Savant of Alhambra

Allegation investigated: Staff inappropriately administered resident's medication Staff did not provide resident with a 30-day eviction Staff did not provide resident with records Staff did not provide a comfortable enviornment for resident

Licensing program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above allegations. LPA met with Ruby Andrade – Office manager and discussed the purpose of the visit. Administrator Madeleine "Maddie" Sievert arrived a short time later and assisted with the visit. The investigation consisted of LPA taking a tour of facility, including random rooms, interviewing six (6) staff S#1 – S#6, ten (10) residents R#1 – R#10, reviewing and obtaining staff and resident roosters, R1 face sheet, medication administration record, medication list, and physician’s report, R1 doctor order for SNF The investigation revealed the following regarding allegation: Staff inappropriately administered resident's medication. It is alleged that facility staff would force R1 to wake up in the middle of the night to take R1 pain medications. (continued on 9099C) Unsubstantiated (continued from 9099) LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations. One staff member stated that staff would enter resident’s room in the early morning hours after knocking on resident’s door to administer resident’s medication. Staff stated staff were asked by resident to enter resident’s room to administer resident’s medication in the early morning hours. One former staff member stated that the facility was instructed by the resident to enter resident's room and administer resident’s medication in the early morning hours. Staff stated resident would change mind often and get angry at staff if staff did not administer resident’s pain medication during the middle of the night. LPA interviewed ten (10) residents and nine (9) of (10) residents could not corroborate the allegations. There is not enough evidence to substantiate this allegation. Allegation: Staff did not provide resident with 30-day eviction. It is alleged that facility illegally evicted resident from facility. Resident has resided at Savant of Alhambra since 12/11/2024. On 10/09/2025 resident was allegedly angry and threatening staff. Staff called the Los Angeles County psychiatric team and was sent to Los Angeles Downtown Medical Center and placed on a 5150 psychiatric hold. A few days later a staff member was sent to skilled nursing facility (SNF) (Green Acres) to reassess resident to admit resident back to facility and staff determined resident required a higher level of care. On 10/28/2025, staff went to the SNF per resident’s request to provide resident’s personal belongings. During the visit, resident signed Acknowledgement of Discharge form dated 10/28/2025. That document shows resident vacating self from facility while acknowledging receipt of resident’s belongings. A staff member stated that the SNF could not accept the belongings of resident due to space and facility took resident’s belongings back to facility and then to storage facility. On 01/09/2026, resident’s relative acknowledged all of resident’s remaining belongings were received and signed a document dated 01/09/2026. Resident has remained at SNF since resident was placed on 5150 holds back on 10/09/2025. At the time of this report, the resident continues to reside in the SNF. This is evidence that the resident requires higher level of care. The evidence shows that facility cannot readmit resident since resident requires higher level of care. This is also documented by resident's doctor. There is not enough evidence to substantiate this allegation. Allegation: Staff did not provide resident with records. It is alleged that facility will not provide resident’s X-ray images taken of his ankle and leg. (continued on 9099C) (continued from 9099C) LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations. LPA interviewed ten (10) residents and nine (9) of (10) residents could not corroborate the allegations. Several staff stated that the facility provided resident with every document they had of resident and that resident signed a form on 01/09/2026 acknowledging that resident received all resident's personal belongings. Several staff stated that X-ray images should be requested to the place they were completed at. Staff stated they never had any resident's Cray images in their possession. There is not enough evidence to substantiate this allegation. Allegation: Staff did not provide a comfortable environment for resident. It is alleged that staff did not provide comfortable environment at facility by allowing other residents to make noise by resident's room. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations. LPA interviewed ten (10) residents and nine (9) of (10) residents could not corroborate the allegations. Resident stated that in the morning hours resident would be awaken due to the noise of other resident’s wheelchairs as they prepared to go to the dining hall for breakfast or to begin their day. LPA inspected both rooms that resident had stayed at and the residents of those rooms stated they do not hear any disturbing sounds or noises and are happy residing at facility. There is not enough evidence to support this allegation. Based on interviews with staff and residents and records review, the information obtained during the investigation is insufficient to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 28-AS-20260623092617

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Madeleine "Maddie" Sievert, . The purpose of the visit was explained. The following (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for thirty (30) residents is approved. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 06/01/2026. A surety bond is not applicable. Facility does not handle resident's money. Staffing: There appears to be always sufficient staffing in the facility, with night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed four (4) staff files with no issues observed. Administrator Madeleine Sievert certificate expires on 06/18/2027 Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, Ombudsman, and let us know poster near the resident mail room (continued on 809C) (continued from 809) Residents Rights-Information: Residents are provided with telephone and internet at the facility. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. On site is away from the area. Plan is reviewed and updated as needed. Due to lack of time, LPA will return another day to complete annual inspection. No deficiencies observed during today's visit. Exit interview and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, May 12, 2026

Allegation investigated: Staff do not assist resident with obtaining medical care Staff do not ensure that resident's dietary needs are met Staff have not provided resident with reappraisal

Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent unannounced visit to deliver findings for abvoe allegations. LPA met with Blanca Soliz, Resdient Service Supervisor and discussed the purpose of the visit. On 04/28/2026 Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced initial visit to investigate the above allegations. LPA met with Administrator Madeleine “Maddie” Sievert and discussed purpose of the visit. Regional Director of Operations Lisa Pham arrived a short time later and assisted with the visit. The investigation consisted of LPA reviewing and obtaining copies of staff and resident rosters. R1 Face sheet, Physician’s report, Admission Agreement, needs and appraisal dated 02/28/2025 and 04/01/2026. Medication Administration Record for 03/2026 and 04/2026, Interview with five (5) staff (S#1 – S#5) ten (10) residents, three (3) incident reports, doctor order reducing medication for R1 and Dietary Communication Notification for R1 and tour of facility. In between visits, LPA obtained reappraisal that was conducted on 02/05/2026 (Continued on 9099C) Unsubstantiated (continued from 9099) The investigation revealed. Allegation: Staff do not assist resident with obtaining medical care. It is alleged that R1 requires B12 injection and bed rails to prevent falls, and that it is not provided by staff. Also, that resident is having additional falls due to missing the B12 injections. LPA interviewed five (5) staff, and all five staff denied the allegation. LPA interviewed ten (10) residents and nine (9) of ten (10) residents could not corroborate the allegation. LPA attempted to contact R1 via phone at least six (6) times and left voice mail but did not get a return call. One staff member stated that there is no doctor’s order for B12 injections or bed rails which are required for facility staff to provide those. LPA reviewed resident’s order for B12, and the dose was lowered on 12/18/2026 from 1000mg tablet daily to every other day. One staff member stated that the tablet has the same effect unless the resident’s absorption is not good. There is no evidence that resident has absorption issues. One staff member stated that staff will follow up with the resident’s doctor to ask for B12 injection order to see if that has positive effect and reduce frequency of falls. The facility provided incident reports for two (2) falls total. There is insufficient evidence to support this allegation. Allegation: Staff do not ensure that resident's dietary needs are met. It is alleged that resident is unable to chew food properly and almost choked on some food recently. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. LPA interviewed Ten (10) residents and nine (9) of ten (10) residents could not corroborate the allegation. There is currently a doctor’s order on file for mechanical/soft diet for R1 dated 07/28/2025. Dietary staff stated that order is being honored and that resident changes mind and can go back and forth on dietary wants. There is insufficient evidence to support this allegation. Allegation: Staff have not provided resident with reappraisal. It is alleged that facility has not conducted a reappraisal for resident since resident was admitted on 02/28/2025. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. LPA interviewed Ten (10) residents and nine (9) of ten (10) residents could not corroborate the allegation. Records show that resident did not undergo a “significant change" in physical, cognitive, behavioral, or functional condition to warrant a reappraisal prior to 2/05/2026. Records reviewed show that a reappraisal for resident was conducted on 02/05/2026 and on 04/01/2026. Which is following Department Regulations. There is insufficient evidence to support this allegation. (continued on 9099C) (continued from 9099C) Based on interviews with staff and residents and records review, the information obtained during the investigation is insufficient to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATEDthe state’s words, verbatim · CDSS document, May 9, 2026 · control 28-AS-20260421112809

Allegation investigated: pmaff did not dispense medications as prescribed Staff did not ensure medications were properly managed Staff did not allow resident to be re-admitted to facility

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced initial visit to investigate the above allegation. LPA met with Administrator Madeleine “Maddie” Sievert and discussed purpose of the visit. Regional Director of Operations Lisa Pham arrived a short time area and assisted wiht the visit. The investigation consisted of LPA interviewing (7) staff (S#1 – S#7 and ten (10) residents (R#1-R#10), reviewing and obtaining staff and resident rosters, R1 physicians report, needs and appraisal, Controlled Medication Administration Records (MAR) for July, August, September 2026, PRN Authorization letter dated 12/11/2024. R1 progress notes from 03/18/2025 – October 8, 2025. and Acknowledgement of discharge form dated 10/28/2025. (continued on 9099C) Unsubstantiated (continued from 9099) The investigation revealed regarding allegation: Staff did not dispense medications as prescribed. It is alleged that facility staff would force him to wake up in the middle of the night to take his pain medications. LPA interviewed seven (7) staff and five (5) of seven (7) staff denied the allegations. One staff member stated that staff would enter resident’s room in the early morning hours after knocking on resident’s door to administer resident’s medication. Staff stated staff were asked by resident to enter resident’s room to administer resident’s medication in the early morning hours. One former staff member stated that the facility was instructed by the resident to enter resident's room and administer resident’s medication in the early morning hours. Staff stated resident would change mind often and get angry at staff if staff did not administer resident’s pain medication during the middle of the night. LPA interviewed ten (10) residents and nine (9) of (10) residents could not corroborate the allegations. There is not enough evidence to substantiate this allegation. Allegation: Staff did not ensure medications were properly managed. It is alleged that facility would run out of resident’s PRN medication and resident would have to go without it for days at times. LPA interviewed Seven (7) staff and all seven (7) staff denied the allegations. LPA interviewed ten (10) residents and seven (7) of (10) residents could not corroborate the allegations. A few residents stated that very seldom, their medications are delay, but have never missed a dose. LPA reviewed residents MAR for 07/2025, 08/2025, and 09/2025 and did not find any discrepancies on the forms for the three months reviewed. Resident received PRN medications for those months. LPA reviewed residents progress notes from March 2025 – October 28 2025 and one note mentioned staff calling resident MD for refills. No notes showed resident running out of PRN oxycodone or other medications. Several staff stated that the facility would contact resident’s physician when refills were needed, but that at that time the physician would not fill the controlled substances right away and may cause slight delay which was out of facility’s control. There is insufficient evidence to substantiate this allegation. (Continued on 9099C) (continued from 9099C) Allegation: Staff did not allow resident to be re-admitted to facility. It is alleged that staff had resident referred to 5150 psychiatric hold and did not allow resident to return. Resident has resided at Savant of Alhambra since 12/11/2024. On 10/09/2025 resident was allegedly angry and threatening staff. Staff called Los Angeles County psychiatric team and was sent to Los Angeles Downtown Medical Center and placed on a 5150 psychiatric hold. A few days later a staff member was sent to skilled nursing facility (SNF) (Green Acres) to reassess resident to admit resident back to facility and staff determined resident required a higher level of care. On 10/28/2025, staff went to the SNF per resident’s request to obtain residents personal belongings. During the visit, resident signed Acknowledgement of Discharge form dated 10/28/2025. That shows resident vacating self from facility while acknowledging receipt of resident’s belongings. A staff staff member stated that the SNF could not accept the belongings of resident due to space and facility took resident’s belongings back to facility and then to storage facility on 01/09/2026. Resident’s relative acknowledged all of resident’s remaining belongings were received and signed a document dated 01/09/2026. Resident has remained at SNF since resident was placed on 5150 hold back on 10/09/2025. At of the time of this report, the resident continues to reside in the SNF. This is evidence that the resident requires higher level of care. The evidence shows that facility cannot readmit resident since resident requires higher level of care. This is also documented by resident's doctor. There is not enough evidence to substantiate this allegation. Based on interviews with staff and residents and records review, the information obtained during the investigation is insufficient to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 28-AS-20260305144046

Allegation investigated: Licensee did not follow proper eviction protocols with resident in care.

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced initial visit to investigate the above allegation. LPA me with Business Office Manager Rugy Andrade and discussed purpose of the visit. Administrator Madaleine “Maddie” Seivert arrived a short time later and assisted with the visit. The investigation consisted of LPA interviewing seven (7) staff (S#1 – S#7 and ten (10) residents (R#1-R#10), reviewing and obtaining staff and resident rosters, R1 admission agreement, physicians report, needs and appraisal, and Acknowledgement of discharge form dated 10/24/2025. The investigation revealed regarding allegation: Licensee did not follow proper eviction protocols with resident in care. It is alleged that resident was evicted without proper notice. LPA interviewed seven (7) staff, and all seven (7) staff denied the allegation. All staff stated the resident self-discharged and signed Acknowledgment of Discharge form showing that on 10/28/2024. LPA interviewed ten (10) residents and Ten (10) ten (10) could not corroborate the allegation. (continued on 9099C) Unsubstantiated (continued from 9099) Resident has resided at Savant of Alhambra since 12/11/2024. On 10/09/2025 resident was allegedly angry and threatening staff. Staff called Los Angeles County psychiatric team and was sent to Los Angeles Downtown Medical Center and placed on 5150 hold. A few days later a staff was sent to skilled nursing facility (SNF) (Green Acres) to reassess resident to admit back to facility and staff determined resident required a higher level of care. On 10/28/2025, staff went to the (SNF) per resident’s request to obtain personal belongings. During the visit, resident signed Acknowledgement of discharge form dated 10/28/2025 that shows resident vacating self from facility while acknowledging receipt of belongings. A staff member stated that the SNF could not accept the belongings of resident and facility took resident’s belongings back to facility and then to storage facility on 01/09/2026, and resident’s relative acknowledged all of resident’s remaining belongings were received and signed a document dated 01/09/2026. Resident has remained at SNF since he was placed on 5150 hold back on 10/09/2025. This is evidence that the resident requires higher level of care. Evidence shows that facility did not evict resident from facility. Based on interviews with staff and residents records review, the information obtained during the investigation is insufficient to support the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 28-AS-20260211155418

Allegation investigated: Staff did not ensure that the facility was kept free of pests

Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent unannounced visit to deliver findings for the above-mentioned allegations. LPA met with Blanca Soliz, Resident Services Supervisor and discussed the purpose of the visit. On 01/13/2026 - Licensing Program Analyst (LPA) Alberto Lopez conducted a 10-day complaint visit at the facility and met with Madeleine Sievert, Administrator, and discussed the purpose of the visit. Investigation consisted of reviewing and obtaining staff roster, resident roster, R1 face sheet and medical assessment, interviewing six (6) staff, interviewing ten (10) residents, walked around and toured the facility and random rooms. Allegation: Staff did not ensure that the facility was kept free of pests. It is alleged that resident’s room is infested with roaches and staff does not ensure it is kept free of pest. (Continued on 9099C) Substantiated (continued from 9099A) The investigation revealed: regarding allegation: Allegation: Staff stole from resident in care. It is alleged that staff have stolen from resident in the past. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. LPA interviewed ten (10) residents and seven (7) of ten (10) residents could not corroborate the allegation. There was a video provided to LPA, but it did not show staff taking any cash or other personal items from the residents. There were no witnesses. There is insufficient evidence to support this allegation Allegation: Staff did not ensure that residents are regularly observed for changes in their condition. It is alleged that one resident had swollen ankle and staff did not observe or address the issue. LPA interviewed ten (10) residents and all ten (10) could not corroborate with the allegation. The resident in question stated that resident takes care of resident’s own needs and does not depend on facility to check on resident. Several residents stated that facility conducts wellness checks and are attentive to resident’s needs. There is insufficient evidence to support this allegation. Based on interviews, record review and observation, the information obtained during the investigation is insufficient to support the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Blanca Soliz, Resident Services Supervisor (continued from 9099) LPA inspected the room and did not observe any living pest. LPA observed one dead cockroach by the refrigerator, two small spiders inside the freezer door and two sacks of cockroach eggs on the floor. Two (2) roach eggs by the microwave oven. LPA interviewed six (6) staff and all six (6) staff stated that residents do not allow staff to dispose of uneaten food and that the food brings the cockroaches to the room. Administrator provided invoices showing pest control coming twice per month. However, the invoices do not show that the resident’s room has been treated during the bi-monthly treatments. LPA interviewed ten (10) residents and seven (7) of ten (10) residents could not corroborate the allegation. Three (3) residents stated they have observed roaches in their rooms. Due to lack of documented proof that resident’s room has been treated by pest control and observation and documentation of dead insects on the floor, the freezer door and cockroaches eggs in the resident’s room, the preponderance of evidence has been met, therefore the allegation is substantiated. Based on LPAs observations and interviews and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 chapter 8 are being cited on the attached LIC 9099D. A copy of the report and LIC9099D was given to Blanca Soliz, Resident Services Supervisor during the exit interview. Appeal rights provided.the state’s words, verbatim · CDSS document, Jan 17, 2026 · control 28-AS-20260105100911

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 27, 2026

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observations, interviews and documents reviewed, the resident’s room continues to have issues with cockroaches and other insects which poses a potential health and safety risk to residents in care. LPA observed dead spiders in freezer door, dead roach on the floor and 4 roach eggs in the room #141the state’s words, verbatim · CDSS document, Jan 17, 2026

Plan of correction: Facility will address the cockroach and insect issue and send progress report that shows room 141 has been treated by pest control to LPA. Facility will remove all dead pest, roach eggs and insects from room and send proof to LPA by POC date of 01/27/2026

Allegation investigated: Staff did not ensure resident's bandages were changed.

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced complaint visit to investigate the above-mentioned allegation. LPA met with Administrator Madeline Sievert and explained the reason for the visit. The investigation consisted of LPA Interviewing five (5) staff S#1 – S#5, 10 (ten) residents R#1 – R#10, one (1) witness W#reviewing and obtaining staff and resident rosters, R1 Physicians Report for Residential Care Facilities for the Elderly (RCFE), Communication log dated 09/19/2025 with instructions for catheter, outside agency documentation from Home Health documenting service provided for R1, Physician’s order for R1 asking for increase in skill nursing visits for R1 to change and clean around catheter port dated 09/19/2025. Readmission of Care for Home Health dated 09/10/2025. Unsubstantiated (continued from 9099) The investigation revealed. Allegation: Staff did not ensure resident's bandages were changed. It is alleged that the facility is sending R1 with the same uncleaned bandages from two (2) days ago when R1 was last at dialysis center. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. Several staff stated that they do not change any bandages for R1 because that is done by Home Health Agency. LPA interviewed ten (10) residents and ten (10) of ten (10) residents could not corroborate the allegation. R1 has been going to dialysis 3 times a week and has had home health visit three times per week, the day after dialysis to inspect the portal site. The facility just got the physician's order for additional home health services on 09/19/2025. The facility stated they are prohibited from changing bandages and that it is the responsibility of Home Health to change/remove/inspect site and facility will be checking R1 after Home Health services R1, to make sure that Home Health is properly servicing R1. R1 stated R1 does not like to have the bandage on and will remove it. W1 stated they prefer that resident come in without bandage as it is for temporary use only. W1 stated that R1 did not come in with soaked bandage. There is not enough supportive evidence to support this allegation. Based on interviews, record review and observation, the information obtained during the investigation is insufficient to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 28-AS-20250918052014

Allegation investigated: Staff do not meet resident's basic needs due to insufficient staffing. Staff do not keep resident's room clean & sanitary.

**This LIC 9099/LIC 9099C/LIC 9099D supersedes the LIC 9099/LIC 9099C/LIC 9099D that was issued on 05/16/25** Licensing Program Analyst (LPA) Nicol Wesley conducted a subsequent visit at the facility and met with Administrator Madeleine Sievert to discuss the purpose of the visit. Investigation consisted of: staff roster, resident roster, incontinence records, house keeping records, interviewed 3 staff, interviewed 15 residents, walked around and toured the facility. Investigation revealed: Regarding allegation: Staff do not meet resident's basic needs due to insufficient staffing, and Staff do not keep resident's room clean & sanitary. On 04/03/25, LPA Wesley and the Administrator Madeleine Sievert toured the facility and found that several rooms were not cleaned Room #104, 105, 108,113, 123, 134, 135, 152 & 230. LPA asked the administrator how many staff were on duty and she provided me with the names 2 med technicians, 5 caregivers, 2 housekeepers, and 1 laundry attendant on duty. LPA visited random Continued on LIC 9099C Substantiated clients rooms and found that the trash was not emptied, restroom has not been cleaned, and their linen was not changed, as well as resident #1 was in a soiled undergarment. Pictures were taken. LPA Wesley interviewed 2 out of 3 direct support staff and they indicated that they are short staff and are in need of help. and 1 out of 3 answered "I'm okay." There was some random people visiting their loved ones and they indicated that they come and clean the rooms, sweep and take their trash away. LPA Wesley interviewed 15 residents and they said there rooms are supposed to be cleaned once a week, linen changed once a week or as needed, and trash is to be emptied daily. There were 12 out of 15 residents who said there rooms are not cleaned/linen changed weekly or as needed, nor are their trash cans emptied daily. There were 3 out of 15 residents didn't want to comment. LPA Wesley and Administrator Sievert observed the rooms were not clean and sanitary. On 04/03/25, LPA Wesley was at the facility from 11:20am-4:30pm. Pictures were taken. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 chapter 8 are being cited on the attached LIC 9099D. Appeal rights were given. A copy of the LIC 9099/LIC 9099C/LIC 9099D was given to the administrator during the exit interview.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 28-AS-20250327140118

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 10, 2025

Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This evidence was not met as required LPA and the Administrator observed several rooms that were not cleaned by staff, which includes emptying the trash, cleaing the bathrooms, and changing the linen. which poses a health and safety issue for all clients in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: The administrator shall ensure all the residents rooms are clean. Create an inservice training "Maintenace and Operations" for all staff and go over what needs to be cleaned, incase they don't understand their dutied. The facility will hire more staff if necessary. Submit the in service training sign in sheet to LPA Wesley 323 980 4912 by the POC date 07/11/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jul 10, 2025

Managed Incontinence, In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. LPA Wesley and Administrator Sievert observed Resident #1 to be in a soiled diaper/undergarment, when asked, he mentioned last night sometime, the Administrator said she dont remember this conversation. Which poses a health and safety issue to clients in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: The facility Administator will ensure all residents diaper/undergarment will be changed and monitored every two hours or as needed. The Administrator will have a log of all the residents who are incontinent and have the staff initial when they have been checked. Send the incontinence log to LPA Wesley by POC date 07/17/25.

Type of visit: Case Management - Other

***This LIC 809/809D/Immediate Civil Penalty supersedes the LIC 809/809D/Immediate civil penalty that was issued on 05/16/25, & 04/03/25*** LPA Nicol Wesley conducted a case management visit at the facility due to a resident smoking cigarettes in a room with oxygen being administered. LPA Wesley and Administrator Sievert was conducting a tour of the facility when LPA Wesley smelled cigarette smoke. LPA Wesley asked the Administrator to knock on the door where the Oxygen sign was posted and when the resident opened the door, the room was filled with cigarette smoke. The Administrator Sievert was speaking to the resident and apparently had spoken to her about this issue before. LPA Wesley informed the residents of the danger of smoking when oxygen is in use. Also while the LPA Wesley was in the facility the second elevator was not working, which means both of the elevators were broken at the same time. The following deficiencies were cited in accordance to the California code of regulations, Title 22. Exit interview conducted. A copy of this report was given to the Administrator, along with Appeal rights.the state’s words, verbatim · CDSS document, Jul 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jul 10, 2025

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This item was not met as evidence by: the facility had two elevators broken at the same time. the 1st elevator was broken since last monday 05/31/25, and the 2nd was in disrepair for at least 3 hours while LPA Wesley was in the building, the facility had it fixed, and it broke again. The Non Ambulatory clients could not get to their room which posed a health and safety issue to the cleints in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: The facility shall ensure all elevators are working properly at all times. Please provide the service repair sheet for the elevator for today encounter to Attn Nicol Wesley 323 980 4912 by POC date 07/11/25

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jul 10, 2025

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This item was not met as evidence by: the facility had two elevators broken at broken since last monday 05/31/25, and the 2nd was in disrepair for at least 3 hours while LPA Wesley was in the building, the had it fixed, and it broke again. The Non Ambulatory clients could not get to their room which posed a health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: The facility shall ensure all elevators are working properly at all times. Please provide the service repair sheet for the elevator for today encounter to Attn Nicol Wesley 323 980 4912 by POC date 07/11/25

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(2) · Plan of correction due date: Jul 10, 2025

Personal rights Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This evidence was not met as required: LPA Wesley and the Administrator found resident #1 was smoking in her room where oxygen was in use. She also shares a room with the another resident who was at risk. Which posed a health and safety risk to the clients in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: The Administrator advised that she spoke to the resident previously and documented her conversation. The administrator shall come up with a plan and give a copy to the LPA to ensure the resident is in compliance by 07/11/25, to Atth: Nicol Wesley 323 980 4912.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Madeleine Sievert, Administrator and Lisa Pham, Regional Director. The purpose of the visit was explained. The following (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for thirty (30) resident is approved. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 06/01/2026. A surety bond is not applicable. Facility does not handle resident's money. Physical Plant/Environment Safety: The building is in a residential neighborhood. The building consists of three floors (ground floor, first floor and second floor). The ground floor/lobby consists of a front desk/reception area, business offices, three (3) activity rooms (tv, game room and activity room), health & wellness office, sales/marketing office, laundry room, beauty salon, storage room, employee break room and garage. The first floor consists of resident rooms, dining room, kitchen, patio area and a storage room. The second floor consists of resident rooms and a storage room. The facility has two (2) operable elevators and were operational during the visit. (Continued on 809C) (continued from 809) All resident rooms located on the first and second floors have a sliding door or a door leading to a balcony. Bedrooms were equipped with a bed, chair, nightstand, adequate lighting, and ample closet/storage space for each resident. Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads and mattress pads were observed. The bathrooms are clean and operational with non-skid mats. The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were clean and all appeared functional. The supply of dishes/cups is adequate. During today's visit, LPA observed an appropriate food supply of two (2) days of perishables and seven (7) days of non-perishables. Last fire drill and disaster drills were conducted on 06/19/2025. Drills are conducted every month. The facility is equipped with a centralized sprinkler system. The facility has a central air and heating system in the common areas of the building and individual AC units inside resident bedrooms. The medications, First-aid kit and resident records are centrally stored and locked in the medication room. First aid kit is fully stocked with a manual. Staff records are centrally stored and locked at the front desk/reception area. Facility does not handle resident P&I monies. The facility smoke detectors are hard wired. Carbon monoxide detectors were observed throughout the facility. The fire extinguishers were fully charged and in compliance. There is a functioning telephone on the premises. The hot water temperature was tested throughout the facility and measured within Title 22 Regulations. Water temperature measure between 107.7 – 112.3 in random rooms that were inspected. All toxins such as cleaning solutions and detergent soap are also locked in the storage room. The grounds of the facility are well landscaped with a ramp that leads to the entrance. A shaded area with chairs is provided in the patio area. The trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. Staffing: There appears to be always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training , medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 10 staff files with no issues observed. Administrator Madeleine Sievert certificate expires on 06/18/2027 Appraisals, TB clearance, Functional Capability Assessment, and emergency information. RCFE complaint poster and Personal rights were observed posted in the facility hallway. (continued on 809C) (Continued from 809C) Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. The facility does have a Resident Council but not active currently. Food Service: Sufficient food supply is stored in the kitchen and storage areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Incident Medical and Dental: Ten (10) centrally stored resident medications were reviewed. All medications are administered as order by the physician. Medical and dental transportation is provided by family, transportation services, or staff. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. No deficiencies observed during the visit. Exit interview was conducted with Administrator Madeleine Sievert and Regional Director Lisa Pham, A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jun 23, 2025

Allegation investigated: Staff is mismanaging resident's medications. Staff does not ensure resident's medical needs are being met. Staff does not ensure resident's grooming needs are being met. Staff does not ensure facility food is free of bugs.

Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent unannounced complaint visit to deliver findings to the above mentioned allegations. LPA met with Administrator Madeline Sievert and explained the reason for the visit. The investigation consisted of the following: On 05/19/25 LPA Nune Margaryan interviewed Staff 1 - Staff 5 (S1-S5), Resident 1 - Resident 14 (R1-R14), obtained copies of staff and residents rosters, reviewed the medication logs for five (5) different residents including R1's. The following documents pertaining to R1 were obtained: Admission Agreement, Identification and emergency Information, Face Sheet, Preplacement Appraisal Information, Physician’s Report, Physician's Order, Resident assessment/ Care Plan, Medication Administration Record. LPA also conducted a tour of facility including kitchen and dining area. LPA observed that there is a sign in the kitchen for recent food inspection with grade "A" and the sign at the front desk for Sing up to see a Podiatrist. Continue 9099C Unsubstantiated Regarding allegation: Staff is mismanaging resident's medications. It was alleged that resident provided with wrong medications and too many medications. Interviewed staff denied the allegation and stated that R1 didn’t complains about mismanaging their medications. They stated that staff didn’t provide wrong medications and / or too many medications to R1 or other residents. Interviewed staff stated that all medications are administrated as prescribed and are noted electronically through a "Quick MAR" program. All residents’ medications are registered under the "Quick MAR" program and administered on a consistent schedule. Staff said that there are occasions in which residents refuse their medications. When residents refuse medication, staff document refusals also. LPA toured the medication room, observed medication dispensing and documentation practices. Staff demonstrated to LPA how is worked "Quick MAR" program. LPA reviewed a random sample of 5 resident medications (including R1's) and observed medications to be documented properly and given as prescribed. No concerns were observed. 13 out of 14 residents interviewed indicated that they receive their medications as prescribed and don’t have any concerns about this matter. Interviewed R1 did not answer LPA’s question about their medications and told LPA to ask staff. Regarding allegation: Staff does not ensure resident's medical needs are being met. It was alleged that R1 has a health concerns and eye pain and has seen the doctor once in 8 months regarding health concerns. Wants to see specialist for eye examination. Staff interviewed revealed that some residents are independent and prefer to handle their own medical appointments or get help from family members. They stated that R1 is self representative and prefer family member to schedule their appointments. However, there is an in-house doctors and specialists who visit the residents on a monthly basis and as needed and the facility provides transportation for residents who need to see doctors, specialists outside of the facility. R1 often refused to be seen by in house doctor. Interviewed staff was not aware that R1 has a pain and want to see the specialist. Interviewed Administrator stated that they will follow up with R1 and R1’s family member to schedule appointment for R1 if needed. 13 out of 14 residents indicated that there are in house doctors that came to the facility for any medical needs that they may have. Those who are independent and handle their own medical appointments stated that the facility provides them the transportation needed to visit with their doctor. R1 stated that they don’t like in house doctors and their family member is scheduling R1’s doctor’s appointments. Continue 9099C Regarding allegation: Staff does not ensure resident's grooming needs are being met. It was alleged that resident not received nail care in a while and wants to see podiatrist to get nails taken of. Interviewed staff stated that grooming is included in the services that facility provides to residents and always willing to help anyone who needs assistance. S1, S4 and S5 stated the podiatrist will schedule a visit every other month and send out flyers so that residents can sign up at the front desk if they would like the service. Facility has an in-house skin specialist that can also assist with cutting / filing residents nails / toenails. Hairdresser also come to assist with hygiene needs. Interviewed S1, S4 and S5 stated that some residents take care of their own podiatry needs. Some of residents prefer to go to nail salon to get the services. 6 of 14 residents interviewed stated they take care of cutting / trimming their hand and toenails. One resident who stated that they take care of their hand and toenails mentioned that they know that facility has a podiatrist who is coming to the facility and residents have to make an appointment to get services. 5 of 14 residents stated that they make an appointment at the front desk to see the podiatrist for their nails. 2 of 14 residents stated that they prefer to go to nail salon for nail services, and facility provide the transportation. Interviewed R1 stated that their family member is scheduling their appointments and don’t know if there is an appointment to see the doctor to cut the toenails. LPA explained R1 that there is a podiatric service at the facility and R1 has to make an appointment at the front desk. R1 stated that they don't like in house doctors / specialist. Regarding allegation: Staff does not ensure facility food is free of bugs. It was alleged that R1 sometimes see black dots in their food that looks like bugs. At the time of visit LPA toured the kitchen and dining area and observed the dining area and kitchen to be clean and in good repair. Interviewed S1 – S5 denied the allegation and stated that they didn’t hear any complaints that residents see the bugs in their food. Interviews with Staff indicated that food is prepared and served in a safe and healthful manner. They stated that no residents or staff complaints about food services. They didn’t hear that Residents complains that they see bugs in their food. Interviewed S2 and S3 stated that staff clean kitchen and dining area on daily basis, 2-3 times a day. S2 stated that there is a no way it will be bugs in the residents food. Everything is fresh and stored in designated area. S3 stated that they speak with residents every day and R1 never mentioned that there was a bug in their food. Interviewed staff stated that Registered Dietitian often come to check the food, the kitchen, check the temperature and quality of food. Also, at the time of Public Health Department visit they graded “A”. (Copies of all documents were provided to LPA). Interviews with 13 Residents indicate that they are satisfied with the facility's food service and cleanliness of the dining area. Residents also stated that no bugs or insects were observed in their foods. Interviewed R1 stated that they don’t know if there is a bug in the food. Based on interviews, record review and observation the information obtained during the investigation does not have sufficient evidence to corroborate the allegations. Although the allegations may have happened or is valid, there are not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and the copy of this report was provided to Administrator, Madeline Sievert.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 28-AS-20250512161006

Allegation investigated: Staff do not meet resident's basic needs due to insufficient staffing. Staff do not keep resident's room clean & sanitary.

Licensing Program Analyst (LPA) Nicol Wesley conducted a subsequent visit at the facility and met with Administrator Madeleine Sievert to discuss the purpose of the visit. Investigation consisted of: staff roster, resident roster, incontinence records, house keeping records, interviewed staff, interviewed residents, walked around and toured the facility. Investigation revealed: Regarding allegation: Staff do not meet resident's basic needs due to insufficient staffing, and Staff do not keep resident's room clean & sanitary. on 04/03/25, LPA Wesley and the Administrator Madeleine Sievert toured the facility and found that several rooms were not cleaned. LPA asked the administrator how many staff were on duty and she provided me with the names 2 med technicians, 5 caregivers, 2 housekeepers, and 1 laundry attendant on duty. LPA visited random clients rooms and found that the trash was not Continued on LIC 9099C Substantiated emptied, restroom has not been cleaned, and their linen was not changed, as well as a resident was in a soiled undergarment. Pictures were taken. LPA Wesley interviewed 2 caregivers and they indicated that they are short staff and are in need of help, and interviewed 1 housekeeper and They indicated that they are okay. There was some random people visiting their loved ones and they indicated that they come and clean the rooms, sweep and take their trash away. LPA interviewed 12 residents and they said there rooms are supposed to be cleaned once a week, and the trash emptied daily, but they do not come the 3 residents didn't want to comment. The rooms were not clean and sanitary. On 04/03/25, LPA Wesley was at the facility from 11:20am-4:30pm. Pictures were taken. Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations,Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Appeal rights were given. A copy of the LIC 9099/LIC 9099C/LIC 9099D was given during the exit interview.the state’s words, verbatim · CDSS document, May 16, 2025 · control 28-AS-20250327140118

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 30, 2025

Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This evidence was not met as required LPA and the Administrator observed several rooms that were not cleaned by staff, which includes emptying the trash, cleaing the bathrooms, and changing the linen.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: The administrator shall ensure all the residents rooms are clean. Create an inservice training "Maintenace and Operations" for all staff and go what needs to be cleaned. HIre more staff if necessary. Submit the in service training sign in sheet to LPA Wesley 323 980 4912 by the POC date 05/30/25.

Type of visit: Case Management - Other

***This LIC 809/809D/Immediate Civil Penalty supercedes the LIC 809/809D that was issued on 04/03/25*** LPA Nicol Wesley conducted a case management visit at the facility due to a resident smoking cigarettes in a room with oxygen being administered. LPA Wesley and Administrator Sievert was conducting a tour of the facility when LPA Wesley smelled cigarette smoke. LPA Wesley asked the Administrator to knock on the door where the Oxygen sign was posted and when the resident opened the door, the room was filled with cigarette smoke. The Administrator Sievert was speaking to the resident and apparently had spoken to her about this issue before. LPA Wesley informed the residents of the danger of smoking when oxygen is in use. Also while the LPA Wesley was in the facility the second elevator was not working, which means both of the elevators were broken at the same time. The following deficiencies were cited in accordance to the California code of regulations, Title 22. Exit interview conducted. A copy of this report was given to the Administrator, along with Appeal rights.the state’s words, verbatim · CDSS document, May 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Apr 4, 2025

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This item was not met as evidence by: the facility had two elevators broken at the same time. the 1st elevator was broken since last monday 05/31/25, and the 2nd was in disrepair for at least 3 hours while LPA Wesley was in the building, the had it fixed, and it broke again. The Non Ambulatory clients could not get to their room which posed a health and safety risk to clients in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: The facility shall ensure all elevators are working properly at all times. Please provide the service repair sheet for the elevator for today encounter to Attn Nicol Wesley 323 980 4912 by POC date 04/04/25

From the deficiency page — Deficiency type: Type A · Section cited: HSC87468.1 · Plan of correction due date: Apr 4, 2025

Personal rights Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This evidence was not met as required: LPA Wesley and the Administrator found resident #1 was smoking in her room where oxygen was in use. She also shares a room with the another resident who was at risk.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: The Administrator advised that she spoke to the resident and documented her conversation. The administrator shall come up with a plan to ensure the resident is in compliance. Give a copy of the plan to Atth: Nicol Wesley 323 980 4912.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Apr 3, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The requirement was not met as evidence by LPA Wesley witnessed the facility elevators(two) were broke at the same time and the non ambulatory clients couldn't go to their rooms or leave their rooms to visit friends, eat lunch etc.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: The facility shall make sure the elevators are working at all times, and have them serviced. please send elevator repair sheet to LPA Wesley 323 980 4912 By POC date 04/04/25.

Allegation investigated: Allegation: Staff did not meet resident's hygiene needs.

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced initial visit to investigate the above allegation. LPA met with Regional Director Lisa Pham and Administrator Madeline Sievert and discussed the purpose of the visit. The investigation consisted of LPA interviewing six (6) staff and eleven (11) residents. Taking tour of facility, reviewing and obtaining staff and resident rosters, R1 face sheet, R1 Physicians report, R1 Admission agreement, and resident service refusal log. The investigation revealed: Allegation, Staff did not meet resident's hygiene needs. It is alleged the facility has failed to provide proper hygiene services to R1, that R1 was observed with dead skin on body and mold fuzz between R1 toes. (continue on 9099C) Unsubstantiated (continued from 9099) LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegation. All six (6) staff stated that resident refuses hygiene/bathing services almost always. One staff stated that R1 has refused at least 6 six times when staff has been scheduled to assist R1. One staff stated that R1 can bathe self, and that staff are assigned to be on standby for R1. LPA interviewed eleven (11) residents and ten (10) of Eleven (11) residents could not corroborate the allegation. R1 stated staff do not come to assist R1 with bathing or personal hygiene. R1 stated R1 never refuses personal hygiene or bathing services. R1 stated R1 wants personal hygiene assistance. R1 stated R1 has no dead skin or uncleaned feet and toes. LPA reviewed and obtained facility shower refusal forms for R1 dated 02/01/2025, 02/18/2025, 02/21/2025, 03/14/2025, 03/21/2025, 03/25/2025, 03/28/2025, 04.01/2025 and 04/08/2025 which contradicts R1 statements. S2 stated R1 has history of fabricating events. R1 was hospitalized from 04/09/2025 to 04/14/2025 and then was sent back to hospital on 04/17/2025 and remains hospitalized to date. R1 appeared to be clean in facetime call from hospital that R1 is currently at. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Administrator Madeleine Sievert.the state’s words, verbatim · CDSS document, Apr 28, 2025 · control 28-AS-20250421133503

Allegation investigated: Facility Elevators in disrepair causing delays in emergency medical response to residents

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced complaint investigation regarding the above allegations. LPA was met by Administrator Madeleine Sievert and explained the purpose of the visit. The investigation consisted of the following: LPA Gutierrez did an inspection of facility elevators located in the front lobby and in garage, requested and obtained copies of staff roster, resident roster, elevator repair receipts, firefighters service operation log, and hydraulic maintenance tasks. LPA conducted interviews with Administrator, staff 1- staff 6 (S1-S6), and residents 1 – 6 (R1-R6). SEE 9099C Unsubstantiated In regard to the allegation” Facility Elevators in disrepair causing delays in emergency medical response to residents”, it is alleged that facility is not in compliance with regards to their passenger elevator. During interviews with staff six (6) out of six (6) stated that although elevator was not working, they called for service on the same day and were waiting for parts. Administrator stated they have two elevators and if they both stop working, they have an emergency plan that consist of evacuation chairs at every stairwell on second floor. During interviews with residents six (6) out of the six (6) stated that they have all witnessed elevators out of service, but staff fixes them in a timely manner. All six (6) residents stated they never had an issue with coming downstairs. LPA checked both elevators at time of visit and observed both of them in working condition. On April 7th,2025, LPA Wesley was conducting a visit and observed both elevators not working deficiency was cited and a $500 immediate civil penalty was assessed. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Administrator Madeleine Sievert.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 28-AS-20250402110122

Type of visit: Case Management - Other

LPA Nicol Wesley conducted a case management visit at the facility due to a resident smoking cigarettes in a room with oxygen being administered. LPA Wesley and Administrator Sievert was conducting a tour of the facility when LPA Wesley smelled cigarette smoke. LPA Wesley asked the Administrator to knock on the door where the Oxygen sign was posted and when the resident opened the door, the room was filled with cigarette smoke. The Administrator Sievert was speaking to the resident and apparently had spoken to her about this issue before. LPA Wesley informed the residents of the danger of smoking when oxygen is in use. Also while the LPA Wesley was in the facility the second elevator was not working, which means both of the elevators were broken at the same time. The following deficiencies were cited in accordance to the California code of regulations, Title 22. Exit interview conducted. A copy of this report was given to the Administrator, along with Appeal rights.the state’s words, verbatim · CDSS document, Apr 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Apr 4, 2025

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This item was not met as evidence by: the facility had two elevators broken at the same time. the 1st elevator was broken since last monday 05/31/25, and the 2nd was in disrepair for at least 3 hours while LPA Wesley was in the building, the had it fixed, and it broke again. The Non Ambulatory clients could not get to their room which posed a health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: The facility shall ensure all elevators are working properly at all times. Please provide the service repair sheet for the elevator for today encounter to Attn Nicol Wesley 323 980 4912 by POC date 04/04/25

From the deficiency page — Deficiency type: Type A · Section cited: CCR8746.1(a)(2) · Plan of correction due date: Apr 4, 2025

Personal rights Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This evidence was not met as required: LPA Wesley and the Administrator found resident #1 was smoking in her room where oxygen was in use. She also shares a room with the another resident who was at risk.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: The Administrator advised that she spoke to the resident and documented her conversation. The administrator shall come up with a plan to ensure the resident is in compliance. Give a copy of the plan to Atth: Nicol Wesley 323 980 4912.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Apr 3, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The requirement was not met as evidence by LPA Wesley witnessed the facility elevators(two) were broke at the same time and the non ambulatory clients couldn't go to their rooms or leave their rooms to visit friends, eat lunch etc.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: The facility shall make sure the elevators are working at all times, and have them serviced. please send elevator repair sheet to LPA Wesley 323 980 4912 By POC date 04/04/25.

Allegation investigated: Facility staff does not provide adequate food service to resident in care. Facility does not provide adequate toileting supplies. Facility staff does not provide adequate housekeeping services.

Licensing Program Analyst (LPA) Alberto Lopez made subsequent visit to the facility for the purpose of continuing investigation and delivering findings for above-mentioned allegations. LPA Lopez met with Maddie Sievert, Administrator and explained the purpose for the visit. 02/28/2025 During the visit, LPA interviewed two residents (2) and one (1) staff and reviewed and obtained copies of staff and resident rosters. The investigation consisted of: LPA taking tour of facility including dining area, random rooms and common areas. LPA reviewed and obtained staff and resident rosters. Copy of food menu, interviews with six (6) staff (S#1-S#6) and twelve (12) residents (R#1-R#12) The investigation revealed, Allegation: Facility staff does not provide adequate food service to resident in care. It is alleged that facility does not provide seconds of food servings to residents or seconds of dessert when residents ask. (continue on 9099C) Unsubstantiated (continued from 9099) LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegation. One staff stated one resident mentioned that portions are small but also stated that staff has seen food in the trash. LPA interviewed twelve (12) residents and eleven (11) of twelve (12) residents were not able to corroborate the allegations. LPA observed residents getting seconds of food and dessert during the visit. There is insufficient evidence to support this allegation. Allegation: Facility does not provide adequate toileting supplies. It is alleged that facility is only providing one roll of toilet paper per person per week and can take hours or days to get more. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegation. LPA interviewed twelve (12) residents and eleven (11) of (12) residents were not able to corroborate the allegation. Several staff stated that they provide each resident with 2 rolls of toilet paper per week and if they require more, they just need to ask and more will be provided. Several residents stated that the facility has increased the initial amount of toilet paper provided and that is enough and if not they will get more if they ask. LPA checked random rooms during the visit and all the rooms had toilet paper in the restrooms. Including common restrooms. There is insufficient evidence to support this allegation. Allegation: Facility staff does not provide adequate housekeeping services. It is alleged that facility is not taking out the trash from resident’s room. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegation. LPA interviewed twelve residents and twelve (12) of twelve (12) residents could not corroborated the allegation. Some residents stated that if their trash bin gets full, they just take it out and place it in the hallway. Residents stated they have extra bags and can replace the bag themselves if they must. LPA inspected random rooms, and all the rooms inspected had the trash removed from the rooms. LPA toured the facility and observed housekeepers cleaning, taking out the trash, and re-stocking toilet paper in the rooms. There is insufficient evidence to support this allegation. Other allegations regarding the mismanagement of medications and response time to call light or request for help were addressed in previous complaint recently. Also allegation that facility is not providing medical records was addressed by LPA previously as well. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Madeleine Sievert Administrator. A copy of this report along with the appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 18, 2025 · control 28-AS-20250221164219

Allegation investigated: Staff are mismanaging residents medication Staff are not responding to residents call buttons in a timely manner Staff are not following infectious control requirements Staff did not prevent residents from wandering from the facility Staff did not provide resident's medical records to physician Staff are not meeting residents dietary needs Staff did not ensure elevators were not in disrepair Staff are not fixing things in a timely manner Staff are not meeting residents needs

Licensing Program Analyst (LPA) Alberto Lopez made subsequent visit at the facility for the purpose of continuing investigation and delivering findings for above-mentioned allegations. LPA Lopez met with Maddie Sievert, Interim Administrator and explained the purpose for the visit. On 02/04/2025 - The investigation consisted of interviews with seven (7) staff (S#1-S#7), nine (9) residents (R#1-R#9). LPA reviewed and obtained, R5 MAR for month of January 2025, reviewed and obtained staff and resident rosters, reviewed medications for R5, and asked facility to send R5 LIC602 and admission agreement. LPA interview total of eight (8) staff and ten (10) residents and reviewed and obtained medication destruction record for S5 medications that were missing. LPA inspected the elevators and room 147 bathrooms. (continued on 9099C) Unsubstantiated (continued from 9099) The investigation revealed: 1) Staff are mismanaging residents medication. It is alleged that residents are not getting their medications or getting them on time. LPA interviewed eight (8) staff and all eight (8) denied the allegation LPA interviewed ten (10) residents and six (6) of ten (10) residents were not able to corroborate the allegation. LPA reviewed medications for R5 and there were medications missing for dates that R5 was at Hospital. Staff sated they were popped out of the bubble in error and destroyed. Staff provided proof to LPA of medication destruction. There is not enough evidence to substantiate this allegation. 2) Staff are not responding to residents call buttons in a timely manner. It is alleged that residents are not getting their assistance on time. LPA interviewed eight (8) staff and all eight (8) denied the allegation LPA interviewed ten (10) residents and eight (8) of ten (10) were not able to corroborate the allegation. There is not enough evidence to substantiate this allegation. 3) Staff are not following infectious control requirements. It is alleged that some residents are not being required to wear mask when there is a COVID outbreak. LPA interviewed eight (8) staff and all eight (8) denied the allegation. Staff stated they encouraged the residents to wear a mask but cannot required them to wear them now. LPA interviewed ten (10) residents and seven (7) of ten (10) residents were not able to corroborate the allegation. The facility cannot require residents to wear a mask any longer. However, the facility continues to encourage wearing a mask during COVID outbreaks. There is not enough evidence to substantiate this allegation. (continued on 9099C) (continued from 9099C) 4) Staff did not ensure elevators were not in disrepair. It is alleged that elevators are in disrepair. LPA interviewed eight (8) staff and all eight (8) denied the allegation. Some staff stated that the residents tend to crowd the elevator and do not abide by the limit of 3 persons and that it causes the elevator to malfunction at times. Staff stated when the elevators do need repair, they are repaired promptly and never have the two elevators been broken down at the same time. LPA interviewed ten (10) residents and eight (8) of 10 residents were not able to corroborate the allegation. One resident stated that the elevator breaks down because too many people get in them at one time. Some residents stated that facility has them repaired right away. Facility has two elevators, and, on both visits, the elevators were working properly. There is insufficient evidence to support this allegation. 5) Staff are not fixing things in a timely manner. It is alleged that bathroom sink in room 147 is in disrepair and facility has not addressed it. LPA took tour of room 147 and the bathroom sink was repaired and working properly during the two separate visits LPA made. LPA interviewed eight (8) staff and all eight (8) denied the allegation. LPA interviewed ten (10) residents and seven (7) of ten (10) residents were not able to corroborate the allegation. Most residents stated that facility repairs things right away. Residents stated they must put in a work order and facility responses in a reasonable time. There is insufficient evidence to support this allegation. 6) Staff are not meeting resident’s needs. It is alleged that staff do not respond to 24 hour phone when called during overnight hours. LPA interviewed eight (8) staff and all eight (8) staff denied the allegation. One staff stated she has used the phone when trying to get access to facility in the early morning hours to begin her shift and the phone is answered promptly and has never been late due to no one answering the 24-hour phone. LPA interviewed ten (10) residents and six (6) of the ten (10) residents were not able to corroborate the allegation. Several residents stated that all their needs are being met. There is insufficient evidence to support this allegation. (continue on 9099) (continued from 9099C) 7) Staff did not ensure elevators were not in disrepair. It is alleged that elevators are in disrepair. LPA interviewed eight (8) staff and all eight (8) denied the allegation. Some staff stated that the residents tend to crowd the elevator and do not abide by the limit of 3 persons and that it causes the elevator to malfunction at times. Staff stated when the elevators do need repair, they are repaired promptly and never have the two elevators been broken down at the same time. LPA interviewed ten (10) residents and eight (8) of 10 residents were not able to corroborate the allegation. One resident stated that the elevator breaks down because too many people get in them at one time. Some residents stated that facility has them repaired right away. Facility has two elevators, and, on both visits, the elevators were working properly. There is insufficient evidence to support this allegation. 8) Staff are not fixing things in a timely manner. It is alleged that bathroom sink in room 147 is in disrepair and facility has not addressed it. LPA took tour of room 147 and the bathroom sink was repaired and working properly during the two separate visits LPA made. LPA interviewed eight (8) staff and all eight (8) denied the allegation. LPA interviewed ten (10) residents and seven (7) of ten (10) residents were not able to corroborate the allegation. Most residents stated that facility repairs things right away. Residents stated they must put in a work order and facility responses in a reasonable time. There is insufficient evidence to support this allegation. 9) Staff are not meeting resident’s needs. It is alleged that staff do not respond to 24 hour phone when called during overnight hours. LPA interviewed eight (8) staff and all eight (8) staff denied the allegation. One staff stated she has used the phone when trying to get access to facility in the early morning hours to begin her shift and the phone is answered promptly and has never been late due to no one answering the 24-hour phone. LPA interviewed ten (10) residents and six (6) of the ten (10) residents were not able to corroborate the allegation. Several residents stated that all their needs are being met. There is insufficient evidence to support this allegation. Based on observations, interviews with staff and residents and record review, There is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Madeleine Sievert Administrator. A copy of this report along with the appeal rights was provided.the state’s words, verbatim · CDSS document, Feb 28, 2025 · control 28-AS-20250130091414

Allegation investigated: Staff mismanaged resident medication. Facility staff left resident in soiled diaper for an extended amount of time.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation on the allegations listed above. LPA arrived unannounced and met with Maddie Sievert, the interim Executive Director. The reason for the visit was explained. The investigation consisted of the following: LPA obtained copies of the resident and staff rosters. LPA also reviewed Resident #1’s file and interviewed Staff and Residents. Resident #1 is no longer residing at the facility and was not interviewed. The investigation revealed the following: Allegation – Staff mismanaged resident medication. It is alleged that Resident #1’s medication was last given on 12/24/24. On 12/25/24, staff could not find the medications that had been delivered the day before. Unsubstantiated LPA interviewed the interim Administrator, 4 Staff and 10 Residents. According to interviews and record review, Resident #1 (R1) moved in on 12/17/24 and moved out on 12/23/24. Staff stated that R1 did not missed any medications. They stated R1 received all the medications from the Skilled Nursing Facility upon admission and did not have any medications delivered during the week of residing at the facility. LPA reviewed the medication log and staff initialed when the medications were given. There were none missed. LPA interviewed 10 residents regarding medications. 7 out of 10 residents stated they get their medications timely and have not missed any medications due to staff mismanagement. Based on information gathered, there is insufficient evidence to prove this allegation. Allegation - Facility staff left resident in soiled diaper for an extended amount of time. It is alleged that resident was left in soiled diaper for over 30 minutes multiple times. LPA interviewed Staff and Residents for this allegation. Staff stated they do not keep any diaper changing logs. Staff denied leaving residents in soiled diaper for over 30 minutes. They stated they do wellness checks every 2 hours and will check the residents’ diapers during that time. They also change their diapers upon request. If a resident calls the front desk for assistance in changing the diaper, staff will immediately respond to the call and provide an estimated time to assist the resident. They stated they will change them as soon as possible. LPA interviewed 10 residents during the visit today. 2 out of 10 residents stated they have to wait a long time, between 2 - 3 hours, before staff will assist with a diaper change. The rest indicated the staff do not leave them in soiled diapers and will assist them timely or they change themselves. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with M. Sievert. A copy of this report along with the appeal rights was provided.the state’s words, verbatim · CDSS document, Jan 3, 2025 · control 28-AS-20241227161938

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to inspect the dementia care section of the facility in order to approve facilities' request to advertise for dementia care. LPA met with Acting Administrator Madeleine (Maddie) Sievert and discussed the purpose of the visit. LPA spoke with former Administrator Lisa Pham via phone and she reported to LPA that facility does not have a specific area for dementia care and will only be accepting early onset dementia residents. LPA reviewed and obtained dementia training proof for all staff, and staff and resident rosters. LPA took tour of facility with Maddie and observed the exit door leading to garage and front exit without any kind of alert system. Maddie stated they will install the audio systems and send proof to LPA when complete. LPA will review Dementia Plan submitted by facility and will address any issue that is missing with facility in order to approved the facility to advertise Dementia Care at Savant of Alhambra. Exit interviewed conducted and copy of report provided.the state’s words, verbatim · CDSS document, Nov 25, 2024

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

Licensing Program Analyst (LPA) Alberto Lopez made subsequent visit to complete investigation and deliver findings. LPA met with Administrator Lisa Pham and discussed the purpose of the visit. On 09/20/2024, LPA made visit and met with Business Manager Ruby Andrade. During this visit LPA interviewed four (4) staff, one (1) witness and eight (8) residents, LPA reviewed R1 file, R1 MAR for month of July 2024, reviewed and obtained staff and resident rosters, controlled substance medication record for July 1 – July 25, 2024 for R1, copy of prescription for R1, San Gabriel Valley Medical Center Discharge paperwork for R1 dated 07/27/2024, 8-hour medication training certificates for staff dated 08/02/2024, SIR dated 7/27/2024, shower refusal log for R1,LIC602, and Admissions agreement. On 10/08/2024 LPA interviewed S7 and S8 and attempted to interview S5. S5 stated she was unable to answer any question due to being too busy and LPA was unable to interview S5. (continued on 9099-C) Substantiated (continued from 9099) The investigation revealed: Allegation: Staff did not ensure correct medications were dispensed to resident. It is alleged that S5 gave R1 another resident's medication. According to SIR dated 07/27/2024, R1 was administered incorrect medication on 7/26/2024 at approximately 9:00 PM LPA Interviewed eight (8) staff and six (6) of eight (8) staff corroborated the allegation. One staff did not know and could not answer and S5 could not answer LPA questions during phone contact and stated S5 was too busy. S1, S2, S3, S6, S7, and S8 admitted the medication error and One (1) of eight (8) residents was able to corroborate the allegation. W#1 who is family member also corroborated the allegation. On 7/26/2024 at approximately 9:00 PM, S5 provided the wrong medication to R1. The error occurred because S5 mistook one resident for another because both residents shared the same last name. There is enough evidence to substantiate this allegation Allegation: Staff did not ensure medications were dispensed in a timely manner. It is alleged that one staff forgot to provided medications to resident at one night. LPA interviewed eight (8) staff and six (6) of (8) staff denied the allegation. S3 admitted that this occurred. S8 who was responsible to administer medications to resident one night stated S8 forgot and called niece immediately to notify her and immediately administered the medication that night. Medication were administered late on at least one night according to S8 statement. LPA interviewed Eight (8) residents and seven (7) of (8) residents could not corroborate the allegation. There is enough evidence to substantiate this allegation. The facility admitted the errors and stated they took corrective action that included additional training of staff. Based on LPA's record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation are SUBSTANTIATED. Exit interview and copy of report, 9099-D and appeal rights provided to administrator Lisa Pham. (continued from 9099) Some staff stated that R1 refused bathing service. LPA interviewed eight (8) residents and seven (7) of eight (8) residents could not corroborate the allegations. LPA reviewed and obtained bathing log documentation for R1 that shows that resident refused bathing services on July 26, 30, 2024, and on August 2,6,9, 2024 for reasons of not feeling well to dizziness. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted, a copy of this report and Appeal Rights were provided to Administrator Lisa Pham.the state’s words, verbatim · CDSS document, Oct 8, 2024 · control 28-AS-20240904092531

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Oct 9, 2024

87465(c)(2) (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: On July 26th 2024, R1 was given medication that belonged to another resident by mistake which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Facility will complete an incident report documenting the medication error. The report will include if the primary physician has been notified of the error. Administrator shall ensure all med-tech staff received additional training. Sign-in sheet and training material will be emailed to LPA by the POC due date. Administrator will include in writing the steps taken to avoid future medication errors by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Oct 9, 2024

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(5) The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Resident #1 did not receive their medication on at least one night on time because S8 stated S8 forgot which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Administrator shall provide additional training to all Staff responsible for medication assistance and provide proof to the department by the POC date.

Allegation investigated: Facility staff not assisting resident with attending dialysis appointments as required

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced subsequent complaint visit at the facility for the purpose of investigating the above-mentioned allegation. LPA Lopez met with Ruby Andrade, Business Manager and explained the purpose for the visit. Administrator Lisa Pham arrived a few minutes later and assisted with the visit. On previous visit on 08/26/2024 LPA Lopez obtained a copy of the resident/staff roster. Toured common areas and Interviewed one (1) Staff (S#1) The investigation consisted of LPA interviewing four (4) staff and eight (8) residents. LPA reviewed and obtained 3 SIR dated 08/19/2024, 08/21/2024, and 08/23/2024 in which department is notified of R1 refusal to go to dialysis, progress notes from 08/14/2024 to 09/3/2024, R1 LIC602, and R1 History and Physical dated 08/22/2024. (Continued on 9099C) Unsubstantiated The Investigation reveled the following: Allegation: Facility staff not assisting resident with attending dialysis appointments as required. It is alleged that facility is not assisting R1 in getting to R1 appointments for dialysis. LPA interviewed four (4) staff and all four (4) staff denied the allegation and all four stated that R1 has refused to attend R1 appointments for dialysis and that R1 primary doctor is notified each time. LPA interviewed eight (8) residents and all eight (8) residents could not corroborate the allegation. LPA spoke with R1 via phone and stated that R1 refused to attend dialysis and did not blame the facility. LPA reviewed SIR dated 08/19/2024, 08/21/2024, and 08/23/2024 and it all three, the facility has reported R1 refusal to attend dialysis. LPA reviewed History and Physical report dated 08/22/2024 in which it reports that R1 has capacity to make medical decisions on R1 own behalf and R1 is not having memory loss. The report also mentions R1 intermittently refused dialysis while hospitalized from 08/14/2024 - 08/18/2024. There is no evidence to substantiated this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted, a copy of this report and Appeal Rights were provided to Lisa Pham, Administratorthe state’s words, verbatim · CDSS document, Sep 3, 2024 · control 28-AS-20240823100907

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Lisa Pham. The following (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for thirty (30) resident is approved. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 06/01/2025. A surety bond is not applicable. Facility does not handle resident's money. Facility changed name of facility to Savant of Alhambra without department approval. Citation issued. Physical Plant/Environment Safety: The building is located in a residential neighborhood. The building consists of three floors (ground floor, first floor and second floor). The ground floor/lobby consists of a front desk/reception area, business offices, three (3) activity rooms (tv, game room and activity room), health & wellness office, sales/marketing office, , laundry room, beauty salon, storage room, employee break room and garage. The first floor consists of resident rooms, dining room, kitchen, patio area and a storage room, and medication room. The second floor consists of resident rooms and a storage room. The facility has two (2) operable elevators. All resident rooms located on the first and second floors have a sliding door or a door leading to a balcony. Bedrooms were equipped with a bed, chair, nightstand, adequate lighting, and ample closet/storage space for each resident. Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed. The bathrooms are clean and operational with non-skid mats. The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were clean and all appeared functional. The supply of dishes/cups is adequate. During today's visit, LPA observed an appropriate food supply of two (2) days of perishables and seven (7) days of non-perishables. The facility is equipped with a centralized sprinkler system. The facility has a central air and heating system in the common areas of the building and individual AC units inside resident bedrooms. The medications, First-aid kit and resident records are centrally stored and locked in the medication room. First aid kit is fully stocked with a manual. Staff records are centrally stored and locked at the front desk/reception area. Facility does not handle resident P&I monies. The facility smoke detectors are hard wired. Carbon monoxide detectors were observed throughout the facility. The fire extinguishers were fully charged and in compliance. There is a functioning telephone on the premises. The hot water temperature was tested throughout the facility and did not measure within Title 22 Regulations. Water temperature measure between 110.6 - 124.5 in random rooms that were inspected. Citation was issued. All toxins such as cleaning solutions and detergent soap are also locked in the storage room. The grounds of the facility are well landscaped with a ramp that leads to the entrance. A shaded area with chairs is provided in the patio area. The trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. Staffing: There appears to be always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 8 staff files with no issues observed. Administrator Lisa Pham certificate expired on 03/01/2024 renewal application was sent 01/2024 and certificate is pending. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman near the resident mail room. A total of four (4) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information. RCFE complaint poster and Personal rights were observed posted in the facility hallway. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. The facility does have a Resident Council and meets monthly. Food Service: Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Incident Medical and Dental: Eight (8) centrally stored resident medications were reviewed. Medical and dental transportation is provided by family, transportation services, or staff. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Plan needs to be updated. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Per California Code of Regulations, Title 22, deficiencies was cited. Technical Advisory provided. Exit interview was conducted with Administrator Lisa Pham. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jun 10, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Facility is in disrepair

This report supersedes report dated 03/14/24 , the reason for the subsequent visit is to correct the citation issued on 3/14/24 and the finding will remain the same.** On previous visit Licensing Program Manager made unannounced visit to investigate the above allegation. LPA met with Ruby Andrade, Business Office Manager and discussed the purpose of the visit. Administrator Lisa Pham arrived later during the visit. Allegation: Facility is unsanitary. it is alleged that facility is very uncleaned that there may be a food shortage. The investigation consisted of interviews with Twelve (12) staff S#1-S#12 and thirteen (13) residents (R#1- #13) residents, tour of all three floors, corridors, hallways, restrooms on all 3 floors, 13 random rooms, and reviewed staff and resident roosters. (Continued 9099C) Substantiated The investigation revealed, based on observation of LPA and photos taken by LPA during the visit that facility is in need of replacing the carpet or deep cleaning the carpet in all the hallways on all 3 floors, and in rooms #140, #109, #152. Room 104 was observed very unclean during the visit by LPA. Administrator stated that facility is in process of replacing the carpets with new floors. LPA interviewed 12 staff and 9 of 12 staff denied the allegation. 3 staff stated that facility is in need of new carpet in hallways and in some rooms. LPA interviewed 13 residents and 10 of 13 could not collaborate the allegations. 3 residents stated that the carpets at facility is very stained, dirty or both. Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6. Exit interview was conducted, a copy of this report and Appeal Rights were provided to Lisa Pham, Administratorthe state’s words, verbatim · CDSS document, Apr 3, 2024 · control 28-AS-20240311164325

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 4, 2024

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by Facility is in need of replacing the carpet or deep cleaning the carpet in all the hallways on all 3 floors, and in rooms #140, #109, #152. Room 104 was observed very unclean during the visit by LPA which pose/posses health and safety hazard to person in care.the state’s words, verbatim · CDSS document, Apr 3, 2024

Plan of correction: Administrator will deep clean or replace all carpets in the hallways and in rooms #140, #109, #152. Also, will provide room 140 an overall cleaning.

Allegation investigated: Facility is unsanitary.

Licensing Program Manager made unannounced visit to investigate the above allegation. LPA met with Ruby Andrade, Business Office Manager and discussed the purpose of the visit. Administrator Lisa Pham arrived later during the visit. Allegation: Facility is unsanitary. it is alleged that facility is very uncleaned that there may be a food shortage. The investigation consisted of interviews with Twelve (12) staff S#1-S#12 and thirteen (13) residents (R#1- #13) residents, tour of all three floors, corridors, hallways, restrooms on all 3 floors, 13 random rooms, and reviewed staff and resident roosters. (Continued 809) Substantiated The investigation revealed, base on observation of LPA and photos taken by LPA during the visit that facility is in need of replacing the carpet or deep cleaning the carpet in all the hallways on all 3 floors, and in rooms #140, #109, #152. Room 104 was observed very unclean during the visit by LPA. Administrator stated that facility is in process of replacing the carpets with new floors. LPA interviewed 12 staff and 9 of 12 staff denied the allegation. 3 staff stated that facility is in need of new carpet in hallways and in some rooms. LPA interviewed 13 residents and 10 of 13 could not collaborate the allegations. 3 residents stated that the carpets at facility is very stained, dirty or both. Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6. Exit interview was conducted, a copy of this report and Appeal Rights were provided to Lisa Pham, Administratorthe state’s words, verbatim · CDSS document, Mar 14, 2024 · control 28-AS-20240311164325

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87003(a) · Plan of correction due date: Apr 4, 2024

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Facility is in need of replacing the carpet or deep cleaning the carpet in all the hallways on all 3 floors, and in rooms #140, #109, #152. Room 104 was observed very unclean during the visit by LPA which pose/posses health and safety hazard to person in care.the state’s words, verbatim · CDSS document, Mar 14, 2024

Plan of correction: Administrator will deep clean or replace all carpets in the hallways and in rooms #140, #109, #152. Also, will provide room 140 an overall cleaning.

Allegation investigated: Staff are not showering residents timely Staff are not changing residents timely Staff are not assisting residents with medications timely Staff are not providing residents with basic hygiene products

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint investigation regarding the above allegations. LPA met with Wellness Coordinator, Madeleine Sievert who assisted with the visit. Administrator, Lisa Pham arrived at the facility later, and also assisted with the visit. Regarding the allegation that : Staff are not showering residents timely. The investigation consisted of interviews with Administrator, Staff #1- Staff #7, and Resident #1- Resident #7. LPA also reviewed caregiver assignment sheets with shower schedule. Staff interviewed did not corroborate the allegation. Six out of eight staff interviewed stated that staff do shower residents timely. Residents interviewed were not able to corroborate the allegation. Seven out of seven residents stated that either they do not need assistance with showering or they do receive assistance timely. Regarding the allegation that : Staff are not changing residents timely. The investigation consisted of interviews with Administrator, Staff #1- Staff #7, and Resident #1- Resident #7. LPA also reviewed caregiver assignment sheet with bathroom assist schedule. Unsubstantiated Staff interviewed did not corroborate the allegation. Six out of eight staff interviewed stated that staff dochange residents timely. Residents interviewed were not able to corroborate the allegation. Seven out of seven residents stated that either they do not need assistance with changing, or they do receive assistance timely. Regarding the allegation that : Staff are not assisting residents with medications timely. The investigation consisted of interviews with Administrator, Staff #1- Staff #7, and Resident #1- Resident #7. Staff interviewed did not corroborate the allegation. Six out of eight staff interviewed stated that staff do assist with medications in a timely manner. Residents interviewed were not able to corroborate the allegation. Seven out of seven residents stated that either they handle their own medication, or they do receive assistance with their medications in a timely manner. Regarding the allegation that : Staff are not providing residents with basic hygiene products. The investigation consisted of interviews with Administrator, Staff #1- Staff #7, and Resident #1- Resident #7. LPA also observed facility hygiene supply. Staff interviewed did not corroborate the allegation. Seven out of eight staff interviewed stated that staff do provide residents with basic hygiene products. LPA observed that the facility has a supply of hygiene products for residents. Residents interviewed were not able to corroborate the allegation. Seven out of seven residents stated that they either have their own hygiene products, or the staff have provided them with hygiene products. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 12, 2024 · control 28-AS-20240305095603