Pasadena Villa Senior Living

Allegation investigated: Licensee does not ensure that residents have access to an operable call system. Staff do not respond to residents' requests for assistance in a timely manner.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint investigation regarding the above-mentioned allegations. LPA met with Anaya Dews, Receptionist and explained the purpose of the visit. Shortly after, administrator, Bryanna Luke arrived and assisted LPA. The investigation consisted of the following: LPA conducted an observational walkthroughs in the common areas and random residents’ rooms. LPA obtained a copy of the staff & resident rosters, Plan of Operation, Facility’s emergency response plan, Staff training (Residents rights, Abuse/Mandated reporting), and (3) Random resident Individualized Care Plans files. At 11:30am, LPA tested the call lights in room #s 10 & 42. LPA interviewed Staff #1 (S1) – Staff #5 (S5) and Resident#1 (R1) – Resident #7 (R7). ****CONTINUED ON LIC9099-C***** Substantiated The investigation revealed the following: Allegation: "Licensee does not ensure that residents have access to an operable call system." It was alleged that the facility failed to provide an operable call system for residents, as many lacked call lights or pendants to alert staff. Staff stated that although some call lights are installed, most do not work, and some rooms were still missing them due to painting/renovations. S1 stated that the management has not yet made a decision on their request for an operable call light system. All (7) residents interviewed stated that they have not been provided with a call pendant. During the inspection of (10) rooms, it showed (5) rooms without call lights, and of the (5) rooms that had call lights installed on the wall, (2) were tested and caregivers did not respond. LPA did not observe audible alerts or wearable devices for caregivers to respond to alerts. Documents reviewed revealed that W1's investigation revealed the absence of a pendant/call light in several of the residents' rooms and bathrooms (pictures provided). W1 observed that a hardwired system, which has since been removed and painted over, was previously installed in the wall. Moreover, no signs of audible warnings to caregivers either. Therefore, there was sufficient evidence to corroborate with this allegation. Allegation: "Staff do not respond to residents' requests for assistance in a timely manner." It was alleged that residents were forced to either use their personal cell phone or call 911 for emergency services because staff were unavailable when called out for help. Staff interviewed stated that caregivers attend residents' calls as quickly as possible and have received training. However, some staff stated that they have heard residents complained to them about not answering the residents' calls for help, especially during the night shift. All (7) residents interviewed corroborated the allegation stating that the call lights installed in their rooms do not work and that they had never received a call light pendant. (5) of (7) residents interviewed stated that they use their cell phones or call out to ask for help instead of a call light system. (2) residents stated that they witnessed other residents call for help during the day and waited for over an hour to get assistance. In order to measure call response times, LPA pushed the call light in Room #10 at 10:25am, and no staff responded after waiting for more than (6) minutes. LPA also tested the call light in Room #42 and received no response from a caregiver after waiting for (5) minutes. Therefore, there was sufficient evidence to corroborate with this allegation. Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided to the Administrator, Bryanna Luke along with the Appeal Rights.the state’s words, verbatim · CDSS document, Aug 24, 2026 · control 28-AS-20260818132842

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)-(2) · Plan of correction due date: Sep 4, 2026

87303 Maintenance and Operation ...(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (2) Facilities having more than one wing, floor or building shall be permitted to have a separate system in each, provided each meets the above criteria. This requirement is not met as evidenced by Based on observation, interviews, records review, the Administrator did not comply with the section cited above in which the facility failed to provide an operable call system for residents, as (5) out of (10) rooms inspected, (Rm #s 8, 10, 18, 22, 24 and 41) lacked call lights or pendants to alert staff which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 2026

Plan of correction: Administrator to develop an alternate call system to alert staff if residents need assistance while waiting for a replacement of call light system in the facility. Administrator to submit the plan in writing to CCLD/LPA by POC due date.

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

87411 Personnel Requirements - General..(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required ....The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by Based on observation, interviews, the Administrator did not comply with the section cited above in which the staff were unavailable when called out for help. LPA pushed the call light in Room #10 at 10:25am, and no staff responded after waiting for more than (6) minutes and Room #42, no response from a caregiver after waiting for (5) minutes, which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 2026

Plan of correction: Administrator to ensure that facility staff shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Administrator to conduct in service training with staff about responding to residents ask for help in a timely manner. Administrator to submit the in service training log to CCLD/LPA by POC due date.

Allegation investigated: Staff did not safeguard a resident’s belongings.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint investigation regarding the above-mentioned allegation. LPA met with Anaya Dews, Receptionist and explained the purpose of the visit. Shortly after, administrator, Bryanna Luke arrived and assisted LPA. The investigation consisted of the following: On 08/14/2026, LPA toured the facility’s common areas, obtained a copy of the staff & resident rosters, Facility’s policies on theft and loss, resident rights, grievance procedures, Staff’s Abuse/Mandated reporting training, Resident #1 (R1) files including: Identification and Emergency Information/Face sheet, Physician’s report, Admission agreement and Appraisal Needs and Services Plan. During today’s visit, LPA conducted a walkthrough of the common areas and obtained a copy of the staff & resident rosters, R1's Unusual incident/injury report, Invoice/Delivery report for ordered items (July 17, 2026 & July 19, 2026). LPA interviewed Staff #1 (S1) – Staff #5 (S5) and Resident#1 (R1) – Resident #7 (R7). ****CONTINUED ON LIC9099-C***** Substantiated The investigation revealed the following: Allegation: "Staff did not safeguard a resident’s belongings." It was alleged that a package for R1 was delivered to the facility on July 19, 2026, with notification that S2 had received it, but the package could not be found. Staff interviewed confirmed that they know that R1 has previously stated that a package that was delivered to the facility is missing. S2 confirmed receiving the package on 07/19/2026 for R1, and stated to have left it on R1's bed in their room the same day. Staff confirmed that they do not have a delivery package tracking system in place or a signed facility inventory list. S1-S2 stated that after R1 complained about the missing package, they started logging the receipt of packages signed by both the residents and facility. Residents interviewed stated they hardly order items online, and if they do, they receive it themselves. Documents reviewed revealed that R1 ordered items on 07/17/2026 and 07/19/2026 with proof of delivery reports. The facility confirmed receipt of a package for R1 during interviews and documents reviewed, however the package could not be located due to a lack of tracking system or log. Despite the presence of a video camera in the facility, S1 stated that they do not have a video evidence of the package's arrival or S2 delivering it to R1's room. Therefore, there was sufficient evidence to corroborate with this allegation. Based on staff interviews, resident interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the administrator, Bryanna Luke along with the appeal rights. The investigation revealed the following: Allegation: "Staff threatened to evict resident." It was alleged that R1 has never been late on his rent but was told by a staff member that if they do not pay $1420 next month, they will be evicted. Additionally, R1 felt that this in retaliation because of the police report filed for theft. Staff interviewed denied the allegation, stating that R1 was enrolled in an Assisted Living Waiver Program/ALW but has not paid his rent (room & board) since moving in the facility in 2023. S1 stated that they have been trying to collect rent from R1 several times and denied that the attempts to collect rent were retaliatory acts brought on by a police report filed by R1. All residents interviewed denied having been threatened with eviction or retaliation. (2) of (6) residents interviewed stated that they know of other residents who had been evicted due to breaking the facility's house rules or for failing to pay their dues. R1 stated that after filing the police report for theft, they received a verbal eviction warning, without witnesses and that the facility did not provide them with an eviction notice. R1 also confirmed that they have not paid anything to the facility because they were told that Medical would cover their rent instead. Documents reviewed revealed that R1 signed the ALW individual service plan agreement when they moved in on 06/20/2023. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. 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. Exit interview conducted and a copy of this report was provided to the administrator, Bryanna Luke.the state’s words, verbatim · CDSS document, Aug 24, 2026 · control 28-AS-20260805102326

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(2) · Plan of correction due date: Aug 31, 2026

(a) The licensee shall ensure an adequate theft and loss program.....(2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property ....The licensee shall.... made reasonable efforts to safeguard resident property ...... to meet each requirement specified in Section 1569.153. This requirement is not met as evidenced by: Based on interviews and record reviewed, Administrator failed to safeguard R1's properties/belongings and cannot locate delivered packages which were confirmed delivered to the facility on 07/17/2026 & 07/19/2026 due to a lack of tracking system or log which poses a potential Health, Safety, and Personal Risk to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 2026

Plan of correction: Administrator agreed to develop a package tracking system or log to be signed by the resident and staff. Administrator also agreed to submit an agreement between staff & R1 that facility will reorder the missing items to replace them. Administrator to send proof/invoice to CCL/LPA by POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced case management visit. LPA met with the Administrator, Bryanna Luke and LPA explained the purpose of the visit. The purpose of the visit is to address possible staffing concerns and to ensure that there are qualified staff to meet the residents needs at all times at the facility at all times. LPA obtained the staff and resident rosters. LPA interviewed the Administrator who confirmed that on 08/14/2026, residents did not obtain prescribed medications between 2:30pm to 10:30pm. Staff #1 (S1) was scheduled to work and administer medications between 2:30pm to 10:30pm on 08/14/2026 but did not arrive to their scheduled shift. Administrator was made aware of this situation at 6pm and that time, Administrator contacted S1 however S1 still did not arrive to their scheduled shift. Staff #2 (S2) who is qualified to pass medications didn’t arrive to the facility until 10:30pm on 08/14/2026 to work the noc shift until 6:30am on 08/15/2026. Administrator also confirmed that the facility does not have staff trained to handle medications during every noc shift. Administrator stated in cases where a resident requests to obtain medications or PRN (as needed medications) and if there are no staff trained to pass medications, the facility contacts the paramedics to transfer the resident to the hospital. LPA interviewed five (5) residents that indicated in which three (3) out of five (5) residents stated that there were two (2) care staff on duty on the night of 08/14/2026. The remaining two (2) of five (5) residents indicated they were unsure of how many staff were on duty on the night of 08/14/2026. LPA obtained documents such as the Caregiver and Medtech monthly work schedule and Medication Management Staff Training. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed are indicated on the LIC809-D page. Exit interview held with Administrator, Bryanna Luke, and a copy of this report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 18, 2026

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on staff interview and record review, it was revealed that on 08/14/2026, between 2:30pm to 10:30pm residents at the facility did not receive their prescribed medications as Staff #1 (S1) failed to arrive to their scheduled shift. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 17, 2026

Plan of correction: Administrator will ensure that there is sufficient staff in numbers, and competent to provide the services necessary to meet residents needs. Administrator to submit a detailed plan to LPA by POC due date that the facility will ensure that there is sufficient coverage and quailed staff at the facility at all times.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(h)(4) · Plan of correction due date: Aug 31, 2026

(h) The administrator shall have the responsibility to: (4) Recruit, employ and train qualified staff, and terminate employment of staff who perform in an unsatisfactory manner. This requirement is not met as evidenced by: Based on staff interview and record review, the administrator failed to ensure that there were competent, qualified, and trained staff working in the facility 24 hours a day seven days a week to provide the care to meet the needs of the residents. This poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 17, 2026

Plan of correction: Administrator will ensure that the facility recruit, employ, and train qualified staff to meet the needs of the residents at all times. Administrator will ensure that there are staff qualified to handle medications when needed at all times. Administrator to train noc shift staff in handling medication and provide training material and signup sheet to the LPA by POC due date.

Allegation investigated: Staff do not provide grab bars for safe showering. Facility does not have hot water. Staff not giving resident personal belonging(s). Staff not preventing resident from disturbing other residents sleep.

Licensing Program Analyst (LPA) Alberto Lopez conducted an initial 10-day complaint visit to investigate the above allegations. LPA met with Administrator Bryanna Luke and LPA discussed the purpose of the visit. The investigation consisted of LPA obtaining a staff and resident roster, interviewing four (4) staff S#1-#4 and seven (7) residents #1 - #7, taking tour of facility and inspecting four (4) common showers. The investigation revealed regarding allegation: Staff do not provide grab bars for safe showering. It is alleged that staff are not providing grab bars in shower and it makes it unsafe for residents to shower. LPA interviewed four (4) staff, and all four staff denied the allegation. LPA interviewed seven (7) residents and six (6) of seven residents could not corroborate the allegation. One (1) resident stated that shower could use a long horizontal grab bar across the side walls adjacent to the shower exit. Administrator stated she will ask her maintenance staff to check to see if grab bar can be installed in the walls and will install them if the walls are structurally sound. (continued on 9099C) Unsubstantiated (continued from 9099) The department requires that facility provide grab bars for shower and toilets and have met that requirement currently. There is insufficient evidence to substantiate this allegation. Allegation: Facility does not have hot water. It is alleged that facility does not have hot running water. LPA interviewed four (4) staff, and all four (4) staff denied the allegation. LPA interviewed seven (7) residents and six (6) of seven (7) residents could not corroborate the allegation. Several residents stated that it takes a while for water to get hot at times. LPA checked the hot running water, and it was at the required temperature. There is insufficient evidence to substantiate this allegation. Allegation: Staff not giving resident personal belonging(s). It is alleged that the facility is not giving resident’s personal belongings. LPA interviewed four (4) staff, and all four (4) staff denied the allegation. LPA interviewed seven (7) residents and seven (7) of seven (7) residents could not corroborate the allegation. One resident stated that he had asked for a table, two chairs and a clock for his room and the items were not personal belongings. Facility administrator was able to provide the resident with two (2) chairs, table and a clock during the visit. There is insufficient evidence to substantiate this allegation. Allegation: Staff not preventing resident from disturbing other residents sleep. It is alleged that a resident has the volume on TV too loud in the late evening hours (after 10:30PM) and is disrupting the resident’s sleep in the adjacent room. LPA interviewed four (4) staff, and all four (4) staff denied the allegation. Two (2) staff stated that they addressed the issue with the resident who put the TV volume too loud and that it was a one-time occurrence. LPA interviewed seven (7) residents and five (5) of seven (7) residents could not corroborate the allegation. Two (2) residents’ stated it happened again last night. The resident accused of putting the volume too loud denied it and demonstrated to LPA how much volume TV is on all the time. Other residents in adjacent rooms stated they do not hear sound of TV or other sounds during the night and are able to sleep well. Facility administrator offered all three (3) residents an opportunity to change rooms, and all three (3) residents turned down the offer. There is insufficient evidence to substantiate this allegation. Based on statements and interviews conducted with residents and staff, there was not enough supportive evidence to corroborate the allegations. 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. Exit interview conducted and a copy of this report was provided to Bryanna Luke, Administrator.the state’s words, verbatim · CDSS document, Jun 23, 2026 · control 28-AS-20260622133923

Allegation investigated: Staff did not ensure medications were dispensed in a timely manner.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegations. The purpose of the visit was explained to med-tech Christian Solorio. Administrator Bryanna Luke arrived later. The investigation consisted of: A physical plant tour of the facility common areas, resident rooms, and medication room was completed. Resident (R1 & R2's) medications were audited. R1's Medication Administration Records (MARs) for months March 2026- May 2026 were reviewed. Staff (S1- S3) and residents (R1- R9) were interviewed. Copies of R1's Medication Administration Records (MARs), Physician's Report, pharmacy email, physician order (5/9/26) and resident and staff rosters were reviewed and obtained. *Report continuation on 9099C. Reviewed R1's medications Substantiated Allegation: Staff did not ensure medications were dispensed in a timely manner. The complaint alleges that on the evening of May 10, 2026 med-techs did not administer resident (R1's) bedtime medication Trazodone, or PRN medication Ibuprofen. According to information obtained, R1 was in pain and had difficulty sleeping without the medications. A total of nine (9) residents were interviewed. Three (3) out the nine (9) residents stated their medications are sometimes not administered on time. A resident stated a new medication was ordered, but has not been filled. Staff were informed and are looking into the concern. A total of three (3) staff were interviewed. Staff stated the facility does not have electronic Medication Administration Records (MARs). Therefore, a pharmacy provides monthly copies of resident MARs. Staff stated that sometimes residents move in without MAR records, and med-techs use a blank facility MAR to document the resident(s) medications. Resident (R1) moved in on March 17, 2026. Staff was unable to recall if their medications were documented on a blank MAR, and did not find a record of R1's March 2026 MAR. Administration reached out to the pharmacy, but they were unable to provide a historical MAR. Resident (R1) & R2's) medications and MAR records were reviewed during the visit. Based on observation, (R1's) May medications showed discrepancies. April 2026 and May 2026 MARs have listed PRN medication Ibuprofen 400 mg and PRN medication Simethicone 80 mg, but the medication bottles dosage did not match the pharmacy MAR. For instance, the med room has two bottles of Ibuprofen 200 mg, physician order states one PRN tablet of Ibuprofen 400 mg every 6 hours. No records were found or provided that demonstrates staff are aware of the dosage discrepancy. Per records, Ibuprofen 400 mg was not administered at all in the months of April 2026 and May 2026. Additionally, a new medication (Trazodone 25 mg) was ordered and delivered on 5/9/2026. However, based on observation the bubble pack showed Trazodone was popped and administered on 5/9/2026 and 5/10/2026, but MAR records do not have any medication technician initials, and staff cannot determine if the medication was in fact administered. The findings indicate there is sufficient information to corroborate the allegation. Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiency was cited. An exit interview was conducted, copy of the report and appeal rights was provided to Administrator Bryanna Luke.the state’s words, verbatim · CDSS document, May 15, 2026 · control 28-AS-20260511094421

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(b) · Plan of correction due date: May 16, 2026

Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. Based on record review, evening med-tech staff did not dispense R1's Ibuprofen 400 mg and Trazodone 25 mg on May 9, 2026 & May 10, 2026 per MD order and PRN medication request. Bubble pack shows Trazodone was popped on 5/9/26 and 5/10/26, but staff did not initial MAR, and Ibuprofen was not administered, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 15, 2026

Plan of correction: Administrator agrees to: 1. Submit a written plan by tomorrow. 1. Submit proof of staff training by 5/22/26. 2. Submit a written plan that addresses centrally stored record keeping/inventory protocols, refill procedures, and facility auditing of medications.

Allegation investigated: Staff did not ensure residents pendent was secure and reachable Due to staff neglect, resident was left in soiled brief for an extended period of time Due to staff neglect, resident was left in bed/clothes not changed Staff did not ensure residents air conditioner was working properly Due to staff neglect, resident was not fed breakfast

Licensing Program Analysts (LPA) Daniel Konishi conducted an unannounced subsequent 10-Day complaint visit to investigate the above allegations. LPA met with Bryanna Luke, Administrator and explained the purpose of the visit. On 3/26/2026, the initial investigation visit was conducted. The investigation consisted of the following: LPA obtained a copy of the staff and resident rosters. LPA interviewed the Administrator, Staff #1 (S1) to Staff #3 (S3), and Resident #1 (R1) to Resident #11 (R11). LPA obtained documents from R1’s file such as: Face Sheet, Physician’s Report and other pertinent documents. LPA also obtained Staff Training, HVAC maintenance documents, Shift to Shift reports and other pertinent documents. During today's visit the investigation revealed the following: in regard to the allegation, “Staff did not ensure residents pendent was secure and reachable.” It is alleged that on 03/17/2026, the call light cord was tangled with the cord for bad remote control. [Continued to LIC9099-C] Unsubstantiated In attempt to detangle cord and lanyard, S1 cut the lanyard leaving call light free floating on client’s bed. It is alleged that R1 has a condition characterized by the inability to control the distance, speed, and power of movements, resulting in overshooting or undershooting targets. As a result, typical movements R1 is likely to knock call light on the floor resulting in inability to request support as needed. LPA interviewed the Administrator and two (2) additional staff that denied the allegation stating that call signals are secure and reachable for all residents. LPA interviewed S1 that denied the allegation stating that R1 requested S1 to cut the cord and the cord to be placed away from the remote control but attached by the bed so R1 is able to reach and use to signal staff for help. LPA interviewed R1 that denied the allegation stating that S1 helped untangle the cord and placed the call signal at a location where S1 can get the call signal and use. During interview with R1, R1 confirmed that R1 asked S1 to cut the cord so that the cords of the call signal and bed remote don’t get tangled. LPA observed that R1 was able to press the call light at 10:11am and care staff arrived in R1’s room at 10:13am. LPA interviewed an additional ten (10) residents that denied the allegation stating that the call light is secure and reachable in their rooms. R1 and the ten (10) residents also stated that the call signals work properly. Administrator, and two (2) out of three (3) staff stated that R1 and all residents pendants are placed in a secure and reachable area and all on-duty care staff carry devices that receive calls. Therefore, there was not enough sufficient evidence to corroborate with the allegation. Allegation, “Due to staff neglect, resident was left in soiled brief for an extended period of time.” It is alleged that on 03/17/2026, R1 was not changed and left in a soiled diaper until 12:15pm. It is also alleged that on 03/19/2026, R1 was not checked on by afternoon until 9:15pm despite R1 pressing call light. LPA interviewed R1 that denied the allegation stating that on 03/17/2026 and 03/19/2026, R1 was kept dry and staff made sure that R1 was checked on, kept dry, and not wet. LPA interviewed six (6) residents that denied the allegation stating that on 03/17/2026 and 03/19/2026, the staff kept residents dry and were changed frequently. LPA interviewed an additional four (4) residents that could not confirm nor deny the allegation stating that they do not require any incontinence supplies change from the staff. LPA interviewed the Administrator and two (2) staff that denied the allegation stated that incontinence change are provided to all residents in a timely manner. S1 and S2 stated that on 03/17/2026, S1 and S2 conducted a status check every two hours and R1 refused incontinence supply change since R1 was with a guest until 12pm. Ultimately, R1 requested incontinence supply change when the guest left at 12pm. On 03/19/2026, S1 stated that R1 was provided status checks and R1 was changed twice in the PM shift. Based on record review, LPA reviewed Shift to Shift Report that indicated that on 03/19/2026, R1 was checked on at 5:45pm and changed at 8:45pm to 9:10pm. LPA interviewed one (1) additional staff that could not confirm nor deny the allegation since they are not involved in providing this service. Therefore, there was not enough sufficient evidence to corroborate with the allegation. Allegation: “Due to staff neglect, resident was left in bed/clothes not changed.” It is alleged that on 03/17/2026, R1 had a diaper change but R1’s clothes were not changed until R1 asked S1 if R1’s shirt was wet in urine. At which time, S1 changed R1’s shirt. LPA interviewed R1 that denied the allegation stating that on 03/17/2026, R1 was changed by S1 and addressed no concerns. LPA interviewed five (5) residents that denied the allegation stating that their clothes are changed and not left in bed. However, LPA interviewed an additional four (4) residents that could not confirm nor deny the allegation stating that they do not require any incontinence supplies change from the staff. LPA interviewed the Administrator, and two (2) staff that on 03/17/2026, S1 and S2 went to R1’s room but R1 was with a guest until 12pm. However, S1 and S2 continued to conduct status checks every two hours and S1 and S2 continued to refuse clothes changes until the guest left at 12pm. Therefore, there was not enough sufficient evidence to corroborate with the allegation. Allegation: “Staff did not ensure residents air conditioner was working properly.” It is alleged that on 03/17/2026, R1’s air conditioning was not working properly so R1 was under warm blankets until 12:15pm. LPA interviewed the Administrator, and three (3) out of three (3) staff that denied the allegation stating that on 03/17/2026, the air conditioner is working in R1’s room and the entire facility. Based on record review, LPA reviewed facility’s HVAC service order invoice dated 02/26/2026 which indicated that all Air Conditioning systems are working and filters were deep cleaned. LPA interviewed R1 and 10 (ten) residents that denied the allegation stating that the facility’s air conditioning system was working on 03/17/2026. One (1) staff stated that due to the warm weather, the facility’s air conditioner makes the facility much cooler so facility staff provide blankets to staff for any residents that requests blankets. There was not enough sufficient evidence to corroborate with the allegation. [Continue to LIC9099-C] Allegation: “Due to staff neglect, resident was not fed breakfast.” It is alleged that on 03/17/2026, R1 was not provided breakfast. LPA interviewed R1 that denied the allegation stating that R1 received breakfast delivered from staff on 3/17/2026. R1 also stated that the staff continue to provide breakfast and helps feeding R1 at 9am daily. R1 had no further concerns regarding staff serving breakfast. LPA interviewed two (2) residents that denied the allegation stating that they received breakfast delivered to their bedroom on 3/17/2026. LPA interviewed eight (8) residents that could not confirm nor deny the allegation since they go to the dining room for all meals on a daily basis. However, the eight (8) residents stated that breakfast is provided at the dining room on a daily basis. LPA interviewed administrator, and two (2) out of three (3) staff denied the allegation stating that on 3/17/2026, R1 declined receiving breakfast when S1 and S2 went to R1’s room at 8:15am. S1 and S2 stated that S1 and S2 both continued to visit R1’s room but R1 continued to decline breakfast on that day. One (1) staff stated that grilled cheese sandwiches for lunch was provided to R1 on 03/17/2026. The Administrator and two (2) staff stated that breakfast is provided and feeding assistance to R1 at 9am daily. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 allegations are UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided to the Administrator, Bryanna Luke.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 28-AS-20260320085012

Type of visit: Office

An informal conference was held at the Monterey Park Adult and Senior Care Program Regional Office on 3/18/26. The individuals present for the meeting were: Tony Vasallo (Regional Manager), David Sicairos (Licensing Program Manager), Daniel Konishi (Licensing Program Analyst), Bryanna Luke (Facility's Administrator), and Stephan Sarmazian (Vice President of Operations). The purpose of the meeting is to discuss the citations issued for staff not assisting resident with Activities of Daily Living (ADLs) and staff did not observe changes in resident’s health for complaint control # 28-AS-20200925154403. The department concluded the investigation on 03/10/2023 and the following deficiencies were issued for: 87459(a)(5)(B) Functional Capabilities and 87466 Observation of the Resident, along with an immediate $500 civil penalty. The department has determined that an additional civil penalty may be assessed due to staff did not observe changes in resident’s health which resulted in resident experiencing severe pain and discomfort while in care. The additional civil penalty may be delivered at a later date and time. Facility representatives indicated that they began receiving consulting services beginning in November of 2024 and believe that they have been in compliance for the last couple of years. The Administrator and Vice President of Operations have been advised that the department is seeking an additional civil penalty. An exit interview, and a copy of this report was provided to Stephan Sarmazian.the state’s words, verbatim · CDSS document, Mar 18, 2026

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced 10-day complaint visit to investigate the above-mentioned allegations. LPA met with Bryanna Luke, Administrator, and the reason for the visit was explained. The investigation consisted of the following: During today’s visit, LPA obtained copies of staff and resident rosters, toured the facility and inspected (10) resident rooms, mobility equipment storage area and linen closet, and interviewed Staff 1 – Staff 5 (S1-S5) and Resident 1 – Resident 8 (R1-R8). The investigation revealed the following: ***Continues on LIC 9099-C**** Substantiated Regarding: Staff did not ensure that resident had clean linen. It is alleged that resident’s bed was smeared with feces and was overall very dirty. Staff deny the allegation. Interviews with (5) out of (5) staff indicated that residents’ bedding is monitored for cleanliness by caregivers and housekeeping staff throughout each shift. Staff indicated that residents’ bedding is not left smeared with feces or other things which may soil the bedding. Staff indicated that full bedding changes are made twice a week during resident showers and that during a bedding change, mattress pads, sheets, pillowcases and blankets are removed and replaced with clean ones. Staff then place soiled bedding into clear bags and are labeled to ensure they get picked up and taken to get washed. Staff stated that if residents have accidents bedding is changed immediately. Staff indicated that the facility has sufficient bedding available for use. Interviews with (8) out of (8) residents revealed that they have everything they need and do not have concerns regarding their bedding. LPA inspected (10) rooms during visit and observed bedding to be clean and in good repair. Beds had mattress pads, fitted sheets and blankets. The facility has extra bedding on hand which is kept in a linen closet and bedding was observed being washed in the large laundry room. Staff and resident interviews and LPA observations do not corroborate the allegation that resident’s bed is smeared with feces and was overall dirty. Regarding: Staff did not ensure that resident's room was free of hazards. It is alleged that shattered glass and large shards were observed in resident’s room and still present covered only by a sheet from a broken glass door. Staff deny the allegation. Interviews with (5) out of (5) staff revealed that they have not observed shattered glass and large shards in residents’ rooms during their visits. S1 indicated that the glass on R1’s sliding door in their rooms was broken on 2/28/2026 due to R1 falling into the glass door while experiencing dizziness; however, maintenance staff were called in to pick up the broken glass immediately after the incident. Staff further indicated that when glass is observed on the floor or on the ground of the facility, it is reported to maintenance immediately and the area is secured to limit access while it gets cleaned up. LPA inspected R1’s room and did not observe shattered glass or large shards. LPA inspected (9) more resident rooms and did not observe broken glass, large shards or other hazards. Interviews with (8) out of (8) residents revealed that they have no concerns regarding their rooms. Staff and resident interviews and LPA observations do not corroborate the allegation that resident’s room was not free of hazards. **Continues on LIC 9099-C page 2** Regarding: Staff did not provide a safe environment for the resident. It is alleged that resident should not have been walking and require a wheelchair, but facility did not have one available for resident to use. It is also alleged that resident had to gain access into the facility through an unlocked side door due to staff not answering the phone in the front office to let resident in. Staff deny the allegation. Interview with S1 indicated that residents are provided with mobility assistance devices like wheelchairs, walkers and canes as ordered by doctors and when needed. S1 indicated that R1 was recently discharged from the hospital; however, hospital staff did not follow protocol by calling the facility to arrange resident’s return so that facility staff can have R1’s wheelchair readily available. S1 indicated that R1 received their wheelchair the same day R1 returned from the hospital after R1 was situated in their room. Interviews with (5) out of (5) staff indicated R1 was provided with their wheelchair upon arrival at the facility from the hospital. LPA interviewed R1 in their room and R1 confirmed that the wheelchair observed in R1’s room belonged to R1. LPA inspected the mobility equipment storage room and observed extra wheelchairs and walkers. Interviews with (8) out of (8) residents indicated that they have everything they need and have no concerns. S1 further indicated that hospital personnel who transport residents back to the facility after being discharged are provided with the front door pin number when arranging for a resident’s return to the facility. S1 stated that hospital personnel who brought R1 back from their hospital visit did not follow protocol and did not call facility staff to coordinate R1’s return by which they would have received the front door pin number to gain access. S1 indicated that receptionists end their day at 4:30 p.m. and therefore, the front office will be temporarily vacant if someone is called to conduct business away from the front desk. S1 indicated that if hospital personnel had called the facility first to coordinate the return of R1 to the facility, they would have been provided with the access pin number to let themselves in or have staff ready to receive R1. Interview with (5) out of (5) staff indicated that the side gate is left unlocked during business hours so that residents can leave the facility if they need to. Staff also indicated that the gate is locked in the evenings to ensure safety. Interviews with (8) out of (8) residents indicated that they feel safe at the facility. LPA observed the facility phones to be working properly during visit. Staff and resident interviews and LPA observations do not corroborate the allegation that staff do not provide resident with a safe environment. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Bryanna Luke, Administrator, and a copy of this report was provided. Regarding: Facility is in disrepair. It is alleged that a door in residents’ room is broken. It is also alleged that doorbell of the facility is not working. Interview with Staff 1 (S1) indicated that the glass on R1’s sliding door in their room was broken on 2/28/2026 due to R1 falling into the glass door while experiencing dizziness. S1 stated that maintenance staff were called in to pick up the broken glass immediately after the incident; however, the glass has not been replaced due to the facility waiting on the door to arrive and to be installed which had to be custom ordered. LPA inspected R1’s room and observed that the door is currently covered with cardboard through the inside and a plywood sheet on the outside. Interviews with (9) out of (10) residents indicated that there are no issues concerning their rooms; however, R1 acknowledged that the sliding door in R1’s room is broken. Interview with (5) out of (5) staff indicated that the sliding door in R1’s room has been broken since 2/28/2026; however, review of purchase invoice for the replacement sliding door indicates that the order was placed on 3/2/2026. LPA tested the doorbell of the facility’s main entrance door and found it to be operable. Further interviews with staff indicated that the doorbell is working and is heard when visitors push it. Interviews, observations and record review corroborate the allegation that door in resident’s room is broken. The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099-D. An exit interview was conducted with Bryanna Luke, Administrator, and a copy of this report was provided and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 28-AS-20260225125552

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 16, 2026

87303(a) Maintenance and Operation (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: sliding door in room 7B was broken on 2/28/2026 the glass has not been replaced. The door is currently covered with cardboard through the inside and a plywood sheet on the outside which poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Mar 3, 2026

Plan of correction: Licensee/Administrator will send LPA, photos of the replaced door. Photos will depict the doorway showing the room number and also to capture the sliding door and the outside of the building (front) to ensure the plywood is removed by POC due date.

Allegation investigated: Staff did not ensure the resident’s incontinence needs are being met

Licensing Program Analysts (LPA) Daniel Konishi conducted an unannounced initial 10-Day complaint visit to investigate the above allegations. LPA met with Bryanna Luke, Administrator and explained the purpose of the visit. The investigation consisted of the following: LPA obtained and reviewed the staff & resident rosters. LPA also obtained Staff Training and other pertinent documents. LPA interviewed the Administrator, Staff #1 (S1) - Staff #3 (S3), and Resident #1 (R1) - Resident #7 (R7). LPA attempted to interview Resident #8 (R8) but R8 was unable to answer the LPA’s questions. The investigation revealed the following: In regards to the allegation: “Staff do not ensure that residents' incontinence needs are met.” It is alleged that R1 sits in a wet diaper for a prolonged periods of time. [Continue to LIC9099-C] Unsubstantiated LPA interviewed the Administrator, three (3) out of three (3) staff that denied the allegation stating that they always change the residents if the briefs are soiled and check on them at least every two (2) hours. The Administrator and three (3) out of three (3) staff stated that when residents press their pendants and request a diaper change, staff will change them right away. Staff also stated they change the bed pads and ensure the residents are clean and dry. Per Administrator, two (2) out of three (3) staff indicated that there are two (2) caregivers on duty per shift to provide incontinence care for 11 residents out of the facility census of 70 residents. Two (2) out of three (3) staff stated that there are times when the staff are providing two (2) person assist on changing a resident, this may cause a delay in changing and/or helping another resident. However, one (1) out of three (3) staff stated that Med-Techs help assist the caregivers with providing incontinence care for residents. LPA interviewed R1 that corroborated with the allegation stating that R1 is kept wet and whenever R1 pushes the call button for help to change R1’s diapers, the staff do not check or change R1’s diapers. However, during the visit when the LPA met R1, LPA observed to time the staff’s response to the resident’s call button, R1 pushed the call button at 10:48am and the care staff arrived to help the resident at 10:49am. R1 also stated that the staff change R1’s diapers three times per day but there were times when R1 was changed only once in a day. LPA interviewed four (4) out of five (5) residents that receives incontinence care from the staff denied the allegation by stating that their incontinence needs are met by staff changing them frequently and never ran out of incontinence supplies and wipes. Four (4) out of (5) residents stated that there can be times when there is a delay and wait from five (5) minutes to one (1) hour to be changed. However, four (4) out of five (5) residents stated that the staff does change their diapers throughout each day, kept dry, and are not kept wet. Four (4) out of five (5) residents stated that they understand that when staff are helping another resident, there can be a delay but stated that most of the time the residents wait for a short time and longer wait times does not occur frequently. LPA attempted to interview an additional one (1) resident that receives incontinence care but was unable interview that resident since the resident could not answer the LPA’s questions. LPA interviewed an additional two (2) residents that could not confirm nor deny the allegation since they only receive incontinence supplies from the facility and change their diapers by themselves. However, those two (2) residents stated that the facility always provides them with the incontinence supplies. Those two (2) residents also stated that whenever the facility ran out of the incontinence supplies, the staff immediately re-stock and provide incontinence supplies to them on that same day. LPA took a tour of the facility and observed that there were sufficient incontinence supplies and wipes. LPA also observed that the bedrooms of the six (6) out of six (6) residents that received incontinence care were free of odors from incontinence. [Continue to LIC9099-C] LPA reviewed the facility’s Shift to Shift Report which notes routine two (2) hour checks and which residents’ diapers were changed. LPA reviewed Staff training on Incontinence Care dated 08/22/2025. There is not enough supportive evidence to concur with the reported allegation. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations 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 allegations are UNSUBSTANTIATED. An exit interview was held, and a copy of this report was provided to the Administrator, Bryanna Luke.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 28-AS-20260206161143

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit. LPA met with Administrator Bryanna Luk and discussed the purpose of the visit. The facility is licensed to care for elderly residents age range 60 and over, 97 non-ambulatory, of which 30 may be bedridden and a hospice waiver for 30 has been approved. On today's date, the LPA observed and reviewed the following seven (7) Compliance and Regulatory Enforcement (CARE) tool domains: Infection Control, Operational Requirements, Physical Plant/Environmental Safety, Resident Rights/Information, Planned Activities, Food Services, and Disaster Preparedness. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an updated Infection Control Plan. Staff are adhering to infection control requirements. Operational Requirements: A fire clearance is in place. Hospice Waiver for 30 is approved. Valid Liability Insurance is in place. Valid Surety bond is in place. Last Fire Drill was conducted on 01/27/2026. Physical Plant/Environment Safety: The facility is a single-story building which consist of reception area, large dining area, forty-nine (49) resident bedrooms, administration office, business office, medication room, kitchen, storage room, cooler, electrical room, conference room, janitor's room, salon and outdoor seating/smoking areas. The interior and exterior physical plant was inspected. Kitchen was inspected, knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. LPA toured random resident rooms which were newly painted and observed each bedroom to contain the required furniture and linens. Bathrooms were observed to be clean. The signal system was tested in various locations and is operable. [Continue to LIC809-C] The fire extinguishers were observed to be fully charged and in compliance. Exit doors are free of any obstruction and there are no pools or large bodies of water. There are no security bars or weapons on the premises. Five (5) fire extinguishers were fully charged and last inspected on 03/24/2025. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in eight (8) random rooms (#9, #13, #24, #27, #34, #40, #42, #46) and the community shower room and the readings vary between 91.2 deg F to 132.6 deg F which did not meet the required 105 - 120 deg F stated in Title 22 regulations. Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Facility provides equipment and space to accommodate both outdoor and indoor activities. LPA observed a monthly activity calendar. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. $ 250.00 Civil Penalty is being issued during today's visit as a result of a repeat violation within a 12-month period ( 87303(e)(2) ). LIC421FC provided to the Administrator during today's visit. ***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection at a later date.*** Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the as provided to the Administrator, Bryanna Luke.the state’s words, verbatim · CDSS document, Feb 12, 2026

Allegation investigated: Staff do not ensure the facility is in good repair. Staff do not provide towels to dry hands in the bathroom.

Licensing Program Analysts (LPA) Daniel Konishi conducted an unannounced initial 10-Day complaint visit to investigate the above allegations. LPA met with Bryanna Luke, Administrator and explained the purpose of the visit. The investigation consisted of the following: LPA obtained and reviewed the staff & resident rosters. LPA also obtained Resident #8 (R8’s) copy of the Admission Agreement. LPA interviewed the Administrator, Maintenance Director, Staff #1 (S1) - Staff #6 (S6), and Resident #1 (R1) - Resident #7 (R7). The investigation revealed the following: In regards to the allegations "Staff do not ensure the facility is in good repair." It is alleged that the facility has ceiling tiles that have fallen and when it rains the staff are putting buckets in the hallway to catch the water and the ceiling tiles have not been fixed. LPA interviewed the Administrator, Maintenance Director and six (6) out of six (6) staff that denied the allegation stating that there are no leaks and any leaks are fixed right away. [Continued in LIC9909-C] Unsubstantiated Administrator stated that the leaks were reported to the Maintenance Director on 01/05/2026 and was repaired on 01/05/2026 but buckets and yellow warning signs were placed as a safety measure until the rain stopped. LPA interviewed five (5) out of seven (7) residents that denied the allegation who all stated they didn't observe any leaks. LPA interviewed two (2) out of seven (7) residents could not confirm nor deny the allegation stating that there were leaks from the ceiling hallways but stated that there were buckets and yellow warning signs until the leaks stopped. LPA observed minimally damaged ceiling tiles and no leaks during the tour of the facility. There is not enough supportive evidence to concur with the reported allegation. Allegation: “Staff do not provide towels to dry hands in the bathroom.” It is alleged that the bathrooms for the residents have empty paper towel dispensers and the residents must take their own towels with them to the bathroom to dry their hands. LPA toured common bathrooms and seven (7) residents’ bathrooms. LPA observed sufficient paper towels in towel dispensers in the common bathrooms. However, LPA observed cloth hand towels hanging but no paper towels in the towel dispensers in four (4) out of seven (7) residents’ bathrooms. LPA observed no towel dispensers but cloth hand towels hanging in three (3) out of seven (7) residents’ bathrooms. LPA interviewed the Administrator and five (5) out of seven (7) staff that denied the allegation stating that the facility provides cloth towels since paper towels have been thrown in the toilets frequently causing the drains to be clogged. Per Administrator, the facility does keep a sufficient supply of paper hand towels which the facility provides when it’s requested by residents. Two (2) out of seven (7) staff could not confirm nor deny the allegation since they are not involved in this matter. LPA also observed sufficient cloth paper towel and paper towel supply in the facility storage room. LPA interviewed one (1) out of seven (7) residents that corroborated with the allegation stating on not being provided a paper or cloth towel and the resident reported to a staff that resident was unable to identify. LPA interviewed one (1) out of seven (7) residents that corroborated with the allegation stating that they are not provided paper or cloth hand towels but they did not report this to staff. LPA interviewed five (5) out of seven (7) residents that denied the allegation stating the staff provides cloth or paper hand towels and would get the clean cloth towels frequently. There is not enough supportive evidence to concur with the reported allegation. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations 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 allegations are UNSUBSTANTIATED. An exit interview was held, and a copy of this report was provided to Administrator, Bryanna Luke.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 28-AS-20260112082142

Allegation investigated: Staff consumed alcohol and drugs during work hours, impairing their ability to provide adequate care and supervision which presents a risk to residents Staff provided resident with alcohol and drugs Staff did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Daniel Konishi conducted a unannounced 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Resident Care Director, Maria Razo. The investigation consisted of the following: LPA reviewed and requested copies of Former Resident #1 (R1’s) file documents such as Face Sheet, Physician's Report, Appraisal/Needs and Services Plan, House Rules, and other pertinent documents. LPA also obtained the Staff & Resident Roster, and staff in-service training documents. LPA toured the facility and LPA interviewed Resident #1 (R1) to Resident #8 (R8), and Staff #1 (S1) to Staff #6 (S6). [Continue in LIC9909-C] Unsubstantiated The investigation revealed the following: in regard to the allegation "Staff consumed alcohol and drugs during work hours, impairing their ability to provide adequate care and supervision which presents a risk to residents", it is alleged that about one to two years ago, the front desk staff and the administrator drank alcohol and did drugs while working. LPA interviewed R1 which corroborated the allegation by stating witnessing the front desk staff and administrator smoking marijuana and consuming alcohol. However, R1 stated not remembering when this occurred and could not provide any witnesses. Per Resident Care Director’s interview, R1’s moved out on 05/09/2024. LPA interviewed an additional seven (7) residents that denied the allegation stating not witnessing the front desk staff and the administrator and any other staff consume alcohol or do any drugs at the facility. LPA interviewed six (6) out of six (6) staff denied the allegation stated not witnessing the front desk staff, the administrator, or any staff consume alcohol and do drugs at the facility. Six (6) out of six (6) staff also stated not consuming alcohol and not do any drugs at the facility. There is not enough supportive evidence to concur with the reported allegation. Allegation: “Staff provided resident with alcohol and drugs”, it is alleged that about one to two years ago, the front desk staff gave R1 marijuana and alcohol. LPA interviewed R1 that corroborated with the allegation stating that the front desk staff handed R1 marijuana and alcohol. However, R1 was unable to provide any witnesses and could not remember when the incident occurred. LPA interviewed an additional seven (7) residents that denied the allegation stating not witnessing the front desk staff and any other staff give any alcohol or drugs to a resident. LPA interviewed six (6) out of six (6) staff that denied the allegation stating that they have not witnessed any front desk staff or other staff provide alcohol and drugs to R1 and any other resident. LPA reviewed staff in-service training on Safety and Supervision dated 01/16/2025 in file. There is not enough supportive evidence to concur with the reported allegation. Allegation: “Staff do not safeguard resident's belongings.” It is alleged that when R1 moved out, R1’s belongings were missing which were five (5) zippered bags, computer, microwave, TV, refrigerator, and coffee maker. LPA interviewed R1 that corroborated with the allegation stating that belongings were missing and stolen by the staff and indicated the following items missing which included five black garbage bags, microwave, TV, computer, and a refrigerator. R1 stated not remembering when this incident occurred. Additionally, R1 did not provide any evidence and did not provide any witnesses stealing the missing items. LPA attempted to interview R1’s former roommate but was unable since R1’s former roommate no longer resides at the facility. LPA reviewed R1’s file and observed the LIC621 Resident Personal Property and Valuables form is blank and signed by R1 stating that R1 waives the right to complete this form. Per Resident Care Director interview, R1 moved out on 05/09/2024 and R1’s remaining belongings were transferred to R1 by staff from the new home. LPA interviewed an additional six (6) residents that denied the allegation stating that their belongings are kept safe and secure and have not been stolen by staff or gone missing. These additional six (6) residents also stated that they have not witnessed any staff stealing other residents’ belongings at the facility. LPA interviewed an additional one (1) resident that could not confirm nor deny the allegation as they stated their belongings were missing in the past but could not provide any evidence to confirm that the staff stole their belongings. LPA interviewed six (6) out of six (6) staff that denied the allegation stating that they have not stolen R1’s or any other resident’s missing belongings. Six (6) out of six (6) staff stated they did not witness any staff stealing R1’s or any other residents’ belongings. LPA also reviewed staff in-service training on Personal Rights dated 10/27/2025 and Abuse Reporting dated 08/22/2025 in file. There is not enough sufficient evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 allegations are UNSUBSTANTIATED. An exit interview was held, and a copy of this report was provided to the Resident Care Director, Maria Razo.the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 28-AS-20251223151118

Allegation investigated: Facility staff did not provide adequate supervision, resulting in non-consensual sexual behavior amongst residents.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit regarding the above mentioned allegation. LPA met with Administrator, Bryanna Luke and explained the purpose of the visit. This investigation was conducted by Investigator Santana with the Investigations Branch and consisted of the following: On 08/21/2025 and 09/15/2025, LPA Pena conducted a tour of facility and common areas, obtained a copy of the Staff and Resident rosters, Facility sketch, House rules, Home Health Notes, pertinent files for Resident #1 (R1) - Resident #2 (R2), Unusual Injury/Incident Reports (May - Aug 2025), Nurse's Notes, SOC341 (08/21/2025), R1’s hospital discharge records and Pasadena Police Dept report #2025-65144. During today's visit, LPA obtained a copy of the Staff and Resident rosters, delivered findings and issued a separate Case Management-Deficiencies. ******CONTINUED ON LIC9099-C***** Unsubstantiated This investigation was completed by Investigator Santana with the Investigations Branch and revealed the following: Allegation: Facility staff did not provide adequate supervision, resulting in non-consensual sexual behavior amongst residents. It is alleged that R1 was inappropriately touched on their private parts by R2 in the dining room on 08/08/2025 because of neglect/lack of supervision at the facility. Interviews and surveillance video made it clear that during R1’s month-long stay at the facility, that R2, who was not cognitively impaired, was romantically pursuing R1, who had dementia. It was also known to facility management that R2 had a history of allegedly making unwanted physical contact with female residents. Staff members witnessed two incidents on 8/01/2025 and 8/07/2025 in which R2 touched R1's thigh and both incidents were reported to facility management. Despite these witnessed incidents, no available facility surveillance footage of the dining room showed R2 touching R1’s breasts or groin. Furthermore, interviewed witnesses were unable to identify the location of the alleged incident, and the claimed witness denied seeing anything. Interview conducted with R1 revealed that there were 2-3 times when R2 touched them inappropriately, however, R1 was unwilling to provide further details. Pasadena Police Department took a report but did not investigate further. As a result, the allegation that R2 touched R1's breasts and/or groin is therefore Unsubstantiated. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. 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. Exit interview conducted and a copy of this report was provided to Bryanna Luke, Administrator.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 28-AS-20250820145116

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a complaint visit (Complaint Control # 28-AS-20250820145116). The purpose of this visit is to issue deficiencies that were reported by IB Investigator Santana at Investigations Branch. The reason for the Case Management - Deficiencies was explained to Administrator Bryanna Luke. IB investigation revealed that on 8/07/2025, R2 inappropriately touched and kissed R1’s face, which was seen in facility surveillance footage, actions which were a result of facility neglect/lack of supervision. Prior to this, several staff members had been informed that R2 had made unwanted physical advances toward two other female residents, making them feel uncomfortable. R2 was verbally told to stay away from these residents, but no written warning was issued. On 8/01/2025, a staff member observed R2 also touched R1’s thigh, and the facility’s only response was to tell R2 to stay away from R1, without informing R2's case manager or increasing supervision. After the 8/07 incident, R2 was verbally warned again, but not followed by outside notifications, written warnings, or one-on-one supervision. It is possible that if the above additional measures had been implemented after 8/01/2025, the 8/07/2025 incident could have been prevented. It has been determined that R1’s personal rights were violated as a result of facility’s neglect/lack of supervision. Deficiencies noted on LIC 809D. Exit interview, a copy of this report along with the appeals rights were provided to Bryanna Luke, Administrator.the state’s words, verbatim · CDSS document, Oct 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 27, 2025

Additional Personal Rights of Residents in Privately Operated Facilities.. (a) In addition to the rights listed in Section 87468.1,..... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) 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 as evidenced by: Based on investigation conducted by Investigation Bureau, it was determined that facility’s neglect/lack of supervision and additional measures, allowed R2 to make unwanted physical advances toward R1 and other female residents which poses an immediate risk to the health, safety, or personal rights to residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Administrator shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87468.2 and retrain all staff on the same regulation. Proof of staff training and the written plan must be submitted to CCL/LPA by POC due date.

Allegation investigated: Resident was not accorded dignity during an interaction with staff while in care. Licensee did not ensure that resident had access to a call pendant while in care. Licensee did not ensure that resident was provided a comfortable environment while in care. Staff member did not accord privacy to resident in care.

Licensing Program Analyst (LPA) Daniel Konishi conducted a unannounced 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator, Bryanna Luke. The investigation consisted of the following: LPA reviewed and requested copies of Resident #1 (R1) file documents such as Face Sheet, Physician's Report, Appraisal Services and Needs Plan. LPA also obtained the Staff & Resident Roster, and staff in-service training document. LPA also interviewed Resident #1 (R1) to Resident #6 (R6), the Administrator, and Staff #1 (S1) to Staff #4 (S4). The investigation revealed the following: in regard to the allegation "Resident was not accorded dignity during an interaction with staff while in care", it is alleged that on 10/16/2025, S1 entered R1’s bedroom and pressed R1’s body in bed by climbing on top of R1 and put S1’s weight on R1 pressing hard on R1’s hip while reaching for R1’s controller that fell on the floor. Unsubstantiated LPA interviewed R1 which corroborated the allegation by stating that R1 went on top of S1’s body pressing on R1’s hip. LPA interviewed five (5) out of six (6) residents that denied the allegation stating there have been no staff that have ever conducted in going over their bodies while in bed and have not witnessed any staff that ever went over another resident’s body while in bed. LPA interviewed S1 and S1 denied the allegation indicating that they never went on top of R1 during the incident. The Administrator and an additional three (3) out of three (3) staff denied the allegation stating that staff does not conduct unwanted touching and does not climb on top of resident’s bodies while resident is lying on the bed. Facility suspended S1 pending an internal investigation. S1 was suspended between 10/18/2025 to 10/20/2025 . S1 returned to work on 10/21/2025 as facility’s investigation did not reveal any evidence that this incident occurred between S1 and R1. There is not enough supportive evidence to concur with the reported allegation. Allegation: “Licensee did not ensure that resident had access to a call pendant while in care”, it is alleged that S1 purposely dropped R1’s call pendant / remote and R1 was unable to retrieve it because it fell on the floor. LPA interviewed R1 did not corroborate the allegation stating that the remote for the bed accidentally fell while R1 was being changed and S1 helped pick it up. LPA confirmed that the remote is not a call pendant but rather a remote for the bed. LPA interviewed five (5) out of six (6) residents that denied the allegation stating on having access to call pendants. LPA interviewed the Administrator, four (4) out of four (4) staff that denied the allegation stating that all residents have access to call pendants. One (1) out of four (4) staff stated that the pendant was not dropped on purpose and it was accidentally dropped on the floor retrieved by the staff slightly moving the bed. There is not enough supportive evidence to concur with the reported allegation. Allegation: “Licensee did not ensure that resident was provided a comfortable environment while in care” and “Staff member did not accord privacy to resident in care”, it is alleged that during the incident, S1 allegedly climbed on top of R1, S1 alleged removed all the clothing of R1. It is also alleged that R1 had to spend the night in cold temperatures. It is alleged that R1’s roommate was laughing at the interaction with S1 making R1 feel uncomfortable. LPA interviewed R1 who denied the allegation stating not being laughed from S1 and R1’s roommate during the interaction. LPA interviewed S1 that denied the allegations stating that R1 was changed and was not kept in the cold overnight. LPA also interviewed five (5) out of six (6) residents that also denied the allegation stating extra blankets are provided to help if it is cold. Six (6) out of six (6) residents also denied the allegation by stating that the staff accord privacy such as when being changed. LPA interviewed the Administrator, four (4) out of four (4) staff that denied the allegation stating that R1 was not kept overnight in cold temperatures. The Administrator and one (1) out of four (4) staff stated that R1 was changed and extra blankets were provided during cold temperatures. LPA toured the facility and observed extra blankets and linens in a locked storage area. The Administrator and four (4) out of four (4) staff also stated that they accord residents’ privacy when they are changing the residents by either closing the door or having that resident only in the room. Administrator and four (4) out of four (4) staff also stated that residents’ roommate are asked to briefly leave the room until the changing is done. LPA also reviewed records on Staff In-service training on Abuse Reporting in file. LPA also reviewed reports that the R1 will be provided care from a different care staff going forward. There is not enough supportive evidence to concur with the reported allegation. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 allegations are UNSUBSTANTIATED. An exit interview was held, and a copy of this report was provided to the Administrator, Bryanna Luke.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 28-AS-20251020094420

Allegation investigated: Staff are not properly intervening between residents altercations

Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Administrator, Bryanna Luke. On 09/02/2025, the initial investigation visit was conducted. The investigation consisted of the following: LPA reviewed and requested copies of Resident #2 (R2), Resident #3 (R3), Resident #4 (R4's) file documents such as Face Sheet, Physician's Report, Admission Agreement, Appraisal Services and Needs Plan, House Rules, Personal Rights. LPA also obtained the Staff & Resident Roster, and staff in-service training document. LPA also interviewed Resident #1 (R1) to Resident #8 (R8), the Administrator, and Staff #1 (S1) to Staff #4 (S4). On 09/15/2025, LPA obtained Special Incident Reports dated 08/28/2025 and 08/30/25 from the Administrator by fax. Unsubstantiated During today's visit, LPA obtained the following documents: staff and resident rosters and documents from R1 to R4’s files. LPA interviewed Resident #9 (R9) to Resident #10 (R10). LPA re-interviewed R1, R2, and the Administrator. The investigation revealed the following: in regard to the allegation "Staff are not properly intervening between residents’ altercations", it is alleged that R1 is being verbally harassed by R2 since June of 2025 with constant requests for favors, physical assistance, and money. It is also alleged that R2 also blocks R1's access to R1’s drawers and R2 makes loud noises when R1 is trying to sleep. R2 has also been observed in various stages of undress and has made unwanted sexual advances toward the R1. It is also alleged that R1 is sexually harassed by R3 and R4 by making unwanted sexual advances towards R1 since June 2025. R1 and three (3) out of ten (10) residents interviewed corroborated with the allegation but stated that inappropriate interactions were not reported to the staff. However, R1 and one (1) out of ten (10) residents stated that after the police visited the facility, R3 has stopped engaging in inappropriate interactions. R2 denied the allegations stating on not making unwanted sexual advances, verbally harassing R1, or asking to borrow money from R1. R3 and R4 interviewed both denied the allegations and stated never inappropriately touching nor making any inappropriate comments to R1 or other residents. LPA interviewed the Admin, and three (3) out of four (4) staff and stated that staff intervene, separate, and re-direct in residents’ altercations. The Administrator and three (3) out of four (4) staff interviewed did not witness R2, R3, or R4 verbally harass or make unwanted sexual advances towards R1. LPA received written documentation dated 8/21/2025 that R1 did not feel uncomfortable when interacting with R3 and the report indicated that R1 witnessed R3 touching another resident’s arm. Per administrator, R1 moved to a different room on 08/28/2025. Based on Special Incident Reports dated 8/28/2025 and 8/30/2025 indicates R4 being verbally aggressive and staff verbally warned R4. LPA interviewed the Administrator, three (3) out of four (4) staff are aware of R3 and R4 has made inappropriate comments and unwanted advances toward other residents. LPA received documentation dated 08/27/2025 in which it states to ensure resident safety, all management and staff are made aware of the incident regarding R3 who was placed on a 24-hour watch and provided additional staffing to ensure adequate supervision. To prevent further incidents, R3 has been lowered to 15-minute checks. Meeting with Management was also held with R3 and per Resident Care Director, R3 understands the severity of the situation. LPA requested documentation on staff training and Administrator provided in-service staff training conducted on 08/22/2025 on Abuse Reporting. LPA asked the Administrator for documentation in R3 and R4’s files of any written warnings for making inappropriate behaviors and unwanted advances to other residents and violating House Rules or 30-Day eviction notices. Administrator provided a written warning dated 09/15/2025 which indicates R4 violating House Rules that continued violations may result in disciplinary action, up to and including discharge from the facility. Administrator also provided a written warning dated 09/15/2025 which indicates R3 violating House Rules that continued failure to respect personal boundaries may result in further action, including behavior contracts, meetings with facility leadership, or reconsideration of R3’s continued residency. Regarding issuing a 30-day eviction notice, Administrator stated that the facility is taking precautions actively communicating with R3 and R4’s Assisted Living Waiver Program Case Managers for guidance and ensuring that they have credible reasons to issue the 30-day eviction notice. At this time, Administrator believes that the facility should not issue a 30-day eviction notice to R3 and R4. There is not enough supportive evidence to concur with the reported allegation. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 allegations are UNSUBSTANTIATED. An exit interview was held, and a copy of this report was provided to the Administrator, Bryanna Luke.the state’s words, verbatim · CDSS document, Sep 19, 2025 · control 28-AS-20250827141339

Allegation investigated: Resident sustained unexplained injury while in care due to staff neglect.

Licensing Program Analyst (LPA) Bennette Penai conducted a subsequent complaint visit regarding the above allegation. LPA discussed the purpose of the visit with Administrator, Bryanna Luke. The investigation consisted of the following: On 08/21/2025, LPA conducted a tour of facility and common areas and obtained a copy of the Staff and Resident rosters, facility sketch, pertinent files for Resident #1 (R1) - Resident #2 (R2), Unusual Injury/Incident Reports (SIR) (May - Aug 2025). Administrator provided a copy of the completed SOC341 (dated 08/21/2025) and Pasadena Police Dept report #2025-65144. LPA also requested House rules, Home Health Notes and Nurse's Notes for R1-R2. During today's visit, LPA obtained a copy of the Staff and Resident rosters, Unusual Injury/Incident Reports (July-Aug 2025) for R1 and reviewed pertinent files for R1 including nurses notes and hospital discharge records. LPA also interviewed Staff #1 (S1) - Staff #4 (S4) and Resident #2 (R2) - Resident #10 (R10). R1 is currently in the hospital, therefore not interviewed. ******CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: Allegation: “Resident sustained unexplained injury while in care due to staff neglect.” It is alleged that R1 has dementia and frequently falls several times a day, including an unwitnessed fall on August 11, 2025, resulting in left hand injury. (4) out of (4) staff interviewed stated that caregivers conduct routine checks every 2 hours or more often if needed. However, R1 requires a higher level of care or 1:1 supervision because of their medical condition and R1 does not have a one-on-one caregiver. Staff interviewed stated that when R1 had an unwitnessed fall on 08/11/2025, a med tech was called by a caregiver who immediately assessed R1, provided first aid and sent R1 to the hospital, where R1 stayed until August 15, 2025, and received stitches for the injury. Additionally, staff interviewed stated they also provided fall mats to R1 and increased their physical therapy sessions to help prevent R1 from falling and sustaining injuries. All (9) residents interviewed denied the allegation, while (7) of the (9) were unaware of the incident. (3) out of (9) interviewed residents experienced a fall and stated the staff conducted body checks, assessed and attended to them. Residents interviewed also stated that staff conduct routine checks daily. Therefore, there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. 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. Exit interview conducted and a copy of this report was provided to Bryanna Luke, Administrator.the state’s words, verbatim · CDSS document, Sep 15, 2025 · control 28-AS-20250820145116

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a complaint visit (Complaint Control # 28-AS-20250820145116). The purpose of this visit is to issue deficiencies that were observed by LPA that are not part of the complaint allegation. The reason for the Case Management - Deficiencies was explained to Administrator Bryanna Luke. During the complaint visit on 09/15/2025, LPA discovered that Resident #1 (R1)'s several unwitnessed fall incidents including those that happened on 08/10/2025, 08/11/2025 and 08/28/2025, resulting in injuries and required emergency visit/hospitalization were not faxed to Community Care Licensing (CCL). Interviews with the Administrator and Staff #2 (S2) confirmed that the incident reports were not faxed to Community Care Licensing (CCL) due to a broken fax machine. Additionally, the Administrator and S2 acknowledged R1's frequent falls and the need for a higher level of care or 1:1 supervision, however, a re-appraisal to assess R1’s condition was not completed. Deficiencies noted on LIC 809D. Exit interview, a copy of this report along with the appeals rights were provided to Bryanna Luke, Administrator.the state’s words, verbatim · CDSS document, Sep 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 15, 2025

87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports..(1) A written report... for the resident within seven days of the occurrence of any of the events specified...report shall include the resident's name, age, sex and date of admission; date and nature of event;....(D) Any incident which threatens the welfare, safety or health of any resident..... This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which R1's unwitnessed fall incidents that happened on 08/10/2025, 08/11/2025 and 08/28/2025, resulting in injuries and hospitalization were not submitted and faxed to CCL which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Administrator agreed to comply with Title 22 Regs. Reporting requirements and will fax the incident reports for R1 on 08/10/2025, 08/11/2025 and 08/28/2025 to CCL/LPA today, 09/15/2025. ****DEFICIENCY CLEARED DURING THE VISIT.*****

From the deficiency page — Deficiency type: Type B · Section cited: HSC87463(b)(1) · Plan of correction due date: Sep 29, 2025

87463 Reappraisals...(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition.... (1) Significant changes in condition, as defined in Section 87101, Definitions, include, but are not limited, to:.. This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which a re-appraisal to assess R1’s condition was not completed which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Administrator will ensure to comply with Title 22 reg 87463 regulation requirement to conduct reappraisals when there has been a change in residents' mental, medical or social condition. Administrator to submit self-certification that she read, reviewed and understood the regulation and submit it to LPA/CCL by POC due date.

Allegation investigated: Staff do not ensure residents medical needs are met

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Bryanna Luke, Administrator and explained the purpose of the visit. The investigation consisted of the following: LPA obtained and reviewed the staff & resident rosters, and Resident (R1's) file such as: Face Sheet, Admission Agreement, and Physician's Report. LPA interviewed the Administrator, Staff (S1) and Resident (R1) - Resident (R5). Interview was conducted telephonically with Wound Care Specialist. The investigation revealed the following: In regards to the allegation Staff do not ensure residents medical needs are met, based on interviews conducted and information gathered it was revealed by the Wound Care Specialist that visits are done every Monday and Wednesday at the facility and Resident R1 is being treated for wounds on the leg and face. Unsubstantiated Stated several times Resident R1 refused to leave the facility to see a specialist as was advised. Resident R1 just wants cream on it. Said Resident R1 is self responsible and has gone to the hospital before and they don't keep him. Stated Resident R1 manages own care and can't force to leave the facility. Said the staff are doing a good job providing care for Resident R1. Spoke with Resident R1 who stated that he will refuse care. Said he doesn't want to lose Pasadena Villa as his home. Stated previously staff said it would be quick and he was in the hospital for months. Said he needs a place to pray and other facility's won't allow it. Stated he doesn't want staff to give medical attention because he doesn't want to leave here, but they will try to help and assist medically. Staff stated that the Wound Care Specialist comes to the facility on Monday and Wednesday. Stated they do try to assist with medical attention, but Resident R1 refuses with the facility and the Wound Care Specialist. Said 911 is for emergency and Resident R1 is self responsible and does not want to leave to see a specialist. Wound Care Notes were documented and reviewed and specified 2 days a week visits for Resident R1. Spoke with Resident's R1- R5 who all stated that staff will provide medical attention when they need it. Stated staff assist right away if they need 911 or to go to the hospital. 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 allegations are UNSUBSTANTIATED. An exit interview was held,the state’s words, verbatim · CDSS document, Aug 12, 2025 · control 28-AS-20250805122051

Allegation investigated: Staff did not provide resident monthly allowance. Staff handled resident in a rough manner.

Licensing Program Analysts (LPA) Daniel Konishi conducted an unannounced initial complaint visit to investigate the above allegations. LPA met with Bryanna Luke, Administrator and explained the purpose of the visit. The investigation consisted of the following: LPA obtained and reviewed the staff & resident rosters, valid surety bond, staff in-service training (Residents' Rights, Mandated Reporter Elder Abuse Prevention), and Resident #1 (R1) files such as: Face Sheet, Admission Agreement, and Physician's Report, Rent Invoice (Nov 2024 – August 2025). LPA interviewed the Administrator, Staff #1 (S1) - Staff #6 (S6), and Resident #1 (R1) - Resident #11 (R11). The investigation revealed the following: In regards to the allegations "Staff did not provide resident monthly allowance." It is alleged that R1 is entitled to receive a $177 monthly personal allowance for clothing/toiletries, provided through R1’s insurance but it has been reported that R1 has not received this allowance from the senior living facility. Unsubstantiated Based on staff interview, the Administrator, business office manager, and five (5) out of five (5) staff denied the allegation. The Administrator and the business office manager stated that when the rent is paid under the assisted living waiver program, there is an amount left for money allowance. However, the facility has not received any rent from R1 from November 2024 to August 2025. Therefore, there is no money allowance. One (1) out of eleven (11) residents corroborated with the allegation. R1 stated that the insurance is R1’s payee and that they are responsible to pay for rent. Unfortunately, R1 could not provide any documents of R1’s insurance information. Based on interview, five (5) out of eleven (11) residents receive money allowance and reported having no issues or problems with receiving money allowance. Based on interview, five (5) out of ten (11) residents reported not receiving money allowance and getting funds from other personal means. There is not enough supportive evidence to concur with the reported allegation. Allegation: “Staff handled resident in a rough manner.” It is alleged that staff struck a resident while changing the resident’s incontinence brief. One (1) out of eleven (11) residents corroborated the allegation. R1 stated on witnessing other residents got hit by care staff. LPA asked when these incidents occurred and R1 stated that the incidents occurred on Dec 2024 and January 2025. R1 did not report these incidents to the staff. When R1 named the residents that R1 witnessed getting struck by staff, R1 named a resident that no longer lives at the facility. LPA interviewed another resident that R1 named and that resident did not report getting struck by staff. Ten (10) out of eleven (11) residents denied the allegation. Based on staff interview, the Administrator and six (6) out of six (6) staff denied the allegations stating they have not witnessed nor themselves hit or push any resident while providing care. Based on staff interview, the Administrator stated that there are no staff that have been verbally or received a written warning for striking or hitting a resident. LPA obtained and reviewed ongoing staff in-service trainings on resident rights held on 1/7/2025 and mandated reporting elder abuse held on 3/18/2025. There is not enough supportive evidence to concur with the reported allegation. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 allegations are UNSUBSTANTIATED. An exit interview was held, and a copy of this report was provided to the Resident Care Director, Maria Razo.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 28-AS-20250728185724

Allegation investigated: Facility staff did not assist resident with obtaining medical care. Facility staff did not dispense medications as prescribed. Facility staff did not provide meals to resident. Facility staff did not provide drinking water to resident.

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced subsequent 10-day complaint visit regarding the above allegations. The LPA discussed the purpose of the visit with Administrator, Bryanna Luke. On 08/01/2025, the initial investigation visit was conducted. The investigation consisted of the following: LPA requested the Staff & Resident Roster. LPA also interviewed Resident #1 (R1) to Resident #9 (R9), the Administrator, and Staff #1 (S1) to Staff #5 (S5). LPA obtained documents from R1’s file including the face sheet, physician’s report, and special incident reports. LPA also reviewed a random sample of six (6) resident's medications. On 08/04/2025, LPA interviewed the Resident Care Director over the phone and requested R1’s medication administration record (May 2025, June 2025, July 2025) and Wound Care Progress Notes. LPA interviewed Witness #1 (W1) over the phone. Unsubstantiated During today's visit, LPA obtained the following documents: Staff and Client roster. LPA interviewed Witness #2 (W2) over the phone. The investigation revealed the following: in regards to the allegation: “Facility staff did not assist resident with obtaining medical care.” It is alleged that R1 had an untreated foot infection and several medical complaints that were often ignored by staff. One (1) out of nine (9) residents interviewed corroborated with the allegation. Eight (8) out of seven (9) residents interviewed denied the allegation. The Administrator and five (5) out of five (5) staff, W1, and W2 interviewed all denied the allegation. Based on staff interview, the Resident Care Director stated that R1’s foot infection is currently being treated by a wound care nurse that visits R1 twice a week. Based on record review, the wound care progress notes confirms that the wound care nurse has visited twice a week in June 2025 and July 2025 to help treat R1’s foot. Based on the Administrator, the Resident Care Director, and the Witness #1 (W1’s) interviews, physician assistant continues to visit R1 twice a week to treat R1’s foot. Based on interview, W2 stated that the facility staff is appropriately assisting R1 in being provided medical care and also stated that there are no issues. R1 stated on waiting for an oxygen device that hasn’t been provided yet. The Administrator, Resident Care Director, and W2 stated that the oxygen concentrator has been addressed to R1’s home health care and primary care physician and currently in process of providing R1’s request of receiving the oxygen concentrator. There is not enough evidence to substantiate. Allegation: “Facility staff did not dispense medications as prescribed.” It is alleged that the facility staff often neglected R1 for pain medication because staff believes that R1 is seeking pain medication in an attempt to get high. LPA reviewed a random sample of medications of R1 and (5) residents and all medications are given as prescribed. LPA interviewed two (2) staff that help administer and they all denied the allegation. Staff indicated that some staff who assist med techs in passing medications have received medication training. Additionally, staff indicated that they have not received any report or complaint about not dispensing medications as prescribed. LPA interviewed nine (9) out of nine (9) residents that receive medication management care all claim to receive all medication as prescribed from the staff and have never been administered the wrong medications by any staff managers. LPA reviewed R1's medications, Doctor’s Prescription Request, and Medication Administration Record from May 2025, June 2025, and July 2025, all medications are given as prescribed. There is not enough evidence to substantiate. Allegations: “Facility staff did not provide meals to resident,” and “Facility staff did not provide drinking water to resident.” It is alleged that R1 is being neglected by not eating in days and staff refuse to give R1 water. The Administrator and five (5) out of five (5) staff denied the allegations stating that they provide meals and water in the dining hall or deliver the meals and water to the residents’ rooms. The administrator and three (3) out of five (5) staff interviewed stated that drinking water is available all day in the dining hall. Nine (9) out of nine (9) residents interviewed denied the allegation and stated that they are provided meals and drinking water from the facility and the staff have not refused to provide meals or water to them. One (1) out of nine (9) residents stated on buying food from outside of the facility since the resident is dissatisfied with the food being provided at the facility. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 allegations are UNSUBSTANTIATED. An exit interview was held, and a copy of this report was provided to the Resident Care Director, Maria Razo.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 28-AS-20250725111346

Allegation investigated: Staff do not treat residents equally. Staff are mismanaging residents medication.

Licensing Program Analysts (LPAs) Bennette Pena and Gabriela Castro conducted an unannounced initial complaint visit to investigate the above allegations. LPAs met with Luisa Razo, Resident Care Directorr and explained the purpose of the visit. The investigation consisted of the following: LPAs obtained and reviewed the staff & resident rosters, Staff in service training (Residents' Rights), Theft & Loss policy, Unusual Incident/Injury reports related to the complaint and Resident #1 (R1) files such as: Identification/Emergency Information, Admission Agreement, Appraisal Needs/Services Plan, Pre-Appraisal, Physician's Report and Resident Personal Property And Valuables. LPAs interviewed Staff #1 (S1) - Staff #4 (S4), and Resident #2 (R2) - Resident #7 (R7). LPAs attempted to speak with Resident #1 (R1) but unsuccessful due to being out in the community. *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegations "Staff did not safeguard resident's personal belongings." It is alleged that R1 noted missing personal items, and had filed a police report regarding missing items but have not heard back. (3) out of (4) staff members stated that they heard several residents complained about missing items after relocating back to the facility. Staff interviewed stated that they heard an individual trespassed and stole items while he facility was vacant. Another staff interviewed stated that they had seen residents personal belongings outside of the room, not in the bags while the facility was under renovation. (5) out of (6) residents interviewed stated that they had personal items missing like clothing, blankets, shoes. Some residents indicated that they reported it to the Administration but no action was taken. Interviewed residents also indicated that several things were still being found since they had been misplaced. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Administrator, Bryanna Luke along with the Appeals Rights. The investigation revealed the following: In regards to the allegation: "Staff do not treat residents equally." It is alleged that a resident is dissatisfied with the treatment they are receiving and believes staff may demonstrate preferential treatment toward other residents based on race. (4) out of (4) staff interviewed denied the allegation. Some staff interviewed stated that some staff members have difficulty speaking English, but it doesn't impact the care they provide to the residents. Staff interviewed stated that they ensure fair treatment of all residents, regardless of their race. (6) out of (6) residents interviewed stated that they have not seen or experienced staff treating them differently on the basis of their race. Residents interviewed stated that staff treat them fairly and interact with them regularly. Therefore there was insufficient evidence to corroborate with the allegation. In regards to the allegation: "Staff are mismanaging residents medication." It is alleged that there are staff members covering for medication technicians who fail to bring the correct medications but the resident has not expressed any immediate safety concerns at this time. (4) out of (4) staff interviewed denied the allegation. Staff stated that there are sufficient med-techs on hand to administer medications to the residents. Staff indicated that some staff who assist med techs in passing medications have received medication training. Additionally, staff indicated that they have not received any report or complaint about mismanaging residents medication. Residents interviewed stated that while several staff members administer the medication, they are the correct medications. Residents also stated that they had never been administered the wrong medication by any staff members and have no concerns at this time. Therefore there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview was conducted. A copy of this report along was provided to the Administrator, Bryanna Luke.the state’s words, verbatim · CDSS document, Jul 25, 2025 · control 28-AS-20250619090615

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(2) · Plan of correction due date: Aug 8, 2025

(a) The licensee shall ensure an adequate theft and loss program.....(2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property ....The licensee shall.... made reasonable efforts to safeguard resident property ...... to meet each requirement specified in Section 1569.153. This requirement is not met as evidenced by: Based on interviews, Licensee failed to safeguard residents property during the relocation due to fire which poses a potential Health, Safety, and Personal Risk to residents in care.the state’s words, verbatim · CDSS document, Jul 25, 2025

Plan of correction: Licensee/Administrator agreed to establish a plan to address how the facility can properly safeguard residents personal belongings during relocations and renovations. Administrator to send statement stating that they have read, reviewed and understood Title 22 Regs 87218 and submit to CCL/LPA by POC due date.

Allegation investigated: Facility staff are not ensuring that the residents have a place for their belongings. Facility staff are not ensuring that residents have working water.

Licensing Program Analyst (LPA) Daniel Konishi conducted an Initial 10-Day complaint investigation visit regarding the above allegations. The LPA discussed the purpose of the visit with Administrator, Bryanna Luke. The investigation consisted of the following: LPA requested the Staff & Resident Roster. LPA also interviewed Resident #1 (R1) to Resident #6 (R6), the Administrator, and Staff #1 (S1) to Staff #4 (S4), and the maintenance handyman. LPA obtained documents from R1’s file including face sheet, physician’s report, and special incident reports. [Continued in LIC-9099-C] Unsubstantiated The investigation revealed the following: in regard to the allegation, “Facility staff are not ensuring that the residents have a place for their belongings.", it is alleged that R1’s dresser has been broken since April 2025. R1 was informed that the facility will replace the dresser but has not yet been replaced so residents place the belongings on the bed. Six (6) out of six (6) residents interviewed denied the allegation. However, based on resident’s interview, R1 stated that the dresser is not broken but asked for an additional dresser which the resident is waiting to receive from the facility. The Administrator and all four (4) staff interviewed denied the allegation and stated that R1 did not report a broken dresser. Based on the administrator, and one (1) out of four (4) staff interviewed, R1 does not have a broken dresser but asked for an additional dresser since R1 has additional belongings. Based on the interview, the administrator stated that the facility currently provides one (1) dresser. During the physical plant tour, LPA Konishi inspected the dressers in several different resident rooms at random. LPA inspected room #7, Room #8, Room #10, Room #16, Room #21, Room #24, and Room #42 and observed the dressers to be in good condition. Therefore, there is not enough evidence to substantiate the allegation. In regard to the allegation: “Facility staff are not ensuring that residents have working water.” It is alleged that the water on the first floor of the facility has not been working since April 2025, which has required the residents to use the water hose outside to brush their teeth. Five (5) out of six (6) residents interviewed denied the allegation and stated that when the water was shut off it was temporary as the facility was working on plumbing or water-related repairs which only took a few hours to complete. One (1) out of six (6) residents interviewed corroborated with the allegation stating that when the resident’s faucet was being repaired, the resident was unable to go to the alternate restrooms since the door was locked so the resident would use the outdoor hose. The administrator and all four (4) staff interviewed denied the allegation. Based on interview, the administrator stated that the date of the sink not working in R1’s room was reported on 06/18/2025. The administrator stated that the sink in R1’s room was completely repaired and working on 07/09/2025. The administrator and the Maintenance handyman both stated that they were waiting for additional parts to arrive to complete the repair. While the repair was in progress, the administrator stated that R1 had access to multiple bathrooms that were unlocked and near R1’s bedroom. The administrator stated that if the bathroom door was locked, it’s either the bathroom was occupied or the residents can contact the staff to unlock the door. Based on record review, LPA obtained a Special Incident Report dated 06/09/2025, the facility had the water temporarily shut off from 9am to 1pm due to an emergency leak on 06/09/2025. During the physical plant tour, LPA Konishi checked that the bathroom faucets and toilets were working properly in Room#7, Room#8, Room#10, Room#16, Room#21, Room#24, Room#42. LPA also toured the alternate bathroom that the residents have access to and observed that the door is unlocked and available to be used. Therefore, there is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 allegations are UNSUBSTANTIATED. An exit interview was held, and a copy of this report was provided to the Resident Care Director, Maria Razo.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 28-AS-20250707160124

Allegation investigated: Staff do not ensure the facility is properly maintained. Staff do not ensure facility remains free of bad odors.

Licensing Program Analyst (LPA) Daniel Konishi conducted an Initial 10-Day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator, Bryanna Luke. The investigation consisted of the following: LPA requested the Staff & Resident Roster. LPA also interviewed Resident #1 (R1) to Resident #11 (R11), the Administrator, and Staff #1 (S1) to Staff #4 (S4), and the maintenance handyman. The investigation revealed the following: in regard to the allegation " Staff do not ensure the facility is properly maintained.", it is alleged that toilet in Rm#49 has been clogged since 6/27/25, and staff did not do anything to address it. There is a sign on by the bathroom door in Rm#49 that instructs the resident to use the bathroom next to the medication room. It is alleged that the bathroom next to the medication room is locked. One (1) out of eleven (11) residents corroborated with the allegation. Ten (10) out of eleven (11) residents interviewed denied the allegation. Unsubstantiated However, three (3) out of eleven (11) residents interviewed stated that it took a few days to unclog the toilet and that the alternate bathroom they could use while their toilet was clogged was too far from their room. The administrator and all four (4) staff interviewed denied the allegation. The administrator stated that when the clogged toilet was reported to the receptionist on 06/28/2025, the on-duty care staff attempted to unclog the toilet with the toilet on that day but was unable to unclog it. Based on interview, the maintenance facility handyman stated that the toilet was fixed and unclogged on 07/01/2025 and the cause of the clogged toilet was due to excessive paper towels put in the toilet drain. One (1) out of four (4) staff interviewed also stated that the staff have informed the residents to not to put too many paper towels in the toilet. Based on observation, the LPA Konishi checked residents’ bathrooms in Rm#49, Rm#47, Rm#46, Rm#16, Rm#23 and the restrooms were clean and the toilets were all working properly and did not notice any clogged drains, and the facility is properly maintained. There is not enough evidence to substantiate. Allegation: “Staff do not ensure facility remains free of bad odors.” It is alleged that there is a strong odor from Rm#49’s bathroom on 07/02/2025. Ten (10) out of eleven (11) residents interviewed denied the allegation. One (1) out of eleven (11) residents corroborated with the allegation stated that the base of the toilet has a leak that hasn’t been fixed which is causing an odor. However, that resident and one (1) of the staff interviewed both stated that the bathroom is being cleaned daily. The Administrator also stated that the toilets in that bathroom, Rm#23, Rm#46, and other bathrooms will have their wax rings fixed on 7/8/25 which will fix the leak and remove any odors. The Administrator and all four (4) staff interviewed denied the allegation. One (1) out of four (4) staff interviewed stated that the bathroom had an odor when the toilet was clogged but there was no odor after the toilet has been unclogged and the room was aired out. Based on observation, the LPA Konishi checked and detected no bad odors in residents’ rooms and bathrooms in Rm#49, Rm#47, Rm#46, Rm#16, and Rm#23. LPA toured the physical plants including the common areas, activity room, and dining hall and did not notice any bad odors. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegations 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to the Administrator, Bryanna Luke.the state’s words, verbatim · CDSS document, Jul 7, 2025 · control 28-AS-20250702150727

Allegation investigated: Facility staff neglect resulted in resident being hospitalized for sepsis Facility staff did not seek timely medical attention for resident Facility staff did not respond to resident's calls for help Facility staff did not ensure resident's dietary needs were met Facility staff did not report incident to resident's responsible person

On 07/01/25 Licensing Program Analyst (LPA) S Vaid made an unannounced subsequent visit to the facility to conduct further investigations, in response to the above-mentioned allegations. LPA met with the Resident Care Director Maria Razo and explained the purpose for the visit. Administrator Bryanna Luke joined shortly after. The investigation consisted of the following: Review of staff and resident rosters, tour of the physical plant with Administrator and viewed common areas and resident rooms. Interviews with staff and residents. LPA did not observe any immediate health and/or safety concerns. On 10/08/2024, Program Analyst (LPA) Bonnie Tao made an unannounced initial visit to the facility to conduct a Health and Safety check inspection, in response to the above-mentioned allegations. LPA met with Resident Care Director Maia Louisa Razo and explained the purpose for the visit. Investigation consisted of the following: LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas with assistance of staff Maria Razo, and obtained the following documents for Residents# 1-2 (R1-R2): facility records and staff/residents’ rosters. CONTINUED ON 9099C..... Unsubstantiated Regarding the allegation: Facility staff neglect resulted in resident being hospitalized for sepsis. It is alleged that facility staff failed to provide an appropriate level of supervision which resulted in the resident developing sepsis in the facility. According to staff statements (investigated by Real) Five (5) out of five (5) staff deny this allegation. The staff notified the hospice nurse and then called paramedics when hospice nurse was late to show. The staff also informed the family of the resident. Six (6) out of seven (7) residents interviewed could not collaborate the allegation. They had no knowledge. According to the family, resident was on hospice and had a history of non-compliance with dialysis. The hospice nurses and aids that saw the resident at/in the facility on a weekly basis did not observe any neglect or lack of care/supervision. A copy of Residents’ hospital records and hospice records were obtained and had no information to support the allegation. Although the allegation 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. Regarding the allegation: Facility staff did not seek timely medical attention for resident. It is alleged that facility staff neglected to seek timely medical attention and treatment for resident in care. Resident was on hospice for heart failure. According to statements (investigated by Real) Five (5) out of five (5) staff deny this allegation. Facility staff stated, hospice staff visited the resident twice per week. Whenever the resident became ill or developed difficulty the hospice nurse was notified and instruct facility staff to administer supplemental medication, when pain did not subdue the paramedics were called and family is notified, never has the facility staff denied medical treatment for residents in care. Hospice staff interviews and documents reviewed. Hospice records confirm staff reported residents change in condition to hospice and was instructed to utilized supplemental medication, re-assessment of resident conducted by hospice nurse and called for paramedics when pain did not subside. Six (6) out of seven (7) residents interviewed could not corroborate this allegation. According to residents the staff has sought medical attention for residents when residents are in medical need. Although the allegation 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. CONTINUED ON 9099C....... Regarding the allegation: Facility staff did not respond to resident’s call for help. It is alleged that the facility staff did not respond to the resident’s call for help. Six (6) out of six (6) staff interviewed deny this allegation, the staff performs health and safety checks on every resident every 2 hours. Residents under hospice care are frequently checked upon depending on their needs and plan of care. Response times are 3-5 minutes after resident alerts the staff. According to staff, when the resident’ fell ill the staff would notify the hospice nurse and the resident’ would be assessed, supplemental medication would be given to the resident’ by the hospice nurse when resident complained of pain and taken to hospital when supplemental medications were not enough. On 10/02/24, resident was sent to hospital due to developing difficult medical condition, at 2am resident was having difficulty with their medical condition and staff notified the residents’ hospice agency, when hospice nurse failed to show up, the facility called for the paramedics and notified the residents POA. Six (6) out of seven (7) residents interviewed could not collaborate this allegation, according to the residents interviewed they stated the staff is always ready to help them with their health conditions and have responded to their needs for help and contacted their family when change of conditions arise and when they are hospitalized. Based on interviews conducted and records reviewed, although the allegation 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. Regarding the allegation: Facility staff did not ensure resident’s dietary needs were met. It is alleged that the staff are not ensuring resident is getting their dietary requirements as determined by their health professionals. Accordingly, resident does not like the food served and does not eat for days, and the staff does not intervene to solve the situation. Six (6) out of six (6) staff interviewed deny the allegation. According to the staff the residents are served three meals per day along with snacks throughout the day. Residents requiring special dietary as ordered by physicians’ will be served meals prepared within dietary requirements (low sodium, puree). The facility dining offers alternative menu for those residents that do not want the regular menu food(salads/soup/sandwiches), snacks and fruits are available throughout the day. Per physicians report dated 03/14/2022, resident was on special diet. The staff states, they cannot force the resident to eat, they can only reason with the resident’ when resident’ refuses to eat and notify the residents family when this occurs. The staff notified the residents’ POA, hospice nurse(resident on hospice) and licensing department when residents’ refused medications, meals, medical treatments. Six (6) out of seven (7) residents interviewed could not collaborate this allegation. According to residents interviewed, the staff is meeting their dietary needs, residents have menu choices and snacks throughout the day. Some residents have been able to receive special meals when requested ahead of time. CONTINUED ON 9099C............. Bedridden residents are served meals in their rooms. Staff makes meal time headcount to account for all residents served and residents that refuse meals served. Based on interviews conducted, records reviewed, and observations made although the allegation 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. Regarding the allegation: Facility staff did not report incident to resident’s responsible person. It is alleged that the facility staff did not contact residents responsible party when resident had developed difficulty and was sent to hospital. Six (6) out of six (6) staff interviewed deny this allegation, according to the Resident Care Director each time residents that are transported to the hospital the facility staff has notified residents family /POA and incident reports are reported to the State Licensing Department. Unusual Incident reports dated 08/04/23, 09/11/23, 01/29/24 and 10/02/24 staff notified the residents’ responsible party. Six (6) out of seven (7) residents interviewed could not corroborate this allegation. According to residents interviewed, they are not privy to the reporting requirements by the facility, however residents confirmed the staff notifies their family when their condition changes and they are taken to the hospital. A few residents interviewed stated, that their families are contacted whenever changes in their health condition occurs, no matter how least serious. Based on interviews conducted and records reviewed, although the allegation 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. An exit interview was conducted, copy of this report was given to administrator Bryanna Luke. Conducted exit interview with Maria Razo, Resident Care Director. LPA experiencing printer issues, amended copies will be emailed to facility.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 28-AS-20241007160218

Allegation investigated: Staff did not prevent resident in care from engaging in inappropriate interactions with another resident.

Licensing Program Analyst (LPA) Daniel Konishi conducted an Initial 10-Day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Administrator, Bryanna Luke. The investigation consisted of the following: LPA reviewed and requested copies of Resident #1 (R1) and Resident #2 (R2's) file documents such as Face Sheet, Physician's Report, Resident Appraisal, Admission Agreement, House Rules, Personal Rights. LPA also requested the Staff & Resident Roster, Special Incident Report. LPA also interviewed R1 to Resident #8 (R8) and Staff #1 (S1) to Staff #5 (S5). The investigation revealed the following: in regard to the allegation "Staff did not prevent resident in care from engaging in inappropriate interactions with another resident", it is alleged that a R1 is being sexually harassing by R2 by tugging on the R1’s pants and touching bottom of the R1’s body and that the R2 always makes inappropriate comments to R1. Unsubstantiated Four (4) out of five (5) staff denied the allegation. One (1) out of five (5) staff could not confirm nor deny the allegation. Four (5) out of five (5) staff stated that R2 is generally friendly, social, and respectful towards residents and staff. One (1) out of five (5) staff indicated that the Pasadena Police Department visited the facility on June 4th, 2025, to conduct a wellness check for a APS report regarding R1. No arrests were made during this visit by the police. Based on record review, R2’s physicians reported indicate that R2 does not engage in inappropriate behavior. R1 and one (1) resident corroborated with the allegation but stated that inappropriate interactions were not reported to the staff. However, R1 stated that after the police visited the facility, R2 has stopped engaging in inappropriate interactions. R2 denied the allegations and stated on never inappropriately touching nor making any inappropriate comments to R1 or other residents. Four (4) out of eight (8) residents interviewed denied the allegation. Two (2) out of eight (8) residents interviewed indicated that after the police visited the facility to speak with R1, R2’s behaviors of inappropriate comments and touching has stopped. One (1) out of eight (8) residents interviewed stated that R2 made an inappropriate comment once but stated that R2 did not ever inappropriately touch another resident. Based on statements and interviews conducted with staff, residents, review of residents files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to the Administrator, Bryanna Luke.the state’s words, verbatim · CDSS document, Jun 10, 2025 · control 28-AS-20250603144912

Allegation investigated: Staff did not assist residents with obtaining medical care. Staff did not ensure residents had access to personal belongings.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with Maria Luisa Razo (Residential Services) and discussed the purpose of this visit. LPA Irra conducted the initial visit on 04/10/25. During this visit, LPA gained entry to this facility by the contractor. Per Mr. Solorio, there were no staff nor residents present at this location as they have not repopulated back from a sister location (residents were temporarily relocated due to the Eaton Fire). Facility Administrator sent LPA a copy of the staff and resident rosters and documentation pertaining to the above allegations. During the course of this investigation, LPA Irra interviewed Staff #1 (S-1) through Staff #4 (S-4), interviewed Resident #1 (R-1) through Resident #6 (R-6), obtained medical appointment calendars for February 2025 through April 2025 (for resident medical appointments including transportation) and staff notes pertaining to retrieving personal belongings for residents. **Refer to LIC 9099C for the continuation of this report.** Unsubstantiated Allegation: Staff did not assist residents with obtaining medical care. It has been alleged that there were on-going issues with residents not being provided transportation to medical appointments since the temporary relocation. Staff interviews revealed that staff assisted residents with their medical appointments including coordinating round trip transportation services from the temporary relocation to residents’ medical appointments. Per staff interviews, transportation services were coordinated with the residents’ pertaining medical insurance companies. Interviewed staff indicated that a Town Hall meeting was held in February 2025 to discuss this matter. Interviewed staff indicated that they did not receive complaints/concerns pertaining to this matter. Resident interviews revealed that staff assisted residents with scheduling medical appointments and coordinating round trip transportation services. Interviewed residents indicated they did not have any concerns pertaining to this matter. Interviews and documentation do not corroborate this allegation. Allegation: Staff did not ensure residents had access to personal belongings. It has been alleged that residents were not able to access their personal belongings that were left at this facility when residents were relocated. Staff interviews revealed that staff retrieved residents’ personal belongings (upon request from residents) and would retrieve mail once per week at this facility. Interviewed staff indicated that staff would retrieve the items without the residents present due to this facility undergoing construction (due to safety purposes). Interviewed staff indicated that a Town Hall meeting was held in February 2025 to discuss this matter. Interviewed staff indicated that they did not receive complaints/concerns pertaining to this matter. Resident interviews revealed that staff retrieved residents’ personal belongings upon request. Interviewed residents indicated they did not have any concerns pertaining to this matter. Interviews and documentation do not corroborate this allegation. 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. Exit interview conducted, appeal rights and a copy of this report was provided to Maria Luisa Razo.the state’s words, verbatim · CDSS document, May 13, 2025 · control 28-AS-20250403094544

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Assistant Administrator, Maria Luisa Razo and discussed the purpose of the visit. The facility is licensed to care for elderly residents age range 60 and over, 97 non-ambulatory, of which 30 may be bedridden and a hospice waiver for 30 has been approved. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an updated Infection Control Plan. Staff are adhering to infection control requirements. Operational Requirements: Hospice Waiver for 30 is approved. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires on 02/01/2026. Surety bond in the amount of $10,000 is current. Physical Plant/Environment Safety: The facility is a single story building which consist of reception area, large dining area, forty nine (49) resident bedrooms, administration office, business office, medication room, kitchen, storage room, cooler, electrical room, conference room, janitor's room, salon and outdoor seating/smoking areas. The interior and exterior physical plant was inspected. Kitchen was inspected, knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. LPA toured random resident rooms which were newly painted and observed each bedroom to contain the required furniture and linens. Bathrooms were observed to be clean. The signal system was tested in various locations and is operable. The fire extinguishers were observed to be fully charged and in compliance. Exit doors are free of any obstruction and there are no pools or large bodies of water. There are no security bars or weapons on the premises. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in eight (8) random rooms (#4, #6, #17, #18, #37, #39, #40, #42) and the readings vary between 84 deg F to 123 deg F which did not meet the required 105 - 120 deg F stated in Title 22 regulations. *****CONTINUED ON LIC809-C**** Staffing: A total of twenty five (25) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records/Staff Training: LPA reviewed (5) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator and Assistant Administrator's applications were submitted for renewal and currently pending. Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Facility does not have a designated staff member to organize, conduct and evaluate planned activities for residents. Additionally, there is no written calendar of activities provided to the residents. The facility has a Resident Council, but currently no active members involved. Facility provides equipment and space to accommodate both outdoor and indoor activities. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Incidental Medical and Dental: Residents medications were reviewed containing 30-day supply of medications. Medications are centrally stored, properly labeled and are in bubble packs. First aid kits are kept in the facility but are not easily accessible. Resident Records/Incident Reports: Resident files are maintained at the facility. A total of (5) resident files were reviewed. They contained Admission Agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent, Medication Records, and P & I money records. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Residents with Special Health Needs: Currently, (6) residents receive hospice care, of which (1) is being administered oxygen and (2) are bedridden. Half bed rails for mobility assistance were observed in some resident beds. Functional Capability and Preplacement Appraisals are on file. Deficiency issued on LIC809-D and Technical violations were issued. An exit interview was conducted, and a copy of this report was provided to Maria Luisa Razo, Assistant Administrator along with the Appeals Rights.the state’s words, verbatim · CDSS document, May 8, 2025

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not safeguard residents personal belongings. Staff did not prevent residents from entering the facility in unsafe conditions.

*This is a corrected version of previously dated report 04/11/2025. LPA Ramirez corrected 9099-D page verbiage. No changes to findings. LPA Ramirez re-delivered findings on 04/26/2025.* Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Blanca Gonzalez conducted an unannounced initial complaint investigation visit on 04/11/2025 regarding the above allegations. During today’s visit, LPAs were greeted by Corporate Maintenance Director- Marlon Mezquita and explained the purpose of the visit. Administrator Alexander Solorio arrived shortly after. The investigation consisted of the following: LPA Ramirez conducted Staff#1 - 3 interviews (S1-S3), Attempted Interview of Staff #4 (S4), Resident# 1- 2 Interviews (R1-R2), Witness#1 Interview (W1), copies of R1 & R2 recent physician’s report (LIC 602), and physical plant tour. SEE 9099-C Substantiated The investigation revealed the following: regarding the allegation(s): Staff did not safeguard residents’ personal belongings- It is alleged staff are not safeguarding residents’ belongings while the facility is under renovation and repair due to the 2025 Eaton wildfires. Two (2) out of the two (2) residents interviewed corroborated this allegation. Interview of W1 corroborated this allegation. Interview Administrator Solorio revealed he instructed the renovation crew to cover all residents’ belongings with plastic wrap and indicate rooms numbers on items so residents can find their belongings easier. LPAs toured the facility in 4/11/202 at 9:04am. LPAs observed the facility to be under renovation. LPAs observed some personal items in such as clothing, blankets, shoes, large and small flat screen TVs, dressers, hygiene products and other personal items, stored in hallways, without plastic wrap, collecting dust and debris from the renovations being conducted. Resident interviews revealed resident’s items are scattered throughout the facility and staff is allowing all belongings to become dusty and several personal items have not been located due to them being scattered throughout the facility. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Staff did not prevent residents from entering the facility in unsafe conditions- It is alleged staff did not prevent R1 & R2 from entering the facility in unsafe conditions. Three (3) out of the three (3) staff interviewed denied this allegation. Interview of W1 corroborated this allegation. Interview with W1 revealed on 4/7/2025, W1 arrived at the facility at 10:04 am and found R1 & R2 inside the facility. W1 revealed R1 & R2 advised W1 they drove to the facility together to look for their items. W1 revealed they did not observe facility staff supervising R1 & R2 while they were in the facility and only the renovations crew were present. W1 revealed it was unsafe for residents to be at the facility without supervision due to the renovations supplies and equipment being accessible to residents. Two (2) out of the two (2) residents corroborated they were present at the facility on 4/7/25. R1 & R2 revealed in past staff would meet them at the facility and supervise them while they searched for personal items. During facility tour, LPAs observed construction equipment such as paint cans, ladders, sanding equipment, and cleaning supplies scattered around the hallways. According to Administrator Solorio, no residents should be at the facility during renovations unless staff is there to supervise them. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Two (2) deficiencies were cited for this complaint investigation. Exit interview was conducted. A copy of this report, 9099-D, and appeals rights was provided via email. Staff did not notify licensing of renovation repairs to the facility- It is alleged the licensee did not notify this licensing agency that the facility would be conducting renovation repairs. Three (3) out of the three (3) staff interviewed denied this allegation. The facility was issued a mandatory evacuation order on 1/8/25 due to the 2025 Eaton wildfires. Although the facility did not experience fire damage, the facility landscaping needed to be repaired, and an outdoor fence had fallen and damaged the HVAC. Since 1/08/2025, facility staff have been in regular communication with Community Care Licensing (CCL) regarding repopulation and renovations and repairs. 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 violations were cited for this allegation. Exit interview was conducted. A copy of this report was provided via email due to printer problems.the state’s words, verbatim · CDSS document, Apr 26, 2025 · control 28-AS-20250408150001

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 18, 2025

87411 Personnel Requirements-General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The licensee did not met this requirement as evidenced by: the licensee did not ensure staff was sufficicient in numbers to prevent residents from accessing the facility while the facility is under renovations and repairs. This poses a potiential risk to the health, safety or personal rights of persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2025

Plan of correction: Administrator Solorio agreed to certify plan to address how the facility will address residents gaining entry into the facility while renovations are being conducted.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Apr 18, 2025

87217 Safeguards for Resident Cash, Personal Property, and Valuables- (b)Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement was not met as evidenced by: Staff did not properly cover and safeguard residents personal belongings during renovations and repairs. This poses a potiential risk to the health, safety or personal rights of persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2025

Plan of correction: Administrator Solorio agreed to certify plan to address how the facility plans to properly safeguard residents personal belongings during renovations and repairs.

Allegation investigated: Staff did not safeguard residents personal belongings. Staff did not prevent residents from entering the facility in unsafe conditions

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Blanca Gonzalez conducted an unannounced initial complaint investigation visit on 04/11/2025 regarding the above allegations. During today’s visit, LPAs were greeted by Corporate Maintenance Director- Marlon Mezquita and explained the purpose of the visit. Administrator Alexander Solorio arrived shortly after. The investigation consisted of the following: LPA Ramirez conducted Staff#1 - 3 interviews (S1-S3), Attempted Interview of Staff #4 (S4), Resident# 1- 2 Interviews (R1-R2), Witness#1 Interview (W1), copies of R1 & R2 recent physician’s report (LIC 602), and physical plant tour. SEE 9099-C Substantiated The investigation revealed the following: regarding the allegation(s): Staff did not safeguard residents’ personal belongings- It is alleged staff are not safeguarding residents’ belongings while the facility is under renovation and repair due to the 2025 Eaton wildfires. Two (2) out of the two (2) residents interviewed corroborated this allegation. Interview of W1 corroborated this allegation. Interview Administrator Solorio revealed he instructed the renovation crew to cover all residents’ belongings with plastic wrap and indicate rooms numbers on items so residents can find their belongings easier. LPAs toured the facility in 4/11/202 at 9:04am. LPAs observed the facility to be under renovation. LPAs observed some personal items in such as clothing, blankets, shoes, large and small flat screen TVs, dressers, hygiene products and other personal items, stored in hallways, without plastic wrap, collecting dust and debris from the renovations being conducted. Resident interviews revealed resident’s items are scattered throughout the facility and staff is allowing all belongings to become dusty and several personal items have not been located due to them being scattered throughout the facility. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Staff did not prevent residents from entering the facility in unsafe conditions- It is alleged staff did not prevent R1 & R2 from entering the facility in unsafe conditions. Three (3) out of the three (3) staff interviewed denied this allegation. Interview of W1 corroborated this allegation. Interview with W1 revealed on 4/7/2025, W1 arrived at the facility at 10:04 am and found R1 & R2 inside the facility. W1 revealed R1 & R2 advised W1 they drove to the facility together to look for their items. W1 revealed they did not observe facility staff supervising R1 & R2 while they were in the facility and only the renovations crew were present. W1 revealed it was unsafe for residents to be at the facility without supervision due to the renovations supplies and equipment being accessible to residents. Two (2) out of the two (2) residents corroborated they were present at the facility on 4/7/25. R1 & R2 revealed in past staff would meet them at the facility and supervise them while they searched for personal items. During facility tour, LPAs observed construction equipment such as paint cans, ladders, sanding equipment, and cleaning supplies scattered around the hallways. According to Administrator Solorio, no residents should be at the facility during renovations unless staff is there to supervise them. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Two (2) deficiencies were cited for this complaint investigation. Exit interview was conducted. A copy of this report, 9099-D, and appeals rights was provided via email. Staff did not notify licensing of renovation repairs to the facility- It is alleged the licensee did not notify this licensing agency that the facility would be conducting renovation repairs. Three (3) out of the three (3) staff interviewed denied this allegation. The facility was issued a mandatory evacuation order on 1/8/25 due to the 2025 Eaton wildfires. Although the facility did not experience fire damage, the facility landscaping needed to be repaired, and an outdoor fence had fallen and damaged the HVAC. Since 1/08/2025, facility staff have been in regular communication with Community Care Licensing (CCL) regarding repopulation and renovations and repairs. 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 violations were cited for this allegation. Exit interview was conducted. A copy of this report was provided via email due to printer problems.the state’s words, verbatim · CDSS document, Apr 11, 2025 · control 28-AS-20250408150001

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 18, 2025

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency maythe state’s words, verbatim · CDSS document, Apr 11, 2025

Plan of correction: require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. The licensee did not met this requirement as evidenced by: the licensee did not ensure the facility was inaccessible to residents while renovations are taking place.Administrator Solorio agreed to certify plan to address how the facility will address residents gaining entry into the facility while renovations are being conducted.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Apr 18, 2025

Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement was not met as evidenced by: Staff did not properly cover residents personal belongings during renovations and repairs.the state’s words, verbatim · CDSS document, Apr 11, 2025

Plan of correction: Administrator Solorio agreed to certify plan to address how the facility plans to properly safeguard residents personal belongings during renovations and repairs.

Allegation investigated: Due to lack of supervision, a resident physically assaulted another resident, resulting in injury and hospitalization.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit in response to the above-mentioned allegation. LPA met with Alexander Solorio, Asst. Administrator and Maria Luisa Razo, Resident Care Director and explained the reason for the visit. The investigation consisted of the following: On 7/17/2024, LPA conducted a health and safety check visit and toured the facility including the common areas. LPA obtained copies of the following documents: Staff and Resident rosters, Facility Sketch, House Rules, Staff #1 (S1) - Staff #2 (S2) files and Resident #1 (R1) - Resident #2 (R2) files such as: Identification and Emergency Information (Face Sheets), Admission Agreements, Physician Reports, Medication Logs/MARs (May 2024-July 2024), Preplacement Appraisal Information, Appraisal Needs and Services Plan, Unusual Incident/Injury Reports (SIRs) dated 7/15/2024 (initial and revised), Huntington Health Hospital Discharge records for R2 (dated 07/15/2024, in Spanish). During today’s visit, LPA obtained copies of the Staff and Resident rosters and delivered finding. *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: “Due to lack of supervision, R1 physically assaulted R2 resulting in injury and hospitalization.” It is alleged that without provocation, R1 began to strike R2 in the face with his right closed fist approximately 8-10 times, R2 sustained laceration to his upper right eyebrow which required hospitalization. This investigation was completed by Investigator Patterson with the Investigations Branch. Per interviews conducted by Investigator Patterson, the physical fight was unforeseen and that the fight started in the main lobby over a light switch being turned on/off by R2. Interviews supported that the two female caregivers on duty did not physically intervene due to both residents using their walking canes as weapons to strike each other. Statements revealed that the caregivers on duty gave the residents verbal instructions to stop and that 911 was promptly called. R1 believed that neglect occurred due to him having to protect himself and because the caregivers were unable to speak English. R2 denied neglect and believed that if the caregivers had intervened, they too may have been hurt. Per review of the police report and video footage of the incident, the footage (with no sound) shows the two caregivers on duty responding within the minute of the altercation. The police investigation regarding this incident was closed due to District Attorney rejection. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. 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. Exit interview and a copy of this report was provided to Alexander Solorio, Asst. Administrator.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 28-AS-20240716150347

Allegation investigated: Staff do not clean residents room properly Staff do not safeguard residents personal property

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced complaint visit regarding the above stated allegations. LPA met with Resident Care Director Maria Razo and explained the reason for the visit. The investigation consisted of the following: LPA Trueman toured the facility's common areas, hallways and Resident R1- R7 bedrooms, obtained copies of the Staff & Resident Rosters and reviewed R1's file. The following was submitted for R1: Face sheet, Admission Agreement, Physician's Report, Appraisal/Needs and Services Plan, and Client/Resident Personal Property and Valuables. Interviews were conducted with Resident Care Director Maria Razo, Staff S1-S3 and Resident's R2-R7. LPA inspected Rooms 9A, 13A, 29A, 30A, 42A, 42B, and 49B. In regards to the allegation Staff do not clean residents room properly, based on interviews conducted, inspection of Resident Rooms 9A, 13A, 29A, 30A, 42A, 42B, and 49B and information gathered it was observed on the inspection of rooms of Resident's R1-R7 that there was no human waste underneath the Unsubstantiated resident beds and all the rooms had been cleaned and there wasn't any water leakage on the floors. Interview with Resident's R2- R7 who all stated that housekeeping cleans their rooms 1x a week. All stated that housekeeping clean all areas and does a good job. Said they do clean under the beds. R2 stated that there was no feces or water leakage in the room. Stated that they mop the bathroom every Friday and clean the bathroom. Interview with Resident Care Director Maria Razo, who stated that they clean rooms 1x a week. If there are accidents will do as needed. They do a deep cleaning. Said Resident R1 is combative toward staff when they go to clean up. Stated Resident R1 hit staff when they were trying to clean up a leak. Interview with Staff S1-S3 who all stated that housekeeping follow a schedule and will clean rooms 1x a week or as needed. Said that Resident R1 has been aggressive with staff trying to hit them with mops. 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. In regards to the allegation Staff do not safeguard residents personal property, based on interviews conducted and information gathered Resident's R2-R7 all stated that they have never had anything stolen at the facility. Resident R2 stated that R1 never told him anything was missing. Said R1 tells staff don't open the door because he doesn't want air to get in. Review of Resident R1's file Client/Resident Personal Property and Valuables document has initials of Resident R1 in which it states I waive the right to complete this form. Admission Agreement dated 01/12/24 has initials of Resident R1 in which it states I understand that the facility cannot be held liable for items which are not inventoried. In addition the box is checked off and initialed where it states I decline to have my personal items inventoried. Interview with Resident Care Director Maria Razo who stated that there has been no one who has issued a complaint that their property was stolen. Usually items may be misplaced and staff will help and they usually find it. Interview with Staff S1-S3 who stated that there have not been any complaints. Also said that facility offers a lock box for money, ID cards and any personal items Also residents can purchase a safe for their room and don't have to give staff access. Staff said Resident R1 will tell them issues, but never did regarding his phone being stolen. 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.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 28-AS-20241203130303

Allegation investigated: Staff pushed resident out of their wheelchair while in care. Staff locked resident in their room while in care. Staff did not safeguard resident's personal belongings while in care.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit regarding the above stated allegations. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: During the initial visit on 7/26/2024, LPA Pena toured the facility's common areas, hallways and Resident #1 (R1)'s bedroom, obtained copies of the Staff & Resident Rosters and R1's files such as: Face sheet, Admission Agreement, Physician's Report, Care Plan, Appraisal/Needs and Services Plan, Unusual Incident/Injury Report (Jan-Mar 2024) and 30-day eviction notice (dated 03/20/2024). During today's visit, LPA obtained copies of Resident & Staff Rosters and conducted a tour of facility and common areas, reviewed files for Resident #1 (R1) and requested additional documents such as; R1's Personal Property and Valuables form (LIC 621), 51/50 Placement for Evaluation and Treatment form (dated 03/25/2024) and copy of the signed release form of R1's personal belongings. LPA interviewed Resident #1 (R1) - Resident #10 (R10) and Staff #1 (S1) - Staff #5 (S5). *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: "Staff pushed resident out of their wheelchair while in care." It is alleged that R1 was pushed out of her wheelchair. No other information provided. Interviews conducted with (5) of (5) staff all denied the allegation. Staff interviewed indicated that they have never pushed any resident, nor have they observed any other staff push any of the residents out of their wheelchair. Staff stated that if they observe residents needing help, they assist in pushing the residents' wheelchair with their consent. (10) of (10) residents interviewed denied the allegation and indicated that staff treat them with dignity, and they feel safe at the facility. (5) out of (10) interviewed residents use wheelchair and stated that they were never pushed out of their wheelchair nor observed any staff push any of the residents out of their wheelchair. Therefore, there was insufficient evidence to corroborate with the allegation. In regards to the allegation: “Staff locked resident in their room while in care.” It is alleged that R1 was locked into the room and that staff would tie the bedroom's doorknob to a metal railing with a sheet so R1 could not get out, and was left there for hours. (5) out of (5) staff interviewed denied the allegation. Staff interviewed stated that they would never lock any resident in their bedroom as it is against the law and a violation of the residents rights. (10) out of (10) interviewed residents denied the allegation. Interviewed residents stated that they have never been locked in their bedrooms by staff nor have seen any other residents being locked in their bedrooms. During the visit, LPA tested R1's bedroom door lock and observed that R1's bedroom cannot be locked from the outside. LPA also observed that there is a sliding door in R1's bedroom that leads to the back patio area and can be used as entrance/exit to R1's bedroom. Additionally, LPA did not observe any metal railing near R1's bedroom door. Therefore, there was insufficient evidence to corroborate with the allegation. In regards to the allegation: "Staff did not safeguard resident's personal belongings while in care." It is alleged that the facility staff kept R1's belongings and was only given (5) bags of donated clothes when R1 left the facility. (5) out of (5) staff interviewed denied the allegation. S1 stated that if a resident leave the facility for a long period of time, the residents' belongings are kept in their bedrooms until they get confirmation that the resident is not coming back to the facility. Staff indicated that they pack, label, hold and store the residents' belongings in the storage room until the resident or family member is ready to pick them up. (10) out of (10) interviewed residents stated that they do not have any issues with their personal belongings. Interviewed residents indicated that they feel that their personal belongings are safe in their bedrooms. Reviewed documentation showed that upon moving in, R1 waived her right to complete a personal inventory list. Documentation reviewed and interviews conducted do not corroborate this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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. An exit interview was conducted, and a copy of this report was provided to Alexander Solorio, Assistant Administrator.the state’s words, verbatim · CDSS document, Sep 3, 2024 · control 28-AS-20240724092144

Allegation investigated: Staff did not prevent the residents from engaging in a physical altercation.

Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced complaint visit regarding the above stated allegation. LPAs met with Assistant Administrator, Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: LPAs conducted a tour of the facility’s common areas, obtained copies of the Resident & Staff Rosters, House rules, In service training log Residents rights, Incident Report dated 8/17/2024 and Police report information. LPAs reviewed and obtained files for Resident #1 (R1) – Resident #2 (R2) such as: Identification and Emergency Information Sheets, Admission agreements, Physician Reports, Personal Rights, Preplacement Appraisal Information, Appraisal Needs and Services Plans. LPAs interviewed Resident #1 - Resident #10 (R10) and Staff #1 (S1) - Staff #6 (S6). *****CONITNUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: "Staff did not prevent the residents from engaging in a physical altercation.” It is alleged that R1-R2 were involved in a verbal argument in the common area that led to physical altercation and was broken up by staff. Interviews conducted with (6) of (6) staff all denied the allegation. S4 witnessed the incident as she was in the dining area when it happened and separated R1-R2 immediately. S4 took R1 to the front office and administered first aid. Some staff interviewed indicated that R1-R2 did not suffer major injuries and did not require hospitalization. S1 and S3 attended to R2 right away to check his condition and interviewed him regarding the incident. S5 stated that he was in the kitchen and intervened as soon as he heard the commotion in the dining room. All staff interviewed indicated that they do not allow any type of altercations or harassments among residents in the facility. R1-R2 admitted being involved in the altercation but stated that the staff intervened right away and separated them. R1-R2 indicated that none of them were desirous of prosecution and refused to be sent to the hospital. All residents interviewed denied the allegation and indicated that facility staff immediately intervene if they see or hear any altercations among the residents. 10 out of 10 residents interviewed stated that they feel safe and comfortable. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. 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. Exit interview and a copy of this report was provided to Alexander Solorio, Assistant Administrator.the state’s words, verbatim · CDSS document, Aug 23, 2024 · control 28-AS-20240818225123

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi initiated a Case Management- Deficiencies after it was discovered during the course of the investigation for complaint control # 28-AS-20240818225123 that the facility's air conditioning in the dining room and the ice machine are broken. LPAs conducted a tour of the dining and kitchen areas and observed the room to be warm and has (1) fan going. And that there's no ice in the ice machine and is broken. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during today's visit is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided to Alexander Solorio, Assistant Administrator.the state’s words, verbatim · CDSS document, Aug 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 6, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include ... 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 and interviews, the Administrator did not comply with the section cited above in which LPAs observed the dining room's air conditioning is inoperable and the ice machine is broken which poses potential health, safety or personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Aug 23, 2024

Plan of correction: Administrator agreed to submit a service report/invoice from Air Conditioning/Heating company to prove that the A/C in the dining room has been fixed. And submit receipt/photos of new ice machine to CCL/LPA by POC due date.

Allegation investigated: Staff do not frequently change a resident while in care. Staff are not meeting a resident's hygiene needs. Staff did not provide cold water to a resident.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit for the allegations listed above. LPA Pena met with Assistant Administrator Alexander Solorio and explained the purpose of the visit. During the initial visit on 05/21/2024, LPAs B. Pena and D. Konishi conducted a tour of the facility’s common areas focusing on R1's bedroom, checked water temperature in the community shower room, and checked hygiene/bathing/incontinent supplies. LPAs obtained copies of Resident & Staff Rosters, Resident #1 (R1) files such as: Face sheet, Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Service Tracker, Hospice Records, Shift to Shift Notes (Apr. 2024). LPAs also interviewed Staff #1 (S1) and Nurse #1 (N1). During today’s visit, LPA Pena obtained Resident & Staff Rosters, police report information, Hospice Records (Apr-May 2024), Shift to Shift Notes (May 2024) and Home Health Notes (April-May 2024). LPA also interviewed Staff #2 (S2) – Staff #6 (S6) and Resident #2 (R2) – Resident #8 (R8). *****REPORT CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: “Staff do not frequently change a resident while in care.” It is alleged that a resident was not being changed. No other information provided. (6) out of (6) staff interviewed denied the allegation and stated that incontinent residents are being changed on a regular basis. S1-S2 stated that they have incontinent schedule/service tracker that’s updated daily. Staff interviewed stated that they have adequate staffing, (2) caregivers per shift plus a 3rd mid shift caregiver. Caregivers follow the service tracker schedule that is provided to them before their shift starts. Some staff interviewed indicated that they monitor the residents and check on them every 2-3 hours or as needed. (6) out of (8) incontinent residents interviewed stated that the staff change them frequently and have not been left throughout the day or overnight without changing undergarments. Residents interviewed stated that staff assist them when they ask for help. Records reviewed revealed that logs are maintained and staff record notes of the care provided to the residents during their shift, whether it's changing undergarments, delivering food or giving the residents a shower. Therefore, there was insufficient evidence to corroborate with this allegation. In regards to the allegation: "Staff are not meeting a resident's hygiene needs." It is alleged that a resident was filthy, no one assists with hygiene and only receives a quick and inadequate bed bath from hospice weekly and no other showers/baths. (6) out of (6) staff interviewed denied the allegation and stated that caregivers have a schedule that they follow during their shifts. Facility maintains a daily service tracker, shift to shift report and shower schedule that lists the residents needing assistance in hygiene and shower. Staff interviewed stated that they assist residents with changing clothes, brushing their teeth, feeding and showering. Staff indicated that they give residents a shower 2-3x a week and recorded on the service tracker and shift to shift notes once finished. S2 states that if home health care provides bathing services to a resident, the staff still step in to shower or bathe the resident in between the home health visits. During the visit on 5/21/2024, N1 stated that R1 is being provided bed bath once a week and indicated that hygiene supplies are provided by the facility. LPAs also observed sufficient hygiene supplies stored in the Administration office which are provided to the residents. Records reviewed revealed that R1 is provided shower service by a home health aide and the facility staff. Therefore, there was insufficient evidence to corroborate with this allegation. In regards to the allegation: "Staff did not provide cold water to a resident." It is alleged that there was no cold water in the facility. No other information provided. (6) out of (6) staff interviewed denied the allegation and stated that the facility has cold water but not hot water. Staff interviewed stated that there is no hot water due to a plumbing issue in the community shower rooms and that the water pressure was very low or water only dripped in some stalls. S1 indicated that a plumber already came and provided the estimate. (5) out of (8) residents interviewed stated that only cold water was available and there was no hot water in the shower rooms. During the visit on 5/21/2024, LPA tested the water temperature and readings were 90.8 deg F in stall #1, 98.6 deg F in stall #2 and 89.2 deg F in stall #3, all stalls were in the large community shower room. LPA observed that there was no hot water and a deficiency was issued on a separate case management report. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview and a copy of this report was provided to Alexander Solorio, Asst. Administrator.the state’s words, verbatim · CDSS document, Jul 26, 2024 · control 28-AS-20240520102446

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a complaint visit (Complaint Control # 28-AS-20240520102446). The purpose of this visit is to issue deficiency that was observed by LPA that is not part of the complaint allegations. During the visit on 5/21/2024, LPA conducted a tour of the facility, and tested the water temperature in the community shower rooms. LPA observed that there was no hot water in any of the stalls in the community shower rooms. Water readings measured by LPA were: 90.8 deg F in stall #1, 98.6 deg F in stall #2 and 89.2 deg F in stall #3, all stalls were in the large community shower room. Interview with S1 confirmed that there has been no hot water due to a plumbing issue in the community shower rooms and that the water pressure was very low or water only dripped in some stalls. S1 indicated that a plumber already came in April 2024 and provided them the estimate. Some residents interviewed stated that only cold water was available and there was no hot water in the shower rooms. Deficiency is noted on LIC 809D. Exit interview, a copy of this report and Appeals Rights were provided to Alexander Solorio, Assistant Administrator.the state’s words, verbatim · CDSS document, Jul 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jul 29, 2024

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows:(2) Faucets used by residents for personal care.... shall deliver hot water. Hot water temperature controls shall be maintained... to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based on interviews and observation, the hot water temperature readings during the visit on 5/21/2024 were 90.8 deg F in stall #1, 98.6 deg F in stall #2 and 89.2 deg F in stall #3, all stalls were in the large community shower room which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 26, 2024

Plan of correction: Asst. Administrator shall ensure that the hot water temperature in the community shower rooms meets Title 22 regulation. Asst Administrator shall immediately repair water pump and submit service report/invoice to CCL/LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management Visit to address additional information obtained during Complaint Control #28-AS-20231229081912 which was investigated by the Department’s Investigations Bureau Branch. During interviews conducted and record review, Investigator Padilla was made aware of the following: · There were inconsistent and false statements from both S1 and S2 about the accounts of R1's injuries and who arranged medical transportation for R1. On the Unusual Incident/Injury Report (SIR) that was submitted to CCL, it states that staff observed R1 with their right arm bleeding, and S3 arranged transportation, however, records obtained revealed that R1 called 911 for help themselves to be transported to hospital for further treatment. Facility should have submitted an addendum to their SIR to provide this updated information. · On an unrelated incident, Investigator Padilla was informed during interviews that R2 had been without a room for 2-3 days because their roommate became aggressive with R1 and kicked R1 out of the room. This was confirmed by S4 who found R1 sleeping on the floor. During interview with R2 Investigator confirmed this information and observed R2 with a few bags in the facility hallway. S1 also confirmed that the two residents were having issues, and S1 was working on getting R2 a new room. · There was an incident that occurred where S1 was involved in a physical altercation with R1's family member and S1 sustained injuries to their eye during the altercation, an incident report was not filed for this incident and police was called. Based on investigation conducted by IB Investigator, along with interviews and statements with Staff and Residents, the following deficiencies listed above are being cited on the attached LIC 809-D. LPA did not observe any health and safety concerns during today’s visit. Exit interview was conducted, a hard copy of this report and appeal rights were provided to Maria Razo.the state’s words, verbatim · CDSS document, May 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: May 17, 2024

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirment is not met evidence by: Based on IB's investigation it was determined that there were inconsistent/false statements from staff about R1's injuries and who arranged medical transportation for R1, the SIR states staff arranged transportation, however, records reveal that R1 911 for help and to be transported to hospital for further treatment.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Licensee/Administrator to submit an addendum to their SIR and provide this updated information. A copy of this addendum/revision to be emailed to LPA by POC Due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(3) · Plan of correction due date: May 17, 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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirment is not met evidence by: During IB interview with R2 it was stated that R2 had been without a room for 2-3 days. This was confirmed by S4 who found R1 sleeping on the floor and S1 also confirmed that the two residents were having issues, and S1 was working on getting R2 a new room. IB also observed R2 with a few bags in the facility hallway.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Licensee/Administrator to submit an SIR detailing incident and what was done to correct this situation, new room/roomate switch and what the facility is doing moving forward to avoid incidents between the two individuals. SIR to be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 17, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirment is not met evidence by: IB discovered there was an incident that occurred where S1 was involved in a physical altercation with R1's family member and sustained injuries to their eye during the altercation, an incident report was not filed for this incident and police was called.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Licensee/Administrator to submit an SIR detailing incident and report must also have police report number. SIR to be emailed to LPA by POC due date.

Allegation investigated: Resident sustained an injury while in care

Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent unannounced complaint visit to deliver finding to the above mentioned allegation. LPA met with Assistant Administrator and explained the reason for the visit. The investigation consisted of the following: On 09/08/22 and 05/02/24 facility tour was conducted, copies of relevant documents were obtained, and Assistant Administrator was interviewed. Continue 9099C Unsubstantiated Regarding allegation: Resident sustained an injury while in care. R1 presented to ED for wound found to have maggots in wound. Interviewed Assistant Administrator denied the allegation. Assistant Administrator stated that R1 was admitted to the facility from the Dreier’s Nursing Care Center with the cellulitis of lower limb. R1 moved in with the Pacific Pace program who managed to coordinate and provide all needed preventive, primary, acute, and long-term care services and was followed by Welbehealth who managed R1’s transportation, medical coordination, Home health. Since R1s stay at Pasadena Villa, resident was on Home Health and received services for wound from West Coast wound and skin care. R1 was on the program from his move-in date until their exit date with nurses, doctors, case managers, and weekly visits. They did facility visits for R1 2 to 3 times a week with biweekly meetings and weekly medical appointments as needed. R1 was put on an additional service for wound care with West Coast Wound Care on 10/27/21 and continued the service until their exit date. LPA obtained and reviewed West Coast Wound Care records / progress notes details and observed that there was wound treatment plan for R1 and R1 was receiving wound care from the agency. There were no reports of maggots on R1’s wound. Assistant Administrator noted that R1 frequently refuses to take their medications and care, and would leave the facility without letting staff know, often disappears for days. Assistant Administrator stated that facility often was receiving calls from the hospitals informing them that R1 at the hospital. R1 used to go to the hospitals and ask for medications. Assistant Administrator stated that because of R1’s behavior, R1 often was placed on 5150 holds. LPA spoke with Social Worker from Glendale Adventist Hospital on 09/08/22 and find out that R1 was admitted to the hospital on 09/04/22 and was received treatment for bilateral leg cellulitis / wound. No other information was provided. According to the SOC 341 On 09/06/22, PD responded to the facility in regard to APS report. Report stated that R1 was admitted into the hospital for a leg wound and maggots in the wound. PD Officer toured the facility and inspected R1’s room. R1 was provided daily medications and medical treatments but R1 frequently leaved the facility and disappeared for days at a time. PD officer opinion was that R1 was a victim of his own self neglect. The information, record reviews and interviews did not support the allegation. 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. Exit interview conducted with Assistant Administrator and the copy of the report was provided.the state’s words, verbatim · CDSS document, May 9, 2024 · control 28-AS-20220907124319

Allegation investigated: Staff allowed resident to be left in soiled clothing for an extended period. Staff do not ensure that residents are adequately fed while in care.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit to continue investigating the above allegations. LPA met with Maria Luisa Razo, Resident Care Director and discussed the purpose of today's visit. During the initial visit conducted on 04/05/2024, LPAs B. Pena and D. Konishi obtained copies of Resident & Staff Rosters and Resident #1 (R1) files such as: Face sheet, Admission's Agreement, Preplacement Appraisal and Personal Rights. LPAs conducted a walk through of the facility, which included, but not limted to the resident bedrooms. LPAs also interviewed Staff #1 (S1) - Staff #2 (S2). During today's visit, the investigation consisted of the following: LPA B. Pena obtained copies of Resident & Staff Rosters, R1's Hospice records/notes and Physician's report, and Staff shift to shift report. LPA interviewed Staff #3 (S3) - Staff #5 (S5), Resident #2 (R2) - Resident #10 (R10). Resident #1 (R1) was transferred to a Skilled Nursing Facility (SNF) after hospitalization, therefore not interviewed. ******CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: "Staff allowed resident to be left in soiled clothing for extended periods of time." It is alleged that the resident was left in soiled clothing on 03/28/2024. All staff interviewed stated that the caregivers do their rounds 2-3x during their shift. Staff stated that incontinent residents are changed daily and bedridden residents are given priority on diaper changes. Staff stated that they did not receive complaints from any resident or responsible parties about incontinence care. A total of nine (9) residents were interviewed, of which (2) residents indicated that they heard residents not being attended or changed diapers as needed. (2) out of (9) residents stated that they heard incontinent residents call and yell for assistance and had to wait before receiving incontinence care. LPA reviewed the records indicating that R1 who wears catheter was on the diaper change list on 3/28/2024 and staff completed the work prior to R1 being transferred to the hospital. Documentation reviewed, and interviews conducted do not corroborate this allegation. In regards to the allegation: "Staff do not ensure that residents are adequately fed while in care." It is alleged that the resident did not receive breakfast. No other details were provided. (5) of (5) staff interviewed stated that residents are aware of the meal schedule and have not received complained that residents were not adequately fed. Staff stated that bedridden residents automatically have their meals delivered to their rooms by the staff who also assist with feeding. Staff indicated that residents are offered 3 meals per day and 2 snacks per day and alternative food options. Interviewed residents denied the allegation and stated that they either get their food delivered to their rooms or they go to the dining area. Residents also stated that the food is okay and facility provide them with alternative options if they don't like the food served on that day. (2) out of (9) residents indicated they are not happy with the food choices and would prefer healthier options like more vegetables. LPA toured the dining area during lunch and observed residents eating and that the food served was on the menu for the day. LPA also inspected the refrigerator and the food pantry and observed sufficient food supplies. Therefore, there is insufficient evidence to corroborate the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview conducted and a copy of this report was provided to Maria Luisa Razo, Resident Care Director.the state’s words, verbatim · CDSS document, Apr 30, 2024 · control 28-AS-20240329134905

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPAs met with Assistant Administrator, Alexander Solorio and the purpose of the visit was explained. There are currently eighty three (83) elderly residents 60 years and older residing in the facility. Facility is licensed to care for elderly residents age range 60 and over, 97 non-ambulatory, of which 30 may be bedridden. Hospice waiver for 30. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed.  There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has Covid-19 signage posted throughout the facility including notification at the front door of exposure to Covid-19 if an individual visits the facility. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Hospice Waiver for 30 is approved. A fire clearance is in place. Fire Drill was last conducted on 3/27/2024. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 04/01/2025. Surety bond in the amount of $10,000 is current. Physical Plant/Environment Safety: The facility is a single story building which consist of reception area, large dining area, forty nine (49) resident bedrooms, administration office, medication room, kitchen, storage room, cooler, electrical room, conference room and outdoor seating/smoking areas. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. LPAs tested hot water temperature in eight (8) random rooms. Water temperature readings in Room #s 11, 33 and 34 did not measure within the required 105 - 120 degrees Fahrenheit. Rm #4 - 111.5 deg F Rm #11 - 124.5 deg F - 2nd reading 113.9 deg F Rm #14 - 109.2 deg F Rm #24 - 113.1 deg F Rm #33 - 134.9 deg F - 2nd reading 132 deg F Rm #34 - 131.3 deg F Rm #38 - 114.6 deg F Rm #45 - 113.5 deg F *****CONTINUED ON LIC809-C**** Staffing: A total of twenty five (25) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records/Staff Training: LPA reviewed eight (8) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator Kandice Vergara's certificate expired on 3/15/2024. Assistant Administrator submitted the renewal on 2/14/2022 and has not received his certificate. Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Per Administrator, facility provides internet services to all residents and have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. LPAs observed that the activities calendar posted near the dining room was not up-to-date. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities. Food Service:  Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen staff workers were observed to be wearing hair nets and disposable gloves while working. Incidental Medical and Dental: Nine (9) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. Resident Records/Incident Reports: Resident files are maintained at the facility. A total of eight (8) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records. RCFE complaint poster and Personal rights were observed posted in the hallway near the dining area. The Incident report binder was reviewed. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Currently, eleven (11) residents receive hospice care and seven (7) bedridden residents. Half bed rails for mobility assistance were observed in some resident beds.  Functional Capability and Preplacement Appraisals are on file. "Oxygen In Use" signs were posted on the resident doors who are using oxygen. Deficiencies issued on LIC809-D. An exit interview was conducted, and a copy of this report was provided to Alexander Solorio, Assistant Administrator along with the Appeals Rights.the state’s words, verbatim · CDSS document, Apr 5, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility failed to seek medical attention for resident's wounds.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit regarding the above allegation. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. The investigation consited the following: During visit the initial visit dated 01/05/2024 LPA toured facility, dining room, various resident bedrooms, and obtained copies of resident and staff rosters, LPA did not observe any immediate health and/or safety concerns during visit and investigation needed further investigation. During todays visit 4/4/24 LPA obtained copies of resident and staff rosters and delievered findings. (Continued on 9099-C) Substantiated The investigation revealed the following: Allegation: Facility failed to seek medical attention for resident's wounds. It is alleged that R1 had wounds on their finger, arms & legs that have gone untreated. This allegation was investigated by Investigator Padilla with the Investigations Branch (IB). Victim, witnesses, and staff member interviews were conducted. The following information was found during IB's investigation: The caregivers, MedTech's, and administration staff failed to seek timely medical attention for R1 on 12/26/2023 which resulted in R1 seeking their own medical treatment by calling 911, after R1 informed multiple facility employees that they had injuries on their finger, arm, and leg. R1 was diagnosed at the local hospital with swelling of the right hand and index finger that had redness, swelling, and drainage as a result of an unwitnessed mechanical slip and fall. Hospital medical records for R1 state: that there were signs of Suspected Abuse and Neglect. Per IB report by investigator: There were too many inconsistent and false statements from both S1 and S2 about the accounts of R1's injuries and who arranged medical transportation for R1. On the Unusual Incident/Injury Report, it states that staff observed R1 with their right arm bleeding, and MedTech S3 arranged transportation. The document has false information, S3 did not arrange transportation for R1. R1 called 911 for help and to be transported to local Hospital for further treatment. Based on observations and interviews which were conducted and record review, 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. Exit interview held and a copy of this report was provided along with appeal rights to Alex Solorio.the state’s words, verbatim · CDSS document, Apr 4, 2024 · control 28-AS-20231229081912

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Apr 18, 2024

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: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by: R1 needing medical attention after sustaining injuries to the right hand and index finger that had redness, swelling, and drainage as a result of an unwitnessed slip and fall, R1 called emergency transportation for treatment themselves on 12/26/23.the state’s words, verbatim · CDSS document, Apr 4, 2024

Plan of correction: The administrator will review the Title 22 Regulations and ensure that and all staff will provide the necessary attention to residents who require medical attention and provide assistance in providing transportation to the nearest available medical facility. The administrator will send a copy of the in-service training and log with participants signature by POC due date to LPA via email.

Allegation investigated: Staff did not treat residents with respect. Residents' personal belongings are missing.

Licensing Program Analyst (LPA) Bennette Pena conducted an initial complaint visit to investigate the above allegations. LPA met with Alexander Solorio, Assistant Administrator and explained the purpose of the visit. The investigation consisted of the following: LPA obtained copies of the Staff roster, Resident roster, Staff In-service Training about Personal Rights, Residents Rights and Zero Tolerance Policy. LPA conducted a facility tour of the common areas. LPA interviewed Staff #1 (S1) – Staff #5 (S5) and Resident #1 (R1) – Resident #8 (R8). In regards to the allegation: “Staff did not treat residents with respect.” It is alleged that staff have been entering the residents’ room and disrespecting them for the last 3 months. No additional details given. Interviews conducted with staff members revealed that they treat all residents with dignity and respect. (5) out of (5) staff members interviewed stated that they never heard or witnessed any staff entering the residents’ room without knocking and without resident’s permission. S1 stated that they have all staff meeting on a monthly basis to discuss reported problems, issues and concerns in the facility. ****CONTINUED ON LIC9099-C***** Unsubstantiated (5) out of (5) staff members stated that they receive training such as personal rights, residents rights and zero tolerance policy regularly. R1-R2 denied the allegation and stated that they did not file a complaint. (8) out of (8) residents that were interviewed stated that staff members treat them with dignity and respect. Interviewed residents stated that staff knock before coming into their rooms, even if the door is open. All interviewed residents stated that they don't have any problem with staff, that staff are nice and respectful. During the tour, LPA did not not observe staff speaking inappropriately or disrespectful to residents. Based on statements and interviews conducted with residents and staff as well as reviewed files, there was not enough supportive evidence to corroborate the allegation. Allegation: "Residents' personal belongings are missing." It is alleged that staff have been stealing the residents’ personal belongings for the last 3 months. No additional details given. Staff interviews revealed that staff are not entering clients’ rooms without permission and stealing the residents’ personal belongings. S1 stated that the facility has zero tolerance policy with that type of behavior and that residents’ rights in service training are being conducted to staff members regularly. Staff interviews revealed that staff have not received any complaints nor have received any report regarding this matter. R1-R2 denied the allegation and stated that they did not file a complaint. Interviewed residents stated that they have not heard anyone complaining about this matter. Interviews conducted with (8) residents revealed that the facility staff respect their belongings and have never taken any of their belongings. Some residents stated that they do not have any concerns with staff as the staff are good and helpful. Resident and staff interviews do not corroborate this allegation. Based on statements and interviews conducted with staff, residents and review of facility file records, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview conducted and a copy of this report was provided to Alexander Solorio, Asst. Administrator.the state’s words, verbatim · CDSS document, Mar 28, 2024 · control 28-AS-20240322134755

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Bennette Pena and Christian Gutierrez conducted an unannounced Case Management Visit to follow up on the Death Report of a Resident faxed to the Department on 03/16/2024. LPAs were met by Alexander Solorio, Assistant Administrator and explained the reason for the visit. Facility reported that around 6:30am on 03/12/2024, a staff noticed the resident/R1 (Robert Polinsky DOB 10/22/1969) sleeping. At around 9am, a staff was conducting med rounds and found R1 unresponsive and had no pulse. The staff called 911, paramedics arrived, checked R1's pulse and declared R1’s time of death at 9:07am. The cause of death is yet to be determined, awaiting autopsy from mortuary as indicated in the death report submitted by the facility. During today's visit LPAs interviewed the Asst. Administrator/S1. S1 stated that he received a call from a staff on Tue., 3/12/2024 regarding R1 who was unresponsive. S1 instructed the staff to call 911 immediately. Paramedics arrived and checked R1's pulse and declared him dead. Pasadena Police came and interviewed the staff members present. Prior to today’s visit, LPA Pena obtained copies of Staff and Resident rosters, House Rules, R1’s files such as Face Sheet, Death Report, Admission Agreement, Appraisal/Needs & Services Plan, Physician's Report, Medication Administration Record (MAR) for Jan 2024-Mar 2024, and Pasadena Police Report information (24-19553). No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPAs also requested the facility to obtain and provide Licensing with R1’s Death Certificate upon receipt if available. Deficiency observed during today's visit and cited on LIC809-D. An exit interview was held and a copy of the report was provided to Alexander Solorio, Administrator.the state’s words, verbatim · CDSS document, Mar 19, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Mar 29, 2024

87506 Resident Records...(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff... This requirement is not met as evidenced by: Based on interviews and review of documentation, R1's Medication Administration Record (MAR) for March 2024 is inaccurate. MAR for March 2024 shows that 2 staff initialed the medication log from 3/12/2024-3/16/2024 even after R1’s passing which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: The Assistant Administrator shall ensure that the Medication Administration Records (MARs) are accurate for all residents. The Assistant Administrator agreed to submit a plan of correction to avoid improper documentation of Medication Administration Record (MAR) and prevent medication errors. Additionally, all facility staff in charge of medication management shall be re-trained on Medication Management & proper documentation. A copy of the in-service training form along with topics discussed and signatures of staff present will be submitted to CCL/LPA by the POC due date.

Allegation investigated: Staff did not prevent resident from hitting another resident in care.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit regarding the above allegation. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of staff & resident rosters, interviewed Assistant Administrator, Staff 1 - Staff 2 (S1 - S2) and Resident 1 - Resident 8 (R1 - R8). LPA obtained copies of the Unusual Incident/Injury Report, SOC 341 and police report. The investigation revealed the following: regarding the allegation "staff did not prevent resident from hitting another resident in care", it is alleged that R2 went into R1's room and hit R1's arm with a stick. Administrator and staff stated that they did not witness R2 hitting R1 with the stick, but R2 did go in R1's room and was immediately removed from the room. Staff stated that they did not see any visible injuries or bruises on R1's arm. The police officer that responded to the incident also did not see any visible injuries or observed that R1 was in pain. (Continued to LIC 9099-C) Unsubstantiated R1 stated that R2 came into the room and grabbed a stick that R1 keeps in the room and hit R1's arm. R1 also stated that R2 did not hit R1 hard and that staff rushed in the room and removed R2 from the room. R1 stated that it is not the staff fault because this happened very suddenly and it was unpredictable. R2 stated that R2 passed by R1's room and the door was open and R1 yelled obscenities at R2. That is why R2 went inside the room and hit the bottom of the bed. R2 denied hitting R1's arm. R1 stated that there has been no further issues with R2 since that incident. Residents interviewed did not witness the incident, but stated that staff do tend to intervene quickly in this kind of matters. There is no concrete evidence that R2 hit R1. However, staff did intervene quickly and prevented any major injuries. 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. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Mar 14, 2024 · control 28-AS-20240305093601

Allegation investigated: Staff were not aware of resident's whereabouts. Staff did not follow reporting requirements.

Licensing Program Anlayst (LPA) Wong conducted an initial 10 days visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1 (Receptionist) Scarlett Munoz who allowed entry into the facility and was later met by Assistant Administrator Alexander Solorio who assisted with the visit. The investigation consisted of the following: On today's date, LPA interviewed the assistant administrator, three staff (S1-S3) and seven residents in the facility, LPA spoke to one staff (S4) via telephone and obtained resident roster, documents about Resident#1 (R1) which include: Face sheet, physician report, admission agreement, needs and service plan, incident report for R1 on 3/1/24, 1/10/24 and 1/20/24 and resident sign out sheet. See LIC 9099C for continuation. Unsubstantiated The investigation revealed of the following: Allegation#1 "Staff were not aware of resident's whereabouts." It's alleged staff were unaware that R1 had left the facility in the middle of the night. LPA interviewed seven (7) residents and all denied the allegation and reported they usually let staff know when they leave from the facility. Staff was aware of where they are going. LPA interviewed staff and denied the allegation. Staff reported they always do the round check in the facility. Once they found out resident was not in the room or the facility and they would report to the office and the office staff would check the camera and see if the resident left from the facility through the back door. The assistant administrator stated the facility is not a locked facility and the resident has the right to go in and out from the facility. For R1 and R1 is able to go out without any assistance. R1 usually did not sign out from the facility or would not let staff know when she's out in the facility but staff knew R1 was gone as they did the room check and they would report to the office or assistant administrator. In addition, some staff did see R1 was around the facility area and they encouraged R1 to be back to the facility but R1 was refused to go back. Allegation#2 "Staff did not follow reporting requirements." It's alleged that the facility did not file any missing person report while R1 had left the facility " LPA interviewed the assistant administrator and reported it's been a pattern for R1 lately which R1 had been in and out from the facility. For the incident on 3/1/24, R1 was left the facility at around 2:30pm on 3/1/24 and staff received a call from hospital before 7am and indicated R1 was at the hospital. The assistant administrator stated R1 hasn't gone for 24 hours yet and therefore they did not file any missing person report. In addition, the assistant administrator reported staff would drive around the area to locate R1 and staff saw R1 was safe and coherent and they would also encourage R1 to be back in the but R1 was refused to go back to the facility. Based on the interviews with staff and residents and documents reviewed, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Alex Solorio.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 28-AS-20240304095151

Allegation investigated: Staff handled a resident in a rough manner.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit regarding the above allegation. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of Staff and Resident Rosters, reviewed surveillance footage of the alleged incident, obtained Police Report Number and card of Officer, Copies of SOC341 and Incident Report were given to LPA, and interviews with 4 Staff and 7 Residents were conducted. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff handled a resident in a rough manner. It is alleged that Staff #1 (S1) grabbed and dug their nails into Resident #1 (R1) wrists. LPA reviewed the surveillance footage of alleged incident and what was observed was R1 in their wheelchair moving towards kitchen with a plate of food on their lap and can be seen speaking to someone ahead of them, as they approached the kitchen you can see S1 (only hands and arms were visible) attempting to take the plate of food from R1’s lap, but R1 tightens their grip on the plate, S1 releases the plate and walks away, R1 continues to move backwards in their wheelchair with plate of food on lap appearing to be yelling and waving a finger in the direction of where S1 was, nothing further was observed. LPA interviewed S1 and Staffs story matched what was observed in the surveillance footage and S1 stated they have been working in their field for many years and have never spoken inappropriately nor inappropriately touched any residents. LPA interviewed a total of 4 Staff and 4 out of 4 Staff stated they have never spoken inappropriately, yelled, touched, or handle any resident in a rough manner, and have never seen another staff do these things either. LPA interviewed 7 Residents during visit and 7 out of 7 Residents stated that they have never been mistreated, yelled at, or handled roughly by any staff at facility. R2 stated that they were present during the time of the alleged incident and did not see S1 touch R1, that S1 attempted to grab the plate of food from R1’s lap, R1 refused, and S1 walked away. Based on statements and interviews conducted with Staff and Residents, and LPA’s observation, there was not enough supportive evidence to concur with the reported allegation. 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. Exit interview held, and a copy of this report was provided to Alex Solorio.the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 28-AS-20240220165855

Type of visit: POC

Licensing Program Analysts (LPAs) Mary Flores and Sanjay Vaid conducted an unannounced plan of correction (POC) visit at the facility regarding deficiencies noted on 1/16/24 during a complaint investigation visit. LPAs met with Alexander Solorio and explained the reason for the visit. On 1/16/24 LPA Flores conducted a complaint investigation visit and noted the following deficiency: 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities: During complaint investigation it was revealed that on 7/2/22 Resident #1(R1) who per physician's report cannot leave the facility unassisted, left the facility with another resident, did not returned to the facility and was found in a hospital the next day. On 1/30/24 Alexander Solorio provided a copy of in-service training provided to the staff on 1/16/24 and 1/17/24 and written statement acknowledging residents will obtain care and supervision. Deficiency cleared as of 1/30/24. Exit interview was conducted with Alexander Solorio and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2024

Allegation investigated: Staff do not maintain clean showers for residents use. Staff do not provide resident with basic laundry service. Staff do not provide residents with housekeeping services. Facility does not ensure residents have hot water for showers. Facility staff does not make menus available for review by resident.

***This report serves as the corrected report and supersedes the original complaint investigation report created on 01/09/24, LPA name of assigned LPA for this complaint investigation was corrected on this report. **** Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. The investigation consisted of the following: On 2/14/23 LPA Calderon obtained a copy of the Staff/Resident rosters and Resident #1's (R1) Admission Agreement. LPA obtained facility laundry schedule for residents, residents shower schedule, food menu, food alternative slips, Staff #1, Staff #2 and Staff #6 (S1, S2 and S6) food handler training certifications. LPA Calderon alongside with Assistant Administrator toured kitchen/cafeteria, three resident showers, residents rooms: Room 1,Room 33, Room 39,Room 40, and Room 46 and laundry room. LPA Interviewed Staff #1- #5 (S1-S5), attempt interview Staff #6 (S6) and interviewed Residents #2-6 (R2-R6). (CONTINUATION 9099-C...) Unsubstantiated Based on Allegation: Facility does not ensure residents have hot water for showers. The investigation revealed the following: 6 out of 6 staff during interview denied the above allegation and informed LPA there is hot water at the facility for residents to shower with. Staff #2- Staff #4 (S2,S3 & S4) informed LPA that hot water in certain common shower rooms takes time to heat up but shower's do deliver hot water. Interviews with residents 4 out of 5 resident's informed LPA that facility has hot waters for showers. R5 cannot collaborate to the above allegation. LPA on visit dates 2/14/23 and 1/9/24 tested hot water in common shower rooms. On 2/14/23 and 1/9/24, hot water was measured and tested and measured between the required Title 22 regulation. LPA tested water and LPA observed hot water taking some time for water to get hot between the required Title 22 measurements. Based on Allegation: Facility staff does not make menus available for review by resident. During the Investigation the following was revealed: During investigation 5 out of 6 staff stated the food menu is readily available for residents to review. S3 was unable to collaborate as their job duties does not pertain to working in the kitchen nor dining room. Interviews with residents on 2/14/23 LPA was informed by 6 out of 6 residents either couldn't collaborate with the allegation above due to not being aware, cannot see, not aware and/ or doesn't care. LPA observed on 2/14/23 and 1/9/24 food menu posted located in kitchen and dining room for resident's review. 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. Exit interview held and a copy of the report was provided. On today's visit 1/9/24, LPA toured common shower rooms, measured hot water in shower rooms, observed food menu, and attempt to interview staff #6 (S6) and attempt interview with R1, LPA received and reviewed housekeeping refusal slips. LPA reviewed documentation's provided on 2/14/23. Based on allegation: Staff do not maintain clean showers for residents use. The investigation revealed the following: LPA interview with staff, 6 out of 6 staff informed LPA they deny the above allegation and shower rooms are kept clean for residents. 3 out of 6 staff members informed LPA that cleaning services are done to maintain cleanliness. Interviews with residents on 2/14/23, 3 out of 5 resident's informed LPA that shower's are maintained clean and resident's denied the above allegation. Resident #2 and resident #5 do not use facility showers and cannot collaborate to the above allegation. LPA Calderon observed on visit dates 2/14/23 and 1/9/24 common shower rooms maintained clean and housekeeping staff cleaning shower rooms. LPA reviewed shower / bedding schedule for residents in care, residents per schedule review receive 2 shower days a week and that R1 was on the schedule twice, for assigned shower dates. Based on allegation: Staff do not provide resident with basic laundry service. The investigation revealed the following: Based on interviews conducted with staff, 5 out of 6 staff members informed LPA that residents receive laundry services and it is based on the laundry schedule, each residents have a schedule date for laundry services. Interviews with residents on 2/14/23 revealed that 5 out of 5 residents informed LPA that the facility provides laundry services to the resident's in care. LPA reviewed laundry services schedule and reviewed R1 scheduled for laundry services once a week, per laundry schedule residents have 1 day of laundry services. LPA during 2/14/23 visit to the facility, observed working laundry machines. Based on allegation: Staff do not provide residents with housekeeping services. The investigation revealed the following: Interview with staff, 5 out of 6 informed LPA that housekeeping staff provide housekeeping services for residents. Interviews with residents on 2/14/23 revealed that 5 out of 5 resident's informed LPA that residents are providing housekeeping services and denied the above allegation. LPA during 2/14/23 visit to the facility, LPA toured random rooms: Room 1, Room 33, Room 39, Room 40, and Room 46; LPA observed clean rooms. On visit date 1/9/24 LPA observed two house keepers on shift cleaning resident's rooms and bathrooms. LPA reviewed R1's refusal of housekeeping services slips, R1 refused housekeeping on February 18 & 24, 2023, March 11, 2023 and April 12 ,17 & 15,2023, slips show staff attempting to provide services for R1. . (CONTINUATION 9099-C...)the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 28-AS-20230207105455

Allegation investigated: Resident eloped from facility.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Maria Razon and explained the reason for the visit. The investigation consisted of the following: On 2/14/23 LPA Flores conducted an initial visit at the facility and requested a copy of resident/staff rosters, physician's report, identification and emergency sheet, incident reports for resident #1 and #2(R1-R2), discharge documents for R1 for the months of July and August for 2022 for R1 and R2 . LPA Flores interviewed resident #1(R1) and staff #1(S1),#2(S2). On 8/23/23 LPA Flores subpoena Medical Records from Huntington Hospital for R1 and faxed Pasadena Police Department Record Division. On 11/1/23 LPA followed up on subpoena. On 11/16/23 LPA followed up on subpoena documents in person/email, and faxed Pasadena Police Department Record Division. On 11/17/23 LPA Flores received subpoena documents for R1. . On 1/16/24 LPA Flores conducted interviews with 4 additional residents and 3 additional staff. (CONTINUED ON LIC (9099C) Substantiated The investigation consisted of the following: Regarding allegation: Resident eloped from facility. It is alleged R1 was lost during the summer of 2022 and picked up by police. Interviews conducted revealed the following: Administrator stated R1 is not a wander and does not leave the facility unattended. Interview with staff revealed R1 has not left the facility unattended, due to R1’s sight tends to wander inside the facility. However, with redirection R1 finds way back to where R1 needs to go. Interview with R1 revealed, R1 does not leave the facility and does not feel comfortable leaving due to R1’s sight not being great and not knowing the area. Interviews with other residents revealed those that are able to leave the facility unattended do. Upon leaving the facility they notify the staff and when they return they let staff know they are back. Documents reviewed revealed: Incident Report dated 7/4/22 notes R1 went out with another resident on 7/2/22 and did not return to the facility, due to a disagreement between the two residents. The following day R1 continue to be out of the facility. Facility staff proceeded to call hospitals and Pasadena Police Department. It was found R1 was taken to the hospital due to sustaining a fall. R1’s responsible party was notified, who requested R1 not go out due to R1 not being familiar with the area. Physician’s report dated 5/6/22 notes R1 cannot leave the facility unassisted due to visual impairment. Although R1 left the facility with another resident. R1 was not assisted by a staff or responsible party. Therefore, allegation of resident eloping is substantiated. Based on LPAs interviews and record review which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to absence of supervision. Refer to LIC 421IM*** Exit interview was conducted with Maria Razo and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegations: Facility abandoned resident at hospital. It is alleged hospital has attempted several times to call facility and was not able to communicate for discharge. During file review conducted on 2/14/23 there were only 2 residents that went out to the hospital during the time of the allegations and per the allegations only R1 meet the criteria for allegations. Interviews conducted revealed: Administrator maintains a group chat to communicate with care staff regarding sending or discharge of residents to and from hospital. Phone lines have been working. Interviews with residents revealed to not have heard of residents having difficulties returning to the facility upon discharge. Interviews with staff revealed staff are aware when residents go and return form the hospital and keep a chat that notifies each other when a resident is being discharge back to the facility. As well as reception staff respond and are notified by the hospital when a resident is being discharge back to the facility. Documents reviewed for R1, reveal R1 has gone out to the hospital twice, on 1/17/23 and on 2/3/23 for the same health complaint. Huntington Hospital Medical Records subpoena for R1’s visit on 2/3/23 revealed no notes that determined facility was not responding hospital for discharge noted. R1 was discharge back to the facility on 2/8/23. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Maria Razo and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2024 · control 28-AS-20230207163621

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 17, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ...care facilities ... shall... (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are ...to meet their needs. This requirement is not met as evidence by: Based on documents review licensee did not ensure R1 did not leave the facility unassisted which resulted on a fall which poses an immediate risk to the health,safety, or personal rights of the person in care. *Immediate civil penalities assess for $500.00*the state’s words, verbatim · CDSS document, Jan 16, 2024

Plan of correction: Administrator will certify in writing that will ensure that residents do not leave unassisted unless assisted by a staff or responsible party and will provide in-service training to staff to inform staff of which residents are able to leave the facility unassited and which are not and will submit a copy of in-service to the department by POC due date 1/17/23.

Allegation investigated: Facility staff are not properly addressing pest infestation in facility. Facility staff are not addressing tripping hazards on the facility floor. Facility staff are not providing residents with furniture that is in good repair.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. The investigation consisted of the following: On 12/21/2023, LPA Mora obtained copies of staff & resident rosters, interviewed Admission Director, Staff 1 - Staff 2 (S1 - S2) and Resident 1 - Resident 4 (R1 - R4), and toured the facility kitchen, dining room and 8 rooms. During today's visit, LPA obtained copies of staff & resident rosters, interviewed Assistant Administrator, Staff 3 - Staff 4 (S3 - S4), Resident 5 - Resident 8 (R5 - R8) and Pest Control Company, obtained copies of monthly pest control invoices dating back to October 2023, housekeeping schedule, reviewed food delivery receipts for the entire month of December 2023, and conducted a tour of the kitchen, dining room, and 8 rooms. (Continued to LIC 9099-C) Substantiated The investigation revealed the following: regarding the allegation "facility staff are not properly addressing pest infestation in facility", it is alleged that on 12/13/2023 cockroaches were observed in the kitchen of the facility and a dried maggot on the soda machine dispenser spout. Assistant Administrator and 3 staff denied the allegation and stated that pest control comes on a monthly basis. The complainant stated that they asked a staff to dispose of the cockroaches that they found which were alive. LPA interviewed this staff and confirmed the complainant's statement to be true. LPA observed monthly pest control invoices dating back to October 2023. However, LPA contacted the pest control company and stated that in the last 3 months they have only service the outside of the building. They only do the inside of the facility if it requested by the facility. Per their records, there was a request made to conduct pest control services inside the facility and it was scheduled for 12/18/2023 at night, but they were unable to conduct this service because they were not able to get inside the kitchen. Pictures and videos of alive cockroaches in the kitchen were submitted to the Community Care Licensing Division (CCLD) along with this complaint. A picture of the soda machine dispenser spout showing what appears to be a dried maggot was also submitted. On 12/21/2023, LPA observed dead cockroaches in the kitchen and could not identified whether the soda machine dispenser spout had a dried maggot or dried syrup. However, the soda machine dispenser spout did appear to be unsanitary and this will be cited on a separate report. Four of the residents interviewed stated that they have seen cockroaches in either their rooms or hallway. Regarding the allegation "facility staff are not addressing tripping hazards on the facility floor", it is alleged that there are pieces of the flooring that are lifted in multiple locations around the facility. On 12/21/2023, LPA observed floor tile lifting in the dining room and loose/damaged floor tile in room #23. During today's visit, the Assistant Administrator stated that the flooring tile in the dining room has been fixed and LPA confirmed. The floor tile in room #23 still needs repair. Regarding the allegation "facility staff are not providing residents with furniture that is in good repair", it is alleged that in room #23 and #46 both of the residents' dressers were broken into pieces and in room #40 the dresser and table were broken and not able to be used properly. On 12/21/2023, LPA observed that room #40 one of the dresser's drawer was broken into pieces and the table was in good condition. In room #46 one of the drawers of the dresser is loose and it is not sliding in or out properly. LPA did not observed any damage to the furniture in room #23 and confirmed with the resident in that room. Based on observation, record review and interviews conducted, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. Exit interview held and a copy of the report and appeal rights was provided. The investigation revealed the following: regarding the allegation "facility staff does not maintain an adequate food supply for residents.", it is alleged that lack of fruits and vegetables for the number of residents in care. Assistant Administrator and staff denied the allegation. Assistant Administrator stated that they received food delivery on Mondays and Thursdays, and that they always have enough vegetable and fruits for all residents. Residents interviewed could not corroborate the allegation. On 12/21/2023, LPA observed sufficient vegetables and fruits in the kitchen freezer. During today's visit, LPA reviewed the facility's food delivery receipts for the whole month of December 2023 and observed that sufficient vegetables and fruits are being delivered every Monday and Thursday. Regarding the allegation "facility staff are not maintaining the washing machines in good repair", it is alleged that one of the two washers are broken and not able to be fixed. Assistant Administrator and staff denied the allegation. Assistant Administrator stated that both their washers have been working in the recent months. There was one broken washing machine that was immediately replaced back in June 2023 and it was placed in the storage room and on 12/11/2023 it was taken to the back of the facility along with other junk for the trash company to come pick it up. Residents interviewed could not corroborate the allegation and none expressed any issues with laundry needs. On 12/21/2023, LPA observed both washing machines in the laundry room to be properly operating. Regarding the allegation "facility staff are not providing residents with assistance in cleaning their rooms", it is alleged that food crumbs were observed on the ground of residents bedrooms. Assistant Administrator and staff denied the allegation. Assistant Administrator stated that deep cleaning is provided once a week and minor cleaning is provided on a daily basis or as needed. Residents interviewed could not corroborate the allegation and none expressed any issues with housekeeping needs. On 12/21/2023, LPA observed housekeeping going around cleaning the residents rooms. During today's visit, LPA reviewed the housekeeping schedule which shows the days that common rooms and residents bedrooms are deep cleaned. The housekeeping schedule also states at the bottom for staff to check all rooms daily to see if any room needs additional cleaning. 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. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Jan 12, 2024 · control 28-AS-20231214121543

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(27) · Plan of correction due date: Jan 13, 2024

General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observation, interviews, and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. There is sufficient evidence to support that the facility has a cockroach issue.the state’s words, verbatim · CDSS document, Jan 12, 2024

Plan of correction: Facility is to ensure that Title 22 Section 87555 regulations are met at all times. Additionally, facility will submit a plan on how they will address the cockroach issue by 01/13/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 19, 2024

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. LPA observed floor tile lifting in the dining room and and damaged floor tile in room #23, and damaged furniture in room #40 and #46.the state’s words, verbatim · CDSS document, Jan 12, 2024

Plan of correction: Facility is to ensure that Title 22 Section 87303 regulations are met at all times. Additionally, facility will repair the damaged floor tile in the dining room and room #23 and repair or replace the furniture in room #40 and #46, and will submit proof by 01/19/2024.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit regarding a deficiency observed during the investigation of complaint control number 28-AS-20231214121543. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. In complaint control number 28-AS-20231214121543 it was noted that there appears to be a dried maggot in the soda machine dispenser spout. On 12/21/2023 and 01/12/2024, LPA observed the soda machine dispenser spout and could not determine if it is a dried maggot or some other unknown residue, but it is unsanitary. The deficiency cited is documented on the LIC809-D. Exit interview held and a copy of the report and appeal was provided.the state’s words, verbatim · CDSS document, Jan 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jan 13, 2024

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. The soda machine dispenser spout has an unknown residue stuck and needs either deep cleaning or replacement.the state’s words, verbatim · CDSS document, Jan 12, 2024

Plan of correction: Facility is to ensure that Title 22 Section 87303 regulations are met at all times. Additionally, facility will either deep clean the dispenser spout or replace it and submit proof by 01/19/2024

Allegation investigated: Staff do not maintain clean showers for residents use. Staff do not provide resident with basic laundry service. Staff do not provide residents with housekeeping services. Facility does not ensure residents have hot water for showers. Facility staff does not make menus available for review by resident.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. The investigation consisted of the following: On 2/14/23 LPA Calderon obtained a copy of the Staff/Resident rosters and Resident #1's (R1) Admission Agreement. LPA obtained facility laundry schedule for residents, residents shower schedule, food menu, food alternative slips, Staff #1, Staff #2 and Staff #6 (S1, S2 and S6) food handler training certifications. LPA Calderon alongside with Assistant Administrator toured kitchen/cafeteria, three resident showers, residents rooms: Room 1,Room 33, Room 39,Room 40, and Room 46 and laundry room. LPA Interviewed Staff #1- #5 (S1-S5), attempt interview Staff #6 (S6) and interviewed Residents #2-6 (R2-R6). (CONTINUATION 9099-C...) Unsubstantiated On today's visit 1/9/24, LPA toured common shower rooms, measured hot water in shower rooms, observed food menu, and attempt to interview staff #6 (S6) and attempt interview with R1, LPA received and reviewed housekeeping refusal slips. LPA reviewed documentation's provided on 2/14/23. Based on allegation: Staff do not maintain clean showers for residents use. The investigation revealed the following: LPA interview with staff, 6 out of 6 staff informed LPA they deny the above allegation and shower rooms are kept clean for residents. 3 out of 6 staff members informed LPA that cleaning services are done to maintain cleanliness. Interviews with residents on 2/14/23, 3 out of 5 resident's informed LPA that shower's are maintained clean and resident's denied the above allegation. Resident #2 and resident #5 do not use facility showers and cannot collaborate to the above allegation. LPA Calderon observed on visit dates 2/14/23 and 1/9/24 common shower rooms maintained clean and housekeeping staff cleaning shower rooms. LPA reviewed shower / bedding schedule for residents in care, residents per schedule review receive 2 shower days a week and that R1 was on the schedule twice, for assigned shower dates. Based on allegation: Staff do not provide resident with basic laundry service. The investigation revealed the following: Based on interviews conducted with staff, 5 out of 6 staff members informed LPA that residents receive laundry services and it is based on the laundry schedule, each residents have a schedule date for laundry services. Interviews with residents on 2/14/23 revealed that 5 out of 5 residents informed LPA that the facility provides laundry services to the resident's in care. LPA reviewed laundry services schedule and reviewed R1 scheduled for laundry services once a week, per laundry schedule residents have 1 day of laundry services. LPA during 2/14/23 visit to the facility, observed working laundry machines. Based on allegation: Staff do not provide residents with housekeeping services. The investigation revealed the following: Interview with staff, 5 out of 6 informed LPA that housekeeping staff provide housekeeping services for residents. Interviews with residents on 2/14/23 revealed that 5 out of 5 resident's informed LPA that residents are providing housekeeping services and denied the above allegation. LPA during 2/14/23 visit to the facility, LPA toured random rooms: Room 1, Room 33, Room 39, Room 40, and Room 46; LPA observed clean rooms. On visit date 1/9/24 LPA observed two house keepers on shift cleaning resident's rooms and bathrooms. LPA reviewed R1's refusal of housekeeping services slips, R1 refused housekeeping on February 18 & 24, 2023, March 11, 2023 and April 12 ,17 & 15,2023, slips show staff attempting to provide services for R1. . (CONTINUATION 9099-C...) Based on Allegation: Facility does not ensure residents have hot water for showers. The investigation revealed the following: 6 out of 6 staff during interview denied the above allegation and informed LPA there is hot water at the facility for residents to shower with. Staff #2- Staff #4 (S2,S3 & S4) informed LPA that hot water in certain common shower rooms takes time to heat up but shower's do deliver hot water. Interviews with residents 4 out of 5 resident's informed LPA that facility has hot waters for showers. R5 cannot collaborate to the above allegation. LPA on visit dates 2/14/23 and 1/9/24 tested hot water in common shower rooms. On 2/14/23 and 1/9/24, hot water was measured and tested and measured between the required Title 22 regulation. LPA tested water and LPA observed hot water taking some time for water to get hot between the required Title 22 measurements. Based on Allegation: Facility staff does not make menus available for review by resident. During the Investigation the following was revealed: During investigation 5 out of 6 staff stated the food menu is readily available for residents to review. S3 was unable to collaborate as their job duties does not pertain to working in the kitchen nor dining room. Interviews with residents on 2/14/23 LPA was informed by 6 out of 6 residents either couldn't collaborate with the allegation above due to not being aware, cannot see, not aware and/ or doesn't care. LPA observed on 2/14/23 and 1/9/24 food menu posted located in kitchen and dining room for resident's review. 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. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 9, 2024 · control 28-AS-20230207105455

Allegation investigated: Staff did not ensure that resident's toileting needs were met while in care. Staff did not ensure that resident's hygiene needs were met while in care. Staff do not provide assistance to resident in a timely manner.

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced subsequent complaint investigation visit at the facility regarding the above allegations. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: On 10/10/23, LPA Calderon conducted interviews with Staff #1-4 (S1-S4) and Residents #1-7 (R1-R7). LPA collected copies of Staff and Resident Rosters. LPA collected and reviewed R1's Face Sheet, Physician Report and R1's Appraisal/ Needs and Service Plan and Incident Reports for incidents relevant to the investigation. LPA via telephone interviewed Case Manager for R1 from DHS- Exodus Recovery. On today's visit date 01/05/24, LPA collected and reviewed Special Incident Reports (SIR) for incidents relevant to the investigation, R1 meeting notes with R1's care team and conducted interview with Assistant Administrator. (Continuation 9099-C) Unsubstantiated Regarding allegation: Staff did not ensure that resident's toileting needs were met while in care. (5) out of (5) staff interviews conducted LPA was informed all residents who require toileting assistance get assistance by staff. (5) out of (5) staff informed LPA their are no residents who are left covered in feces and urine. Assistant Administrator and S4 informed LPA R1 would call the police if they did not get assistance right away upon their request. Per record review on staff notes with DHS meeting for R1 states facility stating concern for R1 due to refusing assistance from staff at times. Per Pasadena Police Department Officer Moreno observed R1 not covered in feces and urine and being assisted by facility staff during time of visit. LPA during interview with R1 was observed to not covered in feces and urine. Regarding allegation: Staff did not ensure that resident's hygiene needs were met while in care. (5) out of (5) interviews with staff, LPA was informed denying the above allegation and that residents are provided assistance with hygiene needs like shower, adult brief and clothing change, laundry services and linen change. During record review special incident report for R1 dated 9/30/23, 10/20&26/23, and 11/18/23 states staff attempt to assist R1 and R1 would refuses assistance from staff personnel's. Per record review on staff notes with DHS meeting for R1 states facility stating concern for R1 refusing assistance from staff at times. LPA observed R1 during interview to be groomed and appears to have hygiene needs met. Regarding allegation: Staff do not provide assistance to resident in a timely manner. LPA interview with (5) out of (5) staff stated resident's get assisted in a timely manner and denied the above allegation. (3) out (5) staff informed LPA residents get check on when calling the signal system or asking for assistance within 5-15 min time frame and if staff are in the middle of job duties helping other residents, staff communicate with resident's letting them know they will be attended to shortly or front office staff assist residents when caregivers are busy attending to others. (4) out (5) staff informed LPA that R1 would not want to wait at all when they requested assistance and at times would refuse care needs. (5) out of (7) residents in care during interviews conducted on 10/10/23 residents informed LPA that they personally are assisted with their activities of daily living in a timely manner and denied the above allegation. Record review on special incident report regarding R1 states staff multiple times attempt to assist R1 and due to R1's behaviors and refusing care R1 calls 911 reports being neglected even when staff attempt to assist resident. During record review special incident report for R1 dated 9/30/23, 10/20&26/23, and 11/18/23 states staff attempt to assist R1 and R1 would refuses assistance from staff personnel's.Per record review on staff notes with DHS meeting for R1 states facility stating concern for R1 refusing assistance from staff at times.Police documentation with Pasadena Police Department Officer Moreno stated neglect and abuse allegation regarding R1 was unfounded. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 5, 2024 · control 28-AS-20231002130434

Allegation investigated: Staff not providing adequate supervision resulting in resident-on-resident altercation.

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced subsequent complaint investigation visit at the facility regarding the above allegations. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: On 10/10/23, LPA Calderon conducted interviews with Assistant Administrator Alexander Solorio, Staff 1-4 (S1-S4) and Residents 1-7 (R1-R7). R1 was not interviewed as resident was not at the facility at the time of the visit. LPA collected copies of Staff and Resident Rosters, Resident #1 and Resident #2 (R1 and R7) face sheet, physician's report and appraisal / needs and service plan. LPA also collected a copy of Unusual Incident/ Injury Report dated 09/29/23, SOC 341 self reporting dated 9/29/23, and Skin Integrity Report for R1 dated 10/6/23. On today's visit, 1/5/24, LPA Calderon along side with LPA Tena Herrera conducted interview with R1. LPA conducted interview with R3. LPA reviewed records provided on 10/10/23 for residents R1 and R7. (CONTINUATION 9099-C) Unsubstantiated Allegation regarding: Staff not providing adequate supervision resulting in resident-on-resident altercation. The investigation revealed the following: S2 during LPA interview conducted informed LPA S2 was passing by R1 and R7 room when hearing an argument between roommates and S2 approached room to see what was occurring. (5) out of (5) interviews conducted informed LPA staff do resident room checks throughout the day and intervene between residents when altercations occur. During interview with R1 conducted on 1/5/23 R1 stated facility did the best they can and roommates were separated into different rooms. R7 denied altercation occurring between self and R1. (5) out of )7) resident interviews informed LPA that facility staff provide adequate supervision and assist residents when altercations arise between residents. It was reported with interview by Hospital staff that are R1 stated to them during hospital visit that staff member walked into residents room were altercation took place and broke up altercation. LPA Calderon reviewed Special Incident Report (SIR) dated 9/29/23 per report: R1 and R7 were involved in an verbal altercation in the AM and S2 observed altercation and S2 as approaching situation observed R2 hitting R1. Action conducted by S2 was to provide first aid to R1 and R1 was taken to the hospital and once R1 returned to the facility after hospital discharge R1 was offered to move rooms. Record review on SOC 341 provided to LPA completed by Assistant Administrator was reviewed and submitted to licensing in a timely manner with SIR, SOC states R1 and R7 were roommates and due to altercation resident's became ex-roommates. LPA reviewed Skin Integrity Report regarding R1 and states staff S2 assisted with care due to injury sustained during altercation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 5, 2024 · control 28-AS-20231002104939

Allegation investigated: Facility staff did not prevent an altercation between residents.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit regarding the above allegation. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit The investigation consisted of the following: During today's visit LPA toured facility, dining room, various resident bedrooms, and obtained copies of resident and staff rosters, copy of Incident Report Regarding Altercation between R1 and R2, Behavior Contract for R1 and conducted interviews with 7 Residents (R1-R7) and 5 Staff (S1-S5). Continued on (9099-C) Unsubstantiated The investigation revealed the following: Allegation: Facility staff did not prevent an altercation between residents. It is alleged that facility staff did not prevent R1 and R2 from being involved in a verbal altercation that then turned physical. LPA reviewed incident report pertaining to the above allegation along with the report of suspected dependent / elder abuse, incident report indicated that authorities were called, no injuries were reported and both parties were left in the care of the facility. Note from authorities indicated the same observation. Interviews with Residents 7 out of 7 residents denied the above allegation and stated that staff try there best efforts to de-escalate altercations and will speak with each resident to mediate the situation until both parties have calmed down. 4 out of 7 residents indicated that staff will relocate a resident if needed to ensure distance and safety of residents. During interview with R1 it was stated that they cannot remember exactly why they threw coffee at R2 but are sure it was because R2 made an inappropriate comment while passing by R1. R1 further stated that R2 pushed them and staff separated the two parties. Interview with R2 stated that they recall the situation, staff separated both parties and the authorities arrived, R2 stated that they refused to press charges against R1. Both R1 and R2 stated that they have since been separated and have no longer had any other altercations and do not speak to one another. During tour, LPA observed R1 and R2 sitting at separate tables on opposite ends of the dining area during breakfast. Interviews with Staff 5 out of 5 Staff denied the above allegation and stated that when they hear residents begin to argue they will speak to the residents, separate them and de-escalate the situation, a report will be made to management and they will then mediate the situation explaining the house rules that each party agreed upon and find a way to keep both parties safe and content. Based on statements and interviews conducted with staff and residents, review resident records, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview held, and a copy of this report was provided to Alexander Solorio.the state’s words, verbatim · CDSS document, Jan 5, 2024 · control 28-AS-20230526075044

Allegation investigated: Staff handle residents roughly during diaper changes. Residents are afraid of retaliation from staff if they disclose concerns to the Ombudsman and Licensing.

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. On 07/06/2023, the investigation consisted of the following: LPA Calderon collected staff and resident roster and resident #1 (R1) and resident #4 (R4) recent service tracker log. LPA Calderon interviewed Assistant Administrator Alex and Staff #1 (S1). LPA interviewed Residents #1-#7 all whom were incontinent care residents. LPA observed and tested Signal system buttons (pendants) in room 4, room 6, room 8, room 14 and room 40. During visit LPA tested signal system and staff assisted in a timely manner, staff responded to residents between 2 minutes- 17 minutes when pendant was tested. On today's visit 1/4/23, LPA's investigation consisted of interview with Staff #2-Staff #4 (S1-S4). Toured facility for required postage of Ombudsman poster and Licensing poster Continuation on 9099-C... Unsubstantiated Based on Allegation: Staff handle residents roughly during diaper changes. Investigation revealed: Assistant Administrator and S1-S4 informed LPA that they haven't witnessed or observed any staff handling residents roughly when having their adult brief's changed. (5) out of (5) staff informed LPA during interviews that they change every incontinent residents in a proper way that is not rough and deny the above allegation. (5) out of (7) residents informed LPA staff haven't treated them rough when getting their adult brief's changed. Based on Allegation: Residents are afraid of retaliation from staff if they disclose concerns to the Ombudsman (LTCO) and Licensing (CCLD). Interviews with (7) out (7) residents interviewed on 7/6/23 LPA was informed that resident deny the above allegation and they are not afraid of staff retaliating residents if disclosing information. R1 informed LPA they are not afraid of retaliation by staff but concern they staff ask what was disclosed to CCLD and LTCO. LPA observed CCLD and LTCO posters with information to contact agencies per rights of the residents/ staff and visitors located in the hallway. 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. Exit interview held and a copy of the report was provided Based on allegation: Night staff do not respond to assist residents with care. (4) out of (7) residents interviews with LPA on 7/6/23 revealed caregivers did not attend to residents during the night. Although residents were not able to inform LPA with a time frame on wait time residents informed LPA they would wait for a long time or the night staff were not doing rounds to check on them. (3) out of (5) staff during interviews informed LPA being aware of residents informing staff that night shift staff were not efficiently responding attending to residents at night. S3 and S4 informed LPA R1 calls staff frequently around 3-5 minutes asking for assistance and although R1 may need to wait at times because staff are doing their duties and caregiving are attending to all residents needs, R1 does receive assistance.LPA reviewed resident(s) in-service log sheet for R1, R2, R4 R5 logs showed no indication of nocturnal shift logging in-service for residents listed between months of June-July 2023. Assisted Administrator and S1 stated caregivers duties are to check on residents every 2 hours during rounds and as needed. Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations per Title 22, are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights.the state’s words, verbatim · CDSS document, Jan 4, 2024 · control 28-AS-20230630094920

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87415(a) · Plan of correction due date: Jan 26, 2024

Night Supervision(a)The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with....planned emergency procedures, shall be trained in first aid..., Incidental Medical and Dental Care Services and shall be available as indicated below to assist in caring for residents in the event of an emergency. The requirement was not met as evidenced by: LPA reviewed R1, R2, R4 R5 in-service alongside with Staff #1(S1) and there were no identifier's showing nocturnal shift provided care and supervision to resident(s). Interviews with (3) out of (5) staff stated residents were being aware of issues with noc shift caring for residents. Interviews with residents (4) of (5) informed LPA night shift staff were not assisting/ responding to residents to provide care and supervision .the state’s words, verbatim · CDSS document, Jan 4, 2024

Plan of correction: Administrator will have a training to refresh staff on care and supervision with night shift staff and review Regulations : 87415 Night Supervision, Health and Safety Reg on Basic Services Requirement 1569.312 and Care and Supervision 1569.2. and go over in-service log and how to properly check on resident's through the night especially incontinent residents. Admin. will provide LPA with in-service sign in sheet and materials used during training.

Allegation investigated: Staff are unable to communicate with resident due to a language barrier.

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced subsequent complaint visit to investigate the aboved allegation. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. On 07/06/2023,the investigation consisted of the following: LPA Calderon collected staff and resident roster. LPA interviewed Residents #1-#7. (R1-R7) and interviewed Assistant Administrator Alexander Solorio and Staff #1 (S1). On today's visit 1/4/23, LPA's investigation consisted of interview with Staff #2-Staff #4 (S1-S4). Based on allegation: Staff are unable to communicate with resident due to a language barrier. Continuation on 9099-C... Unsubstantiated Interviews LPA conducted with Assistant Administrator, S1-S4 informed LPA that although some staff aren't fluent in English, staff understand requests from residents and based on staff and resident's preferred / native language spoken in and in order to communicate among each other staff use google translator when needed to communicate with residents. Assistant Administrator informed LPA having staff that speak English present during each shift and providing resident's and ensuring residents are able to communicate their needs.. (7) out of (7) residents interviewed on visit date 7/6/23 informed LPA not being able to collaborate if other residents who reside at the facility are unable to communicate with staff do to language barriers. (6) out of (7) residents informed LPA that as for their communication needs with staff, staff can communicate with them and language barrier does not interfere with communication. LPA observed during time of visit English and Spanish speaking staff and residents. LPA observed interactions with staff and residents and residents and staff are able to communicate with each other. 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. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Jan 4, 2024 · control 28-AS-20230703095829

Allegation investigated: Staff did not provide resident with medications as prescribed.

Licensing Program Analyst (LPA)Wong conducted an initial 10 days complaint visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Receptionist Scarlett Munoz who allowed entry into the facility and was later met by Admission Director Madison Aceves who assisted with the visit. The investigation consisted of the following: LPA interviewed seven (7) residents (R2-R8), three (3) staff in the facility and Resident#1 (R1) sister in the facility and assistant administrator via telephone and obtained documents including: staff and residents rosters, R1's face sheet, physician report, needs and service plan, care plan, medication list and also reviewed R1-R7 medication in the facility. (See LIC 9099C for continuation) Unsubstantiated The investigation revealed of the following: Allegation "Staff did not provide resident with medications as prescribed. " LPA interviewed seven residents, seven out of seven denied the allegation and reported staff take good care of their medication and staff administrated their medication daily. LPA interviewed staff and stated R1's sister dropped off the medication after R1 was discharged from the hospital but without any doctor's order and it's an injected medication which the facility cannot administer (Fulphia). The staff told R1's sister that they cannot administer as they are not a medical facility. LPA also inspected seven (7) residents' medication and all the medication are centrally stored and all resident medication are following with the doctor's order and seemed accurate and updated. Based on the interviews conducted, observation and documents 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 is UNSUBSTANTIATED. Exit interview held and a copy of the report was provided The investigation revealed of the following: Allegation "Staff did not ensure resident had oxygen." It's alleged that R1's oxygen tanks were not filled and R1 had no oxygen. LPA interviewed staff and stated R1 was discharged from the hospital along with the oxygen tank. Staff reported R1 has been in and out from the hospital recently. LPA asked staff if R1's oxygen tank were empty while R1 was sent out to the hospital and staff stated they do not know anything about it. According to the hospital staff, a witness was observed R1's oxygen tank were not filled and R1 had no oxygen. Based on the observation and interviews conducted with staff, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit Interview conducted and a copy of the report and appeal right was provided.the state’s words, verbatim · CDSS document, Dec 21, 2023 · control 28-AS-20231215162057

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87618(b)(3)(H) · Plan of correction due date: Dec 22, 2023

87618 Oxygen Administration-Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (H) Equipment shall be operable. The requirement was not met as evidenced by a witness observed R1 oxygen tanks were not filled and R1 had oxygen which posed a immediate risk to residents in care.the state’s words, verbatim · CDSS document, Dec 21, 2023

Plan of correction: Licensee agreed to review Title 22 Regulations, 87618(b)(5) and submit a written plan detailing how administrator would ensure staff understand how to operate the oxygen equipment. Licensee would provide proper training to staff how to operate the oxygen machine. POC due on 12/22/23

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christine Wong conducted a Case Management Deficiencies visit due to observation made while investigating complaint control # 28-AS-20231215162057 visit. The purpose of the visit was explained to the Admission Director Madison Aceves During the complaint visit, LPA tried to obtain incident report for Resident#1 (R1) hospital admission for month of December, 2023 and the staff was not able to provide and indicated they do not have access to incident reports except certain staff. Deficiencies are being cited. See LIC 809-D. Exit interview was held and a copy of this report, 809-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Dec 21, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jan 4, 2024

87211 Reporting Requirements: (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 specified in (A) through (D) below.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. The requiement was not met as evidenced: LPA tried to request R1's incident reports for the month of Dec 2023, but staff reported they do not have any access on it and LPA was not able to obtain any incident reports during the complaint visit.the state’s words, verbatim · CDSS document, Dec 21, 2023

Plan of correction: Administrator to submit incident reports to licensing for the period 12/1/23 through 12/21/23 regarding resident #1 and send a plan to licensing regarding how Licensee will ensure that the facility is reporting incident as required by Title 22 regulation by POC due date.

Allegation investigated: Staff did not ensure the resident was accorded privacy during her phone conversation Staff spoke inappropriately to resident in care Facility staff harasses resident Facility staff did not protect resident from being inappropriately touched by another resident Resident’s hair was pulled by another resident due to lack of supervision Facility staff did not safeguard resident’s belongings Facility staff does not provide adequate amount of food Facility staff does not serve nutritious meals Facility staff does not follow food menu

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. The investigation consisted of the following: On 12/14/2022, LPA obtained copies of staff & resident rosters, interviewed Assistant Administrator, Staff 1 (S1), Resident 1 - Resident 6 (R1 - R6) and toured the facility kitchen & dining room. LPA reviewed surveillance video of the incident involving R1 and R2. Copies of R1's appraisal/needs and service plans, R1's incident reports, facility's house rules, and December 2022 menu & alternative menu were obtained and reviewed. Today's visit, LPA obtained copies of staff & resident rosters, interviewed Staff 2 - Staff 3 (S2 - S3), Resident 7 - Resident 8 (R7 - R8) and toured the dining room during lunch time. (Continued to LIC 9099-C) Unsubstantiated The investigation revealed the following: Regarding the allegation "staff did not ensure the resident was accorded privacy during her phone conversation", it is alleged that the Assistant Administrator eavesdrop on a Resident 1 (R1) calls with the ombudsman. Assistant Administrator and staff denied the allegation. Residents interviewed could not corroborate the allegation. Regarding the allegation "staff spoke inappropriately to resident in care" and "facility staff harasses resident", it is alleged that a staff belittles, stares down, gives evil looks, and intimidates Resident 1 (R1). Assistant Administrator and staff denied the allegations. Residents interviewed could not corroborate the allegations and 3 residents stated that R1 was the one insulting and harassing the staff. Regarding the allegation "facility staff did not protect resident from being inappropriately touched by another resident", it is alleged that Resident 3 (R3) inappropriately touches Resident 1 (R1). Assistant Administrator and staff denied the allegation. R3 denied the allegation and stated that R1 falsely accuses R3 whenever R3 does not get R1 alcohol. Residents interviewed could not corroborate the allegation and 2 residents stated that R1 mistreats and harasses R3. Regarding the allegation "resident’s hair was pulled by another resident due to lack of supervision", it is alleged that Resident 2 (R2) pulled Resident 3 (R3) hair for no reason and staff did nothing. Assistant Administrator showed the LPA a video footage of the incident with a date and time of 10/09/2022 at 9:58pm. According to the surveillance video, a staff is observed escorting R1 back to the room in a wheelchair. At the same time, R2 is observed coming in the direction of R1 (from the opposite side) also in a wheelchair. R2 is observed suddenly reaching over with the right hand and pulling the hair of R1. The staff is observed immediately intervening and breaking up the incident and separating both residents. After the incident, the staff is observed continuing to escort R1 back to the room. Although the incident did occur, R2's action was so sudden and unpredictable for the staff to prevent the incident from happening, but the staff quickly intervened and prevented the fight from escalating. This allegation was previously investigated in complaint control number 28-AS-20221014123935 and the allegation was found unsubstantiated. (Continued to LIC 9099-C) Regarding the allegation "facility staff did not safeguard resident’s belongings", it is alleged that Resident 1 (R1) personal belongings were stolen from R1's room. Assistant Administrator and staff denied the allegation. Residents interviewed could not corroborate the allegation. Regarding the allegation "facility staff does not provide adequate amount of food", "facility staff does not serve nutritious meals" and "facility staff does not follow food menu", it is alleged that the facility does not serve enough food to the residents, the food is not healthy because it is all carbs, and the menu is not being followed. Assistant Administrator and staff denied the allegations. Staff 1 (S1) who is the cook stated that an adequate amount of food is served and they follow a menu created by a certified nutritionist. Their food contains proteins, carbs and veggies. The residents are notified in a timely manner if there are any modifications to the menu to give them a chance to decide if they want to order something from the alternative menu. Residents interviewed could not corroborate the allegations. During the tours of the kitchen and dining room, the LPA observed an adequate amount of food being served that consisted of proteins, carbs and veggies. 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. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Dec 12, 2023 · control 28-AS-20221209134534

Allegation investigated: Staff did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit regarding the above allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. The investigation consisted of the following: LPA Mora obtained copies of staff & resident rosters, and interviewed Assistant Administrator, Staff 1, and Resident 1 - Resident 8 (R1 - R8). LPA also reviewed R1's Record of Client's/Resident's Safeguard Cash Resources. The investigation revealed the following: regarding the allegation "staff did not safeguard resident's personal belongings, it is alleged that a staff stole $200 and a bag from a resident's room. Assistant Administrator and staff denied the allegation. Assistant Administrator showed the LPA a lobby video footage of a staff giving Resident 1 (R1) P&I money. The video footage has a date and time of Friday (12/01/23) at 9:21am and per R1's Record of Client's/Resident's Safeguard Cash Resources a total of $200 was given to R1 on 12/01/23. After receiving the money the resident was out in the community all dat Friday 12/01/23. (Continued to LIC 9099-C) Unsubstantiated Assistant Administrator stated that on Sunday 12/03/23, R1 called the police to report theft and R1 accused Staff 1 (S1). He also stated that the bag was found in R1's room on 12/04/2023. LPA interviewed S1 and S1 denied stealing any money or a bag from R1. Information provided by the Pasadena Police Department stated that on Sunday 12/03/23 at 6:00pm they responded to this facility regarding a resident calling to report that he/she was a victim of a theft and the resident suspected S1. Resident told the police that he/she was missing money ($200.00) and a bag from his/her room. However, the resident did not have any evidence to prove that S1 took the items and the police officer was not able to locate any independent witnesses. LPA interviewed R1 and R1 denied calling the police on 12/03/23, and R1 stated that the money was not stolen over the weekend and that it happened Thursday 11/30/23 at night when he asked S1 to help him/her take out a laptop and other things from R1's backpack where he/she had the money (however, the $200 were given to R1 on the morning of Friday 12/01/23). R1 stated every night he/she will ask staff to help him/her take out things from his/her backpack because he/she has no hands. R1 denied receiving the $200 on Friday 12/01/23 and stated that the $200 were given to him/her on the morning of Thursday 11/30/23. R1 also stated that he/she was at school all day on Friday 12/01/23 and got back to the facility around 7pm and that is when R1 realized that the money was missing and he/she complained to the Assistant Administrator and staff. R1 stated that none of his/her bags were stolen only the money. The other 7 residents interviewed could not corroborate with the allegation and they all stated that staff have not stolen from them. 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. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Dec 7, 2023 · control 28-AS-20231204104639

Allegation investigated: Facility illegally evicted a resident in care.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit in response to the above allegation. LPA met with Maria “Luisa” Razo (Resident Care Director) and discussed the purpose of today's visit. The investigation consisted of the following: During today's visit, LPA interviewed Staff members 1 - 5 (S1 - S3) and Resident 1, LPA obtained the following copies from R1’s File: Physician’s Report, Needs and Service Plan, Behavior Contract, Incident Reports, copy of the Written 30-day Eviction Notice, and Facility House Rules. (Continued on the 9099-C) Unsubstantiated The investigation revealed the following: Allegation: Facility illegally evicted a resident in care. It is alleged that R1 was evicted from facility and there was no notice or reason provided on eviction. LPA reviewed R1’s file and found copies of the 30-day eviction notice, with reasoning for eviction, dated 11/20/23. LPA reviewed multiple incident reports for R1 that document dates where resident had left facility and suffered a fall while out in the community, upon return to the facility, resident will appear to be confused, disoriented, lethargic and refusing care. Interviews with staff 5 out of 5 staff stated that R1 will often leave the community and get lost, be returned to the facility by neighbors, pedestrians, and law enforcement on many occasions. 5 out of 5 staff also stated that R1 is an over all friendly and calm resident when sober, however, when intoxicated is when R1 becomes aggressive and refuses care. Staff stated that R1 has returned to facility after being out in the community aggressive, confused, disoriented and what appears to be intoxicated. R1 has been on a Behavior Contract since 7/2/2023 due to noncompliance in following House Rules and aggressive behavior towards staff and residents. LPA interviewed R1, and resident stated that they were informed about the eviction but was not sure why they were being evicted. R1 also stated that they did sign the eviction letter on 11/20/23 but does not have a copy LPA provided copies of 30-day eviction notice and reasoning's behind eviction to R1 prior to end of visit. R1 further stated that there have been times where they would get lost in the community but this hasn’t happened in a long time, when asked about aggressive behavior towards other residents R1 stated that there have been a few altercations but that is in the past and all parties have reconciled since then. R1 did not appear to be confused or disoriented during visit. Based on statements and interviews conducted with Staff and R1, and review of R1's files, there was not enough supportive evidence to concur with the reported allegation. 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. Exit interview held, and a copy of this report was provided to Luisa Razo.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 28-AS-20231127165020

Allegation investigated: Staff does prevent the spread of lice. Staff does not ensure resident's bathing needs are being met. Resident has threatened another resident in care.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit in response to the above allegations. LPA met with Maria “Luisa” Razo (Resident Care Director) and discussed the purpose of today's visit. The investigation consisted of the following: During today's visit, LPA interviewed Staff members 1 - 5 (S1 - S3) and Residents 1-10 (R1 – R10). Reviewed R2’s file and obtained copies of R2’s Physician Report, Shower/Bedding Schedule, Staff Roster, and Resident Roster. (Continued on 9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff does prevent the spread of lice. It is alleged that there is an outbreak of lice at the facility, its alleged that R2 has lice and facility has done nothing to address this issue. Interviews with Staff, 5 out of 5 Staff denied the above allegation and stated that they have not received complaints from residents regarding lice or itching. 5 out of 5 staff stated that if there is ever a resident with lice they follow procedures with disinfecting, cleaning, treating the residents with lice and checking all other residents for lice. Interviews with residents, 9 out of 10 residents denied the above allegation and stated they do not have lice nor have they heard anything about other residents at the facility having lice. Allegation: Staff does not ensure resident's bathing needs are being met. It is alleged that R2 does not bathe, and facility is not doing anything to ensure the resident’s bathing needs are being addressed and met. LPA reviewed R2’s file and it revealed that R2 does need assistance with bathing. There is a Shower Schedule that the facility follows and R2 is provided with assistance in bathing twice weekly. Interviews with staff 3 out of 5 staff stated that although they have to remind R2 about showering R2 is compliant with showers and is being provided with assistance with bathing. LPA reviewed forms of residents who refuse to shower and R2 was not a resident listed as non-compliant. Interviews with residents 9 out of 10 residents denied the above allegation and stated that they are provided with showering/bathing needs and have a scheduled date 2-3 times weekly where they shower. Of the residents that need assistance with bathing each stated that they are provided with the assistance and are showered regularly. Interview with R2, resident stated they bathe at facility twice weekly and at their families home once weekly. LPA observed R2 and R2 was with clean clothing, face and hands clean and appeared well groomed. (Continued on 9099-C) Allegation: Resident has threatened another resident in care. It is alleged that R2 threatened R3, destroyed their personal belongings and has threatened them. Interviews with staff 5 out of 5 staff stated that R2 is not aggressive and have not heard of R2 having altercations with other residents. S4 stated that on one occasion R2 did have a disagreement with roommate but this incident did not become aggressive and was addressed in a timely manner and R2 was located to a different room to avoid further issues by the next day. Interviews with residents 8 out of 10 residents stated that they have not had any altercations with other residents, have never had their personal property destroyed by another resident and feel safe at facility. During interview with R3, resident denied allegation and stated that they have never been in an altercation with another resident and have never had their belongings destroyed by anyone while at the facility. Based on statements and interviews conducted with Staff and residents, and review of residents files, there was not enough supportive evidence to concur with the reported allegation. 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. Exit interview held, and a copy of this report was provided to Luisa Razo.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 28-AS-20231129083238

Allegation investigated: Personal Rights/Resident sustained injuries while in care.

Licensing Program Analyst (LPA) Elizabeth Irra met with Maria Razo/Resident Care Director. The purpose of today's visit is to deliver findings for the above allegation. On 05/26/2021, Licensing Program Analyst (LPA) Nicole Spencer conducted a Health and Safety check visit in response to the above allegation. LPA met with assistant administrator Alex Solorio and explained the reason for the visit. The investigation consisted of the following: LPA Spencer requested a copy of Staff roster and Resident roster. LPA Spencer conducted a health and safety check which included a tour of the lobby, 5 resident rooms, dining room, outdoor patio, kitchen and food supply. LPA observed that there was at least a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. The facility was clean and in good repair and there were no observable signs of neglect, abuse or other immediate health and safety threats. During this visit, it was been determined that the above allegations will require further investigation. Refer to LIC 9099C for the continuation of this report. Substantiated Allegation: Personal Rights/Resident Sustained injuries while in care. The investigation for this allegation was conducted by Investigator Edward Hector. During this investigation, IB Investigator Edward Hector conducted interviews with the Wise & Healthy Aging Ombudsman, Staff #1 (S-1) through Staff #2 (S-2) and Resident #1 (R-1) through Resident #3 (R-3). Investigator Edward Hector obtained and reviewed R-2’s hospital medical records. Per Investigator Edward Hector, “staff admitted that there was a history prior to the incident that showed R-2 may have needed a higher level of care. Interviews of staff, residents and Investigator observations revealed that there was a lack of available staff and staff response when requested. There is sufficient evidence to support the allegation of lack of supervision resulted in R-2 sustaining injury”. LPA Irra obtained additional documentation which revealed that R-2 had (9) falls between 03/25/21 through 05/31/21. On 05/17/21, R-2 fell and sustained a pelvic fracture. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 1 is being cited. Immediate Civil Penalties will be issued today, in the amount of $500.00 due to: Personal Rights/Resident Sustained injuries while in care. Exit interview conducted. A copy of the LIC9099, LIC9099C, LIC9099D and LIC421IM (Civil Penalty Assessment), and Appeal Rights were provided to Maria Razo/Resident Care Director Allegation: Personal Rights/Facility did not seek timely medical treatment for resident. The investigation for this allegation was conducted by Investigator Edward Hector. During this investigation, IB Investigator Edward Hector conducted interviews with the Wise & Healthy Aging Ombudsman, Staff #1 (S-1) through Staff #2 (S-2) and Resident #1 (R-1) through Resident #3 (R-3). Investigator Edward Hector obtained and reviewed S-2’s hospital medical records. Per Investigator Edward Hector, “R-2 admitted to refusing services and not always notifying staff of unwitnessed falls. Staff advised that R-2 would regularly contact R-2’s social worker for assistance, instead of facility staff. Residents confirm that R-2 would routinely not ask for help from facility staff. There is insufficient evidence to support the allegation that staff had a failure to seek timely medical attention. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report and Appeal Rights were provided to Maria Razo/Resident Care Directorthe state’s words, verbatim · CDSS document, Nov 30, 2023 · control 28-AS-20210525125201

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 1, 2023

Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This standard is not met at evidence by: "staff admitted that there was a history prior to the incident that showed R-2 may have needed a higher level of care. Interviews of staff, residents and Investigator observations revealed that there was a lack of available staff and staff response when requested. There is sufficient evidence to support the allegation of lack of supervision resulted in R-2 sustaining injury”.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: Facility Administrator to submit a statement indicating that the facility will update residents’ needs when there is a change in condition. Immediate Civil Penalties will be issued today, in the amount of $500.00.

Allegation investigated: Staff did not ensure resident was clothed Staff did not ensure resident had eaten Staff did not check on resident during the night

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit at the facility regarding the above allegations. LPA met with Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: On 8/22/23 LPA Trueman conducted an initial investigation visit and collected documents. On 11/13/23 LPA Flores conducted interviews with assistant administrator, 3 staff, and 6 residents. LPA collected the following documents: physician’s report, admission agreement, identification and emergency information, medication sheet for July – September 2023, needs and care plan, incident report dated 8/12/23, other documents for resident #1 (R1). The investigation revealed the following: Regarding allegation: Staff did not ensure resident was clothed. It is alleged R1 was completely nude sitting on R1’s wheelchair outside the facility around 9:50am. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews conducted with residents revealed, residents stated that upon residents needing assistance in a situation like R1’s caregivers attempted to assist residents by redirect them even when the residents refuse. Interviews with staff revealed providing assistance with dressing to the residents is part of their duties. There are times when residents become impatience and they may go out without clothes. Residents become distraught and refuse caregivers’ assistance. Caregivers at that point seek for management’s assistance to help the residents. Document reviewed revealed; Incident Report dated 8/12/23 notes the morning of 8/12/23 at 9:00am management observed R1 “was naked in the front patio. Caregiver and manager attempted to assist R1 to return inside and get changed but refused. Management proceeded to set up transportation for a 5150 and contacted Pasadena Police Department”. Additional incident report notes, on 8/12/23 staff attempted at least 5 times to provide care to R1, who refused each time. Although R1 may have been nude, staff attempted to assist and redirect R1 to get dress. However, R1 refused the assistance. Due to R1’s behavior, management team reached out to Pasadena Police Department to assist with a 5150 for R1 to provide proper care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not ensure resident had eaten. It is alleged R1 was upset because R1 wanted food when found outside around 9:50am. Interviews conducted revealed 5 out of 6 residents stated facility provides meals, reminders, or assistance with feeding the residents. 1 out of 6 residents stated to not be receiving meals at the facility as resident is out most of the day. Interviews with staff revealed residents receive meals three times a day and staff provides assistance with feeding to those residents that cannot feed themselves. Assistant administrator stated R1 can feed self as long as R1’s prosthetics are on. Document review revealed R1’s physician’s report notes R1 needs assistance with feeding. However, needs and service plan notes R1 is able to feed self and staff will assist as needed. Incident report dated 8/12/23 notes staff prompted assistance to feed R1 on 8/12/23 during breakfast but R1 refused the assistance. Although R1 may have wanted food and did not receive breakfast the morning of 8/12/23, staff attempted to provide breakfast and R1 refused the assistance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.(CONT.LIC9099C) Regarding allegation: Staff did not check on resident during the night. It is alleged R1 was naked in the morning because R1 had not been checked up on during the night. Interviews conducted with residents revealed, 5 out of 6 residents stated there is staff overnight, who provide assistance or check on the residents as needed and 1 out of 6 residents stated assistance is not provided at night. Interviews with staff revealed that part of the duties of the night shift is to check on the residents during the night and provide care as needed. Documents reviewed revealed, Personnel Report notes there is at least 1 staff during the night shift on duty. Appraisal/needs and services plan dated 3/14/23, notes R1 is to receive assistance with activities of daily living (ADL)’s as needed and provide “extra assistance” with physical health services. However, it also notes R1 is non- compliant with care provided. Although facility staff has been providing care, R1 has not been complaint with staff. LPA was provided a copy of communication between assistant administrator and agencies involved in R1’s care in which R1’s non-compliance is discussed and a plan of action is discussed to better assist R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Alexander Solario and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2023 · control 28-AS-20230814105348

Allegation investigated: Resident's needs are not being met Administrator is unavailable Staff did not clean resident's room Staff did not safeguard resident's personal belongings Facility did not maintain a comfortable temperature for resident Staff not following resident's dietary plan Staff not serving meals in a timely manner

Licensing Program Analyst (LPA) Erik Zaragoza conducted a follow up complaint investigation regarding the allegations listed above. LPA met with Alexander Solorio, Administrator for the facility, and explained the reason for the visit. The investigation consisted of the following: during the initial visit conducted on 06/11/2021, LPA Joe Katrdzhyan obtained documents from Resident #1's (R1) file, along with a copy of the staff roster and resident roster, and on the subsequent visit LPA Zaragoza interviewed Residents# 2 – 11 (R2 - R11), Staff # 1 – 5 (S1 - S5), and toured rooms #3, 7, 18, 21, and 27. LPA Zaragoza also obtained copies of the following documentation during the subsequent visit: Staff Roster, Client Rosters, List of Residents with a Specialized Diet, along with the Admissions Agreement, Physician's Report, Appraisal/Needs and Services Plan, Functional capability assessment, Care Plan, and Inventory list for R1. During today’s visit, LPA Zaragoza interviewed Staff #6 (S6). LPA attempted to interview R12, however R12 is no longer a resident at the facility. Unsubstantiated The investigation revealed the following: In regards to the allegation “Resident’s needs are not being met”, it was alleged that staff did not meet the needs of R1 by not assisting R1 with their showering needs in weeks, and also did not assist R1 with brushing their teeth or responding to the pendant call light system when the residents request assistance. During interviews with the residents, nine (9) out of eleven (11) interviewed did not corroborate the allegation that their needs were not being met. R3 explained that the facility staff always assists R3 with their diaper changing needs and has no issues with their needs being met, and R10 explained that the facility staff does respond to the resident’s call light system in a timely manner. During interviews with the staff, none of them corroborated the allegation that they do not meet the resident’s needs. S1 explained that caregivers of the facility spent a lot of time in R1’s room due to her needs, and that the resident received 2 showers per week, or on an as-needed basis. In regards to the allegation that the “Administrator is unavailable”, it is alleged that the administrator of the facility Alexander Solorio is unreachable, never responds to any of the residents’ requests and blocks their calls. During interviews with the residents, eight (8) out of eleven (11) residents interviewed did not corroborate the allegation that Alex is not available to speak with and assist the residents of the facility. R2 explained that Alex is very nice, helpful, and available for the residents, and R10 explained that Alex assists R10 with scheduling transportation for doctors appointments and that the communication between them is good. During interviews with the staff, none of them corroborated the allegation that the administrator Alex is not available for the residents. S3 explained that Alex often works on the floor of the facility to assist with caregiving duties when the other staff ask for assistance. During an interview with Alex over the phone, he stated that he is very hands-on in his work with the facility, and that he also makes rounds personally to ensure the needs of all residents are being met. He states that he has an open door policy and that any resident that has questions, requests, or concerns to come talk to him, and if he is ever busy he will inform the resident of when he will become available. In regards to the allegation that “Staff did not clean resident’s room”, it was alleged that the resident rooms were not cleaned by the staff members when they should have been. During interviews with the residents, nine (9) out of eleven (11) interviewed did not corroborate the allegation that staff do not clean their rooms. R2 explained that the housekeepers clean R2’s room every other day and also make sure to take the trash out of residents rooms if there ever is any trash visible, and R6 also stated that he gets his room cleaned by the staff and that it is done in an adequate manner. During interviews with the staff, none of them corroborated the allegation that fellow staff members do not clean the rooms of the residents. S1 explained that each of the resident rooms get a deep cleaning at least once per week, and every other day rooms are checked to see if any trash needs to be thrown away, and S4 stated that at the time this complaint was filed it was more difficult to the zoning restrictions that the facility implemented from the Department of Public Health, however they did make sure to clean the rooms at least once per week when this complaint was filed. In regards to the allegation that “Staff did not safeguard resident’s personal belongings”, it was alleged that multiple possessions of R1’s had either gone stolen or missing during R1’s time living in the facility, including clothing, a Christmas Package, a chess set, and a polo winter vest that the facility replaced with an imitation vest. During interviews with the residents, nine (9) out of eleven (11) did not corroborate that their personal items have been stolen. Most of the residents indicated that they have never had one of their personal items go missing in the entire time they have lived in the facility, and all residents who have lived in the facility at the time the complaint was filed claimed none of their belongings have gone missing or gotten stolen. During interviews with the staff, none of them corroborated the allegation that they have failed to safeguard the personal belongings of the residents. S1 stated that she never recalled R1 reporting that her personal belongings had gone missing, and that in the event that this does occur they ask residents to report it as soon as possible so they can work toward finding it by first search the resident’s rooms and then around the facility, and if the item is of sufficiently high value they will also file a police report. S4 stated that R1 had nothing listed on their inventory log, and that they did once complain about not receiving a package, however it did eventually arrive, it was just two (2) days late. During record review of R1’s personal inventory list, they waived their right to have any of their personal belongings safeguarded by the facility staff. In regards to the allegation that “Facility did not maintain a comfortable temperature for resident”, it was reported that the temperature in their resident rooms were between 80-82 degrees, and that staff were deliberately turning off their air conditioning or refusing to turn it on. During interviews with the residents, seven (7) out of the eleven residents interviewed did not corroborate that the temperature is too hot or cold. R2, R4, and R7 all stated that at times the temperature in their rooms can feel a bit cold, however when they ask the facility staff to change the temperature they do help them with adjusting it. During interviews with the staff, none of them corroborated the allegation that they do not keep a comfortable temperature for the residents in the facility. During the physical plant tour of the facility, LPA measured the temperature in the air to be at 74 degrees Fahrenheit in all rooms of the facility and that it was of a comfortable temperature. In regards to the allegation that “Staff not following resident’s dietary plan”, it is alleged that staff was feeding R1 carbohydrate-heavy meals, when R1 was a diabetic and those types of meals were not appropriate for them. During interviews with the residents, ten (10) out of eleven (11) did not corroborate the allegation that residents who have a specialized diet do not get food suited to their diet. LPA interviewed R2, R3, R8, and R9 because they were all indicated to require a diabetic diet, and none of them corroborated that the facility does not follow a resident’s specialized dietary plan if they require one. During interviews with the staff, none of them corroborated the allegation that the facility does not follow the dietary plans of the residents. S3 who works with the kitchen staff stated that within the kitchen of the facility there is a list of the resident’s dietary restrictions and their care plan which details what residents can and cannot eat so that staff know to avoid certain foods with residents. Additionally S4 explained that the facility staff did provide R1 food appropriate for R1’s diabetic diet which was submitted to them through their Care Plan by their physician, however R1 was not happy with the food that the facility offered and often went against their own Care Plan by ordering food from outside dining establishments. During the physical plant tour of the facility LPA observed in the kitchen that the facility does have a list of dietary restriction and Care Plans for all residents that require a specialized diet posted in an area where all kitchen staff can see it. In regards to the allegation that “staff are not serving meals in a timely manner”, it was alleged that around the time this complaint was filed in March of 2021 that food was being delivered to resident rooms late, that the food was served cold, and that staff did not respond to requests to reheat the food. During interviews with the residents, ten (10) out of eleven (11) interviewed could not corroborate the allegation that their food is not served warm. R5 and R6 both lived in the facility around the time that this complaint was filed in March of 2021 and they both explained that the facility did serve meals in a timely manner and never experienced an issue with being served cold meals around this time or in the present day. During interviews with the staff, none of them corroborated the allegation that meals are not served to residents in a timely manner. S1 explained that R1 was served meals on time which was delivered to her room, and that the facility’s kitchen staff made sure to wrap food in saran wrap to ensure that food got delivered warm to residents, and S4 said that around this time it was more difficult for residents to be delivered their food due to the zoning restrictions the facility had to implement due to COVID-19 which forced them to deliver food to residents one zone at a time, however each resident did get their food delivered in a timely manner at the time this complaint was reported and in the current day as well as kitchen staff make sure to deliver food to residents who eat in their rooms first to ensure that it stays warm. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 above allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided. In regards to the allegation that “Facility is without hot water”, it is alleged that there is not hot water in the showers or faucets of the resident bathrooms. During interview with the residents, three (3) out of eleven (11) interviewed corroborated the allegation that the water is too cold. R6 explained that the water has not been sufficiently hot in his time living at the facility, which has been since before the complaint was filed. A separate resident who was not fully interviewed, Resident #13, told LPA and the Resident Care Director Maria Razo in a hallway during the physical tour of the facility that the water in R13’s room was too cold for them to take a shower that morning. During an interview with the staff members, none corroborated the allegation, however they did explain that in certain rooms it can take time for the showers to warm up. S1 explained that it can take 5 – 10 minutes for hot water to turn on in the morning in certain rooms while the hot water temperature is within range for other rooms, and that maintenance is working on the issue and additionally that maintenance states that the issue is being caused by old pipes. S4 likewise stated that hot water is delivered to all rooms in the facility however it can take 5-10 minutes for the hot water temperature in some rooms to reach the required range, and that this is due to the building being old. LPA measured the hot water temperature in rooms 3, 7, and 18 and they all measured 102.3 Degrees F, 88.7 Degrees F, and 84.5 Degrees F respectively. Based on LPAs interviews conducted with the residents and staff, the preponderance of evidence standard has been met for the above allegation, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099D. Exit interview held and a copy of the report and appeal rights was provided to the administrator Alexander Solorio.the state’s words, verbatim · CDSS document, Nov 2, 2023 · control 28-AS-20210302100806

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Nov 17, 2023

87303 (e) (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water (...) to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidenced by: Based on interviews and observation, LPA determined that the hot water temperature in the facility fell below the 105 degree threshold in Rooms 3, 7, and 18, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 2, 2023

Plan of correction: Administrator shall ensure that the hot water temperature will remain within the required range at all times. Administrator will maintain a log of water temperature for the above resident rooms by the POC due date.

Allegation investigated: Resident's room has no call light. Resident's needs are not being met by staff. Staff is not treating resident with dignity. Staff are retaliating against resident.

Licensing Program Analyst (LPA) Ashley Calderon conducted a subsequent unannounced complaint visit regarding the allegations listed above. This licensing report supersedes the licensing report dated 3/27/23. LPA met with Assistant Administrator Alexander Solorio and discussed the purpose of today's visit. Findings remain the same. During visit conducted on 3/27/23, LPA obtained a copy of the resident roster, staff roster, Resident #1 (R1's) file and obtained relevant documentation: R1's Face Sheet, R1's Physician Report, R1's Medical Consent Form, Pre-Placement Appraisal Information, R1's Appraisal, R1's Care Plan, R1's Appraisal/Needs and Service Plan Special Incident Reports,R1's Medical Refusal, Email with R1's Psychiatric Social Worker and Clinical Program Manager, R1's Behavior Contract, R1's Call Button Pendant Agreement. Fire Alarm Notice. LPA toured common areas and R1's bedroom. LPA interviewed Assistant Administrator Alex, Staff #1-4 (S1-S4), attempt interview with Resident#1 and #6 (R1 and R6) and interviewed Resident #2-5 and #7 (R2-R5 and R7). CONTINUATION ON 9099-C... Unsubstantiated LPA Calderon attempt to interview via telephonically R1's Psychiatric Social Worker and LPA via telephonically interviewed R1's Clinical Program Manager from Worker Office of Diversion of Reentry. On 10/20/23 LPA Calderon toured random resident bedrooms: Room’s #4, 6, 18, 39 and 44 to check call light button pendants and redelivered report. Regarding Allegation: Resident's room has no call light. LPA Calderon interview with staff revealed that (5) out of (5) call light buttons are distributed to residents based on their needs; facility uses call pendent buttons. Interviews with (3) out of (5) staff informed LPA Calderon that R1 has a call button pendant. LPA Calderon reviewed R1's call button pendant agreement documentation which stated R1 received a call button pendant. R1 refused to show LPA call button pendant when R1’s room tour was conducted. LPA observed random rooms for call button pendants and residents in rooms # 4,6,18,39 and 44 all had call light buttons /pendants, either on a string or on the wall near bed. Regarding Allegation: Resident's needs are not being met by staff. LPA Calderon interviewed staff, (5) out of (5) staff denied the above allegations, staff informed LPA residents and R1 are receiving services to meet their needs. (5) out of (5) staff during interview with LPA stated R1 does not have a prescription order for bed rails, staff provide laundry service, food service, transportation when needed and medical services when required. Staff stated R1 at times refuses assistance provided by staff and medical professionals and R1 is an independent individual. LPA interviewed R2-R5 and R7 all denied the above allegation and stated they are assisted by staff to meet their needs and staff clean, do laundry and provide meals. During telephone interview with Clinical Program Manager for R1 informed LPA R1 refuses assistance and services offered to R1 to assist with their needs, facility support R1, R1’s medical team is involved with R1 and R1 does not allow assistance. LPA observed R1’s bedroom and observed no half/full bed rails in R1’s bed. LPA reviewed R1’s file, physician report states R1 is not on Hospice, no bed rail order was noted in R1’s file and R1’s Appraisal/Needs and Service Plan states R1 is independent with all Activities of Daily Living. CONTINUATION ON 9099-C... Regarding Allegation: Staff is not treating resident with dignity. LPA Calderon interviewed staff Assistant Administrator and staff S1-S4, staff denied allegation stating all residents are treated with dignity and respect and are do not treated any residents differently. LPA Calderon interviewed residents, R2-R5 and R7 whom denied the above allegation stating staff treat them with dignity and respect and have not observed staff treating residents disrespectfully. During telephone interview with Clinical Program Manager for R1 informed LPA: not having concerns with how staff treat residents and R1 as they’ve observed staff treat residents with dignity and respect, facility is diligent, clean space, and knowledgeable. Regarding Allegation: Staff are retaliating against resident. LPA Calderon interviewed staff Assistant Administrator, S1-S4, staff denied above allegation stating they do not retaliate, and they respect and treat residents the same, staff talk calm and talk with residents. LPA interviewed R2-R5 and R7 denied the above allegation and informed LPA Calderon staff do not retaliate against them or other residents. During telephone interview with Clinical Program Manager for R1 informed LPA staff does not retaliate against R1. Although the allegation(s) 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. Exit interview was conducted and a copy of this report was provided to Alexander Solorio/Assistant Administratorthe state’s words, verbatim · CDSS document, Oct 20, 2023 · control 28-AS-20230324105203

Type of visit: Office

Present during this meeting were Licensing Program Manager (LPM) Fernando Fierros, David Sicairos, and Former Caseload Licensing Program Analyst (LPA) Ashley Calderon conducted an announced informal meeting at Monterey Park Adult and Senior Care Regional Office. Present from Pasadena Villa Senior Living was Licensee/ Eyal Shtorch and Assistant Administrator / Alexander Solorio. The following items listed below were discussed during today's meeting: High Volume of complaints reported to CCL since licensed. Discussed appropriate placement for residents in care. Number of in-house Residents from Department of Health (DHS): 30 residents Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility Licensee agrees to participate in the Technical Support Program (TSP) referral will be submitted by Licensing , TSP: CCL program assisting with free service in assisting facilities with facility issues/concerns. Facility will conduct a Resident meetings to discuss with residents when it is appropriate to call 911. Facility will submit plan by 10-31-23 to ensure staff are being trained to communicate with residents and working with residents to resolve issues in house. Discuss Three (3) Day versus Thirty (30) day eviction procedures and Illegal Eviction Discussed Substantiated complaints 2021/ 2022 / 2023. Continuation 809-C... Change of Administration -CCL waiting hard copy of Board of Resolution Letter, to be submitted to LPA Calderon by 10/27/23. Topics covered: Personal Rights 87486, Personal Accommodations and Services 87307, 87618 Oxygen Administration, Reporting Requirements 87211, Maintenance and Operations 87303, Incidental Medical and Dental Care 87465, Postural Supports 87608, Night Supervision 87415, Eviction Procedures 87224, Basic Services 87464, Criminal Record Clearance 87355, Personnel Requirements- General 87411, Managed Incontinence 87625, Additional Person Rights of Residents in Privacy Operated Facilities 87468.2, and 87468.1 Personal Rights of Residents in All Facilities An exit interview was conducted with Licensee/ Eyal Shtorch and Assistant Administrator / Alexander Solorio, a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 18, 2023

Allegation investigated: Staff not assisting resident with medications.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent unannounced visit at the facility for the purpose of investigating the above-mentioned allegation. LPA Pena met with Assistant Administrator Alexander Solorio and explained the purpose for the visit. During the initial visit on 9/29/2020, Licensing Program Analyst (LPA) Renee Arterberry conducted an unannounced 24 Hour Health and Wellness Check telephonically and virtually (via FaceTime) with Alexander Solorio facility administrator and facility nurse Marisol Cruz, employees of the facility. LPA Arterberry interviewed S1-S2, reviewed the facility file for R1, obtained copies of the following documents: Identification Page/Face Sheet, Pre-Appraisal Assessment, Medication Administration Record (MAR), Admission Agreement, Medical Assessment, Unusual Incident Reports (SIR) and hospice documents. LPA Arterberry also toured the physical plant: kitchen, dining room, and medication room. During the subsequent visit on 2/17/2023, Licensing Program Analyst (LPA) Bennette Pena conducted a tour of the physical plant and obtained copies of the following documents: current resident/staff roster and R1's files such as: Face sheet, Physician's Report, Admission's Agreement, Resident Appraisal, Hospice Health Information, Incident Reports and Medication Administration Records (MARs) for Aug 2020-Oct 2020. LPA also interviewed Resident #2 (R2) - Resident #6 (R6), Staff #1 (S1), Staff #3 (S3), Staff #4 (S4) and telephonically interviewed Staff #2 (S2). During the 2nd subsequent visit on 3/10/2023, Licensing Program Analyst (LPA) Bennette Pena obtained additional documents for R1 such as: National Rehab Center Discharge Instructions (dated 8/11/2020), Plan of Care (POC) Summaries (dated 9/09/2020, 9/24/2020), Physician’s medication order (dated 10/02/2020) and Huntington Hospital Discharge Instructions (dated 10/02/2020). During today's visit, LPA Bennette Pena obtained the staff & resident rosters and conducted a facility tour of the common areas. *****CONTINUED ON LIC9099-C***** Substantiated The investigation revealed the following: Regarding allegation: "Staff not assisting resident with medications." It is alleged that the last time the resident received his medication was two days prior to being admitted at the hospital. And the resident alleged that the staff does not check on the resident enough and that he has been in pain for eight days and constipated for three. Based on documents reviewed, R1 was admitted at Huntington Hospital on 9/23/2020 complaining of severe abdominal pain and was diagnosed of pneumonia and renal failure. R1 was assessed by EMS and observed rigidity, pain, distension and tenderness in all four quadrants. On 9/20/2020, R1 complained to staff of having pain related to his catheter and the staff gave R1 medication. Staff indicated that they emptied R1's urine bag but did not document how much nor how the urine looked. LPA reviewed R1's Medication Administration Record (MAR) for Sep. 2020 which indicated that no pain medication was given to R1 except on the evening of 9/20/2020 for moderate to severe pain and in the afternoon on 9/21/2020. On 9/22/2020, the staff indicated that R1's stool was normal and R1 appeared lethargic but noted to have irregular heart rate. However, there was no evidence that the staff re-checked R1 if the pain medication was effective and no evidence that the foley catheter and urine was checked. Reviews of the documents revealed that the facility did not properly monitor the resident who started to deteriorate on 9/20/2020 and did not provide the available medications to R1 to help alleviate his fever on 9/22/2020 and R1's pain. Additionally, based on the records reviewed, the facility did not properly care for R1's foley catheter as there was no documentation that the instruction for catheter irrigation was followed by staff. The facility did not properly care for R1 when the last foley catheter placement was 10 days prior to being admitted to the hospital. Documents showed that this was not performed by the hospice skilled nurse as the last foley catheter change/insertion by hospice was 8/25/2020. Interview with a staff indicated that a NOC shift caregiver pulled out the catheter and pushed it back in while providing care. Other staff interviewed indicated that they were also aware of it. Therefore, there was enough supportive evidence to corroborate the allegation. Based on LPA’s interviews, and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Assistant Administrator Alexander Solorio along with the Appeals Rights.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 28-AS-20200925154403

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Oct 11, 2023

87465 Incidental Medical and Dental Care...(c) ...resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2)..the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on interviews and review of documentation, R1's Medication Administration Record (MAR) for Sep. 2020, no medication was given to R1 to help alleviate his severe pain and fever except on 9/20/2020 and 9/21/2020 only which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Administrator will submit an effective and written plan to ensure residents receive their medication as prescribed by their Physicians. The written plan will be submitted to CCL/LPA by POC due date.

Allegation investigated: Resident in care was assaulted by unknown individual in the facility.

Licensing Program Analys (LPA) V. Maldonado made a subsequent unannounced visit at the facility for the purpose of continuing the investigtion regarding the above-mentioned allegation. LPA Maldonado met with Assistant Administrator Alex Solorio and explained the purpose for the visit. On 8/17/23, LPA Maldonado made an initial complaint visit and obtained a copy of the resident and staff roster, and the following documents for Resident# 1 (R1): Facesheet, Physician's Report, Pre-Placement Appraisal, Needs and Services Plan, incident reports for July-August 2023, and police reports- if any. LPA also requested to review surveillence video footage for the night of 08/08/23, but was unable to due to time contraints. LPA also interviewed Staff# 1 (S1). During today's visit, LPA conducted interviews with Residents# 2-7 (R1-R7) and Staff# 1-3 (S1-S3). LPA was unable to interview R1 due to R1 being out of the community during the visit. No additional contact information for R1 was avilable for LPA to attempt a telephone interview. (Report continued on LIC9099-C...) Unsubstantiated The investigation revealed the following: Regarding allegation: Resident in care was assaulted by unknown individual in the facility. It is alleged that on Sunday, August 8, 2023 at about 10PM, R1 was using the phone in the staff area and was confronted by a staff named Salvador, who yelled at and hit R1 with two closed fists to the chest, for being in a restricted area. After review of R1’s Physician’s Report, dated: 1/24/23, it was discovered that R1 has an altered mental status and has a history of substance abuse. Per R1's Needs and Serviced Plan, dated: 2/17/23, R1 has frequent outbursts towards other residents and staff due to exhibits of paranoia. It is also noted that R1 is normally alert and oriented, but appears to be disoriented and confused at times due to substance abuse. Per interviews conducted, (3) of (3) staff stated that R1 called the police to report the alleged incident. The police came and investigated the incident with S1, however, it was discovered that there are no staff working at the facility by that name. The police and staff also confirmed through review of surveillance footage that R1 was never in the area during the time R1 stated to have been, when the incident occurred. Per the staff roster, LPA confirmed there is no staff by the name, Salvador. During today's visit, LPA was unable to review surveillance footage for the date of 8/08/23, due to the system keeping footage for the last 30 days only, and no longer available. Per interview with R4, it was stated that R1 told R4 about the incident of staff hitting R1. However, R4 states R4 did not observe any marks on R1 that would indicate R1 was physically assaulted. R4 stated to "personally believe" R1 "hallucinates at times". R1 did not tell R4 who the staff was, where the incident occurred, and when it occurred, but simply stated R1 was hit by a male staff. (4) of (6) residents interviewed could not corroborate the allegation. This allegation is Unsubstantiated. 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. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited. An exit interview was conducted with Assistant Administrator, Alex Solorio, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 3, 2023 · control 28-AS-20230810135252