the facility. The investigation consisted of the following: On 09/03/24 LPA requested and reviewed facility documents and toured the facility. LPA interviewed eleven (11) out of one-hundred and nine (109) clients and two (2) out of sixty-three (63) staff. The investigation revealed the following: regarding the allegation, “Staff does not serve food of good quality”, it has been alleged that the food being served to residents always has the same taste. Between 10:00AM and 10:45AM LPA received the monthly menu for August and the latest dietician's report, dated 07/11/24. Between 10:45AM and 3:00PM LPA interviewed eleven (11) residents and two (2) staff. Between 3:30PM and 5:00PM LPA wrote facilty report and conducted an exit interview with S1. Report continues, see LIC9099C Unsubstantiated Interviews revealed that seven (7) out of 11 residents have disagreed with the allegation and agree that the food served is of good quality. Record reviews have shown appropriate, quarterly, visits have been done by a Dietician during meal service(s). Record reviews also show kitchen staff have completed food handling certification and have certificates on-site, conducted through premier food safety. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. An exit interview was conducted with Tracey Mallaret, General Manager, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Sep 3, 2024 · control 11-AS-20240827114916

Allegation investigated: Resident sustained a fracture while in care.

Licensing Program Analyst (LPA: Ernand Dabuet) made an unannounced visit to the facility and was greeted by Resident Care Director (S3: Yvette Lem). LPA conducted a risk assessment prior to entering the facility. Front desk informed LPA that the facility has no COVID cases nor do the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation. A 24-hour visit was conducted by LPA Jeremiah Randle on 07/20/23 who was met by the Staff #1 (S1: Tracey Mallaret, General Manager) as the Administrator (A1: Debbie Infield) was unavailable. During the visit, LPA Randle toured the physical plant for the health and safety of residents in care. Residents were observed sitting in the Day Area engaged in social activities. Residents observed did not show signs of distress or abuse. (Evaluation Report continues LIC 9099-C) Unsubstantiated LPA Randle requested and obtained copies of the following documents: Staff Work Schedule & Roster (dated 07/11/23), Resident Roster (dated 07/11/23), Pre-placement Appraisal Information (dated 04/11/23), Admission Agreement (dated 04/22/23), Appraisal/Needs and Services Plan (dated 04/22/23), Physician’s Report (dated 03/30/23), Progress Notes (dated 07/20/23 to 04/22/23), Initial Evaluation Results (dated 04/22/23), Capability Evaluation Report (dated 04/22/23), and Unusual Incident Reports (dated 04/25/23, 05/22/23, 06/05/23, 06/19/23, 06/30/23, 07/02/23, 07/11/23, 07/13/23, 07/16/23, 07/17/23). This complaint investigation was referred to California Department of Social Services (CDSS), Investigation Bureau (IB) and assigned to Investigator Dennis Douglas. The investigation included a review of medical records from Torrance Memorial Medical Center (dated 04/25/23, 06/19/23, 06/30/23) and Harbor-UCLA Medical Center (dated 04/25/23, 07/16/23, 07/17/23; interviews were conducted of Facility Staff #S1 – #S5, Resident #1, and Witness #1. INVESTIGATION REVEALED THE FOLLOWING: Regarding Allegation #1: this investigation revealed that Resident #1 moved into the facility on 04/22/23. On 04/25/23 at 8:52 a.m., Resident #1 was outside of the community and had fallen while on a walk. A female passerby observed the resident and called 9-1-1. Resident #1 was transported to Torrance Memorial Hospital ER and diagnosed with a fracture to the right, upper arm due to the fall. That same day, Resident #1 returned to the facility at 3:00 p.m. and was sent back out to Harbor UCLA Medical Center due to being unresponsive. On 05/22/23 at 9:36 a.m., Resident #1 sustained a fall and was found on their right knee on the floor holding on to their walker – no injuries or hospital transport. On 06/05/23 at 2:05 p.m., Resident #1 was observed on the floor (in front of their apartment door) and had fallen on their right knee and was unable to get back up. Resident #1 sustained a skin tear to their right knee and elbow – no hospital transport. On 06/19/23 at 5:30 a.m., Resident #1 was found (on their bed) in a pool of blood by Staff #6 and Staff #7 and 9-1-1 was summoned and the resident was transported to Torrance Memorial Hospital Emergency Room (ER). On 06/30/23 at 9:20 a.m., Staff #4 responded to Resident #1’s pendant alarm. Resident #1 was found lying on their right side (on the fractured right arm) with a skin tear to the right knee. Facility staff called 9-1-1 and the resident was transported to Torrance Memorial Hospital ER. On 07/02/23 at 6:09 a.m., Staff #9 responded to Resident #1’s pendant alarm and found the resident (on the floor) lying on their back. Staff #9 responded and assessed the resident. (Evaluation Report continues LIC 9099-C) Facility staff summoned 9-1-1 as a precaution and paramedics arrived at 6:20 p.m. to assess the resident and their vitals were normal and no head injury – no hospital transport. On 07/11/23 at 2:40 p.m., Resident #1 was walking to the Bistro area and walked too fast (with their wheelchair) and fell on their left knee. Resident #1 was found on the floor by Staff #5 who assisted the resident back up. Resident #1 sustained a skin tear to their left knee – first aid was applied and no hospital transport. On 07/16/23 at 9:15 a.m., Resident #1 was found on the floor (near the closet) lying on their back and bleeding from the forehead. Facility staff summoned 9-1-1 and the resident was transported to Harbor-UCLA Medical Center. On 07/17/23 at 11:00 a.m., Resident #1 was found by Staff #12 lying on the floor (on their back) in the kitchen area (in front of the sink) in their apartment. Resident #1 sustained skin tears to their right elbow, right knee, left elbow, left knee; and old wounds opened: right elbow, right knee; and, a new wound from the forehead. Facility staff summoned 9-1-1 and the resident was transported to Torrance Memorial Hospital ER. During the course of this investigation, it was revealed that Resident #1 sustained several unwitnessed falls during their residency at the facility. (Physician’s Report documented under “Capacity for Self-Care” able to care for self without assistance; under “Physical Health Status” motor impairment/paralysis: mild mobility issues, mild muscular stiffness, and mild difficulty getting up from chair or bed but independent and not a fall risk; under “Mental Condition” able to leave facility unassisted; under “Ambulatory Status” this person is able to independently transfer to and from bed). As a result of Resident #1’s initial fall (outside the facility), the resident sustained a broken clavicle; in which, the resident was transported to Torrance Memorial Hospital. It was disclosed that once Resident #1 was discharged back to the facility on 06/30/23, the resident was no longer independent and required assistance by facility staff. It was revealed that Resident #1 was issued a pendant alarm to summon staff whenever the resident required assistance, a pull cord was also installed next to the resident’s bed in case of an emergency, and reminders were made to Resident #1 to wear their grip socks using their walker and whenever the resident is moving around in their apartment. Based on the evidence gathered and interviews conducted, and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident sustained a fracture while in care is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to the Resident Care Director (Yvette Lem).the state’s words, verbatim · CDSS document, Jun 1, 2024 · control 11-AS-20230719093521

Allegation investigated: Staff yelled at a resident. Staff handled a resident in a rough manner. Staff did not respond to a resident's call for assistance in a timely manner. Staff did not follow reporting requirements.

This report serves as an amendment to clarify the findings. It does not supersede the complaint investigation findings reflected in the report created on 2/7/2024. On 2/7/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Trace Mallaret /Administrator. LPA explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Residents interviews (R#1-R#10) and Staff Interviews(S#1-S#10). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#5) Identification and Emergency Information, (R#1-R#5) Admissions agreements, (R#1-R#5) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#5) Needs and Services Plan, (R#1-R#5) Medication Administration Record (MAR) for the month of January 2024, copies of SRI’s dated on 2/3/24 and copy of Report Information and Victims’ Bill of Rights by Los Angeles Sherrif Department dated on 2/3/24. Evaluation Report continues LIC 9099-C Unsubstantiated This report serves as an amendment to clarify the findings. It does not supersede the complaint investigation findings reflected in the report created on 2/7/2024. Investigation Revealed the Following: Allegation(s):Staff yelled at a resident. The details of the complaint alleged that facility staff yelled at a resident in care. During an interview with resident 1 (R#1), they stated that when (S#1) arrived at (R#1)’s room, (S#1) started to yell at (R#1), saying, “Get up.” (S#1) stated that they suffer from a physical illness that impedes them to get up on their own. During interviews with residents (R#2-R#10), (8) out of (10) residents stated that they have never been yelled at or screamed at by facility staff. Also, (9) out of (10) residents stated that they feel safe interacting with the facility staff. During interviews with staff (S#1-S#10), (10) out (10) facility staff stated that they have never yelled or screamed at a resident in care. Staff handled a resident in a rough manner. The details of the complaint alleged that facility staff handled resident in a rough manner while in care. During an interview with resident 1 (R#1), they stated that when (S#1) stated that they suffer from a physical illness that impedes them to get up on their own. When (S#1) was trying to lift (R#1), they were screaming and pulling (R#1)’s shirt. (S#1) could not lift (R#1) from their chair, so they requested assistance from another caregiver. When the other caregiver arrived, (S#1) left (R#1)’s room. During interviews with residents (R#2-R#10), (9) out of (10) residents stated that they have never been handled roughly by facility staff. Also, (9) out of (10) residents stated that they feel safe living at the facility. In addition, (9) out of (10) residents stated that no facility staff ever forced them to do what they didn’t want to. During interviews with staff (S#1-S#10), (10) out (10) facility staff stated that they have never handled a rough manner a resident in care. Evaluation Report continues LIC 9099-C This report serves as an amendment to clarify the findings. It does not supersede the complaint investigation findings reflected in the report created on 2/7/2024. Staff did not respond to a resident's call for assistance in a timely manner. The details of the complaint alleged that the facility staff is taking long time to attend the residents’ calls. During an interview with resident 1 (R#1), they stated that (R#1) stated that on the night of 1/31/24, they requested assistance from a facility staff (S#1), but the facility staff did not arrive after 30 minutes. During interviews with residents (R#2-R#10), (8) out of (10) residents stated that they had used the facility’s signal system, and it took less than five minutes or almost immediately for the facility staff to tend to the call. During interviews with staff (S#1-S#10), (10) out (10) facility staff stated that it takes them approximately five minutes to tend to the call from the signal system in the resident’s room. Also, (10) out of (10) facility staff stated that no staff member has ever taken more than 30 minutes to respond to a call from the signal system coming from the resident’s room. Staff did not follow reporting requirements. The details of the complaint alleged that the facility did not report to CCLD past incidents involving residents in care. During the records review, LPA Iniguez observed a Special Incident Report (SRI) regarding (R#1) event dated 2/1/24. A copy of the SRI was provided to LPA Iniguez during this visit. During an Interview with staff (S#1-S#10), (10) out of (10) facility staff stated that the facility reports special incidents involving residents in care to CCLD. Evaluation Report continues LIC 9099-C This report serves as an amendment to clarify the findings. It does not supersede the complaint investigation findings reflected in the report created on 2/7/2024. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) is/are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued during this visit. An exit interview was conducted, and a copy of the Complaint Report was given to Casey Ferreras / Senior Caregiver.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 11-AS-20240202093615

Type of visit: Case Management - Incident

On 02/07/24, Licensing Program Analyst, LPA Alfonso Iniguez conducted a Case Management visit to follow up on the incident report that the department received on 2/5/24. LPA was greeted by Tracy Mallaret / Administrator and explained the purpose of the visit is to gather information surrounding the incident of (R#1). The Regional Office (RO) received a copy of the Special Incident Report (SRI) from the facility and reported that (R#1) stated that they were drugged and sexually assaulted by facility staff (S#1). The following documents and interviews were retrieved and conducted: ·Copy (R#1) records and hospital discharge papers. ·Interviews with Administrator (A#1), Staff (S#1) and residents (R#2-R#11) According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of this report was provided to Tracy Mallaret /Administrator.the state’s words, verbatim · CDSS document, Feb 7, 2024

Type of visit: Required - 1 Year

On 11/11/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Tracey Holder/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (150) non-ambulatory elderly adults ages 60 and above. of which (15) may be bedridden. Facility has an approved hospice waiver for (15). The facility is a three-story structure located in a residential/commercial neighborhood. It consists of (114) bedrooms, (124) bathrooms, garage level floor- Lobby, reception area, administrators’ offices, lounge, computer area, Theater, Activity room and office, Discovery room, Soiled room and laundry room, storage room, Prep-Kitchen, Wellness room, Med room, Beauty salon, Refuge room, discovery room, 1st floor- Open Kitchen, Private dining room, Dining room. 2nd - Floor - lounge, refuge room. 3rd Floor - Refuge and housekeeping closet. Garden House (Memory Care Unit) - laundry room, med room, kitchen, dining room, and living room. Shaded back patio and underground parking. LPA Iniguez toured the physical plant with Administrator. There were no bodies of water or obstructions on the premises. A total of (11) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #120, #122, #132, #103(M), #106(M), #216, #211,#210, #222, #220 and #311; call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 107.5F° – 114.2F°. The rooms temperature ranged from 76F° – 78F°. Evaluation Report continues on LIC 809-C LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 10/27/23. Annual fire clearance performed on 11/22/2022. Working landline phones are available on-site. A review of (6) residents' service files and (6) staff personnel files and (3) Medication Administration Records (MAR) were observed. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted throughout the facility. A copy of liability insurance was provided to LPA during visit. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. (See D page) An exit interview was conducted, and a copy of the Facility Evaluation Report and Appeal Rights was provided to the Administrator/ Tracey Holder.the state’s words, verbatim · CDSS document, Nov 11, 2023

Allegation investigated: Facility staff did not properly transfer resident causing resident to fall. Facility staff did not respond to residents call button in a timely manner. Facility staff not maintaining residents hygiene.

On 10/11/23, at 9:40am, Licensing Program Analyst (LPA) Perry Scott initiated a complaint investigation to obtain additional information regarding the allegations listed above. LPA met with Tracey Mallaret, General Manager, and explained the purpose of today’s visit. On 10/11/23, the investigation consisted of the following: During today’s visit LPA toured the facility. LPA requested the following records: Resident roster, staff roster, resident record (Physicians report, ID/Emergency Information, Showering Schedule, Staff training in transferring/Fall Risk for residents, Call Log, Assessment and Needs Plan, Preplacement Appraisal Plan, MAR, and Progress notes). LPA interviewed staff (S1-S5) and residents (R1-R10). The investigation revealed the following- Allegation # 1 Facility staff did not properly transfer resident causing resident to fall. Report continued on LIC9099-C Unsubstantiated On 10/11/23, from 09:40am-2:00pm, LPA interviewed S1-S5 & R1-R10. It is alleged that the staff did not properly transfer R1 causing resident to fall. 5 of 5 staff denied the allegation that the Facility staff did not properly transfer resident causing resident to fall. All staff stated that they are properly trained at transferring residents and maintain that their actions did not result in the resident to fall. LPA reviewed staff records for in-service training for residents who are a fall risk. All staff have verified training in “tending to falls/lifting techniques” for residents and are compliant in annual required trainings for staff. LPA interviewed R1-R10 about the allegation and 10 of 10 residents stated that they were happy with the care and supervision provided by the staff. Based on interviews, there is insufficient evidence to support the allegation that Facility staff did not properly transfer resident causing resident to fall. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 2 Facility staff did not respond to residents’ call button in a timely manner. LPA interviewed S1-S5 & R1-R10. It is alleged that the staff does not answer calls for assistance in a timely manner. 5 of 5 staff denied the allegation that the Facility staff did not respond to residents’ call button in a timely manner. All staff stated that all calls are answered within 10 minutes of receiving the call. LPA interviewed R1-R10 about the allegation and 9 of 10 residents stated that the staff does answer their calls in a timely manner and are happy with the care and supervision. Based on interviews, there is insufficient evidence to support the allegation that Facility staff did not respond to residents’ call button in a timely manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 3 Facility staff not maintaining residents’ hygiene. LPA interviewed S1-S5 & R1-R10. It is alleged that R1 is taking a shower every other day. 5 of 5 staff denied the allegation that Facility staff not maintaining residents’ hygiene. All staff state that there is a shower schedule, and according to the residents’ care plan, they choose the date to take a shower. Report continued on LIC9099-C LPA reviewed R1’s care plan and shower schedule and R1 is scheduled to take a shower on Sundays, Tuesdays, Thursdays, and Saturdays. LPA interviewed R1-R10 about the allegation and 3 of 10 residents stated that they are satisfied with the shower schedule in their care plan. And 7 of 10 residents stated that they don’t need assistance with their hygiene needs and they take their own showers without assistance. Based on interviews, there is insufficient evidence to support the allegation that Facility staff not maintaining residents’ hygiene. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was given to Tracey Mallaret, General Manager.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 11-AS-20221221111340

Allegation investigated: Facility staff did not provide residents current medical records to emergency personnel. Facility staff did not report incident accurately. Staff did not dispense medication as prescribed.

On 10/11/23, at 9:40am, Licensing Program Analyst (LPA) Perry Scott conducted a subsequent complaint investigation to obtain additional information regarding the allegations listed above. LPA met with Tracey Mallaret, General Manager, and explained the purpose of today’s visit. The investigation consisted of the following: During today’s visit LPA toured the facility. LPA requested the following records: Resident roster, staff roster, resident record (Physicians report, ID/Emergency Information, Showering Schedule, Staff training in transferring/Fall Risk for residents, Call Log, Assessment and Needs Plan, Preplacement Appraisal Plan, MAR, and Progress notes). LPA interviewed staff (S1-S5) and residents (R1-R10). The investigation revealed the following- Allegation # 1 Facility staff did not provide residents current medical records to emergency personnel. Report continued on LIC9099-C Unsubstantiated On 10/11/23, from 09:40am-2:00pm, LPA interviewed S1-S5. It is alleged that the staff did not provide the Emergency Medical Team with current medical records when R1 was transported to the hospital. 5 of 5 staff denied the allegation that the Facility staff did not provide residents current medical records to emergency personnel. All staff stated that it is protocol to give 911 packets to the EMT when a resident is transported by emergency services. S1 stated that “the Med-Tech, nurse, or the front desk will supply the EMT with the 911 packets for the resident. This is always done and was done the night the resident R1 fell on 10/21/22. R1 passed away on 10/29/22 and was not interviewed. Based on interviews, there is insufficient evidence to support the allegation that Facility staff did not provide residents current medical records to emergency personnel. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 2 Facility staff did not report incident accurately. On 10/11/23, from 09:40am-2:00pm, LPA interviewed S1-S5. It is alleged that the facility falsified reports claiming that they responded to a pendant call (Call for help) for R1. 3 of 5 staff (S1-S3) denied the allegation that Facility staff did not report incident accurately; while one staff (S4) was not working at the facility at the time, and the other (S5) had no knowledge of the incident. S1-S3 stated that the family members alerted staff that R1 had fallen. Upon being alerted, the staff called 911 for further assistance. S1-S3 stated that there was not a pendant call for help by R1 and it wasn’t documented as it was. LPA reviewed documentation of pendant alarm activity for R1 on 10/21/22, and no calls were made on that date. The last call logged was on 10/19/22 at 12:41am. Based on interviews and a records review, there is insufficient evidence to support the allegation that Facility staff did not report incident accurately. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 3 Staff did not dispense medication as prescribed. On 10/11/23, from 09:40am-2:00pm, LPA interviewed S1-S5 & R1-R10. It is alleged that the facility failed to dispense medication as prescribed. 5 of 5 staff denied the allegation that Staff did not dispense medication as prescribed. Report continued on LIC9099-C All staff stated that all medication administered for R1 was documented and given as prescribed by the physician. They further state that R1’s medication was documented in the residents’ Medication Administration Record. LPA reviewed the Medication Administration Records for R1 and did not observe any discrepancies. LPA interviewed R1-R10 about the allegation and 9 of 10 residents state that staff does dispense their medication as prescribed. Based on interviews and a records review, there is insufficient evidence to support the allegation that Staff did not dispense medication as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was given to Tracey Mallaret, General Manager.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 11-AS-20221116170557