Savant of Tarzana

Allegation investigated: Staff do not ensure the facility is free of pests

At approximately 10:00 a.m. on 06/30/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 06/02/26 and interviewed the administrator at 5:40 p.m., conducted a record review of pertinent records at 5:50 p.m., and toured the facility inside and out at 6:00 p.m. During a subsequent visit on 06/11/26, LPA interviewed ten percent [10%), or thirteen (13) out of 131 residents between 12:45 p.m. and 3:00 p.m. Today, LPA conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, fumigation records, and staff and client rosters at 10:05 a.m. and toured the facility inside and out at 10:30 a.m. Regarding the allegation "Staff do not ensure the facility is free of pests" it was alleged cockroaches were found in the room of Resident #1 (R1). Unsubstantiated Interviews with ten (10) out of thirteen (13) residents interviewed revealed they have not seen any cockroaches in the facility. Two (02) residents have seen cockroaches, but the fumigator killed them. Interview with R1’s roommate, Resident #2 (R2) at 2:30 p.m. today revealed they had not seen any cockroaches in their room. Interview with the administrator revealed they have not observed or heard reports of cockroaches in the facility. The administrator also noted the facility is served by a fumigator twice every month. Record review of fumigation records revealed the facility was last fumigated on 05/06/26, 05/28/26, and 06/08/26. Facility tours today on 06/02/26, and 06/11/26 revealed no cockroaches were observed in the facility or R1’s room. Based on observations, interviews, and record review, staff ensured the facility was free of pests. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 31-AS-20260602090159

Allegation investigated: Staff do not monitor resident for changes in condition Resident fell sustaining injuries due to lack of supervision

At approximately 10:00 a.m. on 06/30/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 04/29/26 and interviewed staff and residents between 12:30 p.m. and 1:45 p.m., requested pertinent records at 1:15 p.m., and toured the facility inside and out at 2:00 p.m. Today, LPA conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 10:05 a.m. and toured the facility inside and out at 10:30 a.m. Regarding the allegation "Staff do not monitor resident for changes in condition” it was alleged Resident #1 (R1) showed signs of cognitive impairment which were not addressed by staff. Also, R1 reported a fall which staff were not aware of. Interview with R1 at 1:00 p.m. on 04/29/26 revealed they felt fine after two (02) falls in April 2026 and received adequate care from staff. Unsubstantiated R1 stated staff were aware of both falls. LPA observed R1 to be in good condition. Interview with the administrator at 12:45 p.m. on 04/29/26 revealed the facility was aware of R1’s falls and submitted incident reports for both. Interview with the Wellness Director at 1:20 p.m. on 04/29/26 revealed the facility followed standard fall protocol and reassessed R1’s needs on 04/20/26. Record review of R1’s medical assessment, care plan, and hospital discharge paperwork showed no changes in condition. R1’s medical assessment revealed a diagnosis of minor cognitive impairment which was addressed on R1’s care plan and reassessment form. Record review also confirmed the facility submitted incident reports for both of R1’s falls. Staff also documented the falls in their daily notes and monitored R1 for pain. Based on observations, interviews, and record review, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Resident fell sustaining injuries due to lack of supervision" it was alleged R1 fell during a walk outside of the facility which should have been supervised. Interview with R1 revealed they walk outside every day and have done so for twenty (20) years. R1 noted they do not require supervision while walking. Interviews with the administrator and Wellness Director confirmed R1 goes on daily walks and does not require supervision. R1 was assessed by the facility on 04/20/26 and was determined to not require assistance with walking. Record review of R1’s medical assessment deemed them capable of leaving the facility without assistance or supervision. Based on interviews and record review, R1 did not fall due to lack of supervision since R1 did not require supervision. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 31-AS-20260427110812

Type of visit: Required - 1 Year

At approximately 8:45 a.m. on 06/11/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit. A file review was conducted prior to the visit. The facility was last visited on 06/02/26 for a complaint visit. It is a three (03) story building with a capacity of 176 residents. LPA observed offices, bedrooms, shared and private bathrooms, kitchen and dining areas, garage, common areas, activity rooms, garage, and a courtyard. It has an approved fire clearance for 176 nonambulatory residents, of which fifty (50) may be bedridden. Approved hospice waivers for thirty (30). At 8:50 a.m., LPA inspected the facility vehicle. All systems were operational. LPA conducted a file review at 9:30 a.m. The Emergency Disaster Plan was last reviewed on 05/10/26. Liability Insurance was updated on 01/01/26. The Infection Control Plan was last updated on 12/05/25. The Dietitian/Nutritionist consultation was performed on 03/06/26. REG4 fire testing was completed on 04/03/26. All systems passed inspection. LPA reviewed at least ten (10) percent of staff and resident files. All files were complete, current, and available for audit. LPA observed new carpets and fresh paint on hallway walls on the first floor. Interview with the maintenance director at 9:05 a.m. revealed the first floor was renovated in February 2026. Between 12:00 p.m. and 2:00 p.m. today, LPA and the administrator toured the facility. Cameras were observed near the main entrance. The designated smoking area at the front contained artificial shrubs and umbrellas for shade. Postings were observed inside for COVID precautions, emergency contacts, Ombudsman contacts, confidential complaint contacts, facility license, facility sketch, emergency disaster plan, administrator certificate, personal rights, rights of resident councils, normal and alternate menus, and daily and monthly activity calendars. Walls, floors, windows, screens, and blinds were clean, free from stains, and in good repair. An activity room near the reception desk had a television, exercise equipment, a piano, a sound system, and sufficient activity space. Activities were observed and conducted at 9:00 a.m. today. The reception area had seating, board games, an administrator office, a business office, and mailboxes. Personnel files were stored and locked in the business office. At approximately 12:15 p.m., fully-charged fire extinguishers were observed near the main entrance, the kitchen, and hallways of all floors. They were last inspected on 04/10/26 with tags attached. At 12:25 p.m. the room temperature was measured to be 78 degrees Fahrenheit. Rooms #314 and #214 were inspected. All rooms contained functional smoke alarms, appropriately furnished bedding, chairs, nightstands, storage, lighting, and bathrooms with paper towels, liquid soap, grab bars near the toilets and showers, and non-skid mats or strips in the shower. All rooms were clean and in good repair. Water temperatures in bathrooms were tested at 12:40 p.m. and 1:10 p.m. and measured to be between 110.1 and 105.4 degrees Fahrenheit, respectively. The second floor contained a medication room, activity room, a locked salon, and resident rooms. The medication room contained a fully-stocked first aid kit, inaccessible medications, medicine refrigerators, and locked medication carts with secondary locks for controlled substances. The activity room contained reading material, games, puzzles, and exercise equipment. Fire doors were observed in hallways. Fire sprinklers were observed throughout the building. Water, coffee, and snacks were available on the first and second floors. The third floor contained resident rooms. The door to the roof access was locked. The rear elevator accessed the third floor and was operational with a permit approved on 06/01/26. Two (02) out of two (02) stairwells had emergency evacuation chairs at the tops of the stairwells. No hazards were observed in stairwells or emergency exit paths. All emergency exits were unlocked. All electrical rooms, maintenance rooms, and roof access doors were locked. The garage was free of hazards. The courtyard contained plants and trees and two (02) shaded seating areas. LPA observed three (03) dining areas near the kitchen. The kitchen contained an adequate supply of perishable, non-perishable, and emergency foods. The dishwashing area was free of debris and vermin. Appliances were in good condition. Cleaning solutions and sharps were inaccessible. At approximately 1:40 p.m. today, the walk-in freezer and refrigerator temperatures were measured to be -20 and 3 degrees Fahrenheit. Temperature and maintenance logs were observed near appliances. Two (02) washing machines and two (02) dryers were located in the laundry room. Both were in working order. Detergents were stored and locked. At 2:00 p.m. the carbon monoxide detector in the lobby was tested to be operational. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety hazards were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 11, 2026

Allegation investigated: Staff do not ensure the facility is free of pests Staff do not answer residents calls for assistance ensuring there is a proper signal system Licensee does not ensure there is an auditory device to monitor exits on exterior doors Staff do not provide activities Staff do not safeguard resident's personal belongings

On 05/27/26, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Narine Mertkhanyan, Administrator. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 05/27/26, LPA Saucedo asked for the census, staff, and resident rosters. On 05/27/26, at 10:30am, LPA Saucedo conducted a physical tour, interviewed both residents and staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff do not ensure the facility is free of pests. It is being alleged that there is a cockroach infestation in the facility. During LPA’s physical tour, LPA did not witness any cockroaches in the facility. In addition, LPA obtained the ORKIN-Pest Control services performed on 05/06/26 and 04/23/26. Furthermore, three (3) staff confirmed that ORKIN-Pest Control comes twice a month to the facility and they have not witnessed any cockroaches in the facility. LPA interviewed twelve (12) residents that have not seen any cockroaches in the facility. Therefore, based on the ORKIN-Pest Control services performed, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not answer residents calls for assistance ensuring there is a proper signal system. It is being alleged that the old signal system for residents was replaced by telephone lines and these telephone lines are not being answered when residents need help. During LPA's physical tour, LPA did observe the telephone lines in twelve (12) random rooms and they were all functional which transmits a visual and/or auditory signal to a central staffed location at the front of the facility which is then communicated with the caregivers. LPA interviewed three (3) staff that confirmed the calls transmit to the front of the facility. LPA interviewed twelve (12) residents that have not had any issues with the new signal system and receiving assistance. Therefore, based on the staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Licensee does not ensure there is an auditory device to monitor exits on exterior doors. It is being alleged that emergency exits lack functional alarms causing dementia residents to elope and wander. During LPA's physical tour, LPA observed several exit doors but only one (1) main entrance to the facility. The facility is not required to have auditory devices because they do not have dementia residents and/or residents that elope and wander. LPA interviewed three (3) staff that confirmed they do not have dementia residents and/or residents that elope and wander. Furthermore, if residents are exhibiting these types of behaviors they are recommended to be transferred to another facility that has a memory care and/or higher level of care for these types of residents. LPA interviewed twelve (12) residents that have not had any issues with eloping and wandering. All twelve (12) residents that were interviewed have ability to leave the facility without any supervision. Therefore, based on the staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff do not provide activities. It is being alleged that the activities on the activity calendar are not being done. During LPA’s physical tour, LPA witnessed the Activity Director outside walking around with some residents which was part of the activity calendar-of stretching and strength. Furthermore, the Activity Director then proceeded to do the next activity on the activity calendar that was reading the daily chronicle. LPA interviewed three (3) staff that confirmed the activities calendar is followed as much as possible because residents look forward to the activities. LPA interviewed twelve (12) residents that say daily activities are performed throughout the facility. LPA also took a picture of the activities calendar. Therefore, based on the activities calendar, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not safeguard resident's personal belongings. It is being alleged that residents receiving personal incontinence of supplies redistribute their incontinence of supplies to other residents that are not paying for those supplies. LPA interviewed twelve (12) residents that were incontinent and had supplies in their room and all twelve (12) residents did not have any issues with anyone taking their personal belongings of incontinence of supplies to give to other residents. LPA also interviewed three (3) staff that confirmed that they do not share incontinence of supplies among residents, each resident that is incontinent has their own incontinence of supplies. Therefore, based on the staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, May 27, 2026 · control 31-AS-20260522114236

Allegation investigated: Facility staff is not properly disposing of their solid waste

At approximately 11:30 a.m. on 05/15/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. Regarding the allegation "Facility staff is not properly disposing of their solid waste" it was alleged staff throw gloves on the street outside. Also, during trash pick up days, pill cups and bed liners fall out of the dumpster and onto the street when the trash truck dumps it. To investigate the allegation, LPA interviewed staff between 11:45 a.m. and 1:15 p.m. today and toured the facility inside and out at 12:00 p.m. LPA toured the trash area and observed no signs of gloves, pill cups, or bed liners on the street, sidewalk, or in the facility. LPA also observed a dedicated trash container for used gloves. Interview with Staff #1 (S1) at 11:50 a.m. and Staff #2 (S2) at 12:15 p.m. confirmed staff always tie trash bags before throwing them in the dumpster. Interview with the administrator at 12:30 p.m. today revealed facility staff never throw their gloves on the street and are trained to dispose them properly. Interviews with S1, S2, and Staff #3 (S3) at 12:30 p.m. today revealed they also have not seen gloves, pill cups, or any trash on the streets or sidewalks around the facility. Unsubstantiated The administrator stated S3 is in charge of cleaning the streets and sidewalks every morning. S3 confirmed they have not seen gloves, pill cups, or bed liners littered improperly outside. Based on interviews and observations, there is not enough evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 15, 2026 · control 31-AS-20260511114248

Allegation investigated: Staff verbally abused resident Staff financially abused resident

At approximately 8:30 a.m. on 05/04/26 Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager Naira Margaryan (LPM) conducted a subsequent complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 02/19/26 and interviewed residents and staff between 2:40 p.m. and 4:15 p.m., conducted a record review at 3:30 p.m., and toured the facility inside and out at 2:45 p.m. Today, LPA interviewed staff and ten (10) percent of residents, or thirteen (13) out of one hundred thirty (130) between 9:00 a.m. and 4:15 p.m. Regarding the allegations "Staff verbally abused resident" and “Staff verbally abused resident” it was alleged staff yelled at Resident #1 (R1) and charged R1’s account without consent. Interviews with thirteen (13) out of thirteen (13) residents revealed none had been verbally or financially abused by staff. Unsubstantiated Interview with the administrator at 2:10 p.m. today revealed they received no reports of verbal or financial abuse. Interview with the Business Office Manager at 2:30 p.m. today revealed R1 consented to charge their account to pay for rent. No other money was charged from R1. Review of R1’s monthly rent ledger revealed they were charged the rate listed on their admission agreement. R1 also signed a consent form for automatic withdrawals for each month’s rent. Based on interviews and record review, staff did not verbally or financially abuse any residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 4, 2026 · control 31-AS-20260210114850

Allegation investigated: Due to improper care, resident developed unstageable pressure injury

At approximately 8:30 a.m. on 05/04/26 Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager Naira Margaryan (LPM) conducted a subsequent complaint visit. LPA met with the Executive Director (ED) and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 11/20/25 and interviewed staff and residents between 2:00 p.m. and 2:20 p.m., requested pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and client roster at 2:15 p.m., and toured the facility inside and out at 2:25 p.m. The Department conducted further staff and witness interviews between 12/08/25 and 03/18/26 and obtained and reviewed hospital records on 12/19/25. Today, LPA toured the facility at 09:30 a.m. At 10:30 am, LPM and LPA discuss the allegation with ED and the Vice President (VP) of Health and Wellness. Regarding the allegation "Due to improper care, Resident developed unstageable pressure injury” it was alleged the facility did not seek the necessary incidental medical care and services for Resident #1 (R1) which led to an unstageable pressure injury on their left heel. Staff interviews revealed on 11/07/25, redness was noted on R1’s left heel, and R1 expressed some pain. Substantiated Caregivers notified the Wellness Director (WD) and Wellness Coordinator (WC). On 11/09/25 redness was noticed on both of R1’s heels at the pressure points. Staff were instructed to put a pillow under R1’s heel to offload the pressure. Although R1’s skin condition was observed by appropriate personnel, no proper skin assessment was provided, and R1’s skin condition was not discussed with their doctor or other skilled professionals. On 11/10/25 and 11/13/25, staff notified R1’s family of the redness on their heels. Multiple staff noticed R1 screaming since 11/07/25. Between 11/07/25 and 11/18/25 conditions of R1’s pressure injuries got worse. On 11/18/25, R1 was sent to the hospital to seek medical attention. A review of facility records revealed the following information: Caregiver notes from 11/07/25 identified redness on R1’s left heel. R1 expressed some pain. By 11/09/25, redness was noticed on both of R1’s heels. On 11/10/25 and 11/13/25, the condition of the pressure injuries worsened. Staff continued to monitor R1’s condition by putting pillows under their heels to keep their legs elevated, though R1’s care plan was not updated with this procedure. Further review of facility records revealed although facility staff had knowledge that R1’s pressure injuries were getting worse, no initial and continued wound assessment were completed. The doctor was not notified to properly assess the wound and assign skilled medical professionals to provide required medical care. Overall investigation revealed that on 11/07/26, while in the facility, R1 developed pressure injuries. Between 11/07/25 and 11/18/25, the condition of the pressure injuries got worse, and facility did not take appropriate steps to ensure R1 is receiving required medical care and other services. On 11/18/26 R1 was sent to the hospital with unstageable wound on their left heel. Therefore, based on interviews and record reviews the allegation is deemed SUBSTANTIATED at this time. A $500 immediate civil penalty is assessed today for a violation resulting and immediate health and safety risk to R1’s health and safety. The ED was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided. Regarding the allegation “Staff changed residents healthcare provider without consent of resident or residents responsible party” it was alleged facility staff switched the insurance of Resident #1 (R1) without consent. Interviews with Staff #6 (S6) at 2:05 p.m. on 11/20/25 and Staff #4 (S4) at 2:15 p.m. on 11/20/25 revealed they had no knowledge of R1’s insurance coverage or changes. Interview with the administrator at 11:45 a.m. today revealed R1 never returned to the facility after their hospitalization on 11/18/25. The administrator also had no knowledge about R1’s insurance coverage or change. Interview with Witness #1 (W1) at approximately 2:00 p.m. on 02/13/26 revealed a dispute in the rental agreement affected R1’s insurance. Staff #7 (S7) requested W1 to switch R1’s insurance in order to qualify for a government program. Interview with S7 at 12:15 p.m. today confirmed they requested R1 to switch insurance, but it never happened. W1 also confirmed R1’s insurance was never changed. No records reviewed indicated R1’s insurance was switched. Based on interviews and record review, staff did not change R1’s healthcare provider. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 4, 2026 · control 31-AS-20251120091051

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: May 5, 2026

87464 Basic Services (d) A facility... shall be responsible for meeting the resident's needs... and providing... other basic services... either directly or through outside resources. This requirement was not met, as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not providing appropriate services for Resident #1 (R1) which posed an immediate threat to the Health, Safety, or Personal Rights of persons in care.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: Licensee to review facility program plan and update procedures regarding resident reassessments, hospital discharges, and care plan updates and submit proof by the POC due date.

Type of visit: Case Management - Other

At approximately 8:30 a.m. on 05/04/26 Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager Naira Margaryan (LPM) conducted a subsequent complaint visit. LPA met with the Executive Director (ED) and disclosed the reason for the visit. This case management visit was conducted in conjunction with complaint investigation # 31-AS-20251120091051 visit to address the issues unrelated to the complaint. During Licensing Visit, LPM Naira Margaryan and LPA Nicholas Reed spoke with ED and VP of Health and Wellness. The following issues and concerns were addressed: 1. LPM, LPA, ED and VP discussed duties, responsibilities of the staff that are responsible for residents’ assessment, reassessment and care coordination. (ED will review job scope for each member managing group of employees, and revise job duties as needed). 2. ED and VP agreed that responsible personnel must provide proper assessment for any issues reported by the caregivers. Physicians and other medical professionals must be involved to ensure proper incidental medical care for each resident. 3. A review of medical records including hospital discharge documents must be completed after each hospitalization of the residents to observe, assess and reassess the residents during admission and/or readmission. 4. The steps facility should take If hospital records identify diagnoses and health conditions previously not addressed. 5. The importance of staff observation, reassessment of the residents and discussion with the Physician and other medical professionals attending residents. 6. Accurate record keeping of internal documentation of the issues addressed by the management upon receiving reports by the caregivers. 7. Immediate reporting all issues and concerns including changes in residents overall physical, mental and psychological conditions to ED as soon as possible. ED and VP informed LPM and LPA that upon review and discussion of job duties of all staff members, a written plan will be drafted, and the meeting will be held with appropriate personnel to ensure compliance with the issues addressed in this report (Bullets 1 through 7), LPM advised ED and VP that if they are updating job duties and scopes, then the updated information must be submitted to CCL to review and update facility file. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 4, 2026

Allegation investigated: Staff does not prevent residents from smoking in non-designated smoking areas of facility

At approximately 12:45 p.m. on 01/22/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA interviewed staff and residents between 12:45 p.m. and 3:30 p.m. today, toured the facility inside and out at 1:00 p.m., and conducted a record review of pertinent records, including but not limited to a medical assessment, care plan, medication record, and resident roster at 1:30 p.m. Regarding the allegation ”Staff do not prevent residents from smoking in non-designated areas” it was alleged residents smoked in the central courtyard and garage which affected the health of Resident #1 (R1). During the facility tour, LPA observed six (06) residents smoking in the designated area near the street corner. LPA inspected the courtyard and garage and found no cigarette butts, residents smoking, odor of smoke, or other indications of smoking in non-designated areas. Unsubstantiated Interview with the administrator at 4:00 p.m. today revealed they spoke with R1 about the matter. To accommodate their needs, the administrator posted new “No smoking” signs around the building and offered R1 a room change. The administrator also provided R1 with an air filter to prevent any hazardous air conditions and designated a staff member to supervise the designated smoking area during the night shift. Interviews with ten (10) out of eleven(11) residents today revealed no residents are smoking in non-designated areas. Record review of R1’s file did not reveal any pertinent information. Based on observations, interviews, and record review, the facility ensured residents smoke in designated areas. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety needs were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 31-AS-20260106084622

Allegation investigated: Staff left resident in soiled diapers for an extended period of time Staff did not ensure they have enough linens for residents

At approximately 12:45 p.m. on 01/22/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 10/01/25 and interviewed staff and at least 10% of residents [eleven (11) out of one-hundred nine (109)] between 8:15 a.m. and 12:45 p.m., toured the facility inside and out at 11:00 a.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and client roster at 12:00 p.m. Today, LPA toured the facility at 1:00 p.m. Regarding the allegation "Staff left resident in soiled diapers for an extended period of time" and "Staff did not ensure they have enough linens for residents" it was alleged Resident #1 (R1) was left in a soiled diaper for over thirty (30) minutes and staff did not supply enough fresh bedsheets afterwards. Unsubstantiated Record review of R1’s medical assessment and care plan at 12:00 p.m. on 10/08/25 revealed they were incontinent and needed toileting assistance at least three (03) times per day. Interview with the administrator at 10:50 a.m. on 10/08/25 revealed R1 had a brief period of accidents in bed and needed several bedsheet changes each week. The administrator ordered five (05) packs of new bedsheets for R1 specifically and consulted with R1’s physician about managing the incontinence. Interview with the Maintenance Director at 10:00 a.m. on 10/01/25 revealed extra bedsheets were stored in the maintenance room. At 10:10 a.m. on 10/01/25 LPA observed an adequate supply of fresh and washed bedsheets, towels, and comforters in the maintenance room. Interview with Staff #1 (S1) at 11:20 a.m. on 10/08/25 revealed R1 was pulling off their diapers in bed and soiling their sheets. S1 had changed R1’s bedsheets on 10/07/25 and 10/08/25. Interview with Staff #2 (S2) at 11:40 a.m. on 10/08/25 confirmed R1’s bedsheets were changed almost daily. S2 also confirmed the facility bought extra bedsheets just for R1. Interview with the Wellness Director at 12:30 p.m. on 10/08/25 revealed staff were aware of R1’s increased incontinence and ensured R1 was changed regularly and not left sitting in soiled diapers. The Wellness Director also confirmed R1’s physician adjusted their medications to reduce incontinent behaviors. Interview with Staff #3 (S3) at 12:45 p.m. on 10/08/25 confirmed R1 had increased incontinence recently, but staff never left R1 sitting in soiled diapers. Interviews with eleven (11) out of eleven (11) residents on 10/01/25 revealed they had never been left in soiled diapers. Based on observations, interviews, and record review, the facility adequately addressed R1’s incontinence needs by changing their diapers and bedsheets in a timely manner. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. No immediate health or safety needs were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 31-AS-20250926093541

Allegation investigated: Licensee did not comply with the terms of a resident's admission agreement

At approximately 12:45 p.m. on 01/22/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 11/05/25 and interviewed residents and staff between 10:35 a.m. and 1:15 p.m., toured the facility inside and out at 11:30 a.m., and conducted a record review of pertinent records, including but not limited to admission agreements, rent statements, and a resident roster at 12:30 p.m. Today, LPA toured the facility at approximately 1:00 p.m. Regarding the allegation "Licensee did not comply with the terms of a resident's admission agreement" it was alleged the facility overcharged Resident #1 (R1) about $400 per month since approximately April 2023. Interview with the Vice President of Regional Operations at 11:35 a.m. on 11/05/25 revealed only the Business Office Manager (BOM) deals with resident rent collections. Interview with the BOM at 12:00 p.m. on 11/05/25 revealed they were not aware of R1’s overpayment, but they promptly worked to correct Substantiated the issue. LPA and the BOM reviewed R1’s admission agreement and ledger of charges which revealed that R1 was charged about $3,500 each month since April 2023. In June 2024, R1 increased their payments to $4000 each month. The current balance owed back to R1 is documented and calculated correctly. The BOM also discussed the balance with R1 and their representatives and resolved the matter. LPA also reviewed admission agreements and rent statements of five (05) other residents who were admitted around the same time as R1, and zero (00) of the five (05) residents were overcharged. However, further review of the ledger of charges and admission agreement of Resident #2 (R2) at 12:00 p.m. on 12/24/25 revealed they were not charged the same amount listed on their admission agreement. R2 was charged less for the month of October 2025 than listed on their admission agreement. Furthermore, R1’s admission agreement and ledger of charges showed R1 was charged a pro-rated amount for the day of 03/31/23, but the facility was not licensed until 04/01/23. Based on interviews and record review, the licensee did not comply with the terms of R2’s admission agreement and charged R1 for a day which they resided under the previously licensed facility Summit Assisted Living of Tarzana (License Number 197610186). Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is issued on the corresponding LIC 9099-D page. No immediate health or safety concerns were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 31-AS-20251103082907

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Feb 2, 2026

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above by not complying with the terms of the admission agreements of two (02) residents which posed a potential risk to the Health, Safety, or Personal Rights of persons in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: The licensee will submit proof of an in-service training regarding the cited section by the POC due date.

Allegation investigated: Staff did not meet a resident's incontinence need Staff did not meet a resident's grooming need

At approximately 9:00 a.m. on 01/08/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 08/14/25 and interviewed staff and residents between 9:15 a.m. and 5:00 p.m. and toured the facility inside and out at 10:15 a.m. LPA conducted a subsequent visit on 10/08/25 and interviewed staff and at least 10% of residents [eleven (11) out of one-hundred nine (109)] between 10:15 a.m. and 12:30 p.m., toured the facility inside and out at 11:00 a.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and client roster at 12:00 p.m. Today, LPA toured the facility at 9:00 a.m. and 4:00 p.m. Unsubstantiated Regarding the allegation "Staff did not meet a resident's incontinence need" it was alleged Resident #1 (R1) developed a Urinary Tract Infection (UTI) due to insufficient catheter care. Interview with R1 at 11:30 a.m. on 11/05/25 revealed staff have met all of their incontinence needs. R1 had no issues with the catheter care provided. Home health nurses come regularly to clean out and change the tubing while facility staff change the bag. Interviews with residents revealed no issues with the facility’s incontinence care. Record review of R1’s home health records revealed they received skilled nursing assistance through home health to flush their catheter weekly and change it monthly. Review of R1’s care plan revealed they can manage their own incontinence care with assistance and reminders from staff. Interviews with the Wellness Director at 9:30 a.m. on 08/14/25 and the administrator at 10:00 a.m. on 08/14/25 revealed staff followed R1’s care plan as directed. Interviews with Staff #1 (S1) at 11:00 a.m. on 08/14/25 and Staff #2 (S2) at 11:15 a.m. on 08/14/25 revealed staff have provided incontinence care to R1 at least once a day, every day. Based on record review and interviews, staff and home health nurses followed R1’s care plan and provided sufficient incontinence care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not meet a resident's grooming need" it was alleged R1’s toenails were too long. Interview with R1 revealed the Wellness Directors have been “on top of things” in regards to arranging podiatry appointments. R1 noted they receive podiatry care for their toe nails every 1 – 2 months. During the interview at 11:30 a.m. on 11/05/25, LPA observed R1 to be neatly groomed with trimmed nails. Interview with a Wellness Director at 9:30 a.m. on 08/14/25 revealed a podiatrist comes to the facility every month. The Wellness Director has ensured that R1 attended all podiatry appointments. Record review of R1’s physician orders from 05/09/25 indicated the facility was to ensure R1 had their toenails trimmed every 2 months. Interviews with residents revealed their podiatry and grooming needs were met by the facility. Based on observations, interviews, and record review, staff met R1’s grooming needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report providedthe state’s words, verbatim · CDSS document, Jan 8, 2026 · control 31-AS-20250812115829

Allegation investigated: Staff do not prevent residents from smoking in non-designated areas

At approximately 8:30 a.m. on 12/22/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA interviewed staff and residents between 8:40 a.m. and 1:30 p.m. today, toured the facility inside and out at 9:00 a.m., and conducted a record review of pertinent records, including but not limited to a medical assessment, care plan, medication record, and resident roster at 11:15 a.m. Regarding the allegation ”Staff do not prevent residents from smoking in non-designated areas” it was alleged residents smoked in the central courtyard, garage, and in a room which affected the health of Resident #1 (R1). During the facility tour, LPA observed four (04) residents smoking in the designated area near the street. Unsubstantiated LPA observed no smokers or smoke in the garage, central courtyard, or within the facility. Interviews with eleven (11) out of eleven (11) residents revealed no residents have detected or witnessed residents smoking in non-designated areas. Interview with Resident #2 (R2) at 10:00 a.m. today revealed they have detected the smell of smoke in the elevator and in hallways. R2 clarified that nobody is smoking in non-designated areas, but the smell of the smoke lingers on people’s clothing and carries into the building. Interview with the administrator revealed they have not received any reports of residents smoking in non-designated areas. The administrator noted that it may help to periodically remind all residents about facility policies on smoking. Interviews with Staff #1 (S1) at 9:10 a.m. today, Staff #2 (S2) at 9:25 a.m. today, and Staff #3 (S3) at 9:45 a.m. today revealed they have not seen or heard reports of residents smoking in non-designated areas. Based on observations and interviews, there is insufficient information to prove the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 31-AS-20251215092514

Allegation investigated: Staff does not ensure resident is provided a safe environment Staff does not ensure resident is administered prescribed medications in a timely manner Staff does not ensure facility is clean

At approximately 8:30 a.m. on 12/22/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA interviewed staff and residents between 8:40 a.m. and 2:00 p.m. today, toured the facility inside and out at 9:00 a.m., and conducted a record review of pertinent records, including but not limited to a medical assessment, care plan, medication record, and resident roster at 11:15 a.m. Regarding the allegation "Staff does not ensure resident is provided a safe environment" it was alleged Resident #1 (R1) was hit with a cane by Resident #2 (R2). R1 declined to be interviewed at 1:55 p.m. today, and R2 was in the hospital and unavailable. Interviews with eleven (11) out of eleven (11) other residents revealed they have not witnessed or experienced abuse in the facility. Unsubstantiated Interview with the administrator at 11:00 a.m. today revealed they have spoken with R1 before, but they have not heard reports from R1 or other residents about getting hit or other types of abuse. Interviews with Staff #1 (S1) at 9:10 a.m. today, Staff #2 (S2) at 9:25 a.m. today, and Staff #3 (S3) at 9:45 a.m. today revealed they had heard no reports of abuse from R1 or any other residents. LPA observed the facility to be safe and free of abuse during today’s visit. Based on observations and interviews, staff have provided a safe environment. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff does not ensure resident is administered prescribed medications in a timely manner" it was alleged the facility did not consistently assist with R1’s medications. Record review of R1’s care plan revealed staff agreed to assist with R1’s medication three (03) times per day. Review of R1’s Medication Administration Record (MAR) revealed staff have assisted with all of R1’s medications at the correct times. Interviews with S2 and Staff #4 (S4) at 1:45 p.m. today revealed R1 has received full assistance with all medications at the proper times. Interviews with eleven (11) out of eleven (11) residents today revealed they have received sufficient assistance with their medications. LPA observed staff assisting with resident medications at approximately 11:15 a.m. today. Based on observations, interviews, and record review, staff have properly ensured residents received assistance with medications. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff does not ensure facility is clean" it was alleged that the facility was filthy. LPA’s tour of the facility today revealed common areas and resident rooms were sufficiently clean. LPA also observed staff cleaning resident rooms between 9:20 a.m. and 10:15 a.m. Interviews with ten (10) out of eleven (11) residents revealed no issues with the condition of the facility or their rooms. Interviews with staff and the administrator revealed staff clean common areas and resident rooms every day. The administrator had not heard of any complaints about facility cleanliness. Based on observations and interviews, there is insufficient information to prove the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 31-AS-20251212092542

Allegation investigated: . Staff did not ensure requested records were provided to resident in a timely manner 2. Staff did not ensure resident was free from retaliation 3. Staff did not ensure emergency call system was responded to promptly

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced initial complaint visit to investigate the above allegations and met with Executive Director, Narine Mertkhanyan and informed her the reason of the visit. Allegation #1: It was alleged that staff did not provide the requested copy of the monthly billing invoice for rent for the month of December. It was also reported that previous monthly statements had been provided by the facility. During today’s visit, from 9:15 a.m. to 3:00 p.m., LPA conducted a physical plant inspection and interviewed ten (10) residents out of 107, as well as five (5) staff members. Interview information revealed that Resident #1 (R1) moved out of the facility on October 10, 2025. On the day R1 moved out, staff had a discussion with R1 regarding the balance owed for the ten (10) days of unpaid rent, during which an invoice was provided to R1. R1 returned back to the facility on December 1, 2025. According to staff, another discussion took place at that time regarding the outstanding balance from October, and staff provided R1 with a copy of the current rent invoice along with the remaining balance owed. R1, however, denied receiving Unsubstantiated any invoices. Residents interviewed stated that invoices are provided upon request, although many reported they do not request them and rely on bank statements as proof of rent payment. Although it was reported that R1 requested monthly rental invoices, there is insufficient evidence to support the claim that R1 did not receive them. Therefore, based on interviews and observations, the allegation is UNSUBSTANTIATED at this time. Allegation #2: It was alleged that staff did not ensure residents were free from retaliation. During today’s visit, from 9:15 a.m. to 3:00 p.m., LPA conducted a physical plant inspection and interviewed ten (10) residents out of 107, as well as five (5) staff members. It was reported that staff were retaliating against residents for requesting documentation from Administration. Residents interviewed by LPA reported they have not experienced any form of retaliation from staff. Residents stated that Administration has consistently provided any requested documentation or assistance. They further shared that some staff are nicer and more helpful than others, but overall, they respect the staff and believe staff work hard. Staff interviewed denied retaliating against any residents when requesting for assistance. Based on interviews and observations, there is insufficient evidence to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation #3: It was alleged that staff did not ensure the emergency call system was responded to promptly. During today’s visit, from 9:15 a.m. to 3 p.m., LPA conducted a physical plant inspection of resident rooms, including observation of the emergency call system at the front desk. LPA also interviewed ten (10) residents out of 107 and five (5) staff members. It was reported to LPA that staff do not answer the emergency call lights promptly when alerts appear at the front desk. It was also reported that an emergency call light was not working in the bathroom. During today’s physical plant inspection and observation of the emergency call system. LPA heard and observed staff communicating via walkie-talkies throughout the facility in response to calls activated by residents. Residents interviewed reported that staff respond to call lights as quickly as they can; however, at times, they may experience longer wait periods before assistance arrives. Although it was reported that staff do not respond promptly to call lights, based on today’s visit—through interviews and direct observations—there is insufficient evidence to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview and copy of report provided to ED.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 31-AS-20251205080850

Type of visit: Office

At 1:30 p.m. on 10/20/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an informal conference at the Woodland Hills-South Adult and Senior Care Regional Office. Along with Licensing Program Manager (LPM) Naira Margaryan, LPA met with the Vice President (VP) of Regional Operations Nirjara Acharya, Regional Director Lisa Pham, and Administrator Narine Mertkhanyan. LPA disclosed the purpose of today’s informal meeting, which was to discuss facility operations, a recent deficiency, and to provide guidance for successful care and supervision of residents. Savant representatives were given an opportunity to review public file prior to the meeting. LPA and LPM discussed the following issues: Elevator maintenance: “RM Whittaker inquired about the status of both facility elevators. Adam stated the front elevator is and has been operating and the modernization of the rear elevator was complete. An inspection was performed recently and a few more parts are required prior to passing a final inspection.” -This was the last update as of 10/15/24. The VP of Operations called LPA on 10/16/25 to notify that it had passed its final inspection. A staff member told LPA that the elevator is not working as of today. The VP clarified that the real elevator is operational as of today. LPM Margaryan noted the importance of submitting work orders and reports from maintenance agencies to keep the Licensing Department up to date on facility operations. VP Acharya stated the facility can provide all records of elevator maintenance. Frequent turnover of facility administrator: Since licensure on 04/04/23, the facility has had five (05) different administrators which may impact continuity in facility operations: Administrators: Nirjara Acharya 04/04/23 – 06/12/23, David Aguiniga 06/12/23 – 10/27/23, Jina Maleksarkissians 11/01/23 – 01/22/24, Rita Meldonian 01/22/24 - 08/26/24, Marilou Mendoza 09/03/24 - Present As of today, the facility has had six (06) administrators. Administrators: Nirjara Acharya 04/04/23 – 06/12/23, David Aguiniga 06/12/23 – 10/27/23, Jina Maleksarkissians 11/01/23 – 01/22/24, Rita Meldonian 01/22/24 - 08/26/24, Marilou Mendoza 09/03/24 - 03/14/25, Narine Mertkhanyan 03/17/25 – Present Care of Residents with special needs Staff ability to meet the needs of residents has been an ongoing issue over the past year. LPA has observed and received incident reports about residents with behavioral expressions which adversely affected the rights of other residents in the community. On 03/05/25, LPA Reed discussed with the former administrator about Resident #1 (R1) having a fall outside of the community while intoxicated. Interview with Staff #1 (S1) at 11:45 a.m. revealed some residents have been drinking alcohol in the facility at night. Interview with Staff #2 (S2) at 12:15 p.m. revealed staff are aware of multiple residents drinking alcohol in the facility. A training was issued after this. On 08/14/25, Resident #1 (R1) overdosed in the facility. The facility was cited a Type A deficiency under Subsection 87466 - Observation of the Resident. LPA expressed the importance of the facility staff’s abilities to provide sufficient care and supervision to all residents considering the increase in population over the past year. LPA reviewed the Dementia Care Plan with facility representatives and suggested modifications according to current facility operations. LPM Margaryan noted that the facility must have a plan of operation specific to any special conditions exhibited by residents with special care needs such as mental disorders or a substance abuse disorder. LPM also noted the importance of specific care plans and reappraisals for residents with mental or substance abuse disorders. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 20, 2025

Allegation investigated: Staff are not providing a resident’s medication in a timely manner Staff are not giving the proper medication dosage Staff are not following a resident’s dietary needs Staff are not treating a resident with respect

At approximately 8:45 a.m. on 09/19/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 08/05/25 and interviewed staff and residents between 11:45 a.m. and 2:00 p.m., toured the facility inside and out at 12:30 p.m., and conducted a record review of pertinent records, including but not limited to a medical assessment, care plan, and staff and client rosters at 1:15 p.m. LPA conducted a subsequent visit on 09/04/25 and interviewed at least 10% of residents [eleven (11) out of one-hundred nine (109)] between 9:30 a.m. and 2:00 p.m. and toured the facility inside and out at 10:00 a.m. Regarding the allegations "Staff are not providing a resident’s medication in a timely manner" and "Staff are not giving the proper medication dosage" it was alleged staff provided medication to Resident #1 (R1) at incorrect times and in imcorrect dosages. Interview with the administrator at 12:30 p.m. on 08/05/25 revealed R1 was recently admitted to the facility and was not accustomed to the facility medication procedures. R1 has received all medications in proper dosages and at the correct times, however they requested staff to Unsubstantiated spend about forty-five (45) minutes to assist with medications. Interview with the Wellness Director at 1:00 p.m. on 08/05/25 and Staff #1 (S1) at 1:15 p.m. on 08/15/25 confirmed that staff have spent at least thirty (30) minutes assisting R1 with medications each time due to R1 questioning their medications and refusing some. The Wellness Director and S1 confirmed staff assisted R1 with medications in the correct dosages and timeframes according to physician’s orders. Interviews with eleven (11) out of eleven (11) residents revealed they had no issues with the facility’s medication assistance. Record review of R1’s medication records revealed R1 received all medications in the correct dosages and at the correct times since their admission. Based on interviews and record review, the facility properly assisted R1 with their medications. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff are not following a resident’s dietary needs " it was alleged the facility did not accommodate R1’s low salt, no sugar diet. Record review of R1’s medical assessment and preplacement appraisal revealed they were prescribed a low salt, low carbohydrate diet. Interview with the administrator revealed all dietary needs are reviewed by the Wellness Director and communicated to the culinary staff. Interview with the Wellness Director revealed they created a dietary card for R1 so the culinary staff could accommodate their diet. Interview with the Culinary Director today at 3:10 p.m. revealed the facility accommodated R1's dietary needs, though R1 refused the foods offered as they did not like them. Interviews with eight (08) out of eleven (11) residents revealed their dietary needs are met by the facility. Interviews with three (03) out of eleven (11) residents revealed they did not like the alternative foods offered by the facility which met their dietary needs. LPA observed dietary cards stored in a binder in the kitchen today at 3:20 p.m. Based on observations, interviews, and record review, the facility followed R1’s dietary needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff are not treating a resident with respect" it was alleged Staff #2 (S2) spoke disrespectfully to R1 during the evening of 08/04/25 when assisting with their medication. Interview with S2 at 3:30 p.m. on 09/04/25 revealed they spent at least thirty (30) minutes assisting R1 with their medications. S2 stated they were patient and respectful towards R1, and it was R1 who spoke disrespectfully towards S2. Interview with S1 revealed R1 frequently spoke disrespectfully towards S1 as well during medication assistance times. Interviews with eleven (11) out of eleven (11) other residents revealed they have been treated respectfully by staff. LPA observed staff treating residents respectfully during this visit. Based on observations and interviews, there is insufficient evidence to verify this allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 31-AS-20250805100141

Allegation investigated: Staff did not prevent resident from wandering from facility

At approximately 10:15 a.m. on 10/08/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 10/01/25 and interviewed staff and residents between 8:45 a.m. and 12:45 p.m., toured the facility at 9:00 a.m., and requested pertinent record at 12:00 p.m. Today, LPA toured the facility inside and out at 11:00 a.m., interviewed Staff #1 (S1) at approximately 12:30 p.m., and conducted a record review of pertinent records, including but not limited to a medical assessment, care plan, and client roster at 2:30 p.m. Regarding the allegation "Staff did not prevent resident from wandering from facility" it was alleged Resident #1 (R1) had wandered away from the facility unsupervised. Interview with Staff #2 (S2) at approximately 9:05 a.m. on 10/01/25 revealed R1 was last at the facility on 11/01/24. R1 was hospitalized and never returned to the facility. Unsubstantiated R1 was admitted to a different facility after discharge from the hospital. Interview with S2 revealed they attempted to contact R1’s family at the phone number listed in their documents to notify of R1’s hospitalization and subsequent discharge, but the family member’s phone number had changed and was never updated. The facility had no other way of notifying R1’s family. Record review of R1’s medical assessment revealed they had no cognitive impairment and were able to leave the facility unassisted. Review of R1’s emergency contact sheet confirmed that Family #1 (F1) was R1’s only other person to be notified in the event of an emergency. LPA attempted to call the number listed at 1:00 p.m. today and confirmed the phone number listed no longer belonged to F1. Review of an incident report submitted by the facility on 11/01/24 confirmed the details of R1’s hospitalization and discharge. Based on interviews and record review, R1 was no longer a resident of this facility when they were discovered. Therefore, R1 never wandered away from the facility and the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 31-AS-20250926082205

Allegation investigated: Licensee is not preventing resident from being bitten by bugs while in care Licensee is not ensuring that staff take out the trash

At approximately 10:15 a.m. on 10/08/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA interviewed staff and at least 10% of residents [eleven (11) out of one-hundred nine (109)] between 10:15 a.m. and 12:30 p.m. today, toured the facility inside and out at 11:00 a.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and client roster at 12:00 p.m. Regarding the allegation "Licensee is not ensuring that staff take out the trash" it was alleged the trash in the room of Resident #1 (R1) was not taken out. Review of R1’s care plan revealed the facility was to assist R1 daily trash pick-up. Interview with the administrator at approximately 10:50 a.m. today revealed housekeepers and caregivers remove resident trash at least once per day. Unsubstantiated LPA inspected R1’s room today at approximately 11:05 a.m. R1’s room was tidy with no trash in the trash bin. Interviews with eleven (11) out of eleven (11) residents revealed staff take out their trash every day. No residents had issues with housekeeping or trash disposal. Interview with Staff #1 (S1) at 11:20 a.m. today revealed they take out trash from resident rooms twice per day; once at the beginning of their shift, and once at the end of their shift. Interview with Staff #2 (S2) at 11:40 a.m. today confirmed that housekeepers and caregivers take out resident trash at least once per shift. LPA also observed staff disposing of common area trash bins and resident room trash bins at approximately 11:45 a.m. and 12:00 p.m. today. Based on interviews and observations, the licensee has ensured that staff take out trash. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Licensee is not preventing resident from being bitten by bugs while in care" it was alleged that R1 was being bitten by bugs due to staff not taking out their trash. Interviews with ten (10) out of eleven (11) residents revealed they had no issues with bug bites. Interview with Resident #2 (R2) at 12:10 p.m. today revealed they get bitten by bugs while outside in the smoking area but never inside the facility. Interviews with the administrator and staff revealed they have not heard of any residents with bug bites except for R1. The administrator noted that staff deep-cleaned R’1s room upon hearing of the issue. Review of R1’s care plan and medical assessment revealed no special care needs pertaining to bug bites or other related factors for which the facility was responsible. Based on observations, interviews, and record review, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 31-AS-20251007124001

Allegation investigated: Staff did not safeguard residents personal property Staff are not meeting residents nutritional needs

At approximately 8:45 a.m. on 09/19/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 09/18/25 and toured the facility inside and out at 9:05 a.m., interviewed staff and residents between 9:15 a.m. and 2:45 p.m., and requested pertinent records at 2:30 p.m. Today, LPA interviewed staff and residents between 8:45 a.m. and 10:45 a.m., toured the facility inside and out at 9:00 a.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and client rosters at 4:30 p.m. Regarding the allegation "Staff did not safeguard resident’s personal property" it was alleged the wallet of Resident #1 (R1) was stolen around August 2024 when they were in a skilled nursing center Unsubstantiated away from their room. Interview with the Business Office Manager at 3:00 p.m. on 09/18/25 revealed R1 was admitted in November of 2024. R1 was discharged to the hospital and skilled nursing center in February 2025 and returned to the facility in June 2025. They have assisted R1 in replacing their missing items. Record review of R1’s inventory sheet revealed they listed clothing and a cell phone but not their wallet to be safeguarded by the facility. Staff interviewed did not know about R1’s missing belongings nor any other lost or stolen items. Interview with the administrator at 3:45 p.m. on 09/18/25 revealed they did not receive any reports of missing items from R1. Interviews with eleven (11) out of eleven (11) residents revealed the facility had adequately safeguarded their belongings. Based on interviews and record review, there is insufficient evidence to confirm that the facility did not safeguard resident property. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff are not meeting residents’ nutritional needs" it was alleged the facility now serves small portions than before. Interviews with seven (07) out of eleven (11) residents revealed the food served is nutritious. Interviews with eight (08) out of eleven (11) residents revealed the portion sizes are sufficient. Interview with Staff #1 (S1) at 9:35 a.m. today revealed portion sizes are standard, and residents are always able to request additional portions. Staff ensure the food served is nutritious and prepared properly. Interview with Staff #2 (S2) at 9:45 a.m. today confirmed that the facility food is nutritious and sufficient in quantity. Interviews with residents and record review of the weekly menu confirmed staff follow the menu. Interview with the administrator revealed the culinary director holds monthly meetings to adjust the menu according to resident requests. LPA observed the breakfast meal served today at 9:30 a.m. to be nutritious and sufficient in quantity. Based on observations, interviews, and record review, the facility meets residents’ nutritional needs with sufficient portion sizes. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety hazards were observed during today's visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 19, 2025 · control 31-AS-20250917085457

Type of visit: Case Management - Other

At approximately 9:00 a.m. on 09/18/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the administrator and disclosed the reason for the visit. Today’s case management visit was conducted in conjunction with the investigation for complaint # 31-AS-20250917085457. LPA investigated potential compliance issues with resident admission agreements as well as facility maintenance issues. LPA discussed the status of the rear elevator with the Maintenance Director at 2:00 p.m. today and requested the facility admission agreement and plan of operations with the Business Operations Manager at 2:30 p.m. Due to the need for more information, LPA will return at a future date to discuss rear elevator operations and the overall plan of operations and adherence to admission agreements. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 18, 2025

Allegation investigated: Staff disposed of resident’s food. Staff stole resident’s personal belongings.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegations and met with executive director, Narine Mertkhanyan. --- Staff disposed of resident’s food. It was alleged that a few days ago (exact date not recalled), a male housekeeper named Alam (last name unknown) came to R1’s room to clean and threw out food that R1 had just put in the refrigerator that same day. To investigate the allegation, LPA Nicholas Reed interviewed residents and staff between 9:35 a.m. and 12:10 p.m. and toured the facility inside and out at 9:50 a.m. LPA toured the facility inside and out at 3:45 p.m., interviewed staff between 4:05 p.m. and 4:30 p.m., and conducted a record review at 4:30 p.m. (CONT. on LIC9099-C) Unsubstantiated On 09/04/2025, LPA Duguma interviewed additional staff from 11:00a.m. – 12:00p.m. and interviewed R1 at around 12:30p.m. During interviews with staff, all staff stated the food was thrown out because it was moldy and a hazard to others. During interviews with R1, R1 stated the food was not moldy, it was perfectly fine, and they threw it out. All other residents stated the facility does not throw out their food. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. --- Staff stole resident’s personal belongings. It was alleged that two months ago (exact date not recalled), R1’s vitamins went missing and staff stole them. To investigate the allegation, LPA Nicholas Reed interviewed residents and staff between 9:35 a.m. and 12:10 p.m. and toured the facility inside and out at 9:50 a.m. LPA toured the facility inside and out at 3:45 p.m., interviewed staff between 4:05 p.m. and 4:30 p.m., and conducted a record review at 4:30 p.m. On 09/04/2025, LPA Duguma interviewed additional staff from 11:00a.m. – 12:00p.m. and interviewed R1 at around 12:30p.m. During interviews with staff, all staff stated they have never stolen or taken any residents’ vitamins. During interviews with R1, R1 stated staff stole their vitamins and they should give a $100 credit towards their rent. All other residents stated they have not experienced any vitamins going missing or suspect that it is being stolen. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 31-AS-20250501102552

Allegation investigated: Staff physically abused resident

At 8:40 a.m. on 09/10/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. Regarding the allegation "Staff physically abused resident" it was alleged staff abuse Resident #1 (R1) by pulling their hair, ripping their clothes, pushing them down, and kicking them. To investigate the allegation above, LPA conducted a file review at 8:30 a.m. today, interviewed staff and at least ten percent of residents [eleven (11) out of one-hundred three (103) residents] between 8:40 a.m. and 2:45 p.m., toured the facility inside and out at 9:00 a.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and client roster at 2:00 p.m. File review revealed R1 was hospitalized on the evening of 08/23/25 after staff found R1 had fallen in their room. LPA Reed attempted to contact R1 at 3:15 p.m. on 09/09/25 and at 11:45 a.m. and 1:15 p.m. today. R1 was unavailable for an interview. Interviews with eleven (11) out of eleven (11) residents today revealed they had not experienced or witnessed physical abuse from staff. Unsubstantiated Interview with Staff #1 (S1) at approximately 10:30 a.m. today revealed R1 wanted to go to a mental hospital, and R1 often complained about minor things. Interview with three (03) ither staff members revealed they had not abused R1 nor seen any signs of abuse. Interview with the administrator at 2:45 p.m. revealed they have spoken frequently with R1, and R1 did not express any issues. R1 was hospitalized on 09/06/25 with an infection which may have affected her judgement. Record review of R1’s facility file revealed no pertinent information to the investigation. Based on observations, interviews, and record review, there was insufficient evidence found through the course of investigation to confirm that staff abused R1 or any other residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 31-AS-20250909101109

Allegation investigated: Staff emotionally abused resident while in care

At 8:40 a.m. on 09/10/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. Regarding the allegation "Staff emotionally abused resident while in care" it was alleged staff tease and make fun of Resident #1 (R1). To investigate the allegation above, LPA interviewed staff and at least ten percent of residents [eleven (11) out of one-hundred three (103) residents] between 8:40 a.m. and 2:45 p.m. today, toured the facility inside and out at 9:00 a.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and client roster at 2:00 p.m. Interview with Staff #1 (S1) at approximately 10:30 a.m. today revealed staff do not tease R1. Instead, R1 incorrectly thinks people talk about them. S1 has seen and heard R1 yelling at people to “Shut up” when they talk near R1. Interviews with Staff #2 (S2) at 10:15 a.m. and Staff #3 (S3) at 10:05 a.m. confirmed staff treat R1 kindly and do not tease R1. Interviews with nine (09) out of ten (10) residents revealed they do not experience any teasing or emotional abuse from staff. Unsubstantiated Interview with R1 at 2:00 p.m. revealed they were doing all right, though they did not appreciate certain staff trying to hug them. Interview with R1’s family at 2:10 p.m. confirmed that R1 cannot distinguish teasing from playful joking. R1’s family member believed the staff treated R1 with respect. Interview with the administrator at 2:45 p.m. today revealed they had received no reports regarding teasing or emotional abuse of R! or other residents. LPA observed staff treating R1 respectfully today. Record review of R1’s facility file revealed no pertinent information to the investigation. Based on observations, interviews, and record review, there is insufficient evidence to indicate staff emotionally abused R1 or any other residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 31-AS-20250904154827

Allegation investigated: Facility staff did not provide a safe environment Facility admitted an unsuitable resident Staff provided inadequate bathing assistance

At approximately 8:45 a.m. on 09/04/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 07/10/25 and interviewed staff and residents between 2:35 p.m. and 3:15 p.m., conducted a record review of pertinent records at 2:45 p.m., and toured the facility inside and out at 3:00 p.m. Today, LPA interviewed residents between 9:30 a.m. and 2:00 p.m. today and toured the facility inside and out at 10:00 a.m. Regarding the allegation "Facility staff did not provide a safe environment" it was alleged Resident #1 (R1) physically and verbally harassed Resident #2 (R2). Interview with R1 at 4:35 p.m. today revealed they did not recall any negative interactions with R1. Interviews with ten (10) out of ten (10) other residents today revealed they did not witness R1 harass R2. No residents felt that they were unsafe in the facility. Unsubstantiated Interview with the administrator at 2:35 p.m. on 07/10/25 revealed they spoke with R1 after hearing R2’s report. R1 claimed they did not remember anything. Interview with Staff #1 (S1) at 3:15 p.m. on 07/10/25 revealed R1 and R2 were friends before R2 reported harassment. Interview with Staff #2 (S2) at 3:30 p.m. on 07/10/25 revealed R2 was intoxicated and said sexual words to R1. S2 stated they separated the R1 and R2 and reprimanded R1 for the incident. Based on interviews, although the allegation may be valid, there is insufficient evidence to provide its validity. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Facility admitted an unsuitable resident" it was alleged a resident slept outside on the smoking area for two (02) nights and was not suitable for the facility. Record review revealed the facility sent two (02) incident reports regarding R3’s behavior. The first report from 07/01/25 revealed Staff #3 (S3) found R3 lying outside and refusing care. The second report from 07/02/25 revealed R3 was admitted to the hospital on a 5150 hold. Interview with S3 at 3:00 p.m. on 07/10/25 revealed R3 spent two nights outside. Staff supervised R3 at least every 2 hours and brought them food, water, and medications as needed. Interview with S1 confirmed staff supervised R3 every thirty (30) minutes and eventually called the paramedics since it was 90 degrees outside. Interview with the administrator revealed Resident #3 (R3) was admitted after a full preadmission appraisal and discussion with R3’s social workers. R3 was part of a street outreach program and needed help adjusting to sheltered life. Review of R3’s care plan revealed they needed assistance “deconditioning”. Review of R3’s medical assessment showed they were appropriate for the facility and did not need a higher level of care. Based on interviews and record review, R3 was suitable for the facility, and staff appropriately handled R3’s refusal of care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff provided inadequate bathing assistance" it was alleged staff did not provide shower assistance to Resident #4 (R4) for over a month. Record review of the shower schedule revealed staff were scheduled to assist R4 on Monday and Thursday afternoons. Interview with R4 today at 4:45 p.m. revealed they have received sufficient assistance with bathing since arriving in June 2025. R4 appeared to be neat and well-groomed today. Interview with S1 confirmed R4 received baths twice a week from staff and did not refuse bathing assistance. S2 and S3 confirmed R4 has regularly received assistance with bathing. Based on observations, interviews, and record review, staff provided adequate bathing assistance to R4. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 31-AS-20250708145658

Allegation investigated: Staff did not provide resident with copies of documents in a timely manner. Licensee did not repair resident’s shower in a timely manner.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegations and met with executive director, Narine Mertkhanyan. --- Staff did not provide resident with copies of documents in a timely manner. It was alleged that in April 2025 (exact date not recalled), Resident #1 (R1) was given some paperwork to sign by staff about R1’s behavior and being a danger to others, but R1 did not read the papers before signing them. R1 asked the administrator for copies of the papers signed but was never provided with them. To investigate the allegation, LPA Nicholas Reed interviewed residents and staff between 9:35 a.m. and 12:10 p.m. and toured the facility inside and out at 9:50 a.m. LPA toured the facility inside and out at 3:45 p.m., interviewed staff between 4:05 p.m. and 4:30 p.m., and conducted a record review at 4:30 p.m. (CONT. on LIC9099-C) Unsubstantiated On 09/04/2025, LPA Duguma interviewed additional staff from 11:00a.m. – 12:00p.m. During interviews with staff, Staff #1 (S1) stated resident was not given documents to sign regarding their behavior during the period in question, rather R1 was given Assisted Living Waiver documents to sign. Copies were proved to R1 within 48 hours. During interviews with R1, R1 confirmed S1’s statement. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. --- Licensee did not repair resident’s shower in a timely manner. It was alleged that a caregiver took a trash can into the bathroom and somehow broke the shower, causing it to flood. To investigate the allegation, LPA Nicholas Reed interviewed residents and staff between 9:35 a.m. and 12:10 p.m. and toured the facility inside and out at 9:50 a.m. LPA toured the facility inside and out at 3:45 p.m., interviewed staff between 4:05 p.m. and 4:30 p.m., and conducted a record review at 4:30 p.m. On 09/04/2025, LPA Duguma interviewed additional staff from 11:00a.m. – 12:00p.m and conducted a physical plant tour. During interviews with staff, all staff stated while a housekeeper was cleaning, they inadvertently broke a shower cartridge but that it was addressed and replaced the same day. During interviews with R1, R1 confirmed staffs’ statements. Although the shower was temporarily in disrepair, facility took immediate action to resolve the issue. During the facility plant tour, LPA did not observe shower in disrepair. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 31-AS-20250501102552

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff are not meeting residents laundry needs

At approximately 8:45 a.m. on 09/04/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 02/06/25 and interviewed staff and residents between 10:45 a.m. and 3:15 p.m., toured the facility at 11:15 a.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at approximately 12:00 p.m. LPA conducted a subsequent visit on 02/07/25 and interviewed staff and residents between 11:05 a.m. and 3:00 p.m. and toured the facility at 11:15 a.m. Today, LPA toured the facility at 9:00 a.m. Regarding the allegation "Staff are not meeting residents laundry needs" it was alleged the laundry of Resident #1 (R1) was not cleaned for three (03) weeks. At 12:30 p.m. on 02/07/25, LPA’s tour of the facility revealed that R1 had a basket full of laundry as well as a pile of soiled blankets in their closet. Substantiated Interview with Visitor #1 (V1) at 12:35 p.m. on 02/07/25 revealed staff put the soiled sheets in the corner of R1’s closet since the laundry basket was overflowing. LPA smelled a faint odor of urine coming from the soiled sheets. Interview with a previous administrator revealed they received a report from S2 that there was a resident who did not receive laundry service in a timely manner. Staff #5 (S5) was the normal laundry staff at the facility, and Staff #6 (S6) was supposed to clean the laundry while S5 was out of the facility. Interview with S2 revealed that “2-3 residents have piles of laundry” in their rooms. Interview with S5 at 12:15 p.m. on 02/06/25 revealed they were hired a few weeks prior to clean laundry after the previous laundry staff left. S5 showed LPA the laundry schedule and stated R1’s laundry is scheduled to be cleaned on Sundays. The facility does not wash laundry on Fridays or Saturdays. When residents soil their sheets, the facility provides fresh sheets, though the resident may have to wait until their scheduled laundry day to have their linens cleaned due to the laundry schedule being full. S5 confirmed that two (02) weeks prior, around 01/27/25, they called out from work and left a note for S6 to do R1’s laundry. When S5 returned to work, they noticed R1’s laundry was not washed. R1 had to wait another week for laundry service due to a full laundry schedule. Based on observations, interviews, and record review, staff did not meet R1’s laundry needs. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency cited on the LIC 9099-D page. No immediate health or safety hazards observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided. LPA’s first call was not answered. LPA was unable to leave a voicemail because the voicemail inbox was full. Staff #1 (S1) answered the call at 8:55 a.m. LPA also called the facility phone at 8:33 a.m. and 8:34 a.m. on 02/07/25. LPA’s call at 8:33 a.m. was not answered, and the voicemail box was full again. Staff #4 (S4) answered LPA’s call at 8:34 a.m. and noted they were opening the garage gate at 8:33 a.m. and were away from the front desk. Interview with a previous administrator at 11:10 a.m. on 02/06/25 revealed that the facility has one phone line which the concierge answers. If the concierge does not answer a call, it also goes to the Wellness office where staff are trained to answer calls and clear the voicemail each day. Residents can call out from any facility phone, but incoming calls must be answered by staff so that residents can receive their calls. If staff do not answer the phone, residents have no way of receiving calls intended for them. Interview with S1 at 11:40 a.m. on 02/06/25 revealed that their concierge shift starts at 9:00 a.m. S1 confirmed that staff in the Wellness office should answer the call when concierge is not present. S1 also stated they clear the voicemail everyday and there may have been technical issues. Interviews with Staff #2 (S2) at 11:50 a.m. on 02/06/25 and Staff #3 (S3) at 11:55 a.m. on 02/06/25 confirmed that concierge should answer calls, and S2 and S3 can answer the call if concierge misses it. S2 and S3 were not aware of any missed calls from the morning. LPA tested the phone system this morning at 9:22 a.m. Staff #4 (S4) answered promptly. Based on observations and interviews, staff ensured the phone was answered. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff are not ensuring the facility is kept clean" it was alleged the floors are dirty and have crumbs on them. Facility tours on 02/06/25, 02/07/25, and today revealed no dirt, stains, or crumbs were observed on facility floors. LPA interviewed nine (09) out of ninety (90) residents, which was 10% of the census. Interviews with six (06) out of nine (09) residents interviewed revealed that they had no issues with the cleanliness of the facility or the floors. Interviews with three (03) out of nine (09) residents interviewed revealed that there are deep stains in the carpets despite facility staff frequently cleaning the carpets. Interview with a previous administrator at 11:10 a.m. on 02/06/25 revealed housekeeping sweeps and vacuums common areas everyday. The Maintenance Director deep cleans the common areas every week. Interviews with maintenance staff, Staff #7 (S7) at 11:30 a.m. on 02/06/25 and Staff #8 (S8) at 12:40 p.m. on 02/06/25 confirmed that the common areas are deep cleaned on a weekly basis. Based on observations and interviews, staff ensure the facility is kept clean. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not ensure there is an activities director" it was alleged the facility has no activities director. Interview with a previous administrator revealed Staff #9 (S9) has been the activity director for about one (01) year. Record review of the staff list confirmed S9 has been the activity director. Interview with S9 at 11:05 a.m. on 02/07/25 confirmed they are and have been the activity director. Based on interviews and record review, the facility has an activity director. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not ensure resident's shower was not in disrepair" it was alleged the shower handle in the bathroom belonging to Resident #1 (R1) was broken for multiple weeks. Tour of R1’s room at 12:30 p.m. on 02/06/25 revealed their shower handle was functioning properly. Interview with the former administrator revealed they had not received any reports of necessary maintenance in R1’s room. Interview with S8 revealed they first received the maintenance order from caregivers on 02/06/25. S8 showed LPA proof of the work order for R1’s shower handle at 11:09 a.m. on 02/06/25. S8 and S7 fixed the issue by 12:00 p.m. on 02/06/25. LPA attempted to interview R1 at 12:40 p.m. on 02/06/25 but received no relevant information. Interviews with nine (09) out of ninety (90) residents revealed that they had no maintenance issues. Based on observations, interviews, and record review, the facility ensured R1’s shower handle was fixed promptly after receiving the work order. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 31-AS-20250205150035

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(F) · Plan of correction due date: Sep 15, 2025

87307 Personal Accommodations and Services (a) ... The following provisions shall apply: (3)... the licensee shall assure provision of: (F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement was not met as evidenced by: Based on observations, interviews, and record review, the licensee did not comply with the section cited above in at least one (01) resident's laundry not being complete for over a week which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Licensee has changed the laundry schedule and added two (02) additional laundry days to ensure all resident laundry is completed weekly or as needed. Deficiency cleared.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management visit at the above facility at 11:30am to verify the relocation of Resident #1 (R1) to this facility and to confirm their health and safety following the transition. LPA met with Executive Director (ED) Narine Metkhanyan and explained the purpose for the visit. At approximately 11:45am, LPA Chochian and ED conducted a tour of the physical plant to ensure compliance with Title 22 regulations, which included a tour of R1’s room. R1 was observed to be in the dining room. LPA met with R1 after lunch and reason for the visit was explained. R1 expressed being satisfied with the transfer and facility at this time. No immediate health or safety concerns were observed during the visit. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

Allegation investigated: Staff illegally evicted a resident in care

At 8:40 a.m. on 08/21/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. To investigate the allegation, LPA interviewed staff and residents today between 8:45 a.m. and 11:30 a.m., toured the facility at 9:00 a.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, care plan, and client roster at 9:30 a.m. Regarding the allegation "Staff illegally evicted a resident in care" it was alleged Staff #1 (S1) provided a 3-day eviction notice to Resident #1 (R1) illegally. Interview with R1 today at 10:35 a.m. revealed S1 never said the word eviction and never provided any eviction paperwork to R1. R1 clarified that S1 was looking for a more suitable home for R1. Interview with S1 today at 11:20 a.m. confirmed they never issued an eviction notice to R1 and never distributed eviction paperwork. Telephonic interview with the administrator at 11:30 a.m. today revealed the facility did not issue an eviction to R1 or discuss eviction. Unsubstantiated Review of R1’s care plan and admission agreement revealed no pertinent information for the investigation. Based on interviews and record review, the facility did not illegally evict a resident. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 31-AS-20250820145246

Type of visit: Case Management - Incident

At approximately 8:45 a.m. on 08/15/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit. Today’s case management visit was conducted after reviewing two (02) incident reports submitted by the facility in which Resident #1 (R1) was admitted to Sherman Oaks Hospital around 10:00 a.m. on 08/02/25 with hip pain and later found unresponsive on the street near Providence-Tarzana Hospital around 2:00 p.m. on the same day. LPA conducted a record review of pertinent documents, including but not limited to R1’s discharge paperwork and face sheet around 9:40 a.m. on 08/14/25 and interviewed Staff #1 (S1) at approximately 9:50 a.m. on 08/14/25. Interview with S1 confirmed R1 was admitted to the hospital during the morning of 08/02/25 for hip pain. R1 was discharged that same day and returned to the facility. S1 later received a phone call from Providence-Tarzana Hospital noting R1 was found unresponsive near the hospital around 2:00 pm.. Record review indicated that R1 was admitted to the Emergency Room at Sherman Oaks Hospital at 11:16 a.m. on 08/02/25 for hip pain, nausea, vomiting, and opioid withdrawal. Discharge paperwork from Providence- Tarzana Hospital indicated that R1 was admitted for an accidental overdose and diagnosed with an altered mental status and opioid dependence on 08/02/25. Review of R1’s face sheet from 07/31/25 revealed they were already diagnosed with opioid dependence prior to these hospitalizations. Today, LPA obtained a resident list around 9:00 a.m. which indicated that R1 was in the hospital. LPA called the hospital around 11:45 a.m. this morning to speak with R1. A nurse in the Intensive Care Unit responded and explained that R1 was admitted yesterday, 08/14/25, for their second overdose in two (02) weeks. Interview with Staff #2 (S2) at approximately 2:00 p.m. today revealed that the home health nurse for R1's roommate reported that they discovered R1 unresponsive in their room around 8:30 a.m. on 08/14/25. The nurse also told S2 that R1 had drugs. Staff called 9-1-1, and S2 performed CPR until paramedics arrived. Review of R1’s plan of care at approximately 2:05 p.m. today revealed staff were to supervise R1 once per shift, or about every eight (08) hours. LPA reviewed a reappraisal from 08/03/25 noted the facility would "continue with wellness check" but did not reference increased supervision. LPA previously addressed the facility’s approach towards residents with substance abuse issues during a case management visit on 03/05/25. Interview with S1 at 12:15 p.m. on 03/05/25 revealed staff were aware of multiple residents drinking alcohol in the facility and staff have not received training on providing care and supervision to residents with substance abuse problems. Interview with the previous administrator at 1:30 p.m. on 03/05/25 revealed the facility could issue a training for all staff on dealing with substance abuse issues as well as updating the facility program plan to address care of residents with substance abuse issues. Based on interviews and record review, the facility did not create an adequate care plan update or reappraisal to address R1's opioid dependence and subsequent overdoses on 08/02/25 and 08/14/25. R1's documents did not address their needs, so staff were unable to prevent R1's second overdose on 08/14/25. Therefore a deficiency is issued today for an inadequate care plan update to address R1's needs and to ensure the facility could provide proper care and supervision for R1. A $500 immediate civil penalty is assessed today for a violation resulting in the overdose of R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). No immediate health or safety concerns were observed during today's visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Aug 18, 2025

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not providing adequate care to Resident #1 (R1) to address their substance use issue which posed an immediate risk to the Health, Safety, or Personal Rights of persons in care.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: Licensee conducted an in-service training on the cited section and submitted proof during the visit. Deficiency cleared.

Type of visit: Case Management - Health Checks

At 11:30 a.m. on 08/05/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the administrator and disclosed the reason for the visit. Today’s case management visit was conduced to ensure the health and safety of two (02) recently admitted residents. Interview with the administrator at 11:45 a.m. and the Wellness Director at 11:55 a.m. today revealed Resident #1 (R1) returned to their friend’s home on Sunday, 08/03/25. LPA reviewed R1’s records for their emergency contacts and home address. LPA also interviewed Resident #2 (R2) at 12:30 p.m. today. R2 noted they are happy and safe at this facility. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 5, 2025

Allegation investigated: Staff do not treat resident with dignity and respect

At approximately 11:30 a.m. on 05/15/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA toured the facility inside and out at 11:40 a.m. today, interviewed staff and 10% of residents, or nine (09) out of ninety (90) residents, between 11:45 a.m. and 2:00 p.m., and conducted a record review of pertinent records, including but not limited to staff and client rosters at 2:00 p.m. Regarding the allegation "Staff do not treat resident with dignity and respect" it was alleged Staff #1 (S1) spoke in a rude tone to Resident #1 (R1). Interview with R1 at 1:30 p.m. today revealed the issue was a misunderstanding about a salad yesterday. Interview with the administrator at 11:45 a.m. today revealed the issue was resolved after it was brought to their attention yesterday. Unsubstantiated Interview with S1 at 12:25 p.m. today revealed they have not spoken rudely to R1 and assisted with their needs. Interview with S1’s supervisor, Staff #2 (S2), at 12:35 p.m. today confirmed that S1 behaved appropriately towards R1 and helped R1 resolve their issue with respect. Interviews with seven (07) out of eight (08) other residents interviewed confirmed that staff treat everyone with respect. During today’s facility tour, LPA observed staff members treating residents with dignity. Based on observations and interviews, staff treat residents with respect. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 15, 2025 · control 31-AS-20250514124916

Allegation investigated: Staff are not assisting residents in a timely manner Staff do not provide adequate food service

At approximately 11:30 a.m. on 05/15/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA toured the facility inside and out at 11:40 a.m., interviewed staff and residents between 11:45 a.m. and 2:00 p.m. today, and conducted a record review of pertinent records, including but not limited to staff and client rosters at 2:00 p.m. Regarding the allegation "Staff are not assisting residents in a timely manner" it was alleged staff do not respond to resident requests for assistance. LPA conducted call system tests at 1:05 p.m. and 2:00 p.m. today. Staff responded to the calls within five (05) minutes. Interviews with seven (07) out of nine (09) residents today revealed staff assist them in a timely manner. Interviews with the administrator, Staff #1 (S1) at 12:45 p.m., and Staff #2 (S2) at 12:55 p.m. confirmed there have been no issues with staff response time to requests for assistance. Unsubstantiated Based on observations and interviews, staff assist residents in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff do not provide adequate food service" it was alleged the facility serves food of poor quality. Tour of the kitchen at 12:30 p.m. today revealed the facility has adequate supplies of perishable and non-perishable foods. Food was good quality and stored properly. Interviews with seven (07) out of nine (09) residents today revealed the facility serves food of good quality. Two (02) out of nine (09) residents interviewed noted they did not like the food. Staff #3 (S3) and Staff #4 (S4) both work in the kitchen. Interview with S3 at 12:25 p.m. today revealed that residents frequently complain, so staff promptly assist them with their needs. Interview with S4 at 12:35 p.m. today revealed they have monthly meetings with residents to incorporate their suggestions into the menu. Interviews with S4 and with the administrator at 11:45 a.m. today revealed that a registered dietitian visits the facility about every three (03) months to approve the menu and quality of food. S3, S4, and the administrator all stated the facility serves good quality food. Based on observations and interviews staff provide adequate food service. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 15, 2025 · control 31-AS-20250509141946

Allegation investigated: Facility does not allow residents to chose their 3rd party health care providers

At approximately 9:30 a.m. on 05/01/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit in conjunction with an annual inspection. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 03/18/25 and interviewed staff and residents between 10:15 a.m. and 4:15 p.m., toured the facility at 10:40 a.m., and conducted a record review of pertinent records, including but not limited to home health records, hospice records, and staff and client rosters at 1:45 p.m. LPA conducted telephonic interviews with Visitor #1 (V1) at 1:00 p.m. on 03/18/25, Visitor #2 (V2) at 11:00 a.m. on 03/25/25, and Visitor #3 (V3) at 4:45 p.m. on 03/28/25. Regarding the allegation "Facility does not allow residents to choose their 3rd party health care providers" it was alleged multiple residents were enrolled into home health and hospice services without alternative choices provided. Substantiated At approximately 11:00 a.m. on 03/18/25, LPA reviewed a list of residents receiving home health and hospice services. Interview with Staff #3 (S3) at approximately 11:15 a.m. on 03/18/25 and Staff #4 (S4) at approximately 11:20 a.m. on 03/18/25 revealed the facility usually offers residents three (03) options when deciding between home health or hospice agencies. S3 also noted that six (06) residents were assigned a new home health agency, Skilled Home Heath, Inc., on approximately 03/04/25. Record review of consent forms revealed all six (06) residents signed admission consent forms with Visitor #4 (V4) who was an employee of Skilled Home Health, Inc. Telephonic interview with V4 at approximately 9:30 a.m. on 03/19/25 revealed they were directed by their boss at Skilled Home Health, Inc. to enroll the six (06) residents into home health services. Telephonic interview with a representative from Skilled Home Health, Inc. (V5) at approximately 3:00 p.m. on 03/18/25 revealed all six (06) residents were prescribed physician’s orders for the home health services. Interviews with five (05) out of the six (06) residents enrolled into Skilled Home Health, Inc. around 03/04/25 revealed they did not remember signing consent forms and did not recall receiving different choices for home health agencies. Interview with Resident #1 (R1) at approximately 2:20 p.m. on 03/18/25 revealed a representative from a different home health agency solicited services to R1 around February 2025. R1 stated that a facility employee later told R1 “we are going to use our own healthcare” when referencing R1's enrollment into Skilled Home Health, Inc. Interview with V1, who was a representative of Resident #7 (R7), revealed they received a phone call from facility staff telling them that they were going to enroll R7 into hospice services. Interview with V2, who was a representative of Resident #8 (R8) revealed facility staff suggested hospice for R8 and that a hospice agency would reach out to them. Both V1 and V2 stated they were not provided options of hospice agencies to choose. Record review of the facility’s admission agreement at 2:30 p.m. today revealed that residents “may utilize home health agencies, or other providers of [their] choice”. Based on interviews and record review, R7 and R8 enrolled into hospice services without them or their representatives being offered choices of hospice agencies. Out of the six (06) residents enrolled into Skilled Home Health, Inc. around 03/04/25, only R1 was provided a choice of home health agencies. R1 was later told they would be enrolled into Skilled Home Health, Inc. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D page. No immediate health and safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided. Staff duties for the morning and afternoon of 03/18/25 were divided amongst three (03) caregivers. Each caregiver was assigned to provide care for approximately twenty-one (21) residents with needs such as escorting to and from meals, incontinence care, shower assistance, and assistance with other activities of daily living. It was estimated that each caregiver was assigned approximately six (06) hours of work for morning and afternoon shifts. LPA, Administrator, and Wellness Coordinators also reviewed the overnight shift assignments, in which two (02) caregivers were assigned to provide incontinence care and supervision for twenty-eight (28) residents. It was estimated that each caregiver was assigned approximately five (05) hours of work for overnight shifts. Interviews with the three (03) morning caregivers revealed that all caregivers had sufficient time to complete all necessary tasks. Interview with Staff #1 (S1) at 1:55 p.m. on 03/18/25 revealed that they do get short staffed at times when a caregiver calls out sick. Interview with Staff #2 (S2) at 2:05 p.m. on 03/18/25 revealed that they assist other caregivers to complete duties. Interviews with nine (09) out of eighty-nine (89) residents, which was at least 10% of the census, revealed that their care needs are met by staff. Based on record review and interviews, the facility is sufficiently staff to meet the needs of the residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 1, 2025 · control 31-AS-20250317141735

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(18) · Plan of correction due date: May 12, 2025

87468.2 Additional Personal Rights... (a) …residents… shall have all of the following personal rights: (18) To select their own... hospice agency, and health care providers in a manner that is consistent with the resident’s admission agreement.This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in at least (08) out of ninety-one (91) residents' rights to choose their own health services which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 1, 2025

Plan of correction: Licensee has agreed to conduct an in-service training on the cited section and submit proof of correction by the POC due date.

Allegation investigated: Facility staff did not ensure resident's call pendant worked

At approximately 9:30 a.m. on 05/01/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit in conjunction with an annual inspection. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 03/18/25 and interviewed staff and residents between 10:15 a.m. and 4:15 p.m., toured the facility at 10:40 a.m., and conducted a record review of pertinent records, including but not limited to staff and client rosters at 1:45 p.m. Regarding the allegation "Facility staff did not ensure resident's call pendant worked" it was alleged Resident #1 (R1) pushed their pendant three (03) times without receiving staff assistance. Interview with R1 at 10:30 a.m. on 03/18/25 revealed staff resolved the issue by providing a new telephone to call the front desk. R1 also noted that their pull cord near their bed was and has been operable. R1’s pull cord and phone were tested at 10:40 a.m. on 03/18/25 and deemed functional. Unsubstantiated Interview with the administrator at 11:00 a.m. on 03/18/25 revealed they were not aware of any issue with pendants. The facility recently switched their call system from resident pendants to a bedside telephone which directly calls the front desk. Interview with Staff #1 (S1) at 12:30 p.m. on 03/18/24 confirmed R1 has not had any issues after the call system update. Between 10:30 a.m. and 2:00 p.m. on 04/20/25, LPA and the administrator tested the facility call system. The facility call system was deemed operational after testing. Based on observations and interviews, facility staff ensured R1 had access to a functional call system through their pull cord and a new phone. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 1, 2025 · control 31-AS-20250314161713

Type of visit: Case Management - Annual Continuation

At approximately 10:30 a.m. on 04/30/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and Vice President of Operations (VP) and disclosed the reason for the visit. The Regional Director of Operations later joined the visit at approximately 1:00 p.m. Due to time constraints, LPA returned to the facility today at approximately 9:30 a.m. and finished the inspection with the administrator and VP. A file review was conducted prior to the visit. The facility was last visited on 03/18/25 for a complaint visit. It is a three (03) story building with a capacity of 176 residents. LPA observed bedrooms, shared and private bathrooms, kitchen and dining areas, garage, common areas, activity rooms, offices, and a courtyard. It has an approved fire clearance for 176 nonambulatory residents, of which fifty (50) may be bedridden. Approved hospice waivers for thirty (30). Between 10:30 a.m. and 3:30 p.m. on 04/30/25 and between 9:30 a.m. and 11:00 a.m. today, LPA, administrator, and VP toured the facility. At approximately 10:00 a.m. on 04/30/25 the facility telephone was called and deemed operational. At 1:30 p.m. on 04/30/25, a medication review was conducted for nine (09) residents. All medications quantities were maintained and documented in the correct amounts. At 3:30 p.m. on 04/30/25, LPA conducted a file review for resident and personnel records. All files were complete and available for audit. LPA also reviewed the most recent fire safety inspection from 11/26/24 in which all systems passed. The most recent fire safety drill was conducted on 04/26/25. Liability insurance and surety bond were both current. At the main entrance, LPA observed a designated smoking area. A doorbell was posted at the front for after-hours entry along with a sign with two (02) phone numbers listed. The designated smoking area at the front contained artificial shrubs and an umbrella for shade. Postings were observed inside for COVID precautions, emergency contacts, Ombudsman contacts, confidential complaint contacts, facility license, facility sketch, emergency disaster plan, administrator certificate, personal rights, rights of resident and family councils, theft and loss policy, nondiscrimination notice, normal and alternate menus, and activity calendars and reminders. Walls, floors, windows, screens, and blinds were clean, free from stains, and in good repair. An activity room near the reception desk had a television, exercise equipment, a piano, a sound system, and sufficient activity space. Activities were observed and conducted at 10:00 a.m. today and yesterday, and a live musical performance occurred around 10:30 a.m. today. The reception area including seating, board games, an administrator office, a business office, and mailboxes. Personnel files were stored and locked in the business office. At approximately 11:00 a.m. on 04/30/25, a fully-charged fire extinguisher was observed near the main entrance. It was last inspected on 06/12/24 and inspected by facility staff every month thereafter. At 11:10 a.m on 04/30/25 the room temperature was measured to be 71 degrees Fahrenheit. Rooms 101, 110, 219, and 209 were inspected. All four (04) rooms contained functional smoke alarms, appropriately furnished bedding, chairs, nightstands, storage, lighting, and bathrooms with paper towels, liquid soap, grab bars near the toilets and showers, and non-skid mats or strips in the shower. All rooms were clean and in good repair. Call systems in the rooms were tested and deemed operational. Staff attended to the calls within one (01) to ten (10) minutes. Water temperatures in bathrooms were measured to be between 105.4 and 109.8 degrees Fahrenheit. The second floor contained a medication room, activity room, and more resident rooms. The medication room contained a fully-stocked first aid kit, inaccessible medications, and locked medication carts with secondary locks for controlled substances. The activity room contained reading material, games, puzzles, and exercise equipment. Fire doors were observed in hallways. Fire sprinklers were observed throughout the building. Water and coffee was available on the first and second floors. The third floor was unoccupied. The rear elevator accessed the third floor but was inoperable. The facility has scheduled maintenance and informed The Department of all updates. A final inspection is set for 05/02/25. Two (02) out of two (02) stairwells had emergency evacuation chairs at the tops of the stairwells. No hazards were observed in stairwells or emergency exit paths. All emergency exits were unlocked. All electrical rooms, maintenance rooms, and roof access doors were locked. The garage was free of hazards. The courtyard contained plants and trees and two (02) shaded seating areas. LPA observed three (03) dining areas near the kitchen. The kitchen contained an adequate supply of perishable, non-perishable, and emergency foods. The dishwashing area was free of debris and vermin. Appliances were in good condition. Cleaning solutions and sharps were inaccessible. At approximately 10:10 a.m. today, the walk-in freezer and refrigerator temperatures were measured to be -8 and 32 degrees Fahrenheit. Temperature and maintenance logs were observed near appliances. Two (02) washing machines and two (02) dryers were located in the laundry room. Both were in working order. Detergents were stored and locked. During yesterday’s and today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety hazards were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: Required - 1 Year

At approximately 10:30 a.m. on 04/30/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and Vice President of Operations (VP) and disclosed the reason for the visit. The Regional Director of Operations later joined the visit at approximately 1:00 p.m. A file review was conducted prior to today’s visit. Between 10:30 a.m. and 3:30 p.m., LPA, administrator, and VP toured the facility. At 1:30 p.m., a medication review was conducted for nine (09) residents. At 3:30 p.m., LPA conducted a file review for resident and personnel records. Due to time constraints, the annual inspection was not completed today. LPA to return tomorrow, 05/01/25, to complete inspection and deliver report on the LIC 809 Annual Continuation. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 30, 2025

Allegation investigated: Staff are not distributing resident's medications as prescribed

At approximately 11:15 a.m. on 03/05/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA toured the facility at 11:20 a.m. today, interviewed staff and residents between 11:30 a.m. and 1:15 p.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 12:30 p.m. Regarding the allegation "Staff are not distributing resident's medications as prescribed" it was alleged Resident #1 (R1) was not receiving staff assistance with their medication. Interview with Staff #1 (S1) at 12:00 p.m. revealed R1 was recently admitted to the facility and has had some difficulty adjusting to the new setting. Record review of R1’s Medication Administration Record (MAR) showed R1 received staff assistance with all of their medications at every required time. No entries in the MAR were blank or missing. Unsubstantiated R1’s MAR showed that they refused medication between 02/23/25 and 02/27/25. Interview with Staff #2 (S2) at 12:30 p.m. and Staff #3 (S3) at 12:40 p.m. confirmed that R1 verbally refused medications on the noted dates. S2 said R1 would yell at them and refuse medication. S3 said R1 would request staff come back at another time as they were not ready for medications. Both staff reported the refusals to their supervisors and R1’s physician. Interview with R1 at 1:00 p.m. today confirmed they are having trouble adjusting to the facility and have refused meals and medications. R1 confirmed staff have thoroughly assisted them with medications. Based on interviews and record review, staff properly distributed R1’s medications. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 5, 2025 · control 31-AS-20250227114052

Type of visit: Case Management - Incident

At approximately 11:15 a.m. on 03/05/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the administrator and disclosed the reason for the visit. Today’s case management visit was conducted after the facility submitted an incident report regarding Resident #1 (R1) having a fall outside of the community while intoxicated. LPA toured the facility at 11:20 a.m. today, interviewed staff and residents between 11:30 a.m. and 1:00 p.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 12:00 p.m. Interview with Staff #1 (S1) at 11:45 a.m. today revealed some residents have a drinking alcohol in the facility at night. Record review of R1’s medical assessment revealed they are able to leave the facility unassisted and do not have a substance abuse problem. Interview with Staff #2 (S2) at 12:15 p.m. today revealed staff are aware of multiple residents drinking alcohol in the facility. S2 further stated that staff have not received training on providing care and supervision to residents with substance abuse problems. Interview with the administrator today at 1:30 p.m. revealed the facility can issue a training for all staff on dealing with substance abuse issues as well as updating the facility program plan to address care of residents with substance abuse issues. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 5, 2025

Type of visit: Case Management - Other

At 11:00 a.m. on 02/07/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later the administrator and disclosed the reason for the visit. Today’s case management visit was conducted in conjunction with a complaint visit for complaint # 31-AS-20250205150035. During the course of investigation, a deficiency was discovered involving the facility’s Activity Director (AD). Interview with the AD at 11:05 a.m. today revealed they were sent to drive the facility van yesterday, 02/06/25, to ensure a resident attended their medical appointment. The driver that the facility recently hired, Staff #1 (S1), was busy with training and could not drive the van. Previous interviews with the AD on 12/21/2023 and 07/12/2024 revealed the AD has had to drive the facility van in previous instances. The AD also noted that they have filled in for front desk staff as needed. Interview with the administrator at 3:15 p.m. today confirmed that the AD had to drive the facility van yesterday when the designated driver was absent. The administrator confirmed that the AD has had to fill the role of the facility driver when no driver was available. When the AD drove the facility van, they were not fulfilling their full-time responsibility as an Activity Director. Therefore, a deficiency is issued on the corresponding LIC 809-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Feb 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(f) · Plan of correction due date: Feb 17, 2025

87219 Planned Activities (f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities Based on interviews and observations, the licensee did not comply with the section cited above through the Activity Director participating in other duties which poses a potential Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 7, 2025

Plan of correction: The licensee has agreed to submit a plan in accordance to 87219(f)(1) to ensure residents are provided with activities and that the Activity Director fulfills their duties.

Allegation investigated: Resident is smoking close to the facility

At 11:00 a.m. on 01/29/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 12/20/24 and interviewed staff and residents between 3:35 p.m. and 4:10 p.m. and toured the facility inside and out at 4:00 p.m. LPA conducted a subsequent visit on 01/24/25 and interviewed staff and residents between 2:00 p.m. and 3:30 p.m. and toured the facility inside and out at 2:30 p.m. Today, LPA toured the facility at 11:10 a.m. and interviewed Resident #1 (R1) at 12:15 p.m. Regarding the allegation "Resident is smoking close to the facility" it was alleged R1 smokes too close to the facility entrance, and the smoke enters the building and affects residents. The facility was issued a deficiency on 10/18/24 for not preventing residents from smoking in non-designated areas. Unsubstantiated A plan of correction was submitted indicating the designated smoking area would be upgraded, and staff were trained to monitor and report residents who smoked outside of designated areas. Interview with the administrator at 3:15 p.m. on 01/24/25 revealed the facility’s designated smoking area is around the corner from the main entrance. Hedges were installed to provide resident safety and comfort while smoking. Facility tours on 01/24/25 and today confirmed that hedges were installed. LPA observed three (03) residents smoking in the designated area around 2:30 p.m. on 01/24/25. LPA observed one (01) resident using the designated area today. LPA did not observe residents smoking outside of designated areas during tours on 12/20/24, 01/24/25, or today. Interview with Staff #1 (S1) at 3:40 p.m. on 12/20/24 who works at the reception area at the main entrance revealed they had not detected any smoke in the facility since the facility instituted the new smoking guidelines. LPA interviewed nine (09) residents out of ninety (90), or 10% of residents, on 12/20/24, 01/25/24, and today. Four (04) out of nine (09) residents were chronic smokers and confirmed that facility staff instructed residents to smoke only in the designated area. Nine (09) out of nine (09) residents interviewed revealed they were not bothered by smoke in the facility or people smoking too close to the entrance. Interview with R1 revealed they had spoken with the administrator about smoking in designated areas and received a written warning. R1 did not think their smoke carried into the facility and did not detect it indoors. Based on observations and interviews, although the allegation is valid, there is insufficient evidence to verify that a resident is smoking too close to the facility and affecting others. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 31-AS-20241213144009

Allegation investigated: Facility not providing a comfortable environment Facility not following reporting requirements Facility not ensuring resident belongings are safeguarded

At 10:20 a.m. on 01/09/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 11/08/24 and interviewed residents and staff between 2:30 p.m. and 3:45 p.m. and toured the facility inside and out at 3:45 p.m. Today, LPA interviewed staff and at least ten percent (10%) of residents, or ten (10) out of 90 residents, between 10:45 a.m. and 1:00 p.m. and toured the facility at 10:45 a.m. Regarding the allegation "Facility not providing a comfortable environment” it was alleged Resident #1 (R1) had verbally harassed Resident #2 (R2) and other residents while staff did nothing about it. Interview with Resident #3 (R3) at 2:40 p.m. on 11/08/24 confirmed they had been harassed by R1 and staff had not helped them. Unsubstantiated R2 noted they did not report the incident to staff. At approximately 3:00 p.m. on 11/08/24, LPA witnessed R1 walk outside and R2 yell at and attempt to fight R1. Staff intervened before an altercation could occur. Interview with the administrator at 3:30 p.m. on 11/08/24 revealed a resident did report concerns with R1 to the administrator, so the administrator spoke to R1 to remind them of house rule and to respect others. Interview with R1 at 3:15 p.m. on 11/08/24 revealed they had not verbally harassed R2 or any other residents. Interviews with staff and nine (09) out of ten (10) residents today revealed they had not been harassed by or heard of concerns with R1. LPA did not observe any negative behavior from R1 during today’s visit. Based on interviews and observations, the facility provided a comfortable environment to residents in care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Facility not following reporting requirements" it was alleged the administrator did not report previous incidents involving R1 and R2. Interview with the administrator revealed R2 had not previously reported any problems with R1. The administrator continued by showing a final written warning for R2 for their behavior and property destruction at the facility. Interview with R1 at approximately 2:45 p.m. on 11/08/24 confirmed that they had not told the administrator about R1’s harassment because they believed the administrator would not do anything about it. Based on interviews and record review, the facility never received a report from R2 and therefore had nothing to report. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Facility not ensuring resident belongings are safeguarded" it was alleged R1 has a master key to all resident rooms and took resident belongings. Interview with R1 revealed they did not have such a key and have not stolen anything. Interview with the administrator revealed they had not received any repots of stolen items from residents. Interview with Resident #3 (R3) at 12:20 p.m. today and Resident #4 (R4) at 11:30 a.m. today revealed they had items stolen and suspected R1 of stealing them. Eight (08) out of ten (10) other residents interviewed today revealed they had not had anything stolen and did not suspect R1 as a thief. Based on interviews and observations, although some residents may have had items go missing and believe R1 to have stolen them, there is insufficient evidence to verify the allegation. Therefore, the facility is sufficiently safeguarding resident belongings and the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 31-AS-20241108111151

Allegation investigated: Staff left resident in soiled bedding for an extended period of time Staff did not ensure resident was showered

At 10:20 a.m. on 01/09/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. To investigate the allegations above, LPA interviewed staff and ten percent (10%) of residents, or ten (10) out of 90 residents between 10:30 a.m. and 1:00 p.m. today, toured the facility inside and out at 10:45 a.m., and conducted a record review of pertinent records, including but not limited to a medical assessment, care plan, and staff and client rosters at 11:15 a.m. Regarding the allegation "Staff left resident in soiled bedding for an extended period of time" it was alleged the colostomy bag of Resident #1 (R1) popped and they were left covered in feces throughout the night. It was also alleged that R1 requested assistance and no staff helped them. Interview with Staff #1 (S1) at 10:45 a.m. today revealed that they were aware R1’s colostomy bag popped and sent staff to Unsubstantiated assist. Interview with Staff #2 (S2) at 11:00 a.m. today revealed that they and Staff #3 (S3) assisted R1 within 30 minutes of the incident. Interview with S3 at 11:15 a.m. confirmed that both S2 and S3 assisted R1 within 30 minutes after their colostomy bag popped. Interview with Resident #2 (R2) at 12:50 p.m. today revealed they witnessed staff assist R1 with their colostomy bag issue about 30 minutes after it had popped. Record review of R1’s preassessment revealed they were able to manage their own toileting needs. Interview with R1 at 10:30 a.m. today confirmed that they are able to and prefer to manage their colostomy care on their own. Based on interviews and record review, staff assisted R1 in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not ensure resident was showered” it was alleged staff did not shower R1 until the following morning after their colostomy bag popped. Interview with S2 revealed they were ready to shower R1 immediately, but they went to smoke a cigarette instead. S2 had to wait about 30 minutes prior to helping R1 shower. Interview with S3 confirmed that R1 went to smoke prior to receiving shower assistance. Interview with R2 confirmed that staff assisted R1 in showering approximately 30 minutes after their colostomy bag popped. Based on interviews, staff provided shower assistance to R1 in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 31-AS-20250102110330

Allegation investigated: Staff do not prevent residents from smoking in prohibited areas

At 8:30 a.m. on 10/18/24 Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 10/16/24 and interviewed three (03) residents and two (02) staff between 9:00 a.m. and 4:00 p.m. and toured the facility at 9:30 a.m. Today, LPA and LPM toured the facility at 8:30 a.m. and 11:00 a.m., interviewed residents and staff between 8:45 a.m. and 11:30 a.m., and conducted a record review of pertinent records, including but not limited to staff and resident rosters at 9:30 a.m. Regarding the allegation "Staff do not prevent residents from smoking in prohibited areas" it was alleged residents were smoking in non-designated areas which affected the health and safety of other residents. Substantiated A similar allegation was previously investigated in May 2024 as part of complaint # 31-AS-20240528173514. During that investigation, the previous administrator noted signs were posted around the central courtyard prohibiting residents from smoking there. Also, the issue was addressed during the May 2024 resident’s council meeting, and a formal warning letter was drafted for residents who continued to disobey staff instruction to smoke only in the designated area. Interview with the current administrator at 4:00 p.m. on 10/16/24 revealed the only designated smoking area was in front of the facility. The front doors are locked at night. Interview with Resident #1 (R1) at 9:10 a.m. on 10/16/24 revealed they have been instructed by staff not to smoke in the courtyard, but they continue smoke in the courtyard despite verbal warnings. Interview with Resident #2 (R2) at 9:15 a.m. on 10/16/24 revealed they were instructed by staff not to smoke in the courtyard but to instead smoke in the garage. Interview with Resident #3 (R3) at 9:00 a.m. today revealed they were instructed by staff to not smoke in the courtyard or the garage. R3 further stated that they have nowhere to smoke at night since the designated area is unattended, unsafe, and residents have had to wait long periods of time to be let back in. Interview with the administrator at 9:45 a.m. today revealed the facility is working to hire an additional staff to supervise residents in the designated smoking area at night. Additionally, the facility is working on renovations to make the designated smoking area safer. The administrator has issued written warnings to multiple residents due to their continued noncompliance with house rules. LPA and LPM toured the facility and observed approximately three (03) cigarette butts on the east side of the courtyard and three (03) cigarette butts on the west side of the courtyard. When LPA toured the courtyard again at 11:00 a.m., a resident was observed smoking. Other residents nearby were disturbed by the smoke. Based on interviews and observations, staff have not prevented residents from smoking in prohibited areas. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is cited on the corresponding LIC 9099-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 18, 2024 · control 31-AS-20241008090434

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 28, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents... shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section cited above in at least two (02) residents affected by others smoking in non-designated areas which poses a potential Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 18, 2024

Plan of correction: After discussion with LPA and LPM, the licensee has already taken reasonable steps to protect residents' health by prohibiting smoking in non-designated areas. The licensee will submit a written plan to address any future issues by the POC due date. The deficiency is cleared a this time.

Type of visit: Case Management - Other

At 8:30 a.m. on 10/18/24 Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced case management visit. LPA met with staff and later the administrator and disclosed the reason for the visit. Today’s case management visit was conducted to survey the facility for appropriate areas to designate for smoking as well as to address any areas of noncompliance and provide guidance. LPA and LPM conducted a facility tour at 8:30 a.m. and noted the following observations: The door to a maintenance storage area near the garage was open. The hallway to the maintenance storage area had a small tripping hazard and a blemish on the wall. Tour of the courtyard revealed some unused items like a pedestal and some cans needed to be disposed. Two (02) screen doors leading to the courtyard needed to be fixed. A face plate in the culinary director’s office area needed to be remounted. The recently repaired area in the kitchen needed to be retiled. Lastly, the laundry area was accessible and unattended. LPA and LPM addressed these concerns around 9:45 a.m. with the administrator and the Vice President of Operations. LPA and LPM also discussed plans for carpet cleaning or flooring renovations, staff training procedures, laundry procedures, ensuring residents’ abilities to attend appointments, and a plan for updating resident, personnel, and facility files. The facility plans to gradually improve all areas of operations within reasonable time frames. Also, the administrator agreed that all facility files can be updated by the end of November 2024. LPA will return at that time to audit files. No deficiencies are assessed at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 18, 2024

Allegation investigated: Facility staff did not ensure hallway was free of tripping hazard

At approximately 10:00 a.m. on 09/26/24 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 09/17/24 and interviewed three (03) residents, four (04) staff, and the administrator between 10:30 a.m. and 11:45 a.m. and toured the facility inside and out at 11:30 a.m. Today, LPA interviewed five (05) more residents and three (03) staff between 10:15 a.m. and 3:00 p.m., toured the facility inside and out at 10:50 a.m., and conducted a record review of pertinent records, including but not limited to a medical assessment, care plan, and staff and client rosters at 2:30 p.m. Regarding the allegation "Facility staff did not ensure hallway was free of tripping hazard" it was alleged a plastic tarp was laid down in the hallway which posed a tripping hazard to Resident #1 (R1). Substantiated ** This page was amended to include relevant information and correct a typo ** - LPA NR, 10/16/24 LPA received three (03) photographs on 09/16/24 of R1 using their walker on the plastic tarp in the hallway. The tarp was not taped down and was wrinkled, posing a tripping hazard to all residents. Record review of R1’s assessment from 12/06/22 revealed they were not a tripping hazard and did use a walker to ambulate. Interview with Staff #4 (S4) at 10:30 a.m. today revealed an outside vendor laid down the tarp in around June 2024 during kitchen repairs. Interviews with S4 and the Wellness Director at 2:30 p.m. today revealed the tarp was eventually taped down. The Wellness Director added that R1 is now nonambulatory and uses a walker. LPA did not observe any tripping hazards in the facility today or on 09/17/24. Based on observations, interviews, and record review, the plastic tarp posed a tripping hazard to R1, and the facility did not ensure the hallway was free of tripping hazards. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the corresponding LIC 9099-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided. During facility tours on 09/17/24 and today, LPA did not detect any foul odors in the facility. Interview with Staff #1 (S1) at 11:30 a.m. on 09/17/24 revealed they performed housekeeping duties in the facility. S1 cleans rooms and common areas everyday, and S1 has only smelled bad odors when residents are assisted with incontinence care. Interview with the administrator at 11:25 a.m. on 09/17/24 revealed they had not received any reports of foul odors in the facility. Interviews with six (06) other staff and eight (08) out of eight (08) residents interviewed revealed they have not detected foul odors in the facility. Based on observations and interviews, staff are ensuring the facility is not malodorous. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Facility staff are not ensuring carpets are clean” it was alleged the facility carpets were dirty. During facility tours on 09/17/24 and today, LPA observed the carpets to be aged but having so obvious signs of dirt which needed cleaning. Interview with S1 revealed carpets are cleaned everyday and shampooed twice a week. Interview with Staff #2 (S2) at 3:45 p.m. today confirmed the carpets are vacuumed everyday and shampooed as needed, though they did appear aged. Interview with the administrator revealed that carpets are cleaned everyday, and they had not received any reports of uncleanliness. Interviews with eight (08) out of eight (08) residents interviewed revealed they had no problems with the conditions of the facility carpets. Based on observations and interviews, staff are ensuring the carpets are clean. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Facility management staff are not available to resident's family" it was alleged no facility representatives from management were available for families. During facility tour on 09/17/24 LPA observed the licensing form LIC 308 Designation of Facility Responsibility posted at the reception area. It was signed on 08/07/24 and designated Wellness Coordinator Pamela Garrovillo as the manager in charge in the administrator’s absence. Interview with Pamela at 2:30 p.m. today confirmed she was in charge during the administrator’s absence. Interview with the administrator and Staff #3 (S3) at 11:15 a.m. on 09/17/24 revealed all staff were trained to report any family concerns to Pamela. Telephonic interview at 3:30 p.m. today with a family member of a resident revealed they were notified how to report concerns to in the administrator’s absence. Based on interviews and observations, although the administrator is not always present at the facility, the facility ensured a management representative was available to families and residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 31-AS-20240913100027

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 7, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents... and visitors. This requirement was not et as evidenced by: Based on observations, interviews, and record review, the licensee did not comply with the section cited above with the plastic tarp in the hallway, posing a potential Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Licensee has agreed to conduct an in-service training for all staff to maintain facility safety for all residents and employees. Training will be subitted by the POC due date.

Allegation investigated: Staff did not ensure that resident was taken to medical appointments

At approximately 10:10 a.m. on 09/25/24 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the Executive Director (ED) and disclosed the reason for the visit. To investigate the allegations above, LPA interviewed staff and a resident between 10:15 a.m. and 12:00 p.m. today, today, toured the facility inside and out at 11:00 a.m., and conducted a record review of pertinent records, including but not limited to a medical assessment, care plan, and a face sheet at 11:15 a.m. Regarding the allegation "Staff did not ensure that resident was taken to medical appointments" it was alleged that Resident #1 (R1) missed multiple medical appointments due to oversleeping and transportation issues. Interview with Staff #1 (S1) at 10:15 a.m. today revealed R1’s transportation has been arranged through their insurance. Unsubstantiated The driver came to the front desk to wait for R1, and on several occasions, caregivers reported that R1 refused to go to their appointment. Interview with Staff #2 (S2) at 11:30 a.m. today confirmed that R1 told S2 directly that they did not want to go to their appointments. Interview with Staff #3 (S3) at 10:30 a.m. today revealed R1 refused multiple appointments due to back pain. LPA called R1 at 1:40 p.m. today. Interview with R1 revealed facility staff notified them of every appointment and transportation was available. R1 denied missing any appointments. Record review of R1’s medical assessment and care plan revealed R1 is able to communicate their needs and can perform all activities of daily living without assistance. Interview with R1’s transportation service at 12:15 p.m. today revealed they came to pick up R1 on all three (03) appointment dates they had missed, and R1 refused to attend the appointments. Based on interviews and record review, the facility ensured R1 was able to attend their medical appointments. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 25, 2024 · control 31-AS-20240917133201

Allegation investigated: Staff did not meet residents' dietary needs Staff do not ensure that the facility is maintained in good repair Staff did not answer a resident's call button in a timely manner

At approximately 2:15 p.m. on 08/16/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator designee and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 06/21/24 and interviewed two (02) residents at 11:45 a.m. and 11:55 a.m., the administrator at 12:15 p.m., conducted a records review at 12:30 p.m. of documents pertinent to the investigation, including but not limited to an admission agreement, medical assessment, service plan, and physician orders, and toured the facility inside and out at 2:00 p.m. LPA conducted a subsequent visit on 07/12/24 and interviewed eight (08) out of seventy-five (75) residents, or 10% of the residents and two (02) staff members between 9:00 a.m. and 3:15 p.m. LPA conducted another subsequent visit on 07/16/24 and interviewed Staff #3 (S3) at approximately 9:30 a.m. and Staff #4 (S4) at 10:00 a.m. on 07/16/24 and toured the kitchen at 9:45 a.m. Unsubstantiated Regarding the allegation “Staff do not ensure that the facility is maintained in good repair” it was alleged that for two (02) weeks the kitchen was out of order due to a gas problem. Interview with the administrator revealed that the issue pertained to the facility’s water line, not gas. Review of an incident report prior to the investigation revealed the facility discovered a maintenance issue with the water line on 06/03/24. The facility ordered maintenance from an outside vendor on 06/04/24 and notified Community Care Licensing on the same day. Interviews with the administrator, S3, and S4 revealed the kitchen had to be shut down for about two (02) weeks. LPA observed the water line in the kitchen had been dug up for maintenance. Based on record review and interviews, the facility appropriately addressed the maintenance issue in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not meet residents' dietary needs” it was alleged that during the kitchen shut down, staff served residents cold cereal, cold meals and food ordered from outside sources which was not suitable for R1. Review of the incident report noted all residents were notified of the maintenance issue and all dinners would be catered in the meantime. The facility served snacks, non-perishable foods, and cold foods through their kitchen as usual. Record review of receipts of to-go orders confirmed the facility provided dinners in sufficient quantities. Interviews with the administrator, S3, and S4 revealed they heard residents enjoyed the catered meals. Interviews with eight (08) out of eight (08) residents revealed no residents had issues with the meals served during the water outage. Record review of R1’s medical assessment revealed they were on a “No Added Salt” diet. Interview with R1 at 10:05 a.m. on 07/12/24 revealed they enjoyed the meals and had no issue with the food in general. Based on interviews and record review, the facility met the residents’ dietary needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not answer a resident's call button in a timely manner” it was alleged staff did not assist R1 in putting on their compression socks. Interview with the administrator revealed the facility told R1 that they needed to first obtain a physician’s order for the compression sock as it was deemed a medical device. Interview with staff #1 (S1) at 2:30 p.m. on 07/12/24 revealed they called R1’s physician to obtain the order. Record review revealed that by 06/17/24 the facility had helped R1 obtain the order and began to assist R1 with the compression sock as prescribed by their doctor. Interview with R1 revealed they felt the staff were good and helpful. Interviews with Staff #2 (S2) at 11:30 a.m. on 07/12/24 and S1 revealed staff are prompt and responsive to resident call button requests. Based on record review and interviews, the facility attended to R1 in a timely and appropriate manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 16, 2024 · control 31-AS-20240613141903

Allegation investigated: Facility elevator is not maintained in good repair

At approximately 2:15 p.m. on 08/16/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator designee and disclosed the reason for the visit. To investigate the allegation above, LPA reviewed emails prior to today’s investigation at 8:00 a.m. on 08/07/24, interviewed the administrator designee at approximately 2:15 p.m. today, and toured the facility at 2:30 p.m. Regarding the allegation “Facility elevator is not maintained in good repair” it was alleged the rear elevator was out of service for about eight (08) months. The elevator being in disrepair was investigated in March 2024 under control #31-AS-20240229083546 and deemed substantiated. Interview with the facility maintenance director at approximately 9:00 a.m. on 05/29/24 revealed the facility has been repairing and upgrading the rear elevator since approximately January 2024. Substantiated Multiple maintenance issues occurred throughout the process causing longer repair times than previously expected. Interview with the administrator at approximately 12:30 p.m. on 05/29/24 confirmed that the facility had reported the issue in a timely manner and has been working to fix it. Review of emails from 08/06/24 revealed the facility is awaiting private vendor maintenance services as well as city inspections before the elevator will be operational. LPA observed that the elevator is still not working today. Based on observations, interviews, and email review, the elevator is still not in good repair. However, due to the facility’s constant requests for maintenance and elevator repair, the allegation is deemed SUBSTANTIATED at this time without deficiency issued. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 16, 2024 · control 31-AS-20240812082142

Allegation investigated: Staff are administering expired medication to a resident in care Staff did not administer medication as prescribed

At 2:30 p.m. on 08/09/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 07/24/24 and toured the facility at 4:00 p.m. and interviewed Staff #1 (S1) at 4:10 p.m. and Staff #2 (S2) at 4:15 p.m. LPA interviewed Resident #1 (R1) over the phone at 10:15 a.m. on 07/25/24. Today, LPA toured the facility at 2:35 p.m., reviewed records pertinent to the investigation, including but not limited to a medical assessment, physician orders, and medication administration records (MARs) at 2:45 p.m., and interviewed Staff #3 (S3) at 3:00 p.m., Staff #4 (S4) at 3:15 p.m., and Staff #5 (S5) at 3:20 p.m. Regarding the allegation “Staff are administering expired medication to a resident in care” it was alleged the facility provided outdated medications to R1. Unsubstantiated R1 clarified that no medications were actually expired. R1 stated they no longer needed ten (10) of their thirteen (13) medications and only wanted to take three (03) of them. LPA reviewed R1’s medications at 3:30 p.m. and saw no expired medications. Review of R1’s physician orders revealed R1 had fourteen (14) routine medications which were prescribed on 07/03/24 when R1 was admitted to the facility. Interview with S3 revealed that the physician prescribed all medications that R1 had at their previous facility. S3, S4, and S5 stated all physician orders are followed when assisting residents with medication and no expired medications are given. Based on interviews, record review, and medication review, the facility properly followed physician orders and did not administer expired medications. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not administer medication as prescribed” it was alleged the facility administered ten (10) additional, unnecessary medications, and that R1 did not receive their medications on 07/17/24. Interview with R1 revealed they believed they only need three (03) of their medications. Interview with S3 revealed R1 often refuses thyroid and seizure medication which they need. Review of R1’s MAR from July 2024 revealed R1 refused fourteen (14) out of fourteen (14) morning medications. Staff documented R1’s reason for refusing medication on 07/17/24 as “I’m not going to take my medications because it made me sick”. Staff documented refusals on other days as “I’m not depressed”, “I don’t have seizures”, and “I don’t have a thyroid problem”, and “I don’t want it”. S3, S4, and S5 confirmed R1 frequently refuses medications. Based on interviews and record review, the facility administered R1’s medications as prescribed. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 9, 2024 · control 31-AS-20240717142213

Allegation investigated: Staff do not provide proper transportation assistance to resident's medical appointments

At 9:15 a.m. on 07/16/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with the Executive Director (ED) and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 12/21/23 and toured the facility at 11:15 a.m., interviewed the previous ED and staff between 11:30 a.m. and 1:00 pm., and reviewed records pertinent to the investigation, including but not limited to an incident report, an abuse report, identification, admission agreement, appraisal, emergency contacts, and a medical assessment at 1:30 p.m. LPA conducted a subsequent visit on 05/29/24 and interviewed resident #1 (R1) at 9:30 a.m. Today, LPA toured the facility at 10:00 a.m. and interviewed additional staff between 9:45 a.m. and 3:30 pm. Substantiated Regarding the allegation “Staff do not provide proper transportation assistance to resident's medical appointments” it was alleged R1 has been late to and left at dialysis appointments. Interview with R1 revealed they had switched health insurance providers which limited their transportation options. R1 required transportation to and from dialysis appointments which were scheduled between 12:00 p.m. to approximately 3:00 p.m. When the facility transported R1 to their dialysis, there were “three (03) to four (04) times” when R1 was “stranded” there until 4:00 p.m. or 4:30 p.m. Interview with the former ED at 11:30 a.m. on 12/21/23 revealed the facility could not exactly fit R1’s schedule due to other residents who required transportation. In total, the facility missed one (01) of R1’s appointment’s. The previous ED spoke with R1’s dialysis agency to coordinate future visits. Interview with Staff #1 (S1) at 12:00 p.m. on 12/21/23 revealed the facility pick up and drop off times “may not match” R1’s appointment times. Interview with Staff #3 (S3) at 12:30 p.m. on 12/21/23 revealed the facility shuttle would leave around 11:30 a.m. to get to R1’s noon appointment, and one (01) time, R1 was left waiting for a while. The facility shuttle went there right away when staff had found out. Interview with Staff #8 (S8) at 1:00 p.m. on 12/21/23 revealed they would drive R1 to their dialysis appointments and wait with R1 if they arrived early. At times, R1 would say they were ready, but S8 had to wait approximately to thirty (30) minutes for R1’s blood to clot. S8 stated there was one (01) occasion when R1 had to wait to be picked up due to other residents requiring transportation. Based on interviews, the facility did not provide proper transportation to at least one (01) of R1’s dialysis appointments. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is cited on the corresponding LIC 9099-D page. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided. Regarding the allegation “Staff did not report incident to resident's responsible party” it was alleged the facility did not report an assault on R1 by another resident. Interview with R1 revealed they were shoved by their roommate around October of 2023 after an argument. R1 fell and bled, but no major injuries were sustained. Interview with Staff #1 (S1) at 3:00 p.m. on 03/06/24 revealed they observed the incident and reported it to their supervisor, Staff #2 (S2). Interview with S2 at 12:00 p.m. on 12/21/23 revealed they reported the incident to R1’s responsible party, physician, and Community Care Licensing on 10/28/23. LPA was unable to contact R1’s responsible party to confirm the report had been received. Record review revealed the incident was reported along with an abuse report. The reports detailed R1 required minor medical care. Both had fax receipts attached. Based on interviews and record review, the facility reported the incident to R1’s responsible party and other necessary parties. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff do not clean resident's room” it was alleged bloody sheets were left in R1’s room for five (05) days. Interview with R1 revealed they had bled on their sheets from the incident with their roommate, and staff left the sheets in a corner of the room. Interview with the previous ED, S1, S2, Staff #3 (S3) at 12:30 p.m. on 12/21/23, Staff #4 (S4) at 12:45 p.m. today, Staff #5 (S5) at 1:10 p.m. today, Staff #6 (S6) at 11:00 a.m. today, and Staff #7 (S7) at 3:15 p.m. today revealed no staff saw or remembered bloody sheets in R1’s room. S5 noted they provided care for R1 almost every day for extensive periods of time. R1 never mentioned bloody sheets to S5 nor did S5 observe dirty sheets in R1’s room. S4 noted they always cleaned R1’s room to their liking. Based on interviews, the facility sufficiently cleaned R1’s room. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff do not keep resident's room free of odors” it was alleged the facility did not address the odor in R1’s room. Interview with R1 revealed a rat had been stuck in a trap in their room which caused a strong odor. Interviews with seven (07) out of seven (07) staff revealed they did not detect an odor in R1’s room. S4 and S5 noted they never noticed a rat trap in the room. Based on interviews, the facility maintained R1’s room free of odors. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff do not provide adequate food service to resident” it was alleged the facility did not provide dinner to R1 after they returned late from dialysis appointments and missed the scheduled dinner times. During the facility tour at 10:00 a.m., today LPA observed the facility meal times posted near the dining rooms. A sign showed Breakfast 7:30 a.m. – 9:00 a.m., Lunch 11:30 p.m. – 1:00 p.m., and Dinner 4:00 p.m. – 5:30 p.m. Interview with R1 revealed they usually returned around 4:30 p.m. and missed dinner. R1 was offered a sandwich or a burger, “but nothing good”. Interviews with the previous ED, Staff #9 (S9) at 9:45 a.m. today, and Staff #10 (S10) at 10:00 a.m. today revealed the facility always has sandwiches and snacks available to residents, and the kitchen staff can save dinner for a resident when they are notified. Interviews with three (03) other staff also revealed that R1 had not missed any meals. Based on interviews and observations, the facility provided adequate food service to R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 16, 2024 · control 31-AS-20231219103438

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jul 26, 2024

87465 Incidental Medical and Dental Care (a) A plan... shall be developed... (2) ...in meeting necessary medical and dental needs. This includes transportation... directly or... arrangements. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above in at least one (01) out of seventy five (75) residents which poses a potential Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Licensee has agreed to review all schedules of resident dialysis and submit a document indicating transportation arrangements by the POC due date.

Allegation investigated: Staff are allowing resident(s) to smoke in non-smoking areas of the facility

At 9:15 a.m. on 07/16/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with the Executive Director (ED) and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 05/29/24 and interviewed the ED at 12:15 p.m. and toured the facility at 12:45 p.m. LPA conducted a subsequent visit on 07/12/24 and interviewed ten (10) percent of residents, or eight (08) out of seventy-three residents between 9:00 a.m. and 3:00 p.m. Today, LPA interviewed six (06) staff between 9:00 a.m. and 3:30 p.m. and toured the facility at 10:00 a.m. Regarding the allegation ““Staff are allowing resident(s) to smoke in non-smoking areas of the facility” it was alleged staff allowed residents to smoke in a central courtyard which affected residents’ comfort and health. Unsubstantiated Interview with the ED revealed some residents were smoking in the courtyard at night due to safety concerns in the designated smoking area. The ED addressed the issue during a May 2024 resident’s council meeting in which the facility’s house rules were reiterated. The ED purchased “No Smoking” signs in June 2024 and posted them around the courtyard perimeter and in the courtyard. The ED also noted that staff told residents they were not allowed to smoke in the courtyard. Four (04) signs were observed during today’s facility tour. Seven (07) out of seven (07) residents interviewed on the first and second floor whose rooms had windows and doors facing the courtyard stated they were not affected by smoke and did not see anyone smoking in the courtyard. Interview with Staff #1 (S1) at 11:00 a.m. today revealed the new signs worked and residents did not smoke in the courtyard. Interview with Staff #2 (S2) and Staff #3 (S3) at 11:30 a.m. and 3:15 p.m. today revealed residents smoke in the garage at night, which is safe and comfortable for them and other residents. Based on interviews, the facility is not allowing residents to smoke in non-smoking areas. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 16, 2024 · control 31-AS-20240528173514

Allegation investigated: Staff did not meet a resident's showering needs while in care Staff allow a resident to be soiled for an extended period of time Staff did not meet a resident's incontinence need while in care Staff did not allow a resident to have access to water Staff leave a resident unattended on the toilet for an extended period of time

At approximately 8:50 a.m. on 07/12/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and later the Executive Director (ED) and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 12/13/2023 and toured the facility at 9:00 a.m., interviewed two (02) staff, the previous ED, and Resident #1 (R1) between 9:15 a.m. and 1:45 p.m., and reviewed records pertinent to the investigation, including but not limited to a physician’s report, admission agreement, shower schedule, Medication Administration Records (MARs), and face sheet. LPA conducted additional phone interviews between 1:45 p.m. and 3:00 p.m. on 03/06/2024 with three (03) staff and at 8:45 a.m. on 03/08/2024 with Staff #6 (S6). Today, LPA conducted another records review at 11:30 a.m. of records including but not limited to staff care notes and a service plan. Unsubstantiated Regarding the allegation “Staff did not meet a resident's showering needs while in care” it was alleged R1 had not showered in twelve (12) days due to lack of assistance. Interview with R1 at 12:45 p.m. on 12/13/2023 revealed they had only showered six (06) times in two (02) months. R1 knew they had missed their scheduled shower time but liked to sleep until noon. Interview with the previous ED at 11:00 a.m. on 12/13/2023 revealed staff follow the facility’s shower schedule to coordinate shower times. The facility offers alternate times to residents if they miss their scheduled time. Although R1 originally chose 10 AM as their preferred shower time, R1 refused a shower on 12/12/2023 due to it being too early. LPA observed Staff #1 (S1) exiting R1’s room around 9:20 a.m. on 12/13/2023. Interview with S1 at 9:30 a.m. on 12/13/2023 confirmed R1 had refused their shower on 12/12/2023, so S1 offered to shower R1 on 12/13/2023. R1 refused the shower the again. S1 further stated other residents also refuse showers occasionally. Record review of the facility shower schedule confirmed R1 was scheduled for showers 10:00 a.m. on Tuesdays and Fridays. Review of shift notes from 12/15/2023 revealed R1 refused their shower. Based on interviews and record review, the facility offered shower services to R1 which were occasionally refused. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff allow a resident to be soiled for an extended period of time” it was alleged R1 remained in soiled diapers throughout the night when staff did not check on them. Interview with R1 revealed they had experienced consecutive days in which they were changed at 10:00 p.m. then changed again at 9:30 a.m. the following day. R1 stated S6 was the only staff to change them more than once during the night. Interview with S6 confirmed they changed R1 throughout the night at 1:00 a.m. and 5:00 a.m., and R1 “kissed their hand”. Interview with S1 revealed they change R1 “about twice a night” and S1 if often sleeping at night and does not wat to be bothered. Interview with Staff #3 (S3) at 2:50 p.m. on 03/06/2024 and Staff #4 (S4) at 3:00 p.m. on 03/06/2024 revealed they changed R1’s diaper as needed and checked on them every two (02) hours. Record review of shift notes from 12/07/2023 revealed R1 “refused to be changed if [they are] sleeping but we still check on her”. Shift notes from 12/20/2023 indicated R1 again refused to be changed due to sleeping. Based on interviews and record review, the facility provided proper supervision and incontinence assistance to R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not meet a resident's incontinence need while in care” it was alleged R1 developed a Urinary Tract Infection (UTI) due to lack of incontinence care. Interview with R1 revealed it burned when they urinated around the end of November 2023. They reported the pain to staff and were diagnosed with a UTI. R1 took a week of antibiotics and cranberry pills to cure it. Record review of R1’s MAR revealed the facility followed physician orders and assisted with all antibiotics from 11/30/23 – 12/07/23 and cranberry pills from 11/28/23 – 12/11/23. Review of R1’s service plan revealed that as of 11/10/2023, R1 had not had a UTI within the past thirty (30) days. Also, R1 was “occasionally incontinent” for bladder and bowels. Interview with Staff #2 (S2) at 9:45 a.m. on 12/13/2023 revealed the R1’s UTI was likely caused by refusals to be changed at night. S2 added that the facility staff check on R1 and attempt to change them to prevent UTIs but respect R1’s right to refuse. No other records revealed relevant information about R1’s UTI. Based on interviews and record review, there is no indication of a lack of care and supervision by the facility. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not allow a resident to have access to water” it was alleged staff did not provide water to R1 at night. Interview with R1 revealed Staff #5 (S5) was too busy to assist R1 and only provided “a little sip” of water, though it was not a big problem for R1. Interview with S5 at 1:45 p.m. on 03/06/2024 revealed they provide adequate care and water to R1, and R1 is accustomed to a higher level of care from a different type of facility. Interviews with S1, S3, and the previous ED confirmed that R1 always has water available to them. Interviews with S2 revealed that R1 preferred to have three (03) cups of water, not just one (01). Based on interviews, the facility provided R1 with access to water. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff leave a resident unattended on the toilet for an extended period of time” it was alleged R1 was left on the toilet longer than preferred. Interview with R1 revealed staff are busy, but toileting is not a big problem. R1 prefers more consistency. Interview with five (05) out of six (06) staff revealed no relevant information about being left on the toilet, and staff assisted R1 as necessary. Record review of R1’s preplacement appraisal from 10/20/2023 revealed the facility would assist with transferring to and from the toilet. Interview with S5 revealed they assisted R1 with toileting and never left them on the toilet for long periods of time. Interview with the ED at 3:00 p.m. on 07/02/2024 revealed R1 used diapers during the nighttime and used the toilet during daylight hours. No issues were reported regarding R1’s toileting. Based on observations and record review, staff did not leave R1 unattended for long periods of time. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 12, 2024 · control 31-AS-20231205151331

Allegation investigated: Staff is threatening a resident with eviction

At approximately 8:50 a.m. on 07/12/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and later the Executive Director (ED) and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 05/29/24 and interviewed the ED at 12:15 p.m., reviewed records pertinent to the investigation including but not limited to R1’s face sheet and emergency contacts form at 12:30 p.m., and toured the facility at 12:45 p.m. LPA called to interview a family member (F1) at 1:20 p.m. and the ED at 1:45 p.m. on 07/11/24. LPA called to interview R1 at 3:30 p.m. today. Regarding the allegation “Staff is threatening a resident with eviction” it was alleged the facility threatened Resident #1 (R1) with eviction after their last two (02) checks bounced. Unsubstantiated Interview with the ED at 12:15 p.m. on 05/29/24 confirmed R1’s check payments from April and May 2024 bounced and therefore the facility was not paid for those months. The facility issued an eviction for nonpayment on 05/27/24 but stated the eviction would be rescinded if R1 paid the outstanding balance. File review at 12:00 p.m. on 05/29/24 revealed the facility properly submitted the eviction notice to Community Care Licensing as well. Interview with F1 revealed the eviction was a “moot point” now as R1 was in the process of applying for the Assisted Living Waiver Program (ALWP) to pay their rent. Interview with the ED at 1:45 p.m. on 07/11/24 confirmed that R1 would return to the facility in approximately two (02) months when they became eligible to pay rent through the ALWP. Additionally, the facility now considers the eviction void. Interview with R1 at 3:30 pm today revealed no pertinent information. Based on interviews and file review, the facility properly issued R1’s eviction for nonpayment of rent. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 12, 2024 · control 31-AS-20240528223247

Allegation investigated: Staff did not recognize resident's change in condition Staff are not giving resident medication timely Staff are not assisting resident with transportation to medical appointments

At approximately 8:50 a.m. on 07/12/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and later the Executive Director (ED) and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 07/02/24 and interviewed the ED at 12:15 pm., Staff #1 (S1) at 12:45 p.m., Staff #2 (S2) at 1:45 p.m., and Staff #3 (S3) at 2:15 p.m., toured the facility at 12:30 p.m., and conducted a records review at 1:30 p.m. of pertinent records including but not limited to incident reports, home health notes, Medication Administration Records (MARs), transportation schedules, and hospital documents. LPA interviewed Resident #1 (R1) at 12:15 p.m. on 07/11/24 and Staff #4 (S4) at 3:00 p.m. today. Regarding the allegation “Staff did not recognize resident's change in condition” it was alleged the facility’s neglect may have been the reason for R1’s leg infection. Unsubstantiated R1 had a heart condition, cellulitis, and wound care. Interviews with S1, S2, and S3 revealed the facility was aware of R1’s infection and followed all physician orders and assisted with all medications to treat the infection. S1 stated R1 had venous Statis dermatitis, but R1 was noncompliant with wound care instructions and does not elevate their legs. S2 stated R1 would remove bandages after home health came to treat R1’s wounds. S3 said R1 would sit in a chair all day which did not allow the wounds to heal. S3 also stated that all antibiotic regimens were completed but were not effective. S1 confirmed that the oral antibiotics were ineffective, so the facility arranged for R1 to receive an intravenous (IV) antibiotic treatment on 06/19/24. Interview with R1 revealed they were fine with how the facility provided care for their infection. Record review of R1’s MAR revealed they received three (03) ten (10) day cycles of an antibiotic from 04/24/24 – 07/05/24. Wound care notes indicated “co-morbidities and ambulatory status may contribute to delayed wound healing” and that previous regiments were ineffective in treating R1’s infection. Based on interviews and record review, the facility provided sufficient care to support R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are not giving resident medication timely” it was alleged R1 did not receive Tylenol until three (03) to four (04) hours after being requested. Interview with R1 revealed they had no issues with medication assistance and that S2 had explained to R1 that the facility could only provide one (01) dose of Tylenol every four (04) hours. S3 revealed that R1 was always provided with Tylenol when requested within the prescribed time frames. Record review revealed R1’s physician order for Tylenol stated “Take 1 tablet by mouth every 4 - 6 hours as needed for pain, max 6 tabs per day”. All entries in R1’s MAR were appropriately completed for each request. Based on interviews and record review, the facility assisted R1 with their medication in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are not assisting resident with transportation to medical appointments” it was alleged the facility was too busy to transport R1 to a doctor’s appointment and also to the hospital for R1’s infection. Interview with the ED revealed the facility arranged for transportation for both of R1’s emergencies on 05/18/24 and 06/19/24. Record review of transportation logs revealed the facility shuttle transported R1 to appointments on 05/01/24, 06/14/24, and 07/03/24. Interview with R1 revealed their requests for transportation were either changed or denied multiple times by S4. Interview with S4 revealed some previous request for transportation were denied, however S4 and the ED offered to arrange for alternative transportation each time. Based on interviews and record review, the facility arranged for transportation for medical care for R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 12, 2024 · control 31-AS-20240628155820

Type of visit: Case Management - Other

At approximately 8:50 a.m. on 07/12/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later the Executive Director (ED) and disclosed the reason for the visit. Today’s case management visit is conducted in conjunction with Complaint # 31-AS-20240628155820. During the course of investigation, LPA interviewed several residents with facility concerns which were unrelated to the investigation. LPA interviewed Resident #1 (R1) at 9:00 a.m. today, Resident #2 (R2) at 9:10 a.m., Resident #3 (R3) at 9:30 a.m., Resident #4 (R4) at 9:45 a.m., Resident #5 (R5) at 10:00 a.m., Resident #6 (R6) at 10:05 a.m., Resident #7 (R7) at 10:20 a.m., Resident #8 (R8) at approximately 2:30 p.m., Resident #9 (R9) at 3:15 p.m., and the ED at 2:45 p.m. LPA conducted a records review of physician reports at 3:00 p.m. today. Interview with R1 revealed they had mold growing in their bathroom. LPA inspected R1’s room at approximately 10:45 a.m. and noticed a discoloration on the ceiling. Interview with the ED noted the facility was aware of the discoloration caused by a leak above the room and had taken action to fix the leak. Interview with R2 revealed R9 had been attacked approximately three (03) days prior by an unknown individual on the street. Interview with R9 revealed they were unharmed with no lasting injuries. The ED discussed the incident with LPA and provided an SOC341 form. Interview with R3 revealed they had been bitten by their roommate, R8 approximately two (02) days ago. R8 did not recall the event. The ED stated nothing had been reported to them, but they would investigate further. Interview with R4 revealed they were forced to sign a document. The ED noted R4 was requested to sign a document which stated they wished to leave the facility but never forced. Interview with R5 and R6 revealed they had an odor of mold or mildew in their bathroom from a leak. The ED stated the leak and the mold issue had already been resolved over one (01) week ago. During today's inspection, the facility was in compliance with Title 22 regulations. No deficiencies were observed, but LPA will return on a future date to further investigate the incident between R3 and R8 and the alleged mold in the bathrooms of R1, R6, and R7. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 12, 2024

Type of visit: Case Management - Deficiencies

At 12:00 p.m. on 07/02/2024, Licensing Program Analyst (LPA) Nicholas Reed and Los Angeles City Fire Inspector Linsay Pellegrini conducted an unannounced case management visit. LPA and Inspector met with the Executive Director (ED) and Maintenance Director (MD) and disclosed the reason for the visit. The reason for today’s case management visit comes from Inspector Pellegrini’s review of the facility’s fire safety compliance on 06/27/2024 in which multiple fire protection systems were deemed past due of their testing or retesting dates. Records reviewed indicated that the facility’s Stored Electrical Energy System and Automatic Closing Fire Assemblies failed tests in February 2024 and have not been retested since. Interview with the MD at approximately 12:20 p.m. today revealed the required corrections were made within a week, and the facility has been waiting for retesting appointments. Record review also revealed the rear elevator and emergency power generator were due for testing in January 2024. Interview with the ED at approximately 12:45 p.m. today confirmed that the facility was waiting on reinspection appointments. Also, the generator was working and the rear elevator contract had been created and is in process. The rear elevator repairs would take some time. At 12:30 p.m., LPA, Inspector, ED, and FM toured the facility inside and out to review known fire safety issues. All Stored Electrical Energy Systems appeared to be in working order. All but one (01) fire door was in working order. At approximately 1:50 p.m. the fire door near Room #105 was tested and observed to not close all the way. The MD made the necessary repairs to the fire door by 4:00 p.m. today. The inspector, MD, and ED all agreed that the main issue was a lack of communication due to an incorrect email address and lack of paperwork from the company in charge of retesting the facility’s fire protection systems. However, due to past due tests and retests of fire protection systems, the facility is in violation of Title 22, Division 6, Chapter 8, Article 04, Subsection 87203 Fire Safety. Therefore, a deficiency is issued and a $500 immediate civil penalty is assessed today for a violation of the facility's fire clearance. The ED was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. Appeal rights discussed. Civil penalty issued. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Aug 7, 2024

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on interviews, record review, and observations, the licensee did not comply with the section cited above in at least two (02) fire protection systems which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2024

Plan of correction: In addition to a retesting appointment tomorrow, 07/03/2024, the Executive Director has agreed to submit in writing a plan and timeline of repairs for the rear elevator and all other necessary fire protection systems by the POC due date.

Allegation investigated: Facility issued improper rent increase notice

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegation. LPA met with Business Office Manager, Rita Limar, and explained the reason for the visit. It was alleged that a rental increase letter issued in November 2023 does not comply with Title 22 regulations. To investigate the allegation, on 03/06/2024, LPA requested documents at 10:30 AM, interviewed one (01) staff between 11:45 AM to 12:30 PM and interviewed thirteen (13) residents between 1:00 PM – 3:00 PM. A review of the facility’s Admissions Agreement states, “The facility reserves the right to increase the basic monthly fee, its rate structure for services including its fees for its level of care by providing a 60-day written notice. The notice, sent to the resident and responsible person will plainly specify the reason for the increase and a general description of the factors for the increase.” This statement from the Admissions Agreement is in accordance with Health and Safety Codes. (CONT. on LIC 9099-C) Unsubstantiated A review of the letter sent to Resident #1 (R1) was dated in November 2023 stating that a rate increase would take effect February 2024 and provided a general reason for the increase. During interview with staff, Staff #1 (S1) stated they provided the letters to R1 more than 60-days in advance and explained the reason for the increase. All residents stated that they did receive the letter with a 60-day notice. Based on record reviews and interview, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 31-AS-20240305091617

Allegation investigated: Staff are not providing housekeeping services for residents. Staff are not providing adequate food service to residents. Staff did not ensure the facility was free from rodents.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with Executive Director, Rita Meldonian, and explained the reason for the visit. ---Staff are not providing housekeeping services for residents. It was alleged that the facility is not providing housekeeping and residents are having to clean themselves. To investigate the allegation on 03/06/2024, LPA requested documents at 10:30 AM, interviewed four (04) staff between 11:45 AM to 1:00 PM and interviewed thirteen (13) residents between 1:00 PM – 3:00 PM. A review of the facility’s staff schedule shows that facility has one (01) housekeeper per shift for both the morning and afternoon shifts. During interviews with staff, all staff stated that facility provides housekeeping services to residents once per week and caregivers clean daily. (CONT. on LIC 9099-C) Unsubstantiated During interviews with residents, nine (11) out of thirteen (13) residents stated facility provides housekeeping service once a week and the remaining two (02) stated they do not bother with housekeeping and do it themselves. Resident #1 (R1) added they clean it well and Resident #10 stated that they do not do a very good job of cleaning. Based on record review and interviews there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff are not providing adequate food service to residents. It was alleged that the facility serves food that is not nutritious and well balanced. To investigate the allegation on 03/06/2024, LPA requested documents at 10:30 AM, conducted a physical plant tour at around 10:45 AM, interviewed four (04) staff between 11:45 AM to 1:00 PM and interviewed thirteen (13) residents between 1:00 PM – 3:00 PM. A review of the facility’s menu indicates residents are offered well balanced and nutritious meals with options to choose from. During the physical plant tour, LPA observed well balanced and nutritious foods available and being prepared. LPA also observed records for residents that have special diets. During interviews with staff, Staff #1 (S1) and Staff #2 (S2) stated, they meet with the resident council once a month, and residents did not have anything to say about the food during their last meeting. All remaining staff stated they do not know as it is beyond their purview. During interviews with residents, five (05) out of thirteen (13) residents stated that the food is not nutritious and well balance. All other residents, including Resident #1 (R1), stated the facility offers well balanced and nutritious meals. Based on record review and interviews there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not ensure the facility was free from rodents. It was alleged that the facility has rodents and rodent droppings. To investigate the allegation on 03/06/2024, LPA conducted a physical plant tour at around 10:45 AM, interviewed four (04) staff between 11:45 AM to 1:00 PM and interviewed thirteen (13) residents between 1:00 PM – 3:00 PM. (CONT on LIC. 9099-C) During the physical plant tour, LPA did not observe any rodents or rodent droppings. During interviews with staff, all staff stated they have never witnessed rodents or rodent droppings in the facility. During interviews with residents, twelve (12) out of thirteen (13) residents stated they have never witnessed rodents or rodent droppings in the facility. One (01) out of thirteen (13) residents stated they witnessed rodents and rodent droppings. Based on observations and interviews there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No other health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, May 30, 2024 · control 31-AS-20240229083546

Allegation investigated: Staff did not prevent resident from hitting other residents

At 4:00 p.m. on 05/15/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the current Executive Director (ED) and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 10/04/2023 and interviewed the former ED at 12:10 p.m., Staff #1 (S1) at 3:20 p.m., and reviewed pertinent records at 1:30 p.m. LPA interviewed Resident #1 (R1) at 11:30 a.m. on 10/24/23 during a subsequent visit. During another subsequent visit on 11/01/23, LPA interviewed six (06) out of fifty-three (53) residents, which was 10% of residents, and five (05) staff members between 8:30 a.m. and 3:00 p.m. Today, LPA toured the facility at 4:00 p.m. and interviewed the current ED at 4:15 p.m. Regarding the allegation “Staff did not prevent resident from hitting other residents” it was alleged Resident #2 (R2) hits residents and staff around the facility. Substantiated Interview with the former ED revealed it was reported that R2 bumped into R1, but the former ED never witnessed it. The former ED stated the facility was aware of R2’s aggressive behavior. The former ED spoke to R2 about the behavior and sent emails to staff to “keep an eye on" R2, but R2’s plan of care was not updated. Record review of R2’s physician’s report revealed R2 had aggressive behaviors and a diagnosis of dementia. Interview with S1 revealed R2 hit S1 with their walker when they got upset. S1 confirmed that the former ED sent staff an email on how to address the behavior, but staff did not receive a formal training. Interview with R2 at 10:20 a.m. on 11/01/2024 revealed they had never hit anyone. Interview with Staff #2 (S2) at 10:45 a.m. on 11/01/23 revealed they witnessed R2 hit S1. Interview with Staff #3 (S3) at 3:15 p.m. on 11/01/23 revealed they had been hit by R2 as well, and the former ED did nothing about it. Interview with the current ED revealed the facility updated R2’s plan of care i January of 2024 and trained staff at the same time. Based on interviews and record review, the facility did not prevent R2 from hitting others. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the attached LIC 9099-D page and cleared due to prior corrective action. No immediate health and safety risks were observed. Exit interview conducted. Appeal rights discussed. Copy of report provided. Interview with the former ED revealed R1’s money was voluntarily placed in a trust account known as Resident Fund Management Service (RFMS).Interview with Staff #2 (S2) at 10:45 a.m. on 11/01/23 revealed residents can access their funds by making a request. After the request, the funds get disbursed in the form of cash a day later. S2 stated they explained this process to R1 while enrolling. S2 stated R1 eventually received their money but R1 did not agree on the amount received. Interview with R1 confirmed they received funds from the account but did not agree that the amount received was correct. Record review at 11:00 a.m. on 11/01/2023 revealed the facility provided all available funds to R1 after rent was paid. Based on interviews and record review, the facility did not mismanage resident funds. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not prevent resident from engaging in inappropriate behaviors” it was alleged Resident #2 (R2) stalked Resident #3 (R3). Interview with R2 at 10:20 a.m. on 11/01/23 revealed they never stalked anyone. Interview with R3 at 12:40 p.m. on 11/01/23 revealed they were not stalked by anyone. Interviews with five (05) out of five (05) staff and four (04) other residents on 11/01/23 revealed they had no knowledge or reports of residents stalking or being stalked. Based on interviews, no residents were stalking or being stalked. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are not meeting resident's medical needs” it was alleged R1 had cellulitis on both feet and a scratch on their leg which was not properly cared for. Interview with the former ED revealed the facility nurse and home health attempted to check R1’s leg and feet. R1 refused help and requested their personal doctor instead. Additionally, R1 used to walk around the facility barefoot, so the former ED bought two (02) pairs of slippers for them to wear. Interview with R1 revealed the facility properly cared for the scratch on their leg. R1 received an antibiotic to reduce an infection. R1 also confirmed the former ED bought them slippers for their feet and ordered home health visits three (03) times per week to heal the wounds on their feet. R1’s physician told them their cellulitis was cured, but R1 disagreed and applied for a different home health agency. R1 believed their cellulitis was finally resolved after visits from the home health agency they had chosen. Based on interviews, the facility properly addressed R1’s medical needs in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 15, 2024 · control 31-AS-20230928152014

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 15, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above in one (01) out of fifty-three (53) residents which posed a potential Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: As of 01/2024, the licensee updated the resident's care plan and trained staff to manage the resident's aggressive behavior. Deficiency cleared.

Type of visit: Required - 1 Year

At 9:15 a.m. on 04/18/2024, Licensing Program Analysts (LPAs) Nicholas Reed and Leizl de la Cerra conducted an unannounced annual inspection. LPAs met with staff and later the administrator and disclosed the reason for the visit. LPAs conducted a file review at 10:00 a.m. of staff and personnel files. LPAs toured the facility inside and out at 11:00 a.m. The facility was last visited on 03/08/24 for a complaint visit. It is a three (03) story building with a capacity of 176 residents. LPAs observed bedrooms, shared and private bathrooms, kitchen area, dining areas, garage, common areas, activity rooms, offices, and a courtyard. It has an approved fire clearance for 176 nonambulatory residents, of which fifty (50) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for thirty (30). At the main entrance, LPA observed a designated smoking area near the street. A doorbell was posted at the front for after-hours entry. Postings were observed inside for COVID precautions, emergency contacts, Ombudsman contacts, confidential complaint contacts, facility license, facility sketch, emergency disaster plan, administrator certificate, personal rights, rights of resident and family councils, theft and loss policy, nondiscrimination notice, and activity calendar and reminders. Walls, floors, windows, screens, and blinds were clean and in good repair. An activity room near the reception desk had a television, exercise equipment, and sufficient activity space. Activities were observed and conducted at 9:30 a.m., and a live musical performance occurred at 10:30 a.m. At 11:35 a.m., LPAs measured the first floor temperature to be seventy-six (76) degrees Fahrenheit. The reception area including seating, an administrator office, a business office, and mailboxes. Personnel files were stored and locked in the business office. At 12:55 p.m. LPAs observed a fully-charged fire extinguisher. It was last inspected on 06/30/2023. LPAs and administrator toured Room 117 at 1:00 p.m. and measured the hot water temperature to be 107.6 degrees Fahrenheit. At 1:05 p.m. the smoke and carbon monoxide detector was tested and operating. At 1:10 p.m. the pull cord system was tested. Staff arrived by 1:11 p.m. The second floor contained a medication room, activity room, and resident rooms. The medication room contained a fully-stocked first aid kit, inaccessible medications, and locked medication carts. The activity room contained reading material, games, puzzles, and exercise equipment. Room 205 was inspected at 1:15 p.m. The bedroom area contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. The water temperature was measured at 1:20 p.m. to be 114.3 degrees Fahrenheit. The smoke detector was tested to be operational. The pull cord system was tested at 1:25 p.m. Staff arrived in less than thirty seconds. Fire doors were observed in the middle of the hallway. Water and coffee was available on the first and second floors. The third floor was occupied by only one (01) resident. Room 314 was inspected at 1:30 p.m. The water temperature was measured at 113.6 degrees Fahrenheit. Private bathrooms on all three floors contained liquid soap, paper towels, trash cans, grab bars near the toilet and shower, and a non-skid mat in the shower. The courtyard contained maintained plants and trees. Two (02) shaded seating areas were in good repair. The walkway was free from debris and tripping hazards. LPAs observed three (03) dining areas near the kitchen. The kitchen contained an adequate supply of perishable and non-perishable foods. The dishwashing area was free of debris and vermin. Appliances were in good condition. Cleaning solutions and sharps were inaccessible. At 2:00 p.m. the walk-in freezer and refrigerator temperatures were measured to be -9 and 32 degrees Fahrenheit. A washing machine and dryer were located in the laundry room. Both were in working order. Detergents were stored in the room which was locked when staff are not present. All emergency exit paths were free from obstructions and unlocked. All electrical rooms, maintenance rooms, roof access doors, and rooms with cleaners were locked. LPAs observed two (02) rooms with signs stating “No smoking-Oxygen in use”. The garage was free of hazards. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 18, 2024

Allegation investigated: Staff do not respond to resident's call button

At 8:45 a.m. on 03/12/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and later the Executive Director (ED) and disclosed the reason for the visit. Regarding the allegation “Staff do not respond to resident's call button” it was alleged staff did not respond to a resident’s request through the call system in a timely manner. To investigate the allegation above, LPA conducted an initial visit on 10/04/2023 and interviewed the former ED at 12:00 p.m., Staff #1 (S1) at 3:30 p.m., and Resident #1 (R1) at 4:00 p.m. LPA conducted a subsequent visit on 11/01/2023 and interviewed ten percent of residents, or six (06) out of fifty-three (53) residents and five (05) staff members between 8:30 a.m. and 3:00 p.m. on 11/01/2023. LPA conducted another subsequent visit on 02/20/2024 and interviewed four (04) staff between 3:00 p.m. and 3:30 p.m. LPA telephonically interviewed Staff #4 (S4) at 2:55 p.m. on 03/06/2024 and Staff #5 (S5) at 3:15 p.m. on 03/06/2024. Unsubstantiated LPA conducted another subsequent visit on 03/08/2024 and interviewed seven (07) out of fifty-nine (59) residents, which was 10% of residents, and four (04) staff members between 8:45 a.m. and 1:00 p.m. Today, LPA interviewed Staff #7 (S7) at 10:15 a.m. and toured the facility at 9:30 a.m. Interview with the former ED revealed caregivers, med techs, and the front desk are alerted on their pagers when a resident uses the call system. S1 confirmed the front desk receives alerts and can notify caregivers of the location of the call. Interview with R1 at 4:00 p.m. on 10/04/23 revealed R1 has heard caregiver pagers going off at the front desk for nearly twenty minutes. Resident #2 (R2) interviewed at 10:20 a.m. on 11/01/23 stated staff have not always come quickly. Resident #3 (R3) interviewed at 2:15 p.m. on 11/01/23, stated staff took a long time to respond to call buttons. Interviews with Resident #4 (R4) at approximately 9:30 a.m. on 03/08/2024 and Resident #5 (R5) at approximately 11:00 a.m. on 03/08/2024 revealed they had to wait over an hour for their calls to be answered. Interview with Staff #2 (S2) at 11:30 a.m. on 11/01/23 revealed care givers respond as quick as they can, but due to short staffing, may take some time if caregivers and med techs are busy. Interview with Staff #3 (S3) at 3:00 p.m. on 11/01/2023 revealed if they were showering a resident, or if another caregiver was on break, there had often been only two caregivers per shift to tend to residents, and call button response times were delayed. Interviews with S4, S5, Staff #6 (S6) at 3:10 p.m. on 02/20/2024, and S7 revealed staff try to respond to requests within 10 – 15 minutes, but if staff need to tend to an emergency or paramedics, some call responses are delayed. Six (06) other staff members stated there were no issues with call response time and staff typically respond within 10 – 15 minutes of a call. During today’s facility tour, LPA observed S7 attend to several residents within a fifteen minute span. LPA tested the call button system of Room 219 at 9:55 a.m. S7 arrived at 10:07 a.m. to assist the resident. LPA tested the call button system of Room 206 at 3:27 p.m. today, and staff arrived at 3:29 p.m. Based on interviews and observations, there are mixed accounts of how long staff take to respond to resident call system requests. Therefore, the allegation is deemed UNSUBSTANTIATED at this time and a note of Technical Assistance is issued pursuant to the California Code of Regulations (CCR) section 87468.2. No immediate health and safety risks were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 31-AS-20230929140905

Allegation investigated: Facility is in disrepair Resident's personal belongings are not being safeguarded Facility not providing reasonable accommodations for resident

At 8:45 a.m. on 03/12/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and later the Executive Director (ED) and disclosed the reason for the visit. To investigate the allegations above, LPA , conducted an initial visit on 02/20/2024 and toured the facility at 2:00 p.m., interviewed three (03) out of fifty-three (53) residents between 2:00 p.m. and 3:00 p.m., and interviewed four (04) staff between 3:00 p.m. and 3:30 p.m. LPA called the ED at 3:00 p.m. on 02/22/2024 for an interview. Today, LPA interviewed the ED again at 10:45 a.m. Regarding the allegation “Facility is in disrepair” it was alleged the lock to the room of Resident #1 (R1) was broken. Interview with Staff #2 (S2) at 3:20 p.m. on 02/20/2024 revealed they work as the facility maintenance person. S2 stated R1 broke their key off in the lock on 02/14/2024. S2 attempted to remove the key with pliers but was unable to. Unsubstantiated S2 went to the store on the following day to purchase and install a new handle and lock. R1 was provided a new key on 02/15/2024. At 2:45 p.m. on 02/20/2024 LPA observed a working door handle, R1’s key, and a secure lock to R1’s door. Based on interviews and observations, R1’s door is secure and working. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Resident's personal belongings are not being safeguarded” it was alleged that R1’s belongings were not safe while their lock was broken, and R1’s Access card is missing. R1 believed they gave their Access card to an unknown staff member. The facility fixed R1’s lock within a reasonable amount of time of approximately 24 hours. R1 stated nothing had been stolen or missing during that period. LPA’s interviews with staff on 02/20/2024 revealed four (04) out of four (04) staff had no knowledge of the location of R1’s Access card. Interview with Staff #1 (S1) at 3:00 p.m. on 02/20/2024 revealed R1 did not have an Access card and needed to apply for one. Interviews with Staff #3 (S3) at 3:30 p.m. and the ED today at 10:45 a.m. revealed R1 likely gave the card to Staff #4 (S4) who resigned in February 2024. The ED also did not know where R1’s access card was. Based on interviews, the facility safeguarded R1’s belongings. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility not providing reasonable accommodations for resident” it was alleged R1’s roommates smelled of smoke and the facility is not providing R1 with another room or roommate. Interview with S1 confirmed R1’s former roommate was caught smoking on the balcony. The facility addressed the matter and provided R1 with a new room and new roommate. S2 confirmed that the facility provided R1 with a new room and roommate, but the new roommate also smokes. Interview with the ED at approximately 3:00 p.m. on 02/22/2024 revealed R1 did not express any concerns to staff or the ED about the new room and roommate. However, the facility provided R1 with a new room and roommate to meet their needs. Based on interviews, the facility provided reasonable accommodations to R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 31-AS-20240214144516

Allegation investigated: Staff did not respond to resident's call for assistance Staff do not provide daily activities for residents in care

At 8:45 a.m. on 03/12/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and later the Executive Director (ED) and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 02/20/2024 and toured the facility at 2:00 p.m., interviewed three (03) out of fifty-three (53) residents between 2:00 p.m. and 3:00 p.m., and interviewed four (04) staff between 3:00 p.m. and 3:30 p.m. LPA conducted a subsequent visit on 03/08/2024 and interviewed seven (07) out of fifty-nine (59) residents, which was 10% of residents, four (04) staff members between 8:45 a.m. and 1:00 p.m., and toured the facility at 11:00 a.m. Today, LPA interviewed three (03) staff members and the ED between 9:00 a.m. and 10:45 a.m., conducted a records review at 9:45 a.m. of pertinent files including but not limited to an admission agreement, activity schedule, activity calendar, medical assessment, and physician’s orders, and toured the facility at 9:30 a.m. Unsubstantiated Regarding the allegation “Staff did not respond to resident's call for assistance” it was alleged that staff did not respond when Resident #1 (R1) used the call system on 02/14/2024 for assistance with a blood pressure reading. Interview with the ED at 10:45 a.m. today revealed R1 called for assistance approximately four (04) to six (06) times each day and demanded assistance from a med tech specifically. The ED explained to R1 that staff will reasonably address their concerns. Interview with Staff #1 (S1) at 3:00 p.m. on 02/20/2024 revealed R1 was independent and could record their own blood pressure. Interview with Staff #3 (S3) at 3:30 p.m. on 02/20/2024 revealed staff respond to all call button requests of residents in a timely manner, regardless of their needs. S3 confirmed that R1 uses the call button very frequently. Record review of R1’s medical assessment revealed they had a full capacity for self-care including bathing, grooming, dressing, toileting, and managing cash resources and medications. LPA tested the call button system of Room 219 at 9:55 a.m. Staff #5 (S5) arrived at 10:07 a.m. to assist the resident. LPA tested the call button system again at 3:27 p.m. today, and staff arrived at 3:29 p.m. Based on interviews, record review, and observations, staff respond to resident calls for assistance. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff do not provide daily activities for residents in care” it was alleged the facility does not provide physical activities for residents. Interviews with Staff #2 (S2) at 3:10 p.m. and Staff #3 (S3) at 3:30 p.m. on 02/20/2024 revealed the facility did not offer activities when the Activities Director (AD) had to drive residents. Interview with S4 revealed that today’s morning exercise would not occur because the AD had to drive Resident #2 (R2) to a medical appointment around 10:00 a.m. and would not be able to lead the morning exercise. At approximately 10:30 a.m., LPA observed staff assisting residents to attend morning exercise. S4 then stated that R2’s appointment and the morning exercise had been rescheduled. Interview with the AD at 10:05 a.m. on 03/08/2024 revealed they are also the facility driver and activities are always provided for residents. Sometimes few or no residents attend so it may seem like no activities are occurring. Interview with the ED and the AD revealed the facility will be hiring a full time driver by 03/18/2024. Record review of the facility’s plan of operations revealed “physical activities such as games, sports, and exercise” are “planned throughout each month”. Review of the March activity calendar revealed “Morning Exercise” was scheduled at 9:30 a.m. today. During the facility tour, LPA observed puzzles, books, and board games throughout the facility as well as a posting for “Flex, Stretch, Move” Mondays through Fridays at 9:30 a.m. Based on interviews, record review, and observations, physical activities were provided to residents but outside of the scheduled time. Therefore, the allegation is deemed UNSUBSTANTIATED at this time and a note of Technical Assistance is issued to ensure residents are provided activities each day pursuant to California Code of Regulations (CCR) section 87219.No immediate health and safety risks were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 31-AS-20240215090447

Allegation investigated: Facility staff verbally abused resident while in care

At 8:30 a.m. on 03/08/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. LPA was joined by Long Term Care Ombudsman (LTCO) Diane Torres at 9:00 a.m. To investigate the allegation above, LPA conducted an initial visit on 02/20/2024 and toured the facility at 2:00 p.m., interviewed three (03) out of fifty-three (53) residents between 2:00 p.m. and 3:00 p.m., and interviewed four (04) staff between 3:00 p.m. and 3:30 p.m. Today, LPA interviewed seven (07) out of fifty-nine (59) residents, which was 10% of residents, and four (04) staff members between 8:45 a.m. and 1:00 p.m. and toured the facility at 11:00 a.m. Regarding the allegation “Facility staff verbally abused resident while in care” it was alleged an unknown staff member verbally abused Resident #1 (R1). Interview with R1 at approximately 3:00 p.m. on 02/20/2024 revealed they never said the allegation and had no issues with verbal abuse from facility staff. Unsubstantiated R1 stated they may have been verbally abused by hospital staff instead. R1 admitted that although they complain often, they were appreciative of the facility staff. Interviews with other residents and staff revealed no information about staff verbally abusing residents. Based on interviews, facility staff did not verbally abuse R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety hazards were observed during this visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 8, 2024 · control 31-AS-20240215141726

Type of visit: Case Management - Deficiencies

At 8:30 a.m. on 03/08/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later the administrator and disclosed the reason for the visit. LPA was joined by Long Term Care Ombudsman (LTCO) Diane Torres at 9:00 a.m. Today’s case management visit was conducted after the administrator submitted a report stating Resident #1 (R1) left the facility unsupervised at approximately 5:00 a.m. on 02/25/2024. The facility reported the incident properly to all appropriate parties and followed the plan of operations for missing residents. The administrator explained the details of the incident to LPA during a phone call at approximately 9:00 a.m. on 02/26/2024. The administrator also revealed that R1’s most recent medical assessment stated R1 was not able to leave the facility unsupervised. The administrator stated Staff #1 (S1) and Staff #2 (S2) searched for R1 but could not find them. R1 was eventually found at the Veteran’s Affairs (VA) office in Long Beach. Due to the absence of supervision of R1, the facility is cited a deficiency on the attached LIC 809-D page and issued an immediate civil penalty of $500 pursuant to California Code of Regulations 87646(d). Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 8, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Mar 15, 2024

87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in one (01) out of sixty (60) residents which poses an immediate Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 8, 2024

Plan of correction: Licensee has agreed to review all current and future resident LIC 602s and update resident care plans to meet supervision needs. Licensee to provide a written statement confirming the update by POC due date.

Allegation investigated: Staff are not providing laundry service for residents. Staff did not ensure elevator was not in disreair.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with Executive Director, Rita Meldonian, and explained the reason for the visit. ---Staff are not providing laundry service for residents. It was alleged that laundry equipment was not working. To investigate the allegation, on 03/06/2024, physical plant tour at around 10:45 AM, and interviewed four (04) staff between 11:45 AM to 1:00 PM and interviewed thirteen (13) residents between 1:00 PM – 3:00 PM. During the physical plant tour, LPA observed that laundry machines were in working order and laundry services were being provided. During interviews with staff, all staff stated that there was an interruption in laundry services as the dryer was not working for three (03) days. (CONT on LIC9099-C) Substantiated (This page of report was AMENDED to correct information regarding the number of elevators that were in disrepair). During interviews with residents, all residents stated that there was an interruption in laundry services. Based on interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): --- Staff did not ensure elevator was not in disrepair. It was alleged that elevators are broken. To investigate the allegation, on 03/06/2024, physical plant tour at around 10:45 AM, and interviewed four (04) staff between 11:45 AM to 1:00 PM and interviewed thirteen (13) residents between 1:00 PM – 3:00 PM. During the physical plant tour, LPA observed that one (01) out of two (02) elevators are not in working order. During interviews with staff, all staff stated that one (01) out of two (02) elevators are working, which is the elevator that goes from floor one (01) to floor two (02), and the other elevator that goes from floor one (01) to floor three (03) is not working. Staff #1 added that there is only one resident on the third floor, and they were offered rooms on levels where there is a working elevator, but that resident refused. During interviews with residents, all residents confirmed that there is an elevator in the facility that is not working. Based on interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 31-AS-20240229083546

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(F) · Plan of correction due date: Mar 6, 2024

87307 Personal Accommodations & Services(a) Living accommodations...The following provisions shall apply:...(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident...(F)Basic laundry service (washing, drying, and ironing of personal clothing). This requirement is not met as evidenced by; Based on interviews, facility dryer was in disrepair for three (03) days which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: A plan of correction was not issued as the facility took the necessary measures to have the machine repaired and LPA observed all laundry machines in working order.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 12, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by; Based on interviews and observations, one out of two elevators are not in working order which poses a potential health, safety and personal rights risk to residents in care. health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Facility will notify the LPA by the POC due date what the plan is to repair the elevators, how residents will not be affected by this and provide an invoice indicating planned repair date.

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 did not adhere resident’s request

At 10:45 a.m. on 01/26/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the Executive Director (ED) and disclosed the reason for the visit. Regarding the allegation “Facility did not adhere resident’s request” it was alleged the facility would not remove the name plate outside of the room of Resident #1 (R1). To investigate the allegation, LPA toured the facility at 11:00 a.m. today, interviewed the ED at 11:30 a.m., Resident #1 (R1) at 11:45 a.m., Staff #1 (S1) at 12:00 p.m., Staff #2 (S2) at 12:15 p.m., and five (05) other residents between 12:30 and 1:15 p.m., and reviewed pertinent records at 1:30 p.m.\ including but not limited to the resident list, a physician’s report, admission agreement, care plan, and the plan of operations. LPA also interviewed the former ED at 11:30 a.m. on 12/21/2023. Unsubstantiated Interview with R1 revealed they wanted their name plate removed if none of the other residents on their floor had name plates. They did not want to be the only resident with a name plate. R1 stated it was “not so much of a safety concern”. The facility tour revealed that seven (07) out of eleven (11) rooms in R1’s hallway had name plates in front of their doors. Three (03) of the eleven (11) rooms were unoccupied and did not have name plates. Interview with the former ED revealed the name plates were present for emergency evacuation procedures. The current ED stated the name plates help to identify residents so staff can correctly assist with medication. S1 and S2 had not heard of any safety or privacy concerns from R1. Five (05) out of five (05) other residents interviewed had no safety or privacy concerns with the name plates. Based on interviews and observations, the facility identifies resident rooms to assist with proper medication assistance, and R1 will allow the name plate to remain if other residents have name plates as well. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety hazards were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 31-AS-20240124132851

Allegation investigated: Staff handled resident in a rough manner Staff did not treat resident with dignity and respect

At 10:45 a.m. on 01/26/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the Executive Director (ED) and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit at 11:15 a.m. on 12/21/23 and toured the physical plant at 11:15 a.m., interviewed the previous ED at 11:30 a.m., Staff #2 (S2) at 12:00 p.m., Staff #3 (S3) at 12:30 p.m., and Staff #4 (S4) at 1:00 p.m., and reviewed records at 1:30 p.m. including but not limited to a face sheet, physician’s report, care plan, daily notes, appraisal, and admission agreement. Today, LPA interviewed Resident #1 (R1) at 12:30 p.m. and Staff #1 (S1) at 1:45 p.m and toured the facility at 11:00 a.m. Unsubstantiated Regarding the allegation “Staff handled resident in a rough manner” it was alleged S1 put their arm around the neck of R1 and tried to pull R1 from the facility van. Interview with R1 revealed S4 was the driver and told S1 to 'jerk' R1 from the van. S1 wrapped their arm around R1's neck three (03) times, and R1 had to push S1 away. S2 and S3 came moments later to diffuse the situation. Interview with S1 revealed they touched R1 at the shoulder and waist and never put their arm around R1’s neck. Interviews with S2, S3, and S4 revealed S1 never had their arm around R1’s neck. S2 and S4 stated S1 let go of R1 immediately when R1 yelled out. Based on interviews, S1 did not handle R1 in a rough manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not treat resident with dignity and respect” it was alleged S4 became upset with R1 and refused to drive R1 to their destination. Interview with S4 revealed R1 had forgotten the address of the destination and therefore S4 did not know where to go. S3 confirmed this has happened before, and S2 stated R1 was suffering from an episode of confusion. S2 and S4 stated R1 grew agitated and yelled at S4 and called S4 a name. R1 confirmed they raised their voice and called S4 a name. The facility agreed to reschedule the ride to another date when R1 could present the correct address. S4 denied becoming upset or rude with R1. R1 stated they were taken to their destination at a later date. Based on interviews, the facility could not drive R1 to an unknown destination and properly rescheduled the appointment. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety hazards were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 31-AS-20231220151703

Allegation investigated: Facility is in disrepair

At 8:30 a.m. on 11/22/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with the administrator and disclosed the reason for the visit. LPA toured the facility at 8:45 a.m. today. To investigate the allegations listed above, LPA conducted an initial visit at approximately 12:00 p.m. on 10/04/2023 and interviewed the former Executive Director at 12:10 a.m., reviewed records at 1:30 p.m., and toured the facility at approximately 3:45 p.m. LPA called the Long Term Care Ombudsman (LTCO) at 8:40 a.m. on 10/19/2023 for information about their visit to the facility on 10/17/2023. During a subsequent visit at 11:20 a.m. on 10/24/2023, LPA interviewed Resident #1 (R1) at 11:30 a.m., the former Executive Director at 12:30 p.m., and toured the facility at 12:00 p.m. LPA conducted another visit at 8:30 a.m. on 11/01/2023 and interviewed ten percent of residents, or six (06) out of fifty-three (53) residents and five (05) staff members between 8:30 a.m. and 3:00 p.m. Substantiated Regarding the allegation “Facility is in disrepair”, it was alleged the front elevator has made a loud squeaking noise when opening since September 2023. A repair company came to fix the elevator on 10/03/2023, but the problem got worse on 10/17/2023 when the elevator made a loud banging noise upon descending to the first floor. Interview with the former Executive Director at 12:10 a.m. on 10/04/2023 revealed the facility schedules maintenance with Elevator Support Services every month. They last visited on 10/03/2023. Telephone call with the LTCO at 8:40 a.m. on 10/19/2023 revealed that although the maintenance company came on 10/16/2023, the issue was not fixed. Interview with the former Executive Director at approximately 12:30 p.m. on 10/24/2023 confirmed that maintenance was scheduled on 10/16/2023 to apply grease to fix the squeaking noise. Interview with Staff #2 (S2) at 8:45 a.m. on 11/01/2023 and R1 at 11:30 a.m. on 10/24/2023 revealed the elevator repair company came three times in the month of October. Nothing changed after the first visit, and R1 confirmed the loud banging noise occurred after the second visit. R1 stated a third visit by the elevator repair company fixed the problem. Two (02) out of the six (06) residents interviewed between 9:00 a.m. and 3:00 p.m on 11/01/2023 revealed they noticed the loud banging noise, and one (01) out of the six (06) residents noticed the squeaking noise but was okay with it. LPA observed the squeaking noise at approximately 3:45 p.m. on 10/04/2023 but not on 10/24/2023. LPA discussed elevator maintenance with the current Executive Director at 5:00 p.m. on 11/01/2023, and LPA was notified that the problem was fixed by 11/02/2023. Based on interviews and observations, the facility requested maintenance multiple times to fix the elevator issue, and the issue was eventually fixed. Therefore, the allegation is deemed SUBSTANTIATED at this time, and a Technical Violation is issued without deficiency. No immediate health and safety hazards were noted during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 22, 2023 · control 31-AS-20231004112343

Allegation investigated: Staff financially abused resident

At 8:30 a.m. on 11/01/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with staff and disclosed the reason for the visit. Regarding the allegation “Staff financially abused resident”, it was alleged Staff #1 (S1) stole personal checks from Resident #1 (R1) and Resident #2 (R2) between April 2022 and December 2022. To investigate the allegation, LPA Cabiness gathered resident and facility documents, and interviewed staff and residents between 10:45 a.m. and 1:30 p.m. on 07/17/2023. LPA Reed conducted a file review at 4:00 p.m. on 10/27/2023 and interviewed staff today between 8:45 a.m. and 2:30 p.m. Based on interviews and records reviewed, the timeframe of the allegation occurred prior to the operation of the current facility, Summit Assisted Living of Tarzana (197610366). The allegation occurred during the operation of the previous facility, Summit Assisted Living of Tarzana (197610186). Therefore, the allegation is false, could not have happened, and/or is without a reasonable basis and is deemed UNFOUNDED at this time. Exit interview conducted. Copy of report provided. Unfoundedthe state’s words, verbatim · CDSS document, Nov 1, 2023 · control 31-AS-20230710114855

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff do not ensure residents receive personal mail in a timely manner

At 8:30 a.m. on 11/01/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with staff and later the Executive Director and disclosed the reason for the visit. Regarding the allegation “Staff do not ensure residents receive personal mail in a timely manner”, it was alleged Resident #1 (R1) did not receive mail the day it was delivered. To investigate the allegation, LPA interviewed six (06) out of fifty three (53) residents and staff between 8:45 a.m. and 2:30 p.m. today. Staff interviews revealed the receptionist sorts the mail on a daily basis and hands the mail to residents or puts the mail in resident mailboxes. Resident interviews revealed no residents experienced issues with receiving mail. Based on interviews, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety hazards were noted during the time of this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 1, 2023 · control 31-AS-20231017115254