Regent Villa Retirement Home

Allegation investigated: Staff do not prevent resident from threatening resident Staff do not safeguard resident's money Staff do not prevent recurring cockroach infestation

On August 6, 2026, the Department of Social Services (DSS) staff conducted an initial unannounced complaint visit at the facility to investigate the above allegations and to deliver the findings. The department was greeted by Assistant Administrator Nicole Lozano, and the purpose of the visit was explained. The investigation consisted of the following: On August 6, 2026, the Department obtained the following documents: Staff roster (No date), Resident roster (dated 6/23/26), R1’s Admission Agreement (dated 10/2/24), signed personal rights (dated 10/2/26), R1’s preplacement appraisal (date 10/2/26), P & I log (2025-2026), R1’s Physician’s report (dated 12/2/25 ), and Orkin Service Report (dated 7/24/26). On August 6, 2026, the Department interviewed: Assistant Administrator (A1), 5 staff (S1-S5), 5 Residents (R2-R6), toured facility and made observations. Page 1 of 4 Unsubstantiated The investigation revealed the following Allegation: Staff do not prevent resident from threatening resident The detail of the complaint alleges that R1 was threatened with a knife by another resident when R1 lived at the facility. On August 6, 2026 at 10:00am the Department interviewed Assistant Administrator (A1), who stated that a R1 informed staff that R1’s roommate threatened R1 with a knife, however when staff searched the room there was no knife found. A1 further stated that sometimes the residents will bring in items that are not allowed, however staff will confiscate the items. Lastly, A1 states that there have been no knives found in the facility. On August 6, 2026 between 10:15am and 11:00am, the Department interviewed 5 staff (S1-S5) regarding the allegation, and of those interviewed, 5 out of 5 stated that no resident had reported to them that they had been threatened with a knife. 4 out of 5 stated that they have never found a knife in the facility. 1 out of 5 stated that she saw a knife in a residents’ room but not recently. She went on to state that as soon and the staff saw a knife, they immediately took it. On August 6, 2026, between 11:00am and 12:00pm, the department interviewed 5 residents (R2-R6). Of those interviewed, 5 out of 5 stated that they have never been threatened with a knife. 5 out of 5 stated that they feel safe and well cared for at the facility. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. Page 2 of 4 Allegation: Staff do not safeguard resident's money The detail of the complaint alleges that “the facility did not give R1 Personal & Incidental (P&I) due to R1 owing the facility.” It was also alleged that the facility was paying R1’s phone bill out of R1’s money, but they allegedly stopped paying, and as a result R1 doesn’t have a working phone. On August 6, 2026 at 10:00am, the Department interviewed Assistant Administrator (A1), who denied the allegation stating that the facility handled R1’s P & I funds, however no funds were withheld from R1. A1 further stated that there is no record of R1 owing the facility money. Lastly, A1 stated that “We were paying for R1’s cell phone bill while R1 was a resident, but it did not come from R1’s P & I, our facility paid for it as service to the resident. When R1 moved out (2/21/26) the payment for the phone stopped. On August 6, 2026, the department reviewed and evaluated the following documents: R1’s admission agreement (dated 10/2/24), signed personal rights (dated 10/2/26), and R1’s P & I log (2025-2026). Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. Page 3 of 4 Allegation: Staff do not prevent recurring cockroach infestation The detail of the complaint alleges that when R1 lived in the facility “there were cockroaches all over the bathroom and despite the services through pest control company Orkin the roaches allegedly kept coming back. On August 6, 2026, at 10:00am, the Department interviewed the Assistant Administrator (A1) who denied the allegation of a cockroach infestation. A1 stated that “we have Orkin pest control come in to do maintenance inspections and we have been cleared.” On August 6, 2026, the Department interviewed 5 staff (S1-S5) regarding the allegation. 5 out of 5 denied the allegation of a cockroach infestation, they stated that they have seen 1 or 2 roaches, but Orkin comes out often to do treatments. On August 6, 2026, the Department interviewed 5 residents (R2-R6) who also stated that they have only seen 1 or 2 roaches and denied that there is an infestation. On August 6, 2026, the department reviewed the Orkin Service report (dated 7/24/26). The report is a maintenance report and according to the report, mild activity was observed and documented. Previous service dates were as follows: 7/10/26, 6/12/26, 3/27/26, 11/7/25, and 10/10/25. The document confirms that the facility is maintaining pest control. On August 6, 2026, the Department toured the facility and observed that it was clean, safe and sanitary. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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 Nicole Lozano. No deficiencies cited during todays visit. Copy of report provided. Page 4 of 4the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 11-AS-20260729111020

Allegation investigated: Staff do not safeguard resident's cash resources

On 7/16/26, at 9:10am, the department conducted an initial complaint visit to the facility and was greeted by Jenni Gordon, Administrator. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegation mentioned above. The investigation consisted of the following: The department investigated the allegation mentioned in this complaint and conducted interviews with staff (S1-S3) and residents (R1-R10). The department received the following documents: Resident Roster (Date: 07/16/2026), Personnel Report (Dated: 07/16/2026), Tenant Ledger (Dated: 03/01/2024-07/13/2026), Resident Fund Management System Statement (Dated: 07/16/2026), Social Security Income Statement (Dated: 05/25/2026), Regent Villa Fax Notes to Social Security (Dated: 05/04/2026), Identification and Emergency Information (Dated: 02/29/2024), Admission Agreement (Dated: 02/29/2024), Transfer Discharge Report Lakewood Healthcare Center (Dated: 04/06/2026), Resident Service Plan (Dated: 01/08/2025), Preplacement Appraisal Information (Dated: 01/08/2025)..... Report Continued On LIC9099-C Unsubstantiated Physicians Report (Dated: 03/27/2025), and Regent Villa Rent Increase Notice (Dated: 01/02/2026) from the facility. The investigation revealed the following: Allegation- Staff do not safeguard resident's cash resources. The details of the complaint allege that money was taken from the resident (R1s) account. It was reported that $1,900 was taken from them and deposited into a Citibank account that the resident does not own, now there is an outstanding balance for rent for the month of April. However, it was reported that R1s rent for May, June, and July were paid. On 7/16/2026, from 9:30am-2:30pm, the department interviewed staff (S1-S3) and residents (R1-R10). 3 of 3 staff denied the allegation that Staff do not safeguard resident's cash resources. All staff (S1-S3) stated that the Citibank account in question is the account that the residents get there social security checks deposited into. Staff stated that the formal name of the account is Resident Fund Management Service which is an account through Citibank for which residents have their checks deposited into to pay rent and once deducted; whatever is left over from that, the residents get to keep. Staff (S1) also stated that the resident went into the hospital for a long period of time and medical reported to social security about the resident being in the hospital, and social security stopped paying rent for R1. Now that the resident has returned, stated (S1) they are working to get (R1) back pay to cover their rent that social security did not pay. S1 stated that the resident has a past due balance for rent which is $1,973.20. S1 stated that resident is getting their current social security check and any Personal and Incidental (P & I) balance due them and their current rent is paid. The department interviewed residents (R1-R10) ) about the allegation and 10 of 10 residents that were interviewed denied that the facility does not safeguard their cash resources. They stated that they never had a problem with financial theft from the facility and that they deposit any checks they get from social security into the Resident Fund Management Service account. This account they stated deducts their rent and they get whatever is left from the deposit. Report Continued On LIC9099-C R1 stated that the facility explained that the Citibank account was the same account that they deposited their checks into in prior months. Once the facility explained what was going, R1 stated that they understood and realized that the facility is safeguarding their financial resources. R1 stated that they were confused and did not realize that “Citibank” was the same as what they have come to know as Resident Fund Management Service account that has deducted their rent in the past. The department reviewed the Resident Fund Management System Statement (Dated: 07/16/2026), Social Security Income Statement (Dated: 05/25/2026), Regent Villa Fax Notes to Social Security (Dated: 05/04/2026), and Tenant Ledger (Dated: 03/01/2024-07/13/2026 and observed that R1s check was being deposited into the Resident Fund Management Service account which is run by Citibank. The department also observed that the resident has an outstanding balance of $1,973.20 for rent that social security has not paid. The department also observed that R1 has an overpayment of $2,281.84 from social security that they are paying back monthly by a deduction of $162.60 from their base social security payment of $1,626.07. R1s current social security payment is $1,463.47. The department did not find any evidence that the facility was not safeguarding the residents’ cash resources. Based on interviews conducted, and records reviewed, there is insufficient evidence to support the allegation that Staff do not safeguard resident's cash resources. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were found and no citations were issued for this complaint investigation. An exit interview was conducted with Jenni Gordon, Administrator, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 11-AS-20260708090818

Allegation investigated: Due to lack of supervision, resident assaulted another resident causing injury.

On 05/21/26, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegation. LPA met with Administrator Jenni Gordon. Investigation consisted of the following: On 05/21/26, the Department obtained Register of Residents (03/17/26 and 05/21/26), Master Schedule, Attendance Roll (03/16/26 – 03/22/26), Facility Sketch, Incident Reports (08/05/24, 03/21/25, 04/19/25, 03/17/26), Resident #1’s Record, Photos of Resident #1 and #2,and R1’s Relocation Statement and Request for Payment (03/25/26). LPA interviewed Staff #1 – 10 and Residents #1 – 10 and toured the second floor. Note: Video camera was offline on 05/21/26. Investigation revealed the following: Allegation: Due to lack of supervision, resident assaulted another resident causing injury. It is being alleged on 03/17/26 around 5:20 PM, Resident #1 (R1) was attacked by Resident #2 (R2) and sustained multiple injuries. Continue to LIC9099-C. Unsubstantiated Record review revealed of Unusual Incident Report (03/17/26) revealed according to R2 and Resident #4 (R4), R1 spit on R2 and the physical altercation occurred. Staff #2 (S2) separated both residents and called 911. Long Beach Police Department described the incident as a “mutual altercation” and no arrests were made. Hospitalization was offered and R1 and R2 declined. R2 complained of shortness of breath and went to the hospital around 9:15 PM that night. R1 was transferred to LA Downtown Medical Center on a 5150 hold, danger to others, the following day. Review of Master Schedule revealed one Licensed Vocational Nurse, MedTech, and two caregivers were working Tuesday PM Shift (4:00 PM – 12:00 AM). Review of Attendance Roll (03/16/26 – 03/22/26) revealed R1 was present during the AM and PM attendance count on 03/17/26. R1's Preplacement Appraisal Information (05/22/24) revealed R1 does not need special observation/night supervision (due to confusion, forgetfulness, wandering). R1's Physician's Report (05/21/24) revealed R1 is able to leave the facility unassisted and has the capacity for self-care. Seven out of nine resident interviews (R1 – R2, R4 – R10) indicated there is sufficient staff supervision on the second floor and in the evenings. R2 indicated R1 spit on R2 because R2 made a comment as R2 walked past R1’s room. R4 indicated R4 witnessed the fight at the elevator and indicated R1 attacked R2. R6 heard the commotion but did not go outside of R6’s room to witness the altercation. R10 indicated R2 did not enter the room to attack R1 but R1 was outside the room sweeping. R10 indicated R10 could not see any injuries on R1. Nine out of nine staff interviews (S1 – S9) indicated there is sufficient staff supervision on the second floor and in the evenings. S2 indicated R1 approached S2 as S2 was exiting the elevator. R1 said R2 attacked R1 in room. S2 then saw R2 approaching them yelling and the two residents were separated. S2 indicated rounds are conducted every 90 minutes or sooner and staff does laundry on the second floor. S2 indicated caregivers were starting to assist residents with showers during the time of the incident. S3 indicated S3 cleansed R1’s bleeding, assessed R1 from head to toe, and provided an ice pack. R1 told S3 that R1 got into a fight and R1 declined the option to go to the hospital. S1 and S3 indicated rounds are conducted every two hours. LPA observed photo of R1 with bleeding on the side of the head and some bleeding on the face. LPA observed photo of R2 and R2 had a busted lip and bruised knuckles. Regarding the allegation, “Due to lack of supervision, resident assaulted another resident causing injury,” based on record review, interviews and observation, the Department found no evidence to support the above allegation. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted and a hard copy of this report provided to Admissions Director Nicole Lozano.the state’s words, verbatim · CDSS document, May 21, 2026 · control 11-AS-20260515113854

Allegation investigated: Due to lack of supervision, resident assaulted another resident causing injury.

On 05/21/26, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegation. LPA met with Administrator Jenni Gordon. Investigation consisted of the following: On 05/21/26, the Department obtained Register of Residents (03/17/26 and 05/21/26), Master Schedule, Attendance Roll (03/16/26 – 03/22/26), Facility Sketch, Incident Reports (08/05/24, 03/21/25, 04/19/25, 03/17/26), Resident #1’s Record, Photos of Resident #1 and #2,and R1’s Relocation Statement and Request for Payment (03/25/26). LPA interviewed Staff #1 – 10 and Residents #1 – 10 and toured the second floor. Note: Video camera was offline on 05/21/26. Investigation revealed the following: Allegation: Due to lack of supervision, resident assaulted another resident causing injury. It is being alleged on 03/17/26 around 5:20 PM, Resident #1 (R1) was attacked by Resident #2 (R2) and sustained multiple injuries. Continue to LIC9099-C. Unsubstantiated Record review revealed of Unusual Incident Report (03/17/26) revealed according to R2 and Resident #4 (R4), R1 spit on R2 and the physical altercation occurred. Staff #2 (S2) separated both residents and called 911. Long Beach Police Department described the incident as a “mutual altercation” and no arrests were made. Hospitalization was offered and R1 and R2 declined. R2 complained of shortness of breath and went to the hospital around 9:15 PM that night. R1 was transferred to LA Downtown Medical Center on a 5150 hold, danger to others, the following day. Review of Master Schedule revealed one Licensed Vocational Nurse, MedTech, and two caregivers were working Tuesday PM Shift (4:00 PM – 12:00 AM). Review of Attendance Roll (03/16/26 – 03/22/26) revealed R1 was present during the AM and PM attendance count on 03/17/26. R1's Preplacement Appraisal Information (05/22/24) revealed R1 does not need special observation/night supervision (due to confusion, forgetfulness, wandering). R1's Physician's Report (05/21/24) revealed R1 is able to leave the facility unassisted and has the capacity for self-care. Seven out of nine resident interviews (R1 – R2, R4 – R10) indicated there is sufficient staff supervision on the second floor and in the evenings. R2 indicated R1 spit on R2 because R2 made a comment as R2 walked past R1’s room. R4 indicated R4 witnessed the fight at the elevator and indicated R1 attacked R2. R6 heard the commotion but did not go outside of R6’s room to witness the altercation. R10 indicated R2 did not enter the room to attack R1 but R1 was outside the room sweeping. R10 indicated R10 could not see any injuries on R1. Nine out of nine staff interviews (S1 – S9) indicated there is sufficient staff supervision on the second floor and in the evenings. S2 indicated R1 approached S2 as S2 was exiting the elevator. R1 said R2 attacked R1 in room. S2 then saw R2 approaching them yelling and the two residents were separated. S2 indicated rounds are conducted every 90 minutes or sooner and staff does laundry on the second floor. S2 indicated caregivers were starting to assist residents with showers during the time of the incident. S3 indicated S3 cleansed R1’s bleeding, assessed R1 from head to toe, and provided an ice pack. R1 told S3 that R1 got into a fight and R1 declined the option to go to the hospital. S1 and S3 indicated rounds are conducted every two hours. LPA observed photo of R1 with bleeding on the side of the head and some bleeding on the face. LPA observed photo of R2 and R2 had a busted lip and bruised knuckles. Regarding the allegation, “Due to lack of supervision, resident assaulted another resident causing injury,” based on record review, interviews and observation, the Department found no evidence to support the above allegation. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted and a hard copy of this report provided to Admissions Director Nicole Lozano.the state’s words, verbatim · CDSS document, May 21, 2026 · control 11-AS-20260515113854

Allegation investigated: Staff did not prevent resident from punching another resident in care resulting in injuries.

On 12/22/25, The Department conducted a subsequent complaint visit to deliver findings. The Department met with Assistant Administrator as the reason for the visit was explained. The investigation consisted of the following: On 08/26/25, The Department requested a copies of the following documents: staff roster (dated 8/17/25 ), resident roster (dated 8/23/25 ), and the following documents for residents #1-2 (R1-R2): R1 Resident Pre-placement Appraisals (dated 12/13/23,) R2 pre-placement appraisal (dated 3/2/23 R1's Incident reports (dated 8/25/25), R1 Physician's Report (dated 11/8/24), R2's Physician’s Report (dated 12/10/24), R1's Admission Agreement (dated12/13/23) and R2's admission agreement (dated 3/2/23). On 09/03/25 The Department conducted a subsequent visit and conducted interviews with S1 and Resident #3 (R3). On 09/03/25 The Department also obtained copies of the following for R1 and R2: Identification and emergency information, physicians orders and medication logs for July and August 2025. Unsubstantiated On 09/12/25 The Department attempted to conduct an interview with R1, but were unsuccessful due to communication barrios. On 09/23/25 The Department conducted interview with witness #1 (W1), and on 10/02/25 The Department conducted interview with staff #2 (S2). The investigation revealed the following: Allegation: Staff did not prevent resident from punching another resident in care resulting in injuries It is being alleged that a resident in care obtained an injury after being punched in the face by another resident. On 09/03/25 The Department conducted interview with S1 regarding the allegation above. S1 confirmed the allegation above, however S1 indicated that R1 and R2 had no prior disagreements leading to the incident. S1 also reported that R2 had no prior history of aggressive behaviors. 09/03/25 The Department conducted interview with R3 regarding the allegation above. R3 confirmed the allegation above, however, R3 report that facility staff arrived quickly to assist. On 09/12/25 The Department attempted to conduct an interview with R1 but were unsuccessful due to communication barrios. On 09/23/25 The Department conducted interview with witness #1 (W1) regarding the allegation above. W1 reported being aware of the incident between R1 and R2 and stated R2 has no history of aggression. On 10/02/25 The Department conducted interview with S2 regarding the allegation above. Per S2, S2 arrived at the dining room when the altercation ended. Additionally, S2 reports there were staff members present and had already intervened by the time S2 arrived. On 12/16/25 The Department conducted a review of R1 and R2 physician reports dated: 11/08/24 and 03/26/25, and R1 and R2 needs and individual service plans both date 2/21/25. Upon review it was observed that neither resident has a documented history of aggressive behaviors or altercations with residents nor staff. 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 conducted, and a copy of this report was provided to the Assistant Administrator.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 11-AS-20250825155922

Allegation investigated: Staff did not provide resident with personal care supplies. Staff did not safeguard resident's mail.

On November 17, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Jenni Gordon, administrator greeted the (LPA). (LPA) explained the purpose of the visit is to investigate the allegations mentioned above. The investigation included a collection of records, and an observation of the facility. The Department obtained several documents, including the Facility Staff Roster (dated 11/17/25), the Resident Roster (dated 11/17/25), service records for Resident #1 (R1) Identification and Emergency Information LIC 601 (dated 02/07/21), Medical Assessment for Residential Care Facilities for the Elderly LIC 624A (dated 06/24/25), Preplacement Appraisal Information LIC 603 (dated 08/20/18), Resident Personal Property and Valuables LIC 621 (dated 08/20/18) and Personal Rights Residential Care Facilities for the Elderly LIC 613C (dated 08/20/18) and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION #1: Staff did not provide resident with personal care supplies. ALLEGATION #2: Staff did not safeguard resident's mail. The complaint alleges that the staff failed to provide Resident #1 (R1) with personal care supplies and did not protect (R1's) mail. Reports indicate that incontinence care supplies intended for (R1) were delivered to the facility, but a staff member withheld them for several days without providing any explanation for the delay. Additionally, a staff member retrieved and opened (R1's) incoming mail and stole its contents. No further information about this situation has been provided. On November 17, 2025, between 09:30 AM and 10:25 AM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) of the three (3) staff members were unable to confirm the accusations. (S1-S3) stated that (R1) has not experienced any issues with receiving, tampering with, or mishandling mail or packages at the facility. According to (S1), on November 12, 2025, at around 4:00 PM, (S1) reported that three large boxes of personal supplies arrived for (R1) in the front lobby. (S1) noted that two care staff were busy helping residents, and the maintenance staff had finished their shift. (S1) informed (R1) about the delivery but mentioned there was no one available to take the packages to (R1's) room at that time. The packages were stored securely overnight in a secure storage room and scheduled for delivery the next day. (S1) claimed that on the following day, the care staff got busy and forgot to ask maintenance to deliver the packages to (R1). (R1) received packages as soon as it was discovered that they were still in the storage area. Staff members (S1-S4) reported that (R1) regularly receives monthly incontinence supplies and personal mail, all delivered on time. They stated that no staff member has tampered with, withheld, or stolen any resident's mail or packages. (S1 and S4) explained that USPS delivers mail around midday. The office staff sorts it, and it is usually sent to residents during lunch or dinner times. If a resident is not present during meals, the mail is taken to their room the same day. On November 17, 2025, between 10:00 AM and 10:20 AM, the Department interviewed a resident identified as Resident #1 (R1). (R1) explained that (R1) panicked with anxiety when the packages were not delivered on time. (R1) recalled being informed that the packages would be stored in a secure area, but (S1) never provided a reason for the delivery delay. Despite the confusion, (R1) believes it was a misunderstanding resulting from poor communication. (Evaluation Report continues LIC 9099-C) (R1) confirmed receipt of boxes of personal supplies and stated that (R1) did not believe the delivery delay was intentional or intended to cause discomfort. (R1) mentioned that issues with USPS mail, including tampering and theft, had occurred several years ago. (R1) stated that the incident happened with a former employee and did not want to go into detailed information about that incident. (R1) noted that it had never happened again. (R1) also expressed a positive opinion about the current staff at the facility, stating they are good and honest, and feel safe and secure as a resident in care at this facility. (R1) said to have not encountered any further issues with mail or package delivery since. On November 17, 2025, between 10:30 AM and 11:40 AM, the Department conducted interviews with resident members, identified as Resident #2 through Resident #9 (R2-R9). Eight (8) of the eight (8) resident members are unable to corroborate these claims. (R2-R9) reported no issues with package or USPS mail delivery at the facility, stating that all deliveries arrived on time. They also indicated that they had never experienced any personal items being tampered with, lost, or stolen through mail or freight delivery. Furthermore, all residents expressed their satisfaction with the services provided by the staff. The Department reviewed (R1’s) Identification and Emergency Information LIC 601 (dated 02/07/21), Medical Assessment for Residential Care Facilities for the Elderly LIC 624A (06/24/25), Preplacement Appraisal Information LIC 603 (dated 08/20/18), Resident Personal Property and Valuables LIC 621 (dated 08/20/18) and Personal Rights Residential Care Facilities for the Elderly LIC 613C (dated 08/20/18). Further review of Physicians Order Medications (dated 11/17/25) revealed (R1) is prescribed 29 medications and 20 of them present side effects that include: headache, dizziness, restlessness, anxiety or confusion (ref: National Institute of Health). During the investigation on November 17, 2025, the Department inspected (R1’s) room and verified the receipt of personal items. The Department observed staff members interacting with residents and noted that their conduct was appropriate. The Department found that the facility upholds the rights of its residents. Posters detailing Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. Based on the information gathered from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. An exit interview was conducted with Jenni Gordon and copies were provided.the state’s words, verbatim · CDSS document, Nov 17, 2025 · control 11-AS-20251113113954

Type of visit: Case Management - Annual Continuation

On September 13, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced Case Management-Annual Continuation visit using the CARE Inspection Tool to continue inspection from 8/28/25. LPA met with Nicole Lozano. LPA explained the purpose of today’s visit. The facility is licensed to serve (188) elderly adults ages 60 and above, of which (40) can be non-ambulatory. The facility has an approved hospice waiver for (3) Structure: The facility is a two-story commercial building that consists of (94) resident bedrooms, (94) resident bathrooms, eight (8) common bathrooms, dining room, commercial kitchen, staff area, office area, commercial washer and dryer room/ storage area, Movie room, activity room, and backyard with umbrella with table and chairs. LPA reviewed 5 resident files and found 5 out of 5 contained all the necessary documentation. LPA reviewed 5 staff files and found 5 out of 5 contained the required documentation, certification, and training. LPA observed all required posting throughout the facility. Page 1 of 2 Medication LPA observed all centrally stored medications in their original packaging and are secured in the facility’s med room. During today's visit there were no deficiencies cited. Exit interview conducted and copy copy of report give to Nicole Lozano Page 2 of 2the state’s words, verbatim · CDSS document, Sep 13, 2025

Type of visit: Required - 1 Year

On August 28, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Jenni Gordon. LPA explained the purpose of today’s visit. The facility is licensed to serve (188) elderly adults ages 60 and above, of which (40) can be non-ambulatory. The facility has an approved hospice waiver for (3) Structure: The facility is a two-story commercial building that consists of (94) resident bedrooms, (94) resident bathrooms, eight (8) common bathrooms, dining room, commercial kitchen, staff area, office area, commercial washer and dryer room/ storage area, Movie room, activity room, and backyard with umbrella with table and chairs. Physical Plant: LPA Lee and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (6) bedrooms and (6) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Page 1 of 2 The bathrooms were found to be within Title 22 regulations and were operational. The water temperature ranged from measured between 105 and 120 degrees F. Safety During the visit, LPA observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. All fire extinguishers were charged and operable with last date inspected (1/21/25). The last Fire/Disaster Drills were conducted on 7/30/25. Fire system inspected by Long Beach Fire on 7/4/25 Kitchen The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. The kitchen was clean and sanitary. The dinning area was also clean and sanitary with plenty of seating for the residents. Common rooms were clean and sanitary with ample lighting and room for the residents in care. Walk ways inside and outside of the facility were free of obstruction. Due to time constraint , LPA to complete inspection on a subsequent visit No deficiencies issued during today’s visit. Exit interview conducted and copy of report providedthe state’s words, verbatim · CDSS document, Aug 28, 2025

Allegation investigated: Licensee does not ensure that the facility has enough staff to meet the needs of residents in care. Staff did not provide assistance to resident in care as necessary.

*This report serves to clarify investigation findings and is created to supersede the LIC 9099 and LIC 9099C reports created on 04/11/25. Although this report supersedes the previous report, the complaint investigation findings remain the same. * On June 19, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted a subsequent complaint visit regarding the above allegations. LPA Lee met with Jenni Gordon and explained the reason for the visit. The investigation consisted of the following: On April 11, 2025, LPA obtained and reviewed the following: staff roster (No date), resident's roster (dated 4/10/25), Unusual Incident Report (UIR) dated 4/7/25, Pre-Appraisal/Need and Services Plan for R1 (dated 8/2/2019, 1/23/25), Physician's Report for Residential Care for the Elderly (RCFE) for R1(dated 2/4/25), Residents Rights training/ALW disclosures (dated 6/23/24), Assistance with Transfer and Ambulation policy (dated 3/6/25); Written Fall Protocol (3/6/25). LPA reviewed R1’s file. LPA Lee conducted 5 staff interviews (S1- S5), Administrator (A1), Assistant Administrator (A2), and 5 resident interviews (R1-R5). On June 19, 2025, LPA Lee conducted subsequent interviews with staff (S6-S8). Page 1 of 3 Unsubstantiated Investigation revealed the following: Allegation: Licensee does not ensure that the facility has enough staff to meet the needs of residents in care. The complaint alleges that R1 was walking towards the front door when R1 lost balance and fell to the ground and facility staff was unable to lift R1 to R1’s feet, staff then called 911 for assistance. Facility staff allegedly told the paramedics that “they do not have enough staff to lift someone.” On 4/11/25 at 9:45am, LPA interviewed Administrator (A1) who denied allegation and stated that the facility has sufficient staff to meet residents’ needs. On 4/11/25 between 10:45 am and 12:00pm, LPA interviewed 5 staff (Staff #1-5) and Assistant Administrator (A2) regarding the allegation; 5 out of 5 staff and A2 denied the allegation and reported that there is enough staff to meet the needs of the residents. On 6/19/25 during subsequent visit, between 1:00pm and 2:00pm, LPA interviewed 3 staff (S6-S8); 3 out of 3 staff interviewed denied allegation and reported that they never told paramedics that “they do not have enough staff to lift someone” as mentioned in the complaint. 3 out of 3 also stated that there is enough staff to meet the residents needs. On 4/11/25 between 1:00pm and 2:00pm, LPA interviewed 5 Residents (Residents #1-5). Of the 5 Residents interviewed, 5 out of 5 denied the allegation. 5 out of 5 stated that their needs are taken care of and that there is enough staff to meet their needs. On 4/11/25, LPA observed sufficient staff present at time of visit. On 4/11/25 and 6/19/25, LPA obtained, reviewed, and evaluated staff schedules and resident roster (current and week of incident) and found that sufficient staffing is maintained at the facility to meet the residents’ needs. Based on the information gathered, there is insufficient evidence to support the stated allegation Page 2 of 3 Allegation: Staff did not provide assistance to resident in care as necessary. The complaint alleges that when R1 lost balance and fell while entering the building, staff refused to assist R1 from the ground and stated that “it is not their policy to lift people up.” On 4/11/25, LPA interviewed Administrator (A1) who denied the allegation and stated that according to their policy, when a resident has fallen and can’t get up, they don’t move them because the extent of the injury is unknown. A1 further stated that for the safety of the resident and the staff, we do not move them, we call the paramedics who can better assess the situation. Consequently, if the resident can get up we then aid them by offering a chair to use as leverage to assist them in getting up. On 4/11 /25 between 10:45 am and 12:00pm, LPA interviewed 5 Staff (Staff #1-5) and Assistant Administrator (A2) regarding the allegation; 5 out of 5 staff and A2 denied the allegation, stating that staff assist residents when it is safe to do so. On 4/11/25, LPA obtained, reviewed and evaluated a copy of the Assistance with Transfer and Ambulation policy (dated 3/6/25) which provides guidance to caregivers regarding lifting resident--it states that Caregivers are not to lift a resident who has fallen and appears to be injured, due to the risk of injury to both the resident and Caregiver(s) involved. On 4/11/25, LPA also obtained and reviewed a copy the facility’s fall policy (dated 3/6/25). On 4/11/25 between 1:00pm and 2:00pm LPA interviewed R1-R5 and of those interviewed 5 out of 5 stated that staff assists them when needed. R1 stated that R1 had a recent fall and staff helped immediately, by calling 911 because R1 was unable to get up. Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegations above 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 are UNSUBSTANTIATED. There were no deficiencies cited during today's visit. Exit interview conducted and report provided to Jenni Gordon, Administrator Page 3 of 3the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 11-AS-20250407123024

Allegation investigated: Staff pushed a resident in care. Staff mentally abused a resident in care.

On May 29, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted an initial complaint visit regarding the above allegations. LPA Lee met with Jenni Gordon, Administrator and explained the reason for the visit. The investigation consisted of the following: On May 29, 2025, LPA obtained and reviewed the following: staff roster (No date), resident's roster (dated 5/28/25), Pre-Appraisal/Need and Services Plan for R1 (dated 7/3/21), Physician's Report for Residential Care for the Elderly (RCFE) for R1(dated 11/26/24), Residents Rights training (dated 6/22/24), and Abuse, Neglect,and Exploitation in a Elder Care setting (dated 4/4/25). LPA reviewed R1’s file. LPA Lee conducted 4 staff interviews (S1- S4), Administrator (A1), and 5 resident interviews (R1-R5). Page 1 of 3 Unsubstantiated Investigation reveals the following: Allegation: Staff pushed a resident in care The complaint alleges that "staff pushed R1." On 5/29/25 at 11:00am LPA interviewed Administrator (A1) who denied the allegation stating that there has been no reports of staff pushing or hitting a resident in care. Additionally, A1 reported that all staff had training on Resident Rights and Suspected Elder Abuse. On 5/29/25 between 11:30 am and 12:30pm, LPA interviewed 5 residents (R1-R5). Of those interviewed, 5 out of 5 stated that staff have never pushed or hit them. Additionally, 5 out of 5 stated that staff treat them with respect. Lastly, 5 out of 5 residents stated that they feel safe and comfortable living at the facility. On 5/29/25, between 12:30pm and 1:45pm LPA interviewed 4 staff (S1-S4) regarding the allegations. Of those interviewed, 4 out of 4 staff denied the allegation stating they have never hit or pushed a resident in care nor have they witness any other staff push or hit a resident it care. Lastly 4 out of 4 stated to have had Resident Rights and Suspected Elder Abuse training. On 5/29/25, LPA obtained and reviewed copies of staff training : Residents Rights training (dated 6/22/24), and Abuse, Neglect, and Exploitation in a Elder Care setting (dated 4/4/25). Based on the information gathered, there is insufficient evidence to support the stated allegation Page 2 of 3 Allegation: Staff mentally abused a resident in care. The complaint alleges that "staff mentally abused R1, however it was not disclosed how R1 was mentally abused." On 5/29/25 at 11:00am LPA interviewed Administrator (A1) who denied the allegation stating that there has been no reports of staff mentally abusing a resident in care. Additionally, A1 reported that all staff had training on Resident Rights and Suspected Elder Abuse. On 5/29/25 between 11:30 am and 12:30pm, LPA interviewed 5 residents (R1-R5). Of those interviewed 5 out of 5 stated that staff has never mentally abused them in anyway. Additionally, 5 out of 5 stated that staff treat them with respect. Lastly, 5 out of 5 residents stated that they feel safe and comfortable living at the facility. On 5/29/25, between 12:30pm and 1:45pm LPA interviewed 4 staff (S1-S4) regarding the allegation. Of those interviewed, 4 out of 4 staff denied the allegation stating they have never mentally abused a resident in care nor have they witness any other staff mentally abusing a resident it care. Lastly, 4 out of 4 staff stated to have had Resident Rights and Suspected Elder abuse training. On 5/29/25, LPA obtained and reviewed copies of staff training : Residents Rights training (dated 6/22/24), and Abuse, Neglect, and Exploitation in a Elder Care setting (dated 4/4/25). Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegations above 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. There were no deficiencies cited during today's visit. Exit interview conducted and report provided for Jenni Gordon, Administrator. Page 3 of 3the state’s words, verbatim · CDSS document, May 29, 2025 · control 11-AS-20250523155627

Type of visit: Case Management - Incident

On May 6, 2025 Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced 24 hour case management visit to gain additional information pertaining to the death of a resident (R1) that was reported to the Regional Office (RO) on May 5, 2025. LPA Lee met with Nicole Lozano, Admissions Director who granted access to the facility and the purpose of the visit was explained. Subsequently, Jenni Gordon Administrator arrived to assist with the visit. On May 5, 2025 at 7:42 am R1 was found laying on side in a fetal position observed to have a knife lodged in his abdominal cavity. 911 called, and first responder observed that resident was deceased on arrival. An investigation was conducted by Long Beach PD and based on their investigation; the stabbing appeared to be self-inflicted. LPA Lee and Jenni Gordon conducted a tour of the facility. The following documents were obtained/reviewed: Staff roster Resident roster, R1 and R2 files, Physician's Orders (dated 5/5/25) for R1 and R2, Physician's report for R1 and R2 (dated 3/25/25 and 10/29/24 ), copy of County of Los Angeles medical examiner investigator's card-case number 2025-07419), Search Warrant and Affidavit (dated 5/5/25), LBPD search warrant property report (dated 5/5/25), Individual Service Plans for R1 and R2 (dated 4/21/25, 1/30/25). Medication Administration Record (MAR) for R1 and R2. LPA observed the meeting Administrator and psychologist Dr. Salman Shully had with the residents informing them of what happened and offering any grief counseling if anyone needed it. There were no deficiencies cited during today’s visit. An exit interview was held and a copy of the report was provided to Administrator Jenni Gordon.the state’s words, verbatim · CDSS document, May 6, 2025

Allegation investigated: Licensee does not ensure that the facility has enough staff to meet the needs of residents in care. Staff did not provide assistance to resident in care as necessary.

On April 11, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted a complaint visit regarding the above allegations. LPA Lee met with Nicole Lozano, Admissions Director, and explained the reason for the visit. Subsequently, Jenni Gordon Administrator arrived and assisted with visit. The investigation consisted of the following: On April 11, 2025, LPA obtained and reviewed the following: staff roster (No date), resident's roster (dated 4/10/25), Pre-Appraisal/Need and Services Plan for R1 (dated 8/2/2019, 1/23/25), Physician's Report for Residential Care for the Elderly (RCFE) for R1(dated 2/4/25), Residents Rights training/ALW disclosures (dated 6/23/24), Assistance with Tranfer and Ambulation policy (dated 3/6/25); Fall Policy (3/6/25). LPA reviewed R1’s file. LPA Lee conducted 5 staff interviews (S1- S5), Administrator (A1), Assistant Administrator (A2), and 5 resident interviews (R1-R5). Page 1 of 3 Unsubstantiated Investigation revealed the following: Allegation: Licensee does not ensure that the facility has enough staff to meet the needs of residents in care. The complaint alleges that facility staff admitted to not having enough staff to “lift” resident. On 4/11/25 at 9:45am, LPA interviewed Administrator (A1) who denied allegation and stated that the facility has enough staff to meet residents needs.On 4/11/25 between 10:45 am and 12:00pm, LPA interviewed 5 Staff (Staff #1-5) and Assistant Administrator (A2) regarding the allegation; 5 out of 5 staff and A2 denied the allegation, and reported that there is enough staff to meet the needs of the residents. On 4/11/25 between 1:00pm and 2:00pm, LPA interviewed 5 Residents (Residents #1-5). Of the 5 interviewed, 5 out of 5 denied the allegation. 5 out of 5 stated that their needs are taken care of and that there is enough staff to meet their needs. On 4/11/25, LPA observed adequate staff present at time of visit. On 4/11/25, LPA reviewed staff and resident rosters which confirmed that adequate staffing is maintained. Based on the information gathered, there is insufficient evidence to support the stated allegation Allegation: Staff did not provide assistance to resident in care as necessary. The complaint alleges that facility staff on scene admittedly refused to assist patient from the ground and stated that it is not their policy to lift people up. Page 2 of 3 On 4/11/25, LPA interviewed Administrator (A1) who denied the allegation and stated that according to their policy, when a resident has fallen and can’t get up, they don’t move them because the extent of the injury is unknown. A1 further stated that for the safety of the resident and the staff, we do not move them, we call paramedics who can better assess the situation. Consequently, if the resident is able to get up then we provide assistance to them such as offer a chair to use as leverage to assist them in getting up. On 4/11 /25 between 10:45 am and 12:00pm, LPA interviewed 5 Staff (Staff #1-5) and Assistant Administrator (A2) regarding the allegation; 5 out of 5 staff and A2 denied the allegation, stating that staff assist residents when it is safe to do so. On 4/11/25, LPA obtained and reviewed a copy of the Assistance with Transfer and Ambulation policy (dated 3/6/25) which provides guidance to caregivers regarding lifting resident--it states that Caregivers are not to lift a resident who has fallen and appears to be injured, due to the risk of injury to both the resident and Caregiver(s) involved. On 4/11/25, LPA obtained and reviewed a copy fall policy (dated 3/6/25) which states in part that care staff will be trained by Wellness Director on providing lift assistance when appropriate. On 4/11/25 between 1:00pm and 2:00pm LPA interviewed R1-R5 and of those interviewed 5 out of 5 stated that staff assists them when needed. 1 out of 5 stated that she had a recent fall and staff helped her immediately, by calling 911 because she was unable to get up. Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegations above 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 are UNSUBSTANTIATED. There were no deficiencies cited during today's visit. Exit interview conducted and report provided to Jenni Gordon, Administrator page 3 of 3the state’s words, verbatim · CDSS document, Apr 11, 2025 · control 11-AS-20250407123024

Allegation investigated: Staff does not award resident privacy. Staff does not treat resident with respect.

On 3/12/25, at 9:25am, the department conducted an initial complaint visit to the facility and was greeted by Jenni Gordan, Administrator. The department explained the purpose of this visit is to gather information about the complaint, gather facility files, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The Department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R10) from 10:00am-2:00pm. The department received the following: Resident Roster (Dated: 03/12/2025), Staff Roster (Dated: No Date) for the facility. Physicians Reports (Dated: 4/30/24, 4/16/24, 9/12/24, 1/16/24, & 8/13/24), In-Service Staff Trainings (Dated: 9/14/21-12/23/24), Personal Rights (Dated: 3/20/12, 5/22/23, 10/16/24, 8/18/16, & 8/20/18), Pre-Placement Appraisal (Dated: 2/4/20, 4/16/24, 9/12/24, 8/20/18), Admission Agreement (Dated: 3/1/23, 5/22/23, 10/16/24, 8/18/16, & 8/13/24) and Identification and Emergency Information (Dated: 7/24/20, 5/22/23, 10/16/24, 8/18/16, & 2/7/21) for residents from the facility. Page 1 of 3 Unsubstantiated The investigation revealed the following: Allegation #1-Staff does not award resident privacy. The details of the complaint alleged that the facility staff keeps unlocking the residents’ room when they are not present to get the resident upset. On 3/12/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. Staff (S1-S4) denied the allegation that the Staff does not award resident privacy. Staff (S1-S4) stated that they do not violate the residents right to privacy. They state that all residents have a right to their privacy and are made aware of their rights once they move into the facility. The Department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that the Staff does not award resident privacy. The majority of the residents interviewed (9 of 10) stated that the staff does give them their privacy and does not have an issue with their personal rights being violated because of a lack of privacy. 9 of 10 residents further state that they have not had a problem with staff leaving their bedroom doors unlocked. The Department reviewed In-Service Staff Training (Dated: 9/14/21-12/23/24) and observed that the staff has training in Personal Rights, Abuse, Neglect of Residents, Ethics and Caring, Skills for Effective Communication, and Cultural Diversity. Additionally, the department reviewed a sampling of residents’ files and observed that each file reviewed contained Personal Rights (Dated: 3/20/12, 5/22/23, 10/16/24, 8/18/16, & 8/20/18) documents signed and acknowledged by the residents. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff does not award resident privacy. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #2- Staff does not treat resident with respect. The details of the complaint alleged that the facility staff does not treat the resident with dignity and respect because of concerns the resident raised and that are still on-going without resolution. On 3/12/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. Staff (S1-S4) denied the allegation that the Staff does not treat resident with respect. All staff (S1-S4) stated that the facility does treats all their residents with dignity and respect and try to foster an atmosphere of respect and inclusion. They further state that the personal rights and well-being of their residents is a high priority. The Department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff does not treat resident with respect. The majority of residents that were interviewed (9 of 10) stated that the facility does treat them with dignity and respect and are happy living at the facility. Page 2 of 3 The Department reviewed In-Service Staff Training (Dated: 9/14/21-12/23/24) and observed that the staff has training in Personal Rights, Abuse, Neglect of Residents, Ethics and Caring, Skills for Effective Communication, and Cultural Diversity. Additionally, the department reviewed a sampling of residents’ files and observed that each file reviewed contained Personal Rights (Dated: 3/20/12, 5/22/23, 10/16/24, 8/18/16, & 8/20/18) documents signed and acknowledged by the residents. The department further observed during the interview process, that the residents are aware of their personal rights and a majority stated that their rights have not been violated because of a lack of respect given to them by the staff. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff does not treat resident with respect. 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 citations were issued. An exit interview was conducted with Jenni Gordon, Administrator, and a hard copy of this Complaint Investigation Report was provided. Page 3 of 3 Complaint Investigation Reportthe state’s words, verbatim · CDSS document, Mar 12, 2025 · control 11-AS-20250305094429

Allegation investigated: Staff do not ensure urinary catheter is emptied for resident in a timely manner. Staff do not ensure resident receives assistance with activities of daily living. Staff do not ensure the facility is kept free of malodors. Staff do not ensure the facility is kept free of pests. Staff do not ensure medications are dispensed as prescribed to residents in care.

On 11/20/23, at 08:38am, Licensing Program Analyst (LPA) Mario Leon conducted an initial unannounced visit to the facility and was greeted by Jenni Gordon, Administrator (S1). LPA explained the purpose of this visit is to gather information for the complaint and tour the facility. The investigation consisted of the following: An initial complaint visit was completed by LPA Mario Lopez on 11/20/2023. A subsequent visit was completed by LPA Perry Scott on 10/17/2024. The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S8) and residents (R1-R9). Personnel Report (Dated: 11/20/2023), Resident Roster (Dated: 11/20/2023); Preplacement Appraisal Information (Dated: 10/30/2023), Physician’s Report (Dated: 10/30/2023), Medication Administration Record (Dated: 10/1/2023-11/1/2023), Weekly Shower/Laundry Schedule (Dated: 11/20/2023), Relias Training Report (Dated: 11/20/2023), & Pest Control Service Report (Dated: 09/08/2023-11/13/2023) documents were obtained from the facility. Complaint Investigation Report continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Staff do not ensure urinary catheter is emptied for resident in a timely manner. The details of the complaint alleged that the facility admitted a new resident (R3) that wears a urinary catheter bag, and the care staff are neglecting to assist the resident with emptying the bag when it gets full causing the urine to leak all over the facility when the resident walks around causing the facility to smell of urine. On 11/20/23, from 09:00am-4:00pm, LPA interviewed staff (S1-S8) and residents (R1-R9) regarding the allegation. 7 of 8 staff denied the allegation that the Staff do not ensure urinary catheter is emptied for resident in a timely manner. 7 of 8 staff that were interviewed stated that the resident (R3) does not have a catheter but has incontinence issues. One staff had no knowledge of the resident. They state that the staff never neglects (R3) in any way. The resident is always assisted by the caregivers with bathing, showering, grooming, and changing R3s adult briefs, stated S1. LPA reviewed the Physicians Report (Dated: 10/30/2023) and it did not indicate that R3 had a urinary catheter. LPA reviewed the Weekly Shower/Laundry Schedule (Dated: 11/20/2023) and it indicated that the resident is scheduled to take daily showers and have their laundry cleaned daily as well. The majority (7 of 8) staff that were interviewed, indicated that the resident needs to be encouraged to take the scheduled showers, and that they assist the resident in taking the showers. LPA interviewed residents R1-R9 about the allegation and 7 of 9 residents that were interviewed denied the allegation that Staff do not ensure urinary catheter is emptied for resident in a timely manner. Residents stated that they have not noticed any urine in the hallways or a smell of urine in the facility because of one resident. They also state that they do not know if the resident (R3) has a catheter or not. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not ensure urinary catheter is emptied for resident in a timely manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #2- Staff do not ensure resident receives assistance with activities of daily living. The details of the complaint alleged that the staff does not ensure the resident receives assistance with activities of daily living causing the client to smell of urine. In that they don’t make sure the client is bathed, groomed, and in fresh clothing. On 11/20/23, from 09:00am-4:00pm, LPA interviewed staff (S1-S8) and residents (R1-R9) regarding the allegation. 8 of 8 staff (S1-S8) denied the allegation that the Staff do not ensure resident receives assistance with activities of daily living. All staff (S1-S8) stated that resident (R3) is assisted with activities of daily living that involve showering, grooming, and washing the residents clothing. They stated that although the resident has incontinence problems the resident is not neglected and that the caregivers are changing the residents’ adult briefs and assisting the resident with showering, daily. LPA reviewed the Weekly Shower/Laundry Schedule (Dated: 11/20/2023) and it indicated that the resident is scheduled to take daily showers and the residents’ laundry is done daily. They also state that the resident does need to be encouraged to take the scheduled showers but does assist the resident in maintaining R3s hygiene. Complaint Investigation Report continued on LIC9099-C LPA interviewed residents R1-R9 about the allegation and 7 of 9 residents that were interviewed denied the allegation that the Staff do not ensure resident receives assistance with activities of daily living. The majority (7 of 9) clients interviewed stated that they have not smelled any urine scents in the facility because of the residents’ incontinence issue and that the caregivers are assisting with the residents’ activities of daily living. They also state that they are always assisted with their ADLs when needed. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not ensure resident receives assistance with activities of daily living. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3- Staff do not ensure the facility is kept free of malodors. The details of the complaint alleged that the facility staff does not ensure the facility is kept free from very unpleasant smells, mainly urine. On 11/20/23, from 09:00am-4:00pm, LPA interviewed staff (S1-S8) and residents (R1-R9) regarding the allegation. 8 of 8 staff (S1-S8) denied the allegation that the Staff do not ensure the facility is kept free of malodors. All staff (S1-S8) interviewed stated that housekeeping cleans the facility daily and it is free from odors. S1 stated that they do deep cleaning once a week, which includes mopping the floors, scrubbing the bathrooms, laundry cleaning and changing the sheets. For the hallways, we do the floors from 11:30pm-4:30am to treat common areas Monday through Saturday. Specifically on floors, high-touch areas, windows, and common areas such as table surfaces, etc., stated (S1). LPA interviewed residents R1-R9 about the allegation and 7 of 9 residents that were interviewed denied the allegation that the Staff do not ensure the facility is kept free of malodors. The majority (7 of 9) of the residents interviewed stated that the staff does ensure the facility is kept free of malodors; and they have not noticed any unpleasant smells in the facility. LPA did not smell any malodors in the facility. Based on interviews, there is insufficient evidence to support the allegation that the Staff do not ensure the facility is kept free of malodors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #4- Staff do not ensure the facility is kept free of pests. The details of the complaint alleged that the facility does not ensure that the facility is kept free from pests. On 11/20/23, from 09:00am-4:00pm, LPA interviewed staff (S1-S8) and residents (R1-R9) regarding the allegation. 8 of 8 staff (S1-S8) denied the allegation that the Staff do not ensure the facility is kept free of pests. Complaint Investigation Report continued on LIC9099-C All staff (S1-S8) interviewed stated that there were no concerning pest issues in the facility and that they have not seen any pests. S1 stated that they have semi-monthly inspections for roaches, ants, bedbugs, mice, and pigeons. Twice a year K9 inspection is done for bedbugs, they come out and if they’re found, they do treatment for them, stated (S1). Lastly, stated S1, K9 then does a follow-up about one week later to double check. LPA reviewed Pest Control Service Report (Dated: 09/08/2023-11/13/2023) and observed that the facility is actively treating and preventing any pest issues that may arise in the facility. LPA interviewed residents (R1-R9) about the allegation and 6 of 9 residents that were interviewed denied the allegation that the Staff do not ensure the facility is kept free of pests. The majority (6 of 9) of the residents interviewed stated that they have not seen any pests in the facility or their rooms. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not ensure the facility is kept free of pests. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #5- Staff do not ensure medications are dispensed as prescribed to residents in care. The details of the complaint alleged that the facility staff does not ensure that the clients are receiving the correct medications as prescribed. On 11/20/23, from 09:00am-4:00pm, LPA interviewed staff (S1-S8) and residents (R1-R9) regarding the allegation. 8 of 8 staff (S1-S8) denied the allegation that the Staff do not ensure medications are dispensed as prescribed to residents in care. All staff (S1-S8) interviewed stated that the med-techs are ensuring that the residents are dispensing medications as prescribed; and if any errors occurred it is recorded in the Medication Administration Record (MAR). S2 stated that there is a system in place in the E-Mar, that detects new medication and discontinued medication, which prevents a lot of medication errors. S2 also stated that when S2 is dispensing medication, S2 is required to ask the residents name before giving the medication to make sure it is the right medication for the resident. LPA reviewed the Medication Administration Records (Dated: 10/1/2023-11/1/2023) and did not find any discrepancies. LPA interviewed residents (R1-R9) about the allegation and 8 of 9 residents that were interviewed denied the allegation that the Staff do not ensure medications are dispensed as prescribed to residents in care. The majority (8 of 9) of the residents interviewed stated that they have not had any problems with getting their medication. They also state that they always get the correct medication that is prescribed for them. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not ensure medications are dispensed as prescribed to residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with Jenni Gordon, Administrator, and a hard copy of the Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Oct 17, 2024 · control 11-AS-20231114111202

Allegation investigated: Questionable Death Staff failed to respond to signal system in a timely manner. Staff are not properly trained in emergency procedures.

On 10/16/2024 LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Jenni Gordon /Administrator. LPA explained the purpose of this visit. Investigation Consisted of: Investigations Branch (IB) referral accepted dated 2/12/24 and completed investigation on 6/26/24. CCLD staff conducted the following interviews: Administrator Interview (A#1) 4/22/24, Facility Staff Interviews (S#1, S#2 and S#5) 4/22/24,5/7/24, Witnesses Interviews (W#1-W#2) 3/6/24 and 5/8/24, and Residents Interviews (R#2-R#5) 4/22/24. IB investigator conducted the following records reviewed: R#1’s Physicians Assessment dated: 1/5/23, Pacific Villa discharge papers dated: 12/21/22, 911 Long Beach Fire Department call log regarding R#1’s emergency call dated:1/8/23, and R#1’s death certificate provided by McKenzie Mortuary and copy of list of staff with their current CPR training. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Questionable Death. The details of the complaint alleged that (R#1) died due to facility staff not following up on their change of condition and not providing CPR when need it. During the records review gathered by CCLD staff, the department observed that on (R#1)’s physician assessment dated 1/5/23. It states that (R#1) was ambulatory and could bathe, groom, feed, and care for their needs. (R#1)’s medical diagnosis was not related to respiratory comorbidities. In addition, CCLD staff reviewed (R#1)’s discharge papers from Pacific Villa Skill Nursing Home; the discharge papers listed the same medical diagnosis found on their physician’s assessment and did not list any respiratory issues. Moreover, CCLD staff reviewed (R#1)’s death certificate dated 1/25/23; it is listed that the cause of death was cardiac arrest and hypertensive heart disease. During an interview conducted by CCLD staff with facility administrator (A#1) on 4/22/24, she stated that on 1/8/23, (R#1)’s roommate (R#2) pulled the emergency cord and (S#3) saw the light on the switchboard, then (S#3) called (S#2) that went to check on (R#1) while she contacted the facility nurse (S#1). (S#1) told (S#5) to contact emergency services-911, “All this happened within minutes. When (S#1) checked on (R#1), they had a pulse, and we do not do CPR if residents have a pulse”. During an interview conducted by CCLD staff with facility nurse (S#1), she stated that she would check on (R#1)’s blood pressure and sugar levels at least once during her shift. In addition, (S#1) stated that on the day of (R#1)’s incident, (R#2) pulled the emergency cord at approximately 18:50 PM hours, (S#1) arrived at approximately 18:55 PM hours to (R#1)’s room where they were laying on the floor unresponsive, (S#1) assessed (R#1)’s vitals and found they had a pulse, (S#1) mentioned per facility policy we do not performed CPR if resident has a pulse. (S#1) positioned (R#1) in a supine position and told (S#3) to call 911; Long Beach Fire Department arrived at the facility at approximately 19:05 PM and performed CPR on (R#1) for approximately 20 minutes before declaring them dead at approximately 19:37 PM. Evaluation Report continues LIC 9099-C During an interview conducted by CCLD staff with facility staff (S#2), she stated that on the day of (R#1) incident, she was the one that went first to check on them upon arrival (S#2) observed (R#1) lying on their right side on the floors unconscious, (S#2) callout (R#1) by their name but (R#1) failed to responded. At this point, (S#2) checked on (R#1)’s pulse and informed (S#3) to come and assist her with (R#1). (S#3) called facility nurse (S#1) to come and check (R#1) vitals. During an interview conducted by CCLD staff with facility staff (S#3), she stated that the day of (R#1)’s incident, she saw a light turn on the signal switchboard, she contacted (S#2) and told her to go and check on (R#1)’s room, when (S#2) arrived at (R#1)’s room, (S#2) called (S#3) and let her know that (R#1) was on the floor, (S#3) when to assist (S#2) with (R#1) and called facility (S#1) nurse on her way. (S#3) observed (S#1) arrive at (R#1)’s rooms and promptly check on their vitals. (S#1) instructed (S#5) to call 911. (S#3) returned to the office to call 911 and prepared (R#1) needed paperwork for the emergency department. (S#3) stated that the Long Beach Fire Department arrived at the facility at approximately 19:05-19:10 PM, less than 10 minutes after the call. During an interview conducted by CCLD staff with residents in care (R#2-R#5), (4) out of (4) residents stated that facility staff does a good job taking care of them and that they feel “happy” living there. During an interview conducted by CCLD staff with (R#1)’s Primary physician (W#2), he stated that (R#1) did not note any issues with their breathing; he stated that he would rarely receive calls for any issues with them. (W#2) stated that had (R#1) complained about shortness of breath, especially within a month prior to their discharge to Regent Villa, he would have documented this, which he did not, “a sudden death like that is likely due to (R#1)’s diagnosis not related to breathing issues. During an interview conducted by CCLD staff with witness 1 (W#1), they stated that they felt that the staff should have conducted CPR on (R#1) once they found them on the floor instead of waiting until Long Beach Fire Department arrived. Evaluation Report continues LIC 9099-C Allegation: Staff failed to respond to signal system in a timely manner. The details of the complaint alleged that facility staff does not respond to resident’s signal system in a timely manner. During an interview with the administrator (A#1), she stated that it takes the facility staff less than 3 to 2 minutes to assist a resident when they pull the alarm cord. In addition, (A#1) stated that depending on the situation, if a resident needs immediate medical assistance, we call 911, and sometimes the residents pull the cord for non-emergency situations. During an interview with facility staff (S#4-S#6), (3) out of (3) stated that it takes approximately between 3 to 5 minutes to answer the pull alarm cord. During an interview with a resident in care (R#6-R#14), (7) out of (9) stated that they have never used the emergency cords, and (2) out of (9) stated that they have used it once and the time they used it, it took the facility staff less than 3 minutes to assist them. Allegation: Staff are not properly trained in emergency procedures. The details of the complaint alleged that facility staff are not properly trained for emergency procedures. During the records review, department staff observed a list from facility staff showing that all direct care employees have their current CPR training/card. Evaluation Report continues LIC 9099-C During an interview with the administrator (A#1), she stated that facility staff is trained in emergencies. We take CPR training every year or two, and once a month, we discuss it during our monthly staff meetings. In addition, (A#1) stated that the protocol that facility staff follows in an emergency is the following: we call immediate 911, assess the resident if the resident is not responsive, and perform CPR. During an interview with facility staff (S#4-S#6), (3) out of (3) stated that they take their CPR training every year or two. Also, every month, in our staff meeting, we talk about emergency procedures. During an interview with a resident in care (R#6-R#14), (9) out of (9) stated that they feel the facility staff is trained in emergencies. During this investigation, the department did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Jenni Gordon /Administrator.the state’s words, verbatim · CDSS document, Oct 16, 2024 · control 11-AS-20240209152545

Type of visit: Required - 1 Year

On 9/7/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Karina Salomon /Assistant Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (188) elderly adults ages 60 and above, of which (40) can be non-ambulatory. The facility has an approved hospice waiver for (3). The facility is a two-story commercial building that consist of (94) resident bedrooms, (94) resident bathrooms, eight (8) common bathrooms, dining room, commercial kitchen, staff area, office area, commercial washer and dryer room/ storage area, Movie room, activity room, backyard with umbrella with table and chairs. LPA Iniguez and the Assistant Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (6) bedrooms and (6) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 109.5°F to 110.2°F, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 7/31/24. A review of (6) residents' service files and (6) staff personnel files was maintained in order. LPA reviewed (6) Medication Administration Records (MARs) discrepancies found. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -MedTech’s not documenting medication given/refusal on MARs for R#2 and R#5. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Karina Salomon / Assistant Administrator.the state’s words, verbatim · CDSS document, Sep 7, 2024

Allegation investigated: Staff do not allow residents to select the doctor of their choice.

On 08/29/24, at 11:54am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Jenni Gordon, Administrator. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegation mentioned above. The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R10). Resident Roster (Dated: 08/29/2024) Staff Roster (Dated: No Date), ID/Emergency Information (Dated: 08/20/2024 & 08/15/2024), Admission Agreement (Dated: 08/15/2024 & 08/20/2024), Physicians Report (Dated: 08/15/2024), and Pre-Placement Appraisal (Dated:08/15/2024) were obtained from the facility for R1-R3. Report continued on LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation- Staff do not allow residents to select the doctor of their choice. The details of the complaint alleged that the facility does not allow residents to have a choice in choosing their own doctor. On 08/29/24, from 12:00pm-2:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 5 of 5 staff (S1-S5) denied the allegation that the Staff do not allow residents to select the doctor of their choice. 5 of 5 staff (S1-S5) interviewed stated that the residents do have a choice in who their doctor will be. Staff stated that before admittance to the facility the future residents are given a choice to keep their current doctor or transition over to the in-house doctors. The in-house doctors may be more beneficial to the residents that have doctors outside of the Long Beach area because of transportation issues, stated staff. But at no time are they not allowed to keep their current doctor if they choose to. The facility can provide transportation to take them to their doctor of choice, in the Long Beach area. However, the residents will have to provide their own transportation if the primary doctor of choice is outside of the Long Beach area. LPA interviewed R1-R10 about the allegation and 10 of 10 residents that were interviewed denied the allegation that Staff do not allow residents to select the doctor of their choice. Residents R1-R3 stated that they were given an option to keep their current doctor or transition to the facilities in-house doctors. R1-R3 stated that they decided to transition to the in-house doctors after they had a chance to interview them and come to a decision on their own. They decided that it was more convenient and cost effective to use the in-house doctors. Residents R4-R10 stated that no one in the facility tried to coerce them into using the in-house doctors against their wishes and that they are satisfied with the care and supervision provided by the in-house doctors. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not allow residents to select the doctor of their choice. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with Jenni Gordon, Administrator, and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 11-AS-20240822204910

Allegation investigated: Staff altered resident's record

On 04/15/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Jenni Gordon, Administrator (S1), and the purpose of the visit was explained. S1 and LPA toured the facility. The investigation consisted of the following: On 04/15/24 LPA requested and reviewed facility documents and toured the facility. LPA interviewed four (4) out of one-hundred and forty (140) residents (R1-R4) and four (4) out of forty (40) staff (S1-S4). LPA interviewed two (2) out of four (4) witnesses (W1-W4). Witness two and witness four (W2, W4) were not available for interview. Report continues, see LIC9099C Unsubstantiated The investigation revealed the following: Regarding the allegation: "Staff altered resident's record.". It has been alleged that staff has altered resident one's Physican Orders for Life-Sustaining Treatment (POLST). Interviews revealed that all 4 staff and all 4 residents have denied the allegation, while one (1) (W3) out of 2 witnesses informed LPA that R1 had a fall at Los Angeles Downtown Medical Center (LADMC) and one out of 2 witnesses (W1) informed that R1 had made a choice to file his POLST for Do Not Resuscitate and additionally to deny artificial means of nutrition, including feeding tubes, using his own mental capacity. Record reviews revealed that R1 had began to deny one of his medications during May 2023, slowly increasing his refusal of one medication through July 2023. R1 later began to completely refuse this medication in December 2023. Then, January 12, 2024, R1 refused all medications. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. An exit interview was conducted with Jenni Gordon, Administrator (S1), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 11-AS-20240411130558

Allegation investigated: Facility staff did not seek medical attention in a timely manner.

On 11/30/23 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unanounced, complaint investigation visit to the above-mentioned facility. LPA arrived at facility and was met by Jenni Gordon, Administrator, and explained the purpose of the visit. The investigation consisted of the following: On 08/21/23, LPA toured the inside and outside of the facility. During the course of the investigation LPA requested and received copies of the following: client roster, staff roster; ID and emergency information, physicians’ reports, resident appraisal and all medical records for Resident #1 (R1). On 11/30/23, LPA interviewed ten (10) out of one-hundred and forty-four (144) residents and seven (7) out of thirty-nine (39) staff. LPA obtained heart rate, blood pressure, blood sugar and insulin dosing of R1 for the month of admission January 2023. LPA obtained training records for Licensed Vocational Nurses (LVN) (S4-S5) and Caregivers (S3,S6), along with FirstAid/CPR certificates (S3-S6). Report Continues, see LIC9099C. Unsubstantiated LPA also received three (3) declarations from Jenni Gordon (S1), Noemi Callimquim (S3) and Elizabeth Gibson (S4). The investigation revealed the following: Regarding the allegation: "Facility staff did not seek medical attention in a timely manner." It has been alleged that Resident one's (R1) medical care departed from the prevailing professional standard of care. According to LPA's record reviews Noemi Calimquim, Med-Tech (S3), was the first to receive the call light provided from roommate Resident #2 (R2). R2 pulled the call light at 6:50PM, due to Resident #1's (R1) fall. Nelia Ramos, Caregiver (S6), responded to the call light at 6:54PM. At 6:55PM S6 then informed S4, who went to observe R1's heart-rate and blood-pressure, measured at 174mg/dl, recorded at 7:00PM. S4 requested S3 to call 911. According to LiveFireRECORDS Incident Report, Long Beach Fire Department (LBFD) received the alarm at 7:03PM and later arrived to the above-mentioned facility at 7:07PM. During that time, LBFD delivered CPR, beginning at 7:08PM. Anaphalaxis (EPI) was provided and a restart of a sustained heart rhythm (ROSC) was obtained at 7:20PM, which was sustained for two (2) minutes, after which R1 rearrested with Pulseless Electrical Activity (PEA). Sodium Bicarbonate and Calcium Chloride was given to R1 per base orders along with additional EPI for total of 4units. CPR was given to patient for 29 minutes, with a final rhythm of Asystole and R1 was then pronounced deceased at 7:37PM. According to LPA's interviews, the staff responded to the call light within four (4) minutes. After Staff's observations and assistance, Emergency Medical Services (LBFD) were contacted approximately eight (8) minutes after S3 received the non-responsive report of R1 from S6, around 7:03PM. LPA interviewed 7 staff (S1-S7). All staff have denied the allegation. LPA interviewed 10 residents (R2-R11). Nine (9) out of 10 residents have disagreed with the allegation and have stated that they feel that their medical needs are being appropriately met and that if emergency services were needed, their needs would be met. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been no deficiencies cited during this visit. An exit interview was held with Administrator, Jenni Gordon (S1) and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 11-AS-20230811153533