Savant of Santa Monica

Allegation investigated: Staff stole residents’ personal belongings.

*On 09/01/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit to deliver an updated complaint investigation report for the allegation listed above. This report supersedes the report dated 08/08/2026. This report has been updated to edit the timeline of events. This report does not change the findings; the findings remain as “Substantiated”. LPA met with Joe Saldana, and the purpose of the visit was explained.* On 08/08/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegation listed above. LPA met with the Maintenance Director, Christian Rivera and the purpose of the visit was explained. LPA was granted entry to the facility. Substantiated Investigation consisted of the following: On 12/01/2025, interviews were conducted with Resident 1 (R1) to Resident 6 (R6). On 01/15/2026, interviews were conducted with R1, R2, R4, R5, R6, and Staff 2 (S2). On 03/24/2026, interviews were conducted with R1, R2, R4, and Staff 3 (S3) to Staff 6 (S6). On 04/03/2026, interviews were conducted with Witness 1 (W1) and Witness 2 (W2). Interviews were attempted with Staff 1 (S1) and Resident 7 (R7). Facility records reviewed consisted of Client Roster, Personnel Report dated 12/01/2025, Staff Schedule from 11/14/2025 to 11/25/2025, Staff Roster with contact information, and Facility Sketch. Staff 1’s (S1) records reviewed consisted of Position Description, General Handbook Acknowledgement, Identification Information, and Personnel Record dated 07/21/2025. R1 to R7’s records reviewed consisted of Face Sheet and Emergency Information, Unusual Incident/Injury Reports dated 11/22/2025, SOC341 Reports of Suspected Dependent Adult/Elder Abuse dated 11/19/2025, and Resident Statements dated 11/28/2025. Police Reports reviewed consisted of Los Angeles County Sheriff’s Department (LASD) Booking Information, Culver City Police Department Report #25-0005809, Santa Monica Police Department Reports #25-109912, 25-10097, and 25-110099. Investigation revealed the following: Allegation: “Staff stole residents’ personal belongings”, it is being alleged that S1 stole residents' personal belongings. Interviews with R1 to R6 revealed the following: 1 out of 6 residents were unable to provide additional information. 5 out of 6 residents agreed with the allegation, furthermore, residents indicated that S1 stole from them and/or other residents in the facility, additionally, residents indicated that they were informed that S1 had been arrested, moreover, they were notified by the Culver City Police Department to retrieve their stolen items, in addition, residents indicated that the facility has not reimbursed them for the valuables that have not been returned to them. Interviews conducted with S2 to S6 revealed the following: 1 out of 5 staff were unable to provide additional information. 4 out of 5 staff agreed with the allegation, moreover, staff indicated that residents informed them that their personal belongings had gone missing and S1 was a suspect, furthermore, staff indicated that days later the Culver City Police Department called the facility informing them that S1 had been arrested and found with residents’ personal belongings. Records reviewed of the Staff Schedule for 11/2025, SOC341 Report of Suspected Dependent Adult/Elder Abuse dated 11/19/2025, Unusual Incident/Injury Report dated 11/22/2025, Los Angeles County Sheriff’s Department (LASD) Booking Information, Culver City Police Department Report #25-0005809, Santa Monica Police Department Reports #25-109912, 25-10097, and 25-110099 revealed the following timeline of events: S1 was on shift on 11/15/2025 from 10:00 PM to 11/16/2025 at 06:30 AM. On 11/16/2025 at approximately 9:00 AM, residents reported to staff that items had gone missing from their rooms and management immediately suspended the alleged suspect S1. On 11/16/2025 at approximately 6:10 PM, S1 was arrested by the Culver City Police Department and found to be in possession of R1 to R5’s and R7’s personal belongings such as, Identification Cards (IDs), bank cards, social security card, a phone, and personal belongings. A criminal case against S1 has been filed for charges that include PC530.5(a) (identity theft) and PC530.5(c)(1) (possession of identifying information). On 11/16/2025 at approximately 8:31 PM the Santa Monica Police Officer responded to a petty theft incident at the facility and interviewed R1, R2, and R4. On 11/18/2025, the facility was notified by the Culver City Police Department that S1 had been arrested, and residents were notified to retrieve their belongings. There is no documentation indicating that the facility reimbursed residents’ stolen property (stolen property not provided back to residents from the Culver City Police Department). Substantiated: Based on observations, interviews and record reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, appeal rights were reviewed, plans of corrections were developed, and a copy of this report was left with the Maintenance Director, Christian Rivera.the state’s words, verbatim · CDSS document, Sep 1, 2026 · control 11-AS-20251121141444

Type of visit: Case Management - Other

On 09/01/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit to deliver a case management technical advisory. LPA met with the Administrator Joe Saldana and the purpose of the visit was explained. LPA was granted entry to the facility. A technical assistance was observed during the course of the complaint investigation control number 11-AS-20251121141444 regarding contacting local law enforcement and reporting requirements. · According to a resident, two months prior to 11/2026 someone stole their personal belongings, and they informed facility staff (name unknown). Facility staff informed them to go to the police station and report it. Resident felt that it was wrong to tell them to go to the police and report it. · There are no unusual incident reports regarding said incident. An exit interview was conducted, and a copy of this report was provided to the Administrator Joe Saldana.the state’s words, verbatim · CDSS document, Sep 1, 2026

Allegation investigated: Staff are not ensuring resident attends medical appointments.

On 08/26/26 at 10:30 am Licensing Program Analyst (LPA) Villegas conducted an initialcomplaint visit regarding the allegation above. LPA met with Resident Services Director Hannah Mousa as the purpose of today’s visit was explained. The investigation consisted of the following: On 08/26/26 LPA Villegas obtained copies of the staff and resident rosters, facility transportation request form, and copies of the following documents for Resident #1-2 (R1-R2): Emergency ID forms, pre-appraisals, Physicians reports, needs and service plans, medication lists, and copies of any facility notes. On 08/26/26 from 10:40 am- 12:30 pm LPA conducted Interviews with resident #1-10 (R1-R10), and at 1pm- 2pm LPA conducted interviews with staff #1-5 (S1-S5). LPA conducted a review of R1's file. Unsubstantiated The allegation consisted of the following: Allegation: Staff are not ensuring resident attends medical appointments It is alleged that resident in care has not shown up to their last 3 medical appointments. On 08/26/26 from 10:40 am- 12:30 pm LPA conducted Interviews with R1-R10 regarding the allegation above. 7 of the 10 residents denied the allegation above and reported they do not refuse to attend scheduled medical appointments, 2 of the 10 residents reported having no knowledge of the allegation as they do not have scheduled medical appointments to attend, 1 of the 10 residents confirmed the allegation above and reported they have not attended their medical appointments because they do not like the treatment and believe they do not need it. Additionally, 1 of the 10 residents reports it is their right to decide if they want to go or not. 8 of the 10 residents interviewed reported receiving medical services outside of the facility, 2 of the 10 residents reported they do not receive services outside of the facility. 6 of the 10 residents reported having their own transportation service such as Access, 2 of the 10 residents reported that they facility provides transportation to medical appointments, 2 of the 10 residents reported they do not require transportation. On 08/26/26 from 1pm- 2pm LPA conducted interviews with S1-S5 regarding the allegation. 5 of the 5 staff interviewed denied the allegation above and stated that residents are reminded the day before and the day of of the upcoming appointment. Additionally, staff report that the facility provides transportation to residents that request it at the front desk. On 08/26/26 LPA conducted a review of R1's file, R1 if self responsible. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 11-AS-20260821112736

Allegation investigated: Staff did not ensure resident's room was free of pests.

On 08/26/26 at 10:30 am Licensing Program Analyst (LPA) Villegas conducted an initialcomplaint visit regarding the allegation above. LPA met with Resident Services Director Hannah Mousa as the purpose of today’s visit was explained. The investigation consisted of the following: On 08/26/26 LPA Villegas obtained copies of the staff and resident rosters, facility cleaning schedule, Orkin pest control reports, Extermination pest control Inc. reports, and copies of the following documents for Resident #1-2 (R1-R2): Emergency ID forms, pre-appraisals, Physicians reports, needs and service plans, medication lists, and copies of any facility notes. On 08/26/26 from 10:40 am- 12:30 pm LPA conducted Interviews with residents #1-10 (R1-R10), from 1pm - 2pm LPA conducted interviews with staff #1-6 (S1-S6). Unsubstantiated On 08/26/26 LPA conducted a review of Orkin pest control reports, Extermination pest control Inc. reports, and conducted a tour the facility. The investigation revealed the following: allegation: Staff did not ensure resident's room was free of pests. it is alleged that for the past several weeks there has been a rat problem at the facility. On 08/26/26 from 10:40 am- 12:30 pm LPA conducted Interviews with R1-R10 regarding the allegation above, 5 of the 10 residents denied the allegation above, 4 of the 10 residents confirmed the allegation above and reported seeing mice inside the facility, 1 of the 10 residents reported seeing a mouse in the outside patio. 2 of the 10 residents stated that they have reported pest to the staff, 3 of the residents stated they did not report the pest to the staff, 4 of the 10 residents stated that they have not had anything to report. Additionally, 8 of the 10 residents reported that the facility does have pest control come out to the facility however 2 of the 8 residents stated they do not believe that pest control services have been effective. 1 of 10 residents reported that they have not observed pest control services at the facility, 1 of the 10 residents stated they are unaware of pest control visits the facility. On 08/26/26 from 1pm - 2pm LPA conducted interviews with S1-S6 regarding the allegation above. 4 of the 6 staff confirmed the allegation above and stated that residents have reported pest in their bedrooms and the front desk and the maintenance department is made aware. 2 of the 6 staff denied the allegation above. per 6 of 6 staff resident bedrooms are cleaned once a week but trash is taking out everyday. 5 of 6 staff interviewed confirmed that the facility has pest control services come out regularly. 1 of the 6 staff stated that they are unaware if the facility has a pest control services. LPA conducted a review of the last Orkin pest control report dated: 07/16/26. Per report, liquid residual treatment was placed along the interior perimeter of the property, including the foundation, the doorways and interior perimeter of the units. The units that were treated were: 43, 33, 51,71, 73, and 21 upon request. No pest activity was noted in unit 21. Per Extermination pest control Inc. report dated: 07/21/26, Service for roaches conducted in units 32,39, and 73, service for roaches completed on perimeter behind appliances and the bathrooms. LPA conducted tour of facility and inspected bedrooms 25, 28, and 31, LPA observed bedrooms to be cluttered and to have food in open bags and containers on furniture. LPA did not observe any pest activity at the time of visit. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 11-AS-20260821121421

Allegation investigated: Staff are mismanaging resident's medication resulting in resident being hospitalized. Staff are not checking resident's insulin levels. Staff does not have a qualified skilled professional to provide resident with injections.

On 08/19/26, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather additional information regarding the above allegations. This report does not change the findings delivered on 07/28/26. LPA met with Executive Director Joe Saldana and Health & Wellness Director. Investigation consisted of the following: On 07/27/26, The Department obtained Personnel Record, Register of Residents, Resident #1 - #8 Notes and Incidents, After Visit Summary, July 2026 Work Schedule. LPA interviewed Staff #1 – 5 and Resident #1 – 6. On 07/28/26, the Department obtained R1’s Medication Administration Records (May 2026 – July 2026), Physician’s Telephone Order, R1’s Face Sheet and Emergency Info, Physician Order Form, Physician’s Report for Residential Care facilities for the Elderly, New Prescription Summary, After Visit Summary (03/03/26, 06/03/26, 07/10/26), Besht Wellness (02/26/26), Clinical Requisition (07/20/26), Medication Technicians’ Trainings, and interviewed Staff #6 - #10, Residents #7 - #10, and Witness #1. On 08/19/26, the Department obtained Personnel Record, Register of Residents, R1’s Medication Administration Record (July 2026) and interviewed Staff #5. Continue to LIC9099-C. Unsubstantiated Allegation: Staff are mismanaging resident's medication resulting in resident being hospitalized. It is alleged staff administered discontinued medication instead of the most recent prescribed (07/10/26) medication to Resident #1 (R1). Record review revealed the following: After Visit Summary (07/10/26) revealed R1’s active medications: Dorzolamide-timolo PF2-0.5%, Latanoprost 0.005%, and Lubricant eye drops 0.5%. Review of R1’s Notes & Incidents revealed R1 complained of blurry eyesight on 07/12/26 9:52 PM. Review of Clinical Requisition (07/20/26) revealed all eye drops to be discontinued except for Artificial tears, Cosopt eye drops 2-0.5%, and Latanoprost 0.005%. Review of Medication Administration Record (July 10, 2026 to July 31, 2026) revealed Dorzol/Timol Sol 2-0.5% Solution was administered 0 times after 07/10/26 and 11 times after 07/20/26. Medication was held from 07/13/26 06:13 to 07/24/26 16:03. Genteal Tear Sol Mod was give 16 times after 07/10/26 and 15 times after 07/20/26. Miebo Dro 1.3GM.ML was given 23 times after 07/10/26 and 0 times after 07/20/26. Simbrinza Sus 1-0.2% was given 6 times after 07/10/26 and 0 times after 07/20/26. Lantanoprost Sol 0.005% was administered 2 times after 07/10/26 and 10 times after 07/20/26. Hold until 07/20/26. Rhopressa Sol 0.02%. was administered 2 times after 07/10/26 and 0 times after 07/20/26. Lubricnt eye drop 0.5%. was administered 0 times after 07/10/26 and 0 times after 07/20/26 (hold 07/13/26 - 07/20/26).Email Correspondence (08/08/26) revealed R1 saw the ophthalmologist on 07/28/26 and the PRN Lubricnt Eye Drop was placed on hold 07/28/26 by the Primary Care Physician (PCP). On 07/28/26, LPA observed two of the three medications in stock. The PRN Artificial tears was out of stock. Interviews revealed the following: Eight out of eight staff interviews (S2 – S6, S9 – S10) disagree with the allegation. The Resident Service Director (S5) indicated the facility has to wait for the Primary Care Physician (PCP) to discontinue the medication and the PCP work directly with the pharmacy. In addition, the Pharmacy will place certain medications on hold until it is approved by the PCP, including hospital orders. In regards to the PRN artificial tears, S5 indicated the pharmacy did not have a refill order and received a verbal discontinuation by the Nurse Practitioner on 07/28/26. S5 indicated the Nurse Practitioner visits R1 monthly and also reviews the medication list. R1 goes to a lot of different specialists and they will prescribe different medications and send it directly to the pharmacy. Eight out of ten residents (R1 – R10) indicated they have not experienced staff medication errors that resulted in hospitalization. R1 indicated that the medication irritated R1’s eye because it was the wrong medication. Regarding the allegation, “Staff are mismanaging resident's medication resulting in resident being hospitalized,” based on record review, interviews, and observation, the preponderance of evidence standard has not been met, therefore the above allegation(s) is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Continue to LIC9099-C Allegation: Staff are not checking resident's insulin levels. It is alleged staff does check Resident #1 (R1) glucose levels before meals. Record review revealed the following: Review of R1's Physician Order Form (printed 02/25/26) revealed R1’s blood sugar is to be tested three times a day before meals and every day at bedtime (start 07/16/25). Interviews revealed the following: Seven out of eight staff interviews (S2 – S6, S8 – S10) disagree with the allegation. The Resident Service Director (S5) indicated residents have to go to the medication room to get tested before mealtime. R1 is independent, had a glucose testing machine in room, and also receive reminders to test glucose levels when R1 eats in room. S5 indicated the glucose levels are not recorded in the system. S6 indicated R1 does not come to down for breakfast sometimes S6 has to test R1’s glucose levels in R1’s room. Four out of five residents (R1 - R2, R4 – R6) indicated they disagree with the allegation. R7 – R10 does not have their glucose levels checked. Witness #1 (W1) indicated checking R1’s glucose weekly. Regarding the allegation, “Staff are not checking resident's insulin levels,” based on record review and interviews, the preponderance of evidence standard has not been met, therefore the above allegation(s) is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff does not have a qualified skilled professional to provide resident with injections Record review revealed the following: Review of Register of Residents revealed eight residents receive insulin injections. Interviews revealed the following: Five out of seven residents (R1– R7) indicated they do their own injections or a nurse comes to the facility to administer the injections. R1 indicated the MedTechs and Nurse assist with R1’s injections. Eight out of eight staff interviews (S2 – S6, S8 – S10) disagree with the allegation. The Resident Service Director (S5) and S6 indicated residents are responsible for their own injections with the exception of a few who see a Home Health Nurse. S5 indicated many residents are taking metformin. Interview with Licensed Vocation Nurse (W1) indicated W1 visits the facility weekly to assist seven to eight residents with injections, including R1. R1 receives Ozempic injections on Thursdays. Regarding the allegation, “Staff does not have a qualified skilled professional to provide resident with injections,” based on record review and interviews, the preponderance of evidence standard has not been met, therefore the above allegation(s) is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to the Executive Director Joe Saldana.the state’s words, verbatim · CDSS document, Aug 19, 2026 · control 11-AS-20260720122129

Allegation investigated: Staff mismanaged residents' funds. Staff did not allow resident to return back to the facility. Staff refused to return items back to the resident.

On 08/14/2026, at 1:00pm, the department conducted a subsequent complaint visit to the facility and was greeted by Joe Saldana, Administrator. The department explained the purpose of this visit was to complete the complaint investigation and deliver findings for the allegations mentioned above. On 5/21/2026, at 10:00am, the department conducted an initial complaint visit to the facility and was greeted by Joe Saldana, Administrator, and Hannah Mousa, Resident Services Director. The department explained the purpose of this visit was to gather facility files, interview staff and residents, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department conducted interviews with staff (S1-S2) and residents (R2-R10) and on 05/28/2026, the department interviewed resident (R1).The department received the following documents from the facility: Personnel Report (Dated: 05/06/2026), Resident Roster (Dated: 05/21/2026), Medical Assessment (Dated: 06/06/2025), Preplacement Appraisal (Dated: 11/15/2025), Identification and Emergency Information (Dated: No Dated)....... Report Continued On LIVC9099-C Unsubstantiated Admission Agreement (Dated: 10/28/2025), Service Plan (Dated: 10/28/2025), Incident Reports (Dated: 03/13/2026, 11/09/2025, 11/13/2025), Resident Assessment (Dated: 10/29/2025), Warning Notice (Dated: 02/24/2026), Notice to Pay Basic Services (Dated: 01/20/2026), Eviction Fax Confirmation (Dated: 01/26/2026), Proof of Service of Notice to Tenant (Dated: 01/26/2026), Application for 72-Hour Assessment & Evaluation (Dated: 03/12/2026), After Visit Summary (Dated: 11/13/2025), Rent Statement Balance Due (Dated: 04/30/2026), and Email Correspondence (Dated: 03/29/2026, 04/17/2026). The investigation revealed the following: Allegation #1- Staff mismanaged residents' funds. The details of the complaint alleged that the facility staff were asking for resident (R1) debit card to get their social security benefits for rent. On 5/21/2026, from 10:00am-2:00pm, the department interviewed staff (S1-S2), residents (R2-R10), and on 5/28/2026, the department interviewed resident (R1) regarding the allegation. 2 of 2 staff denied the allegation that Staff mismanaged residents' funds. All staff (S1-S2) stated that they have never requested resident (R1) debit card to pay rent. Staff stated that (R1) has not paid rent since their admission and they handled their own finances. Staff stated that they have never had access to (R1) funds to mismanage them. The department interviewed residents (R2-R10) about the allegation and 9 of 10 residents that were interviewed stated that the facility has never mismanaged any of their funds. While resident (R1) states the facility did mismanage their funds and (R1) admits that they haven’t paid any rent since their admission on 10/28/2025. The department reviewed the Rent Statement Balance Due (Dated: 04/30/2026), Notice to Pay Basic Services (Dated: 01/20/2026) and observed that the resident (R1) had not paid any rent since admission. Documents show that there was a balance due of $6,470.50 as of 03/01/2026. The department did not find any evidence that the facility had access to the residents’ funds and nor were they actively mismanaging them. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff mismanaged residents' funds. 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. Report Continued ON LIC9099-C The investigation revealed the following: Allegation #2- Staff did not allow resident to return back to the facility. The details of the complaint alleged that the facility staff had resident (R1) placed on a 51/50 hold (Involuntarily held for mental health challenges) and did not allow the resident to return to the facility. On 5/21/2026, from 10:00am-2:00pm, the department interviewed staff (S1-S2), residents (R2-R10), and on 5/28/2026, the department interviewed resident (R1) regarding the allegation. 2 of 2 staff stated that the resident was exhibiting aggressive behavior towards staff and other residents in the facility. Staff also stated that due to the nature of the residents escalating behavior and concern for the staff, residents, and (R1), a 51/50 hold was initiated. Staff also stated that they had given a warning letter to the resident on 02/24/2026 for verbal abuse, offensive language, and aggressive behavior towards staff and residents but things did not get any better. The department interviewed residents (R2-R10) about the allegation and 9 of 10 residents that were interviewed stated that they had left the facility but was allowed to return. They had no knowledge of why the facility might refuse them reentry. Resident (R1) stated that they believed their behavior did not warrant them from not returning to the facility. The department reviewed the Application for 72-Hour Assessment & Evaluation (Dated: 03/12/2026) that detailed history and escalated behavior of the resident, Incident Reports (Dated: 03/13/2026, 11/09/2025, 11/13/2025), and Warning Notice (Dated: 02/24/2026) and observed that the resident had an increase in aggressive and escalating behavior that precipitated in the need for a 51/50 hold of the resident. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff did not allow resident to return back to the facility without just cause. The department observed that the resident had escalating behavior that put the staff and other residents in danger, as noted in the application for a 51/50 hold. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. The investigation revealed the following: Allegation #3- Staff refused to return items back to the resident. The details of the complaint alleged that the facility staff refused to return items back to the resident (R1) after they left the facility. On 5/21/2026, from 10:00am-2:00pm, the department interviewed staff (S1-S2), residents (R2-R10), and on 5/28/2026, the department interviewed resident (R1) regarding the allegation. 2 of 2 staff denied allegation that Staff refused to return items back to the resident. Staff stated that the resident was given thirty days to get all of their belongings from the facility. Staff stated that the resident came and collected some of their items but left others. Staff also stated that they communicated through email advising the resident that if they did not get all of their belongings in thirty days, they could not hold them any longer. Report Continued On LIC9099-C The department interviewed residents (R2-R10) about the allegation and 9 of 10 residents that were interviewed stated that they had no knowledge of the facility not giving someone’s belongings back after they have moved or been evicted. While resident (R1) states that the facility still has some of their belongings. The department reviewed Email Correspondence (Dated: 03/29/2026, 04/17/2026) and observed that the resident requested that the facility bring their belongings to the address they were living at after they left the facility. The facility stated in the email that they could not do that and they (R1) were responsible for picking up their belongings. They also advised that the resident be aware that they have 30 days to get all of their belongings. The department also observed that (R1) acknowledges that they picked up most of their belongings within that timeframe but left some things. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff refused to return items back to the resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued for this complaint investigation. An exit interview was conducted with Joe Saldana, Administrator, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Aug 14, 2026 · control 11-AS-20260512102108

Allegation investigated: Staff stole residents’ personal belongings.

On 08/08/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegation listed above. LPA met with the Maintenance Director, Christian Rivera and the purpose of the visit was explained. LPA was granted entry to the facility. Substantiated Investigation consisted of the following: On 12/01/2025, interviews were conducted with Resident 1 (R1) to Resident 6 (R6). On 01/15/2026, interviews were conducted with R1, R2, R4, R5, R6, and Staff 2 (S2). On 03/24/2026, interviews were conducted with R1, R2, R4, and Staff 3 (S3) to Staff 6 (S6). On 04/03/2026, interviews were conducted with Witness 1 (W1) and Witness 2 (W2). Interviews were attempted with Staff 1 (S1) and Resident 7 (R7). Facility records reviewed consisted of Client Roster, Personnel Report dated 12/01/2025, Staff Schedule from 11/14/2025 to 11/25/2025, Staff Roster with contact information, and Facility Sketch. Staff 1’s (S1) records reviewed consisted of Position Description, General Handbook Acknowledgement, Identification Information, Personnel Record dated 07/21/2025, and other pertinent information. R1 to R7’s records reviewed consisted of Face Sheet and Emergency Information, Unusual Incident/Injury Report dated 11/22/2025, SOC341 Report of Suspected Dependent Adult/Elder Abuse dated 11/19/2026, and Resident Statements dated 11/28/2025. Police Reports reviewed consisted of Los Angeles County Sheriff’s Department (LASD) Booking Information, Culver City Police Department Report #25-0005809, Santa Monica Police Department Reports #25-109912, 25-10097, and 25-110099. Investigation revealed the following: Allegation: “Staff stole residents’ personal belongings”, it is being alleged that S1 stole residents' personal belongings. Interviews with R1 to R6 revealed the following: 1 out of 6 residents were unable to provide additional information. 5 out of 6 residents agreed with the allegation, furthermore, residents indicated that S1 stole from them and/or other residents in the facility, additionally, residents indicated that they were informed that S1 had been arrested, moreover, they were notified by the Culver City Police Department to retrieve their stolen items, in addition, residents indicated that the facility has not reimbursed them for the valuables that have not been returned to them. Interviews conducted with S2 to S6 revealed the following: 1 out of 5 staff were unable to provide additional information. 4 out of 5 staff agreed with the allegation, moreover, staff indicated that residents informed them that their personal belongings had gone missing and S1 was a suspect, furthermore, staff indicated that days later the Culver City Police Department called the facility informing them that S1 had been arrested and found with residents’ personal belongings. Records reviewed of the Staff Schedule for 11/2025, SOC341 Report of Suspected Dependent Adult/Elder Abuse dated 11/19/2026, Unusual Incident/Injury Report dated 11/22/2025, Los Angeles County Sheriff’s Department (LASD) Booking Information, Culver City Police Department Report #25-0005809, Santa Monica Police Department Reports #25-109912, 25-10097, and 25-110099 revealed the following timeline of events: S1 was on shift on 11/15/2025 from 10:00 PM to 11/16/2025 at 06:30 AM. On 11/26/2025 at approximately 9:00 AM, residents reported to staff that items had gone missing from their rooms and management immediately suspended the alleged suspect S1. On 11/26/2025 at approximately 8:31 PM the Santa Monica Police Officer responded to a petty theft incident at the facility and interviewed R1, R2, and R4. On 11/16/2025 at 6:10 PM, S1 was arrested by the Culver City Police Department and found to be in possession of R1 to R5’s and R7’s personal belongings such as, Identification Cards (IDs), bank cards, social security card, a phone, and so on. A criminal case against S1 has been filed for charges that include PC530.5(a) (identity theft) and PC530.5(c)(1) (possession of identifying information). On 11/18/2025, the facility was notified by the Culver City Police Department that S1 had been arrested, and residents were notified to retrieve their belongings. There is no documentation indicating that the facility reimbursed residents’ stolen property (stolen property not provided back to residents from the Culver City Police Department). Substantiated: Based on observations, interviews and record reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, appeal rights were reviewed, plans of corrections were developed and a copy of this report was left with the Maintenance Director, Christian Rivera.the state’s words, verbatim · CDSS document, Aug 8, 2026 · control 11-AS-20251121141444

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

Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the licensee did not comply with the section cited above by not safeguarding residents’ personal property and not reimbursing/replacing residents’ stolen property which posed potential safety or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Aug 8, 2026

Plan of correction: The Maintenance Director has agreed to return residents’ stolen property (property that was not returned to them from the Culver City Police Department) for R1 to R5 and R7. Email proof of correction to Socorro.Leandro@dss.ca.gov

Type of visit: Case Management - Other

On 08/08/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit to deliver a case management technical violation. LPA met with the Maintenance Director, Christian Rivera and the purpose of the visit was explained. LPA was granted entry to the facility. A technical violation was observed during the course of the complaint investigation control number 11-AS-20251121141444 regarding video surveillance. · There are video cameras throughout the facility, but they were in disrepair according to staff and residents (the video cameras do not record) due to that, video recordings were not provided to the department. · The facility plan was reviewed and there was no mention of video surveillance. · The admission agreement was reviewed and there is mention of continuous video surveillance in the facility. The licensee has an option of updating the plan of operation to include video surveillance or update the admission agreement to exclude video surveillance in the admission agreement. An exit interview was conducted and a copy of this report was provided to the Maintenance Director, Christian Rivera.the state’s words, verbatim · CDSS document, Aug 8, 2026

Allegation investigated: Staff mismanages resident's money Staff are unlawfully evicting resident in care

On 08/05/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced Complaint Visit to the facility listed above. LPA met with Joe Saldana, Executive Director, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today's visit, LPA interviewed Staff S4-S7 and interviewed Residents R4-R13. During an initial visit conducted on 06/17/2026, LPA interviewed Staff S1-S3, interviewed Residents R1-R3, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Identification and Emergency Information (dated 03/17/2026), Admission Agreement (dated 07/09/2025), Physician’s Report (dated 07/01/2025), Needs and Service Plan (dated 03/01/2026), Eviction Notice (dated 04/29/2026), Warning Notices (dated 03/12/2026), Proof of Service of Notice to Tenant (dated 04/29/2026), and Resident Statement Balance Due (dated 05/31/2026). The investigation revealed the following: Unsubstantiated Allegation: Staff mismanages resident’s money The allegation alleges that a resident observed charges on their statement that they did not authorize. During record review, LPA received and reviewed the Admission Agreement, dated 07/09/2026, and observed on page 47, Appendix G Resident Financial/Responsibility Form has R1 listed as the Responsible Party. On page 58, Appendix L Personal Rights of Residents, states residents shall have the personal right “to keep, have access to, and use their own personal possessions, including toilet articles, and to keep and be allowed to spend their own money.” On page 59 states they have the right “to manage their financial affairs.” Additionally, LPA received and reviewed Resident R1’s Medical Assessment for Residential Care Facilities for the Elderly, dated 07/01/2025, that indicates on page 5 that R1 is “able to manage own cash resources.” During interviews with Staff S1-S7, were asked if there have been any reports from residents whose finances they manage, regarding unauthorized charges to their personal accounts, seven (7) out of seven (7) stated no, there have been no reports from residents regarding unauthorized charges. Additionally, Staff S1-S7 were asked if any resident reported unauthorized charges to their personal accounts, two (2) out of seven (7) stated yes, there have been two (2) residents who reported unauthorized charges to their personal account. Staff S2 stated they offered the residents assistance by contacting the bank and the police to make a report. During interviews with Resident’s R1-R13, were asked if they have had any charges to their personal accounts that they did not authorize, two (2) out of thirteen (13) stated yes, they have had unauthorized charges to their personal accounts. Additionally, Residents’ R1 and R2 were asked if they have concerns that the unauthorized charges were made by a staff member, two (2) out of two (2) stated no, they have no concerns regarding staff being responsible for the unauthorized charges. Allegation: Staff are unlawfully evicting resident in care The allegation alleges that a resident has been evicted for money owed and staff will not allow a partial payment. During record review, LPA received and reviewed the Notice to Pay Basic Services Fees in Ten (10) Days or Quit in Thirty (30) Days noticed given to Resident R1 on 04/29/2026. LPA observed the notice includes the required information including the date the notice was issued, the effective date of the notice, the amount due to the facility for Basic Service Fees from 11/01/2025 through 04/29/2026, a list of recourses and referral services available to assist with finding new housing, a list of agencies to file a complaint with, and the Health and Safety Code 1569.683(a)(4). LPA received a billing statement dated 05/31/2026, for R1 indicating Past Balance Due, current Charges, payment Credits, and current Amount Due. Additionally, LPA received and reviewed Resident R1’s Admission Agreement, dated 07/09/2025, that state on page 14, section VII. Termination, under subsection B. Termination by Us, 1. Upon Thirty (30) Days Notice. We may terminate this Agreement upon thirty (30) day's written notice to you if any of the following events occur: a. Nonpayment of the rate for basic service (ie., the Monthly Fee, Care Fees, or other ancillary chargers) within ten (10) days of the due date. LPA received and reviewed a letter that was given to R1, dated 03/12/2026, regarding their Delinquent Amount and indicating R1 has not made arrangements for a payment plan. During interviews with Staff S1-S7, were asked if there have been any eviction notices issued to residents, five (5) out of seven (7) stated there are a few evictions in process due to non-payment. One (1) out of seven (7) staff stated they believe the residents have received warnings. One (1) out of seven (7) stated to their knowledge there has been no eviction notices issued. During interviews with Resident’s R1-R13, were asked if they have been issued an eviction notice, two (2) out of thirteen (13) stated yes, they were issued an eviction notice due to non-payment. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. During today's visit LPA did not observe or cite any deficiencies. An exit interview was conducted with Joe Saldana, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 5, 2026 · control 11-AS-20260610143752

Allegation investigated: Staff are mismanaging resident's medication resulting in resident being hospitalized. Staff are not checking resident's insulin levels. Staff does not have a qualified skilled professional to provide resident with injections.

On 07/28/26, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegations. LPA met with Executive Director Joe Saldana and Staff. Investigation consisted of the following: On 07/27/26, The Department obtained Personnel Record, Register of Residents, Resident #1 - #8 Notes and Incidents, After Visit Summary, July 2026 Work Schedule. LPA interviewed Staff #1 – 5 and Resident #1 – 6. On 07/28/26, the Department obtained R1’s Medication Administration Records (May 2026 – July 2026), Physician’s Telephone Order, R1’s Face Sheet and Emergency Info, Physician Order Form, Physician’s Report for Residential Care Facilities for the Elderly, New Prescription Summary, After Visit Summary (03/03/26, 06/03/26, 07/10/26), Besht Wellness (02/26/26), Clinical Requisition (07/20/26), Medication Technicians’ Trainings, and interviewed Staff #6 - #10, Residents #7 - #10, and Witness #1. Continue to LIC9099-C. Unsubstantiated Investigation revealed the following: Allegation: Staff are mismanaging resident's medication resulting in resident being hospitalized. It is alleged staff administered discontinued medication instead of the most recent prescribed medication to Resident #1 (R1). Record review revealed the following: Review of Physician's Telephone Order (02/23/26) revealed Rhopressa, Latanoprost, and Cyclosporine was prescribed. Review of Physician Order Form (printed 02/25/26) revealed: R1 to take Genteal Tear Sol Mod PF (start 05/19/25), Miebo Dro 1.3GM/ML (start 05/29/25), Simbrinaz Sus 1-0.2% (start 08/28/25), Systane Ultr Sol Pf (start 01/02/26), and Lantanoprost Sol 0.05% (start 08/28/25) were active. After Visit Summary (07/10/26) revealed R1’s active medications: Dorzolamide-timolo PF2-0.5%, Latanoprost 0.005%, and Lubricant eye drops 0.5%. Review of R1’s Notes & Incidents revealed R1 complained of blurry eyesight on 07/12/26 9:52 PM. On 07/15/26 9:20 PM, R1 complained about the eyedrops not being correct. Review of Clinical Requisition (07/20/26) revealed all eye drops to be discontinued except for Artificial tears, Cosopt eye drops 2-0.5%, and Latanoprost 0.005%. LPA observed two of the three medications in stock. The PRN Artificial tears was out of stock. Interviews revealed the following: Eight out of eight staff interviews (S2 – S6, S9 – S10) disagree with the allegation. The Resident Service Director (S5) indicated the facility has to wait for the Primary Care Physician (PCP) to discontinue the medication and they work directly with the pharmacy. The Nurse Pracitioner visits R1 monthly and also reviews the medication list. R1 goes to a lot of different specialist and they will prescribe different medications and send it directly to the pharmacy. Sometimes the pharmacy will double check with the PCP and sometimes the PCP tells them to move forward with the medication. S5 indicated that the hospitals will put medications on hold until the PCP approves it. Eight out of ten residents (R1 – R10) indicated they have not experienced staff medication errors that resulted in hospitalization. R1 indicated that the medication irritated R1’s eye because it was the wrong medication. Regarding the allegation, “Staff are mismanaging resident's medication resulting in resident being hospitalized,” based on record review, interviews, and observation, the preponderance of evidence standard has not been met, therefore the above allegation(s) is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Continue to LIC9099-C. Allegation: Staff are not checking resident's insulin levels. It is alleged staff does check Resident #1 (R1) glucose levels before meals. Record review revealed the following: Review of R1's Physician Order Form (printed 02/25/26) revealed R1’s blood sugar is to be tested three times a day before meals and every day at bedtime (start 07/16/25). Review of R1’s Notes & Incidents revealed R1’s glucose levels were tested before lunchtime (06/05/26), breakfast, dinner and bedtime (06/06/26), and breakfast (06/07/26). Interviews revealed the following: Seven out of eight staff interviews (S2 – S6, S8 – S10) disagree with the allegation. The Resident Service Director (S5) indicated residents have to go to the medication room to get tested before mealtime. S5 indicated the glucose levels are not recorded in the system. S6 indicated R1 does not come to down for breakfast. Sometimes S6 has to test R1’s glucose levels in R1’s room. Four out of five residents (R1 - R2, R4 – R6) indicated they disagree with the allegation. R7 – R10 does not have their glucose levels checked. Witness #1 (W1) indicated checking R1’s glucose weekly. Regarding the allegation, “Staff are not checking resident's insulin levels,” based on record review and interviews, the preponderance of evidence standard has not been met, therefore the above allegation(s) is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff does not have a qualified skilled professional to provide resident with injections Record review revealed the following: Review of Register of Residents revealed eight residents receive insulin injections. Review of R1’s Notes & Incidents revealed R1 self-administered insulin on 06/04/26 – 06/07/26. Interviews revealed the following: Five out of seven residents (R1– R7) indicated they do their own injections or a nurse comes to the facility to administer the injections. R1 indicated the MedTechs and Nurse assist with R1’s injections. Eight out of eight staff interviews (S2 – S6, S8 – S10) disagree with the allegation. The Resident Service Director (S5) and S6 indicated residents are responsible for their own injections with the exception of a few who see a Home Health Nurse. S5 indicated many residents are taking metformin. Interview with Licensed Vocation Nurse (W1) indicated W1 visits the facility weekly to assist seven to eight residents with injections, including R1. Continue to LIC9099-C. Regarding the allegation, “Staff does not have a qualified skilled professional to provide resident with injections,” based on record review and interviews, the preponderance of evidence standard has not been met, therefore the above allegation(s) is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted and a copy of this report was provided to the Executive Director Joe Saldana.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 11-AS-20260720122129

Allegation investigated: Staff are not providing resident with their records.

On 07/28/26, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Executive Director Joe Saldana and Staff. Investigation consisted of the following: On 07/27/26, the Department obtained Personnel Record, Register of Residents, Unusual Incident Report (03/13/26), Application for up to 72 hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (03/12/26), and Warning Letter (02/24/26). LPA interviewed Staff #1 – 5 and Resident #2 – 6. On 07/28/26, the Department obtained Face Sheet and Emergency Info, CalAIM Tier Level Assessment Form (10/24/25), Preplacement Appraisal Information (11/15/25), Medical Assessment (06/06/25), Notice of Pay Basic Services Fees in Ten Day or Quit in Thirty (01/20/26), Email Correspondence (04/17/26), and Email Correspondence (06/25/26). LPA interviewed Staff #6 - #8 and Resident #7 - #11. Note: Resident #1 no longer lives at the facility. Continue to LIC9099-C. Unsubstantiated Investigation revealed the following: Allegation: Staff are not providing resident with their records. It is alleged the facility is not providing Resident #1 (R1) with medical records. Record review revealed the following: Review of R1’s record includes CalAIM Tier Level Assessment Form (10/24/25), Preplacement Appraisal Information (11/15/25) and Medical Assessment (06/06/25). Review of Email Correspondence revealed R1 requested for inventory to be delivered (04/17/26). A former Staff informed R1 that R1 would need to pick up items within 30 days. Review of Email Correspondence (06/25/26) revealed R1 moved out on 03/16/26. R1 came back with a friend and spoke with former Staff and collected belongings. Executive Director indicated, per former Staff, R1 had already taken everything R1 wanted. Another former Staff looked in storage and did not find anything. Plus it was beyond thirty days. Interviews revealed the following: Five out of five staff interviews (S2 – S6) disagree with the allegation. The Executive Director (S1) and Resident Service Director (S5) indicated R1 has not requested documents but inventory items only. The Business Office Manager (S7) indicated R1 has not requested documents. Seven out of seven resident interviews (R2 - R3, R7 – R11) disagree with the allegation. Regarding the allegation, “Staff are not providing resident with their records,” based on record review and interviews, the preponderance of evidence standard has not been met, therefore the above allegation(s) is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to the Executive Director Joe Saldana.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 11-AS-20260720131801

Allegation investigated: Allegation: Staff did not ensure that the facility is free of pest.

On 7/22/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver the findings for the alleged allegation above. LPA met with Executive Director, Joe Saldana and he was informed of the purpose of the visit On 04/07/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced complaint visit to investigate the alleged allegation above. LPA met with Executive Director, Joe Saldana and he was informed of the purpose of the visit. The investigation consisted of the following: At 2:50 AM, LPA Bernadette requested a copy of staff roster dated 4/7/2026, resident roster, Orkin email correspondence dated 4/7/2026 regarding extensive extermination services (K-9) post and pre inspection which is pending management approval along with Bug free Central Inc, along with copies of ongoing contract with Orkin exterminators for all types of pests control from 4/11/2025 through 1/9/2026. Unsubstantiated invoices for treatments conducted on 1/15/2026 and 3/06/2026. LPA also conducted interviews with staff members (S1-S6) and residents R1-R6. The investigation revealed the following: Allegation #1: Allegation: Staff did not ensure that the facility is free of pest. On 4/7/2026, LPA reviewed documents showing that continuous pest control services have been conducted at the facility by Orkin Exterminating Service and Bug Free Central Inc. LPA received records dated from 1/15/2026 through 6/26/2026, which included extensive extermination services such as K-9 post and pre-inspections, along with documentation of rooms treated and heat treatment pending approval documents. The facility also maintains an ongoing contract with Orkin for monthly treatment and recommendations from 4/11/2025 through 1/9/2026. Interviews were conducted with Staff Members 1–6 (S1–S6), and 6 out of 6 staff members reported that there has been an ongoing problem with pests/bedbugs and action has been taken to resolve the problem. Staff stated the maintenance director Frank is informed and Orkin comes out to spray/ treat for bedbugs. Frank- maintenance director, stated that they have been taking measures to prevent the problem from worsening by having Orkin provide services as needed, in addition to the facility’s ongoing monthly contract. Frank also stated that extensive measures have been taken with K-9 and heat treatments which have been planned for the facility and were pending at the time of the visit on 4/7/2026, but have since been approved 4/24/2026. Interviews were also conducted with Residents 1–7 (R1–R7) and 5 out of 7 residents stated that they have experienced issues with pests/bedbugs in their rooms. Residents R1–R5 reported that maintenance staff and exterminators have been coming to their rooms weekly to address their concerns. When asked whether their rooms had been treated with heat treatments, they confirmed that they had. The remaining residents, R6 and R7, stated that they have not experienced any issues with pests/bedbugs in their rooms and that they see maintenance staff and exterminators in the facility on a regular basis. The documents reviewed are as follows: The Bug Free/Orkin contract indicates that K-9 and extensive heat treatment measures were authorized on 4/24/2026. A Pests/Bed Bug Service Preparation Sheet dated 5/8/2026 was also received, along with detailed documentation of the locations and rooms treated from 1/15/2026 through 6/26/2026. The administrator also confirmed that, as of 7/22/2026, there have been no reports of pests or bed bugs and the facility will continue to utilize Orkin Exterminators ongoing contract, services. Although there had been a problem with pests/bed bugs continuous action was taken on a regular basis and as needed along with extensive measures to resolve the problem. On 7/22/2026 LPA toured the following rooms 3,9,18 or 19. and did not observe bedbugs. Based on interviews, observations and documents reviewed during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Joe Saldana -Executive Director at conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 11-AS-20260406191122

Allegation investigated: Licensee does not ensure that facility is maintained in a good condition. Licensee does not ensure that the facility is kept free from mold. Licensee does not ensure that the facility is free of clutter.

On 7/22/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver the findings for the alleged allegations. LPA met with Administrator Joe Saldana- Administrator and LPA explained the purpose of the visit. The investigation consisted of the following: On 1/20/2026, LPA conducted interviews with Staff members 1-7 (S1-S7), Residents 1-8 (R1-R8) and attempted to interview residents 9-13 (R9-R13). LPA reviewed/obtained Orkin work orders from 4/11/2025 through 1/9/2026 which indicated there were treatments of rodents, and all other pests, along with a work order from Bug free Central Inc. Dated 1/15/2026 which also indicates services for bedbugs were provided on 1/6/2026. LPA toured the building and observed renovations being conducted throughout the facility and observed the following rooms 2,9,11,21,30,31,32, 39,43,45,46, 64,65,57,59,73, 80, and 86. Unsubstantiated The investigation revealed the following: Allegation 1: Licensee does not ensure that facility is maintained in a good condition. On 1/20/2026 LPA conducted interview with Staff members 1-7 (S1-S7) and 7 out of 7 staff stated that the facility is maintained in good condition residents rooms are cleaned daily and the facility common areas are cleaned throughout the day, however when issues or concerns need to be addressed the maintenance director Frank is informed, and the repairs are usually made immediately. Additionally, residents have not informed them of any issues/or concerns. LPA also conducted interviews with Residents 1-8 (R1-R8) and attempted to interview residents 9-13 (R9-R13). The interviews with residents R1-R8 revealed that they have not had any issues or concerns and when staff members are informed of a problem their issues or concerns are addressed. They also stated they believe the facility is maintained in good condition. On 1/20/2026, LPA did not observe any clutter, debris or obstructions throughout the facility or in residents’ rooms it appeared that the facility and rooms appeared to be maintained in good condition. Allegation 2: Licensee does not ensure that the facility is kept free from mold. On 1/20/2026 LPA conducted interview with Staff members 1-7 (S1-S7) and 7 out of 7 staff stated that there were leaks in the ceiling in three (3) rooms and mold was not observed, however the maintenance director Frank was informed, and the repairs were made immediately. LPA also conducted interviews with Residents 1-8 (R1-R8) and attempted to interview residents 9-13 (R9-R13). The interviews with residents R1-R3 revealed that there were leaks in their rooms but there was no visible mold and Frank was informed and repairs were immediately repaired. R4-R8 stated that they have not had any leaks or mold in their room. The remaining residents, R9-R13, were not available to be interviewed during the investigation. On 1/20/2026, LPA did not observe any of the following deteriorating dry wall scattered on the floor, clutter, or a visible hole in the ceiling, or mold growth on the ceiling surface throughout the facility or in residents’ rooms. It appeared that all repairs were made on or before 1/20/2026. Allegation 3: Licensee does not ensure that the facility is free of clutter. On 1/20/2026 LPA conducted interview with Staff members 1-7 (S1-S7) and 7 out of 7 staff stated that there are a few residents in the facility that will not always allow staff to assist with cleaning of their rooms, but residents are encouraged and informed of their agreement regarding keeping their living area free of clutter or obstructions and residents will usually allow them to assist in their presence. The 7 staff members stated that the facility and residents’ rooms are cleaned daily and the facility is cleaned throughout the day. LPA also conducted interviews with Residents 1-8 (R1-R8) and attempted to interview residents 9-13 (R9-R13). The interviews with residents R1-R8 revealed that their room is free of clutter, and they have not seen the facility with clutter additionally all 8 residents stated housekeeping cleans their room and the facility daily. The remaining residents, R9-R13, were not available to be interviewed during the investigation. On 1/20/2026, LPA did not observe any clutter, debris or obstructions throughout the facility or in residents’ rooms and it appeared that the facility and rooms appeared to be maintained in good condition. Record from the City of Santa Monica Community Development Department dated 1/15/2026 reflects that room 73 is habitable. Based on interviews, documentation and observations during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Joe Saldana- Administrator at conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 11-AS-20260113091403

Allegation investigated: Staff is physically abusing residents. Staff is verbally abusing residents. Staff is mismanaging resident's medications. Staff falsifies documents. Staff does not meet administrator requirements. Staff is operating out of scope of license.

On 7/14/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver the findings for the alleged allegations. LPA met with Administrator Joe Saldana- Administrator and he was explained the purpose of the visit. The investigation consisted of the following: On 10/10/2025 at 10:10 AM, LPA Allen requested the following documents: staff roster dated 10/10/2025 and resident roster. LPA also conducted interviews with staff members 1-8 (S1-S8) and resident 1-9 (R1-R9) ,conducted record review for resident 1-9 (R1-R9) pre-placement appraisals, medication administration records (MAR's) admissions agreement, and needs and service plans. There was also a review of records/files for 3 staff members who are listed as Administrators. Unsubstantiated The investigation revealed the following: Allegation 1: Staff is physically abusing residents. On 10/10/2025 at 10:10 AM, LPA conducted interviews with Staff members 1–8 (S1–S8) and 8 out of 8 staff members stated that they have not seen or heard of any resident being physically abused by a staff member, nor has any resident reported to them that they were physically abused in any way by a staff member. LPA also conducted interviews with Residents 1–9 (R1–R9) and 9 out of 9 residents stated that they have not been physically abused by any staff member in any way, nor have they heard another resident reports being physically abused by a staff member. During the investigation, while LPA was conducting interviews, LPA did not observe or hear any residents in care being physically abused in anyway by staff members. Allegation 2: Staff is verbally abusing residents. On 10/10/2025 at 10:10 AM, LPA conducted interviews with Staff members 1–8 (S1–S8) and 8 out of 8 staff members stated that they have not seen or heard of any resident being verbally abused by a staff member, nor has any resident reported to them that they were verbally abused in any way by a staff member. LPA also conducted interviews with Residents 1–9 (R1–R9) and 9 out of 9 residents stated that they have not been verbally abused by any staff member or in any way, nor have they heard another resident report being verbally abused by a staff member. During the investigation, while LPA was conducting interviews, LPA did not observe or hear any residents in care being verbally abused or abused in any way. Allegation 3: Staff is mismanaging resident's medications. On 10/10/2025 at 10:10 AM, LPA conducted interviews with Staff members 1–8 (S1–S8) and 5 out of 8 staff members stated that they are not aware of residents’ medications being mismanaged and believe that medications are administered to residents as prescribed by their physicians. The remaining 3 staff members stated that residents’ medications are given as prescribed by their physicians and that no concerns have been brought to their attention regarding residents not receiving their medications or medications being mismanaged by any staff member. When asked if residents’ medications are given daily, 8 out of 8 staff members stated yes. LPA also conducted interviews with Residents 1–9 (R1–R9) and 9 out of 9 residents stated that they have received their medications daily or as needed and do not believe their medications are being mismanaged by staff members. During the investigation, LPA reviewed 9 residents files and it appears that residents are receiving their medications as prescribed by their physicians. Allegation 4: Staff falsifies documents. On 10/10/2025 at 10:10 AM, LPA conducted interviews with Staff members 1–8 (S1–S8), and 8 out of 8 staff members stated that they are not aware of staff members falsifying documents of any kind, nor have they ever been instructed to falsify documents. Staff 1–3 (S1–S3) were asked directly whether they have ever falsified documents for any reason, and all three stated that they have never falsified documents, never directed any staff to falsify documents, and have never received such directives. They further stated that staff and resident files are updated as needed based on changes in condition. LPA also conducted interviews with Residents 1–9 (R1–R9), and 9 out of 9 residents stated that they are not aware of any staff members falsifying documents. When asked whether they have ever been asked to sign documents that were not applicable to them or their circumstances, 9 out of 9 residents stated no. During the investigation, the records/files for Residents 1–9 (R1–R9) were reviewed, including pre-placement appraisals, medication administration records (MARs), admission agreements, and needs and service plans. All documents appeared to be valid and signed by all required parties, and no discrepancies were observed. Allegation 5: Staff does not meet administrator requirements. LPA conducted interviews with Staff members 1–8 (S1–S8) and 6 out of 8 staff members stated that they assume the administrator is qualified to run the facility. S1 stated that they do meet the requirements as the administrator and S2 stated that the administrator does meet the requirements to serve as an administrator. LPA also conducted interviews with Residents 1–9 (R1–R9), and 9 out of 9 residents stated that they are not sure whether the administrator meets the requirements to operate as an administrator. During the investigation, files for the staff certified as administrators were reviewed, and 3 out of 3 staff members’ files showed that they have met the requirements to operate as administrators. Allegation 6: Staff is operating out of scope of license. LPA conducted interviews with Staff members 1–8 (S1–S8) and 8 out of 8 staff members stated that, to their knowledge, the facility is operating within the scope of its license and is not caring for any residents outside their license. LPA also conducted interviews with Residents 1–9 (R1–R9) and 9 out of 9 residents stated that they are unsure whether the facility is operating outside the scope of its license; however, they noted that many residents appear to have similar health concerns or issues and believe the facility is providing care to individuals with similar needs. During the investigation, including the pre-inspection file review and records reviewed, it was determined that the facility is operating in accordance with its plan of operation. Based on the evidence gathered, observations, and interviews conducted during the investigation, the above allegations are is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Joe Saldana Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 11-AS-20251005203158

Allegation investigated: Client sustained bruise and injury due to staff neglect or physical abuse. Staff did not provide healthful and comfortable accomodations

On 07/08/2026 around 10:00AM, Licensing Program Analyst (LPA) Jose Anguiano & Licensing Program Manager (LPM) Ulysses Coronel conducted an unannounced complaint investigation. The Department met with the Administrator Joe Saldana and the purpose of the visit was explained. The investigation consisted of the following: On 07/08/2026 around 10:00AM, The Department interviewed nine Residents (R1–R9) and seven staff members (S1-S7), including two witnesses (W1-W2). Reviewed facility records Staff roster & Resident roster, Medical emergency/911 log for R1, Incident reports of falls and hospitalizations between June 18th & July 8th, and R1-R3 resident files. The investigation revealed the following: Regarding the allegation resident sustained bruise and injury due to staff neglect or physical abuse it is being alleged that staff did not prevent residents from being physically abused while in care. Please see report continuation on (LIC9099-C) Unsubstantiated Interviews conducted revealed the following: 8 out of 9 Residents disagreed with the allegation. R1 indicated not knowing how the fall occurred and denied having any injuries. 7 out of 7 Staff disagreed with the allegation. 2 out of 2 Witnesses disagreed with the allegation. Observations revealed the following: During today’s visit the Department observed R1 walking independently and did not appear to be injured or in pain. Records review revealed the following: Incident reports of falls and hospitalizations between June 18th & July 8th did not indicate R1 having any medical emergencies. Review of R1 Medical emergency report indicates that on July 2nd at 10pm R1 called 911 when the police responded and there was no indication of a medical emergency. Based on the evidence gathered, interviews conducted, observations, and records reviewed, although the allegation “resident sustained bruise and injury due to staff neglect or physical abuse” 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. Regarding the allegation staff did not provide healthful and comfortable accommodations, it is being alleged that the facilities generators are too loud. Interviews conducted revealed the following: 7 out of 9 Residents disagreed with the allegation. 7 out of 7 Staff disagreed with the allegation. S1 indicated construction workers scheduled noise times take place from 10AM-3pm. S3 stated generator only activates when there is power failure. 2 out of 2 witnesses disagreed with the allegation. Observations revealed the following: During today’s visit the Department did not observe any loud noises inside the facility. Based on the evidence gathered, interviews conducted and observations although the allegation “Staff did not provide healthful and comfortable accommodations” may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. No deficiencies were cited in today’s visit. An exit interview was conducted, and a copy of this complaint report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 11-AS-20260702085008

Allegation investigated: Staff are not responding to residents call buttons in a timely manner. Staff did not ensure the plumbing was not in disrepair. Staff make inappropriate comments towards residents. Staff are not ensuring resident's room is kept clean. Staff are not meeting resident's showering needs.

On 06/24/26 at 10:00 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Resident Service Supervisor Nancy as the purpose of today’s visit was explained. The investigation consisted of the following: On 06/24/26 LPA Villegas obtained copies of the staff and resident roster, as well as the file for Resident 1 (R1). File for R1 could not be provided as there is no Resident in care with the name listed in the complaint. LPA conducted interviews with (5) staff members. The investigation revealed the following: On 06/24/26 LPA conducted interviews with (5) staff members, who stated that there is currently no Resident receiving services at the facility with the name listed in the complaint. On 06/24/26 LPA was permitted to review facility records for a Resident and based on the review of Facesheet, Preplacement appraisal dated: 03/31/26, admissions agreement dated: 03/31/26, and physicians Unfounded report dated:03/31/26, documents did not list the resident in question within the complaint. Based on interviews conducted and evidence gathered during the investigation, the above allegation is found to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and provided a copy of this report was provided to Resident Service Supervisor Nancy Conaty.the state’s words, verbatim · CDSS document, Jun 24, 2026 · control 11-AS-20260619152608

Allegation investigated: Resident was sexually assaulted by another resident.

On 06/17/26, the department conducted an unannounced subsequent complaint visit to deliver findings on the above listed allegation. The department met with Executive Director, Joe Saldana, and the purpose of the visit was explained. The department was granted entry to the facility. The investigation consisted of the following: On 02/11/26, the department received an Unusual Incident Report dated: 02/11/26 via fax. On 02/18/26, the department requested a copy of the staff and resident rosters. The department reviewed service records for residents #1-#4 (R1-R4) and requested a copy of the following documents: Face Sheet and Emergency Info, Service Plan, and Medical Assessment for Residential Care Facilities for The Elderly (LIC602A) for R1-R4. Additionally, the department conducted a tour of entire facility and observed the residents to identify any signs of neglect, abuse or other immediate health and safety threats. Continued on LIC9099-C Unsubstantiated On 02/24/26, the department obtained a copy of the Santa Monica Police Department report (dated: 02/11/26). Furthermore, the department conducted interviews with staff #1-#3 (S1-S3), and R1-R4. The investigation revealed the following: For the allegation: Resident was sexually assaulted by another resident. It is being alleged that on 02/10/26, R2-R4 were in R1’s room and that R2 sexually assaulted R1. On 05/20/26, and 05/26/26, the department conducted interviews with S1-S3. Of those interviewed, 3 out of 3 staff could not corroborate the allegation. 3 out of 3 staff said they observed R4 in the lobby area the entire night of 02/10/26. On 03/04/26, 03/18/26, 03/19/26, and 04/21/26, the department conducted an interviews with R1-R4. Of those interviewed, 3 out of 4 residents denied the allegation. R4 stated that on the night of the alleged assault, they spent the night in the lobby area of the facility. 4 out of 4 residents said they feel safe living in the facility, and that staff provide them with care and supervision. An Unusual Incident Report dated 02/11/26 reported that on 02/11/26 at approximately 12 PM, R1 reported to the facility’s Executive Director that they were sexually assaulted by R4 the night before. It states that police were contacted and responded to the facility to investigate. Santa Monica Police Department (SMPD) report (dated:02/11/26) was obtained and reviewed on 02/24/26, and revealed that on 02/11/26, SMPD officers responded to the facility to investigate the possible rape of R1 by alleged suspects R2-R4. Officers interviewed R1-R4, and R2-R4 denied the allegation and of being in R1’s room that night. R2-R3 reported being in their rooms, and R4 told officers that they were downstairs during that night, and not upstairs where R1’s room is located. No arrests were made. A review of R4’s Physician’s Report (dated: 02/06/26) revealed that R4 is non-ambulatory. Based on records reviewed, and interviews conducted, there is not enough evidence 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. An exit interview was conducted and a copy of the report was provided to Joe Saldana.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 11-AS-20260213165626

Type of visit: Required - 1 Year

On 06/15/26, Licensing Program Analysts (LPAs) Regina Cloyd and Bernadette Allen conducted an unannounced annual visit using the CARE Inspection Tool. LPAs met with Executive Director Joe Saldana and explained the purpose of today’s visit. The facility is licensed to serve one hundred seventy-four (174) non-ambulatory residents of which twenty-four (24) may be bedridden. Bedridden rooms limited to the first level rooms (10 – 12, 14 – 16, 27-32). The facility has a hospice waiver for thirty (30) residents. Three residents are receiving hospice services. Thirty-four residents are currently receiving home health services. Annual Fees are current. The facility is a two-story building. The first floor consists of a kitchen, dining room, beauty shop, reception area, card room, library, Executive Director’s office, linen storage room, north and south patio, north and south lounge, and resident rooms (1 – 12, 14 – 33). The second floor consists resident rooms (34 – 87). There is an underground parking garage that includes the laundry room and maintenance storage room. Executive Director accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed.Continue to LIC809-C. Resident bedrooms (2, 6, 7, 19, 27, 32, 34, 41, 60, 72, 73, and 79) had bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, a non-skid mat was in place, and water temperature measured between 105 – 116.6-degree Fahrenheit. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Extra comforters and linen are stored in a room near room 17 and in storage room #2 in the garage area. LPA tested emergency pull cords (rooms 34 and 116) and aiphone page to the front desk (room 41). LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives were kept in knife box in a secure kitchen. Emergency supplies are stored in the garage and in a storage closet on the first floor. First aid kit was available in the MedTech room. Fire extinguishers were observed on each floor. California Department of Forestry & Fire Protection conducted an annual fire alarm test on 05/22/26. LPA observed evacuation chairs in the stairwells. Ten staff records were reviewed; ten out of ten staff records had the required criminal record clearances or criminal record exemptions. Ten resident records were reviewed; ten out of ten resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. An exit interview was conducted, technical assistance provided and a copy of this report was discussed and left with VP of Operations Nirjara Acharya.the state’s words, verbatim · CDSS document, Jun 15, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure resident received medical treatment in a timely manner

On 5/13/2026 at 8:30 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a complaint investigation and deliver the findings for the alleged allegation above. LPA identified herself and met with Administrator Joe Saldana-administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 05/13/2026, the Department conducted interviews with staff members 1–3 (S1–S3) and attempted to interview resident 1-2 (R1-R2) but they were not in the facility at the time of the visit. The department also obtained and reviewed the 90-day move-out report, and the staff and client roster dated 5/13/2026. Continued Unfounded The investigation revealed the following: Allegation #1: Staff did not ensure resident received medical treatment in a timely manner The department conducted interviews with Staff Members 1–3 (S1–S3) and 3 out 3 staff members stated that Resident 1 (R1) has never lived at Savant of Santa Monica. The department attempted to interview R1; however, the facility rosters dated 5/13/2026 and 5/6/2026 did not list R1 as a resident. The department also attempted to interview Resident 2 (R2), but R2 was not in the community at the time of the visit. The Department received and reviewed the facility’s 90-day move-out report, which did not reflect that R1 had ever moved out of the facility, and no documentation could be provided to confirm that R1 had ever lived at the facility. Based on staff interviews and documentation reviewed, the allegation is determined to be Unfounded, meaning the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, the complaint is dismissed. An exit interview was conducted with Joe Saldana- Administrator and a copy of this report was provided at the conclusion of the visit, along with appeal rights.the state’s words, verbatim · CDSS document, May 13, 2026 · control 11-AS-20260506103448

Allegation investigated: Staff are verbally abusing resident Staff are psychologically abusing resident Staff are not feeding resident

On 05/13/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met with Executive Director Joe Saldana who was informed of the purpose of the visit. The investigation consisted of: On 5/6/2026, At 10:00 AM, LPA Allen requested the following documents: Staff roster dated 5/5/2026 and Resident roster. LPA also conducted a tour of the kitchen. There was a menu available for review, as well as an alternate menu posted on the door outside of the dining area. LPA observed that the menu coincided with the lunch being prepared for the day. During the kitchen tour, LPA observed that there was a 5 day supply of perishables and a 7 day supply of non perishables. Continued Unsubstantiated On 5/6/2026 At 12:15 PM, The department conducted interviews with thirteen (13) staff members and the department was successful in conducting interviews with residents 1–10 (R1–R10) and attempted interviews with residents 11–14 (R11–R14), who were not willing to have a conversation, and R15 who was interviewed at the end of the day on 5/6/2026. The investigation revealed the following: Allegation #1: Staff are verbally abusing resident The department conducted interviews with Staff Members 1-13 (S1-S13) and 13 out of 13 staff members stated that they have not experienced or overheard rumors of staff verbally abusing residents in care. The department was successful in conducting interviews with residents 1–10 (R1–R10) who stated the staff members have not been verbally abusing them. The department attempted interview residents 11–14 (R11–R14), but they were not willing to be interviewed. R15, who was available at the end of the visit was interviewed and they stated they have been verbally abused by the staff when asked who two (2) staff members names were given and it was stated that when their issues or concerns are told to them they try and make them think the problem is just in their head and not real. When asked to provide additional examples or details this information was not provided. During the tour of the facility, the LPA did not observe or hear any residents being psychologically or verbally abused by any staff member. Continued Allegation #2: Staff are psychologically abusing resident The department conducted interviews with Staff Members 1-13 (S1-S13) and 13 out of 13 staff members stated that they have not experienced or overheard rumors of staff psychologically abusing residents in care. The Department was successful in conducting interviews with Residents 1-10 (R1–R10) and 10 out of 10 residents interviewed stated that staff members have not been psychologically abusing them. The Department attempted to interview Residents 11-14 (R11–R14); however, they were not willing to be interviewed On 5/6/2026, R15, who was available at the end of the visit was interviewed and they stated they have been psychologically abused by staff members. When asked who was allegedly psychologically abusing them, R15 provided the names of two (2) staff members and stated that when issues or concerns are reported to these staff, they respond by making R15 feel that the problem is “just in their head” and not real. When asked to provide additional examples or further details, no additional information was provided. During the tour of the facility, the LPA did not observe or hear any residents being psychologically or verbally abused by any staff member. Allegation #3: Staff are not feeding resident The department conducted interviews with Staff Members 1-13 (S1-S13) and 13 out of 13 staff members stated that staff are ensuring that the residents in care are fed daily at least 3 meals a day and if residents are not able to come to the dining room tray service is provided to them by taking meals to their rooms. Continued The Department was successful in conducting interviews with Residents 1-10 (R1–R10) and 10 out of 10 residents interviewed stated that staff members are making sure they are fed daily when asked how often all 10 residents said 3 meals plus snacks. Residents also stated alternative options are available and additional portions can be requested and when requested or required food is taken to their rooms. The Department attempted to interview Residents 11-14 (R11–R14); however, they were not willing to be interviewed. On 5/6/2026, R15, who was available at the end of the visit was interviewed R15 stated that they have been fed but there have been times when they ask for food to be brought to them and other residents, and staff will have them waiting or don’t come bring food at all saying that they are just being encouraged to move for physical exercise which they can’t do all the time because of their health. When asked does this occurs regularly R15 said no. When asked for occurrences dates and individuals involved details were not provided. When asked if food is eventually provided R15 said yes. During the tour of the facility there was a menu available for review, as well as an alternative menu posted on the door outside of the dining area. LPA observed that the menu coincided with the lunch being prepared for the day. During the kitchen tour, LPA observed that there was a 5-day supply of perishables and a 7-day supply of non-perishables. Based on interviews, file review and observation during the investigation, the above allegations are found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Joe Saldana- Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, May 13, 2026 · control 11-AS-20260429090325

Allegation investigated: Unlawful eviction.

On 04/30/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to the above mentioned facility. LPA met with Executive Director Joe Saldana and the purpose of the visit was explained. LPA was granted access to the facility. The investigation consisted of the following: On 04/30/26, the department requested the following documents: Personnel Report (LIC500 dated 04/28/26), and resident roster. The department conducted a review of resident #1’s (R1) service records, and requested copies of the following documents: Admission Agreement (dated 11/26/25), Admission Record, House Rules (dated 11/26/25), Personal Rights (dated 11/26/25), Physician’s Report (LIC602 dated 11/24/25), Service Plan (dated 03/23/26), Face sheet and Emergency Information, Billing Agreement (dated 11/10/25), Acknowledgement of Prorated Charge and Monthly Rent (signed/dated 10/22/25), Resident Fund Management Service (signed/dated 02/09/26), Resident Ledger Report , and Balance Due Statement (dated 04/30/26). Unsubstantiated Additionally, the department conducted interviews with staff #1-#3 (S1-S3) and attempted to conduct an interview with R1. The investigation revealed the following: Allegation: Unlawful eviction. It is being alleged that a resident is being asked to leave the facility due to non-payment. On 04/30/26, the department conducted interviews with S1-S3. Of those interviewed, 3 out of 3 staff denied the allegation. An interview with S1 revealed that R1 owes approximately $5,000 or more in unpaid rent. S1 confirmed that no eviction notice has been issued and that all conversations regarding non payment have been verbal. On 04/30/26, the department attempted to conduct an interview with R1 but was unable to as they were out of the facility. A review of R1’s records was conducted on 04/30/26, and revealed the following: the Admission Agreement, House Rules, and Personal Rights forms for R1 were all signed on November 26, 2025. The department did not observe any Special Incident Reports (SIRs) related to R1. The department did not observe an Eviction Notice, because R1 was never issued one. A Resident Ledger Report, and a Balance Due Statement dated April 30, 2026, indicates that R1 has an outstanding balance of $6,195.10 owed to the facility. Based on records reviewed, and interviews conducted, there is not enough evidence 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. An exit interview was conducted and a copy of the report was provided to Joe Saldana.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 11-AS-20260421203404

Allegation investigated: Staff does not ensure resident is provided a bed in good repair

On 04/28/2026 at 8:43am, the Department conducted a initial complaint visit at the facility listed above to deliver the complaint findings for the allegation. During today’s visit, the Department met with Joe Saldana (Executive Director) and explained the purpose of the visit. The investigation consisted of the following: On 04/28/2026, the Department conducted interviews between 9:13am – 1:16pm with the Administrator (A1), Staff (S1–S11), and Residents (R1–R11). The Department also requested the staff roster (dated 04/28/2026) and resident roster (dated printed 04/28/2028). Report continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff does not ensure resident is provided a bed in good repair. It was alleged that the resident’s bed was removed due to the suspected infestation and that a replacement bed was not provided in a timely manner. As a result, the resident reportedly slept in a chair in a common area overnight. It was also alleged that the resident would not have an appropriate bed available upon returning to the facility after medical treatment. On 04/28/2026 between the hours of 9:13am – 9:48am, the Department interviewed Administrator (A1) regarding the allegation. A1 denied the allegation and stated becoming aware of the bed bug concern in room 86B on 04/21/2026 when the resident reported it. A1 stated that during the night of 04/21/2026 going into the morning of 04/22/2026, staff removed the resident’s from their bedroom to address the infestation, laundered the resident’s clothing, provided a shower, and supplied clean clothing. A1 stated the resident was immediately offered a temporary room (87A) with a bed, but the resident refused and chose to remain in the common area. A1 stated the resident later requested to go to the emergency room at the direction of her social worker and was transported on 04/22/2026. A1 stated the resident returned on 04/24/2026 and agreed to stay in temporary room 87A until room 86B could be treated. A1 stated the facility’s protocol requires a replacement or temporary bed to be provided immediately when a bed is removed and that pest control services were contacted to conduct heat treatment in all affected rooms. On 04/28/2026, between the hours of 11:48am – 1:16pm, the Department interviewed Staff (S1–S11) regarding the allegation. 2 out of 11 staff were unaware of the allegation. 9 out of 11 staff denied the allegation. Staff reported that the resident in room 86B was offered relocation to a temporary room with a bed. Staff stated the facility maintains multiple new replacement beds and that maintenance is responsible for bed replacement. Several staff reported that the resident chose to remain in the common area despite being offered a room with a bed. No staff reported that the resident was denied a bed or that a replacement bed was unavailable. Report continues on LIC 9099-C On 04/28/2026, between the hours of 10:00am – 12:08pm, the Department interviewed Residents (R1–R11) regarding the allegation. Based on resident interviews, 1 out of 11 residents confirmed the allegation, 7 out of 11 residents denied the allegation, and 3 out of 11 residents were unaware of the allegation. The resident who confirmed the allegation reported sleeping in the lobby due to not having a suitable bed available and stated they was instructed to continue sleeping in their bed despite K9 detection of bed bugs. The other residents who were unaware of the allegation did not report being without a bed nor bed not being in good repair. The remaining residents who denied the allegation expressed not experiencing any issues with their beds nor sleeping arrangements and mentioned feeling safe and comfortable in their rooms. On 04/28/2026, between the hours of 1:23pm - 1:45pm, the Department conducted a record reviews, a physical plant tour and observed the following: the Resident Roster (received & printed on 04/28/2026) verify the room assignment for all the residents who reside at the facility. The beds in Room 7A, Room 11A, Room 16, Room 30B, Room 78A, Room 86B, and Room 87A to be in good repair. Beds were observed to be intact, stable, and free of visible damage or safety hazards with the bed frames or mattresses being in good condition during the walk-through. Based on information gathered through interviews, record reviews and observation, there is not enough evidence 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 with Joe Saldana (Administrator) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 11-AS-20260422153130

Allegation investigated: Staff do not provide a safe and comfortable environment for resident in care. Staff do not meet the needs of residents. Staff do not ensure resident room was free of odors. Staff did not provide clean linens to resident in care. Staff yell at residents in care.

On 4/7/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver the findings for the alleged allegations above. LPA identified herself and met with Administrator Joe Saldana who was informed of the purpose of the visit. The investigation consisted of the following: On 12/10/2025, the department attempted to conducted interviews with Resident 1-12 (R1-R12); however only resident 1-2 (R1-R2) were intervied at the time of visit. On 12/11/2025,the department successfully interviewed R3–R9 and the remaining three (3) residents were unavailable for interviews at the time of the visit. The Department also conducted interviews with staff members 1–10 (S1–S10) and completed a facility tour. Observations included residents being in a safe and comfortable environment, resident rooms and common areas free of odors/hazards and staff maintaining and providing clean linens as well as observations of residents and staff interactions/communications during visit. Unsubstantiated The investigation revealed the following: Allegation 1: Staff do not provide a safe and comfortable environment for residents in care. The Department attempted to conduct interviews with twelve (12) residents, R1–R12, LPA successfully interviewed R1–R9 and One (1) out of the twelve (12) residents interviewed reported that staff do not provide a safe and comfortable environment. Residents R2–R9 stated that staff and housekeeping maintain a safe and comfortable environment by cleaning rooms daily, removing trash, vacuuming, and encouraging residents to dispose of unused or unwanted items to reduce clutter. The remaining three (3) residents were unavailable for interviews at the time of the visit. The Department also conducted interviews with staff members 1–10 (S1–S10), and ten (10) out of ten (10) staff members reported that residents are provided with a safe and comfortable environment by reminding and assisting residents to dispose of urinal contents after each use, encouraging the removal of unnecessary items, and ensuring rooms are cleaned daily by housekeeping, including trash removal and vacuuming. During the tour, LPA did observed staff assisting residents with care, providing medications, and performing housekeeping duties. Allegation 2: Staff do not meet the needs of residents. The Department attempted to conduct interviews with twelve (12) residents, R1–R12. LPA successfully interviewed R1–R9 and One (1) out of the twelve (12) residents interviewed reported that staff does not meet the needs of residents while residents R2–R9 reported that staff meet their needs by aiding with their Activities of Daily Living (ADLs), including administering medications daily or as needed. The remaining three (3) residents were unavailable for interviews at the time of the visit. The Department also conducted interviews with staff members 1–10 (S1–S10), and ten (10) out of ten (10) staff members reported that they assist residents with their ADLs, including administering medications daily or as needed. Staff stated that when staffing concerns arise, the facility contacts its staffing agency, Clipboard, to ensure adequate coverage. All ten (10) staff members reported that staffing levels typically include three (3) to six (6) caregivers assigned to the following shifts: 6:00 AM–2:30 PM, 2:30 PM–10:30 PM, and 10:30 PM–6:30 AM. LPA also obtained and reviewed the shift schedule, which reflected sufficient staffing at the facility. During the tour, LPA observed staff assisting residents with care, administering medications, and performing housekeeping duties Allegation 3: Staff do not ensure room was free of odors. The department attempted to conduct interviews with twelve (12) residents, R1–R12. LPA successfully interviewed R1–R9. One (1) out of nine (9) residents stated that staff does not ensure rooms are free of odors, while residents R2–R9 reported that staff does ensure their rooms and the facility remain free from odors and that staff regularly encourage them to dispose of unnecessary items and food to avoid gnats, smells, and other insects. The remaining three (3) residents were unavailable for interviews at the time of the visit. The department conducted interviews with staff members 1–10 (S1–S10), and ten (10) out of ten (10) staff members stated that they do ensure residents rooms are cleaned daily and that residents are encouraged to remove unnecessary items and food to prevent odors, gnats, insects, and clutter. During the tour of the facility, the department did not observe any obvious causes of foul odors or experience any foul odors in resident rooms or facility areas During the tour, the department also observed staff assisting residents with care, providing medications, and performing housekeeping duties nor were any gnats, insects, or clutter observed. 4. Staff did not provide clean linens to resident in care. The department attempted to conduct interviews with twelve (12) residents, R1–R12. LPA successfully interviewed R1–R9. One (1) out of nine (9) residents stated that staff did not provide clean linens to residents in care while residents R2–R9 reported that staff does provide clean linens as needed when accidents occur or as needed the remaining three (3) residents were unavailable for interviews at the time of the visit. The department also conducted interviews with staff members 1–10 (S1–S10), and ten (10) out of ten (10) staff members stated that residents’ linens are changed weekly or as needed. During the tour of the facility, LPA observed clean linens on residents’ beds, linens being washed in the laundry area, and an overflow of clean linens stored in the reception area. Allegation 5: Staff yell at residents in care. The department attempted to conduct interviews with twelve (12) residents R1–R12. LPA successfully interviewed R1–R9. One (1) out of nine (9) residents stated that staff yell at resident in care while residents R2–R9 reported that staff does not yell at residents in care the remaining three (3) residents were unavailable for interviews at the time of the visit. The department also conducted interviews with staff members 1–10 (S1–S10), and ten (10) out of ten (10) staff members stated they have not observed or heard any reports of staff yelling at residents. During the tour of the facility, LPA did not observe any staff members yelling or speaking inappropriately at residents in care. Continued Based on LPA’s interviews conducted, records reviewed, observations, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted where this report was discussed and provided to Joe Saldana- Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 11-AS-20251209121524

Allegation investigated: Staff does not ensure rodent issue is being treated properly for residents in care Staff does not ensure residents bathing needs are being met Staff does not ensure call buttons are answered in a timely manner

***This report supersedes the original report delivered on 12/10/2025 On 4/7/2026, LPA Allen arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 12/10/2025. *** On 12/10/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met with Administrator Nathaniel Venzon who was informed of the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with Resident 1-11 (R1-R11) and Staff members 1-6 (S1-S6). A review of Resident 1 (R1) file was reviewed which consisted of admissions agreement dated 12/26/2024, pre-placement, face-sheet, emergency information, physicians report 12/20/2024, needs and service plan date 7/2/2025, BugFree Central, Inc. work orders dated 8/14/2025, 8/27/2025, and Orkin Service contract dated 7/25/2025, and 8/22/2025. LPA also conducted a tour of the facility which consisted of the dining and kitchen area and nine (9) residents’ bedrooms 56,65,57,59,55,18,20, 25, and 16. Unsubstantiated The investigation revealed the following: Allegation 1: Staff does not ensure rodent issues are being treated properly for residents in care On 9/9/2025, LPA conducted interviews with Residents 1- 11 (R1–R11). Resident 1 (R1) stated they have seen rodents in their room and reported that exterminators have visited the facility on several occasions to address the rodent concern; however, rodents continue to be observed in their bathroom and closet areas. Interviews with R2, R3, R4, R5, and R6 indicated that they have heard about rodents but have not personally seen them. Interviews with R7, R8, R9, R10, and R11 indicated that they have neither heard about nor seen rodents in the building. LPA also conducted interviews with Staff Members 1- 6 (S1–S6). S1, S2, S3, and S4 stated that they have not seen rodents, but they have heard reports of rodents being in the building and Pest control have been at the facility to address the problem. Staff members 5-6 (S5- S6) stated that they have heard complaints about rodent sightings and have personally observed rodents in the facility. 6 out of 6 staff members confirmed that they have observed pest control services provided at the facility to address rodent concerns. LPA also conducted a tour of the facility which consisted of the dining and kitchen area and LPA didn't observe any visible holes in the walls and nine (9) residents’ bedrooms 56,65,57,59,55,18,20, 25, and 16 and there were no visible bugs/pest during the inspection. LPA also reviewed records from BugFree Central, Inc. work orders dated 8/14/2025, 8/27/2025, and Orkin Service contract dated 7/25/2025, and 8/22/2indicatenot indicated that (3) three of the resident’s rooms were treated only. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation 2: Staff does not ensure residents’ bathing needs are being met. On 9/9/2025 LPA conducted interviews with Residents 1- 11 (R1–R11). Residents 1-10 (R1-R10) stated they have received their showers on their scheduled shower days and if alternative measures are needed staff are willing to assist. LPA also conducted interviews with Staff Members 1- 6 (S1–S6) and 6 out of 6 staff members stated that there are times when R1 is not willing to be showed at their scheduled time or R1 may even decline a shower all together, but caregivers offer at least 3 times before alternate days or times are adjusted. LPA also observed the resident shower schedule, log/notes which appear that R1 and other residents bathing needs are being met by the staff. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation 3: Staff does not ensure call buttons are answered in a timely manner On 9/9/2025, LPA Allen conducted interviews with Residents 1–11 (R1–R11) and 1 out of 11 residents stated their call button does work but staff members take too long to assist them when called. When asked further, it was clarified that it can take staff too long to respond, which can take 15 minutes or longer when the call button was used. Residents 2-11 (R2-R11) denied the allegation, stated that the staff responded to their call button in a timely manner and stated their call buttons were in working condition during the visit. When asked how long the response time is 10 out of 11 said it can take 5-15 minutes before staff arrive and depends on if they are assisting others. LPA also conducted interviews with staff members 1-6 (S1-S6) and 6 out of 6 staff members stated that staff does ensure call buttons are answered in a timely manner. When asked how long the response time can be staff stated assistance normally happens between 5-10 minutes and if additional time is needed the receptionist is informed of the estimated time or another staff member is asked to assist. LPA observed the log for calls, and it appeared that staff members do respond to call buttons between 5-15 minutes The facility’s call log, dated August 30, August 31, and September 1 through September 8, 2025, was reviewed and revealed that staff members have responded within 5-15 minutes. Call buttons in rooms 56, 65, 57, 59, 55, 18, 20, 25, and 16 were tested and found to be in working condition. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Administrator Nathaniel Venzon at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 11-AS-20250905150543

Allegation investigated: Allegation 2: Staff inappropriately spoke to resident.

***This report supersedes the original report delivered on 12/10/2025 On 4/7/2026, LPA Allen arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 12/10/2025. *** On 12/10/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met with Administrator Nathaniel Venzon who was informed of the purpose of the visit. The investigation consisted of the following: On 9/9/2025, At 11:30 AM, LPA Allen requested the following documents: staff and resident roster dated 9/9/2025, LPA conducted interviews with Resident 1-11 (R1-R11) and Staff members 1-7 (S1-S7). LPA also requested that Brooke Lamotte-wellness director provided Resident 1 (R1) file which consisted of Continued..... Substantiated R1s admissions agreement 5/8/2025, pre-placement, face-sheet, emergency information, physicians report & needs and service plan dated 5/8/2025 by email on 9/10/2025. At 2:30PM LPA conducted a tour of the facility which consisted of the dining and kitchen area and nine (9) residents’ bedrooms 56,65,57,59,55,18,20, 25, and 16. The investigation revealed the following: Allegation 2: Staff inappropriately spoke to resident. On September 9, 2025, Licensing Program Analyst (LPA) conducted interviews with Residents 1- 11 (R1–R11). Resident 1 (R1) reported that Staff inappropriately spoke to them about matters that were unrelated to their care. Resident 2 (R2) stated that they also heard S1 speaking to R 1 inappropriately by making inappropriate comments that were unrelated to caregiving. Residents 3-11 (R3–R11) reported that they had not experienced being spoken to inappropriately by any staff members. On 12/10/2025, LPA attempted to interview Staff 1 (S1); however, S1 was unavailable during the investigation and did not respond to phone contact made. Staff 2 (S2) and Staff 3 (S3) reported that S1 admitted to speaking to Resident 1 (R1) inappropriately while providing care on 9/1/2025. They stated they were aware of the allegation and that an internal investigation had been initiated. During this investigation, S1 was placed on probation and later terminated for violating company policy and failing to complete the introductory period. Staff members S4, S5, S6 and S7 stated that they did not personally witness or hear S1 speaking inappropriately to R1, but they were aware of the incident through other sources. Continued....... On 9/9/2025, LPA reviewed email correspondence sent to S1 on 9/4/2025 and S1’s personnel file that Included a notice of suspension and notice of separation form dated 9/9/2025 which reflected that S1 failed to complete their introductory period of employment and violated company policy. The LIC624 received stated that the resident in care was inappropriately spoken to on 9/1/2025 and SOC341 which was self reported to Ombudsman. Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Continued ....the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 11-AS-20250905102718

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 10, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature..... This requirement was not met as evidenced by: Based on interviews and records reviewed it was determined that S1 was suspended on 9/1/2025 and separated from employment on 9/19/2025 for inappropriate workplace conduct and unprofessional interactions involving resident(s) R1.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: The POC was cleared during the visit on 9/9/2025. LPA was provided documents that shows S1 last day of work as 9/1/2025 which was signed by S1.

Allegation investigated: Staff did not safeguard residents' funds. Staff did not follow reporting requirements.

On 03/19/2026 at 9:56am, Licensing Program Analyst (LPA) Zina Brown conducted an subsequent visit at this facility to deliver the complaint investigation findings for the allegations above. During today’s visit, LPA met with Shiree McCutchen (Business Office Manager) and explained the purpose of the visit. The investigation consisted of the following: On 02/18/2026 at 8:50am, Licensing Program Analysts (LPA) Zina Brown conducted interviews with Staff (S1-S10) & Residents (R1-R11), between the hours of 9:30am - 12:31pm and requested the following documentation: Staff Roster (dated 02/05/2026), Resident Roster (received on 02/18/2026), Resident 1's (R1), records such as Admission Agreement (dated 10/10/2025), LIC 601: Identification & Emergency Information (01/01/2026), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (dated 10/10/2025 & 09/19/2025) , LIC 603: Preplacement Appraisal Information (dated 02/18/2026), Service Plan (dated 02/18/2026), Reappraisal (for R1), Medication Administration Record (December 2025 – February 2026), LIC 624: Unusual Incident/Injury Report (dated 02/11/2026) and Staff Schedule (01/17/2026 - 02/04/2026). Unsubstantiated Allegation: Staff did not safeguard residents' funds It was alleged that facility staff did not safeguard a resident's funds when the resident's bank account was accessed without authorization and all funds were withdrawn. It is suspected that a staff member at the facility, who had access to their personal information in their room, may have been responsible for the unauthorized access. On 02/18/2026 between the hours of 10:51am - 11:13am, LPA interviewed A1. A1 who denied the allegation and stated being aware of R1 reporting missing money from unauthorized bank account withdrawals activity. A1 also mentioned that R1 safeguard their own finances. A1 stated staff do not handle or have access to residents' checkbooks, PIN numbers, or bank cards, and that the facility's policy is to safeguard residents' personal and financial information. On 02/18/2026 between the hours of 9:30am - 12:14pm, LPA interview 10 staff regarding the allegation. 1 of 10 staff were aware of the incident. For the 1 staff who was aware of the incident stated that money was stolen from R1's account from May 2025 - January 2026. R1 did not authorize any of the transactions made during that time period. The facility assisted R1 with alerting their financial institution about the fraud transactions made. The facility & R1 discovered that the transaction made with the use of R1's account number and routing number. The financial institution advised for the a debit freeze by closing the account. R1 did close the old account but refused for the facility to take R1 back to the financial institution to create a new account.9 out of 10 staff denied the allegation and stated staff does not have any access to resident's personal banking information. Also none of the residents have reported missing money or unauthorized bank account access, and have no access to residents' financial information. On 02/18/2026 between the hours of 10:08am - 12:57pm, LPA interviewed 11 residents regarding the allegation. 7 of 11 residents denied the allegation and stated not having any money missing from their account. 1 of 11 residents mentioned that no staff have used their bank card. But did confirm unauthorized transaction were made but doesn’t believe the staff made any of the purchases using therr bank car because they keep their bank card with them at all times. 1 of 11 residents acknowledge that staff electronically withdrawal money from their account for payment of the rent. 2 of 11 residents did not confirm nor deny the allegation and stated not knowing of any money missing from their account. Based on information gathered through interviews and record reviews, there is not enough evidence 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 with Shiree McCutchen (Business Office Manager) and a copy of this report was provided. The investigation consisted of the following: Allegation: Staff did not follow reporting requirements It was alleged that facility staff did not follow reporting requirements when staff failed to file an Adult Protective Services (APS) report regarding a resident's bank account being accessed without authorization and all funds being withdrawn. On 02/18/2026 between the hours of 10:51am - 11:13am, LPA interviewed A1. A1 who denied the allegation and stated the facility did file a report regarding the incident that occurred R1. A1 mentioned that a report was filed and referenced a SOC 341 that was submitted. A1 indicated that the facility is required to report to APS, the Ombudsman, and CCL when a resident reports financial abuse and that the protocol also includes notifying law enforcement. On 02/18/2026 between the hours of 9:30am - 12:14pm, LPA interview 10 staff regarding the allegation. 1 of 10 staff were aware of the allegation and stated that the incident was faxed to Community Care Licensing. 7 of 10 staff were unaware of the allegation and stated not having any knowledge of the incident that occurred. 2 of 10 staff did not confirm nor deny the allegation and stated believe that Ombudman came out in regards to the incident that occurred. On 02/18/2026 between the hours of 10:08am - 12:57pm, LPA interviewed 11 residents regarding the allegation. 3 of 11 residents did not confirm nor deny the allegation and of the three (3), one (1) resident reporting to staff in July upon realizing money was gone from their account .not reporting anything but should. While another resident stated not having the opportunity to report anything due to nothing going wrong nor being stolen 8 of 11 residents denied the allegation who all stated if somethings goes wrong or if something is stolen and or missing would report to the front desk receptionist, caregivers, the executive director, and law enforcement. On 02/18/2026 between the hours of 1:30pm - 2:00pm, LPA conducted a record review and observed the following: The department received the LIC 624: Unusual Incident/Injury Report (dated 02/11/2026) and SOC 341 in regards R1's bank account being accessed without authorization and all funds being withdrawn. Based on information gathered through interviews and record reviews, there is not enough evidence 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.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 11-AS-20260212175852

Allegation investigated: Staff consumes alcohol while caring and supervising residents.

On 3/14/2026, at approximately 1:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez conducted a subsequent unannounced complaint visit. LPA Iniguez met Britney Phetbourom/Medtech. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: The department conducted the following interviews: Wellness Director Interview (A#1), Staff Interviews (S#1-S#4) and Residents Interviews (R#1-R#10). The department gathered the following documents: copy of facility resident roster dated: 1/29/26, copy of facility staff roster or LIC 500 dated: 1/9/2026, and copy of employee handbook dated: August 2025. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Allegation: Staff consumes alcohol while caring and supervising residents. The details of the complaint alleged that (S#1) left the facility during NOC shifts to purchase alcohol and returned with alcoholic beverages in various containers. On March 5, 2026, at 11:00 AM, during the records review, LPA Iniguez examined the August 2025 employee handbook. Under “Drug and Alcohol-Free Workplace,” the handbook states the facility has a program balancing respect for individuals with maintaining a drug- and alcohol-free environment. In addition, under “Prohibited Behavior,” the handbook lists use, possession, sale, trade, or offering for sale of alcohol or illegal drugs, or being impaired during job duties, as violations of the policy. Staff #1 (S1) acknowledged these statements. On March 5, 2026, at approximately 10:00 AM, during an interview with the facility administrator (A#1), he stated that staff are not permitted to leave the facility while on duty, including overnight (NOC) shifts. Staff may leave the premises only during designated breaks. (A#1) stated that the facility became aware of an allegation involving Staff #1 (S1) consuming or bringing alcohol onto the premises only a few days prior. The facility received an anonymous tip and began an internal investigation. NOC staff and residents were interviewed, and all denied the allegation. Evaluation Report continues LIC 9099-C... Also, (A#1) added that corporate was notified, and the Chief Human Resources Officer and Resident Services Director planned a surprise visit during the night of 03/05/2026, before 4:00 AM, to further investigate. (A#1) reported that the facility responded to the anonymous email with follow-up questions to validate the report but had not received a reply. The facility is prepared to conduct drug and alcohol testing if there is reasonable suspicion of impairment. In addition, (A#1) stated that supervisors are always present, a NOC Lead oversees overnight operations, and the facility is hiring a Resident Services Supervisor for the PM shift to further support staff performance and resident care. When asked about his understanding of the facility’s policies regarding (a) staff leaving the premises during a shift and (b) the possession or consumption of alcohol by staff, and how he ensures his actions align with those policies during NOC shifts, (A#1) reiterated that staff are allowed to leave only during scheduled breaks. (A#1) stated that leaving the facility and not returning during a scheduled shift is not permitted. On March 5, 2026, at approximately 11:30 AM, during interviews with residents in care (R#1–R#9), (9) out of (9) residents stated that they have only observed staff leaving the facility during the overnight hours when staff are on break to obtain food. Residents reported that, for the most part, staff remain on the premises and frequently order food for delivery rather than leaving the facility. In addition, Residents were asked if they had ever seen any facility staff with drinks or containers that appeared unusual or different from what staff normally bring to work during the overnight (NOC) shift. Evaluation Report continues LIC 9099-C... (9) out of (9) residents stated they have not observed any unusual drinks or containers in staff possession during this time. Residents were also asked whether they had observed anything concerning staff behavior, mood, or the way staff provided care during the NOC shift. (9) out of (9) residents reported no concerns, stating that staff behavior and care practices appeared normal and consistent during NOC hours. On 03/05/26, the Department attempted to contact Staff #1 (S#1) for an interview; however, (S#1) could not be reached because she worked the night shift and was unavailable for an interview. On 03/06/26, the Department made a second attempt to contact (S#1). During this attempt, the Department spoke with the Executive Director, who stated that (S#1) was no longer employed at the facility. On March 5, 2026, at approximately 11:00 AM, during interviews with facility staff members (S#2 through S#5), (4) out of (4) staff stated that they have not observed Staff #1 (S#1) leaving the facility before 2:00 a.m. Staff reported that when they previously worked the night shift, they never saw (S#1) leave during the NOC shift. In addition, staff were asked if they had ever seen (S#1) bring any beverages or containers into the facility that appeared to contain alcohol, or if they had observed any signs that (S#1) might have consumed alcohol while on duty. Evaluation Report continues LIC 9099-C... In addition, (4) out of (4) staff stated no, they have not observed (S#1) with any unusual or suspicious beverages or containers. Staff were also asked if they had noticed any changes in (S#1)’s behavior, performance, or interactions with residents during NOC shifts that raised concerns regarding staff conduct or resident supervision. (4) out of (4) staff reported no concerns, stating that when they previously worked NOC shifts with (S#1), they did not observe any behavior that appeared unusual or concerning. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Britney Phetbourom/Medtech.the state’s words, verbatim · CDSS document, Mar 14, 2026 · control 11-AS-20260226161929

Allegation investigated: Staff did not seek timely medical care for resident. Staff did not notify authorized representative of incident. Due to lack of supervision, resident fell resulting in a fracture.

** This report dated 03/02/2026 supersedes report dated 01/30/2026 and changes the findings for one allegation ** On 03/02/2026, Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit to deliver finding for the allegations listed above.The purpose of this visit was explained to the Administrator Joe Saldana and LPA Troy Watson was allowed entry into the facility. Investigation consisted of the following: On 11/05/2024 LPA Troy Watson requested and obtained the following: Facility Census 11/05/2024, Staff Schedule: October 2024, Unusual Incident Reports, VITAS Continuous Care Shift Care Notes for R1 dated 11/01/2024-11/03/2024, ID and Emergency Information for R1, Face Sheet for R1. CONTINUED ON LIC9099-C Substantiated Internal Occurrence Reports, Residence and Care Agreement for R1, California General Durable Power of Attorney for R1, Facility Census (11/05/2024), Physician’s Report for R1 (04/24/24). Physician Orders for Life‑Sustaining Treatment (POLST) for R1, Individual Service Plan from Assisted Living Waiver (ALW) Program (4/23/2024), Durable Power of Attorney for R1, and Assessment Tool generated by Carling Connection for the Assisted Living Waiver Program for R1 (4/23/2024). LPA Troy Watson interviewed Staff #1-#5 (S1-S5) and Residents #2-13 (R2-R13). An attempt to interview Resident#1 was made but (R1) was not available at the facility during the time of visit. Investigation revealed the following: Allegation:Staff did not seek timely medical care for a resident It is being alleged that facility staff failed to provide timely medical care after R1 experienced a fall, which resulted in hospitalization for a leg fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (A1). During the interview conducted on 11/17/2024, Administrator Narine Mertkhanyan (A1) stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. A1 also reported that R1 was in hospice prior to being admitted and continued hospice with a nurse periodically checking on her throughout the night. On 12/23/2025, LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 4 out of 5 staff members denied the allegation. On 12/23/2025, LPA Troy Watson interviewed Residents #2–13 (R2–R13). Out of those interviewed 12 out of 12 residents denied the allegation. LPA Troy Watson obtained and reviewed facility and medical records for R1. Per R1’s Face Sheet, R1 was admitted to the facility on 10/29/2024. A Facility Internal Occurrence Report dated 10/31/2024 states that a caregiver reported R1 had an unwitnessed fall, after which the Wellness Coordinator assessed R1 and noted scratches to the hand but no other injuries. Facility Notes and Alert Charting dated 11/01/2024 indicate that the caregiver reported that on 10/31/2024, R1 was found on the floor. The 11/01/2024 charting also notes that a body check was completed, revealing no injuries other than to the left hand, although R1 complained of leg pain. Facility Notes and Alert Charting dated 11/02/2024 documents that the hospice agency requested an X-ray. Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D CONTINUED ON LIC9099-C Allegation: Staff did not notify authorized representative of incident. This complaint alleges that staff failed to contact R1’s authorized representative after R1 was found on the floor. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (A1) regarding the facility’s response to R1’s fall. A1 stated that the fall in question was the only documented fall R1 experienced during her stay at the facility. On 12/23/2025, LPA Watson interviewed Staff #1–#5 (S1–S5). Out of those interviewed 5 of 5 staff members denied the allegation. On 12/23/2025, LPA Watson interviewed Residents #2–#13 (R2–R13). Out of those interviewed 12 out of 12 residents denied the above allegation. LPA Watson obtained and reviewed documentation and medical records pertaining to R1. Per facility notes / Alert Charting dated 11/04/2024, R1’s family was present at the facility on that date; however, no documentation was provided indicating that the facility contacted or notified R1’s authorized representative regarding R1’s fall. LPA Watson requested verification of communication to R1’s responsible party, but the facility was unable to provide any records showing that such notification occurred. Based on the lack of documentation confirming that R1’s authorized representative was notified of the fall, the allegation that staff failed to contact R1’s authorized representative is substantiated. Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. Allegation: Due to lack of supervision, a resident fell resulting in a fracture. It is being alleged that facility staff did not complete a proper assessment of resident#1 (R1) and had no knowledge of R1 being a fall risk, which led to R1 falling and sustaining a fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (administrator 1-A1) regarding the circumstances surrounding R1’s fall. A1 stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. LPA Troy Watson reviewed facility records. Facility provided department with a copy of the Assisted Living Waiver Individual Service Plan dated 04/23/2024, when R1 still lived in their own home, and it identified R1 as a fall risk. LPA Watson requested from the facility a Needs and Service Plan, Fall Risk Plan and Preplacement Appraisal but none were provided. On 12/23/2025 LPA Troy Watson interviewed Staff #1–5 (S1–S5). CONTINUED ON LIC9099 - C Out of those interviewed 4 out of 5 staff members denied the above allegation. On 12/23/2025 LPA Troy Watson interviewed Residents #2-#13 (R2-R13). Out of those interviewed 12 out of 12 residents denied the above allegation. LPA Troy Watson obtained and reviewed records for R1. Facility Internal Occurrence report dated 10/31 states caregiver reported that R1 had an unwitnessed fall. R1 was checked by Wellness Coordinator who noted scratches to R1’s hand but no other injuries. Per medical records from Ronald Reagan UCLA Medical Center, R1 was admitted to Ronald Reagan UCLA Medical Center on 11/04/2024 with a diagnosis of an acute distal fibular diaphysis transverse fracture with half-shaft-width lateral displacement of the distal fracture fragment. R1 was discharged to a skilled nursing facility on 11/08/2024. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. A $500 civil penalty was assessed previously on 01/15/2026. An exit interview was conducted with Administrator Joe Saldana and copies were provided.the state’s words, verbatim · CDSS document, Mar 2, 2026 · control 11-AS-20241104144122

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1)(g) · Plan of correction due date: Mar 2, 2026

Incidental Medical and Dental Care 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: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on interviews and records review, R1 experienced an unwitnessed fall on 10/31/2024, and despite telling staff their leg was injured, R1 was not seen by a physician until they were admitted to Ronald Reagan UCLA Medical Center on 11/04/2024 and diagnosed with a distal tibial and fibular diaphysis fracture. This violation posed an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: The licensee shall ensure that all staff are retrained on the facility’s policies and procedures regarding responding to changes in a resident’s condition and seeking timely medical care. Licensee will submit training plan to submitted to the Department via email or fax by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 2, 2026

Additional Personal Rights of Residents in Privately Operated Facilities In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure adequate supervision for Resident 1. Staff failed to provide the level of care and supervision necessary to meet the residents’ needs, which resulted in R1 experiencing a fall that caused a fracture. This lack of supervision posed an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: The licensee shall retrain all staff on intake assessments, appraisals and monitoring residents who are at risk of falls. Licensee will submit training plan to submitted to the Department via email or fax by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(b) · Plan of correction due date: Mar 2, 2026

Reporting Requirements. Requires the licensee to report specified incidents and to notify the resident’s authorized representative of events affecting the resident. Based on interviews and record review, the licensee did not notify Resident 1’s authorized representative after R1 was found on the floor, as required by 87211.On 11/05/2024 LPA Watson obtained and reviewed facility records and found no documentation that indicated that R1’s responsible party was contacted and made aware of R1’s fall on 10/24/2024.This violation posed an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: The licensee shall ensure that all incidents requiring notification are reported to the resident’s authorized representative in accordance with 87211. The Administrator will provide proof of staff training and reporting procedures, shall be submitted to CCL by the POC due date.

Type of visit: Case Management - Other

On February 17, 2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a case management visit to obtain documents. Upon arrival, LPA met with Business Office Manager Shiree McCutchen and explained the purpose of the visit. At 9:45 AM., LPA requested and received documents for Residents 1-3 (R1-R3) and the staff and resident roster dated 2/17/2026. ID and Emergency Information Admission Agreement Physicians Report Needs and Service Plans During the visit LPA Allen did not identify any health or safety concerns. An exit interview was conducted where this report was discussed and provided to Regional Resident Services Specialist Adriana Ruiz at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 17, 2026

Allegation investigated: Facility is not kept free of pests

On 2/11/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the alleged allegation. LPA identified herself and met with Executive Director Joe Saldana who was informed of the purpose of the visit. The investigation consisted of: At 9:00 AM, LPA Allen requested the following documents: Staff roster dated 2/5/2026 and Resident roster dated 2/11/2026. LPA conducted interviews with Resident 1-10 (R1-R10) and attempted interviews with Resident 11 and 12 (R11-R12). LPA Also conducted interviews with Staff Members 1-10 (S1-S10) and obtained work order documents from Bugfree Central Pest Control dated 10/15/2025 and 01/15/2026 listing details of treatments, locations treated in the building and recommendations to eliminate attractants to ensure effectiveness of exclusion measures. Orkin Service Reports dated for 1/9/2026 and 1/23/2026 with details of locations treated and recommendations. Continued Unsubstantiated LPA also conducted a tour of the facility which consisted of the hallways, staircase between the 1st and 2nd floors, and bedrooms 29,18,36,72,1,31,55, 59 and 62. The investigation revealed the following: Allegation 1: Facility is not kept free of pests On 2/11/2026, LPA attempted to interview residents 1(R1) and residents (R2) but they were not at the facility during the investigation. The interviews with R3- R12 (R3–R12) stated that they have not personally experienced seeing mice/pests themselves in their room or in the facility, but they have heard others complaining about seeing mice. When asked for details of who and when the mice sightings occurred the residents could not provide details. When asked, have they observed exterminators in the facility 10 out of 12 residents stated that they have seen exterminators at the facility often. LPA conducted interviews with staff members 1-12 (S1–S12) and 12 out of 12 staff members stated that they have not personally observed mice/pests within the facility; however, they have heard reports from residents regarding the presence of mice or other pests in the building/bedrooms. When asked whether pest control services have been utilized to address these concerns, all twelve staff members confirmed that they have observed pest control companies providing services at the facility to address mice/pests issues. LPA has also obtained work order documents from Bugfree Central Pest Control dated 10/15/2025 and 01/15/2026 listing details of treatments, locations treated in the building and recommendations to eliminate attractants to ensure effectiveness of exclusion measures. As well as Orkin Service Reports dated 1/9/2026 and 1/23/2026 with details of locations treated and recommendations. Continued The interviews conducted with staff and residents revealed that the administration staff has and will continue to have a plan in place utilizing their pest control measures to eliminate the mice/pest problems. LPA also conducted a tour of the facility which consisted of the hallways and staircase between the 1st and 2nd floors, bedrooms 29,18,36,72,1,31,55, 59 and 62. During the observations LPA did not see any signs of rodent droppings, holes in the walls or sightings of any mice/rodents during the inspection. Based on interviews conducted, records reviewed and observations, the preponderance of evidence standard has not been met. Which means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Joe Saldana Executive Director at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 11-AS-20260205100519

Type of visit: Case Management - Other

On February 11, 2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for Complaint Control Number 11-AS-20260205100519. During the investigation, LPA observed potential health and safety concerns involving Residents 1 through 6 (R1–R6). During the visit, LPA obtained several documents for Resident 1 (R1), including a Preplacement Appraisal dated January 6, 2026; patient results and plan from SoCal Hospital at Hollywood dated November 25, 2025; Needs and Service Plans dated February 2, 2026, and February 11, 2026; and current and prior Physician’s Reports dated September 24, 2025. LPA also collected seven Unusual Incident/Injury Reports dated December 19, 2025; December 28, 2025; January 10, 2026; January 14, 2026; January 19, 2026; and February 4, 2026, as well as a Resident Assessment and a report from Providence Saint John’s Health Center dated January 17, 2026. For Residents 2 through 6 (R2–R6), LPA obtained files that included Needs and Service Plans and Physician’s Reports. LPA requested home health notes for R1 that could not be provided at the time of LPA visit. LPA advised Angel Roman RSS that the notes could be emailed to LPA Allen by 2/13/2026. LPA informed Joe Saldana that further review of records and interviews may be necessary to determine whether immediate health and safety concerns exist and if corrective actions are required. A exit interview was conducted and the report was discussed and provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 11, 2026

Allegation investigated: Resident in care sustained multiple falls due to staff neglect/lack of supervision. Staff did not order a new oxygen generator for resident in care in a timely manner. Staff engaged in the misuse of the emergency 9-1-1 system.

On 2/4/2026, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met Jose Saldana/Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Wellness Director Interview (A#1), Staff Interviews (S#1-S#5) and Residents Interviews (R#1-R#10). LPA gathered the following documents: copy of facility resident roster dated : 1/29/26, copy of facility staff roster or LIC 500 dated: 1/9/2026, copy of (R#1-R#3)’s Medical Assessment or LIC 602A, copy of (R#1-R#3), copy of (R#1)’s Post fall assessment dated: 12/23/25, copy of (R#1) facility assessment, copy of (R#1)’s hospital discharge papers various dates and copy of (R#2)’s home health notes and copy of PIN 25-06-ASC. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Resident in care sustained multiple falls due to staff neglect/lack of supervision The details of the complaint alleged that (R#1) sustained multiple falls due to staff neglect and lack of supervision. On February 4, 2026, at approximately 11:00 AM, during the records review, LPA Iniguez examined a copy of (R#1)’s care plan dated January 20, 2025. The care plan indicates that (R#1) requires full assistance with transfers and mobility, including escorts for meals and activities, wheelchair use, fall risk assessment, and daily observation. The care plan reflects Level 179; the highest level of care provided at the facility. LPA Iniguez also reviewed (R#1)’s Post-Fall Assessment dated December 23, 2025, which is a checklist completed by facility staff after each incident to document and identify the cause of (R#1)’s falls. Additionally, LPA Iniguez reviewed (R#1)’s Medical Assessment (LIC 602A) and observed that it states (R#1) has a medical condition that predisposes them to falls. On February 4, 2026, at approximately 10:00 AM, during an interview with the Wellness Director (A#1), she stated that a fall-risk assessment and supervision plan is in place for (R#1). (A#1) explained that because (R#1)’s falls are related to seizures, the protocol requires staff to call 911 immediately when an incident occurs. (A#1) further stated that due to (R#1)’s medical condition, the emergency response system is programmed to activate in such situations. Regarding staffing levels and supervision, (A#1) reported that (R#1) receives routine checks every two hours and is on the highest level of care (Level 5). For example, in the morning, staff assist (R#1) with changing their incontinence products and transferring to a wheelchair before escorting them to the dining room for breakfast. After breakfast, staff provide another change and a shower, then escort (R#1) back for lunch, followed by additional changes and assistance throughout the day, including dinner. (A#1) emphasized that (R#1) is supervised by facility staff every two hours and as needed. Evaluation Report continues LIC 9099-C On February 4, 2026, at approximately 11:30 AM, during interviews with residents in care (R#1–R#10), (10) out of (10) stated that staff provide assistance when needed for moving or getting around. In addition, when asked whether they had ever fallen or felt unsafe because staff were not available to help, (10) out of (10) residents reported that any falls were due to their own medical conditions, not to staff's lack of availability or negligence. On January 29, 2026, at approximately 11:00 AM, during interviews with facility staff members (S#1 through S#5), (5) out of (5) stated that residents identified as high fall-risk are placed on an alert chart, which requires staff to check on them every two hours and as needed. Staff also reported that these residents wear a wristband indicating “fall risk” for easy identification. In addition, when asked what actions are taken after a fall incident, (5) out of (5) facility staff explained that they increase monitoring beyond the standard two-hour checks and inspect the resident’s environment to ensure there are no trip hazards. Allegation: Staff did not order a new oxygen generator for resident in care in a timely manner The details of the complaint alleged that facility staff did not order oxygen generator for (R#2) in a timely manner. On February 4, 2026, at about 11:00 AM, during the records review, LPA Iniguez examined (R#2)’s home health notes binder. The documentation shows the home health agency provides and maintains (R#2)’s oxygen supply and equipment, including the concentrator. The notes describe routine visits and monitoring by the agency. LPA Iniguez found no entries indicating the oxygen concentrator ran out of battery or stopped working. There were no reports of equipment failure, emergency interventions, or communication about oxygen supply issues between the facility and the home health agency. Evaluation Report continues LIC 9099-C On February 4, 2026, around 10:00 AM, the Wellness Director (A#1) stated that the facility monitors (R#2) the oxygen equipment, routinely checking battery life and functionality. Staff verify the oxygen concentrator is operating and the battery is charged each day. (A#1) confirmed (R#2) had no battery depletion or oxygen interruption. If issues arise, staff immediately contact the home health agency. When asked about vendor contact or interim measures such as portable tanks, (A#1) reiterated that there was no depletion and that the home health agency provides all necessary services. On February 4, 2026, at approximately 11:30 AM, during interviews with residents in care (R#1–R#10), (10 out of (10) stated that the facility provides their medical equipment and supplies when needed. When asked whether they had ever experienced delays in receiving something important for their health, such as oxygen or other medical equipment, (10) out of (10) residents responded that they had not. On January 29, 2026, at approximately 11:00 AM, during interviews with facility staff members (S#1 through S#5), (5) out of (5) stated that they have never observed (R#2)’s oxygen machine malfunction or stop working. When asked about the process for checking oxygen equipment and reporting issues such as low battery or malfunction, staff explained that they routinely monitor the equipment during their rounds and would immediately report any concerns to the Wellness Director and contact the home health agency for service. When asked what actions were taken when the oxygen generator stopped working, (5) out of (5) staff reiterated that (R#2)’s machine had never stopped working. Allegation: Staff engaged in the misuse of the emergency 9-1-1 system The details of the complaint alleged that facility staff misused the 9-1-1 system to send the (R#1, R#2 and R#3) to the hospital Evaluation Report continues LIC 9099-C LPA Iniguez also reviewed PIN 25-06-ASC: Calling 9-1-1 in Residential Care Facilities for the Elderly (RCFE), which provides guidance to licensees on appropriate responses to medical emergencies. The PIN states that licensees must immediately call 9-1-1 if an injury or circumstance poses an imminent threat to a resident’s health, such as a life-threatening medical crisis, severe difficulty breathing, chest pain, prolonged seizures, suspected head injury from a fall, or other critical conditions. The PIN further clarifies that the Department does not instruct or advise facilities to refrain from calling 9-1-1; rather, when there is any uncertainty about a resident’s condition or potential imminent threat to health, facilities should prioritize resident safety and call 9-1-1 to ensure appropriate medical attention. On February 4, 2026, at approximately 10:00 AM, during an interview with the Wellness Director (A#1), she stated that the facility has a policy in place for contacting emergency services (911). According to (A#1), if a resident experiences a fall or a medical concern, staff first assess the resident, notify the resident's primary care physician (PCP), and notify the responsible party. In most cases, the PCP determines whether the resident should be transported to the hospital via emergency services. When asked about the decision-making criteria and policy used to call 911 for (R#2) (cough/congestion, no acute distress) and (R#3) (equipment issue), (A#1) explained that the facility follows this protocol and acts based on the PCP’s recommendation or the resident’s immediate medical needs. Regarding non-emergent alternatives, (A#1) stated that the facility considers contacting the PCP, using on-call medical professionals, telehealth, same-day clinic visits, urgent care, or arranging non-emergency transportation to the hospital. However, if the resident requires immediate medical attention or the PCP advises emergency transport, the facility will utilize the 911 system. (A#1) emphasized that these decisions are made to ensure resident safety and timely access to care. Evaluation Report continues LIC 9099-C On February 4, 2026, at approximately 11:30 AM, during interviews with residents in care (R#1–R#10), (10) out of (10) stated that when they have a health concern, facility staff explain their options before calling 9-1-1 or sending them to the hospital. In addition, (10) of (10) residents confirmed that staff call 9-1-1 only when it is truly an emergency. On January 29, 2026, at approximately 11:00 AM, during interviews with facility staff members (S#1 through S#5), (5) out of (5) stated that when a resident requires medical assistance, they inform the MedTech on duty. Staff explained that before calling 9-1-1, the facility’s process includes notifying the Wellness Director, who assesses the resident’s condition and contacts the resident’s primary care physician (PCP) to determine the next steps. In addition, (5) out of (5) staff indicated that the decision to call 9-1-1 is based on the assessment and PCP recommendation, and emergency services are used only when immediate medical attention is necessary. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Joe Saldana/Executive Director.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 11-AS-20260126140413

Allegation investigated: Staff did not seek timely medical care for resident. Due to lack of supervision, resident fell resulting in a fracture.

On 1/29/26, (LPA) Troy Watson conducted a subsequent complaint visit for the allegations listed above. The purpose of this visit is to clarify findings rendered on 01/15/2026. The findings remain unchanged. This report supersedes the report created on 01/15/2026. LPA Watson explained to the Residence Service Coordinator Angel Roman the purpose of the visit. LPA Troy Watson was allowed entry into the facility. Investigation consisted of the following: On 11/05/2024 LPA Troy Watson requested and obtained the following: Facility Census 11/05/2024, Staff Schedule: October 2024, Unusual Incident Reports, VITAS Continuous Care Shift Care Notes for R1 dated 11/01/2024-11/03/2024, ID and Emergency Information for R1, Face Sheet for R1, Internal Occurrence Reports 10/31/2024, Residence and Care Agreement for R1, California General Durable Power of Attorney for R1, Facility Census (11/05/2024). Physician’s Report for R1 (04/24/24). CONTINUED ON LIC9099-C Substantiated Physician Orders for Life‑Sustaining Treatment (POLST) for R1, Individual Service Plan from Assisted Living Waiver (ALW) Program (4/23/2024), Durable Power of Attorney for R1, and Assessment Tool generated by Carling Connection for the Assisted Living Waiver Program for R1 (4/23/2024). LPA Troy Watson interviewed Staff #1-#5 (S1-S5) and administrator Narine Mertkhanyan (A1) and Residents #2-13 (R2-R13). An attempt to interview Resident#1 was made but (R1) was not available at the facility during the time of visit. Investigation revealed the following: Allegation: Staff did not seek timely medical care for a resident It is being alleged that facility staff failed to provide timely medical care after R1 experienced a fall, which resulted in hospitalization for a leg fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (A1). During the interview conducted on 11/17/2024, Administrator Narine Mertkhanyan (A1) stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. A1 also reported that R1 was in hospice prior to being admitted and continued hospice with a nurse periodically checking on her throughout the night. On 12/23/2025, LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 4 out of 5 staff members denied the allegation. On 12/23/2025, LPA Troy Watson interviewed Residents #2–13 (R2–R13). Out of those interviewed 12 out of 12 residents denied the allegation. LPA Troy Watson obtained and reviewed facility and medical records for R1. Per R1’s Face Sheet, R1 was admitted to the facility on 10/29/2024. A Facility Internal Occurrence Report dated 10/31/2024 states that a caregiver reported R1 had an unwitnessed fall, after which the Wellness Coordinator assessed R1 and noted scratches to the hand but no other injuries. Facility Notes and Alert Charting dated 11/01/2024 indicate that the caregiver reported that on 10/31/2024, R1 was found on the floor. The 11/01/2024 charting also notes that a body check was completed, revealing no injuries other than to the left hand, although R1 complained of leg pain. Facility Notes and Alert Charting dated 11/02/2024 documents that the hospice agency requested an X-ray. CONTINUED ON LIC9099-C LPA Troy Watson reviewed Vitas Hospice notes dated 11/01/2024 through 11/03/2024 which confirm that R1 remained at the facility during that period. On 11/04/2024, Facility Notes and Alert Charting indicate that R1’s family had R1 sent to UCLA. Records from Ronald Reagan UCLA Medical Center show that R1 was admitted on 11/04/2024, and X-rays taken upon admission showing an acute distal fibular diaphysis transverse fracture with half shaft width lateral displacement of the distal fracture fragment. No documents were provided by facility indicating any other medical interventions were provided by facility to R1 from the date of fall on 10/31/2024 to date of hospitalization on 11/4/2024.Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099D. Allegation: Due to lack of supervision, a resident fell resulting in a fracture. It is being alleged that facility staff did not complete a proper assessment of resident (R1) and had no knowledge of R1 being a fall risk, which led to R1 falling and sustaining a fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (administrator 1-A1) regarding the circumstances surrounding R1’s fall. A1 stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. LPA Troy Watson reviewed facility records. Facility provided department with a copy of the Assisted Living Waiver Individual Service Plan dated 04/23/2024, when R1 still lived in their own home, and it identified R1 as a fall risk. LPA Watson requested from the facility a Needs and Service Plan, Fall Risk Plan and Preplacement Appraisal but none were provided. On 12/23/2025 LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 4 out of 5 staff members denied the above allegation. On 12/23/2025 LPA Troy Watson interviewed Residents #2-#13 (R2-R13). Out of those interviewed 12 out of 12 residents denied the above allegation. LPA Troy Watson obtained and reviewed records for R1. Facility Internal Occurrence report dated 10/31 states caregiver reported that R1 had an unwitnessed fall. R1 was checked by Wellness Coordinator who noted scratches to R1’s hand but no other injuries. Per medical records from Ronald Reagan UCLA Medical Center, R1 was admitted to Ronald Reagan UCLA Medical Center on 11/04/2024 with a diagnosis of an acute distal fibular diaphysis transverse fracture with half-shaft-width lateral displacement of the distal fracture fragment. CONTINUED ON LIC9099-C R1 was discharged to a skilled nursing facility on 11/08/2024. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. A $500 civil penalty was assessed previously on 01/15/2026. An exit interview with Nathaniel Venzon was completed and a copy of this report was provided. California General Durable Power of Attorney for R1, Facility Census (11/05/2024), Physician’s Report for R1 (04/24/24). Physician Orders for Life‑Sustaining Treatment (POLST) for R1, Individual Service Plan from Assisted Living Waiver (ALW) Program (4/23/2024), Durable Power of Attorney for R1, and Assessment Tool generated by Carling Connection for the Assisted Living Waiver Program for R1 (4/23/2024). LPA Troy Watson interviewed Staff #1-#5 (S1-S5) and Residents #2-13 (R2-R13). An attempt to interview Resident#1 was made but (R1) was not available at the facility during the time of visit. Investigation revealed the following: Allegation: Staff did not notify authorized representative of incident. This complaint alleges that staff failed to contact R1’s authorized representative after R1 was found on the floor. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (A1) regarding the facility’s response to R1’s fall. A1 stated that the fall in question was the only documented fall R1 experienced during her stay. On 12/23/2025 LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 4 out of 5 staff members denied the above allegation. On 12/23/2025 LPA Troy Watson interviewed Residents #2-#13 (R2-R13). Out of those interviewed 12 out of 12 residents denied the above allegation. LPA Troy Watson obtained and reviewed documentation and medical records for R1. Per facility notes / Alert Charting dated 11/04/2024, R1’s family was present at the facility on 11/04/2024. No other notes were provided. Based on information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information gathered from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. An exit interview was conducted with Resident Service Coordinator Angel Roman and copies were provided.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 11-AS-20241104144122

Allegation investigated: Staff did not adequately address bed bugs in the facility

On 1/21/2026 Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver findings for the alleged allegation. LPA identified herself and met with Nathaniel Vezon-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 1/20/2026, LPA conducted interviews with Staff members 1-7 (S1-S7), Residents 1-8 (R1-R8) and attempted to interview residents 9-13 (R9-R13). LPA reviewed/obtained Orkin work orders from 4/11/2025 through 1/9/2026 which indicates there were treatments of rodents, and all other pests, along with a work order from Bugfree Cental, Inc. dated 1/15/2026 which also indicates services for bedbugs were provided on 1/6/2026. LPA toured the building and observed renovations being conducted throughout the facility and observed the following rooms 2,9,11,21,30,31,32, 39,43,45,46, 64,65,57,59,73, 80, and 86. continued..... Unsubstantiated The investigation revealed the following: On 01/20/2026, LPA conducted interviews with residents 1-8 (R1–R8) and attempted to interview residents 9-13 (R9–R13). Of those interviewed, R1 and R2 reported that they experienced bedbugs a few weeks ago. They stated that facility staff offered to relocate them to another room so that each affected room could be exterminated and furniture replaced. R1 stated they declined the move, while R2 stated they agreed to be relocated. Residents 3, 4, 5, 6, 7, and 8 stated they had only heard about other residents experiencing bedbugs but had not seen or experienced bedbugs in their own rooms. LPA attempted to interview residents 9, 10, 11, 12, and 13; however, they were not available. LPA toured their rooms and did not observe any bedbugs on the mattresses or box springs. LPA also conducted interviews with staff members 1 through 7 (S1–S7). and 7 out of 7 staff members stated they were verbally informed that some residents had seen bedbugs in their rooms. S1 stated they did not personally observe bedbugs in any resident’s room but were informed of the issue and that immediate action was taken by offering residents relocation so exterminators could treat the rooms. S1 stated R1 declined relocation, and R2 agreed to move. Continued...... S2 stated they observed signs of bedbugs in R1 and R2’s rooms and that Bugfree Central Inc. was contacted immediately to conduct an inspection and extermination. This service was provided in conjunction with Orkin’s monthly pest control services for other rodent and pest concerns. LPA obtained and reviewed records showing that the facility receives monthly pest control services. Additionally, a work order from BugFree Central, Inc., dated 01/15/2026, confirms that bedbug treatment was performed on 01/06/2026. Based on interviews and the reviewed documentation, the facility has taken immediate action and implemented an ongoing plan to address bedbug and other pest control issues. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated An exit interview was conducted where this report was discussed and provided to Nathaniel Venzon at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 11-AS-20260115134114

Allegation investigated: Staff is not ensuring the resident has an updated care plan to include a fall plan

On 1/20/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met withNathaniel Venzon-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with Resident 1-8 (R1-R8) and Staff members 1-8 (S1-S8). LPA conducted a review of Resident 1 (R1) file which consisted of admissions agreement, resident appraisal dated 3/14/2025, Connections Care Home Consultants Level Assessment Form dated 7/17/2025, face-sheet dated 12/23/2025, Medication Administration Records (MARS) for October-November 2025, physicians report dated 7/22/2025, needs and service plan dated 10/5/2025, and EMT note dated 11/2025. Continued Unsubstantiated The investigation revealed the following: Allegation: Staff is not ensuring the residents has an updated care plan to include a fall plan On 12/23/2025 LPA conducted interviews with Resident 1-8 (R1-R8). LPA attempted to interview R1; however, R1 was unavailable. R3 stated that they have experienced falls in the past and believe their care plan is current. Residents R2, R4, R5, R6, R7, and R8 stated they are unsure whether their care plans are up to date and stated that they have not experienced any falls, either previously or recently. LPA also interviewed staff members S1–S8, and 8 out of 8 staff members stated that each resident does have an update care plan on file which includes a fall plan if it applies to the resident. Staff members were also asked about the protocol regarding falls, and 8 out of 8 staff members stated that when a resident falls, the person who made initial contact with the resident makes observations and make sure the resident if ok or not, and contact is made with the medical technician (Medtech) or nurse on duty, who conducts a body check of the resident. If it is determined that any form of trauma is present, 911 is called immediately. Once the resident returns, and if necessary, their care plan is updated, staff are notified of required adjustments, and observations are made for the following 48-72 hours. During the visit LPA conducted a record review of eight (8) residents files which included needs and service plans, with physicians’ reports, and 8 out of 8 files appeared to be current. Based on LPA interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. which means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the report was provided to Nathaniel Venzon at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jan 20, 2026 · control 11-AS-20251218145535

Allegation investigated: Staff did not seek timely medical care for resident. Due to lack of supervision, resident fell resulting in a fracture.

On 01/15/2026 Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit for the allegations listed above. LPA Watson explained to the Administrator Nathaniel Venzon the purpose of the visit. LPA Troy Watson was allowed entry into the facility. Investigation consisted of the following: On 11/05/2024 LPA Troy Watson requested and obtained the following: Facility Census 11/05/2024, Staff Schedule: October 2024, Unusual Incident Reports, VITAS Continuous Care Shift Care Notes for R1 dated 11/01/2024-11/03/2024, ID and Emergency Information for R1, Face Sheet for R1, Internal Occurrence Reports 10/31/2024, Residence and Care Agreement for R1, California General Durable Power of Attorney for R1, Facility Census (11/05/2024). CONTINUED ON LIC9099-C Substantiated Physician’s Report for R1 (04/24/24), Physician Orders for Life‑Sustaining Treatment (POLST) for R1, Individual Service Plan from Assisted Living Waiver (ALW) Program (4/23/2024) , Durable Power of Attorney for R1, and Assessment Tool generated by Carling Connection for the Assisted Living Waiver Program for R1 (4/23/2024). LPA Troy Watson interviewed Staff #1-#5 (S1-S5) and administrator Narine Mertkhanyan (A1) and Residents #2-13 (R2-R13). An attempt to interview Resident#1 was made but (R1) was not available at the facility during the time of visit. Investigation revealed the following: Allegation: Staff did not seek timely medical care for a resident It is being alleged that facility staff failed to provide timely medical care after R1 experienced a fall, which resulted in a hospitalization for a leg fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (A1). During the interview conducted on 11/17/2024, Administrator Narine Mertkhanyan (A1) stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. A1 also reported that R1 was in hospice prior to being admitted and continued hospice with a nurse periodically checking on her throughout the night. On 12/23/2025, LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 5 out of 5 staff members denied the allegation. On 12/23/2025, LPA Troy Watson interviewed Residents #2–13 (R2–R13). Out of those interviewed 12 out of 12 residents denied the allegation.LPA Troy Watson obtained and reviewed facility and medical records for R1. Per R1’s Face Sheet, R1 was admitted to the facility on 10/29/2024. A Facility Internal Occurrence Report dated 10/31/2024 states that a caregiver reported R1 had an unwitnessed fall, after which the Wellness Coordinator assessed R1 and noted scratches to the hand but no other injuries. Facility Notes and Alert Charting dated 11/01/2024 indicate that the caregiver reported that on 10/31/2024, R1 was found on the floor. The 11/01/2024 charting also notes that a body check was completed, revealing no injuries other than to the left hand, although R1 complained of leg pain. Facility Notes and Alert Charting dated 11/02/2024 documents that the hospice agency requested an X-ray. LPA Troy Watson reviewed Vitas Hospice notes dated 11/01/2024 through 11/03/2024 which confirm that R1 remained at the facility during that period. On 11/04/2024, Facility Notes and Alert Charting indicate that R1’s family had R1 sent to UCLA Hospital. CONTINUED ON LIC9099-C Records from Ronald Reagan UCLA Medical Center show that R1 was admitted on 11/04/2024, and X-rays taken upon admission showing an acute distal fibular diaphysis transverse fracture with half shaft width lateral displacement of the distal fracture fragment.. No documents were provided by facility indicating any other medical interventions were provided by facility to R1 from the date of fall on 10/31/2024 to date of hospitalization on 11/4/2024. Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099D. Allegation: Due to lack of supervision, a resident fell resulting in a fracture. It is being alleged that facility staff did not complete a proper assessment of resident 1 (R1) and had no knowledge of R1 being a fall risk, which led to R1 falling and sustaining a fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (administrator 1-A1) regarding the circumstances surrounding R1’s fall. A1 stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. LPA Troy Watson reviewed facility records. Facility provided department with a copy of the Assisted Living Waiver Individual Service Plan dated 04/23/2024, when R1 still lived in their own home, and it identified R1 as a fall risk. LPA Watson requested from the facility a Needs and Service Plan, Fall Risk Plan and Preplacement Appraisal but none were provided. On 12/23/2025 LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 5 out of 5 staff members denied the above allegation. On 12/23/2025 LPA Troy Watson interviewed Residents #2-#13 (R2-R13). Out of those interviewed 12 out of 12 residents denied the above allegation. LPA Troy Watson obtained and reviewed records for R1. Facility Internal Occurrence report dated 10/31 states caregiver reported that R1 had an unwitnessed fall. R1 was checked by Wellness Coordinator who noted scratches to R1’s hand but no other injuries. Per medical records from Ronald Reagan UCLA Medical Center, R1 was admitted to Ronald Reagan UCLA Medical Center on 11/04/2024 with a diagnosis of an acute distal fibular diaphysis transverse fracture with half-shaft-width lateral displacement of the distal fracture fragment. R1 was discharged to a skilled nursing facility on 11/08/2024. CONTINUED ON LIC9099-D At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. An exit interview with the Nathaniel Venzon was completed and a copy of this report was provided. Physician Orders for Life‑Sustaining Treatment (POLST) for R1, Individual Service Plan from Assisted Living Waiver (ALW) Program (4/23/2024) , Durable Power of Attorney for R1, and Assessment Tool generated by Carling Connection for the Assisted Living Waiver Program for R1 (4/23/2024). LPA Troy Watson interviewed Staff #1-#5 (S1-S5) and Residents #2-13 (R2-R13). An attempt to interview Resident#1 was made but (R1) was not available at the facility during the time of visit. Investigation revealed the following: Allegation: Staff did not notify authorized representative of incident. This complaint alleges that staff failed to contact R1’s authorized representative after R1 was found on the floor.On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (A1) regarding the facility’s response to R1’s fall. A1 stated that the fall in question was the only documented fall R1 experienced during her stay.On 12/23/2025 LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 5 out of 5 staff members denied the above allegation. On 12/23/2025 LPA Troy Watson interviewed Residents #2-#13 (R2-R13). Out of those interviewed 12 out of 12 residents denied the above allegation. LPA Troy Watson obtained and reviewed documentation and medical records for R1. Per facility notes / Alert Charting dated 11/04/2024, R1’s family was present at the facility on 11/04/2024. No other notes were provided. Based on information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information gathered from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. An exit interview was conducted with Nathaniel Venzon and copies were provided.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 11-AS-20241104144122

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1)(g) · Plan of correction due date: Jan 16, 2026

Incidental Medical and Dental Care 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: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on interviews and records review, R1 experienced an unwitnessed fall on 10/31/2024, and despite telling staff their leg was injured, R1 was not seen by a physician until they were admitted to Ronald Reagan UCLA Medical Center on 11/04/2024 and diagnosed with a distal tibial and fibular diaphysis fracture. This violation posed an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The licensee shall ensure that all staff are retrained on the facility’s policies and procedures regarding responding to changes in a resident’s condition and seeking timely medical care. Licensee will submit training plan to submitted to the Department via email or fax by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 16, 2026

Additional Personal Rights of Residents in Privately Operated Facilities In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure adequate supervision for Resident 1. Staff failed to provide the level of care and supervision necessary to meet the residents’ needs, which resulted in R1 experiencing a fall that caused a fracture. This lack of supervision posed an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The licensee shall retrain all staff on intake assessments, appraisals and monitoring residents who are at risk of falls. Licensee will submit training plan to submitted to the Department via email or fax by POC due date..

Type of visit: Case Management - Deficiencies

On 1/15/26, Licensing Program Analyst (LPA) Felisa Shirley arrived at this facility to conduct a case management on complaint #11-AS-20250429151406 investigated on 5/8/25. On 1/13/26, LPA Shirley reviewed the Dispatched Call Logs from Santa Monica’s Office of Emergency Management from the facility listed above. The breakdown of number of calls to 911 from Savant of Santa Monica from May 2025 to October 2025 are as follows: May 25 calls made from the facility to 911 8 SIRS received in total from facility 7 SIRS total for 911 calls from facility Facility reports 13 faxes sent to CCLD Con'd on 809-C June 2025 30 calls made from the facility to 911 27 SIRS received in total from the facility 11 SIRS received for 911 calls from facility Facility Reports 34 faxes sent to CCLD July 2025 33 calls made from the facility to 911 15 SIRS received from the facility 9 SIRS total received for 911 calls from facility Facility reports 28 faxes sent to CCLD August 2025 39 calls made from the facility to 911 44 SIRS received from the facility 27 SIRS total for 911 calls. Facility reports 45 faxes sent to CCLD Con'd on 809C September 30 calls made from the facility to 911 30 SIRS received, 12 SIRS total for 911 calls Facility reports 23 faxes sent to CCLD October 28 calls made from the facility to 911 25 SIRS received, 14 SIRS total for 911 calls Facility reports 23 faxes sent to CCLD Based on the documents reviewed, staff at Savant of Santa Monica did not provide a written report and submit to CCLD within seven days of the occurrence. Deficiencies are being cited based on documents reviewed and interviews conducted in accordance with the California Code of Regulations, Title 22, Divisions 6 chapter 1, see LIC 809D. An exit interview was conducted, Plans of Corrections were discussed and a copy of this report and appeals rights were left with the Executive Director, Nathaniel Venzon whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jan 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jan 29, 2026

87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...of the occurrence of any of the events... (D) Any incident which threatens the welfare, safety or health of any... This requirement is not met as evidenced by: Based on record reviews, the Licensee failed to submit incident reports for every call that was made to 911 from facility. From May 2025 to October 2025, the facility made 185 calls to 911, but only submitted 80 incident reports regarding 911 calls. This violation poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The Executive Director shall provide a copy of an In-Service training regarding reporting incidents to CCLD within seven days of occurence by the POC due date of 1/29/26. Please forward copies of training to LPA Felisa Shirley at felisa.shirley@dss.ca.gov or fax to 424-544-1016.

Allegation investigated: Staff physically abused resident

On 12/29/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Savant of Santa Monica and was greeted by Director Brooke Lamotte (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S5, resident R1-R14. LPA Calderon obtained the following records: Email from Psychiatric Medical Group (dated 11/16/2025), Physician Report (dated 07/02/2025) for R1. LPA Calderon toured the facility with S1. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff physically abused resident. This complaint alleged that the facility staff abused residents in care. LPA Calderon noted staff serving breakfast to residents. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions between staff and residents. LPA Calderon reviewed the following records: The Physician Report (dated 07/02/2025) indicates that R1 lives independent life and has cognitive issues. Email reviewed (dated 11/16/2025) suggests that R1 has cognitive issues. Interviews indicate the following: 5 out of 5 staff deny the allegation. R1 cannot be interviewed due to not being in the facility. 13 out of 14 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff physically abused resident” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Director Brooke Lamotte (S1).the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 11-AS-20251223113746

Type of visit: Case Management - Other

On 12/16/2025 at approximately 09:30 AM Licensing Program Analyst (LPA) Troy Watson conducted an unannounced case management visit regarding complaint # 11-AS-20251209121524. The investigation between 09:30AM - 12:25PM the department met with the Administrator Nathan Venzon and during the visit the department requested the following records : Staff Roster 12/16/2025, Personnel Report 12/16/2025, Residence and Care Agreement 09/24/2025, Electronic Observation Chart 11/09/2025. An Exit interview was conducted with the Administrator Nathan Venzon and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 16, 2025

Allegation investigated: Staff is not meeting the needs of resident

On 12/11/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver the findings for the alleged allegation. LPA identified herself and met with Administrator Nathaniel Venzon who was informed of the purpose of the visit. The investigation consisted of the following: Allegation 1: Staff is not meeting the needs of resident. On 12/10/2025, LPA conducted interviews with Resident 1-2 (R1-R2). On 12/11/2025 LPA attempted to interview resident 3-5 (R3-R5) who were not available at the time of visit. LPA was able to conduct interviews with Resident 6-12 (R6-R12). Interviews were also conducted with staff members 1-10 (S1-S10). LPA also obtained and reviewed the needs & service plans, physicians report, and Medication Administration Records (MARS) for 12 residents. Unsubstantiated The investigation consisted of the following: Licensing Program Analyst (LPA) conducted interviews with twelve residents (R1–R12). 9 out of 9 residents stated that staff members are meeting their daily needs. The remaining three (3) residents were unavailable for interviews at the time of the visit. LPA reviewed documentation for Residents 1-12 (R1-R12) which included the Needs and Services Plans, Physician’s Reports, and Medication Administration Records (MARs). Based on this review, it appears that facility staff are appropriately meeting the needs of residents in care. Additionally, LPA interviewed staff members 1-10 (S1–S10) and 10 out of 10 staff members stated that they are capable of meeting the needs of the residents. They also stated that, in the event of staffing concerns, the facility contacts the staffing agency, Clipboard, to ensure adequate coverage. All ten staff members reported that staffing levels typically include three (3) to six (6) caregivers scheduled for each shift: 6:00 AM – 2:30 PM, 2:30 PM – 10:30 PM, 10:30 PM – 6:30 AM LPA also obtained and reviewed the shift schedule and it appears that there is sufficient staff at the facility. Continued..... Additionally, there are two (2) Medication Technicians assigned to each shift. Based on LPA’s interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted where this report was discussed and provided to Nathaniel Vezon Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 11-AS-20251204085354

Allegation investigated: Allegation 1: Staff physically abused resident

On 12/10/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met with Administrator Nathaniel Venzon who was informed of the purpose of the visit. The investigation consisted of the following: On 9/9/2025, At 11:30 AM, LPA Allen requested the following documents: staff and resident roster dated 9/9/2025, LPA conducted interviews with Resident 1-11 (R1-R11) and Staff members 1-6 (S1-S6). LPA also requested that Brooke Lamotte-wellness director provided Resident 1 (R1) file which should consist of admissions agreement 5/8/2025, pre-placement, face-sheet, emergency information, physicians report & needs and service plan dated 5/8/2025 by email on 9/10/2025. At 2:30PM LPA conducted a tour of the facility which consisted of the dining and kitchen area and nine (9) residents’ bedrooms 56,65,57,59,55,18,20, 25, and 16. Continued Unsubstantiated The investigation revealed the following: Allegation 1: Staff physically abused resident On September 9, 2025, Licensing Program Analyst (LPA) conducted interviews with Residents 1- 11 (R1–R11). Resident 1 (R1) reported being physically abused by Staff 1 (S1). Resident 2 (R2) stated they observed S1 handling R1 roughly while providing care and making inappropriate comments that were unrelated to caregiving. Residents 3-11 (R3–R11) reported that they had not experienced or heard of any staff member physically abusing residents in care. LPA attempted to interview Staff 1 (S1), but S1 was unavailable during the investigation. Staff 2-3 (S2–S3) confirmed they were aware of the allegations of physical abuse and inappropriate communication and stated that an internal investigation had been initiated. They reported that S1’s last day of work was September 1, 2025, and that S1 was officially disassociated from the facility on September 9, 2025. Staff members S4, S5, and S6 stated that they did not personally witness S1 physically abusing R1, but they were aware of the incident through hearsay. During the investigation, LPA observed a bruise on the thigh of Resident 1 (R1). However, based on the information available, LPA was unable to determine the cause of the bruise or whether it was related to staff interaction. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted where this report was discussed and provided to Nathaniel Vezon Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Dec 10, 2025 · control 11-AS-20250905102718

Allegation investigated: Staff does not ensure rodent issue is being treated properly for residents in care Staff does not ensure residents bathing needs are being met Staff does not ensure call buttons are answered in a timely manner

On 12/10/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met with Administrator Nathaniel Venzon who was informed of the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with Resident 1-11 (R1-R11) and Staff members 1-6 (S1-S6). A review of Resident 1 (R1) file was reviewed which consisted of admissions agreement dated 12/26/2024, pre-placement , face-sheet, emergency information, physicians report 12/20/2024, needs and service plan date 7/2/2025, BugFree Central, Inc. work orders dated 8/14/2025, 8/27/2025, and Orkin Service contract dated 7/25/2025, and 8/22/2025. LPA also conducted a tour of the facility which consisted of the dining and kitchen area and nine (9) residents’ bedrooms 56,65,57,59,55,18,20, 25, and 16. Continued.... Unsubstantiated The investigation revealed the following: Allegation 1: Staff does not ensure rodent issue is being treated properly for residents in care On 9/9/2025, LPA conducted interviews with Residents 1- 11 (R1–R11). Resident 1 (R1) stated they have seen rodents in their room and reported that exterminators have visited the facility on several occasions to address the rodent concern; however, rodents continue to be observed in their bathroom and closet areas. Interviews with R2, R3, R4, R5, and R6 indicated that they have heard about rodents but have not personally seen them. Interviews with R7, R8, R9, R10, and R11 indicated that they have neither heard about nor seen rodents in the building. LPA also conducted interviews with Staff Members 1- 6 (S1–S6). S1, S2, S3, and S4 stated that they have not seen rodents, but they have heard reports of rodents being in the building and Pest control have been at the facility to address the problem. Staff members 5-6 (S5- S6) stated that they have heard complaints about rodent sightings and have personally observed rodents in the facility. 6 out of 6 staff members confirmed that they have observed pest control services being provided at the facility to address rodent concerns. LPA has also obtained documents that reflects the pest control companies have been out to the building. The interviews conducted with staff and residents revealed that the administration staff does have a plan in place and have actively been utilizing their pest control measures to eliminate the rodent problems based on recommendations of the exterminator. LPA also observed a document dated 8/25/2025 signed by R1, stating that they refused to be relocated to another room. LPA also conducted a tour of the facility which consisted of the dining and kitchen area and LPA didn't observe any visible holes in the walls and nine (9) residents’ bedrooms 56,65,57,59,55,18,20, 25, and 16 and there were no visible holes in the wall or sliding door screens during the inspection. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. The investigation revealed the following: Allegation 2: Staff does not ensure residents’ bathing needs are being met. On 9/9/2025 LPA conducted interviews with Residents 1- 11 (R1–R11). Resident 1 (R1) stated that staff members have assisted him with showers but there have been times when adjustments had to be made because of not having washcloths available or they requested to be showered on another day or time. When asked if the caregivers provide them with showers R1 replied yes. Residents 2-10 (R2-R10) stated they have received their showers on their scheduled shower days and if alternative measures are needed staff are willing to assist. LPA also conducted interviews with Staff Members 1- 6 (S1–S6) and 6 out of 6 staff members stated that there are times when R1 is not willing to be showed at their scheduled time or R1 may even decline a shower all together, but caregivers offer at least 3 times before alternate days or times are adjusted. LPA also observed the resident shower schedule, log/notes which appear that R1 and other residents bathing needs are being met by the staff. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Continued.... The investigation revealed the following: Allegation 3: Staff does not ensure call buttons are answered in a timely manner On 9/9/2025, LPA Allen conducted interviews with Residents 1–11 (R1–R11) and 1 out of 11 residents stated their call button does work but staff members take too long to assist them when called. When asked further, R1 clarified that it can take staff too long to respond which can take 15 minutes or longer when the call button was used. The facility’s call log, dated August 30, August 31, and September 1 through September 8, 2025, was reviewed and revealed that staff members have responded within 5-15 minutes. Call buttons in rooms 56, 65, 57, 59, 55, 18, 20, 25, and 16 were tested and found to be in working condition. Interviews with Residents 2-10 (R2-R10) indicated staff do respond to their call button in a timely manner and stated their call buttons were in working condition during the visit. When asked how long is the response time 10 out of 10 said it can take 5-15 minutes before staff arrive and depends if they are assisting others. LPA also conducted interviews with staff members 1-6 (S1-S6) and 6 out of 6 staff members stated that staff does ensure call buttons are answered in a timely manner. When asked how long can the response time be staff stated assistance normally happens between 5-10 minutes and if additional time is needed the receptionist is informed of the estimated time or another staff member is asked to assist. LPA observed the log for calls, and it appeared that staff members do respond to call buttons between 5-15 minutes Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted where this report was discussed and provided to Administrator Nathaniel Venzon at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Dec 10, 2025 · control 11-AS-20250905150543

Allegation investigated: Allegation 2: Staff inappropriately spoke to resident

On 12/10/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met with Administrator Nathaniel Venzon who was informed of the purpose of the visit. The investigation consisted of the following: On 9/9/2025, At 11:30 AM, LPA Allen requested the following documents: staff and resident roster dated 9/9/2025, LPA conducted interviews with Resident 1-11 (R1-R11) and Staff members 1-6 (S1-S6). LPA also requested that Brooke Lamotte-wellness director provided Resident 1 (R1) file which should consist of admissions agreement 5/8/2025, pre-placement, face-sheet, emergency information, physicians report & needs and service plan dated 5/8/2025 by email on 9/10/2025. At 2:30PM LPA conducted a tour of the facility which consisted of the dining and kitchen area and nine (9) residents’ bedrooms 56,65,57,59,55,18,20, 25, and 16. Continued.... Substantiated The investigation revealed the following: Allegation 2: Staff inappropriately spoke to resident On September 9, 2025, Licensing Program Analyst (LPA) conducted interviews with Residents 1- 11 (R1–R11). Resident 1 (R1) reported being physically abused by Staff 1 (S1). Resident 2 (R2) stated that they observed S1 handling R1 roughly while providing care and making inappropriate comments that were unrelated to caregiving. Residents 3-11 (R3–R11) reported that they had not experienced being spoken to inappropriately by any staff members. LPA attempted to interview Staff 1 (S1), but S1 was unavailable during the investigation. Staff 2 and Staff 3 (S2–S3) confirmed they were aware of the allegations of inappropriate communication and stated that an internal investigation had been initiated. S2 and S3 stated S1 admitted to speaking to the resident inappropriately while providing care. Records reviewed revealed that S1’s last day of work was September 1, 2025, and that S1 was officially disassociated from the facility on September 9, 2025. Staff members S4, S5, and S6 stated that they did not personally witness or hear S1 speaking inappropriately to R1, but they were aware of the incident through other sources. LPA also reviewed the facility’s personnel records for S1, which revealed that S1 failed to complete the introductory period and violated company policy. Based on information gathered, the department did find sufficient evidence to support allegation that the staff inappropriately spoke to resident. Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. A citation is being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 11-AS-20250905102718

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 10, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions..... This requirement was not met as evidenced by: which poses a potential health, safety or personal rights risk to persons in care. The interviews conducted and the review of S1 file reviewed revealed that they were terminated because of admitting to speaking inappropriatley to R1 which resulted in s1 failing to completed introductory period and violation of company policy.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: The POC was cleared during the visit on 9/9/2025. LPA was provided documents that shows S1 last day of work as 9/9/2025 which was signed by S1.

Type of visit: Case Management - Other

On November 21, 2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced Case Management visit. The purpose of the visit was to serve the facility with an Immediate Exclusion Order for Staff #1 (S1). Upon arrival, LPA met with Administrator Nathaniel Venzon and informed him of the purpose of the visit. LPA confirmed that S1 was not present at the facility during the visit. Nathaniel stated that S1 has not been permitted to work and has been removed from the roster and will be removed from Guardian with an effective date of 11/21/2025. LPA was provided with documentation: · Current staff roster dated 11/20/2025 and resident roster · S1 Complete personnel file and confirmed last day of employment 11/16/2025 · Police report card copies (3Qty) During the visit, LPA was informed that S1’s separation date has been updated to 11/21/2025. An exit interview was conducted where this report was discussed and a copy of this report was emailed to Nathaniel Venzon at the conclusion of the visit due to technical difficulties being unable to print.the state’s words, verbatim · CDSS document, Nov 21, 2025

Allegation investigated: Staff did not prevent a resident from causing harm to another resident

On 11/10/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct and deliver the findings for the above elledged allegation. LPA was met with Business Office Manager, Shiree McCutchen and Wellness Director, Brooke LaMotte and they both were explained the purpose of the visit. The investigation consisted of the following: On 11/10/2025, LPA obtained and reviewed copies of the following records: Staff and Resident Roster dated 11/10/2025, a copy of LIC624 dated 10/5/2025, SOC341 dated 10/6/2025 and LIC624 dated 10/14/2025.LPA also conducted an interview with Witness 1(W1), Staff Member (S1) and attempted to interview Resident 1(R1). Continued.... Unfounded The investigation revealed the following: Allegation Staff did not prevent a resident from causing harm to another resident LPA reviewed the following documents: a copy of LIC624 dated 10/5/2025, SOC341 dated 10/6/2025, and LIC624 dated 10/14/2025. The LIC624 dated 10/14/2025 did not indicate that there was a incident which occurred involving one resident causing harm to another resident in the facility. An interview with S1 confirmed that staff did not fail to prevent harm between residents, as no such incident took place. S1 clarified that R1 was placed on a 5150 hold on 10/14/2025 due to aggressive behavior directed toward a staff member, not another resident. LPA attempted to interview R1 however they were not at the facility and could not be contacted. An interview with W1 also confirmed that the allegation was fabricated and not true. Based on interviews and record review the evidence gathered during the investigation revealed, the above allegation is found to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and discussed with Brooke LaMotte Wellness Director, and a copy of the report was provided at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Nov 10, 2025 · control 11-AS-20251105154028

Type of visit: Office

On November 05, 2025, at 1:00 PM, an office meeting was held to discuss Savant of Santa Monica’s operations. Present at the meeting were Stephanie Cifuetnes, Licensing Program Manager (LPM); Bernadette Allen, Licensing Program Analyst (LPA); Felisa Shirley Licensing Program Analyst (LPA); Nirjara Acharya, Vice President of Operations and Nathaniel Venzon, Administrator. During the meeting, the LPM discussed the following: · PIN 25-06-ASC Calling 9-1-1 in Residential Care Facilities for the Elderly. · Use of 911 for non-emergency purposes: Review of 911 call logs shows the following amount of calls for each month from January to October 2025: January: 21, February: 21, March: 20, April: 40, May: 25 June: 30, July: 33, August: 39, September: 30, October: 28 Reporting Requirements: · Facility will provide proof of submission of incident reports for the 911 calls made each month as shown above and submit to LPA Bernadette Allen by 11/24/2025 by the close of business. Exit interview conducted and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 5, 2025

Allegation investigated: Facility staff are not allowing residents to reject medical services when a threat is not imminent

On 10/28/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Wellness Director, Brooke LaMotte and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 10/28/25 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Plan of Operations, “Handling of Medical Emergencies,” Face Sheet, R-1’s Service Plan, Medication Reconciliation form, Resident Appraisal, Medical Assessment for Residential Care Facilities for the Elderly. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-8 (S1 – S8), and Resident -1 – Resident -10 (R1-R10). The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Facility staff are not allowing residents to reject medical services when a threat is not imminent It is being reported that R-1 was adamant about not needing emergency medical services. LPA Shirley reviewed incident report dated 10/26/25 with an occurrence date of 10/19/25, stating that R1 slipped and fell while entering the elevator and struck her head. R1 had visible bruising and stated she had a headache. During interviews on 10/28/25, S-2 stated that staff follows required handling of medical emergencies which includes assessing the resident and calling 911 if needed. On 10/28/25, LPA Felisa Shirley reviewed the Plan of Operation observed that procedures for medical emergencies are being followed. LPA interviewed staff 1 – staff 8 (S-1 – S-8). Of those interviewed 5 out of 8 denied the allegation, 3 did not know. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 10 out of 10 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation, “Facility staff are not allowing residents to reject medical services when a threat is not imminent,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Wellness Director, Brooke LaMotte.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 11-AS-20251021095038

Allegation investigated: Staff pushed resident Staff refused to give resident medication Staff did not treat resident with respect

On 10/21/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Wellness Director, Brooke LaMotte and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 10/21/25 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, De-Escalation In- Service Training Signature Sheet, Exodus Recovery Client Aftercare Plan, two (2) R-1 Warning Letters, Police Incident Report number, unusual Incident/Injury Reports, S-1 written notes, S-4 Written Statement, Client Face Sheet, Medication list, Preplacement Appraisal Information, Medical Assessment for Residential Care Facilities for the Elderly, and Service Plan. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-6 (S1 – S6), and Resident -1 – Resident -10 (R1-R10)). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation Staff pushed resident It is being reported that staff pushed a resident. On 10/21/25, LPA Felisa Shirley reviewed the incident reports for R-1 and observed that, S-3 and S-4 observed R-1 being upset and screaming at S-1 per incident report dated 10/5/25. Per review of Exodus Recovery, Client AfterCare Plan, R-1 was transferred by the police department to a recovery program following the incident involving the attack of a staff member. Per interviews conducted on 10/21/25, S-3 and S-4 observed R-1’s elbow approaching S-1’s neck/throat. Per S-4’s written statement, she observed R-1 kick the Med Room door shut. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 4 out of 6 denied the allegation, 2 did not know. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 9 denied the allegation, 1 confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff pushed resident,” therefore, the allegation is unsubstantiated. Allegation Staff refused to give resident medication It is being reported that staff refused to give R-1 their medication. Per interview with S-3 on 10/21/25, R-1 called the front desk requesting their medication and was told to come down to the Med Room. S-1 stated that he observed R-1 visibly shaking when the resident entered the Med Room from the wrong entrance for residents and S-1 sat R-1 down to assist and assess the resident to report to the doctor when suddenly R-1 began yelling and slammed the door shut. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 8 denied the allegation, 2 confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff refused to give resident medication,” therefore, the allegation is unsubstantiated. Con'd on 9099-C Allegation Staff did not treat resident with respect It is being reported that staff did not treat a resident with respect. Per review of Unusual incident reports dated 10/14/25, R-1 was transferred to Los Angeles Downtown Medical Center, (LADMC) on an ordered 51/50 hold secondary to aggressive and violent behavior towards S-1 on 10/5/25 and is currently still in the medical center. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 8 denied the allegation, 1 confirmed the allegation and 1 was not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not treat resident with respect,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Wellness Director, Brooke LaMotte.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 11-AS-20251015092819

Allegation investigated: The facility failed to ensure designated substitute coverage

On 10/10/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver the findings for the alleged allegation. LPA met with Administrator Nathaniel Venzon and he explained the purpose of the visit. The investigation consisted of the following: At 10:10 AM, LPA Allen requested the following documents: staff roster dated 10/10/2025, resident roster, a list of residents who tested positive for Covid Resident 1-5 (R1-R5), In-service training for infection control dated 2/13/2025 and 9/20/2025. Cleaning and disinfection log dated from 9/15/2025- 9/29/2025, Relias trainings for infection control and acute care transfer log dated from 6/15/2025 through 9/29/2025. LPA also conducted interviews with staff members 1-8 (S1-S8), resident 1-9 (R1-R9). continued Unsubstantiated The investigation revealed the following: Allegation #1: The facility failed to ensure designated substitute coverage. It was reported that the facility failed to ensure that a designated substitute was at the facility for coverage during the absence of the Administrator Nathaniel Venzon. LPA conducted interviews with staff member 1-8 (S1-S8) and of those interviewed 8 out of 8 stated that there is always coverage in the absence of the administrator Nathaniel Venzon. The interviews with S1 stated they have their Administrators License on file which LPA observed during the visit and S2 and S3 confirmed that S1 has their Administrators certificate. LPA also conducted interviews with residents 1-9 (R1-R9) and of those interviewed 9 out of 9 residents stated there is always someone there to cover when the administrator Nathaniel Venzon is not at the facility. On 10/10/25, LPA reviewed the infection control plan and staff were found to be following protocols. During the tour of this facility, LPA did not observe any PPE stations being used due to there not being any current covid cases. Based on the evidence gathered,observations, and interviews conducted during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Nathaniel Venzon at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Oct 10, 2025 · control 11-AS-20251007152227

Allegation investigated: Staff does not ensure to meet resident's wheelchair accommodations.

On 10/08/2025, Licensing Program Analyst (LPA) Troy Watson conducted an initial complaint visit and delivered findings for the allegation listed above. LPA Watson met with the Executive Director Nathaniel Venzon and explained the purpose of the visit was to investigate a complaint and was granted entry. The Investigation consisted of the following. On 10/08/2025 LPA Watson requested, obtained and reviewed the following documents: Personnel Records, Resident records, and an Order Summary receipt.On10/08/2025 LPA Watson conducted interviews with Staff#1-Staff#5 (S1-S5) and Residents #1 – Residents#12 (R1-R12). LPA Watson toured the facilty with the Wellnes Director Brooke Lamotte and found the facilty clean and in good repair, CONTINUED ON LIC9099-C Unsubstantiated Allegation: Staff does not ensure to meet resident's wheelchair accommodations. On 10/08/2025 LPA Watson interviewed Residents #1- Residents #12 (R1-R12). Out of those interviewed 11 out of 12 residents denied the above allegation. On 10/08/2025 the department conducted interviews with Staff #1 – Staff # 5 (S1 -S5). Of those interviewed 5 out of 5 staff denied the above allegation. LPA Watson requested, obtained and reviewed the Order Summary and it showed that a Drop Arm Bedside Commode with Padded Seat and Backrest for adults was purchased on 09/26/2025 to accommodate the residents need to transport from a wheelchair to the showers. LPA Watson interviewed the Wellness Director Brooke Lamotte and during the interview she stated that accommodations were made to mitigate the problem of resident being able to self-assist movement from a wheelchair to the shower. Based on the information collected from the facility, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted with the Wellness Director Brooke Lamotte and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 11-AS-20250929091754

Allegation investigated: Staff are not ensuring the residents are being fed Staff allow smoking while residents are present Staff allows a resident to threaten other residents

On 10/08/2025 at approximately 2:00 PM, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent visit to deliver findings regarding the above allegations and met with the facility’s Wellness Director Brooke Lamotte. The investigation consisted of the following: On 09/17/2025 at approximately 11:00 AM, LPA conducted an initial visit to conduct interviews and gather records. On 10/03/2025, LPA returned to the facility to conduct a kitchen tour, interviews, and collected further records to review. A total of (5) staff members (S1–S5) and interviewed sixteen (16) residents (R1–R16) across both visits. Investigation revealed the following: Regarding allegation “Staff are not ensuring the residents are being fed”: Observations conducted during the visit revealed that residents were being served meals and receiving assistance as needed. No residents were observed without food or care. Interviews with the culinary chef, cook, and wellness director revealed no concerns regarding meal provision. Please see LIC9099-C for report continuation. Unsubstantiated Of the thirteen (13) residents interviewed, twelve (12) denied the allegation and reported receiving meals regularly; one (1) resident agreed with the allegation. Records reviewed included diet reports for bedridden residents, a meal tracking roster, and a resident service refusal form documenting when meals were declined. Although the allegation ‘Staff are not ensuring the residents are being fed’ may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. Regarding allegation “Staff allow smoking while residents are present”: Observations revealed that residents were smoking only in designated outdoor patio areas. No smoking was observed in prohibited areas or near non-smoking residents. Records reviewed included a resident acknowledgment form confirming receipt of a written warning regarding prohibited indoor smoking, indicating that the facility is enforcing its smoking policy. Interviews revealed that two (2) out of thirteen (13) residents agreed with the allegation, while eleven (11) denied it. Although the allegation “Staff allow smoking while residents are present” may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. Regarding allegation “Staff allows a resident to threaten other residents”: Observations conducted during the visit revealed no immediate or potential threats to resident safety. Records reviewed included incident reports documenting that behavioral concerns were reported and addressed by facility staff. Interviews revealed that Nine (9) out of thirteen (13) residents denied the allegation and reported feeling safe in the facility; four (4) residents agreed with the allegation. Although the allegation “Staff allows a resident to threaten other residents” may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the Resident Service Wellness Director.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 11-AS-20250908223446

Allegation investigated: Staff did not take proper steps to mitigate the spread of a communicable disease.

On 9/29/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Business Office Manager, Shiree McCutchen and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 9/29/25 LPA Shirley reviewed copies of the following records: Staff and Client Roster, In- Service Training Signature Sheet, Cleaning and Disinfection Log, Client Face Sheet, Admission Record, Preplacement Appraisal Information, Medical Assessment for Residential Care Facilities for the Elderly, Immunization History Report, Service Plan, Special Incident Reports, Infection Control Plan. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-8 (S1 – S8), and Resident -1 – Resident -10 (R1-R10)). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not take proper steps to mitigate the spread of a communicable disease. It was reported that there were deficiencies in staff’s covid-19 prevention efforts. On 9/29/25, LPA Felisa Shirley reviewed Savant of Santa Monica’s Infection Control plan and staff were found to be in compliance with established protocols. Upon further investigation LPA Shirley observed the annual In-Service Signature Sheet for Covid, Infection Control and PPD done and doffing. LPA Shirley also observed the Cleaning and Disinfection Log for sanitizing frequently touched surfaces signed by staff and the Maintenance Director. During the tour of this facility, LPA Shirley observed the PPE Supply Carts that were utilized by staff during the period of isolation for the purpose of preventing the spread of infectious disease. LPA interviewed staff 1 – staff 8 (S-1 – S-8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 8 denied the allegation, 1 confirmed the allegation and 1 was not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not take proper steps to mitigate the spread of a communicable disease,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Business Office Manager, Shiree McCutchen.the state’s words, verbatim · CDSS document, Sep 29, 2025 · control 11-AS-20250924105048

Allegation investigated: Staff did not assist resident with obtaining medical care services.

***This report supersedes the original report delivered on 8/14/2025. On 9/25/2025, LPA Allen arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 08/14/2025. *** On 8/14/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the alleged allegation. LPA identified herself and met Dylan Barrett- Activity Director, who was informed of the purpose of the visit. Nathaniel Venzon arrived at approximately 10:00 AM, he was also informed of the purpose of the visit The investigation consisted of the following: At 9:06 AM, LPA Allen requested the following documents: staff and client roster dated 8/14/2025, Resident 1 (R1) file which included the face sheet dated 8/14/2025, preplacement appraisal, physicians report dated 7/25/2025, admission agreement date 7/29/2025. University Park Healthcare Center Order Summary Report and face sheet July 25,2025. Skilled Home Healthcare Agency reports dated 8/4/2025. Unsubstantiated Correspondence between R1's Physician and Brooke Lamotte-Wellness Director from 7/31/2025 through 8/7/2025, and weight charts dated for 8/5,8/7/2025, and interviews with Staff members 1-8 (S1-S8) and Residents 1-8 (R1-R8). The investigation revealed the following: Staff did not assist resident with obtaining medical care services. At 9:30 AM, LPA Allen conducted interviews with Residents 1- 8 (R1–R8). 7 out of 8 residents stated they are receiving assistance with obtaining medical care services. Residents R2, R3, and R4 stated they have not needed staff assistance for scheduling doctor’s appointments or running errands. However, they expressed confidence that if such assistance were needed, staff would ensure the necessary services were provided. LPA attempted to interview R6, but they were not available. Residents R5, R7, and R8, confirmed that staff have assisted them with medical appointments and care services, including transportation to and from appointments and errands. Additionally, Residents R2 - R8 stated that when the facility’s transportation van is unavailable, alternative transportation arrangements are made to ensure residents can be picked up and dropped off as needed. These arrangements include the use of services such as Lyft, Uber, and Access. LPA Allen also conducted interviews with Staff Members 1-8 (S1–S8). 8 out of 8 staff members interviewed stated residents are assisted with obtaining medical care services. Staff stated residents, MedTechs, Brooke Lamotte- Wellness director and residents coordinates together to assist with scheduling appointments for medical care services as well as personal errands. Additionally, staff stated that when the facility’s transportation van is unavailable, alternative transportation arrangements are made to ensure residents can be picked up and dropped off as needed. These arrangements include the use of services such as Lyft, Uber, and Access. At 12:45 PM, LPA Allen also reviewed Resident 1’s (R1) file and observed that the facility staff has been providing medical care services since R1’s admission. Services have been in place and utilized from July 29, 2025, through August 14, 2025. A referral to R1’s primary care physician has been initiated and is currently pending. Additionally, R1 has received physical therapy services from Skilled Home Health, Inc., an outside agency twice a week, from August 3, 2025, through August 9, 2025, and the review of documentation does not reflect any evidence of excessive weight loss. Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Nathaniel Venzon- Administrator at conclusion of the visit with appeal rights. Nathan authorized Dylan Barrett-Activity director to sign corrected report.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 11-AS-20250808092032

Allegation investigated: Staff did not assist resident with obtaining medical care services.

***This report supersedes the original report delivered on 8/14/2025. On 9/18/2025, LPA Allen arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 08/14/2025. *** On 8/14/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the alleged allegation. LPA identified herself and met Dylan Barrett- Activity Director who was informed of the purpose of the visit. Nathaniel Venzon arrived at approximately 10:00 AM, he was also informed of the purpose of the visit The investigation consisted of the following: At 9:06 AM, LPA Allen requested the following documents: staff and client roster dated 8/14/2025, Resident 1 (R1) file which included the face sheet dated 8/14/2025, preplacement appraisal, physicians report dated 7/25/2025, admission agreement date 7/29/2025. University Park Healthcare Center Order Summary Report and face sheet July 25,2025. Skilled Home Healthcare Agency reports dated 8/4/2025. Continued..... Unsubstantiated Correspondence between R1's Physician and Brooke Lamotte-Wellness Director from 7/31/2025 through 8/7/2025, and weight charts dated for 8/5,8/7/2025, and interviews with Staff members 1-8 (S1-S8) and Residents 1-8 (R1-R8). The investigation revealed the following: Staff did not assist resident with obtaining medical care services. At 9:30 AM, LPA Allen conducted interviews with Residents 1- 8 (R1–R8). 7 out of 8 residents stated they are receiving assistance with obtaining medical care services. Residents R2, R3, and R4 stated they have not needed staff assistance for scheduling doctor’s appointments or running errands. However, they expressed confidence that if such assistance were needed, staff would ensure the necessary services were provided. LPA attempted to interview R6, but they were not available. Residents R5, R7, R8, and R9 confirmed that staff have assisted them with medical appointments and care services, including transportation to and from appointments and errands. Additionally, Residents R2 - R8 stated that when the facility’s transportation van is unavailable, alternative transportation arrangements are made to ensure residents can be picked up and dropped off as needed. These arrangements include the use of services such as Lyft, Uber, and Access. LPA Allen also conducted interviews with Staff Members 1-8 (S1–S8). 8 out of 8 staff members interviewed stated residents are assisted with obtaining medical care services. Staff stated residents, MedTechs, Brooke Lamotte- Wellness director and residents coordinates together to assist with scheduling appointments for medical care services as well as personal errands. Continued Additionally, staff stated that when the facility’s transportation van is unavailable, alternative transportation arrangements are made to ensure residents can be picked up and dropped off as needed. These arrangements include the use of services such as Lyft, Uber, and Access. At 12:45 PM, LPA Allen also reviewed Resident 1’s (R1) file and observed that the facility staff has been providing medical care services since R1’s admission. Services have been in place and utilized from July 29, 2025, through August 14, 2025. A referral to R1’s primary care physician has been initiated and is currently pending. Additionally, R1 has received physical therapy services from Skilled Home Health, Inc., an outside agency twice a week, from August 3, 2025, through August 9, 2025, and the review of documentation does not reflect any evidence of excessive weight loss. Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Nathaniel Venzon- Administrator at conclusion of the visit with appeal rights. Nathan authorized Dylan Barrett-Activity director to sign corrected report.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 11-AS-20250808092032

Type of visit: Case Management - Deficiencies

On 09/17/2025, at approximately 11:00AM, Licensing Program Analyst (LPA) Jose Anguiano while touring the facility with Director of Resident Services, Broke Lamotte, observed that an emergency exit door leading to the alleyway, located near a resident’s room, was not in good repair. The door, which is equipped with a push-to-open mechanism, only opened approximately 30% of the way when tested. The door was visibly slanted and misaligned, restricting the opening to a narrow gap and gets stuck. This condition poses a potential hazard by obstructing safe and timely evacuation in the event of an emergency and does not meet the requirement for maintaining the facility in a safe and operable condition. According to California Code of Regulations, Title 22, Division 6, Chapter 1, the following deficiency was observed: Based on observations, the licensee did not comply with regulations by failing to maintain an emergency exit door in good repair. Plans of Correction were discussed and developed with the Director of Resident Services. A copy of this report, LIC 809-D, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Sep 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 24, 2025

87303(a) – Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times... Based on observation the licensee did not comply with the section cited above. Licensee failed to maintain an emergency exit door in good repair., which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: Licensee has agreed to repair the door within 24 hours. Licensee will submit a plan to ensure that exit door is fixed and stays in good repair at all times and email LPA Anguiano by due date.

Type of visit: Case Management - Other

On 9/15/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Director of Resident Services, Brook LaMotte and explained the purpose of the visit is to follow-up on complaint #11-AS-20250429151406. LPA was granted access to the facility. LPA Felisa Shirley interviewed Resident 4, 6, 7, and 8. Resident R-2 and R-9 were not available for interview. There were no deficiencies issued. An exit interview was conducted with the the Director of Resident Services, Brook LaMotte and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 15, 2025

Allegation investigated: Staff abuses resident

On 8/21/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the alleged allegation. LPA identified herself and met Dalyn Barrett- Activity Director who was informed of the purpose of the visit. Brooke Lamotte-Wellness Director arrived to assist with the investigationat approximately 10:30 AM. The investigation consisted of the following: At 9:00 AM, LPA Allen requested the following documents: staff and resident roster dated 8/19/2025, Resident 1(R1) facility file that included the following. Pre-placement appraisal dated 3/15/2023, and unsigned by resident physicians report dated 3/14/2023. LPA also conducted interviews with Resident 1-9 (R1-R9) and staff members 1-9 (S1-S9) and supplemental documentation. The investigation revealed the following: Continued Unsubstantiated The investigation revealed the following: Staff abuses resident At approximately 9:45 AM, Licensing Program Analyst (LPA) Allen conducted interviews with Residents 1- 9 (R1–R9). During the interviews, one resident (R1) reported experiencing physical, emotional, and financial abuse by staff members and the Savant of Santa Monica Organization. When asked to provide specific details regarding the alleged incidents, including names of staff members involved, dates, or times R1 declined to provide further information. Additionally, R1 stated that they do not allow staff to assist them with their finances, activities of daily living (ADLs), or medication management. Residents 2 - 9 (R2–R9) stated that they have not experienced any form of physical, emotional, or financial abuse by facility staff or the Savant of Santa Monica Organization. LPA also conducted interviews with Staff members 1-9 (S1-S9) of those interviewed 9 out of 9 staff members stated that they have not experienced, seen or heard of any resident being abused in any way, which included physical, emotionally, or financially. During interviews with staff members LPA specifically asked has R1 ever complied to them about being abused by staff in any way which includes physically, emotionally, or financially and 9 out of 9 staff members stated R1 has never informed them of any occurrence or type of abuse. Staff members 7,8, and 9 stated the facility does not handle R1's finances, they are their own responsible party. During the review of Resident 1’s (R1) file and through interviews with staff and R1, it was confirmed that R1 does not permit staff to assist with their finances, activities of daily living (ADLs), or medication management. Continued Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Brooke Lamotte-Wellness Director at conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 11-AS-20250814104715

Allegation investigated: Staff did not assist resident with obtaining medical care services.

On 8/14/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the alleged allegation. LPA identified herself and met Dalyn Barrett- Activity Director who was informed of the purpose of the visit. Nathaniel Venzon arrived at approximately 10:00 AM he was also informed of the purpose of the visit The investigation consisted of the following: At 9:06 AM, LPA Allen requested the following documents: staff and client roster dated 8/14/2025, Resident 1 (R1) file which included the face sheet dated 8/14/2025, preplacement appraisal, physicians report dated 7/25/2025, admission agreement date 7/29/2025. University Park Healthcare Center Order Summary Report and face sheet July 25,2025. Skilled Home Healthcare Agency reports dated 8/4/2025. Correspondance between R1's Physician and Brooke Lamotte-Wellness Director from 7/31/2025 through 8/7/2025, and weight charts dated for 8/5,8/6 8/7/2025, and interviews with Staff members 1-8 (S1-S8) and Residents 1-9 (R1-R9). Continued Unsubstantiated The investigation revealed the following: Staff did not assist resident with obtaining medical care services. At 9:30 AM, LPA Allen conducted interviews with Residents 1 through 9 (R1–R9). Of those interviewed, 1 out of 9 residents stated they are not receiving assistance with obtaining medical care services. Residents R2, R3, and R4 stated they have not needed staff assistance for scheduling doctor’s appointments or running errands. However, they expressed confidence that if such assistance were needed, staff would ensure the necessary services were provided. Residents R5, R6, R7, R8, and R9 confirmed that staff have assisted them with medical appointments and care services, including transportation to and from appointments and errands. Additionally, Residents R2 through R9 stated that when the facility’s transportation van is unavailable, alternative transportation arrangements are made to ensure residents can be picked up and dropped off as needed. These arrangements include the use of services such as Lyft, Uber, and Access. LPA Allen also conducted interviews with Staff Members 1-8 (S1–S8). 8 out of 8 staff members interviewed stated residents are assisted with obtaining medical care services. Staff stated residents, MedTechs, Brooke Lamotte- Wellness director and residents coordinates together to assist with scheduling appointments for medical care services as well as personal errands. Additionally, staff stated that when the facility’s transportation van is unavailable, alternative transportation arrangements are made to ensure residents can be picked up and dropped off as needed. These arrangements include the use of services such as Lyft, Uber, and Access. At 12:45 PM, LPA Allen also reviewed Resident 1’s (R1) file and observed that the facility staff has been providing medical care services since R1’s admission. Services have been in place and utilized from July 29, 2025, through August 14, 2025. Continued.. A referral to R1’s primary care physician has been initiated and is currently pending. Additionally, R1 has received physical therapy services from Skilled Home Health, Inc., an outside agency twice a week, from August 3, 2025, through August 9, 2025, and the review of documentation does not reflect any evidence of excessive weight loss. Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Nathaniel Venzon- Administrator at conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Aug 14, 2025 · control 11-AS-20250808092032

Allegation investigated: Facility staff are not dispensing medication as prescribed. Facility staff are not safeguarding residents personal property.

** This report supersedes the report dated 03/27/25. It does not supersede the findings but is being used to clarify the findings. ** On 03/27/2025, Licensing Program Analyst (LPA) Troy Watson conducted a subsequent visit to deliver findings for the allegations listed above. LPA Watson met with Wellness Director Brooke Lamotte explained the purpose of the visit and was granted entry. The investigation consisted of the following On 03/26/25 LPA Watson requested, obtained and reviewed the following documents: Medication Administration Records (MAR’s), and Resident Theft and Loss Records for Residents #1- #6. On 03/26/25 interviews were conducted with Staff#1-Staff#8 (S1-S8) and Residents #1 – Residents#6 (R1-R6). CONTINUED ON LIC9099-C Unsubstantiated The Investigation revealed the following Allegation: Facility staff are not dispensing medication as prescribed. It is alleged that staff are administering medication as a cream, not the powder prescribed. On 03/27/2025 LPA Watson toured the medication room and reviewed facility records. Per medication administration log (MAR) dated 03/2025, R1 has been consistently receiving the correct medication for her wound treatment, which has been documented on the MAR as being administered as a powder. On 03/26/2025 LPA conducted interviews with Staff #1- Staff #8 (S1-S8). Of those interviewed 8 out of 8 staff denied the above allegation. On 03/26/25 LPA conducted interviews with Resident #1 – Resident #6 (R1-R6). Of those interviewed 6 out of 6 staff denied the above allegation. Based on the information collected from the facility, observations, interviews, and records analysis, LPA Watson found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. Allegation: Facility staff are not safeguarding residents’ personal property It is alleged that medical cards and documents were stolen from Resident #1’s (R1) room. On 03/26/2025 LPA Watson interviewed Executive Director Nathaniel Venzon about(R1’s) allegedly stolen medical cards and documents. During the interview, Nathaniel Venzon stated that it was reported to him by Resident #1 (R1) that items were missing, and or stolen during a move from one room to another. Executive Director Nathaniel Venzon stated that a Theft and Loss Report was filed on behalf of (R1), but R1’s items were later found and returned. On 03/26/2025 LPA Watson conducted interviews with Staff#1 – Staff#8 (S1-S8) Of those Interviewed 8 out of 8 staff denied the above allegation. On 03/26/25 LPA Watson interviewed Resident #1 – Resident #6 (R1 -R6). Of those interviewed 5 out of 6 denied the above allegation. Based on the information collected from the facility, observations, interviews, and records analysis, LPA Watson found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted with the Wellness Director Brooke Lamotte and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 12, 2025 · control 11-AS-20250317141858

Allegation investigated: Facility staff did not meet resident's incontinence care needs

On 07/30/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Savant of Santa Monica Facility and met with Administrator Nathaniel Venzon (S1). LPA Calderon explained that the purpose of this visit is to deliver an updated investigation report that supersedes the investigation report that was delivered on 04/09/2025. The findings have changed to substantiated. The investigation consisted of the following: On 04/08/2025 LPA Calderon interviewed witness W1. On 04/09/2025 LPA Calderon interviewed 5 staff (S1-S5) and 9 residents (R1-R9). LPA Calderon obtained the following records: Physician report (dated 01/11/2024), incident report (dated 04/01/2025), shower logs (dated 02/10/2025 to 04/07/2025), Service plan (dated 09/06/2024), and Providence Saint John medical records (dated 04/02/2025). Substantiated The investigation revealed the following: Regarding the Allegation: Facility staff did not meet residents’ incontinent care needs. It is alleged that residents’ Urinary Tract Infection (UTI) was a result of staff not meeting residents’ incontinent care needs. Records reviewed indicate the following: Physician report dated 01/10/2024 indicates that R1 is non-ambulatory, is not able to care for own toileting needs and requires continuous bed care. The service plan dated 09/06/2024 indicates that R1 needs full assistance with toileting. Incident reports indicate that R1 was taken to the hospital on 04/02/2025 and evaluated with a urinary tract infection (UTI). Saint John records indicate that R1 was diagnosed with a UTI on 04/02/2025. Interviews indicate the following: 5 out of 5 staff denied the allegation. 7 out of 9 residents denied the allegation. 2 out of 9 residents agree with the allegation. R1 indicated that staff do not change R1 diaper prior to 12 noon most of the time. R2 indicates that R2 witnessed that staff does not change R1 diaper prior to 12 noon. W1 indicates that on 03/29/2025 W1 witnessed that R1 diaper was not changed and was full. Based on interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the allegation “Facility staff did not meet residents’ incontinent care needs.” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are being cited on the attached LIC 9099D. Per Title 22 Regulation 87761(c)(1) Penalties a civil penalty is being cited please see LIC421IM. An exit interview was conducted, and a copy of the Complaint Investigation Report, Civil Penalty Assessment and Appeal Rights were provided to the Administrator Nathaniel Venson (S1).the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 11-AS-20250403105629

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Aug 1, 2025

Managed Incontinence. In addition to …, 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. This requirement was not met as evidence by: Based on observations and interviews conducted, the licensee did not ensure that R1 was clean and dry, which caused R1 to be taken to the hospital with a UTI. This poses an immediate health and safety and personal rights risk for residents in care.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: License agreed to update R1’ and Physician Report (LIC602A) and Appraisal/Needs and Service Plan (LIC625). And agreed to conduct staff training based on 87625(b)(1-10) Managed Incontinence. Proof of Correction will be emailed to jose.calderon@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 7/9/25, Licensing Program Analyst (LPA) Felisa Shirley arrived at this facility to conduct a case management on complaint #11-AS-20250429151406 investigated on 5/8/25. On 5/8/25, LPA Shirley reviewed the Dispatched Call Log from Santa Monica’s Office of Emergency Management and requested all Special Incident Report's, (SIR’s) from 1/25 to 4/25 from the facility listed above. LPA Shirley received 8 SIR's classified as falls. Savant of Santa Monica only reported 8 falls for residents as CCLD had records for 24 falls. There were 16 falls not reported. Based on the documents reviewed, staff at Savant of Santa Monica did not provide a written report and submit to CCLD and to the person responsible for the residents within seven days of the occurrence. Deficiencies are being cited based on documents reviewed and interviews conducted in accordance with the California Code of Regulations, Title 22, Divisions 6 chapter 1, see LIC 809D. An exit interview was conducted, Plans of Corrections were discussed and a copy of this report and appeals rights were left with the Executive Director, Nathaniel Venzon whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B)(D) · Plan of correction due date: Jul 23, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the licensee did not comply with the section cited above by not providing reports to CCLD regarding resident falls within seven days of the occurrence of any events listed above which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2025

Plan of correction: The Executive Director shall provide a copy of an In-Service training regarding reporting incidents to CCLD in a timely manner by the POC due date of 7/23/25. Please forward copies of training to LPA Felisa Shirley at felisa.shirley@dss.ca.gov or fax to 424-544-1016

Allegation investigated: Resident developed a pressure injury while in care. Staff do not ensure residents bathing needs are being met.

On 7/2/25 at 9:45am Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Executive Director Nathaniel Venzon as the purpose of the visit was explained. The investigation consisted of the following: On 01/22/25 LPA requested copies of the following: resident and staff rosters, list of residents receiving hospice, home health, and/or wound care services, and shower log for January 2025. On 01/22/25 LPA also requested the following documents for resident #1 (R1): emergency ID form, admission agreement, physicians report, physicians’ orders, needs and service plan, pre-appraisal, and home health paperwork. On 01/22/25 between 11am- 1:05 pm LPA conducted interviews with residents #2-10 (R2-R10), LPA unable to interview R1 as R1 is currently admitted at Cedar Sinai hospital. On 01/30/25 LPA obtained copies of staff and resident rosters, shower logs for January 2025, and conducted interviews with ED, and staff #1-5 (S1-S5). The investigation revealed the following: Unsubstantiated Allegation: Resident developed a pressure injury while in care It is being alleged that facility staff were not assisting resident in care with repositioning which resulted in resident developing a pressure injury. On 01/22/25 between 11am- 1:05 pm LPA conducted interviews with R2-R10 regarding the allegation above, 7 of 9 residents interviewed denied the allegation above, 2 of 9 residents interviewed reported obtaining wounds in the past but could not provide a time frame. On 01/22/25 LPA unable to interview R1 as R1 was receiving care at Cedar Sinai hospital. On 1/30/25 LPA unable to interview R1 as R1 was receiving treatment outside of Savant Of Santa Monica. On 1/30/25 LPA conducted interviews with ED, and S1-S5 regarding the allegation above, 6 of 6 staff interviewed denied the allegation above and reported that residents that require repositioning are checked out and repositioned every 2 hours. On 7/2/25 LPA conducted a review of R1s physician report and appraisal, LPA observed there is no order that R1 needed to be re positioned. There is no documentation that R1 had a pressure injury upon admission to Savant Of Santa Monica. On 7/2/25 LPA reviewed medical records obtained from Cedar Sinai hospital, per medical records Injury was observed at the hospital but never staged. Allegation: Staff do not ensure residents bathing needs are being met. It is being alleged that facility staff are not providing showers to residents in care. On 01/22/25 between 11am- 1:05 pm LPA conducted interviews with R2-R10 regarding the allegation above, 5 of 9 residents interviewed denied the allegation above and reported receiving showers 2 times a week. 3 of 9 residents interviewed reported they do not require assistance from staff for showers. 1 of 9 residents interviewed confirmed the allegation above and reported going more than 2 days without shower assistance from staff. On 01/22/25 LPA unable to interview R1 as R1 was receiving care at Cedar Sinai hospital. On 1/30/25 LPA unable to interview R1 as R1 was receiving treatment outside of Savant Of Santa Monica. On 1/30/25 LPA conducted interviews with ED, and S1-S5 regarding the allegation above. On 1/30/25 LPA conducted interviews with ED, and S1-S5 regarding the allegation above, 6 of 6 staff interviewed denied the allegation above and reported that that showers are provided 2 times a week. 3 of 6 staff interviewed reported that a resident may go more than 2 days without a shower if the resident refuses. On 7/2/25 LPA conducted a review of shower logs and observed documentation indicating showers are done twice a week, LPA also observed documented refusals from residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 11-AS-20250115134552

Allegation investigated: Staff did not respond to resident's call for assistance

***This report supersedes the original report delivered on 4/23/2025. On 6/18/2025,LPA Allen arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 04/23/2025. *** LPA met with Nathaniel Venzon- Administrator who was informed of the purpose of the visit. On 4/23/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the alleged allegation. LPA identified herself and met Brooke Lamotte- who was informed of the purpose of the visit. The investigation consisted of the following: At 9:30 AM, LPA Allen reviewed resident 1 (R1) file, face sheet, pre-placement appraisal dated 9/5/2024,physicians report dated 9/11/2024, admissions agreement dated 12/2/2024, notes/logs dated 4/1/2025- 4/23/2025. LPA also requested and reviewed the following documents: Staff roster (LIC 500), shift schedule for 4/1/2025 - 4/15/2025 continued ... Unsubstantiated resident roster and LPA Allen conducted interviews with staff 1- staff 10 (S1 - S10), resident 1- resident 9 (R1- R9). The investigation revealed the following: Allegation: Staff did not respond to resident's call for assistance At 11:30 AM, LPA Allen interviewed ten (10) staff members staff 1- staff 10 (S1 - S10) of those interviewed 10 out of 10 staff stated they are informed by the concierge on duty by portable two-way radios of the resident requiring assistance. Assistance is provided in a timely manner which can range between 5-10 minutes. Staff also stated if there are staffing issues residents wait time can be between 5-15 minutes, however staff members communicate with each other to ensure residents are acknowledged as needing help and given an estimated wait time to insure assistance is provided. The interview with Brooke Lamotte- Wellness Director stated there are some staffing concerns which have been addressed by having a job fair on 4/22/2025 and they expect to have eight (8) additional care staff members and three (3) MedTech’s with estimated start dates of May 1, 2025. LPA Allen also observed the 11 potential new hire roster/schedule. At 1:15 PM, LPA Allen interviewed resident 1- resident 9 (R1- R9) of those interviewed, 1 out of 9 residents stated they did not get assistance when they used their call button which happened on one occasion. The interviews with the remaining 8 residents stated help is received when they use their call buttons, however they also stated on occasion it may take longer than usual for staff to come assist them, but assistance is provided which they believe is because of staffing issues. LPA Allen also toured the facility including five (5) rooms and observed call buttons to be in operable condition and observed residents getting assistance when their call buttons were used. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted where this report was discussed and provided to Nathan Venzon at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 11-AS-20250415095739

Allegation investigated: Facility staff are not dispensing medication as prescribed. Facility staff are not safeguarding residents personal property

+This report supersedes the report dated 03/27/2025. It does not supersede the findings but is being used to clarify the findings. On 05/29/2025, Licensing Program Analyst (LPA) Troy Watson conducted a subsequent visit to deliver findings for the allegations listed above. LPA Watson met with the Executive Director Nathaniel Venzon and explained the purpose of the visit was to deliver findings and was granted entry. On 03/26/25 LPA Watson requested, obtained and reviewed from the following documents: Administration Records (MAR’s) dated (03/2025), and Resident Theft and Loss Records for Residents #1- #6. On 03/26/25 interviews were conducted with Staff#1-Staff#8 (S1-S8) and Residents #1 – Residents#6 (R1-R6). CONTINUED ON LIC9099-C Unsubstantiated The Investigation consisted of the following. Allegation: Facility staff are not dispensing medication as prescribed. It is alleged that staff are administering medication as a cream, and not the powder prescribed. On 03/27/2025 LPA Watson toured the medication room and reviewed facility records. Per medication administration log (MAR) for R1 has been consistently receiving the correct medication for wound treatment which has been documented on the MAR as being administered as a powder. On 03/26/2025 LPA conducted interviews with Staff #1- Staff #8 (S1-S8). Of those interviewed 8 out of 8 staff denied the above allegation. On 03/26/25 the department conducted interviews with Resident #1 – Resident # 6 (R1 -R6). Of those interviewed 6 out of 6 residents denied the above allegation Allegation: Facility staff are not safeguarding residents’ personal property. It is alleged that medical cards and documents were stolen from Resident #1’s (R1) room. On 03/26/2025 the department interviewed the Executive Director Nathaniel Venzon about (R1’s) alleged stolen medical cards and documents. During the interview Nathaniel Venzon stated that it was reported to him by Resident #1 (R1) that items were missing and or stolen during a move from one room to another. Executive Director Nathaniel Venzon stated that he filed a Theft and Loss Report on behalf of (R1) but R1'S items were later found and returned.On 03/26/25 the department conducted interviews with Staff #1- Staff #8 (S1-S8). Of those interviewed 8 out of 8 staff denied the above allegation. On 03/26/25 the department interviewed Resident #1 – Resident #6 (R1 -R6). Of those interviewed 5 out of 6 denied the above allegation. Based on the information collected from the facility, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted with the Wellness Director Brooke Lamotte and a copy of this report was given.the state’s words, verbatim · CDSS document, May 29, 2025 · control 11-AS-20250317141858

Allegation investigated: Facility staff neglect is resulting in residents suffering from multiple falls. Facility staff not seeking medical assistance for residents in a timely manner.

On 5/21/25 at 11:00 am, Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced subsequent complaint visit to the address listed above. LPA Shirley arrived and spoke to the Wellness Director, Brooke LaMotte and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 5/08/25, LPA Shirley spoke to facility Executive Director, Nathaniel Venzon and the Wellness Director, Brooke LaMotte and reviewed facility records. LPA requested copies of staff and resident rosters, copies of all special incident reports January 2025 through April 2025. LPA reviewed copies of residents Physicians Reports, and Service Plans. LPA also interviewed staff 1 thru staff 9(S1 thru S9) and residents 1 thru resident 10(R-1 thru R-10). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Facility staff neglect is resulting in residents suffering from multiple falls On 5/21/25, LPA Shirley reviewed special incident reports from January 2025 to April 2025. During review of the incident reports LPA Shirley observed 8 incident reports that were resident falls. File review revealed that one resident, R5, is considered a fall risk. R5 fell on 2/1/25 and 4/30/25. LPA observed that there was an assessment completed on 3/30/25, and interview with the Wellness Director stating that there was a care plan in place. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff neglect result in residents suffering from multiple falls. Of those interviewed, 9 out of 9 staff answered no. LPA interviewed Resident-1 thru Resident-10 (R-1 thru R-10). LPA asked, does staff neglect result in residents suffering from multiple falls. Of those interviewed, 5 out of 10 answered yes, and 5 answered no. Allegation: Facility staff not seeking medical assistance for residents in a timely manner On 5/21/25, LPA Shirley reviewed special incident reports from January 2025 to April 2025. During review of the incident reports LPA Shirley observed that residents were assisted timely by staff members upon request by residents, per incident occurrences or by observation. LPA Shirley reviewed the Acute Care Transfer log received on 5/8/25 and 5/21/25 regarding staff assisting residents by transferring the residents from this facility and the reasons for the transfers. Con'd on 9099-C LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff seek medical assistance for residents in a timely manner. Of those interviewed, 9 out of 9 staff answered yes. LPA interviewed Resident-1 thru Resident-10 (R-1 thru R-10). LPA asked, does staff provide medical assistance for you in a timely manner. Of those interviewed, 5 out of 10 answered yes, and 5 answered no. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above 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 allegation is Unsubstantiated. Regarding the allegations, the Department found no evidence to support the allegations mentioned above. 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, as a result, the allegations are Unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Wellness Director Brooke LaMotte.the state’s words, verbatim · CDSS document, May 21, 2025 · control 11-AS-20250429151406

Allegation investigated: Staff did not dispense medication(s) to resident as prescribed. Staff did not assist resident with incontinence care needs in a timely manner.

On 4/23/25 at 10:30 am, Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Wellness Director, Brooke LaMotte and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 4/23/25 LPA requested and reviewed copies of the following records: Staff Roster, Resident Roster, Medication Technician Schedule, Medication Training certificates, and incontinence sheets. LPA Felisa Shirley toured the facility and interviewed Staff #1 – 9 and Residents #1 – 9. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not dispense medications to resident as prescribed. On 4/23/25, LPA Shirley observed medication training certificates for all three staff. LPA observed the Medication Technician schedule and saw that there are 2 medication staff in the morning, 2 in the evening and 1 on the Nocturnal shift (NOC). The Wellness Director assist the team as needed. LPA Shirley monitored S5 dispense medications through the QuikMar system to five residents during lunch. S5 matched resident’s picture and name to resident, and dispensed medication according to time of day and dose prescribed by doctor. Once the medication was dispensed the picture turns grey to indicate that medication was administered. LPA Shirley confirmed that MAR matched physical medication. Per interview with Wellness director, there were there were an additional six Medication Technicians hired with a start day of May 1st. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff dispense medications to residents as prescribed. Of those interviewed, 9 out of 9 staff answered yes. LPA interviewed Resident-1 thru Resident-9 (R-1 thru R-9). LPA asked, does staff dispense your medications on time as prescribed. Of those interviewed, 6 out of 9 answered yes, 2 answered, no and 1 resident administered their own medications. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above 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 allegation is Unsubstantiated. Allegation: Staff did not assist resident with incontinence care needs in a timely manner. On 4/23/25, LPA Shirley Reviewed the incontinence schedule for 2 residents and observed that residents are being changed every 2 hours. Per interview with 5 staff members residents are changed every 2 hours or when called. Per interview with Wellness Director, the facility is short staffed and there were eight additional caregivers hired with an estimated start date of May 1st. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff assist residents with incontinence care needs in a timely manner. Of those interviewed, 9 out of 9 staff answered yes. LPA interviewed Resident-1 thru Resident-9 (R-1 thru R-9). LPA asked, does staff assist you with your incontinence needs in a timely manner. Of those interviewed, 5 out of 9 answered yes, and 4 stated that they were independent. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above 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 allegation is Unsubstantiated. Regarding the allegations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies were cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Wellness Director, Brooke LaMotte.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 11-AS-20250417162558

Allegation investigated: Staff did not respond to resident's call for assistance

On 4/23/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the alleged allegation. LPA identified herself and met Brooke Lamotte- who was informed of the purpose of the visit. The investigation consisted of the following: At 9:30 AM, LPA Allen reviewed resident 1 (R1) file, and notes/logs. LPA Allen requested and reviewed the following documents: Staff roster (LIC 500), shift schedule for 4/6/2025 - 4/7/2025,and resident roster. It is alleged that the facility staff did not respond to residents call for assistance. Continued ... Unsubstantiated At 11:30 AM, LPA Allen interviewed nine (9) staff members staff 1- staff 9 (S1 - S9) of those interviewed 9 out of 9 stated they are informed by the concierge on duty by portable two-way radios of the resident requiring assistance and assistance is provided in a timely manner. The interview with Brooke Lamotte- Wellness Director stated there are some staffing concerns which have been addressed by having a job fair on 4/22/2025 and they expect to have eight (8) additional care staff members and three (3) MedTech’s with estimated start dates of May 1, 2025. LPA Allen also observed the 11 potential new hire roster/schedule. At 1:15 PM, LPA Allen interviewed resident 1- resident 9 (R1- R9) of those interviewed, 1 out of 9 residents stated they did not get assistance when they used the call button on one occasion. The interviews with 8 of the 9 residents (R2 - R9) stated when staff members are called by using the call button it may take longer than usual, but they do get assistance. LPA Allen also toured the facility including five (5) rooms and observed call buttons to be in operable condition and observed residents getting assistance when the call button was used. Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Brooke Lamotte Wellness Director at conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 11-AS-20250415095739

Allegation investigated: Facility staff did not meet resident's incontinence care needs

On 04/09/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Savant of Santa Monica Facility and was greeted by Administrator Nathaniel Venzon (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the finding pertaining to the above-mentioned allegation. The investigation consisted of the following: LPA Calderon interviewed Administrator S1, Staff S2-S5, resident R1-R9. LPA Calderon obtained the following records: Preplacement information (dated 01/10/2024), physician report (dated 01/11/2024), incident report (dated 04/01/2025), Service Plan (dated 09/06/2024), shower logs (dated 02/10/2025 to 04/07/2025) for R1. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Facility staff did not meet residents’ incontinence care needs. This complaint alleged that staff did not meet incontinence care plan for R1. LPA Calderon toured the facility to include R1 room. LPA noted diapers, cleaning supplies, shower seat, creams to take care of R1 private parts. Records review indicate the following: R1 ISP, Physician report indicate health issues Incident reports indicate that R1 was taken to the hospital and evaluated with a UTI. Shower logs indicate that R1 was given a bed bath 11 times between 02/10/2025 to 04/07/2025. St. John Hospital record for medication for diagnosis Acute Cystitis without hematuria. Interviews indicate the following: 5 out of 5 staff deny not providing incontinence care for R1 or any other resident in care. R1 indicates that staff did not change R1 diaper until 12 noon. R1 indicates that staff did provide a shower to R1 every day of the week. R2 indicates that staff did not change R1 diaper until lunch and did not provide a shower weekly. 7 out of 9 residents indicate no need for incontinence care currently. 7 out of 9 residents indicate that they have seen staff provide incontinence care to other residents. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “facility staff did not meet residents’ incontinence care needs” found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report were provided to the Administrator Nathaniel Venzon (S1).the state’s words, verbatim · CDSS document, Apr 9, 2025 · control 11-AS-20250403105629

Allegation investigated: Facility staff do not ensure residents personal belongings are safely secured

On 4/2/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Nathaniel Venzon and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 4/2/25 LPA requested and reviewed copies of the following records: Staff roster, Resident Roster, Identification and Emergency Information, 4/30/24, Physician’s Report, 4/29/24, Resident Service Plan, 3/8/25, cute Care Transfer Log/list of Hospitalizations, March 2025, Laundry Schedule, Resident Personal Property list,4/30/24, Resident Theft and Loss Record, 3/24/25, Unusual Incident/Injury Report,3/24/25. LPA Felisa Shirley spoke to facility Administrator, Nathaniel Venzon, did a facility tour and interviewed Staff 1 through Staff 9 and Resident 1 through Resident 7. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Facility staff do not ensure residents personal belongings are safely secured The details of the complaint allege that resident stated that upon her return to the facility she noticed that her personal belongings had been taken. LPA Felisa Shirley toured the facility and went to R1’s room, searched lost and found, and searched the facility’s laundry room lost and found. LPA Shirley spoke to R1 and wrote down alleged missing items. LPA Shirley searched R1’s closet and dresser and found an article of clothing that R1 mentioned during phone call. During the tour of the facility, LPA Shirley observed the lost and found box located underneath the receptionist desk and did not locate R1’s missing items. LPA Shirley reviewed laundry schedule and went to the laundry room and searched through the lost and found clothing and did not observe other missing items of clothing mentioned by R1. During file review, LPA observed R1’s Resident Personal Property log dated, 4/30/24 and the log did not have alleged missing items listed as property that R1 brought with her to the facility. LPA Shirley spoke with and interviewed staff 1 thru staff 9 (S-1 thru S-9). LPA ask, does staff ensure that residents personal belongings are safely secured? Of those interviewed, 9 out of 9 answered yes. LPA Shirley interviewed residents 1 thru resident 7 (R1 thru R7). LPA ask, does staff ensure that residents personal belongings are safely secured? Of those interviewed, 6 out of 7 answered yes and 1 resident answered no. Con'd on 9099-C Based on interviews, available evidence, information received, and records reviewed there was not enough sufficient evidence 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. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Business Office Manager, Shiree McCutchenthe state’s words, verbatim · CDSS document, Apr 2, 2025 · control 11-AS-20250324095901

Allegation investigated: Staff did not attend to resident's in a timely manner Staff sleep while on shift Staff did not provide reasonable privacy to residents in care

On 4/2/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Business Office Manager, Shiree McCutchen and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 2/21/25 LPA requested and reviewed copies of the following records: Staff roster, Resident roster, resident face sheet, Identification and Emergency Information, Physician’s Report, Admission Agreement, Release of Client/Resident Medical Information, Client/Resident personal property and valuables, copy of resident ID, and Your right to make decisions about medical treatment. LPA Felisa Shirley spoke to facility Administrator, Nathaniel Venzon, did a facility tour and interviewed Staff 1 through Staff 9 and Resident 1 through Resident 9. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not attend to residents in a timely manner The details of the complaint allege that the residents calls are not answered by night shift staff and they are left in soaked briefs until morning staff arrives. On 2/21/25 between 9:03am – 10:30am, LPA Shirley interviewed R1 – R9. On 2/21/25 LPA Shirley toured the facility and pushed the call buttons in rooms 21A, 21B, 28, 34, 32B, and 50. LPA Shirley noted that the call box in room #28 was not working correctly. LPA Shirley pushed the call button on the call box three times and observed that the indicator on the call box did not light up. LPA Shirley turned the box over and observed that the wires were loose and therefore not giving an alert to the front desk. LPA Shirley assembled the wire around the screw behind the call box and then again pushed the button and the indicator lit up. As soon as the indicator lit up, the staff assigned to the front desk answered and said, “Front desk, how can I help you.” LPA Shirley spoke with and interviewed staff 1 thru staff 9 (S1 thru S9). LPA ask, does staff attend to residents in a timely manner? Of those interviewed, 7 out of 9 staff answered yes, and 2 answered other than yes or no. LPA Shirley interviewed residents 1 thru resident 9 (R1 thru R9). LPA ask, does staff attend to your needs in a timely manner? Of those interviewed, 5 out of 9 residents answered no, 4 residents answered yes. Regarding the allegation “Staff did not attend to residents in a timely manner, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Con'd on 9099-C Allegation: Staff sleep while on shift LPA Shirley spoke with and interviewed staff 1 thru staff 9 (S1 thru S9). LPA ask, does staff sleep while on shift? Of those interviewed, 6 out of 9 staff answered no, 2 staff answered yes and one answered other than yes or no. LPA Shirley interviewed residents 1 thru resident 9 (R1 thru R9). LPA ask, do you believe the staff sleep during the nightshift? Of those interviewed, 3 out of 9 residents answered yes, 2 residents answered no and 4 answered other than yes or no. Regarding the allegation “Staff sleep while on shift, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation: Staff did not provide reasonable privacy to residents in care The details of the complaint allege that staff listens in on the rooms through the call boxes without the resident’s knowledge. On 2/21/25 between 9:03am – 10:30am, LPA Shirley interviewed Resident#1 – 9. During interviews, six residents stated that they can tell when the call box comes on because they can hear the static. LPA Shirley pushed six residents call buttons that were in their rooms during the time of the interviews. LPA Shirley verified that the call buttons were working and could hear when staff is about to speak and all received immediate responses once the buttons were pushed. Con'd on 9099 LPA Shirley spoke with and interviewed staff 1 thru staff 9 (S1 thru S9). LPA ask, does staff provide reasonable privacy to residents in care? Of those interviewed, 9 out of 9 staff answered yes. LPA Shirley interviewed residents 1 thru resident 9 (R1 thru R9). LPA ask, do you believe that you receive reasonable privacy? Of those interviewed, 7 out of 9 residents answered yes and 2 residents answered no. Regarding the allegation “Staff did not provide reasonable privacy to residents in care, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Business Office Manager, Shiree McCutchen.the state’s words, verbatim · CDSS document, Apr 2, 2025 · control 11-AS-20250219081756

Allegation investigated: Facility staff does not dispense residents’ medications as prescribed. Facility staff does not provide comfortable accommodations to residents in care. Facility staff did not provide residents with medical attention in a timely manner. Staff did not treat residents with dignity and respect.

The investigation consisted of the following: On 02/27/2025, Community Care Licensing Division (CCLD) Staff conducted a complaint investigation at the above facility to address the following allegations. CCLD Staff met with Executive Director Nathaniel Venzon and explained the purpose of the visit. CCLD Staff conducted staff interviews, toured the laundry room area and first floor common areas, and reviewed facility, resident, and staff training records. On 03/20/2025, Licensing Program Analysts Regina Cloyd and Jose Anguiano conducted a subsequent complaint visit. LPAs met with Executive Director and Nurse Brooke. LPAs conducted resident and staff interviews, reviewed medication, observed residents’ rooms, and toured the facility. On 03/27/25, LPA Cloyd conducted a subsequent complaint visit and met with Business Office Manager Shiree McCuthchen. LPA interviewed residents, reviewed records, and delivered findings. Continue to LIC9099-C. Unsubstantiated Allegation: Regarding the allegation "Facility staff does not dispense residents’ medications as prescribed,” it is being alleged that staff are not regularly providing residents with their medications, and in some cases, they do not receive them at all. Resident #1 (R1) alleged medication #1 and medication #2 has not been given. R1 did not know the name of medication #2 but described why it is needed. Resident #2 (R2) alleged medication #3 is not given at nighttime. January and February 2025 Medication Administration Records’ revealed R1 received medication #1 as prescribed. On 03/20/25, LPA Cloyd observed medication #1 in stock. On 03/20/25, LPA Cloyd observed three medications that addresses the same condition as medication #2. These medications were dispensed as prescribed. R2’s January and February 2025 MAR revealed medication #3 was taken as prescribed. Six out of eight staff interviews indicated they have not received complaints regarding medication errors. Five out of six resident interviews indicated medication is being dispensed as prescribed. Three out of three residents interviews indicated that they manage their own medication. Regarding the allegation “Facility staff does not dispense residents’ medications as prescribed," based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation: Regarding the allegation "Facility staff does not provide comfortable accommodations to residents in care,” it is being alleged that Resident #1 and Resident #2’s room is extremely cold and heater and blankets are not provided. Five out of eight staff interviews indicated residents have complained about the room temperatures being too cold. Eight out of nine resident interviews indicated that it does get too hot and too cold. Six out seven residents indicated that staff respond with blankets or open their doors. Interview with the Maintenance Director indicated that the thermostat controls 10-15 rooms at once and different residents want different temperatures. We’ll leave it at 75 degrees cool so that it won't be too cold or too hot. If the weather is cooler then the heater is set at 75. LPA Anguiano observed the thermostat set at 72 degrees (first floor) and 73 degrees (second floor). Regarding the allegation “Facility staff does not provide comfortable accommodations to residents in care," based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Continue to LIC9099-C. 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, as a result, the allegation is Unsubstantiated. Allegation: Regarding the allegation "Facility staff did not provide residents with medical attention in a timely manner,” it is being alleged that Resident #1 (R1) and Resident #2 (R2) have been ill and have not received medical attention. R2 indicated that the illness was not reported. Record review of Care Transfer Log revealed thirty-one residents, including R1, were sent out for medical attention in January 2025. Care Transfer Log revealed nineteen residents were sent out for medical attention in February 2025. Seven out of eight staff interviews (S1 – 6, 9, 10) indicated that they respond to residents with medical attention in a timely manner. Four out six of resident interviews indicated they receive medical attention in a timely manner. Two out of two residents indicated staff sometimes responds in a timely manner. Regarding the allegation “Facility staff did not provide residents with medical attention in a timely manner," based on record reviews and interviews the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation: Regarding the allegation "Staff did not treat residents with dignity and respect,” it is being alleged that staff laughed at Resident #1 (R1) when R1 requested for medical assistance. Record review revealed six out of ten staff completed "Knowing the Rights of Residents" training. Nine out of ten staff interviews (S1 – S10) indicated they respond to residents with medical concerns with dignity and respect. Eight out of nine resident interviews indicate staff respond to them with dignity and respect. Regarding the allegation “Staff did not treat residents with dignity and respect," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Wellness Director Brooke Lamotte.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 11-AS-20250220150259

Allegation investigated: Facility staff are not dispensing medication as prescribed. Facility staff are not safeguarding residents personal property.

On 03/27/2025, Licensing Program Analyst (LPA) Troy Watson conducted a subsequent visit to deliver findings for the allegations listed above. LPA reviewed LPA met with Brooke Lamotte and explained the purpose of the visit. LPA was granted entry to the facility. as Administration Records (MAR’s) for Residents #1- #6, and Resident Theft and Loss Records. On 03/26/25 interviews were conducted with Staff#1-Staff#8 (S1-S8) and Residents #1 – Residents#6 (R1-R6). Investigation revealed the following: CONTINUED ON LIC9099-C Unsubstantiated Allegation: Facility staff are not dispensing medication as prescribed. It is being alleged that R1’s medication is supposed be given in a powder form and not a cream. LPA observed that R1’s medication comes in both a powder and a cream, and according to the MAR’S has been consistently receiving the correct medication for her wound healing, which is documented on the MAR as being administered as a powder. toured the facility and while touring the medication room LPA observed medication is both in a powder and cream. On 03/27/2025 LPA reviewed facility records per medication administration log (and they are) MAR R1. On 03/26/2025 LPA conducted interviews with Staff #1- Staff #8 (S1-S8). Of those interviewed 8 out of 8 staff denied the above allegation. On 03/26/25 the department conducted interviews with Resident #1 – Resident # 6 (R1 -R6). Of those interviewed 6 out of 6 residents denied the above allegation Allegation: Facility staff are not safeguarding residents’ personal property. It is alleged that medical cards and documents were stolen from Resident #1’s (R1) room. On 03/26/2025 LPA Watson interviewed the Executive Director Nathaniel Venzon. During the interview Nathaniel Venzon stated that a resident reported items stolen but it was replaced during a move from one room to another. Staff offered to replace items not located. The department conducted interviews with Staff #1- Staff #8 (S1-S8). Of those interviewed 8 out of 8 staff denied the above allegation. On 03/26/25 the department interviewed Resident #1 – Resident #6 (R1 -R6). Of those interviewed 6 out of 6 denied the above allegation. Based on the information collected from the facility, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted with the Wellness Director Brooke Lamotte and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 11-AS-20250317141858

Allegation investigated: Facility staff are not keeping the facility free from pests. Facility staff are not providing clothing to residents. Facility staff did not safeguard residents' property and valuables.

The investigation consisted of the following: On 02/27/2025, Community Care Licensing Division (CCLD) Staff conducted a complaint investigation at the above facility to address the following allegations. CCLD Staff met with Executive Director Nathaniel Venzon and explained the purpose of the visit. CCLD Staff conducted staff interviews, toured the laundry room area and first floor common areas, and reviewed facility, resident, and staff training records. On 03/20/2025, Licensing Program Analysts Regina Cloyd and Jose Anguiano conducted a subsequent complaint visit. LPAs met with Executive Director and Wellness Director Brooke Lamotte. LPAs conducted resident and staff interviews, reviewed medication, observed residents’ rooms, and toured the facility. Continue to LIC9099-C. Unsubstantiated Allegation: Regarding the allegation "Facility staff are not keeping the facility free from pests,” it is being alleged that Resident #1 and Resident #2 had recurring bed bugs the past year. Record review revealed that pest control services for bed bugs was provided on 10/28/24, 11/14/24, and 02/19/25 for room 86. Six out of eight staff interviews indicated pest control services are called to resolve pest. Interview with the Executive Director and Maintenance Director indicated that the reoccurrence may be caused by R2. R2 to leaves the facility but R1 remains the facility. Eight out of nine resident interviews indicated they have not had an issue with bed bugs. Regarding the allegation “Facility staff are not keeping the facility free from pests," based on record reviews and interviews the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation: Regarding the allegation "Facility staff are not providing clothing to residents,” it is being alleged that the facility has extra clothing in the basement but refuse to retrieve them. Record review of the Admission Agreement does not reveal that the facility will provide clothing to residents. Seven out of nine staff interviews indicated the facility provides donated clothes to residents when needed. Nine out of nine resident interviews indicated they have their own clothing and do not have issues. Regarding the allegation “Facility staff are not providing clothing to residents," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Continue to LIC9099-C. Allegation: Regarding the allegation "Facility staff did not safeguard residents' property and valuables,” it is being alleged that staff took Resident #1 and Resident #2’s clothes to be washed eight months ago and they haven’t received them back yet. Record review of Housekeeping Schedule laundry is done for room R1 and R2 on Saturday. Five out of six staff interviews indicated staff has not taken residents’ clothes for an extend amount of time. Four staff interviews indicated laundry is returned on the same day. Interview with the Executive Director indicated that the clothes for residents with bed bugs will be returned gradually because the facility has to stick with the laundry schedule. Nine out of nine resident interviews indicated they receive their clothes back within two hours. Regarding the allegation “Facility staff did not safeguard residents' property and valuables," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was left with the Wellness Director Brooke Lamottethe state’s words, verbatim · CDSS document, Mar 20, 2025 · control 11-AS-20250220150259

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At 8:50 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct an annual inspection. LPA Allen was greeted by Francisco Orozco-Maintenance Director upon arrival. LPA introduced herself and explained the purpose of the visit,to Francisco Orozco who granted access into the facility. At 9:00 AM, Nathaniel Venzon- Administrator arrived and he was informed of the purpose of the visit. The facility is licensed to serve at the capacity of (174) age range 60 and over adults. The fire clearance is approved for (150) non-ambulatory, (24) bedridden residents and hospice waiver for 30. At 9:25 AM LPA reviewed ten (10) clients files for admission agreements, updated physician reports, and needs and services plans which were up to date. At 10:15 AM, LPA and Francisco Orozco toured the physical plant. There were no bodies of water or obstructions in the indoor and outdoor passageways, stairways, open areas, and other areas of potential hazard are free of obstructions. LPA also observed the common areas to have furniture that appeared to be in good repair and sufficient for clients and visitors. The facility also has a shaded patio area for smoking and non-smoking with seating that can accommodate clients and visitors. The fire extinguishers were fully charged, and the last fire drill was conducted on 2/28/2025. LPA toured five (5) bedrooms downstairs and five (5) bedrooms upstairs which all have the required furniture,storage areas, and the bathrooms appeared to be clean and operational. LPA and Francisco tested the water temperature in the ten (10) bedrooms which ranged from 105-115 degrees F. At 11:45 AM, LPA, conducted a tour of the kitchen and there was a menu available for review and there appeared to be enough perishable and non-perishable food available, which is stored properly and appeared to be sufficient for the number of clients in care. At 12:43 PM, LPA reviewed ten (10) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings which were all current. At 1:21 PM, LPA conducted a random audit for 6 (six) clients medications that appeared to be dispensed as prescribed by their physician and they were centrally stored and properly locked. The first aid kits and manual were checked and fully stocked. LPA observed that all window screens were clean and in good repair. Facility temperature is between 68° degrees and 85° degrees. Overall, the facility appeared to be clean, sanitary, and in good repair. Based on the observations made during today’s visit, no deficiencies were cited. An exit interview was conducted, and this report was discussed and provided to Nathaniel Venzon- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 19, 2025

Allegation investigated: Staff do not respond to resident's call for assistance in a timely manner. Staff are mismanaging resident medication. Staff are not meeting resident's hygiene needs. Staff are not keeping the facility clean or sanitary.

On 03/04/2025 Licensing Program Analyst (LPA) Elvira Gonzalez conducted a subsequent unannounced complaint visit to further investigate the allegations listed above and deliver findings. LPA met with Maintenance Director, Francisco Orozco, and the purpose of this visit was explained. LPA was granted entry to the facility. Executive Director, Nathaniel Venzon, joined LPA shortly after. The investigation consisted of the following: On 10/09/24, LPA Gonzalez obtained and reviewed the following documents: resident roster, staff roster, staff schedules for September 2024 and October 2024, facility maintenance schedule, and shower schedule. LPA Gonzalez conducted interviews with Narine Mertkhanyan, Administrator (A1), and staff #1 (S1), and conducted a tour of the facility. On 02/20/25, LPA Gonzalez received and reviewed the following documents: resident roster, staff roster, Admissions Agreement, Physician’s Report, Physician’s Order Report, Face Sheet, Personal Rights, and Medication Administration Records (MARs) for R2 dated: October 2024 – December 2024. Unsubstantiated Additionally, LPA Gonzalez inspected the Medication Room, and conducted interviews with staff #2-#5 (S2-S5), and residents #1-#6 (R1-R6). On 02/27/25, LPA Gonzalez conducted telephonic interviews with residents #7-9 (R7-R9). On 03/03/25 LPA received Medication Administration Records (MARs) dated: October 2024 – December 2024 for R10-R11. The investigation revealed the following: Allegation: Staff do not respond to resident's call for assistance in a timely manner. It is being alleged that residents are not attended to in a timely manner. On 10/09/24 between 10:45 AM – 11:30 AM LPA Gonzalez conducted interviews with A1 and S1, and on 02/20/25 between 09:30 AM – 11:30 AM LPA Gonzalez conducted interviews with S2-S5. Based on interviews conducted, 5 out of 6 staff interviewed denied the allegation. 6 out of 6 staff interviewed confirmed residents have a callbox located in their rooms. They use the call button to alert staff, that call will go to a central monitoring station that is in the reception area. The receptionist will then answer the call, and radio a care staff to respond to the resident requesting assistance. 5 out of 6 staff interviewed stated that they are responding to residents’ call button alerts in a timely manner. On 02/20/25 between 12:30 PM – 2:30 PM LPA Gonzalez conducted interviews with R1-R6 and on 02/27/25 between 02:05 PM – 02:45 PM LPA Gonzalez conducted interviews with R7-R9. Based on interviews conducted, 6 out of 9 residents interviewed stated that staff responds to their calls for assistance in a timely manner. 9 out of 9 residents interviewed stated that they are satisfied with the staff at this facility and the services provided to them. Based on interviews conducted, the department did not find sufficient evidence 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. Continued on LIC9099-C Allegation: Staff are mismanaging resident medication. It is being alleged that resident’s medications are routinely late. On 10/09/24 between 10:45 AM – 11:30 AM LPA Gonzalez conducted interviews with A1 and S1, and on 02/20/25 between 09:30 AM – 11:30 AM LPA Gonzalez conducted interviews with S2-S5. Based on interviews conducted, 4 out of 6 staff interviewed denied the allegation. 5 out of 6 staff interviewed stated that all resident’s medications are dispensed according to the physician’s orders. On 02/20/25 between 12:30 PM – 2:30 PM LPA Gonzalez conducted interviews with R1-R6 and on 02/27/25 between 02:05 PM – 02:45 PM LPA Gonzalez conducted interviews with R7-R9. Based on interviews conducted, 7 out of 9 residents interviewed stated that staff administers their medication according to the physician’s orders. 7 out of 9 residents interviewed stated they have no issues with staff and their medications not being dispensed on time. LPA Gonzalez conducted a record review of the MARs (dated: 10/01/24 – 12/31/24) and did not observe any discrepancies or mismanaging of resident’s medication. Based on observation, interviews conducted, and records reviewed, the department did not find sufficient evidence 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. Allegation: Staff are not meeting resident's hygiene needs. It is being alleged that there have been issues with the residents getting help with bathing. It is also being alleged that a resident was left soiled and unattended. A record review of the shower schedule for residents who require assistance revealed that residents are scheduled with an assisted shower 1 to 3 times a week. On 10/09/24 between 10:45 AM – 11:30 AM LPA Gonzalez conducted interviews with A1 and S1, and on 02/20/25 between 09:30 AM – 11:30 AM LPA Gonzalez conducted interviews with S2-S5. Based on interviews conducted, 6 out of 6 staff interviewed denied the allegation. 5 out of 6 staff interviewed stated that residents bathing service needs are being met. 6 out of 6 staff interviewed stated that residents are scheduled to shower 1-3 times a week, and as needed. On 02/20/25 between 12:30 PM – 2:30 PM LPA Gonzalez conducted interviews with R1-R6 and on 02/27/25 between 02:05 PM – 02:45 PM LPA Gonzalez conducted interviews with R7-R9. Based on interviews conducted 9-9 residents interviewed stated that they have not been left soiled and unattended by staff. 9 out of 9 residents interviewed stated that they are assisted with showering 1-3 times a week, and as needed. 9 out of 9 residents interviewed stated that they are satisfied with the staff at this facility and the services provided to them. Based on observation, interviews conducted, and records reviewed, the department did not find sufficient evidence 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. Allegation: Staff are not keeping the facility clean or sanitary. It is being alleged that the carpet in a resident’s room is now black from spills. On 10/09/24 between 10:45 AM – 11:30 AM LPA Gonzalez conducted interviews with A1 and S1, and on 02/20/25 between 09:30 AM – 11:30 AM LPA Gonzalez conducted interviews with S2-S5. Based on interviews conducted, 6 out of 6 staff denied the allegation. 5 out of 6 staff stated that the facility is kept clean and sanitary. An interview with S2 communicated that the carpets are cleaned monthly and as needed. S2 stated that they have been working on removing the carpet from resident’s rooms and replacing it with wood flooring, and that they are averaging to do two rooms a month, sometimes three. On 02/20/25 between 12:30 PM – 2:30 PM LPA Gonzalez conducted interviews with R1-R6 and on 02/27/25 between 02:05 PM – 02:45 PM LPA Gonzalez conducted interviews with R7-R9. Based on interviews conducted 9 out of 9 residents interviewed denied the allegation. 9 out of 9 residents interviewed that the facility is kept clean and sanitary. On 10/09/24, LPA Gonzalez conducted a tour of the facility. LPA observed the facility to be clean and, sanitary and in good repair. LPA did not notice any black stains in the rooms that had carpet. Based on observation, interviews conducted, and records reviewed, the department did not find sufficient evidence 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. An exit interview was conducted with Executive Director, Nathaniel Venzon, and a copy of this report and appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 4, 2025 · control 11-AS-20241002120926

Allegation investigated: Staff did not provide resident with a 60 day notice prior to rate increase

On Februray 20, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced complaint visit to address the allegation listed above. LPA Lee met with Shiree McCutchen, Business Office Manager and explained the purpose of this visit. Brooke Lamotte, Welness Director subsequently joined to assist with visit. Investigation Consisted of the following: LPA conducted the following interviews: Business office Manager Interview (A1), Staff Interviews (S1-S3 ) and Resident’s Interviews (R1-R4). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, Physicians Report for Residential Care Facilities for the Elderly for R1(Dated 3/7/24) Needs and Services Plan for R1 dated (1/25/25), copy of rate increase letter for R1 (dated 12/23/24), copy of email conversations between R1 and Business office manager (Dated 2/12/25 and 2/13/25). LPA reviewed R1's files. Page 1 of Unsubstantiated Allegation: Staff did not provide resident with a 60-day notice prior to rate increase The details of the complaint alleged that that R1 received a notice for a rate increase and that the facility did not give a 60 day notice. During an Interview with the Business Office Manager (A1), she stated that rent increases occurs annually, and that they give the letters 60-days prior to increase. Additionally, A1 stated that notices are provided to the residents via their mail boxes or in person. Letters are always sent in a timely manner. Lastly, A1 states that if a notification is missed, they would work with the resident and offer a payment plan if needed and/or modify the due date. During interviews with staff (S1-S3), (3 ) out ( 3 ) staff stated that residents receive their mail on time including notices about rate increases. (3) out of (3)state that there has been no complaints from residents regarding not receiving mail in a timely manner. During interviews with residents (R1-R4), ( 2 ) out of ( 4) stated that they get their rent increase notices on time. (1) out of (4) expressed that they didn't get their notices in time but it was resolved in a fair manner. LPA obtain/reviewed a copy of emailed conversations between R1 and the Business Office Manager (Dated 2/12/25 and 2/13/25) where R1 acknowledges that the situation was resolved to his satisfaction. During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Brooke Lamotte, Wellness Directorthe state’s words, verbatim · CDSS document, Feb 20, 2025 · control 11-AS-20250212094338

Allegation investigated: Illegal eviction.

On 01/22/24, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent visit in order to render investigation findings. LPA met with Business office manager Shiree McCutchen as the purpose of the visit was explained. The investigation consisted of the following: On 10/9/24 the department conducted an initial visit. On 1/22/25 the department spoke with Administrator (A1) and Staff #1 via telephone. On 1/22/25, the department was provided documents regarding the allegation such as a settlement agreement. The investigation consisted of the following: The department conducted a review of the eviction noticed served to R1 on 04/01/2024. The review of the eviction notice revealed R1 was being evicted for non-payment of the rent with a balance owed of $12,500. The eviction notice appeared to follow Title 22 Regulations for eviction procedures. On 1/22/2025, the department interviewed A1, A1 stated he just became the administrator and is aware R1 was issued an Unsubstantiated eviction but the corporate office would be able to provide additional details. On 1/22/2025, the department spoke with S1 regarding the allegation, S1 stated R1 was issued an eviction and did not leave so an unlawful detainer was filed. S1 stated the hearing was held late last year and a settlement agreement was reached. On 1/22/2025, LPA was unable to conduct interview with R1 as R1 refused interview. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. 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 allegation is unsubstantiated. An exit interview was conducted, and a copy of the Complaint Report was given to Business office manager Shiree McCutchen.the state’s words, verbatim · CDSS document, Jan 22, 2025 · control 11-AS-20241003091622

Allegation investigated: Staff are not addressing resident behavior.

On 12/4/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Narine Mertkhanyan /Administrator.LPA explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interview (S#1-S#6) and Resident’s Interview (R#1-R#8). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#4) Identification and Emergency Information, (R#1-R#4) Admissions agreements, (R#1-R#4) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#4) Needs and Services Plan, (R#1-R#4) Medication Administration Record (MAR) for the month of November 2024. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff are not addressing resident behavior. The details of the complaint alleged that facility staff are not addressing resident disruptive behavior. During an Interview with the Administrator (A#1), she stated that we address the resident’s disruptive behavior when it is brought to our attention. Also, (A#1) stated that residents are not getting intoxicated and leaving the facility at night. The facility has not received complaints regarding residents getting intoxicated and leaving the facility at night. During interviews with staff (S#1-S#6), (6) out (6) stated that the facility is addressing residents’ disruptive behavior when it is brought to their attention or witnessed. Also, (6) out of (6) staff stated that the residents are not getting intoxicated and leaving the facility at nighttime. The facility has not gotten complaints regarding residents leaving the facility at nighttime intoxicated. During interviews with residents (R#1-R#8), (6) out of (8) stated that the facility is addressing residents’ disruptive behavior, and they have never witnessed residents getting intoxicated and leaving the facility at nighttime. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Evaluation Report continues LIC 9099-C Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Narine Mertkhanyan /Administrator.the state’s words, verbatim · CDSS document, Dec 4, 2024 · control 11-AS-20241125101629

Allegation investigated: Staff are mismanaging resident's medication Staff did not ensure resident's room was cleaned Staff did not safeguard resident's clothing Staff did not ensure the a/c was not in disrepair Staff did not ensure the bathroom fan was not in disrepair

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Savant of Santa Monica Facility on 09/05/2024 and was greeted by Administrator Narine Mertkhanyan S1. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Administrator S1, staff S2-S4, residents R1-R7. On 09/04/2024 LPA Calderon requested and reviewed copies of the following: Pre-placement Report (dated 08/15/2024), Medication Administration Record (MAR) (date 08/2024), Overland Terrace Medical records (dated 08/15/2024), Admission Agreement (dated 08/15/2024), Market Pharmacy order form (dated 08/21/2024) for R1. The investigation revealed the following: Unsubstantiated Regarding Allegation #1: Staff are mismanaging residents’ medication. It is being alleged that staff neglected to provide medication to R1. LPA Calderon toured the facility with S2. LPA walked into the medication room and noted residents taking their medications. LPA also noted staff in the dining room giving medications to residents. Reviewed the MAR (dated 08/2024) for R1. Per the admission agreement (dated 08/15/2024 R1 moved into the facility and per the MAR staff started to give medication to R1 starting on 08/16/2024. Reviewed Market Pharmacy order form (dated 08/22/2024), drug Lacrollmus, last office visits 08/21/2024, message from NewRx, “not covered prior authorization required. We already send paperwork to MD office, please follow up with MD”. 4 out of 4 staff indicate that R1 was provided medication on time. 2 out of 2 staff indicate that R1 medication for R1 liver was rejected by R1 insurance company. 6 out of 7 residents indicate no issues with staff giving medications. 6 out of 7 residents indicate staff have never run out of their medications. Regarding Allegation #2: Staff did not ensure residents room was cleaned. It is being alleged that staff did not clean R1 room. LPA Calderon toured the facility with S2. LPA inspected all common areas and all areas appeared to be clean. LPA noted staff cleaning rooms and common areas. LPA inspected room 3, 17, 36, 46, 65 (R1 room), 76 and 85. All rooms appeared to be clean, bathrooms were clean, and trash was picked up. Per R1 admission agreement (dated 08/15/2024) page 9 “staff will clean residents’ room weekly”. 4 out of 4 staff indicate that staff do clean residents’ room weekly. 6 out of 7 residents indicate that staff do clean their rooms weekly and pick up trash daily. 6 out of 7 residents indicate no issues with facility staff cleaning their rooms. Regarding Allegation #3: Staff did not safeguard residents clothing. It is being alleged that staff washed and damaged R1 clothes. LPA Calderon toured the facility with S2. LPA inspected the laundry room and noted residents wash being cleaned. LPA also noticed staff transporting folded clothes in a basket to resident’s room. Reviewed admission agreement (dated 08/15/2024) for R1. Per page 8 "states that laundry will be provided weekly". 4 out 4 staff indicate that there have been no complaints regarding staff washing residents’ clothes. 6 out of 7 residents indicate no issues with staff washing their clothes. Regarding Allegation #4: Staff did not ensure the AC was not in disrepair. It is being alleged that the AC in R1 room was not working. LPA Calderon toured the facility with S2. LPA noted the AC working in the common areas. LPA inspected room 3, 36, 46, 65 (R1 room), 76 and 85. LPA noted that the AC was working in each room. 4 out of 4 staff indicate that there have been no issues with the AC unit and 4 out of 4 staff indicate that all AC units are working for each room. 6 out of 7 residents indicate that the AC in their room is working fine and they have no issues. Regarding Allegation #5: Staff did not ensure the bathroom fan was not in disrepair. It is being alleged that the bathroom fan in R1 room was not working. LPA Calderon toured the facility with S2. LPA inspected room 3, 17, 36, 46, 65 (R1 room), 76 and 85. LPA noted the fan in each bathroom and bedroom fan was working. 4 out of 4 staff indicate that all bathroom fans are working, and no complaints have been made. 6 out of 7 residents indicate that the bathroom fan in their room work fine and they have no issues. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “staff are mismanaging residents medication”, “staff did not ensure residents room was cleaned”, “staff did not safeguard residents clothing”, “staff did not ensure the AC was not in disrepair”, “staff did not ensure the bathroom fan was not in disrepair” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Narine Mertkhanyan S1.the state’s words, verbatim · CDSS document, Sep 5, 2024 · control 11-AS-20240827154736

Allegation investigated: Staff did not ensure resident's showering needs were met

***This amended report supersedes the report dated 5/24/2024. This report is being created to remove unsubstantiated allegation “Staff did not ensure resident's showering needs were met." This unannounced subsequent complaint inspection is being conducted on 08/13/24 by Licensing Program Analyst (LPA) Wendy Gibbs, for the purpose of delivering findings for the investigation into the above identified complaint allegation. The LPA met with facility Administrator, Narine Mertkhanyan, and the purpose of today's visit was explained. On previous visits conducted on 05/24/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced 10-day complaint visit. LPA met with Administrator, Ruby Cruz, and the purpose of the day’s visit was explained. During the visit, LPA toured the facility, interviewed Staff S1-S5, interviewed Residents R1-R7, and received documents pertinent to the investigation. The documents include a Staff Roster, Resident Roster, Shower Log, Resident’s Physician Reports, Resident’s Pre-appraisal Evaluation, Resident Needs and Service Plan, and Staffing Notes for the past three (3) months. Substantiated Allegation: Staff did not ensure resident’s showering needs were met The allegation alleges a resident, who is a fall risk, did not receive assistance with a shower for 1 ½ months despite asking for assistance. During record review of the shower schedule for residents who require assistance, LPA observed that residents are scheduled with an assisted shower 1 to 3 times a week. LPA reviewed four (4) Residents Physician’s Report, Needs and Service Plan, and Appraisal to see they type of assistance Residents require. During record review of R1’s Admission Agreement, LPA observed under Basic Services, R1 initialed number 9 indicating the acceptance of services, which include assistance with bathing. Additionally, LPA reviewed R1’s Service Plan that indicates R1 will be assisted once a week with showering and bathing. LPA reviewed the facility Shower Schedule which indicates R1 is to be assisted with a shower once a week. During review of the facility Staff Notes, LPA did not see any notes regarding R1 receiving assistance with a shower. During interviews with Staff S1-S5, were asked if residents who require assistance with a shower receive assistance, five (5) out of five (5) stated residents who require assistance with a shower receive assistance. Additionally, five (5) out of five (5) stated if a resident who requires assistance with a shower requests a shower on a non-scheduled day the staff will accommodate the resident as soon as they are available, unless it is related to incontinence. During interviews with Residents R1-R7, were asked if they receive assistance with a shower, four (4) out of seven (7) stated they receive assistance with showers when scheduled and when need or requested. Additionally, Residents R1-R7, were asked if there was a time, they not receive assistance with a shower, three (3) out of seven (7) stated they require assistance and was not provided with it. Additionally, two (2) out of the seven (7) stated they have either gotten into the shower without assistance or have taken a shower without assistance while being a fall risk. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted 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 Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator, Narine Mertkhanuan, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2024 · control 11-AS-20240520092651

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 27, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and... as specified in Section 87608, Postural Supports. This was not met based on interviews and record review Administrator did not ensure resident R1 received assistance with a shower as indicated on Admission Agreement and Service Plan which could be a health and safety risk to the resident.the state’s words, verbatim · CDSS document, Aug 13, 2024

Plan of correction: Administrator will ensure residents receive assistance with showering according to resident’s Needs & Service Plan and keep shower log notes indicating residents take a shower or refused and email shower log to LPA, at wendy.gibbs@dss.ca.gov, by POC date.

Allegation investigated: Staff are stealing clients' personal food items Staff do not provide adequate amount of food. Staff pulled resident's hair. Staff inappropriately touched resident.

On 08/13/24, Licensing Program Analyst (LPA), Wendy Gibbs conducted and unannounced subsequent visit to the facility listed above to deliver findings for the complaint indicated above. LPA met with Administrator, Narine Mertkhanan, and the purpose of today’s visit was explained. During a previous visit conducted on 07/31/24, Licensing Program Analysts (LPAs), Wendy Gibbs and Deborah Lee, conducted an unannounced 10-day complaint visit to the facility listed above. LPAs met with Business Office Manager, Ashley Fernandez and the purpose of that visit was explained. We were later joined by Administrator, Narine Mertkhanan. During the visit, LPAs toured the facility, interviewed Staff S1-S8, interviewed Residents R2-R9, and received documents pertinent to the investigation. The following documents were received Staff Roster, Resident Roster, Weekly Menu’s, Nutritionist Menu Review, Alternative Meal Menu Selections, Snack Menu, Theft/Loss Policy, residents Admission Agreement, resident Safeguard of Valuables/Property, Staff Mandated Reporting Training, and Staff End of Shift book. The investigation revealed the following: Unsubstantiated Allegation: Staff did not safeguard residents’ personal property The complaint allegation alleges staff have been stealing residents personal belonging such as perfume. During record review, LPA reviewed the facility’s Theft/Loss Policy, that indicates that the resident or responsible party does have the option to refuse or disclose personal items being brought into the facility to be inventoried. LPA reviewed Resident’s R1, R2, R5, and R7 Client/Resident Personal Property and Valuables (LIC621) observed two of the residents opted not to have their personal items inventoried, and two (2) of the residents listed minimal personal belongings on the LIC621. LPA reviewed R1s LIC621 and did not observe perfume listed. During interviews with Resident’s R2-R9, were asked if they have had any personal items go missing, eight (8) out of eight (8) stated they have had no item go missing or that were stolen. During interviews with Staff S1, S2, S4-S8, were asked how staff help residents safeguard their personal belongings, seven (7) out of seven (7), stated they remind residents to lock their door when they leave their room. Additionally, two (2) of the seven (7) stated they encourage residents to keep their valuables in their room, so they do not get lost in the facility. During interviews with Staff S2, S4-S8, were asked if there were any reported missing or stolen items in the past two (2) months, four (4) out of six (6) stated two (2) residents have reported missing items. One resident reported a missing phone and money which were found in the resident’s room with staff assistance, and the other resident is R1, who according to staff, gives their belongings and money to other residents. (2) Continued On LIC9099-C During an interview with S2, they stated R1 was upset that a bottle of perfume was stolen by another resident. S2 and the former administrator spoke with R1 and was informed that R1 gave R2 a bottle of perfume, R2 did not like the perfume so R2 gave it away to someone else. LPAs asked R2 about the incident with a bottle of perfume R1 had given them and R2 stated “I sprayed it on myself, and I did not like it.” Additionally, two (2) out of six (6) stated they have witnessed R1 giving belongings away and have told R1, they do not have to give their belongings or money to other residents in the facility. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff do not provide adequate amount of food The complaint allegation alleges that the food received is minimal. During the facility visit, LPA’s observed kitchen staff making the plates for residents’ lunch. LPA’s observed ample portions of food on each plate. LPAs observed staff using measuring ladle for portioning the sides. During record review, LPAs received and reviewed a copy of the weekly menus and the Alternative Option Menu available if residents do not want what is on the menu. During interviews with Resident’s R2-R9, were asked if they are provided with enough food, seven (7) out of eight (8) stated they are provided with enough food to eat. Additionally, one resident stated they sometimes get hungry after dinner, (3) Continued on LIC9099-C and they don’t want to go downstairs to get a snack. During interviews with staff S2-S8 were asked if residents were provided with enough food throughout the day, seven (7) out of seven (7) stated yes residents are provided with 3 meals a day and snacks are always available. Additionally, during interviews with Staff S2-S8, were asked if there have been any complaints about the portion of food provided, six (6) out of seven (7) stated they have not heard any complaints. One staff stated there were a few complaints over a month ago that the portions were small, but no new current complaints. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff pulled resident’s hair The complaint allegation alleges a staff pulled residents hair out. During record review, LPAs reviewed and received staffs signed Mandated Reporting that states if they observe or suspect abuse occurring, they will report it. Additionally, LPAs received and reviewed a copy of the facility’s Employee Handbook stating, on pages 71-72, employees responsibility to report any incident of resident abuse, or suspected resident abuse. During interviews with Residents R2- R9, were asked if their hair has been pulled by staff or have been handled in a rough manner, eight (8) out of eight (8) stated staff has not pulled their hair nor have they been handled in a rough manner. (4) Continued on LIC9099-C During interviews with Staff S2, S4-S8, were asked if they have observed staff or if they have pulled a resident’s hair or have handled a resident in a rough manner, six (6) out of six (6) stated they have not pulled a resident’s hair or handled a resident in a rough manner, nor have they observed, or heard of that occurring. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff inappropriately touched resident The complaint allegation alleges a staff grabbed a resident’s butt. During record review, LPAs reviewed and received staffs signed Mandated Reporting that states if they observe or suspect abuse occurring, they will report it. Additionally, LPAs received and reviewed a copy of the facility’s Employee Handbook stating, on page 71-72, employees responsibility to report any incident of resident abuse, or suspected resident abuse. During interviews with Residents R2- R9, were asked if staff have touched them inappropriately, eight (8) out of eight (8) stated staff have not touched them inappropriately at any time. During interviews with Staff S2, S4-S8, were asked if they have observed staff, have heard of staff, or if they have touched a resident inappropriately, six (6) out of six (6) stated they have not seen or heard of a staff touching a resident inappropriately and if they did, they would report it to the Administrator immediately. Additionally, six (6) out of six (6) stated they have not touched a resident inappropriately. (5) Continued on LIC9099-C During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator, Narine Mertkhanan, and a copy of this report was provided. (6)the state’s words, verbatim · CDSS document, Aug 13, 2024 · control 11-AS-20240725205758

Allegation investigated: Facility unlawfully evicted resident

On 5/29/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived at 10:15am and spoke to Administrator, Ruby Cruz and explained the purpose of the visit and was granted access to the facility. The investigation consisted of the following: On 5/29/24 LPA reviewed resident’s file and toured the facility. LPA requested and reviewed copies of the following records: LIC 500, Resident roster, 30day notice, ID and emergency information, face sheet, Admission Agreement, physicians report, resident appraisal, physician’s orders, resident charting notes, incident reports, memo of incident 10/22/23, and a release of personal property 5/21/24. The investigation revealed the following: Con'd 9099 Unsubstantiated Allegation: Facility unlawfully evicted resident It is being reported that this facility unlawfully evicted a resident. LPA Shirley reviewed the 30day notice dated 3/21/24. LPA Shirley observed that notice was issued again on 4/9/24. Notice was issued again as the first notice effective date fell on a Sunday. During file review, LPA observed resident’s charting notes in which R1 violated house rules four separate times. Per S1 resident was warned verbally to stop violating general policies of the facility. During the interview process and file review LPA learned that resident was sent to the hospital on 5/13/24. S1 stated while still in the eviction process, on 5/20/24, R1 called S2 to discharge himself from Savant of Santa Monica. S1 contacted the facility’s attorney and was told that they didn’t need to move forward as R1 discharged himself. On this same day 5/20/21, R1 asked to release their personal belongings to their friend W1. On 5/21/24, W1 came to pick up R1’s belongings and signed a release of personal property. LPA interviewed staff S-1 through S-7 (S-1 – S-7) LPA interviewed staff and ask, has this facility unlawfully evicted a resident. Of those interviewed 5 out of 7 answered no. LPA interviewed residents R-2 through R-7 (R-2 – R7). R1 is not available. LPA ask, does this facility unlawfully evict residents. Of those interviewed, 6 out of 6 answered no. Based on information gathered, the department did not find sufficient evidence to support allegations "Facility unlawfully evicted resident. 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. An exit interview was conducted and a copy of the LIC 9099 was provided to the Administrator, Ruby Cruz.the state’s words, verbatim · CDSS document, May 29, 2024 · control 11-AS-20240523121300

Allegation investigated: Staff did not ensure resident's showering needs were met

On 05/24/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced 10-day complaint visit. LPA met with Administrator, Ruby Cruz, and the purpose of today’s visit was explained. During today’s visit, LPA toured the facility, interviewed Staff S1-S5, interviewed Residents R1-R7, and received documents pertinent to the investigation. The documents include a Staff Roster, Resident Roster, Shower Log, Resident’s Physician Reports, Resident’s Pre-appraisal Evaluation, Resident Needs and Service Plan, and Staffing Notes for the past three (3) months. The investigation revealed the following: Allegation: Staff did not ensure resident’s showering needs were met The allegation alleges a resident, who is a fall risk, did not receive assistance with a shower for 1 ½ months despite asking for assistance. CONTINUED ON LIC9099-C Unsubstantiated During record review of the shower schedule for residents who require assistance, LPA observed that residents are scheduled with an assisted shower 1 to 3 times a week. LPA reviewed four (4) Residents Physician’s Report, Needs and Service Plan, and Appraisal to see they type of assistance Residents require. During interviews with Staff S1-S5, were asked if residents who require assistance with a shower receive assistance, five (5) out of five (5) stated residents who require assistance with a shower receive assistance. Additionally, five (5) out of five (5) stated if a resident who requires assistance with a shower requests a shower on a non-scheduled day the staff will accommodate the resident as soon as they are available, unless it is related to incontinence. During interviews with Residents R1-R7, were asked if they receive assistance with a shower, four (4) out of seven (7) stated they receive assistance with showers when scheduled and when needed or requested. Additionally, Residents R1-R7, were asked if there was a time, they not receive assistance with a shower, three (3) out of seven (7) stated they require assistance and was not provided with it. Additionally, two (2) out of the seven (7) stated they have either gotten into the shower without assistance or have taken a shower without assistance while being a fall risk. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. During today's visit LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator, Ruby Cruz, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 24, 2024 · control 11-AS-20240520092651

Allegation investigated: Staff threatened a resident with eviction.

On 05/23/24, at 10:00am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Ruby Cruz, Administrator. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegation mentioned above. The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S3) and residents (R1-R3). Resident Roster, Staff Roster, ID/Emergency Information, Physicians Report, and Charting Notes for R1 were obtained from the facility. The investigation revealed the following: Allegation #1- Staff threatened a resident with eviction. The details of the complaint alleged that on 05/16/24, R1 and another resident were having an argument and two staff members came into the room and threatened to evict R1 because of the argument. Report continued on LIC9099-C Unsubstantiated On 05/23/24, from 10:00am-1:00pm, LPA interviewed staff (S1-S3) and residents (R1-R3) regarding the allegation. 3 of 3 staff denied the allegation that the Staff threatened a resident with eviction. All staff (S1-S3) stated that no one has ever threatened to evict R1 with eviction. All staff (S1-S3) stated that on several occasions the staff has spoken to the resident about R1s behavior in the facility and emphasized following the house rules. But at no time has any one issued R1 an eviction notice or threatened R1 with an eviction notice. LPA interviewed R1 about the eviction notice and R1 stated that R1 had no knowledge of an eviction notice, nor did staff threaten R1 with an eviction notice. LPA interviewed R1-R3 about the allegation and 3 of 3 residents that were interviewed denied the allegation that Staff threatened a resident with eviction. All residents interviewed stated that they have not been issued or threatened with an eviction notice and are happy with the care and supervision the staff is providing them. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff threatened a resident with eviction. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with Ruby Cruz, Administrator, and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, May 23, 2024 · control 11-AS-20240516143559

Type of visit: Required - 1 Year

On 05/16/2024 Licensing Program Analyst (LPA), David España conducted an unannounced annual visit using the full care tools. LPA met with Administrator Ruby Cruz and the purpose of today's visit was explained. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections. The facility is licensed to serve (174) age range 60 and over adults. The fire clearance is approved for (150) non-ambulatory and (24) bedridden residents. LPA toured facility Kitchen, Dining Room, Living Room areas, (8) Bedrooms, (8) Bathrooms, Garage, and Patios with shaded areas. LPA observed sufficient storage areas for kitchen supplies, linens, medications (secured) and chemicals (secured). LPA observed the following during this visit: There is a locked centralized storage area for Resident medications. LPA reviewed 5 resident medications. LPA interviewed 7 residents in care. LPA interviewed 5 staff members. LPA observed the facility is clean, sanitary, and in good repair. Indoor and outdoor passageways, stairways, open areas, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68° degrees and 85° degrees. Open patios, and areas of potential hazard are well-lit. LIC809-C (cont) Carbon monoxide/Smoke detectors operate properly. No client bedroom is a passageway to another room, bath, or toilet. There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. There is dresser and closet space for each client that includes at least two (2) drawers of dresser space per client. There is a chair and lamp for each client and at least one (1) nightstand per two (2) clients. There are plenty toilets and washbasins for clients, family, and personnel. There are plenty showers for clients, family, and personnel. Hot water temperature is between 105°-120° degrees Fahrenheit. Bathrooms are located inside client bedrooms and common areas. Public restroom calling system is operational. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths. Dining room is near kitchen. Refrigerator and freezer are clean and have the capacity to store at least two (2) days of perishable foods. There is storage for seven (7) day supply of non-perishable food. There are enough tableware, tables, dishes, and utensils. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. There is confidential storage for personnel records at the facility. There is storage for Resident confidential information and records at the facility. The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. LIC809-c (cont) There is an outdoor activity space with a shaded area and furnished for outdoor use. There are at least 3 common areas available to clients for visitors. There are activities scheduled during the current month. There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. LPA observed a sign-in/sanitation station at the facility entry. There is hand sanitizer located at the entrance of the facility. Facility has screening process for all visitors, sanitizer/soap, paper towels, and additional PPE supplies are stored inside the facility. LPA observed fire extinguishers were fully charged and last serviced on 05/09/2024. Fire alarm and sprinkler system were last serviced on 04/29/2024. Carbon Monoxide detector was operable.LPA inspected the First Aid and found it contained all the required items. The elevator was last serviced on 04/28/2023. There was one technical assistance provided on today's visit. Resident Records/Incident Reports - Technical Assistance: 87506(b)(11) - LPA with Administrator Ruby Cruz did not observe resident #1 (R1) complete file. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time. A exit interview was conducted with Ruby Cruz Administrator and a hard copy of a LIS 809s document was provided.the state’s words, verbatim · CDSS document, May 16, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility staff are not assisting resident with bathing Facility staff are not assisting the resident with toileting Facility staff are not providing resident with an accessible toilet Facility staff are not providing resident with an accessible shower

On 02/29/2024 at 8:00 am Licensing Program Analyst (LPA) David España conducted a subsequent complaint continuation investigation visit for the allegation listed above to deliver findings. Upon arriving at the facility, LPA met with the Administrator Ruby Cruz and MarieAnn Chan, Business Office Manager who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections. During the records review on 02/15/2024, LPA observed and requested copies of the annual staff training for residents' personal rights. Also, LPA observed the rights posted on the facility walls. In addition, LPA observed and requested copies of the personal rights in the resident's admissions agreement; with signatures of representatives upon moving into the facility. Complaint Investigation Report LIC9099-C Unsubstantiated LPA requested copies of the following: Three (3) months copies of (1) The number of residents receiving in incontinent, diapers changed; (2) The number of residents receiving daily cleaning of their bathroom (log); (3) The number of residents who have received their showers, sinks or toilets repaired; (4) The amount of residents being provided assistant for incontinent care, diapers changes; (5) The facility log or record keeping of reported repairs of any bathroom within the facility; (6) The timeline of how long it takes to repair bathroom fixture; and (7) The list of residents in care who have not received services they have requested (i.e., outstanding). On 02/29/2024 LPA interviewed, observed, and reviewed facility room numbers #68, #24, #23, and #30 (photos) were found within Title 22 regulations. On 02/15/2024 LPA interviewed, observed, and reviewed facility room numbers #37, #86, #72, #28, and #29 were found within Title 22 regulations. At 10:30 am LPA confirmed that there are Fifty-One (51) residents in care at the time of visit. At 10:30 am LPA confirmed that there are Twenty-Six (26) staff members at the time of visit. LPA interviewed Five (5) out of Fifty-One (51) residents. LPA interviewed Five (5) out of Twenty-Six (26) staff members. LPA interviewed One (1) Witness (W#1) for the alleged Four (4) complaints listed. Allegation # 1: Facility staff are not assisting resident with bathing. It is alleged residents’ bathing needs are not being met. On 02/13/2024 LPA España at 10:10 am Licensing Program Analyst (LPA) David España met with Witness #1 (W1) to discuss the complaint investigation. Complaint Investigation Report LIC9099-C W1 explained that W1 finally reached the Executive Director on 12/19/23 and explained the needs for the modification W1 further stated that the facility would address the grab bars and look into a gray toilet, but they (facility) would not be able to pick up the vanity or install anything else that the resident could use. W1 stated that Adam (owner of the facility) did not address the shower. On 02/29/2024 LPA interviewed, observed, and reviewed facility room numbers #68, #24, #23, and #30 (photos) that were found within Title 22 regulations. On 02/15/2024 LPA interviewed, observed, and reviewed facility rooms numbers #37, #86, #72, #28, and #29 that were found within Title 22 regulations. LPA interviewed Five (5) out of Fifty-One (51) residents. LPA interviewed Five (5) out of Twenty-Six (26) staff members. During the records review, LPA reviewed staff yearly training regarding residents' personal rights. All staff have taken the training. During an interview with the Executive Director, Narine Mertkanyan and Five (5) out of Twenty-Six (26) staff members, per Executive Director, Narine Mertkanyan stated that all staff know the residents' rights and do annual training. During interviews with Four (4) out Fifty-One (51) residents stated that they personally have not had issue with a staff member at the facility, and facility staff are assisting resident with bathing. During interviews with W1, they disagreed facility staff are assisting resident with bathing. During interview(s) with Executive Director, Narine Mertkanyan,“Savant senior living has a motion in place, and it will be addressed on Monday 02/26/2024 with regional maintenance regarding our wheelchair bound residents and their bathroom sinks. Here are the following Rooms that will need to be worked on #68, #24, #23, and #30.” Complaint Investigation Report LIC9099-C Based on interviews, observations, record reviewed there is insufficient evidence to support the allegation: Facility staff are not assisting resident with bathing. 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. Allegation # 2: Facility staff are not assisting the resident with toileting. It is alleged facility staff are not assisting the resident with toileting. It was reported that the staff is not providing proper toileting services to the residents. When interviewed Five (5) out of Twenty-Six (26) staff members and Four (4) out Fifty-One (51) residents all denied the allegation. During interviews with Four (4) out Fifty-One (51) residents stated that the resident’s toilet work and if assistance was needed, they (residents) believe they would receive it from staff members. Five (5) out of Twenty-Six (26) staff members also stated that they were not aware of other residents having issues with sanitary wipes, toileting, and that the facility has more than enough for the residents. R1 did not confirm those stated, LPA took photos of the bathroom and did not observe a portable toilet in R1’s bedroom or room. Four (4) out Fifty-One (51) residents reported that they are not considered incontinent and do not require those types of services. During an interview with the Executive Director, Narine Mertkanyan and Five (5) out of Twenty-Six (26) staff members, per Executive Director, Narine Mertkanyan stated that all staff know the residents' rights and do annual training. During interviews with Four (4) out Fifty-One (51) residents stated that they personally have not had issue with a staff member at the facility, and facility staff are assisting resident with toileting. Cont'd LIC-9099-C Per W1 the facility stated that they (facility) were working on the other toilet seat, and they (facility) were unlikely to modify anything else. W1 followed up with the resident in February and found out that the grab bars were installed and nothing else. On 02/29/2024 LPA interviewed, observed, and reviewed facility room numbers #68, #24, #23, and #30 (photos) that were found within Title 22 regulations. On 02/15/2024 LPA interviewed, observed, and reviewed facility rooms numbers #37, #86, #72, #28, and #29 that were found within Title 22 regulations. Per Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87307 Personal Accommodations and Services, LPA has observed toilets and bathrooms conveniently located. LPA observed at least one toilet and washbasin for each six (6) persons, which include residents, family and personnel. LPA observed at least one bathtub or shower for each ten (10) persons, which includes residents, family and live-in personnel. LPA observed individual privacy being provided in all toilet, bath and shower areas. LPA observed space and safety provisions provided by the facility. LPA observed each room that accommodates residents being served in a comfort and safety environment. LPA observed the premises being maintained in a state of good repair and is providing a safe and healthful environment. Based on interviews, observations, record reviewed there is insufficient evidence to support the allegation: Staff is not providing proper toileting services to resident in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is Unsubstantiated. Cont'd LIC-9099-C Allegation # 3: Facility staff are not providing residents with an accessible toilet. It is alleged staff are not providing residents with an accessible toilet. On 02/13/2024 at 10:10 am Licensing Program Analyst (LPA) David España interviewed Witness #1 (W1) to discuss the complaint investigation. The interview with W1 revealed that the grab bars, raised toilet seat and bathroom counter have not been addressed or corrected. Per W1 CEO Adam stated that the facility believed that the facility would address the grab bars and possibly the toilet seat, but it is unlikely the facility would take out the vanity and install a new sink. On 02/29/2024 LPA interviewed, observed, and reviewed facility room numbers #68, #24, #23, and #30 (photos) that were found within Title 22 regulations. On 02/15/2024 LPA interviewed, observed, and reviewed facility room numbers #37, #86, #72, #28, and #29 that were found within Title 22 regulations. When interviewed Five (5) out of Twenty-Six (26) staff members and Four (4) out Fifty-One (51) residents all denied the allegation. During interviews with Four (4) out Fifty-One (51) residents stated that the resident’s toilet is accessible and if assistance needed, they (residents) believe they would receive facility help. Five (5) out of Twenty-Six (26) staff members also stated that they were not aware of other residents having issues accessing their toilet. Based on interviews, observations, record reviewed there is insufficient evidence to support the allegation: Facility staff are not providing residents with an accessible toilet. 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. Cont'd LIC-9099-C Allegation # 4: Facility staff are not providing resident with an accessible shower. It is alleged staff are not providing residents with an accessible shower. LPA interview with Resident 1 (R1) who stated that the alleged violation “Facility staff are not providing resident with an accessible shower,” has occurred and location. R1 stated they (facility) agreed to move R1 to another room because of accessibility concerns. LPA took photos of R1 wheelchair accessibility while interviewing. Based on interviews, observations, and record reviewed, and the facility (i.e., Adam Zenou) acknowledged progress at the facility which has been made due to rebranding of the facility, namely, the restrooms being wheelchair accessible at the facility. W1 stated that the resident is unable to maneuver in his wheelchair and the bathroom. On 02/29/2024 LPA interviewed, observed, and reviewed facility room numbers #68, #24, #23, and #30 (photos) that were found within Title 22 regulations. On 02/15/2024 LPA interviewed, observed, and reviewed facility rooms numbers #37, #86, #72, #28, and #29 that were found within Title 22 regulations. The R1 stated they required assistance getting into the shower and required a shower seat to use in the restroom. R1 stated services are being provided, caregivers are accessible for showers “they are great and hard working.” When interviewed Five (5) out of Twenty-Six (26) staff members and Four (4) out Fifty-One (51) residents all denied the allegation. During interviews with Four (4) out Fifty-One (51) residents stated that the resident’s showers are accessible and if assistance needed, they (residents) believe they would receive facility help. Five (5) out of Twenty-Six (26) staff members also stated that they were not aware of other residents having issues accessing their showers. Based on interviews, observations, record reviewed there is insufficient evidence to support the allegation: Facility staff are not providing resident with an accessible shower. 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. No deficiencies were cited. A exit interview was conducted with AnnMarie Chan, Business Office Manager and hard copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 11-AS-20240209152909

Allegation investigated: Staff yell at resident(s) in care. Staff speak inappropriately to resident(s) in care. Staff member smokes marijuana on facility premises. Facility does not have an Administrator.

On 12/20/2023 at 09:00 am Licensing Program Analyst (LPA) David España conducted an initiated a 10-day complaint investigation visit for the allegation listed above. Upon arriving at the facility, LPA met with S#1 and later S#2 who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is not clear of Covid-19 infection (Has one case). LPA was granted access and allowed to enter the facility to conduct inspections. During the records review, LPA observed and requested copies of the annual staff training for residents' personal rights. Also, LPA observed the rights posted on the facility walls. In addition, LPA observed and requested copies of the personal rights in the resident's admissions agreement; with signatures of representatives upon moving into the facility. LPA requested copies of the following: Staff and Resident Roster, staff ratios, Physician report, Needs and Service, incident reports of residents (see LIC-811s). Continued on LIC9099-C. Unsubstantiated On 12/20/2023 Licensing Program Analyst (LPA) David España conducted interviews with Eight (8) out of Twelve (12) current staff members working at the time of visit with a total of Twenty-One (21) staff member employed. At 10:30 am LPA confirmed that there are Forty-Three (43) residents in care at the time of visit. LPA confirmed there are Twenty-One (21) total staff employed as of 12/20/2023. LPA confirmed there is only Four (4) resident in care who receive oxygen as of 12/20/2023. LPA confirmed there are only One (1) total resident in care with dementia at the time of visit 12/20/2023. LPA confirmed there are Six (6) total residents in care with wheelchairs at the time of visit 12/20/2023. LPA confirmed there are Ten (10) total residents in care with diapers at the time of visit 12/20/2023. Investigation Revealed the Following: Allegation: Staff yell at resident(s) in care. The details of the complaint alleged that a staff member yelled at a resident in care. During the records review, LPA reviewed staff yearly training regarding residents' personal rights. All staff have taken the training. During an interview with the Administrator (A#1) and Seven (7) out of Twelve (12) staff members, per A#1 stated that all staff know the residents' rights and do annual training. In addition, per (A#1), she said no staff has yelled at a resident before. (A#1) said, "We do not scream or yell at our residents; we only speak loudly to them when they have a hard time hearing us." During interviews with Four (4) out of Forty-Three (43) residents stated that they personally have not had issue with a staff member at the facility, and no staff has ever yelled or screamed at them. During interviews with Eight (8) out of Twelve (12) current staff members stated that they are familiar with the resident's rights, and Eight (8) out of Twelve (12) current staff members stated that they have never yelled or screamed at a resident. Based on information gathered, LPA did not find sufficient evidence to support allegation " Staff yell at resident(s) in care.” Investigation Revealed the Following: Allegation: Staff speak inappropriately to resident(s) in care. The details of the complaint alleged that a Staff speaks inappropriately to resident(s) in care. LPA interviewed Administrator Narine Mertkhanyan who stated she has not received any reports of staff speaking to a resident inappropriately. LPA interviewed with Four (4) out of Forty-Three (43) residents regarding the allegation. Of those interviewed, Four (4) out of Forty-Three (43) residents stated staff do not speak inappropriately to them with one not being able to answer due to their diagnosis. Eight (8) out of Twelve (12) staff interviewed, Eight (8) out of Twelve (12) staff stated there has not been any issues with staff speaking inappropriately to resident. LPA also interviewed Four (4) out of Forty-Three (43) residents stated there were no issues with staff speaking inappropriately to resident. Based on information gathered, LPA did not find sufficient evidence to support allegation " Staff speak inappropriately to resident(s) in care. Investigation Revealed the Following: Allegation: Staff member smokes marijuana on facility premises. Based on the interviews conducted with Four (4) out of Forty-Three (43) residents, statements obtained did not corroborate this allegation. Eight (8) out of Twelve (12) staff interviewed statements obtained did not corroborate this allegation. The details of this allegations state that staff smoke marijuana on the premises - when staff works in a rooms where staff closes door and smokes marijuana in a room. LPA toured the facility with staff, namely rooms #15, #17, #77, #71, #34, and #19. Based on the interviews conducted with Four (4) out of Forty-Three (43) residents, statements obtained did not corroborate this allegation. Eight (8) out of Twelve (12) staff interviewed have not observed Marijuana smoke coming out of rooms or facility. Based on the information gathered, there is not sufficient evidence to support this allegation " Staff member smokes marijuana on facility premises.” Investigation Revealed the Following: Allegation: Facility does not have an Administrator. Based on the interviews conducted with Four (4) out of Forty-Three (43) residents, statements obtained did not corroborate this allegation. Based on the interviews conducted with Eight (8) out of Twelve (12) staff interviewed statements obtained did not corroborate this allegation. Based on the interviews conducted with Four (4) out of Forty-Three (43) residents they have met with certified Administrator. Based on the interviews conducted with Four (4) out of Forty-Three (43) residents stated that the Administrator should devote more time. Continued on LIC9099-C. Based on the interviews conducted with Four (4) out of Forty-Three (43) residents stated that the Administrator manages two facility at this time of visit. Based on the interviews conducted with Four (4) out of Forty-Three (43) residents felt that there should be sufficient number of hours to permit adequate attention to residents. Based on the interviews conducted with Eight (8) out of Twelve (12) staff stated the Administrator does provide adequate time and personal integrity to the facility. Eight (8) out of Twelve (12) staff stated that they are provided guidance from the Administrator for the standard care and supervision of Forty-Three (43) residents in care. Based on information gathered, LPA did not find sufficient evidence to support allegation "Facility does not have an Administrator.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator Narine Mertkhanyan and a hard copy was provided the Administrator.the state’s words, verbatim · CDSS document, Dec 20, 2023 · control 11-AS-20231214094855

Allegation investigated: Staff did not respond in writing regarding any action or inaction taken in response to resident council concerns or recommendations within 14 calendar days.

On 02/29/24 Licensing Program Manager, Ulysses Coronel (LPM), and Licensing Program Analyst (LPA), Mario Leon, arrived at the facility to deliver an amended document. This is an ammendment of the complaint investigation report delivered on 12/04/23. The purpose of this amendment is to provide additional information. LPM and LPA were met by Anne Marie Chan, Business Office Manager and there have been no changes to the initial findings. On 12/04/23 LPA requested facility documents and toured the facility. LPA interviewed four (4) out of forty-four (44) residents and three (3) out of nineteen (19) staff. The investigation consisted of the following: 12/04/23 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unanounced, complaint visit at the above-mentioned facility. LPA was met by Ashley Trimble, Activities Director, and later by Narine Metkhanyan, Administrator (S1). Report continues see LIC9099C Substantiated The investigation revealed the following: Regarding the allegation: "Staff did not respond in writing regarding any action or inaction taken in response to resident council concerns or recommendations within 14 calendar days.". It has been alleged that Administrator, Narine Mertkhanyan (S1) had not responded to the resident council's request on 10/31/23. LPA interviewed three (3) staff (S1-S3). One (1) staff has denied the allegation, one (1) staff agrees with the allegation and one (1) staff was unaware of the allegation. LPA interviewed four residents (R1-R4). All residents have agreed with the allegation. Record reviews revealed that the email sent to the above-mentioned facility, from resident council at 11:20AM on 10/31/23, did not contain any response from facility staff members. The same email, presented to LPA from the facility, did not present any element of response, in writing, made to the resident council. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099D. An exit interview was conducted on 12/04/23 with Narine Mertkhanyan, Administrator, and a copy of facilities’ appeal rights and this report has been provided to Anne Marie Chan, on 02/29/24, Business Office Manager.the state’s words, verbatim · CDSS document, Dec 4, 2023 · control 11-AS-20231128163348

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(24)(c) · Plan of correction due date: Dec 14, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1,....shall have all of the following personal rights: (24) To organize and participate in a resident council...HSC1569.157. (c)If a resident council submits written concerns..respond in writing..within 14 calendar days. This has not been met as evidenced by: LPA observed email written to Administrator(S1) on 10/31/23. S1 forwarded email to fellow staff, not respond to resident(s) in writingthe state’s words, verbatim · CDSS document, Dec 4, 2023

Plan of correction: LPA and Administrator have agreed that, moving forward, facility will respond in writing to residents' concerns or recommendations. Town-hall meetings will address the concerns and recommendations presented by residents. Each monthly flyer will display topic(s) to be discussed, including residents' concerns and recommendations. Monthly flyer(s) will be sent to Mario.Leon@DSS.CA.GOV.

Allegation investigated: Licensee does not ensure the facility is free from pest. Licensee does not provide adequate food services for residents.

**This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 11/15/23. On 11/15/23 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived at 10:26am and spoke to Wellness Director Amber Lollar and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility. The investigation consisted of the following: On 11/1/23 LPA reviewed resident files and toured the facility. LPA reviewed and requested copies of the following records: Client Roster, Staff roster, LIC 500, weekly menus, fumigation service records, and staff training. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Licensee does not ensure the facility is free from pests On 11/1/23 LPA conducted interviews with both staff and residents. LPA Shirley reviewed the service reports from Orkin for the months of September and October of 2023. During review, LPA observed that the facility is serviced every 2 weeks. There is a comment section on the report where the technician list the services and treatments done for the days serviced. LPA did observe ongoing treatment for termites and cockroaches, but there is no activity found on service dates. LPA interviewed staff, staff 1 – staff 4 (S-1 – S-4). LPA asked if they had observed termites or cockroaches in the facility. Of those interviewed 4 out of 4 stated no. LPA interviewed residents 1 – resident 6 (R-1 – R-6). LPA asked residents, if they had observed termites or cockroaches in the facility. Of those interviewed, 4 out of 6 answered, No. Based on information gathered, the department did not find sufficient evidence to support allegations "Licensee does not ensure the facility is free from pests. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Licensee does not provide adequate food services for residents On 11/1/23 LPA conducted interviews with both staff and residents. LPA Shirley reviewed kitchen staff files and observed that both food handlers are accredited with certificates of completion for California Food Handlers. Cont'd on 9099-C LPA reviewed weekly menus and found that there are nutritionally balanced meals listed and a healthy balance of both cold and hot meals. There are also available options listed on the bottom of weekly menus offering both hot and cold deli sandwiches. LPA observed hair nets on kitchen staff during interviews as it is a requirement to enter the kitchen. LPA interviewed staff and ask them if they believed that the meals are well balanced and nutritious. LPA interviewed staff S-1 through S-4 (S-1 – S-4). Of those interviewed 4 out of 4 answered yes. LPA interviewed residents R-1 through R-6 (R-1 – R6). LPA ask, do you think meals are nutritious? Of those interviewed, 3 out of 6 answered yes. Based on information gathered, the department did not find sufficient evidence to support allegations "Licensee does not provide adequate food services for residents. 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. An exit interview was conducted and a copy of the LIC 9099 was provided to Ruby Cruz, Business Office Manager.the state’s words, verbatim · CDSS document, Nov 15, 2023 · control 11-AS-20231025163724

Allegation investigated: Facility staff is not properly managing residents medication. Staff did not ensure residents received prescribed medications. Staff are not responding to residents call button in a timely manner. Facility is falsely advertising services to prospective residents.

The investigation consisted of the following: LPA observed facility, as well as common areas of the facility. A comfortable temperature is maintained throughout the facility. LPA observed the facility to be operational and in good repair, LPA reviewed pertinent documents pertaining to the investigation. The following documents were gathered or reviewed: Staff and Client Rosters, file for resident (R1) and any other pertinent documentation needs and service, physician report, residency agreement, medication records for R1. On 11/01/2023 LPA Randle interviewed Narine Mertkhanyan Administrator (S1). On 11/01/2023 LPA interviewed residents (R1-R4). LPA requested, received, and reviewed the following information: file of R1, Staff roster, Resident roster, and other documents relevant to the investigation. LPA received the following pertinent documents pertaining to the investigation: Resident Roster, Staff Roster, Admissions Agreement, Needs and Services Plan, LPA reviewed Staff schedule, resident generated CALL ALERT signal times were not available due to system design, On 11/2/2023 LPA interviewed staff (S2-S5) and resident (R5). regarding the allegations listed above. Unsubstantiated Cont. The investigation revealed the following: Allegation: Facility staff is not properly managing residents’ medication. LPA interviewed staff (S1-S5) and residents (R1-R5) regarding the allegation listed above. Staff S1and staff S2- S5 denied the allegation and confirmed use of central pharmacy were all resident using the facility for medication assistance and electronic recording MAR, LPA observed MARS of random resident and found no errors. Residents R2-R5 interviewed denied the allegation and all stated they did not have any issues with receiving medications on time or not having medication or receiving the wrong medication. R1 was interviewed regarding the allegation when R1 was asked if the facility was not properly managing his medication R1 stated to LPA “I handle my own medication, and I order my own medication the facility is not doing that for me I am independent”. During the course of the investigation, LPA was unable to find any documents or witnesses supporting the allegation above. LPA reviewed a copy of the R1’s admissions agreement, needs and services plan and physician report. All staff S1-S5 and residents R2-R5 denied the allegation and stated there were no issues or concerns about the facility staff not properly managing residents’ medication. Cont. Based on information gathered, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not ensure residents received prescribed medications. LPA interviewed staff (S1-S5) all denied the allegation. LPA interviewed residents (R1-R5) regarding the allegation listed above, residents R2-R5 denied the allegation. Staff S1 and Staff S2- S5 confirmed use of central pharmacy were all resident using the facility for medication assistance receives their medication. Residents R2-R5 interviewed denied the allegation and all stated they did not have any issues with receiving medications on time or not having medication per physician order. R1 was interviewed regarding the allegation when R1 was asked if the facility was not properly ordering R1’s medication, R1 stated to LPA “I handle my own medication, and I order my own medication the facility is not doing that for me I am independent”. During the course of the investigation, LPA was unable to find any documents or witnesses supporting the allegation above. LPA reviewed a copy of the R1’s admissions agreement, needs and services plan and physician report. LPA reviewed med cart for medication of random residents there were no cases were medication was not available for residents as prescribed. All staff and residents R2-R5 denied the allegation and stated there were no issues or concerns about the facility staff not ensuring residents received prescribed medications.. Based on information gathered, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated. Cont. Allegation: Staff are not responding to residents’ call button in a timely manner. LPA interviewed staff (S1-S5) and residents (R1-R5) regarding the allegation listed above. Staff S1- S5 confirmed residents use of centralized call system when residents have needs, or general announcement for activities meals, and or emergency notification. Staff S2-S5 interviewed denied the allegation and all staff stated, staff are responding to residents’ call button in a timely manner. Residents R2-R5 interviewed denied the allegation and all stated they did not have any issues with staff are not responding to residents’ call button in a timely manner. S1 stated to LPA “residents indeed activate there call buttons often for assistance for care and staff responds to the calls for assistance timely”. S1 stated to LPA that S1 was unaware of any complaints from R1 or any other resident regarding delayed assistance and denies the allegation. LPA interviewed resident R1. R1 stated to LPA “I used the call button twice” LPA asked if R1 recalled why R1 used the call button, R1 stated to LPA “I don’t remember when or why I used the button the first time, but the second time I think it was because someone knocked at my door”. LPA interviewed Staff S, S1 stated to LPA all the staff responds timely to every call for assistance from all the residents. LPA interviewed staff (S2-S5) and staff confirmed they respond quickly to the call alerts from residents promptly as trained. LPA interviewed residents (R2-R5). regarding allegations listed above -Staff did not answer resident's call button in a timely manner, residents R2-R5 interviewed by LPA reported they had not encountered a problem with staff not responding timely. Based on information gathered, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated. Cont. Allegation: The facility is falsely advertising services to prospective residents. LPA interviewed S1, S1 denied the allegation. S1 stated all residents, or their responsible party are given a pamphlet of services and are required to sign admission agreement and care plans incorporated into their agreement and a provided a copy at the time of admission or shortly thereafter. LPA interviewed Business Office Manager S2, S2 denied the allegation. S2 confirmed all residents, or their responsible party are given a pamphlet of services and are required to sign admission agreement and care plans incorporated into their agreement and a provided a copy at the time of admission or shortly thereafter. S1 was asked by LPA if R1 made any request for services and if services advertised were denied S1 stated “no”. LPA asked Staff S2 if R1 made any request for services and if services advertised were denied S2 stated “no”. LPA reviewed resident R1’s file and required documents were in the file and signed. LPA interviewed R1, R1 was asked if he received a copy of his admissions agreement R1 stated to LPA ‘I think I have a copy of my paperwork’. R1 was asked how he heard about the facility R1 stated “ I think from a web site Caring dot com”. LPA asked R1 if R1 remembers seeing any advertising form this facility R1 stated “ I did not see any advertising about this place”. LPA interviewed resident (R2-R5) all denied the allegation, Resident R2- R5 confirmed that they have had no issues regarding false advertising or not receiving services.. Based on information gathered, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated. Findings Based on information gathered, the department did not find sufficient evidence to support the allegations listed above. 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 the LIC 9099 was provided to Narine Mertkhanyan Administrator (S1the state’s words, verbatim · CDSS document, Nov 2, 2023 · control 11-AS-20231025152757

Allegation investigated: Facility is not maintaining a comfortable temperature for residents in care. Staff did not ensure that facility vents were cleaned. Facility laundry appliances are in disrepair

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Friday, October 27, 2023. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Wellness Director Amber Lollar. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: Interviews were conducted with staff members 1-5 (S1-S5) and residents 1-5 (R1-R5). LPA Bunker posed relevant inquiries pertaining to the nature of the complaint. Accompanied by Ms. Amber, LPA Bunker inspected the laundry room, meticulously assessing the operational status of the washers and dryers. We diligently inspected the facility's ventilation system and air filters. The facility's thermostat was verified to be set at a comfortable room temperature of 74 degrees. During the visit, LPA Bunker carefully assessed the cleanliness, safety, sanitation, and general state of repair of the facility's vents, all of which were found to be in compliance with Title 22 Regulation standards, promoting the safety and well-being of clients, employees, and visitors. LPA Bunker formally requested copies of the staff and residents' roster. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Allegation #1: Facility is not maintaining a comfortable temperature for residents in care. Staff members 1-5 (S1-S5) and residents 2-5 (R2-R5) unequivocally affirmed that the facility consistently maintains a comfortable room temperature for its residents. S1-S5 and R2-R5 further affirmed that the facility's environment remains cool, ensuring a comfortable range, even lower than the ambient outside temperature. Additionally, S1-S5 and R2-R5 stated that staff proactively adjust the thermostatic controls to ensure residents are comfortable at all times. During our investigation, we meticulously examined the facility's room temperature and confirmed that the thermostat was set at a comfortable 74 degrees. However, Resident 1 (R1) raised a concern, asserting that the temperature inside the facility reached an uncomfortably high 94 degrees. Allegation #2: Staff did not ensure that facility vents were cleaned. S1-S5 and R2-R5 asserted that the facility's vents are consistently cleaned, with no residents experiencing bronchial cough symptoms. S1-S3 stated they had no physician reports, medical records, or documentation indicating residents with bronchial cough issues. S5 attested to taking proactive measures by cleaning the vents, replacing filters, and ordering new ones. S5 stated the facility underwent a change in ownership, and the previous owner had engaged an AC company to service all 17 units. S5 stated he is currently in charge of maintenance, and assured that the vents are clean, and filters have been ordered and replaced. Our inspection confirmed the operational condition of the facility's ventilation system and air filters. R1 contended that the facility's vents had not been cleaned and filters had not been changed, resulting in residents developing bronchial cough symptoms. S1-S5 and R2-S5 staunchly denied this allegation. Allegation #3: Facility laundry appliances are in disrepair. S1-S5 and R2-R5 affirmed that the facility's washers and dryers are fully operational, with housekeeping staff washing residents' clothing and linen on a daily basis or as needed. Our inspection of the facility's washer and dryers validated their working condition. However, R1 claimed that the facility's washing machine and dryers were non-functional. S1-S5 and R2-S5 firmly refuted this allegation. Investigation revealed the following: The investigation yielded consistent responses from staff members 1-5 (S1-S5) and residents 2-5 (R2-R5), all of whom adamantly denied the veracity of the allegations. S1-S5, in particular, emphasized the facility's commitment to maintaining a comfortable room temperature for residents, ensuring the cleanliness of vents, and upholding the functionality of laundry room appliances. Our inspection further corroborated these assertions, as the ventilation system and air filters were found to be both clean and operational, and the laundry room's washers and dryers were in working order. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence 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 deemed unsubstantiated. There were no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 27, 2023 · control 11-AS-20231026162040