Pearl of West Hills

Allegation investigated: Staff hit a resident while in care Staff denied a resident from food while in care

At approximately 9:10 a.m. on 07/10/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA interviewed the administrator, two (02) residents, and a social worker between 9:15 a.m. and 11:45 a.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, care plan, and medical assessment, at 9:30 a.m., and toured the facility inside and out at 9:40 a.m. Regarding the allegation "Staff hit a resident while in care" it was alleged the administrator slapped and karate chopped Resident #1 (R1). Interview with the administrator at 9:15 a.m. today revealed they never hit R1. The administrator noted R1 was having difficulty adjusting to the facility. Interview with R1’s roommate, Resident #2 (R2) revealed they never witnessed R1 get hit by anyone. R2 noted R1 panicked recently about something imaginary. Unsubstantiated Interview with R1 at approximately 9:35 a.m. revealed they had never been hit by the administrator and enjoyed the facility. Interview with a social worker at R1’s day program at 11:30 a.m. revealed R1 had difficulty adjusting to the day program as well. The social worker also did not observe any marks or bruising on R1. Record review of R1’s file indicated some cognitive impairment but otherwise no pertinent information. LPA observed no bruising or marks on R1 during the interview. Based on observations and interviews, nobody indicated that the administrator had hit or hurt R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff denied a resident from food while in care” it was alleged the administrator denied R1 a second portion of food when requested. Interview with the administrator revealed R1 was diabetic and often requested food s high in sugar when they saw other residents eating. The administrator noted they had to verbally redirect R1 from eating pastries and cakes as they may be harmful to their health. The administrator also confirmed they never denied R1 any food and offered healthier options instead. Interviews with R1 and R2 revealed that neither had been denied food and both were fed well and enjoyed the facility food. Record review revealed R1 was taking medication three (03) times daily for diabetes. LPA observed adequate supplies of perishable and non-perishable food in the home. Based on observations, interviews, and record review, the administrator offered R1 healthy alternatives but never denied R1 any food. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 31-AS-20250706210620

Type of visit: Required - 1 Year

At approximately 9:30 a.m. on 06/27/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Staff #1 (S1) and disclosed the reason for the visit. The facility was last visited on 04/20/34 for an annual inspection. It is a single story building with four (04) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) non-ambulatory residents, of which one (01) may be bedridden in Bedroom #4. The facility serves residents with dementia. Approved hospice waivers for six (06). At the main entrance, LPA observed postings for COVID precautions, personal rights, rights of resident councils, family councils, neighborhood complaint procedures, theft and loss policy, visitation policy, non-discrimination notice, facility sketch and license, confidential complaint contacts, ombudsman contacts, and administrator certificate. At approximately 10:00 a.m., S1 told LPA that today was their first day in the facility. S1 did not know how to access staff and resident files. At approximately 10:10 a.m. LPA observed the resident in Bedroom #1 lying in bed with full bed rails. At approximately 10:12 a.m. LPA observed two (02) bedridden residents in Bedroom #4. S1 confirmed both residents were bedridden. Both residents had full bed rails. Phone call with the administrator at approximately 10:15 a.m. revealed only one resident, Resident #1 (R1), who resided in Bedroom #4, had hospice services and physician orders for full bed rails. The administrator said the other two residents had full bed rails because that was the only bed they had available. The administrator noted neither R1’s roommate, Resident #2 (R2), nor the resident in Bedroom #1, Resident #3 (R3), were enrolled in hospice services. Neither R2 nor R3 had physician orders for full bed rails. Additionally, the administrator noted that they submitted a criminal background clearance transfer request for S1 but they were not yet associated to the facility. S1 was required to work today since the administrator could not be present and the main staff, Staff #2 (S2), was ill. S2 was also the administrator designee. No qualified administrator or designee was in charge of the facility’s operations today. The administrator called Staff #3 (S3) to come to the facility. Record review at 10:18 a.m. today revealed S1 was not associated to the facility and S3 was associated and cleared to work in the facility. S3 arrived at approximately 10:50 a.m. These deficiencies are cited on the corresponding LIC 809-D page. Civil penalties are issued in the amounts of $100 per day per unassociated staff member and a $500 immediate civil penalty for a fire clearance violation. The administrator was notified that additional civil penalties would be issued if the violations are not corrected by the POC due date. Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:20 a.m. LPA measured the room temperature to be 73 degrees Fahrenheit. Puzzles, board games, and art supplies were provided in the living room. At approximately 10:25 a.m., LPA observed a fully charged fire extinguisher near the stove. A receipt was attached from 04/20/2020. The licensee was cited for this same expired fire extinguisher on 04/30/24. The deficiency was never corrected. A new deficiency is cited on the LIC 809-D page. At 10:50 a.m. LPA and S1 tested all auditory alarms. One (03) out of three (03) auditory alarms was operational. This deficiency is cited on the corresponding LIC 809-D page. The facility has three (03) bathrooms. One (01) bathroom is private, and two (02) are shared. Two (02) out of two (02) resident bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 11:00 a.m. LPA measured the water temperature in the bathroom near the main entrance to be within regulatory range. The facility has four (04) bedrooms. Two (02) bedrooms are private and two (02) are shared. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator and pantry. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter. Cleaning solutions were locked in a closet near the kitchen. Medications and a complete first aid kit were locked above the washer and dryer. The washing machine and dryer were located in the kitchen. Both were in working order. LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition. Ramps leading out were secure. The emergency exit path was free from obstructions. Two (02) out of two (02) exit gates were unlocked. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 27, 2025

Type of visit: Required - 1 Year

At 12:35 p.m. on 04/30/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Staff #1 (S1) and disclosed the reason for the visit. LPA and staff contacted the administrator at approximately 1:00 p.m. and disclosed the reason for the visit. LPA and S1 toured the facility inside and out. The facility was last visited on 03/22/2024 for a complaint visit. It is a single story building with four (04) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) non-ambulatory residents, of which one (01) may be bedridden in Bedroom #4. The facility serves residents with dementia. Approved hospice waivers for six (06). The front yard was well maintained and free of hazards. At the main entrance, LPA observed postings for COVID precautions, personal rights, rights of resident councils, family councils, neighborhood complaint procedures, theft and loss policy, visitation policy, non-discrimination notice, facility sketch and license, confidential complaint contacts, ombudsman contacts, and administrator certificate. Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:50 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. Puzzles, board games, and exercise equipment were observed in the living room. Surveillance cameras monitored common areas. Three (03) out of three (03) auditory alarms were tested and functioning. At approximately 12:55 p.m. two (02) out of four (04) smoke and carbon monoxide detectors were tested and operational. Two (02) smoke alarms were removed. S1 showed LPA two (02) new smoke alarms were purchased due to the old detectors malfunctioning. The facility has three (03) bathrooms. One (01) bathroom is private, and two (02) are shared. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 12:58 p.m. and 1:03 p.m. LPA measured the water temperatures in the bathrooms near the main entrance to be 135.1 degrees Fahrenheit and 136.3 degrees Fahrenheit. This deficiency is addressed on the LIC 809-D page. The facility has four (04) bedrooms. Two (02) bedrooms are private and two (02) are shared. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All hospital beds had locked, secured wheels. LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator and pantry. The stove hood was clean. Appliances were in good condition. At approximately 1:15 p.m. LPA observed a fully charged fire extinguisher near the stove. A receipt was attached from 04/20/2020. LPA discussed this deficiency with the administrator at approximately 2:00 p.m. The deficiency is cited on the LIC 809-D page. Sharps were locked below the counter. Cleaning solutions were locked in a closet near the kitchen. Medications and a complete first aid kit were locked above the washer and dryer. The washing machine and dryer were located in the kitchen. Both were out of order. S1 stated the facility is seeking repairs for the machines and performing resident laundry at a local laundromat in the meantime. LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition. The wind had knocked down the large retractable umbrella. Ramps leading out were secure. The emergency exit path was free from obstructions. Exit gates were unlocked. At approximately 1:45 p.m. LPA conducted a record review of resident and personnel files. S1’s tuberculosis test and updated CPR and First Aid certificates were not available for audit. Resident #1 (R1) and Resident #2 (R2) had diagnoses of dementia on their medical assessments. Their most recent medical assessments were older than 12 months. These deficiencies were cited on the LIC 809-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 30, 2024

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not follow resident's care plan. Staff did not give resident medication as prescribed. Facility night staff were not available to assist the resident. Staff did not properly handle resident's medication. Staff did not meet resident's hygiene needs.

At 3:10 p.m. on 04/03/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the licensee and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 10/24/2023 and toured the facility at 10:30 a.m., reviewed pertinent records at 10:40 a.m. of pertinent records including but not limited to the resident list, staff list, medical assessment, and hospital records, and interviewed Staff #1 (S1) at 10:50 a.m. and the licensee at approximately 12:00 p.m. LPA conducted a subsequent visit on 03/20/2024 and interviewed the licensee at 9:45 a.m. and two (02) out of three (03) residents at 3:45 p.m. and toured the facility at 10:15 a.m. Today, LPA toured the facility at 3:15 p.m. Regarding the allegation “Staff did not follow resident's care plan” it was alleged staff did not turn Resident #1 (R1) as instructed on their care plan. Interview with S1 revealed they turned R1 whenever they requested and R1 could turn themselves as well. Unsubstantiated Interview with the licensee revealed R1 did not like to be rotated often due to pain, but staff rotated R1 approximately every two (02) to three (03) hours. Residents interviewed revealed they had no concerns with the care provided by the facility. Based on interviews, staff repositioned R1 sufficiently. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not give resident medication as prescribed” it was alleged staff provided R1 double doses of medication. Interviews with S1, the licensee, and residents confirmed the facility does not provide double doses of medications. Staff provide medications at the time prescribed and follow physician orders for “as needed” medications. No residents reported any issues with receiving incorrect amounts of medications. Based on interviews, staff did not provide R1 with double doses of medication. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility night staff were not available to assist the resident” it was alleged staff “was asleep upstairs” and unable to assist R1 at night. Interview with S1 revealed they are on-call at night and available to assist residents if needed. Interview with the licensee confirmed they and S1 assist residents at night if needed. S1 and the licensee further clarified that the facility does not have an upstairs. Interview with residents confirmed staff are available to assist them at night. Residents had no issues receiving care at night. Based on interviews, staff were available to help residents at night. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not properly handle resident's medication” it was alleged staff left R1’s medication out and accessible on their nightstand. Interview with the licensee revealed all medications are locked and centrally stored. When R1 requested pain medication, the licensee prepared one nighttime dose in a plastic bag. S1 then assisted with the nighttime dose. S1 and the licensee stated they do not and have not left medications on nightstands or out in the open. Interviews with residents confirmed staff do not leave medication out. Based on interviews, staff properly handled R1’s medication. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not meet resident's hygiene needs” it was alleged staff did not assist with R1’s toileting needs. Interview with S1 revealed they changed R1 whenever necessary. The facility also ordered a urinal for R1 to use. S1 stated R1 had no bowel movements during their time at the facility. Interviews with residents revealed they had no concerns about the facility’s incontinence care. Based on interviews, staff met R1’s hygiene needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 3, 2024 · control 31-AS-20231020083303

Allegation investigated: Staff member is physically abusing a resident Staff member is verbally abusing a resident

At 3:00 p.m. on 03/22/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with staff and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 03/20/2024 and interviewed Staff #2 (S2) at 9:45 a.m., Family #1 (F1) at 10:30 a.m., and two (02) out of three (03) residents at 3:45 p.m., conducted a records review at 10:00 a.m., and toured the facility inside and out at 10:15 a.m. Today, LPA interviewed F1 again at 1:40 p.m., Resident #1 (R1) at 3:30 p.m., and staff #1 (S1) at 3:40 p.m., and toured the facility at 3:20 p.m. Regarding the allegation “Staff member is physically abusing a resident” it was alleged S2 slapped R1. Interview with R1 at 4:00 p.m. on 03/20/24 revealed S2 slapped R1. No further details were provided about the time or place of the slap. Unsubstantiated Interview with S2 revealed they did not slap R1 and R1 was fabricating. Interview with Resident #2 (R2) at 3:50 p.m. on 03/20/2024 revealed they have not witnessed, heard, or experienced physical abuse in the facility. Interviews with F1 revealed R1 had difficulty distinguishing between delusions and reality. Interview with S1 confirmed S2 never slapped R1. Based on interviews, residents, family, and staff did not witness S2 slap R1 and cannot confirm if it did or did not happen. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff member is verbally abusing a resident” it was alleged S2 yelled at R1. Interview with R1 at 4:00 p.m. on 03/20/24 revealed S2 got angry and yelled at R1. No further details were provided. Interview with S2 revealed they did not yell at R1. Interview with R2 revealed they have not witnessed, heard, or experienced verbal abuse or yelling in the facility. Interviews with F1 revealed they were not aware of R1 being yelled at. Interview with S1 confirmed S2 did not and does not yell at R1. Based on interviews, residents, family, and staff did not witness or hear S2 yell at R1 and cannot confirm if it did or did not happen. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 22, 2024 · control 31-AS-20240315142734