Montecedro

Allegation investigated: Resident sustained a fracture due to staff neglect Staff did not seek medical attention to resident in a timely manner

Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver finding of the above noted allegations. LPA met with receptionist and granted entry to the facility. LPA explained the reason for this visit. At 10:40a.m., LPA and Director Resident Health Services (DHS) & Director Resident Services (DRS) conducted a physical plan tour and observed no health no safety issues. During initial visit on 01/07/26 LPA Alvizar-Ettima requests and receives copies of the facility resident and staff rosters. At 10:15a.m., DHS and LPA conducted a physical plant walk-through. Between 10:45a.m. – 2:00p.m., LPA interviewed Executive Director (ED), Director of health Care Services (DHS) and five (05) out of one hundred and twelve (112) residents including Resident #1 and #2 (R1-R2). In addition, LPA request copies of resident’s Physician Report, Identification Emergency Information, Assessment need and service plan and other pertinent documentation. LPA Alvizar - Ettima attempt to interview resident #1 (R1) was unsuccessful due to R1’s inability to respond to the questions. Prior to this visit on 2/13/26 LPA reviewed facility records. Cont. LIC 9099-C Unsubstantiated Cont. from LIC 9099 Resident sustained a fracture due to staff neglect It was alleged that on 11/20/25, Resident #1 (R1) woke up screaming with a swollen arm. Staff interviews consistently denied knowledge of any fall or incident involving R1 at the facility. Staff (S1) reported that when swelling was observed on R1’s left elbow, the condition was immediately reported to management and R1’s Power of Attorney (POA). Facility staff reported observing swelling to R1’s left elbow and taking appropriate reporting actions. Interview with Resident #2 (R2), who was a spouse of R1 revealed that R1 did not experience a fall or other incidents within the facility. R2 reported that R1 had a previous shoulder injury and had been scheduled for shoulder replacement surgery on 09/24/24 but declined the procedure. During interviews with other residents indicated no concerns about staff care or supervision. No environmental hazards or immediate safety concerns were observed during the visit related to this allegation. Incident report and facility record were reviewed. Records did not indicate that R2 sustained a fracture as a result of an incident occurring in the facility. Based on interviews, observation and record review there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Staff did not seek medical attention to resident in a timely manner It was alleged that staff failed to obtain timely medical care for R1 following a fracture. Information received indicated that during surgery, medical staff suggested the fracture could have occurred approximately two weeks to one month prior. Staff interviews indicated that upon receiving a report of R1’s injury, emergency services were contacted and pain medication was provided as requested by the POA. Interview with resident #2 (R2) revealed that staff provided care and acted appropriately. Staff and residents’ statements were consistent that an ambulance was called, and follow-up actions were taken in timely manner. No information and/or evidence was available indicating delay in emergency responses, once staff identified the need for medical attention. A review of available records supported staff actions seeking medical evaluation after assessing R1 and observing concerning symptoms. Based on interviews and record review, there is insufficient evidence to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues were observed during this visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 31-AS-20251231133821

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced case management Annual Continuation visit to the facility. LPA met with Resident Health Services (RHS), Ruzanna Sergeyev and Director of Resident Services (DRS), Kohar Kelkelyan and explained the reason for the visit. This visit was conducted to complete Required 1 year inspection initiated on 08/08/2025. During this visit at 10:45a.m., LPA and RHS toured the physical plant areas inside and outside to ensure there are no health and safety hazards in the facility. At about 11:15a.m., LPA reviewed nineteen (19) residents medication and MAR’s records. Medications are in a centrally stored and locked medication room in Memory Care unit and Independent/Assisted Living including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation forms. First-aid kits have all proper items and were observed to be stored in the medication room. At approximately 1:05p.m. LPA reviewed six (06) out of one hundred and eighty-nine (189) residents records and they were complete at the time of this visit. LPA reviewed five (05) staff files, and they had criminal record clearance and Cardiopulmonary Resuscitation (CPR) certificate at the time of this visit. All required documents were appropriately signed and dated. No health and safety issues noted at the time of this visit. An exit interview was conducted. A copy of this report was issued.the state’s words, verbatim · CDSS document, Aug 19, 2025

Allegation investigated: Facililty failed to follow proper evacuation procedures

This is an amendment to the Licensing report previously issued to the facility on 08/08/2025. Licensing Program Analyst (LPA) Antonia Alvizar Ettima and Regional Manager (RM) Angela Whittaker conducted an unannounced subsequent complaint visit to the facility to continue an investigation of the above allegation. During the initial investigation that was conducted virtually on 02/06/2025 at 1:30pm, Licensing Program Manager (LPM) Naira Margaryan, and LPA interviewed former Executive Director (ED), Residents Care Director and Director of Health Care Services. During subsequent visit on 07/11/2025, LPM and LPA interviewed facility staff who worked on 01/07/2025 on various shifts. Interviews were conducted in person and over the phone, which included Administrative Personnel, Managers, Licensed Vocational Nurses (LVNs), Caregivers, Security Guard, Human Resources Personnel and Activities Director. During the subsequent visit on 07/11/2025 LPA and LPM gathered the following information from the interviews. Cont. on LIC9099C Substantiated Cont. from LIC 9099-C They notified the ED that they had evacuated. At around 7:00am, after everyone arrived at the emergency shelter, the facility staff completed roll call and noted that 2 residents were not at the Pasadena Convention Center. Facility staff notified the Sheriff’s Department. They returned to the facility and conducted a sweep of the facility. This was when they located resident #1 (R1) in the hallway. While they were evacuating R1, Resident #2 (R2), was walking towards the facility from outside. R2 had no knowledge about the evacuations. They were coming back after walking their dog. Both residents were taken to the Pasadena Convention Center. No one was able to explain how R1 was left in their room and how R2 end up being outside of the facility walking their dog, it was not clear how long R2 was outside and where was R2, after ED ordered “Shelter in Place.” Interviews revealed that an annual emergency disaster training was provided only to the administrative personnel and managers. On 01/07/2025 when the wind picked up in Altadena most administrative personnel and management left the facility and went home. They worked in the morning between 7:00am-5:00pm. During the review of the facility’s Disaster Protocol Procedures, the LPM and LPA read that during an emergency, designated staff should remain at the facility physically. The designated staff was the ED (pg.1). If a disaster occurs all staff on shift are responsible for the residents. (pg. 4). The ED is responsible for notifying Community Care Licensing (CCL) of the disruption of services. ED is also responsible for arranging additional staff to report to the facility through the emergency recall list. During the initial visit, when the LPA requested the recall list from the ED, ED replied that there was no recall list available with staff’s names and phone numbers, and no staff was contacted to assist. The ED left the facility the night before and informed S1 to contact him should they need anything. Based on the information revealed during interviews and records review, it was concluded that 2 residents were left behind due to the facility’s failure to follow facility emergency evacuation procedures. Therefore, the allegation is SUBSTANTATED at this time. No health and safety issues were noted during this visit. Exit interview conducted. Deficiency issued on 9099-D. Report signed and issued. Appeal rights delivered. Cont. from LIC 9099 On 01/07/2025 from 11:00pm-7:00am there were only 5 individuals working at the facility: the Building and Safety Manager Staff #1 (S1); one security guard Staff #2 (S2), two caregivers Staff #3 (S3) and Staff #4 (S4), and one LVN Staff #5 (S5). ED, who was assigned as the emergency contact per the facility’s emergency evacuation procedures, left the facility at approximately 10:30pm. At 11:30pm they called the facility and gave an order to S1 to “Shelter in Place”. The only person who had knowledge of facility emergency evacuation procedures and was on shift was S1 who was busy securing the building, preparing water hoses, checking generators, and other parameters. Interviews also revealed that LVNs that work each shift were allegedly in charge of the facility operations in the absence of the Executive Director. However, the nurse working the night shift on 01/07/2025 and 01/08/2025, was not a facility staff. Due to staff shortages the facility brought in a nurse from an outside agency. The ED that was responsible for putting the emergency procedures into action did not inform the LVN of the emergency evacuation procedures, before they left the facility at 10:30pm. No additional instructions were given, and no arrangements were made to bring additional qualified staff who had knowledge of the facility evacuation procedures were put in place. Facility residents, except those who got the information from the news, were not notified about the high winds, possible power outage, or any other concerns. When the wind worsened and fires started in the area, the ED and other Executive members and managers were communicating via a group chat and were waiting to receive a mandatory evacuation order from the Sheriff Department. Interim, staff did not receive any instructions to walk through the facility, check the residents or bring them down to the assembly area to prepare in case an evacuation was needed. The individuals that had specific assigned emergency duties were not present in the facility and did not return to the facility until after 5:00am on the following day 01/08/2025. On 01/08/2025 at approximately 3:00am after many attempts to contact the Sheriff’s Department, S1 and S2 were able to contact the Sheriff’s Department and requested assistance to evacuate the residents in care. In total, the Sheriffs provided 6 buses, and the facility had 2 buses to transport the residents to the Pasadena Convention Center. At approximately 5:30am the evacuation started, and residents and staff were transported to the Pasadena Convention Center. Cont. on LIC9099-Cthe state’s words, verbatim · CDSS document, Aug 8, 2025 · control 31-AS-20250130140733

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.695(a)(7)(H) · Plan of correction due date: Aug 11, 2025

Emergency Plans (a) … A residential care facility... shall have an emergency... plan that shall include, but not be limited to, ... the following: (7) Procedures that address, … the following: (H) Procedures for confirming the location of each resident during an emergency response. This requirement was not met as evidenced by. The Licensee failed to confirm the location of 2 residents during an evacuation. This possess an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: Administrator agrees to provide information on subsequent resident and staff training in regard to emergency response protocols. Administrator will provide proof of completed training and content outlines. Documentation will be submitted by POC due date via email to CCLD.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted unannounced Required 1-year inspection to the facility. LPA met with the Resident Health Services(RHS) and Director of Resident Services(DRS). LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. At 2:00PM, with the assistance of RHS and DRS conducted a tour of the facility inside and out. The facility consists of 4 main buildings. The Independent Living section of the CCRC includes floors 1 through 4 of the "Main" building and 3 separate multi story Villa's named Marsten, Green and Hunt. The independent living units have their own laundry, kitchen, bathrooms, living rooms and dining area. There is a separate beauty salon and a spa “Mariposa” on first floor. There is a swimming pool and of which is completely fenced with 5-foot-high fencing. The gates are locked. The independent residents are given Fob key for access. There are two restaurants, Theater, Fitness Room, Art Studio, Library, Card Room, Bar “Station 8”, Grab & Go snacks, Auditorium/Chapel, Multiple Activity spaces and available to the independent residents. There is a fountain located at the independent living entrance that is gated with large stones that will only allow 3 inches of water on the surface. The Memory Care Unit has 20 studio rooms with bathrooms, a dining area, a courtyard, food servicing area, laundry area, and medication room. The memory care unit has delayed egress and roam alert. LPA checked the egress alert and functioned properly at the time of this visit. Roam alerts are located at all the exits in memory care unit. Cont. on LIC 809-C During today’s inspection LPA inspected independent living apartments and memory care studios. The hot water in the bathrooms of the independent living apartments, memory care studios as well as in the community bathrooms, was tested between 108.1*F and 114.1*F. Due to time constraints, LPA had to terminate the visit and will return on a later date to complete the Required - 1 Year inspection by reviewing medication, residents and staff records. No health and safety issues noted at the time of this visit. An exit interview was conducted. A copy of this report was issued.the state’s words, verbatim · CDSS document, Aug 8, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Antonia Alvizar- Ettima and Licensing Program Manager (LPM) Naira Margaryan conducted unannounced Required 1-year inspection to the facility. LPA and LPM met with the Resident Health Services, Ruzana Sergeyen and Director of Resident Services Kohar Kelkelyan. At 10:08AM the Executive Director, David Weidert joined us. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. At about 10:35AM, with the assistance of the Environment Services (EVS) Celina Miranda and Executive Director, David Weidert LPA Alvizar – Ettima and LPM Margaryan conducted a tour of the facility inside and out. The facility consists of 4 main buildings. The Independent Living section of the CCRC includes floors 1 through 4 of the "Main" building and 3 separate multi story Villa's named Marsten, Green and Hunt. The independent living units have their own laundry, kitchen, bathrooms, living rooms and dining area. There is a separate beauty salon and a spa “Mariposa” on first floor. There is a swimming pool and of which is completely fenced with 5-foot-high fencing. The gates are locked. The independent residents are given Fob key for access. There are two restaurants, Theater, Fitness Room, Art Studio, Library, Card Room, Bar “Station 8”, Grab & Go snacks, Auditorium/Chapel, Multiple Activity spaces and available to the independent residents. There is a fountain located at the independent living entrance that is grated with large stones that will only allow 3 inches of water on the surface. The Memory Care Unit had 20 studio rooms with bathrooms, a dining area, a courtyard, food servicing area, laundry area, and medication room. The memory care unit had delayed egress and roam alert. At 12:00PM LPA and LPM checked the egress alert and functioned properly at the time of this visit. Roam alert is located leading into the Terres area and all the exits. During todays inspection LPA Alvizar-Ettima and LPM Margaryan inspected independent living apartments and spoke with the residents present in their apartment. The hot water in the bathrooms of the independent living apartments as well as in the community bathrooms, was tested between 115.5*F and 118.0*F. At 12:28PM, LPA Alvizar – Ettima and LPM Margaryan reviewed six randomly selected residents record, residing at the Independent Living and Dementia apartments. During inspection, LPM and LPA observed memory care residents having lunch. One of the staff was feeding a resident by putting the spoon in resident’s mouth. LPM Margaryan spoke with the Resident’s Care Director and other staff available in the dining area and discuss the personnel requirements and training for the staff feeding residents vs providing assistance with food intake. Residents Care Director and ED were advised that to promote resident’s independency, the staff should only provide feeding assistance by using training tools and other technics to prolong residents independency as long as possible. Upon review of the Care and Residence Agreement, LPA Alvizar-Ettima and LPM Margaryan noted that the agreements does not contain additional addendums to the original agreement/contract regarding the annual fee increase and/or service fee increase based on noted changes in residents physical and mental conditions. Other minor issues regarding residents’ appraisal, need and service plan as well as the usage of the facility amenities, including the pool. The administrative personnel were advised that the facility should have a plan in place explaining how they are assisting residents, that are using a pool, to ensure that their health and safety is being protected. Prior to entering the facility LPA Alvizar - Ettima and LPM Margaryan noted the construction work next to the facility. There were signs posted through the construction site advertising “MonteCedro expansion coming soon.” ED stated that they are working on a new project trying to expend Montecedro. ED was able to explain what they have done up to date and how they inform the residents and try to accommodate them during construction. LPM advised ED to provide written statement explaining the steps they are following to ensure that residents are accommodated during construction period. No citations were issued during this visit. However, ED was advised that that all noted issues (discussed during this visit) that may pose potential risk to the health and safety of residents in care, should be addressed in writing and the documentation must be submitted to CCL no later than by COB 08/12/2024. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Aug 7, 2024