Savant of West Hollywood

Allegation investigated: Staff are not following resident's care plan Staff do not provide adequate food service to resident resulting in resident losing weight

On 07/20/26, at 9:30am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Adam Syncheff, Administrator. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 07/20/26, LPA Saucedo asked for the census, staff, and resident rosters. On 07/20/26, at 10:20am, LPA Saucedo conducted a physical tour, interviewed both resident(s) and staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff are not following resident's care plan. It is alleged that resident #1 (R1)’s care plan is not being followed. LPA attempted to interview R1 but due to R1’s son/Power of Attorney (POA) being in the room while the interview was being conducted and answering R1’s questions by LPA, LPA concluded their interview with R1. During LPA’s interview with R1’s son/POA, they stated several things that were under R1’s care plan. They stated that R1 has dentures that are supposed to be cleaned and put on and taken off from R1, R1 is not supposed to eat in their bed but instead transferred and moved to their recliner if R1 does not want to go to the dining hall, R1 is also on a special diet and their food is not supposed to be touching each other, R1’s food is supposed to be in separate plates, R1 is supposed to not be waken up between the hours of 6AM-9AM, R1 is not supposed to attend activities but to be returned to their room after their shower and/or after eating, R1 is supposed to be on a two (2) hour watch. During LPA’s interview with four (4) staff, it was confirmed that R1 used to eat on their own, R1 still wakes up on their own, R1 is on a regular staff watch which is several times per shift, R1 is now assisted with their new dentures, R1 is still assisted with showers, incontinence care, changing of clothes and R1 can take their own medication being assisted. The four (4) staff confirmed that R1 receives all the services in their care plan, and they try their best accommodating all of R1’s needs and of the needs R1’s son/POA wants. During LPA’s interview with one (1) staff out of four (4) they also confirmed when R1 refuses to eat in the dining hall their food is taken to their room and R1 is not paying for those extra services also they have asked R1’s son/POA to pay for a one-on-one for R1 to get additional help and R1’s son/POA has declined to pay for those services. Three (3) out of the four (4) staff have confirmed that R1 is now requiring a higher level of care based on different areas that R1 cannot do on their own anymore like showering, incontinence, moving out of bed, eating by themselves is now requiring more than one staff. During LPA’s review of R1’s file-R1 reviewed and obtained R1’s Face Sheet and Emergency Information, R1’s Service Plan, R1’s Resident Assessment, Preplacement Appraisal Information, R1’s original physician report dated 04/2019 and the new updated Medical Assessment dated 06/2026 showing R1 is now non-ambulatory and their level of care has increased from having one (1) staff assisting to having two (2) staff assists, their cognitive/alertness has also declined and their behavior has become more aggressive. Two (2) out of the four (4) staff interviewed have been hit and bitten several times by R1. LIC 9099C-continued Let it be noted on R1’s service plan although it does not specify the care for R1’s dentures, it does state dental and oral hygiene and it does state a special diet but it does not state the food to be separated in different plates and not touching each other, it does not state that R1 is not supposed to eat in there room on their bed and instead to be transferred to a recliner and eat and it does not state that R1 is supposed to not be awaken between the hours of 6AM-9AM. During LPA’s physical tour, R1’s son/POA was at the facility, when LPA asked R1’s son/POA if R1 had home health or hospice and R1’s son/POA denied R1 to have those services. R1’s son also refused to pay for a one-on-one for R1 and has opted not to have those extra services and pay out of pocket. Furthermore, R1’s food was removed by their son/POA because they stated R1 is not supposed to be eat in their bed. Therefore, based on the interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not provide adequate food service to resident resulting in resident losing weight. It is alleged that resident #1 (R1) has lost weight within the last year because of being served food R1 will not eat and it also takes R1 a long time to eat. In addition, the facility forgot to put R1’s dentures in on 07/06/26, resulting in R1 not being able to eat. During LPA’s interview with R1’s son and/or power of attorney (POA), they told LPA that R1’s food is supposed to be separated on their plate because R1 will choose what to eat and then R1 will not eat all their food. Furthermore, per R1’s son/POA, R1 is not supposed to eat in their bed. They are supposed to be moved to their recliner and eat there. During LPA’s physical tour, LPA observed R1’s son/POA remove the food from R1 because they stated, “R1 is not supposed to eat in their bed.” Let it be noted, R1’s son/POA was at the facility at the time LPA was conducting their investigation/physical tour. During LPA’s interview with four (4) staff, it was confirmed that R1’s son/POA is not happy with the food and the service that is being provided to R1. The four (4) staff also confirmed that R1 is on a special diet and could only eat certain foods. Two (2) out of the four (4) staff confirmed that R1’s son/POA wants to control everything about R1-how they sleep, what time they sleep, what time they wake-up, what they eat, where and how they eat, how many times R1 is changed and R1’s son/POA does not want to turn off the cameras when R1’s diaper/incontinence care is being taken care of which violates R1’s rights to privacy. In addition, two (2) out of the four (4) staff confirmed that R1 needs and qualifies for home health or hospice because their level of care has changed and R1’s son/POA has declined to get those services for R1. LIC 9099C-continued During LPA’s interview with R1, LPA asked R1 how they were doing and R1 stated, “Okay.” LPA asked R1 how the staff was treating them and R1 stated, “fine.” LPA attempted to continue to interview R1 but R1’s son/POA continued to answer and interrupted LPA’s interview with R1. Upon reviewing R1’s file, LPA confirmed that R1 is on a special diet which is a diabetic diet which is noted on their medical assessment and service plan. Furthermore, R1's service plan does not state that R1's food is supposed to be separated into different categories/plates. Therefore, based on the interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jul 20, 2026 · control 31-AS-20260713103718

Allegation investigated: Staff handled resident in care in a rough manner. Staff left resident in care in a soiled diaper for an extended period of time. Staff did not ensure that the resident in care was properly dressed.

On 5/29/26, Licensing Program Analyst, (LPA) Raymond Comer conducted a subsequent visit to the facility to complete investigation of the above allegation(s). LPA Comer conducted the initial complaint visit on 11/24/25, at which time, LPA Comer conducted a review of Resident#1's, (R1) file which includes, Physician Report, Need/Service Plan, Pre placment appraisal, and other documents relevant to the investigation. Between 11:20 am and 12:30 pm, LPA Comer conducted interviews with Staff and R1. At the time of today's visit, at 8:15 am, LPA Comer conducted a tour of the facility; no health/safety issues observed. Between 8:35 am, and 10:00 am, LPA Comer conducted interviews with the Administrator and two (2) additional staff. Between 10:15 am, and 12:05 pm, LPA Comer interviewed twelve (12) residents. Allegation:Staff handled resident in care in a rough manner. [LIC9099C] Continued- Unsubstantiated It was alleged that Resident#1 (R1) was physically abused when assisted by staff. LPA Comer interviews with Admin and staff revealed the following: Both refute this allegation, stating to LPA that R1 suffers with chronic pain and that staff strive to make R1 feel calm and comfortable. Per Staff, R1's PCP authorized pain relief meds that have reduced R1's pain issues and improved his mood when being provided assistance by staff. LPA Comer's observations revealed the following: R1 was observed both in their bedroom, and in the facility dining area as clean, properly dressed, and not appearing as distressed. LPA Comer's interviews with twelve (12) out of a total of one hundred sixteen (116) residents stated that staff treat them with respect and consistently interact with residents in a gentle and professional manner. LPA Comer’s review of available documents did not reveal any information to support the allegation. Based on interviews, LPA observation, and records review, there was insufficient evidence to support the allegation, therefore, the allegation is found to be UNSUBSTANTIATED at this time. Allegation: Staff left resident in care in a soiled diaper for an extended period of time.It was alleged that staff left Resident#1 (R1) soiled in a soaked diaper for a least an hour. LPA Comer interviewed the Administrator, and staff who refuted this allegation, stating to LPA that R1 has neuro-cognitive issues that challenge his perception of the passage of time. Per Admin and Staff, R1 is provided well checks every two (2) hours, and is provided two (2) person incontinence assistance which is provided a minimum of three (3) times per day, or more frequently as needed. LPA Comer's interviews with twelve (12) out of a total one hundred sixteen (116) residents stated their satisfaction with toileting, changing and other assistances provided by staff. LPA Comer’s review of available documents did not reveal any information to support the allegation. Based on interviews, and records review, there was insufficient evidence to support the allegation, therefore, the allegation is found to be UNSUBSTANTIATED at this time. Allegation: Staff did not ensure that the resident in care was properly dressed. It was alleged that staff left Resident#1 (R1's) pants opened up to his thigh and not fully covering his diaper. LPA Comer interviewed the Administrator, and staff who refuted this allegation, stating to LPA that R1 is changed by staff and ensures the R1's clothes are clean, odor-free and is fully dressed. Per Staff, when R1 is in his room, R1 chooses to unbutton his pants for comfort. However, staff stated to LPA that R1 is provided staff supervision and assistance when moving about the facility and that staff ensure that R1 is properly dressing and not left exposed among the community. LPA Comer observed R1 in the facility dining room as clean and fully dressed. LPA Comer's interviews with twelve (12) out of a total one hundred sixteen (116) residents stated their satisfaction with toileting, changing and other assistances provided by staff. LPA Comer’s review of available documents did not reveal any information to support the allegation. Based on interviews, LPA observation, and records review, there was insufficient evidence to support the allegation, therefore, the allegation is found to be UNSUBSTANTIATED at this time. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 29, 2026 · control 31-AS-20251117094420

Allegation investigated: Staff allowed a resident to be soiled for extended periods of time. Staff did not timely respond to a resident's alerts. Staff spoke inappropriately towards a resident. Staff mistreated a resident while in care.

On 5/17/26, Licensing Program Analyst, (LPA) Raymond Comer conducted a subsequent visit to the facility to complete investigation of the above allegation(s). LPA conducted the initial complaint visit on 9/29/25, at 10:10 am. During initial visit, between 10:35 am the 11:45 am, LPA conducted a review of Resident#1's, (R1) file which includes, Physician Report, Need/Service Plan, Home Health Reports, and other documents relevant to the investigation. Between 12:00 pm and 2:00 pm, LPA conducted interviews with Admin, Staff, Residents, including R1. At the time of today's visit, between 9:00 am, and 10:24 am, LPA Comer conducted interviews with additional two (2) staff, and five (5) residents. Allegation: Staff allowed a resident to be soiled for extended periods of time. It was alleged that Resdient#1 (R1) was left in soiled diapers for several hours due to staff neglecting to provide required toileting assistance. [LIC9099C] Continued- Unsubstantiated LPA Comer interviewed the Administrator who refuted this allegation, stating to LPA that R1 is aggressive and conformational with staff when attempting to assist R1 with toileting, transfers, and other ADL tasks. Admin and other staff stated to LPA that R1 is provided with a two-person assist during toileting/changing assistance a minimum of three (3) times a day, or more frequently, as needed. LPA Comer's interviews with ten (10) out of a total one hundred sixteen (116) residents stated their satisfaction with toileting, changing and other assistances provided by staff. LPA Comer’s review of available documents did not reveal any information to support the allegation. Based on interviews, and records review, there was insufficient evidence to support the allegation, therefore, the allegation is found to be UNSUBSTANTIATED at this time. Allegation: Staff did not respond timely to a resident's alerts. It was alleged that call button was activated by Resident#1 (R1) and would not be responded to by staff. LPA Comer interviews with Admin and staff revealed the following: Admin and other Staff refuted the allegation and stated that resident service calls are responded to within a maximum average of seven (7) minutes. LPA Comer activated R1’s call button while interviewing R1 and observed that staff responded within five (5) minutes of the service button’s activation. LPA Comer's interviews with ten (10) out of a total one hundred sixteen (116) residents stated that staff respond to service calls between five (5) to ten (10) minutes; Interviewed residents stated satisfaction with the timeliness of staff's response. LPA Comer’s review of available documents did not reveal any information to support the allegation. Based on interviews, and records review, there was insufficient evidence to support the allegation, therefore, the allegation is found to be UNSUBSTANTIATED at this time. Allegation: Staff spoke inappropriately towards a resident. It was alleged that staff made hurtful comments when assisting Resident#1 (R1). LPA Comer interviews with Admin and staff revealed the following: Admin and Staff refuted the allegation and stated that R1 was communicated to with dignity and respect. R1 suffers with chronic pain, and the condition negatively affects their opinion of staff's interactions. LPA Comer's interviews with ten (10) out of a total one hundred sixteen (116) residents stated that staff communicate to residents respectfully. LPA Comer’s review of available documents did not reveal any information to support the allegation. Based on interviews, and records review, there was insufficient evidence to support the allegation, therefore, the allegation is found to be UNSUBSTANTIATED at this time. Allegation: Staff mistreated a resident while in care. It was alleged that staff mistreat Resident#1 (R1) to the point that R1 does not want to remain at the facility. LPA Comer interviews with Admin and staff revealed the following: Admin and Staff stated their awareness that R1 suffers with chronic pain and strive to make R1 feel calm and comfortable. LPA Comer's interviews with ten (10) out of a total one hundred sixteen (116) residents stated that staff treat them with respect and consistently interact with residents in a pleasant and friendly manner. LPA Comer’s review of available documents did not reveal any information to support the allegation. Based on interviews, and records review, there was insufficient evidence to support the allegation, therefore, the allegation is found to be UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, May 17, 2026 · control 31-AS-20250923155751

Allegation investigated: Staff does not ensure medications are dispensed as prescibed for residents in care. Staff do not ensure medications are properly managed for residents in care. Licensee does not ensure staff are adequately trained to dispense medications to residents in care.

On 5/05/26, Licensing Program Analyst, (LPA) Raymond Comer, arrived at the facility to conduct a subsequent visit regarding the allegation(s) listed above. LPA Comer conducted the initial complaint visit on 12/08/25, at which time, Between 11:05 am and 1:45 pm, LPA recieved and reviewed Resident#1 (R1) file, and conducted interviews with Administrator and one (1) Staff. During today's visit, at 8:35 am, LPA Comer conducted a tour to the facility; no health/safety issues were observed. Between 8:50 am and and 10:15 am, LPA spoke with Administrator and two (2) staff. Between 10:25 am and 11:30 pm, LPA Comer spoke with ten (10) out of a total of one hundred sixteen (116) residents. Between 12:00 pm and 1:10 pm, LPA Comer observed med-tech staff administer medications to residents and conducted observations of the medication room. Between 1:30 pm and 2:15 pm, LPA Comer recieved and reviewed facility roster, staff roster, staff medications certification training, Centrally Stored Medication and Destruction Records (CSMDR) and other documents relevant to the investigation. [LIC 9099C] Continued- Unsubstantiated Allegation: Staff does not ensure medications are dispensed as prescribed for residents in care. It was alleged that med-tech staff are not labeling the dispensed med cups; thus potentially giving incorrect medication to residents. To investigate the allegation, LPA Comer interviewed the Administrator, and two (2) med tech staff whom refute the allegation, stating that staff follow the prescription and dispense medication as indicated by the prescribing physician. LPA Comer's observation of meds distribution revealed the following: Staff Med Tech labelled the med cups, which are placed in medication trays (which are also labeled with residents last name and first initial) LPA Comer interviewed ten (10) out of a total one hundred sixteen (116) total residents; all ten (10) residents interviewed stated having no issues with availability nor quality of medication distribution assistance by staff. LPA records review revealed the following: Centrally Stored Medication and Destruction Records (CSMDR) and medication was accounted for in the facility. Based on LPA interviews, observations, and records review, there is not sufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff do not ensure medications are properly managed for residents in care. It was alleged that the medtech allowed resident medications to run out of supply. It was alleged that when this occurred, med tech staff took from another residents medication supply. To investigate the allegation, LPA Comer interviewed the Administrator, and two (2) med tech staff whom refute the allegation, stating to LPA that most resident medications are categorized by the pharmacy as "on cycle" and are refilled automatically on a monthly basis. "Off cycle" resident medications refills are ordered by med tech staff electronically, via the "QuickMAR" system approximately ten (10) days before a resident's medication is depleted. LPA observed the refilled orders in QuickMAR, which shows the date a refill order is requested. LPA Comer interviewed ten (10) out of a total one hundred sixteen (116) total residents; all ten (10) residents interviewed stated having no issues with availability, nor quality of medications assistance provided by staff. Based on LPA interviews, and observations, there is not sufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Licensee does not ensure staff are adequately trained to dispense medications to residents in care. It was alleged that med-tech staff make errors while providing residents medication assistance, due to a lack of proper training. To investigate the allegation, LPA Comer interviewed two (2) med tech staff whom confirmed receiving required training on how to dispense medication, as well as having completed required hours of shadow training with experienced staff. LPA interviewed the Administrator who also denied the allegation, stating that all staff have completed the required hours of training in dispensing medication. LPA Comer interviewed ten (10) out of a total one hundred sixteen (116) total residents; all ten (10) residents interviewed stated their satisfaction with the medications assistance provided by staff. LPA records review revealed the following: All Med Tech staff have completed Initial medications trainings, and subsequent annual medications trainings. Based on LPA interviews, observations, and records review, there is not sufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, May 5, 2026 · control 31-AS-20251208102021

Allegation investigated: Staff did not assist resident in a timely manner. Staff physically force-fed resident medication. Staff hit and mishandled resident. Staff do not provide sufficient activities to resident.

On Thursday, 2/26/26, Licensing Program Analyst, (LPA) Raymond Comer conducted a subsequent visit to the facility to complete investigation of the above allegation(s). LPA conducted the initial complaint visit on 05/15/25, at which time LPA spoke with Executive Director at 8:05am and discussed the allegations. At 8:15am, LPA requested and received residents’ facility file, including but not limited to physician report, need and service plan, Medication Administration and Destruction (MAR) records, incident reports, activity schedule, and other pertinent documents. Records were reviewed at 11:05 am. Between 11:25 am and 2:40 pm, LPA conducted interviews with the Administrator, three (3) Staff, and Responsible family member involved with R1’s care provided at the facility. At the time of this visit, at 11:45 am, LPA requested and reviewed additional facility files including facility incident reports, and other records. In addition, Betwenn 12:00pm and 1:35 pm, LPA interviewed additional residents. [LIC9099C] Continued- Unsubstantiated Allegation: Staff did not assist resident in a timely manner. It was reported that R1 was admitted to the hospital due to a fall incident resulting in subdural hematoma. R1 had a history of multiple falls. The Administrator and staff stated that on 04/29/25, at around 7PM, R1 had an un-witnessed fall in their bedroom. R1 was found on the floor by staff #1 (S1). R1 told S1 that they slid down from bed. S1 assessed a resident, offered to send them to the hospital and R1 refused. Later, R1 complained of headache and agreed to go to the hospital. Upon returning to the community, R1 was monitored to prevent possible falls. S1 and other staff verified the information revealed by ED. Staff present in the facility deny neglecting R1 or other residents, indicating that R1, and other residents, are observed and assessed as per their needs and service plan. Most residents are being checked every 2 hours, and more often if needed. Other residents interviewed during investigation had no concerns regarding their care and supervision. An interview of a witness did not reveal any information to support the allegation. A review of R1’s facility file and incident reports verify the information revealed by staff. Based on interviews and record review, it was concluded that although the allegation may have happened, there was not sufficient information to verify validity of the complaint. Hence, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff did not assist resident(s) in a timely manner. Concerns were addressed that staff take long time to respond to a resident #1 (R1) for assistance. R1 alleges waiting for help sometimes 30 minutes, to 2 hours. LPA interviews with Staff revealed the following: Staff stated that their response time to the residents’ requiring assistance is ten (10) minutes on average. Residents interviewed during investigation had no concerns regarding timely assistance. During physical plant inspection, LPA checked call buttons from the residents’ rooms and staff responded within 10-12 min. Records reviewed by LPA did not reveal any information to verify the allegation. Based on inspection, observation, interviews and record review, there is insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. [LIC9099C] Continued- Allegation: Staff physically force-fed resident medication. It was reported that while R1 was complaining of pain, two (2) nurses came to R1’s room and offered a Tylenol, which R1 refused; Staff forced the pill into R1’s mouth. During investigation, staff denied force-feeding medication to R1, or any other residents. The residents interviewed during investigation did not address any concerns regarding their medication assistance. A review of R1’s medication records revealed that R1 had pain medication (Tylenol) as a PRN and it was dispensed to R1 as needed. No verifiable information was available during this investigation to support the allegation. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff hit and mishandled the resident. It was reported that staff are rude to R1. They physically strike R1. While changing R1, Two (2) staff slammed R1 against the wall and pushed their head between the rails of the bed. The Administrator and staff denied being rude, mishandling and/or hitting any residents. Residents interviewed during investigation stated that staff assist residents with respect, are gentle, and never hit anyone. Facility records did not provide any information to verify the allegation. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not provide sufficient activities for resident. It was reported that staff do not give R1 enough therapy like walking around etc. The Administrator and staff stated they provide activities in the morning, in the afternoon and before bedtime. All residents are notified of scheduled activities, and it is their choice if they want to participate. Residents verified the information provided by the staff. A review of activity schedule verified that throughout the day, facility provides different activities to all residents. During investigation, LPA Comer observed residents participating in various activities. Overall investigation did not reveal any sufficient information to support the allegation.the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 31-AS-20250508163945

Allegation investigated: Staff did not properly address a resident's change in condition. Staff did not provide required care and supervision to assist resident with ADLs.

At 9:00 am, Friday, 2/20/26, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an initial visit to investigate the above allegation(s). LPA met with the facility Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. At 9:15 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegations, LPA received facility resident roster, staff roster, and Resident#1 (R1's) file. Between 9:30 am and 11:00 am, LPA conducted interviews with Administrator , Staff and R1's Primary Care Physician. Between 11:20 am, and 12:40 pm, LPA conducted interviews with Residents, Between 12:50 pm, and 1:45 pm, LPA conducted review of Resident#1 (R1) file, and other documents relevant to the complaint. [LIC9099C] Continued- Unsubstantiated Allegation:Staff did not properly address a resident's change in condition. It is alleged that staff did not observe changes in R1's health condition. LPA's Interview with Administrator and Staff#1 (S1) revealed the following: Both Administrator and S1 refute the allegation, stating that R1 is monitored and assessed by staff, medical attention is provided when requested or needed, and timely communication of health changes are provided. Administrator and Staff stated that R1's change in condition was immediately communicated to R1's Primary Care Physician, and Family contacts. Staff did submit an Incident Report (IR) to the Licensing agency regarding the incident. Based on LPA interviews, and records review, the allegation is deemed Unsubstantiated at this time. Allegation: Staff did not provide required care and supervision to assist resident with ADLs. It is alleged that staff neglected to provide R1 with hygiene, incontinence, and mobility assistance. LPA observed staff providing assistance to R1, and other residents throughout the facility. LPA interviews with Administrator and Staff#1 (S1) revealed the following: Both Administrator and S1 refute the allegation, stating that staff implement required care plan components, such as assisting R1 with showering, supervision with toileting/changes when needed, and providing R1 with reminders/encouragement to use his walking cane. LPA Interviews with ten (10) out of ten (10) residents revealed that residents receive consistent and sufficient assistance by staff. Based on LPA observation, interviews and records review, there is not enough information to verify the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit Interview conducted/Copy of report given.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 31-AS-20260210104311

Allegation investigated: . Due to staff neglect, resident has had multiple falls resulting in injuries 2. Staff did not conduct a reassessment of residents needs resulting in neglect of resident

Licensing Program Analyst (LPA) Tuesday Cabiness met with med-tech Marina Adan and informed her the reason of the visit. Administrator Adam Syncheff was not available, but was notified the reason of the visit. Today's visit was to deliver the final findings of the allegations mentioned above. Allegation #1: It was alleged that staff neglect resulted in Resident #1 (R1) experiencing multiple falls, which led to injuries. To investigate the allegation, on 03/06/2025, from 12:30 p.m. to 2:30 p.m., (LPA) Raymond Cromer conducted an initial complaint visit to gather evidence and obtain documentation related to the allegation. On 10/21/2025 and 12/23/2025, from 9:00 a.m. to 2:00 p.m., LPA Tuesday Cabiness conducted subsequent visits to interview six (6) staff members and numerous residents. Additional documentation pertinent to the allegation was also obtained and reviewed. (see LIC9099C -cont'd) Unsubstantiated According to the complaint, R1 had been admitted to the hospital several times within the past year for various reasons, including falls and related injuries. Medical records reviewed revealed R1 has been diagnosed with a nervous system disorder resulting in an unstable gait, as well as other significant medical conditions. Documentation further identified R1 as generally independent but requiring staff assistance with certain activities of daily living (ADLs). Interviews with staff and documentation from medical professionals indicated R1 was advised to use assistive devices for mobility, which were provided by the facility. However, R1 was reported to be resistant to using assistive devices and selective in accepting staff assistance. Staff further reported that during a period of medication changes and other medical concerns, R1 exhibited behavioral changes that may have contributed to an increase in falls. Incident reports documented that R1 experienced un-witnessed falls resulting in injuries. However, facility records and medical documentation consistently reflected that R1’s falls were associated with documented medical conditions, including an unstable gait, neurological issues, and refusal to utilize assistive devices despite staff encouragement. Residents interviewed reported they were generally independent. While residents acknowledged that falls occurred, they stated that staff provided assistance when notified or contacted. Based on a review of facility and resident documentation, incident reports, medical records, and interviews with staff, there is insufficient evidence to prove that staff intentionally neglected R1, resulting in multiple falls and injuries. Therefore, the allegation is determined to be Unsubstantiated at this time. Allegation #2: It was alleged that staff failed to conduct a reassessment of Resident #1’s (R1) needs, resulting in neglect. To investigate the allegation, on 03/06/2025, from 12:30 p.m. to 2:30 p.m., Licensing Program Analyst (LPA) Raymond Cromer conducted an initial complaint visit to gather evidence and obtain documentation related to the allegation. On 10/21/2025 and 12/23/2025, from 9:00 a.m. to 2:00 p.m., LPA Tuesday Cabiness conducted subsequent visits to interview six (6) staff members and numerous residents. Additional documentation pertinent to the allegation was obtained and reviewed. (LIC9099C cont'd) Records reviewed revealed that R1 was admitted to the facility on 05/08/2023. Prior to admission, on 05/02/2023, facility staff conducted a pre-admission assessment and obtained medical records. Documentation reflected that R1 was diagnosed with a nervous system disorder resulting in an unstable gait, as well as other significant medical conditions. Documentation further revealed that on 04/09/2024, R1 was assessed for participation in the Assisted Living Waiver (ALW) Program through the Department of Health Services (DHS). A comprehensive assessment was conducted at that time to determine eligibility and level of care needs. R1 also received home health services during 2024. A follow-up reassessment was conducted with DHS on 10/11/2024. Records reviewed indicated that facility staff implemented and assisted with the care plan developed in coordination with DHS and home health providers. Documentation reflected ongoing monitoring of R1’s condition, including updates to needs and service plans, communication with R1’s primary care physician, documentation of health changes, and completion of incident reports as appropriate. Records further indicated that R1 experienced hospitalization's beginning in approximately October 2024 and again in early January 2025. Facility documentation reflected updates to R1’s medical records and continued monitoring of health status following hospitalization's. Based on the review of resident records, assessment documentation, care plans, physician communications, and interviews conducted with staff, there is insufficient evidence to support that facility staff failed to reassess R1’s needs or that neglect occurred as alleged. Therefore, the allegation is determined to be Unsubstantiated at this time. Exit interview and copy of report provided to staff.the state’s words, verbatim · CDSS document, Feb 14, 2026 · control 31-AS-20250224091447

Allegation investigated: Staff hit resident.

On Tuesday, 1/27/26, Licensing Program Analyst, (LPA) Raymond Comer conducted an unannounced subsequent visit to the facility to complete investigation of the allegation noted above. LPA conducted the initial complaint visit on 03/28/25. LPA met with facility Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:20 am, LPA conducted a physical plant tour; no health and safety issues were observed. It was alleged that Resident #1 (R1) was slapped by staff #1 (S1). To investigate this allegation on 03/28/25 LPA Comer conducted initial visit, at which time at 10:00 am, LPA conducted a physical plant tour and noted no health and safety issues. While inspecting the facility LPA requested and received resident and staff roster. [LIC 9099C]-Continued Unsubstantiated At 10:30 am, LPA received and reviewed facility records, including, but not limited to R1’s facility file, internal incident reports. LPA conducted interviews with the Administrator, three (3) Staff including S1, ten (10) out of one hundred-six (106) residents and other witnesses who had knowledge of the allegation. During interviews by LPA, S1 denied hitting R1. S1 indicated that while assisting R1, they slid down from the bed. S1 had to apply a little pressure to move R1 backwards towards bed to prevent R1 from falling. Other staff also denied hitting R1 or other residents. All residents interviewed during investigation confirm having no issues, nor concerns regarding the allegation. A review of R1’s file revealed that R1 had health conditions that may reflect their judgment. Other records did not provide any information to support the allegation. Based on interviews, observation and record review, there is not sufficient information or evidence to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview was conducted, and a copy of this report was provided to the administrator.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 31-AS-20250318084931

Allegation investigated: Staff are not providing laundry services to resident. Staff are not transporting residents to appointments.

This report is amended to make a correction. On Friday, 1/9/26, Licensing Program Analyst (LPA) Ray Comer, and Licensing Program Manager, Naira Margaryan conducted an unannounced subsequent visit at this facility to further investigate the above allegation. LPA and LPM met with the Administrator, and the reason for the visit was discussed. Allegation: Staff are not providing laundry services to resident. Concerns were addressed that staff are not doing R1’s laundry. Per staff interviews, they do laundry every day, as per laundry schedule. At times they need to do additional laundry to wash linens for incontinent residents. R1 was interviewed and stated that staff make sure all their stuff is washed, dried and returned to R1. Other residents interviewed during investigation did not address any concerns regarding laundry services. [LIC9099C]-Continued Unfounded During this visit on 12/11/25, LPA requested and reviewed laundry schedule which verified the information revealed by staff. Based on overall investigation it was concluded that the allegation, could not have happened, and/or is without a reasonable basis. Therefore, it is deemed UNFOUNDED at this time. Allegation: Staff are not transporting resident(s) to appointments. The complainant’s concern is that the facility did not provide transportation to appointments resulting in missed medical appointment. A facility file review was conducted for transportation policy. Transportation notes and the Residents Handbook were reviewed. Per review the licensee will provide and/or arrange transportation. LPA obtained a copy of the transportation schedule for residents dated Dec 3, 2023, to March 3, 2024. LPA reviewed the Resident’s handbook. At 10:45 am LPA conducted a sample of 10 resident and 5 (five) staff interviews. On 07-16-2024 the Administrator was interviewed and revealed that the facility driver had recently quit and was looking to fill the position. In the interim, the Administrator stated that third-party transportation services (i.e. Access, Uber, Lyft, Taxi, private ambulance service, etc.) were provided for residents. LPA reviewed the transportation schedule. The schedule was noted with residents’ names, dates, time, and location of appointments. Interviews with 8 out of 10 residents indicate there was no issue with the facility providing transportation. Two (02) pf ten (10) residents stated that a request for transportation must be made. No resident complaint of missing their medical appointments. Based on interviews, and document review, there is no information to verify the validity of the complaint allegation. Hence the allegation is unfounded at this time This agency had investigated the complaint alleging “Staff are not providing laundry services to resident”, and staff are not transporting residents to appointments. We have found that the complaint was without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted and a copy of report is issued.the state’s words, verbatim · CDSS document, Jan 9, 2026 · control 31-AS-20240215114434

Allegation investigated: Resident was raped at the facility by an unknown perpetrator.

On 12/20/25, Licensing Program Analyst, (LPA) Ray Comer, conducted a subsequent visit to conclude investigation of the above allegation. LPA spoke with the Administrator, via phone, met with the Staff Resident Service Supervior, and the reason for the visit was disclosed. At 10:40 am, LPA inspected the facility; no health and safety hazard were noted. It was alleged that resident #1 (R1) told a family member that they had been raped in the facility. On 04/10/25, LPA, Gina Saucedo conducted an initial visit to investigate the allegation, at which time, LPA obtained facility records pertaining to R1. The complaint was referred to the Investigations Branch, (IB) of the Community Care Licensing Department (CCLD) and accepted by Senior Investigator, (SI) Olivia Spindola, for assignment. SI Spidola's investigation consisted of an interview with Resident#1. (R1) The following is a summary of SI’s investigation: [continued on LIC9099C] Unsubstantiated On 04/23/25, SI Spindola interviewed R1 who was living at the facility for an unknown number of months. R1 stated that they like living in the facility, that staff treat R1 well, and that R1 likes the food prepared for them. R1 stated to Investigator Spindola they had not been either physically, nor sexually assaulted by anyone at the facility, nor anywhere else. According to SI Spidola's report, R1 denied ever telling the anyone they were sexually assaulted in the facility, or anywhere else. On 12/08/25, at 12:30 pm, LPA Ray Comer spoke with the Administrator, who indicated that R1’s family member spoke with them about the issue. An internal investigation was conducted, and R1 denied being sexually assaulted or abused. In addition, on 12/08/25, on or around 1:15pm, LPA Comer reviewed the documents gathered from the facility. Documents included, but are not limited to, Physician report, needs and service plan, and other records. Records review revealed that although R1 has health conditions that may affect their mental state, they are alert enough to respond to the questions coherently, and were able to articulate their needs. A review of incident report verified the information revealed by staff. Based on inspection, interviews and record review, there is not sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit Interview conducted, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Dec 20, 2025 · control 31-AS-20250409121903

Allegation investigated: Staff did not prevent resident from having bed bugs Staff are not transporting resident to appointments. Staff are not providing resident with housekeeping services. Staff are not meeting resident(s) dietary needs: Staff are not providing laundry services to residents.

This is an adendum to the reports issued 07-16-2024 and 01-30-2025. Based upon further review, citations issued for Staff did not prevent resident from having bed bugs, Staff are not transporting residents to appointments, Staff are not providing housekeeping services, Staff are not meeting resident’s dietary needs, have been dismissed. Findings for the allegations have been changed from substantiated to unsubstantiated. On 12/011/25, Licensing Program Analyst Ray Comer met with the Administrator and reason for the visit was explained. On 02-20-2024 LPA Huma Rahimi initiated the complaint. At 10:40 am LPA made request for records, which include but not limited to resident roster, progress notes and documentation from the exterminator. LPA interviewed five (5) staff, and nine (9) out of ten (10) residents. At 10:45 am, LPA conducted a sample tour of 10 rooms and interviewed residents and staff. Other visits were conducted 05-13-25, 07-23-25 and 09-11-25 by LPM Eva Miller and LPA Raymond Comer for additional staff and resident interviews, and to gather additional information. [LIC9099C]-Continued Unsubstantiated Allegation: Staff did not prevent resident(s) from having bed bugs. The complainant’s concern is that a resident’s room is infested with bed Bugs. LPA toured rooms and did not observe any infestation of bed bugs and or any other pests. LPA requested to review the pest control records from March 2023 to Feb 27, 2024. The licensee contracted with Bug Free Central 06-5-2023, Harvey’s Pest control January 13 and January 18, 2024, and currently contracts with Orkin Pest control for bed bugs or any other pest control services that are needed. Services are provided monthly or more if necessary. Inspections are assisted with K9(dog) trained to sniff out bed bugs. All rooms are inspected. A findings log is produced at the end of the inspection to indicate areas of problem. Upon review it was noted that visual inspections for bed bugs were performed for residents who were bed bound or had cluttered rooms. This limited the search for bed bugs in the resident’s room. Facility progress notes from the same period noted refusals of services for (1) out of the ten (10) rooms sampled at times. Alternate schedule for service was made to continue the inspection for bed bugs. No proof of active bed bugs was found. Therefore, upon review of the information gathered the allegation is unsubstantiated at this time. Allegation: Staff are not transporting resident(s) to appointments. The complainant’s concern is that the facility did not provide transportation to appointments resulting in missed medical appointment. A facility file review was conducted for transportation policy. Transportation notes and the Residents Handbook were reviewed. Per review the licensee will provide and/or arrange transportation. LPA obtained a copy of the transportation schedule for residents dated Dec 3, 2023, to March 3, 2024. LPA reviewed the Resident’s handbook. At 10:45 am LPA conducted a sample of 10 resident and 5 (five) staff interviews. On 07-16-2024 the Administrator was interviewed and revealed that the facility driver had recently quit and was looking to fill the position. In the interim, the Administrator stated that third-party transportation services (i.e. Access, Uber, Lyft, Taxi, private ambulance service, etc.) were provided for residents. LPA reviewed the transportation schedule. The schedule was noted with residents’ names, dates, time, and location of appointments. Interviews with 8 out of 10 residents indicate there was no issue with the facility providing transportation. Two of 10 residents stated that a request for transportation must be made, when reviewing the documentation LPA was unable to verify their request and could not determine whether any medical appointments were missed. Therefore, after review of the information gathered the allegation is unsubstantiated at this time. Allegation: Staff are not providing housekeeping services: The complainant’s concern is that staff are not providing housekeeping services. At 10:45 am LPA conducted a sample tour of 10 rooms (111, 119B,122, 207A,208A, 210A, 210B,214A, 214B, 215) and interviewed residents and staff. LPA conducted a file review for housekeeping policy. LPA reviewed the Resident Handbook and collected a copy of the housekeeping schedule. According to the Resident Handbook, housekeeping is responsible for providing a weekly deep cleaning including changing bed sheets. Additional housekeeping is available for an additional charge. According to the admissions agreement, Housekeeping will make beds and take out trash daily. Weekly services include dusting, vacuuming, and cleaning the bathroom. LPA collected a copy of 5 Housekeeping schedules. The schedules are noted with resident room numbers and the day of the week on which housekeeping services were provided. Interviews with 8 out of 10 residents reveal that housekeeping is conducting weekly cleaning but were not happy with the quality of their work. Residents state that housekeeping overall does a poor job in cleaning. Two out of 10 residents state there are no complaints about housekeeping. Per LPA’s observation during the visit, the first and second floor had a noticeable odor of urine. All rooms were noted to have visible thick dust on or under furniture. Room 214A, 214B, and 208A was observed to be cluttered with many boxes; a possible safety hazard for falls. Rooms 214A and 214B were noted to have dirty clothing on the floor. During the visit LPA also observed housekeeping going in and out of rooms with cleaning sprays, towels, and trash bags providing services.Therefore, after review of the information gathered the allegation is unsubstantiated as housekeeping services are being provided but the quality of service is poor which will be addressed separately. Allegation: Staff are not meeting resident(s) dietary needs: The complainant’s concern is that the facility staff are giving food that the residents cannot eat due to dietary restrictions. LPA conducted sample interviews with residents and food service staff. LPA reviewed the regular and alternate menu. Alternate menus are prepared with low salt and low sugar to promote overall health. LPA reviewed Facility Registered Dietician Approval of Menus dated 01-5-2024. LPA conducted resident file review to determine any doctors order for any dietary restrictions. LPA requested food service training and documentation. A review of R1 and R2s Clinical Requisition report which indicates dietary changes, food modifications, allergies and food restrictions. Per review of the documentation R1 is on a special NAS (No Salt Added) diet. Per staff interviews, meals are prepared with low sodium and sugar options. Interviews with eight (8) out of ten (10) residents confirmed that dietary services are followed if necessary and did not express any concerns regarding this allegation. On 07/16/2024, an additional interview with the Executive Chef was conducted and LPAs were informed that the facility provides required dietary service to residents to meet their specific needs. Kitchen staff are informed daily about any changes to a resident’s dietary requirements from the facility nurse. Furthermore, they offer alternatives upon request from a resident. After review of the information gathered the facility has provided R1 and other residents with meals per their dietary orders. Therefore, after review of the information gathered the allegation is unsubstantiated at this time. Exit interview conducted.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 31-AS-20240215114434

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Nov 14, 2024

Safeguards for Resident Cash, Personal Property, and Valuables: (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables... This requirement is not met as evidenced by: Based on interviews, licensee did not comply with the section sited above. Eight (8) out of ten (10) residents confirmed their personal items/belongings had gone missing, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: On 11/12/24, Licensee/Administrator conducted in-service training with all staff regarding this Section and submitted proof of training will be submitted to LPA.

Allegation investigated: Facility lacks an adequate amount of staff to meet resident's care needs in a timely manner.

This is an addendum of the previous Licensing Report issued on 11/13/2025. Upon further review of the information received during initial visit it was noted that additional investigation is required to render final findings. Therefore, this visit was conducted to obtain additional information. Licensing Program Manager (LPM) Naira Margaryan joined Licensing Program Analyst (LPA) Raymond Comer. Allegation - Facility is insufficiently staffed to provide adequate care and supervision to residents. It was alleged that the facility is understaffed. The only interaction Resident #1 (R1) receives is being brought down to the dining hall for meals and brought back to their room. [LIC9099] Continued- Unsubstantiated On 11/13/25 at 10:05 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an initial 10-day visit to investigate the above allegation. At the time of visit, LPA conducted a physical plant tour; no health and safety issues were observed. LPA requested and received resident and staff roster, Resident#1 (R1's) file, and documents relevant to the investigation. Between 11:15 am the 1:45 pm, LPA conducted interviews with Admin, Staff, and Residents. Prior to this visit on 01/06/2026, LPA Comer conducted a phone interview with the Resident Services Supervisor, and discussed staffing schedule and duties. In addition LPA Comer spoke with other parties involved in R1’s care. At the time of this visit, at 11:15am, LPM Margaryan and LPA Comer conducted a tour of physical plant and observed facility staff assisting residents for various activities of daily living. In addition, between 11:45am and 12:30pm, additional interviews were conducted with the staff present at the facility. Administrator and Staff revealed that the facility maintains sufficient number of staff to provide adequate care and supervision for all residents. Staff interviewed during investigation were able to explain their work assignments and the time they spent assisting each resident with various tasks of the activities of daily living. Staff stated their response to residents is completed within an average of two to ten minutes. Resident's room health checks are completed a minimum of every two hours per shift. LPA interviews with ten (10) out of (11) residents stated that they had no concerns about staff assistance, and they feel there is adequate staffing at the facility. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted with the Administrator. A copy of this report was provided, and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 31-AS-20251104131041

Type of visit: Case Management - Other

At 10:20 am, Tuesday, 9/16/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced case management visit. LPA met with facility Administrator, presented official CDSS badge identification, and stated the purpose of the visit to review facility's medical training documentation. At 10:40 am, LPA conducted a physical plant tour; no health and safety issues were observed. LPA requested copies of the Resident Roster, current LIC 500, and documents relevant to staff medication training requirements. LPA conducted a review of Facility's medical training for a total of ten (10) med tech staff. LPA requested copies of documents to verify completion of twenty four (24) hours of initial medication training, and eight (8) hours of in-service training on medication for each succeeding 12-month period. Facility Administrator agreed to scan and email the requested documents to the LPA by close of business on Wednesday, 9/16/25. An exit interview was conducted and a copy of the LIC 809 provided.the state’s words, verbatim · CDSS document, Sep 16, 2025

Allegation investigated: Facility staff do not respond to call bell in a timely manner. Facility staff are not adhering to resident care plan.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with Abbygaile Macaso and explained the reason for the visit. ---Facility staff do not respond to call bell in a timely manner. It was alleged that Resident #1’s (R1) pressed the call button and R1’s responsible party called the facility to assist R1 but the caregiver arrived fifty-five (55) minutes later. To investigate the allegation, on 08/06/2025 LPA conducted a physical plant tour at around 11:00a.m. LPA interviewed four (04) staff from 12:00p.m. to 1:30p.m. and ten (10) residents from 1:30p.m. to 3:00p.m. During physical plant tour, LPA observed a working call button and an average response time of four (04) minutes. During interviews with staff, all staff stated the average response time is five (05) minutes. (CONT on LIC 9099-C) Unsubstantiated Staff #1 (S1) added that on the evening in question, R1 needed a two (02) person assist to transfer so R1 waited approximately ten (10) to fifteen (15) minutes for the additional staff. During interviews with residents, eight (08) out of ten (10) stated staff respond to call button in a timely manner and the remaining two (02) stated staff take an extended time to respond to call buttons. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Facility staff are not adhering to resident care plan. It was alleged that R1 often receives items like lettuce that R1 cannot eat and staff fail to cut up R1’s food as specified in the care plan. To investigate the allegation, on 08/06/2025 LPA conducted a physical plant tour and requested documents at around 11:00a.m. LPA interviewed four (04) staff from 12:00p.m. to 1:30p.m. and ten (10) residents from 1:30p.m. to 3:00p.m. A review of R1’s Needs and Service Plan states in part that R1’s food is to be served cut, deboned and free from mixed fresh vegetables. During physical plant tour, LPA observed R1’s lunch which was according to the agreed upon care plan. The food was cut up, deboned and LPA did not observe mixed vegetables on the plate. LPA also observed special laminated posters throughout the kitchen notifying kitchen staff of R1’s preferences. During interviews with staff, all staff stated they follow the food plan as agreed upon with R1’s responsible party. Staff #2 (S2) added they are trying their very best to accommodate all of R1’s requests. During interviews with residents, all residents stated they feel facility is following care plan. Based on observations, record review and 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 issued.the state’s words, verbatim · CDSS document, Sep 9, 2025 · control 31-AS-20250729123022

Type of visit: Case Management - Annual Continuation

On Friday, 8/15/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to continue the required annual Inspection initiated on 08/14/2025. LPA met with Administrator, Adam Syncheff, and the purpose of visit was disclosed. The following remaining domains were observed, reviewed and inspected: Medications: Medication room is located on first floor by the Administrator’s office; LPA observed room as locked and inaccessible to residents. Inside the room, medications are properly labeled, and stored in secured cabinets. Resident medication documentation and distribution records appear to be complete. First aid kits were observed on carts stored in the medication room. Laundry: At 1:25pm, LPA observed the laundry room located on sub-floor, adjacent to the kitchen. Laundry area is inaccessible to residents, and is clear from obstruction. Laundry machines are functioning properly. Detergents, cleaning supplies, and other toxins are securely stored and inaccessible to residents. Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Eight (8) resident rooms (#110, #113,#117, #119, #207, #208, #230, #233) were inspected and observed to maintain required furnishings, sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction. [Continued on LIC 809-C] Bathrooms were observed to be clean and sanitary, with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured between 107°F and 109°F; Within the required range. Outdoor: Courtyard area(s) observed to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. Staff records: A total of six (6) Staff files were reviewed. Criminal record clearances were present and Staff are associated to this facility. Staff records appear to be complete and current. Resident records: A total of seven (7) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, medication logs, and resident identification. Resident records appeared to be complete and current. There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility Administrator.the state’s words, verbatim · CDSS document, Aug 15, 2025

Type of visit: Required - 1 Year

On 08/14/25, 10:15 AM, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced annual inspection of the Facility. LPA met with Facility Administrator, Adam Syncheff, and reason for the visit was disclosed. Facility is licensed as a two-story building. Fire clearance approved for (130) non-ambulatory, of which, eight (8) may be bedridden. Hospice waiver for thirty (30). There are currently four (4) residents receiving hospice care services, and one (1) bedridden. At 10:40 AM, LPA conducted a tour of the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Facility provides dementia care; LPA observed delayed egress system working properly throughout all access points of the facility. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 76.0°F. within the required range. The facility maintains approved Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted in July 2025. [LIC 809C -Continued]- Fire Detection/Protection system is present in the facility. Multiple dual smoke/carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire alarm system was tested and is working properly. Fire drill last conducted July 2025. Fire Extinguishers observed as fully charged with service date of 3/05/2025. Fire suppression system (i.e. Sprinklers, Valve Controls, Main Drains, etc.) were inspected on 4/01/2025; Annual fire alarm equipment inspection shows PASSED results. Kitchen: LPA observed kitchen as clean, commercial refrigerators and freezers observed as maintaining required temperatures, appliances and fixtures functional, with a sufficient amounts of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons, were observed near food areas. Commons: Activity room, dining room, and library observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. Due to time constraints, LPA was unable to complete this required annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report given to Administrator.the state’s words, verbatim · CDSS document, Aug 14, 2025

Allegation investigated: Lack of supervision resulting in resident being assaulted by another resident-

At 10:05 am, Tuesday, 7/15/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an initial 10-day visit to investigate the above allegation. LPA met with the facility Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:15 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received facility resident roster, and staff roster. At 10:35 am, LPA recieved Resident#1 (R1) and Resident#2 files and conducted a review of the documents. Between 11:00 am, and 12:45 pm, LPA conducted interviews with the Reporting Party, (RP) Administrator, Staff, and Residents. [LIC 9099C] Continued- Unsubstantiated Allegation: Lack of supervision resulting in resident being assaulted by another resident- The RP states that R1 was assaulted by R2 (R1's roommate) in their shared bedroom. To investigate the allegation, LPA conducted an interview with the RP, which revealed the following: Per the RP, R1 reported to their Primary Care Physician (PCP) that R2 slapped R1 in the face, attempted to grab R1's clothing in the torso area, and pulled R1's hair. Although the allegation states that "lack of supervision" resulted in R1 being assaulted by R2, the RP states that R1 did not report any supervision issues to either the RP, nor R1's PCP. LPA conducted interviews with the Administrator, and Staff, which revealed the following: The incident occurred on the morning of 7/10/25, around 9:00 am. Both administrator and staff state that an argument was heard between R1 and R2 coming from their shared bedroom. The Administrator denies that "lack of supervision" was a factor in the incident. Per the Administrator, this incident was the first time that interactions between R1 and R2 resulted in any physically aggressive action. During R1's tenure of residency, R1 has a history of confusion, but has never acted in an aggressive manner. Per both Administrator, and Staff, R2 prefers to stay in their room most of the day reading and watching television. R2 does not socialize amongst the community, is easily provoked to react with verbal insults, but has no history of being aggressive towards either residents or staff. Per the Administrator, and Staff, R1 and R2 were heard arguing, prior to any physical altercation, and staff immediately attempted to de-escalate the situation. It was at this time that R2 suddenly reacted, slapping R1. According to both the Administrator, and Staff, neither residents sustained any injuries during the conflict. Per Admin, R1 has been moved to a different bedroom and assigned a new resident roommate. LPA conducted interviews with ten residents. Nine (9) out of ten (10) residents could not confirm the allegation that lack of supervision resulted in physical assault committed between residents. Although there was an altercation between R1 and R2, leading to R2 striking R1, there is not corroborating evidence to support the allegation, as staff were present to intervene and redirect both residents. Moreover, licensee did submit an Incident Report (IR) to the Licensing agency regarding the incident. Therefore, based on the information obtained, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 31-AS-20250711112216

Allegation investigated: Facility staff are not properly supervising residents who are a fall risk- Facility staff did not seek timely medical attention for resident-

On Tuesday, 7/08/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit to continue investigation of the above allegation(s). The initial 10-day visit was conducted on 2/04/25. Today, LPA met with facility Administrator, Adam Syncheff, presented official CDSS badge identification, and reason for the visit was disclosed. At 8:45 am, A physical plant tour of the facility was conducted by LPA; No health or safety issues observed. To investigate the allegation(s), LPA received Facility resident roster, and staff roster. At 9:15 am, LPA reviewed Resident 1's (R1) file. Between 10:45 am and 12:40 pm, LPA interviewed Staff. [LIC 9099]-Continued Unsubstantiated Allegation: Facility staff are not properly supervising residents who are a fall risk- The reporting party (RP) alleges that Resident#1 (R1) sustained a fall injury in late December 2024. However, the RP states at the time of R1's reported fall, staff stated that R1 was doing "fine", suggesting that staff neglected R1's care. LPA's review of R1's records revealed the following: R1 was assessed as "non-ambulatory", however, is able to transfer from the bed and ambulate throughout the facility using a walker, requiring staff assistance and supervision. LPA interviews with Staff revealed the following: Staff refute the allegation, stating that facility caregivers consistently follow R1's care plan, are aware of R1's fall risk, and provide R1 with mobility assistance a minimum of three, or more times per day. Staff#2 (S2) states witnessing R1 on the floor during the fall incident and called additional staffers to assist R1. R1 was assessed, transferred to a wheelchair with staff assistance, and sent to the hospital for medical treatment; R1's responsible family member was informed. Based on the information gathered during this subsequent and prior initial visit, the allegation is deemed unsubstantiated at this time. Allegation: Facility staff did not seek timely medical attention for resident- The reporting party (RP) alleges that R1 was not provided medical attention in a timely manner. LPA's review of R1's records revealed the following: R1 was assessed as a fall risk, requiring some assistance when ambulating. R1's file does not show a a history of multiple falls prior to the fall incident in December 2024. Documentation reviewed shows that on the occasion of R1's fall incident. the facility followed proper procedures, including providing first aid, contacting medical professionals, calling 911, and sending R1 to the hospital when necessary. The facility also notified R1’s family following the fall incident. Additionally, facility staff state their awareness of R1' care plan and confirm providing consistent well checks and assistance for R1 to reduce the risk of further falls. LPA interview with R1's responsible family member (F1) revealed the following: F1 refutes the allegation, stating that facility staff consistently inform them of R1's health status and injury reporting and that R1 is well cared for by staff. Based on the information gathered during this subsequent and prior initial visit, the allegation is deemed unsubstantiated at this time. Based on records review, interviews with staff, and responsible family member, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 31-AS-20250128112646

Allegation investigated: Facility staff are not properly transferring resident to their wheelchair resulting in injury

On 6/17/2025 at approximately 10:00 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation(s). LPA was greeted by the Executive Director (ED), Adam Syncheff and stated the reason for their visit was to gather information, conduct interviews and deliver findings for this complaint. To investigate the allegation(s) at 10:15 AM, LPA requested census, resident, and staff roster. At approximately 10:30 AM, LPA requested pertinent documents pertaining to the investigation such as but not limited to: Medication, Staff Training and Staff schedule. At 11:30 AM LPA conducted a physical plant tour, to ensure the health and safety of the residents. Between 10:30 AM – 1:00 PM, LPA attempted interviews with four (4) staff members (S1-S4) and one (1) resident (R1). (continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Facility staff are not properly transferring resident to their wheelchair resulting in injury. It was alleged that R1 fell while being transferred to their wheelchair resulting in injuries. To investigate the allegation, LPA interviewed four (4) staff members. Interview with S3 revealed that while R1 was being assisted within the shower area, R1 began to slide down from their chair. S3 stated the facility self reported the incident on an Unusual Incident/Injury Report (SIR) and noted that R1 was assisted, “…to the floor in a controlled manner”. LPA’s interview with S4 revealed that R1 was checked for any injuries which they noted, R1 did not complain of any pain and/or showcased any signs of injuries. S4 stated that R1 was safely transferred back to their chair with assistance by S2 where no further incident occurred. LPA attempted to interview S2, but S2 no longer works at the facility and could not be contacted. LPA’s record review confirmed that the facility did report the incident to the appropriate reporting parties including Community Care Licensing Division (CCLD). Further record review of staff observational notes of R1 for the remainder of the date of occurrence showcased that R1 was observed to be in good health and complained of no pain. Additional record review revealed that R1 has various medical diagnosis, which can contribute to the weaking of the skin resulting in self-bruising. During LPA’s physical tour, LPA observed R1 to appear to be in good health and participating in activities with their peers. LPA attempted to interview R1 but R1 was participating in group activities, LPA terminated the interview. Furthermore, based on LPA’s interviews, record review and observations there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 31-AS-20241113154930

Allegation investigated: Staff did not administer resident’s medications as prescribed-

At 8:30 am, Tuesday, 4/29/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation listed above. LPA conducted the initial complaint visit on 3/28/25. LPA met with facility Administrator, Adam Syncheff, presented official CDSS badge identification, and reason for the visit was disclosed. At 8:40 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received Facility resident roster, and staff roster. At 8:55 am, LPA recieved and reviewed Resident 1's (R1) file. LPA also conducted interviews with the Administrator, Staff and Residents. [LIC 9099C] Continued- Unsubstantiated Allegation: Staff did not administer resident’s medications as prescribed. - The reporting party, (RP) alleges that Staff do not administer R1's medications as prescribed. LPA interviews with Medical Technician Staff revealed the following: S1, S2 and S3 refute this allegation, stating that R1's medications are administered as prescribed. Interviewed staff state that R1 frequently demands her medications be provided immediately upon request. However, per med tech staff, if R1 has already taken her medications, R1 must wait another six (6) or twelve (12) hours, depending on the prescription, before subsequent meds can again be administered. Per med tech staff, when explaining to R1 that staff must wait the required passage of time until subsequent medication can be provided, R1 "acts out" becoming verbally aggressive and acuses staff of "holding out" and refusing to provide R1 her meds. LPA review of R1's file revealed the following: Records review of R1’s Medication Administration Record (MAR) showed R1 received staff assistance with their medications, as required. No entries in the MAR were blank or missing. LPA interview with Resident#2 (R1's roommate) revealed the following: Per R2, R1 "is constantly telling staff to give her pills throughout the day" stating that if staff make R1 wait, "she [R1] "will yell and complain that staff are breaking the law". R2 confirms witnessing staff provide R1 her medications on a daily basis stating that R1 needs to "calm down and let the med staff do their job". LPA interviews with ten (10) out of one hundred and four (104) total facility residents revealed the following: ten (10) out of ten (10) residents interviewed confirm that staff assist them providing their medications consistently. Based on the information obtained, there is insufficient evidence to corroborate the allegation that staff do not administer resident's medications as prescribed. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Apr 29, 2025 · control 31-AS-20250327094450

Allegation investigated: Staff are not following resident's doctor recommended dietary needs- Staff are not meeting resident's bathing needs- Resident's call button is in disrepair- Staff do not treat resident with dignity and respect- Facility did not comply with reporting requirements-

At 10:00 am, Monday, 4/28/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation(s) listed above. LPA conducted the initial complaint visit on 3/28/25. LPA met with facility Administrator, Adam Syncheff, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:10 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received Facility resident roster, and staff roster. At 10:35 am, LPA recieved and reviewed Resident 1's (R1) file. LPA also conducted interviews with the Administrator, Staff and Residents. [LIC 9099C] Continued- Unsubstantiated Allegation: Staff are not following resident's doctor recommended dietary needs- The reporting party (RP) alleges that Resident#1 (R1) is not consistently offered a water-diluted juice beverage, and that the only meal substitutions offered to R1 are peanut butter and jelly sandwiches and eggs, which RP states are not healthy nutritional options as R1 is a diabetic. LPA interview with Food Service Staff and Administrator revealed the following: Both Admin and S1 refute this allegation, stating that R1 is offered, fish, hamburger, salads, and fresh fruit as meal alternatives. S1 states that a diluted juice beverage is consistently made available, and is offered to R1 a minimum of every two hours. A tour of R1's room by LPA revealed the following: LPA observed two cups of a water-diluted juice drink placed on a small table accessible to R1, and that a drink pitcher filled with the diluted juice beverage was observed in R1's small refrigerator. LPA interviews with ten (10) out of one hundred and four (104) total facility residents revealed the following: Nine (9) out of ten (10) residents interviewed confirm their satisfaction with the food and drink provided by staff to residents while in care. Based on the information obtained, there is insufficient evidence to corroborate the allegation that staff are not following doctor recommendations regarding R1's dietary needs. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff are not meeting resident's bathing needs- The reporting party (RP) alleges that Staff neglect to provide Resident#1 (R1) with showering/bathing assistance, stating that R1 hasn't been bathed in several weeks. LPA interview with caregiver staff revealed the following: S3 refutes this claim, stating that on the morning of today's LPA visit, R1 had showered, with the assistance of caregiver staff. S3 stated to LPA that "R1 does not like washing up and sometimes yells at us to go away". S3 states that when R1 refuses staff assistance with showering/bathing, it is reported to med tech staff, who then contact the responsible family member. LPA interview with the responsible family member (F1) revealed the following: F1 confirmed to LPA that R1 does not like taking showers and gets agitated by/aggressive with caregiver staff when offered their assistance with this task. However, F1 states they are contacted by staff requesting F1 to encourage R1 to accept staff assistance with showering/bathing tasks. A tour of R1's room by LPA revealed the following: LPA observed R1 sitting in a recliner chair, wearing clean and dry clothing. LPA observed R1 as clean and having no odor. [LIC 9099C] Continued- LPA interviews with ten (10) out of one hundred and four (104) total facility residents revealed the following: Ten (10) out of ten (10) residents interviewed confirm their satisfaction with the showering/bathing assistance provided by staff to residents while in care. Based on the information obtained, there is insufficient evidence to corroborate the allegation that staff are not meeting R1's bathing needs. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Resident's call button is in disrepair- The reporting party (RP) alleges that Resident#1 (R1's) room call button is detached from the wall. LPA interview with caregiver staff revealed the following: Both the facility Administrator and S3 refute this claim, stating that, on some occasions, R1 will change positions in his recliner chair, which causes the cord to detach. Per staff, during periodic room well checks, staff with observe and reattach the cord to the wall. A tour of R1's room by LPA revealed the following: Both call button assistance cords in R1's room (located by R1's recliner chair and by R1's bed) were attached, tested by the LPA, and found to be functioning properly. LPA interviews with ten (10) out of one hundred and four (104) total facility residents revealed the following: Ten (10) out of ten (10) residents interviewed confirmed their room's call button functioned properly. Based on the information obtained, there is insufficient evidence to corroborate the allegation that R1's call button is in disrepair. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff do not treat resident with dignity and respect- The reporting party (RP) alleges that as he was speaking to the main medical technician, a staff colleague standing next to the med tech began laughing as the RP was speaking. Per the RP, they felt that the staff was laughing at them, which they felt was being rude and disrespectful to both R1 and the RP. LPA interview with caregiver staff revealed the following: S4 refutes this claim stating she recalls the situation, and informed LPA that the incident was a misunderstanding. S4 states their colleague was not a participant in the conversation and was merely, "laughing about something she was listening in her earpiece which was covered by her hair". LPA interview with RP revealed the following: RP confirmed to the LPA that he had never witnessed undignified conduct committed upon R1 by staff, and felt disrespected himself by the laughing staffer. [LIC 9099C] Continued- LPA interviews with ten (10) out of one hundred and four (104) total facility residents revealed the following: Nine(9) out of ten (10) residents interviewed confirm that staff treat them with dignity and respect. Based on the information obtained, there is insufficient evidence to corroborate the allegation that staff do not treat R1 with dignity and respect. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff did not comply with reporting requirements- The reporting party (RP) alleges that on 12/06/24 Resident#1 (R1) was transferred out of the facility on a "5150" hold due to aggressive behavior committed by R1 upon caregiver staff. However, the RP states that, as a responsible family member, they were not informed of R1's transfer in a timely manner. LPA interview with both the Administrator and S4 revealed the following: Both the facility Administrator and S4 refute this claim, stating that, on 12/06/24, Responsible Family Member for R1 was contacted, informed of R1's transfer, and and reason why the transfer was necessary for staff/resident safety. Based on the information obtained, there is insufficient evidence to corroborate the allegation that staff failed to comply with reporting requirements. Therefore, the allegation is deemed Unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 28, 2025 · control 31-AS-20250318132449

Allegation investigated: Facility staff does not ensure that resident has an adequate amount of food. Facility staff does not ensure that resident has access to phone.

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with Haigaz Kazazian and explained the reason for the visit. LPA conducted physical plant tour at 9:43 AM, requested facility documents relevant to the investigation at 10:18 AM, reviewed facility records between 10:30 AM to 11:30 AM and interviewed witness and staff between 11:30 AM to 1:00 PM. Regarding the allegation that the facility staff does not ensure that resident has an adequate amount of food, it was alleged that Resident #1 (R1) is always still hungry. LPA's interview with the reporting party (RP) today at 12:18 PM revealed that it wasn't the facility who is withholding food for R1 but R1's family member. LPA's interview with Wellness director today at 10:48 AM, revealed that R1 is on Hospice services since admission about a month or so ago. LPA's record review today between 10:30 to 11:30 PM confirmed that R1 was on hospice services and currently on liquid diet per doctor's order lest R1 might choke on solid food due to R1's medical condition. (continued on LIC 9099-C) Unsubstantiated continued from LIC 9099) LPA's interview with R1's friend who was on R1's bedside during visit revealed that R1 was non-responsive for the last two (2) hours or since the friend arrived at R1's room. Regarding the allegation that Facility staff does not ensure that resident has access to phone, it was alleged that R1's family member took R1's phone. LPA's interview with staff today revealed that everyone has access to phone at the facility as they have a cord less phone available for everyone. LPA's interview with the witness/friend today revealed that it was R1's doctor who advised the family member to take away the phone from R1 as it was a source of R1's anxiety. Further, R1's friend stated that R1 could no longer receive nor place a call at R1's current state. Based on the information gathered during this visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 31-AS-20250416154440

Allegation investigated: Staff do not ensure that resident's bed is in good working order

At 9:45a.m., Licensing Program Analyst (LPA) Antonia Alvizar-Ettima made an initial complaint visit to investigation of the above stated allegation. LPA was greeted by Concierge, Emily Cordova granted LPA entrance and contacted Executive Director (ED). ssssAt about 10:05a.m., LPA met the ED and explained the reason for the visit. At 10:12a.m., LPA request and received resident and staff rosters. At 10:15a.m., ED and LPA conducted a physical plant tour. Between 10:30a.m – 11:45a.m., LPA conducted interviews with ten (10) out of one hundred- four (104) residents including resident #1 (R1), ED, Maintenance Director and four (04) staff. LPA asked questions relevant to the nature of the complaint. At approximately 11:55a.m., LPA request resident #1 (R1) Physician Report, Preplacement Appraisal and other relevant documents. Cont. on LIC 9099-C Unsubstantiated Cont. from LIC9099 Staff do not ensure that resident's bed is in good working order. It was alleged that resident #1 (R1) hospital electric bed has roll up on top of them like an accordion three (03) times. During physical plant tour LPA inspected resident #1 (R1) hospital electric bed. R1 demonstrated how the bed operates. R1 indicated that bed is working correct and did not know why the bed was not rolling up like an accordion. LPA inspected and checked the operation of the bed in R1’s room and did not observe the bed rolling up. ED interview revealed that R1 never reported that the bed rolled up on top of them. ED insists that the bed is adjustable for changing the resident or setting it for positioning. Maintenance Director interview revealed that R1 did not notify facility staff regarding bed rolling up on top of them like an accordion. Residents interview revealed their hospital bed only moves when they press a button on the remote control their beds are in good working order and had no issues. Staff interviews confirm the information provided by ED and Maintenance Director. Based on interviews and observations, there is not enough sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. No 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, Apr 7, 2025 · control 31-AS-20250401083408

Allegation investigated: Due to neglect residents contracted a viral infection. Resident received hospice services without consent.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above noted allegations. LPA met with Ubaldo Guerrero and explained the reason for the visit. ---Due to neglect residents contracted a viral infection. It was alleged that due to neglect, residents Resident #1 (R1) and Resident #2 (R2) contracted a Rhino infection at the Garden of Palms facility. To investigate the allegation, on 06/28/2024, LPA Tihesha Smith requested documents and interviewed two (02) staff from 11:00a.m. to 1:20 p.m. On 04/06/2025, LPA Duguma interviewed eleven (11) residents. According to interviews with two (02) staff members, R1 and R2 had limited interaction with the facility community, as they primarily remained in their rooms and opted for in-room dining. (CONT on LIC9099-C) Unsubstantiated Both staff members stated that they had not contracted any infection at the facility and were unaware of any resident or staff member being diagnosed with a Rhino viral infection between April and June 2024. An interview with the facility administrator on June 28, 2024, confirmed that no known cases of Rhino viral infections had been reported among residents or staff from January 2024 to June 2024. The administrator stated that the facility follows regular cleaning protocols and adheres to established health and safety guidelines. Additionally, the administrator confirmed that the facility has a current infection control plan in place. LPA review of the Department’s did not show that a viral outbreak was reported during the time in question and that facility does have an infection control plan in place. During interviews with residents, all residents stated they are not aware of any viral infection or outbreak during the time in question. Based on interviews and records review there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Resident received hospice services without consent. It was alleged that facility enrolled R1 to receive hospice services without their consent. To investigate the allegation, on 06/28/2024, LPA Tihesha Smith requested documents and interviewed two (02) staff from 11:00a.m. to 1:20p.m. A review of the R1’s hospice documents revealed that resident consented to hospice services. During interviews with staff, all staff stated resident was not coerced in any way by any staff and that those decision are made between the resident or resident’s responsible party and the resident’s physician or other medical professional. Based on interviews and records review there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 6, 2025 · control 31-AS-20240621110324

Allegation investigated: Staff did not administer resident’s medications as prescribed-

At 9:45 am, Friday, 3/28/25, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced, initial 10-day complaint visit to invesitgate the above allegation. LPA met with Administrator, Adam Syncheff, presented official CDSS badge identification, and reason for the visit was disclosed. At 10:00 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received Facility resident roster, and staff roster. At 10:30 am, LPA recieved and reviewed Resident 1's (R1) file. Between 11:05 am and 1:40 pm, LPA conducted interviews with the Administrator, Three (3) Staff, the Reporting Party (RP), and ten (10) residents. [LIC 9099C]- Continued Unsubstantiated Allegation: Staff did not administer resident’s medications as prescribed- It is alleged that night staff-Med Tech (S2) did not distribute Resident#1 (R1's) medications, as prescribed. LPA interviews with staff revealed the following: Both the Administrator, Staff#1 (S1) and (S2) refute the allegation, stating that R1's medications are consistently administered, as prescribed. Staff state that R1 frequently requests "as needed" PRN pain medications, such as OXYCODONE, or TRAMADOL. However, R1 does not wait for the prescribed "once every four hours" or "once every twelve hours" time window before requesting staff to provide her the aforementioned medications. Staff state they must temporarily withhold administration of these pain medications to R1 when she requests taking said medications outside the prescribed time frames. LPA review of R1's Medication Administration Records (MAR) lists all medications; staff notations are consistent and in good order. LPA Interviews with ten (10) residents revealed the following: Nine (9) out of ten (10) residents state having no issues with medication assistance, stating that med staff administer medications on a consistent basis, as prescribed. Based records review, and interviews with residents and staff, the facility assisted R1 with the proper administration of their medications, as prescribed. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Mar 28, 2025 · control 31-AS-20250327094450

Allegation investigated: Facility Staff failed to inform resident's representatives of medical services provided, and health status updates of resident while in care-

On Tuesday, 1/28/25, at 9:00 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation listed above. LPA conducted the initial complaint visit on 1/27/25. LPA met with facility Administrator, Adam Syncheff, presented official CDSS badge identification, and reason for the visit was disclosed. At 9:15 am, A physical plant tour of the facility was conducted by LPA; No health or safety issues observed. Allegation: Licensee failed to inform Resident#1's (R1's) representative of provided wound care services and notification that R1 was transferred out of the facility and transported to Hospital for health assessment. To investigate the allegation, LPA received Facility resident roster, and staff roster. [LIC 9099C Continued] Unsubstantiated At 9:25 am, LPA reviewed Resident 1's (R1) file, and other documents relevant to the investigation. Between 10:15 am and 12:30 pm, LPA conducted on-site interviews with Administrator, Staff, and six (6) responsible family members of facility residents. The Reporting Party (RP) alleges that staff failed to provide health status notifications regarding wound care services provided to R1. Additionally, the RP states facility staff did not attempt to notify the responsible family member that, in the month of December 2024, R1 had been transferred out of the facility, and transported to Hospital to diagnose the possibility of a stroke. LPA conducted a review of R1's file, and relevant documentation, finding the following: Prior to R1's September 2024 admission into the facility, R1 was identified as having a foot wound requiring medical care. R1's file contains documentation confirming that wound care service assistance was initiated in the same month of R1's admission, and continues to the current date. Facility Administrator provided LPA phone texts communicating to R1's responsible family member (F1) the status of R1's wound care assistance. LPA interview with F1 revealed the following: F1 confirmed to LPA that the Administrator did provide them notification that wound care services were being provided by Agency, Skilled Home Health, and that R1's wound is currently "dry and healing." LPA interview with the Administrator and Staff revealed the following: Both Administrator, and Staff refute this allegation, stating that facility medical staff informed F1 regarding status updates of R1's wound care, and notification of R1's transfer and hospitalization. LPA interview with six (6) responsible family members of residents revealed the following: Six (6) out of six (6) responsible family members state that facility staff consistently report activities related to resident care and services. Based on LPA documents, interviews with staff, and responsible family members of residents, The allegation is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jan 28, 2025 · control 31-AS-20250122094309

Allegation investigated: Facility Staff lack the ability to communicate with residents- Resident(s) room(s) not maintained clean, safe and sanitary at all times- Resident(s) medical needs not met- Staff do not consistently provide the services that meet the needs of residents- Staff do not consistently manage incontinence needs of resident(s)-

At 8:35 am, Tuesday, 1/14/25, Licensing Program Analyst (LPA) Raymond Comer, conducted a subsequent visit regarding the allegation listed above. LPA conducted the initial complaint visit on Thursday 8/29/24, and subsequent visit on Thursday, 09/19/24. LPA met with Administrator Adam Syncheff, and the purpose of the visit was disclosed. At 9:00 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received Facility resident roster, and staff roster. At 9:10 am, reviewed Resident files, and other documents relevant to the investigation, and conducted on-site interview with the Administrator, three (3) Staff and seven (7) Residents. [LIC 9099C]- Continued Unsubstantiated Allegation: Staff lack the ability to communicate with residents- The Reporting Party (RP) alleges that Resident#1's (R1's) care is neglected, due to a language barrier prohibiting communication between R1 and staff caregivers. To investigate the allegation, LPA observed staff and residents communicating in common areas of the facility, conducted interviews with three (3) staff from 9:20 am, to 11:45 am, and interviewed seven (7) residents from 12:00 pm, to 3:00 pm. Staff interviewed by LPA state they are able to communicate with residents on a level satisfactory in meeting resident needs. LPA interviews with seven (7) residents revealed the following; six (6) out of seven (7) residents state that communications between residents and staff is satisfactory in meeting resident needs. Although this allegation may have occurred, or is valid, there is not a preponderance of evidence to prove the alleged did, or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. Allegation: Resident(s) room(s) not maintained clean, safe and sanitary at all times- The Reporting Party (RP) alleges that Resident#1's (R1's) room, and the rooms of other residents, are unsanitary, and emit foul odors. To investigate the allegation, LPA conducted random observations of resident room(s) #104, #109, #115, #116, #202, and #208. LPA observations found resident rooms as clean, properly furnished, and not exhibiting any foul odors. LPA conducted interviews with three (3) staff from 9:20 am, to 11:45 am, and interviewed seven (7) residents from 12:00 pm, to 3:00 pm. Staff interviewed by LPA state rooms are cleaned daily by housekeeping staff. LPA interviews with seven (7) residents revealed the following; seven (07) out of seven (07) residents state that facility bedrooms are cleaned daily by staff. Although this allegation may have occurred, or is valid, there is not a preponderance of evidence to prove the alleged did, or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. Allegation: Resident medical needs not met. -The Reporting Party (RP) alleges that Resident#1 (R1) is not provided proper hydration, a "dietetic diet", nor are R1's feet elevated. [LIC 9099C]- Continued To investigate the allegation, LPA conducted review of Resident#1's (R1's) file and other relevant documents. Per documents review, R1's feet are to be elevated, a diabetic diet provided, and a juice beverage made available. In the morning, LPA conducted an observation of R1's room, which revealed the following: R1 was found sitting in a recliner chair with feet elevated. Water and juice beverage were observed sitting on a small table next to R1's recliner chair. A small refrigerator in R1's room contained a pitcher with juice beverage. LPA interviewed three (3) staff from 9:20 am, to 11:45 am, which revealed the following: Staff are aware of R1's needs and state they fulfill care plan directives on a consistent basis. LPA interviewed seven (7) residents from 12:00 pm, to 3:00 pm. which revealed the following; six (6) out of seven (7) residents state that staff provide satisfactory care/assistance and have no concerns. Although this allegation may have occurred, or is valid, there is not a preponderance of evidence to prove the alleged did, or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not consistently provide the services that meet the needs of residents. The Reporting Party (RP) alleges that staff do not check on Resident#1 (R1) often enough, neglecting R1's need for staff assistance. To investigate the allegation, LPA conducted review of Resident#1's (R1's) file and other relevant documents, conducted interviews with three (3) staff from 9:20 am, to 11:45 am, and interviewed seven (7) residents from 12:00 pm, to 3:00 pm. Staff interviewed by LPA state that R1 is visited by staff every two hours, and sometimes more frequently if R1 appears either agitated or anxious. LPA interviews with seven (7) residents revealed the following; six (6) out of seven (7) residents state that staff provide satisfactory assistance on a consistent basis. Although this allegation may have occurred, or is valid, there is not a preponderance of evidence to prove the alleged did, or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not consistently manage incontinence needs of resident(s)- The Reporting Party (RP) alleges that Resident #1 (R1) is not being changed on a timely and consistent basis. To investigate the allegation, LPA interviewed three (3) staff from 9:20 am, to 11:45 am, and interviewed seven (7) residents from 12:00 pm, to 3:00 pm. LPA interviews with with staff revealed the following: Interviewed staff state checking on R1, and all other residents every two (02) hours, or more frequently, if needed. LPA interviews with seven (7) residents revealed the following: seven (7) out of seven (7) residents state visitations by staff a minimum of every two hours. Although this allegation may have occurred, or is valid, there is not a preponderance of evidence to prove the alleged did, or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 31-AS-20240821100726

Allegation investigated: Facility is not in compliance with approved Hospice Waiver-

At 9:25 am, Monday, 1/13/25, Licensing Program Analyst (LPA) Raymond Comer, conducted a subsequent visit regarding the allegation listed above. LPA conducted the initial complaint visit on 7/30/24, and subsequent visit on Friday, 10/04/24. LPA met with Administrator Adam Syncheff, and the purpose of the visit was disclosed. At 9:35 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received Facility resident roster, and staff roster. At 9:40 am, reviewed Resident files, and other documents relevant to the investigation, and conducted on-site interview with the Administrator. [LIC 9099C]- Continued Unsubstantiated The Reporting Party (RP) alleges that facility has failed to comply with title 22 regulations regarding the admission of residents receiving hospice care services. LPA interview with the Administrator confirms their awareness and requirement to comply with Title 22 regulation regarding acceptance of terminally ill persons accepted by the facility as residents. LPA review of resident records revealed the following: Facility has four (4) residents receiving hospice care. Records contain approved hospice waiver, required terminal diagnoses by a Physician, facility agreement to accept/retain terminally ill residents, and singed agreements of those residents sharing a room with co-residents receiving hospice care. Based on interview, and record reviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jan 13, 2025 · control 31-AS-20240723125344

Allegation investigated: Staff do not ensure residents care plan is being followed-

At 8:35 am, Tuesday, 1/07/25, Licensing Program Analyst (LPA) Raymond Comer, conducted an unannounced initial complaint visit at this facility to invesitgate the above allegation. LPA met with Administrator, Karla Garcia, presented official CDSS badge identification, and reason for the visit was disclosed. At 8:45 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received Facility resident roster, and staff roster. At 9:00 am, LPA reviewed Resident 1's (R1) file, and other documents relevant to the investigation. Between 9:30 am and 11:15 am, LPA conducted on-site interviews with three (3) Staff, and five (5) Residents. [LIC 9099C]- Continued Unsubstantiated The Reporting Party (RP) alleges that staff do not provide Resident#1's (R1) a juice beverage, that R1's legs are not elevated when sitting in his recliner, and that R1's smart watch battery is not charged for use. LPA's review of (R1's) file found summary care notes memorializing a "Care Conference" meeting which took place between the RP, the Staff Wellness Director, and the Administrator. LPA Interview with Staff#1 (S1) states that R1 is provided juice daily, that staff ensure R1's recliner is elevated, and that ensure that R1's smart watch is charged and placed on R1's arm when charging is complete. LPA interview with the Staff#2 (S2) revealed that R1 is provided the aforementioned service, as stated in the care plan notes. Residents interviewed by LPA revealed they have no concerns with the care provided to them by facility Staff LPA toured R1's bedroom and found R1 resting comfortably in a recliner chair; R1's legs were elevated. LPA observed juice and bottled water setting on a table next to R1, and R1's smart watch was observed as activated and attached to R1's arm. Based on LPA observations, documents review and interviews with staff and residents, The allegation is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jan 7, 2025 · control 31-AS-20250106095138

Allegation investigated: Staff not assisting resident in a timely manner-

On Tuesday, 11/19/24, at 9:30 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation listed above. LPA conducted the initial complaint visit on 11/18/24. LPA met with facility Administrator, Adam Syncheff, and the purpose of the visit was disclosed. At 9:40 am, A physical plant tour of the facility was conducted by LPA; No health or safety issues observed. Allegation: Staff not assisting resident in a timely manner- It was alleged that staff take an average of two (2) hours to respond when Resident#1's (R1's) call button is activated. [LIC 9099C Continued] Unsubstantiated To investigate the complaint, LPA conducted observations of the facility, interviews with staff, residents, and responsible family member of R1. During LPA observations, LPA inspected resident rooms (#202, #214, #123, #219, #104) for required fixtures, furnishings, and overall conditions; no health/safety issues were found during LPA observations. LPA activated the services call button of all inspected rooms: Caregiver staff responded to activated call buttons within two (2) to five (5) minutes. LPA interview with F1 revealed the following: F1 states, "I can't recall a time that staff responded to R1's service call button in less than twenty (20) minutes from it's activation. F1 states that staff do a "great" job of providing care at the facility. F1 stated to LPA that they are not "complaining" about staff response times; they just want to see some overall improvement in quality by staff. LPA interviews with staff revealed the following: When residents activate the service call button, the central "base station", located in the reception area, displays the resident's room number and actual time the button was activated. The base station automatically alerts all caregiver staff, via pager. An available caregiver staff arrives to the resident's room, provides service to the resident, and de-activates the room's call button. Staff state that, on average, caregivers response to an activated call button within two (2) to seven (7) minutes, depending on the demands made upon staff at the time a button is activated. Staff states that R1 gets frustrated at times when their call button is not immediately responded to by caregivers. LPA interviews with residents revealed the following: Seven (7) out of Nine (9) residents state staff response time to service calls is satisfactory, saying that staff usually respond within five (5) to ten (10) minutes, at most. Based on the information obtained through LPA observation, and interviews, it cannot be proven that staff fails to respond to resident service calls in a timely manner. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Nov 19, 2024 · control 31-AS-20241114124546

Type of visit: Case Management - Deficiencies

This is an amendment to the original report issued on 11/12/2024. Additional information was added to clarify the investigation. Licensing Program Analysts (LPAs) Huma Rahimi and Angela Panushkina, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240215114434. LPAs met with the Executive Director and explained the reason for the visit. On 02/15/2024 the Regional Office (RO) received a complaint and on 02/20/2024, LPA conducted an initial complaint visit. On 07/16/2024, LPA conducted a subsequent complaint visit. During the initial and subsequent visits, LPA reviewed R1's Physican's reportfacility file, Physician's report, and conducted interviews. According to the Physician report, R1 was on a special diet (Soft Mechanical) that the facility provided; however, R2 denied and controlled R1's food. Furthermore, LPA conducted a file review of R1 and observed that R2 is not the Power of Attorney or a conservator on R1's decision making. The facility staff did not report the abuse to the appropriate authorities. Based on interviews and record review It was determined that an additional deficiency will be issued. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is cited and noted on LIC809-D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Nov 12, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Jan 31, 2025

Reporting Requirements: (c) Any suspected abuse that does not result in serious bodily injury... ...shall be reported to the local ombudsman, the corresponding licensing agency... ...within twenty-four (24) hours. This requirement is not met as evidenced by: Based on interviews and records review facility staff failed to report R2 withheld food from R1. This poses/posed a potential risk to the health and personal rights of a resident in care.the state’s words, verbatim · CDSS document, Nov 12, 2024

Plan of correction: The Licensee agreed to provide a refresher course in Mandated Reporting to all staff by an approved Vendor and submit to LPA by the due date.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Huma Rahimi and Angela Panushkina, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240215114434. LPAs met with the Executive Director and explained the reason for the visit. On 02/15/2024 the Regional Office (RO) received a complaint and on 02/20/2024, LPA conducted an initial complaint visit. On 07/16/2024, LPAs conducted a subsequent visit to deliver a report. During that time one of the allegations': "Staff are not providing laundry services to resident" was found SUBSTANTIATED. LPAs were unable to Amend the original report from 07/16/2024. Thus, a Case Management is conducted for an additional information to be added to clarify the investigation. Allegation: "Staff are not providing laundry services to resident" It is alleged that the facility is not providing laundry services. To investigate this allegation LPA conducted interviews with Executive Director and Housekeeper who informed LPA that the facility does provide laundry services on weekly basis to all residents in care. Additionally, LPA was informed that the facility has a set schedule for each floor of the facility. Review of facility Admission Agreement confirmed that the laundry is part of basic services and are provided to all residents. Lastly, during the subsequent visit, LPAs toured the laundry area and observed all washers and dryers running and multiple baskets with residents clothes were also observed. Based on interviews, record review and LPAs observation, LPA have found that the complaint was Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. LPA have therefore dismissed the above allegation. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Nov 12, 2024

Allegation investigated: Staff left resident soiled in urine resulting in a rash- Call button not accessible to resident-

On Thursday, 10/31/2024, at 09:35 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to the Facility to initiate the10-day complaint investigating the above allegation(s). LPA was met by the Administrator, Adam Syncheff, and reason for the visit was discussed. At 9:45 am, LPA conducted a physical plant tour of the facility; No health and safety issues were observed. Allegation: Staff left resident soiled in urine, resulting in a rash- Reporting Party (RP) states Staff is not providing R1 timely care regarding diaper changing. To investigate the complaint. LPA conducted a records review, observation, interviewing resident, and staff. [LIC 9099C] Continued Unsubstantiated From 10:00am to 11:30am, LPA interviewed the Administrator, and staff. Interviewed Staff deny the allegation, stating that R1 is checked on a minimum of two-hour intervals to insure they are made comfortable, clean, and dry. Both the Administrator, and Staff#1 (S1) recently conducted a "care conference" to discuss and optimize R1's level of care. The results of Staff conference objectives were communicated to R1's responsible family member. A review of documents by LPA revealed Staff's agreement to provide enhanced care, due to R1's frequent incontinence needs. Staff state they encourage R1 to go to the bathroom every couple of hours, and communicate with R1's responsible family member when R1 refuses caregiver assistance. LPA observed R1 in their bedroom, sleeping in a chair recliner. At the time of LPA's observation, R1 appeared as well groomed, clean, with no trace of urine smell. Based on the information obtained, there was insufficient evidence to prove that R1 is left soiled for an extended period of time. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Call button not accessible to resident- RP states that R1 must wait 20 to 40 minutes, or longer, for a caregiver to respond to the call. To investigate this complaint, LPA conducted interviews with staff, residents and facility observation. Five (5) out of five (5) residents states that caregivers respond to service calls at a reasonable time. LPA conducted an observation of R1's room, pressing the service call button; staff responded within three minutes of its activation. Based on the information gathered during this, and prior visits, this allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 31-AS-20241030142514

Allegation investigated: Staff do not safeguard resident’s personal property- Licensee retaliates against facility staff for reporting-

On Friday, 10/04/24, at 9:20am, Licensing Program Analyst (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation(s) listed above. LPA conducted the initial complaint visit on 7/30/24. LPA met with facility Administrator, Adam Syncheff, and the purpose of the visit was disclosed. At 9:30 am, A physical plant tour of the facility was conducted by LPA; No health and safety issues were observed. Allegation: Staff do not safeguard resident’s personal property- It was alleged that residents personal items are stolen by facility staff. To investigation this allegation, LPA conducted records review, interviewed residents and staff. [LIC 9099C Continued] Unsubstantiated Residents interviewed by LPA from 10:50am to 12:00 pm revealed that seven (7) out of seven (7) residents believe staff provide satisfactory service regarding the safeguarding of their personal belonging, and have not reported any instance of theft of personal belongings as committed by facility staff. LPA interviews with staff from 12:00pm to 1:20pm did NOT reveal sufficient evidence to support this allegation. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, Based on interviews with Residents and Staff, This allegation is unsubstantiated. Allegation: Licensee retaliates against facility staff for reporting- It is alleged that staff, whom may have reported incidents of theft upon residents committed by other staff members, have been fired by licensee as an intimidation tactic. To investigate this allegation, LPA interviewed Administrator, and Staff. LPA interviews with four (4) out of four (4) staff did NOT reveal sufficient evidence to support that licensee is retaliating against staff for reporting on the acts of other staff members. Interview with Administrator, and review of facility termination records indicate that employee termination procedures are evaluated in conjunction with specific regards to job performance expectations. Although the allegation may have happened,or is valid, there is not a preponderance of evidence to prove the alleged violation did, or did not occur, Therefore, Based on records review, interviews with Administrator, and Staff, This allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Oct 4, 2024 · control 31-AS-20240723125344

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: Facility Signal System is not consistently functional-

On Thursday, 9/19/24, Licensing Program Analyst, (LPA) Raymond Comer, made a subsequent visit to continue a complaint investigation. The initial complaint visit was conducted on 08/29/24. LPA met with facility Wellness Director, Solange Nkafu, and the purpose of the visit was disclosed. Allegation: Facility Signal System is not consistently functional- RP states the Resident 1's (R1's) service call system does not work consistently, that the system does not confirm if call was responded to, and that it takes staff 25 minutes minimum for staff to respond. LPA conducted a physical plant tour at 10:10 AM; No Health/Safety issues were observed. LPA requested copies of facility documents relevant to the investigation at 11:05 AM (Resident Files, LIC500) and interviewed Staff from 11:15 AM, to 12:30 PM. [LIC 9099C Continued] Unsubstantiated LPA assessed the Reporting Party's (RP) allegation with investigation of the following: LPA visited R1's room, and activated the call service button. Within two minutes of activation, a facility caregiver Staff entered the room to response to the service call. R1's call service button was activated while LPA observed the facility service call system network, which is located in the front office reception area. Once activated, R1's room number displayed on the system's monitoring screen, and a caregiver staff was promptly notified. Within two minutes of the activation of R1's service call, caregiver alerted receptionist staff that R1's service call was answered. LPA interview with Staff (S1) stated that all Medication Technicians and Caregivers are notified, via work pager, of service calls activated by residents. Resident interviews with six (6) out of seven (7) residents state that resident service calls are answered and responded to in a timely manner. Based on observation, and interviews, This allegation is unsubstantiated. Exit interview was conducted, appeal rights discussed, and a copy of the report was given to the Administrator.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 31-AS-20240821100726

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: Residents concerns are ignored in the facility

Licensing Program Analysts (LPAs) Gary Tan and Angelica Segovia conducted an unannounced subsequent visit at this facility to further investigate the above allegation. LPAs met with the Wellness Director Solange Nkafu and explained the reason for the visit. LPAs conducted physical plant tour 9:30 AM, requested copies of facility documents relevant to the investigation at 10:34 AM and conducted interview with staff and residents between 10:45 AM to 1:00 PM. It was alleged that staff often ignore residents who request additional service such as soup or coffee, etc. and ignored their request and just turn around away from them. LPAs interview with eleven (11) residents today or more than 10% of the current census revealed that ten (10) out of eleven residents interviewed believed that they get what they ask in a timely manner and not being ignored by the staff. One (1) out of eleven (11) residents refused to be interviewed. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) LPAs also observed during lunch at around 12:36 PM that there are four (4) staff serving residents and all the meals were given on time and all the requests of the residents eating were accommodated when appropriate. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 31-AS-20240223154316

Allegation investigated: Staff are not administering medication(s) to resident(s) as prescribed by their physician Staff are not ensuring that resident's dietary restrictions are being met Staff do not respond to resident(s) requests for assistance in a timely manner

At 10:15am Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted unannounced complaint visit to the facility to complete investigation of the above noted allegations and to deliver final report. At 10:30am LPA met with the Administrator. To investigate the above noted allegations, during initial visit conducted on 10/27/23, LPA requested facility records at 10:30am. The documents included, but not limited to staff and resident roster, residents (R1 - R2) physician report, needs and service plan and pertinent documents relevant to the investigation. At the time of visit between 10:45 am – 1:00 pm LPA and Administrator toured the physical plant and at approximately 1:05pm LPA spoke with Administrator, Staff (S1), and four (4) Residents (R1-R4). LPA Alvizar asked questions relevant to the nature of the complaint. Staff are not administering medication(s) to resident(s) as prescribed by their physician. Cont. LIC9099c Unsubstantiated It is alleged that R2 is not receiving the appropriate blood pressure and diabetes medications. R#2 is not receiving appropriate cancer care and has been mislabeled, because of dementia and subsequently placed on hospice care. LPA interview ten (10) out of one hundred – four (104) residents including Resident’s R1 and R2. R1 agreed with the allegation and R2 did not respond. The other resident that where interview revealed that they did not have any concerns about the allegation. Administrator and other staff indicated only R1, who is R2’s spouse, orders R2’s medication refill and when medication arrives to facility, Med – Techs takes it to room and R1 receives it. Staff interview revealed that R1 does not allow Med – Tech’s to administrator R2’s medication. Prior to this visit LPA Alvizar-Ettima reviewed facility records including Physician Report and Preplacement Appraisal Information. The information revealed from records supported the information provided by the facility personnel. According to record review R2’s primary diagnosis is unspecified dementia and R2 currently is under hospice. Based on interviews and record review, there is no pertinent information to support the allegation. Therefore, the allegation are deemed UNSUBSTANTIATED at this time. 2.) Staff are not ensuring that resident's dietary restrictions are being met. It is alleged that food they receive does not honor their dietary restrictions and the quality of the food is poor. LPA Alvizar - Ettima interview with Resident (R1) who stated that R2 cannot have citrus food and staff continue to provide it. R2 did not provide a response to the allegation. Interview with eight (8) out of one hundred and four (104) residents did not have any concerns regarding quality and variety of food served at the facility. Six (6) out of the eight (8) residents indicated that the food was good, and they liked the chicken and fish. Administrator indicated that facility staff are ensuring that they follow R2’s (No Added Salt) dietary restriction. During initial inspection LPA observed the “AL Special Diet” list posted in the kitchen board. The list identifies all residents that are under special medical diet. Prior to this visit LPA Alvizar-Ettima reviewed facility records including “AL Special Diet”. According to record review R2 is in a “no added salt diet”. There was no dietary restriction for “citrus food”. The information revealed from records supported the information provided by the facility personnel. Based on interviews and record review, there is no pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Cont. LIC 9099c 3.) Staff do not respond to resident(s) requests for assistance in a timely manner. It is alleged that staff taken hours to respond to calls for assistance and due to insufficient staff to meet appropriate care needs of residents, there is a long delays in obtaining assistance. During inspection conducted at the time of initial visit, LPA randomly selected six (06) out of one hundred - four (104) residents and the call buttons were tested in their rooms. All call buttons appeared to be functional, and LPA observed staff answering to call between two (2) to three (3) minutes. LPA Alvizar - Ettima interview with Resident (R1) revealed that staff does not respond to the call button on time. R2 did not provide a response to the allegation. Staff interviews reveal that they do respond to resident(s) request for assistance in a timely manner. The Call LIght system was recently upgraded. Administrator indicated that R1 sometimes refuses assistance from staff for themselves and R2, because R1 only requested certain staff to assistance. Interviews with eight (8) out of one hundred – four (104) residents indicated that staff do respond to their request for assistance. Prior to this visit LPA Alvizar-Ettima reviewed facility records including “Important Notice - Call Light System will be upgraded. The information revealed from records supported the information provided by the facility personnel. Based on observation, interviews and record review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit interview is conducted and copy of report was provided to Administrator.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 31-AS-20231025122256

Allegation investigated: Staff do not assist residents with ambulation Staff do not provide residents with a sufficient amount of living accommodations Staff do not serve residents with food of good quality

At 10:15am Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted unannounced complaint visit to the facility to complete investigation of the above noted allegations and to deliver final report. At 10:30am LPA met with the Administrator, Adam Syncheff. To investigate the above noted allegations, during initial visit conducted on 09/26/23, LPA Gina Saucedo requested copies of personnel report, resident roster and conducted a physical plant tour at 1:30pm. During subsequent visit conducted on 08/09/24, at 10:30am LPA Alvizar-Ettima and Wellness Assistant, Karla Garcia conducted a physical plant tour. At approximately 2:15pm, LPA requested and obtained copies of facility documents including but not limited to staff and resident roster. At the time of visit at approximately 10:30am LPA and Wellness Director, Solange Nkafu toured the physical plant and between 11:00am -1:30pm LPA spoke with Administrator, Staff (S#1 -S#2), and Residents (R#1 -R#10). LPA Alvizar asked questions relevant to the nature of the complaint. Unsubstantiated 1.) Staff do not assist residents with ambulation It is alleged that resident (R1) along with other residents ambulating in wheelchairs, constantly cry for staff to help them push their wheelchairs into the TV room. Staff interviews reveal that they are always assist residents with ambulation from the diner to the TV room or anywhere else resident's want to go in the facility. LPA interview ten (10) out of one hundred – four (104) residents requiring ambulation assistance including R1. R1 and other residents indicated that staff are always assisting them, and they did not have any concerns about the allegation. R1 indicated that they refuse staff assistance because they are strong and prefer to push themselves. Administrator and staff revealed that residents are always assisted with their ambulation needs. R1 sometimes refuses to be wheel and prefers to self propel around the facility to maintain their independence. During investigation, LPA did not observe residents crying for staff assistance. Prior to this visit LPA Alvizar-Ettima reviewed facility records including Care Staff Assignments. The information revealed from records supported the information provided by the facility personnel. According to record review R1 uses a wheelchair and needs minimum staff assistance. Based on interviews, observation and record review, there is no pertinent information to support the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. 2.) Staff do not provide residents with a sufficient amount of living accommodations It is alleged that there aren’t enough chairs available for all of the residents in care, resulting in residents constantly fighting over chairs. During prior inspections visits Licensing Program Analyst (LPA’s) Saucedo and Alvizar-Ettima conducted physical plan tour and observed sufficient number of chairs and did not witnessed residents fighting over chairs. Residents interviewed during this investigation revealed that the facility always has sufficient amount of chairs for everyone. Administrator and staff indicated that there are sufficient chairs in the facility. During today’s visit LPA Alvizar-Ettima observed sufficient number of chairs and did not witnessed residents fighting over chairs. Based on interviews and observation, there is no pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 3.) Staff do not serve residents with food of good quality It is alleged that staff watered down the orange and apple juices. R3 is used to drinking freshly squeezed orange juice. During the time of this investigation R3 no longer resides at the facility therefore, LPA Alvizar-Ettima was not able to interview them. Interview with ten (10) out of one hundred and four (104) residents revealed that the orange & apple juices are not watered down and had no concerns about the food quality. Staff indicated that the juice is not watered down for residents. Resident’s that are on a special diet are provided a sugar free juice. During inspection LPA Alvizar-Ettima did not observed watered down juice. Based on interviews and observation, there is no pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit interview is conducted and copy of report was provided to Administrator.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 31-AS-20230926094138

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst, (LPA) Raymond Comer, arrived to continue the required 1 Year Annual Inspection initiated on 09/12/2024. LPA met with Administrator, Adam Syncheff, and the purpose of visit was disclosed. The following remaining domains were observed, reviewed and inspected: Fire Detection/Protection system (continued) Fire extinguishers were observed throughout the facility on all floors, all extinguishers were last serviced on July 16, 2024. Evacuation chair was observed at the stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted. Laundry: At 12:35pm, LPA observed the laundry room located on sub-floor, adjacent to the kitchen. Laundry area is inaccessible to residents, and is clear from obstruction. Detergents, cleaning supplies, and other toxins are securely stored and inaccessible to residents. Commons: Activity rooms, dining room, and library observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Eight (8) resident rooms (#105,#113,#121,#208,#201,#211,#231,#226) were inspected and observed to maintain required furnishings, sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction. Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 107.5°F. Within the required range. [Continued on LIC 809-C] Outdoor: Courtyard area observed to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. Staff records: A total of eight (8) Staff files were reviewed. Criminal record clearances were present and Staff are associated to this facility. Staff records appear to be complete and current. There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility representative, Administrator Adam Syncheff.the state’s words, verbatim · CDSS document, Sep 13, 2024

Type of visit: Required - 1 Year

On 09/12/24, 9:45 AM, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced Annual inspection of the Facility. LPA met with Facility Administrator, Adam Syncheff, and reason for the visit was disclosed. Facility is licensed as a two-story building. Fire clearance approved for (122) non-ambulatory, and an additional eight (08) bedridden; Hospice waiver for thirty (30). There are currently three (3) residents receiving hospice care services, and one (1) bedridden. At 10:30 AM, LPA conducted a tour of the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Facility provides dementia care; LPA observed delayed egress system working properly throughout all access points of the facility. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 76.0°F. within the required range. The facility maintains approved Mitigation and Infection Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted in June 2024. Fire Detection/Protection system is present in the facility. Multiple dual smoke/carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire alarm system was tested at the time of LPA visit and is working properly. Fire drill last conducted June 2024. [LIC 809C -Continued] Kitchen: At 11:25AM, LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons, were observed near any food areas. Medications: Medication room is located on first floor by the Administrator’s office; LPA observed room as locked and inaccessible to residents. Inside the room, medications are properly labeled, and stored in secured cabinets. Resident medication documentation and distribution records appear to be complete. First aid kits were observed on carts stored in the medication room. Commons: At Activity room, dining room, and library observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. Resident records: A total of eight (8) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, centrally stored medication logs, and resident identification. Resident records appeared to be complete and current. Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report given to Administrator, Adam Syncheff.the state’s words, verbatim · CDSS document, Sep 12, 2024

Allegation investigated: Staff is unlawfully evicting a resident while in care

Licensing Program Analyst LPA Antonia Alvizar-Ettima conducted a subsequent complaint visit to deliver final findings of the investigation of the above allegation. LPA met with Executive Director and explained the reason for the visit. It was reported that the resident #1 (R1) received 30-day eviction notice due to default of payment. R1’s responsible party was unable to pay rent due to pandemic. The checks provided to the facility were bounced and the owner was refusing to take partial payment. Initial investigation was conducted on 10/27/2023 by LPA Antonia Alvizar and LPM Naira Margaryan. During initial visit at 7:30am, LPM spoke with the Executive Director (ED) Rena Hirsch. At 10:30 a.m. LPA Alvizar-Ettima requested copies of the facility documents including, but not limited to staff and resident roster, resident #1 (R1’s) physician report, needs and service plan, admission agreement and other pertinent documents relevant to the investigation. Unsubstantiated Between 10:45 a.m. and 1:00 p.m. LPA and Executive Director toured the physical plant. On or around 2:48 p.m. LPA spoke with facility owner, Adam Zenou via phone and asked questions relevant to the nature of the complaint. Prior to this visit LPA Alvizar-Ettima reviewed records previously received from ED. ED and the owner indicated that they had no intention to evict R1. Per ED R1 is residing in the facility on 05/22/2019. Since admission R1’s responsible party was either paying partial payment or was not paying at all. ED was trying to communicate with R1’s responsible party and they were not responding. On 11/10/2022 R1 and their responsible party were notified in writing that either R1’s responsible party would pay a 50% of default payments or they will proceed with eviction procedures. On 12/10/2022 R1’s responsible party paid back due payments until November 2022 and requested a new 30-day eviction notice and a copy of the bill to apply for rental assistance for R1. On 12/14/2022 ED e-mailed a new copy of eviction notice to R1’s responsible party, so that they could apply for rental assistance. A review of facility records conducted on 05/17/2024 at 4:00pm, verified the information provided by ED. At the time of this visit LPA was informed that R1 moved out of the facility on 11/10/2023. Based on the interviews, and record review, there is no sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety hazard is noted during this visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 31-AS-20231018121826

Allegation investigated: Staff do not accurately manage resident’s medications.

At 10:00AM, on Tuesday, 7/30/24, Licensing Program Analyst, (LPA) Raymond Comer, arrived to the facility to conduct an unannounced complaint visit and investigate the above allegation. LPA met with administrator, Adam Syncheff, and disclosed the reason for the visit. Allegation: Staff do not accurately manage resident’s medications- Is is alleged that Staff do not track, nor record Residents' expired medications. To investigate the allegation, on 07/30/2024, LPA, Raymond Comer, conducted an observation of the medication room and mobile medication carts from 10:35 AM to 11:25AM, completed interviews with two (2) Med-Tech Staff employees from 11:30 AM to to 12:30 PM, and requested documents at 12:45 PM. LPA observed the medication room as locked and inaccessible to Residents. [LIC 9099C- Continued] Unsubstantiated Upon entry, LPA observed the medication room as clean and organized as purposed. A camera is installed to video record Staff activities. All Resident medications were observed as secured in locked cabinets; no medications were observed as loose and/or outside secured containment. LPA, with the assistance of the Staff Wellness Director (S1) and Staff Wellness Coordinator (S2) conducted an audit of the medications for sixteen (16) Residents. A comparison of each Resident's medication control log with their corresponding medications resulted in LPA finding no discrepancies. LPA gathered Medication Destruction Records, reviewed the facility's Medication Destruction Records Log finding no discrepancies. All expired medications, used syringes, and all other pharmaceutical waste is placed in a closed container and scheduled for bio-hazard disposal by vendor. (Market Rx) LPA interviewed S1 and S2 who stated all expired medications are tracked, recorded and scheduled for picked up by bio-waste management vendor for destruction. Staff confirms all medications are logged, dispensed to Residents, and expired medications destroyed as per facility policy and Tittle 22 regulations. Based on LPA observation, file review, and interviews, the allegation is UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 31-AS-20240723125344

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 did not prevent resident from having bed bugs Staff are not providing resident with housekeeping services Staff are not transporting resident to appointments Staff are not meeting resident's dietary needs Staff did not safeguard resident's personal belongings

This is an Amendment to the original report issued 07/16/2024. Additional information was added to clarify the investigation. At 10:00 AM, Licensing Program Analysts (LPAs) Huma Rahimi, Ray Comer conducted an unannounced subsequent complaint visit. LPAs met with the Executive Director and explained the reason for the visit. An initial visit was conducted on 02/20/2024. At 10:35 AM, LPA requested resident and staff roster. At 10:40am, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Appraisal Needs and Services Plan, Laundry, and Housekeeping Log, etc., relevant to the investigation. At approximately, 10:45am LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:45am – 2:00pm, LPA conducted an interview with the Executive Director, one (1) MedTech, two (2) staff, one (1) housekeeper, and nine (9) out of ten (10) residents who, were able to communicate. During today’s visit, additional interviews were conducted with Maintenance Supervisor, the Housekeeping Laundry Attendant, and the Kitchen Chef. Continue on LIC 9099 Substantiated Staff did not prevent resident from having bed bugs: To investigate this allegation, LPA conducted an interview with the Executive Director who provided documentation of bed bug inspection and pesticide eradication treatment with pest control vendor Orkin Services. On 02/10/24 Pest control vendor, Orkin Services discovered the three (3) resident rooms having bed bugs and were immediately treated. Additionally, the facility ordered an inspection on R1’s and R2’s room for bed bugs with Bugfree Central Company on 06/05/2023; however, R2 refused the entry to their room for inspection to happen. LPA was also informed that the facility has a signed contract with Orkin to provide services monthly to prevent future bed bugs incident from happening. Based on LPA's interview and record review the allegation is SUBSTANTIATED. Staff are not providing resident with housekeeping services: During the initial visit on 02/20/2024, LPA conducted interviews with staff and residents. Staff revealed they always provide housekeeping services on daily basis from 8:00 AM to 4:00 PM, Monday to Sunday. Staff also confirmed that the facility also provides deep cleaning services at least once a week to all residents in care. Interviews with residents revealed that the facility does not provide daily or deep cleaning services to residents. Moreover, some residents clean their own rooms. Additionally, LPA observed residents’ rooms dirty and unsanitary. Based on LPA's interview and observation the allegation is SUBSTANTIATED. Staff are not transporting resident to appointments: It is alleged that the facility not providing transportation to appointments. LPA's record review revealed that the facility does provide transportation within ten (10) mile radius. Requests for the transportation has to be made 24 hours in advance through the front desk of the facility. Facility staff revealed that there is only one vehicle and one driver available for all residents at the facility. Interview with residents revealed that due to the lack of transportation they missed doctor’s appointments on multiple occasions. LPA was informed that residents were hospitalized since they did not go to their regular doctor’s appointments. Based on the information gathered during this and prior visit, the allegation is SUBSTANTIATED. Continue on LIC 9099C Staff are not meeting resident's dietary needs It is alleged that R1 is on a special diet (Soft Mechanical) that the facility does not provide. LPA conducted interviews with Executive Director and Staff #3 (S3) and it was revealed that the facility does provide required dietary needs to R1; however, R2 refuses the meals provided to R1 as indicated by the primary physician on their physician’s report. Interviews with eight (8) out of ten (10) residents confirmed that the dietary services are followed if necessary and did not express any concerns regarding this allegation. On 07/16/2024, an additional interview with the Executive Chef was conducted and LPAs were informed that the facility provides required dietary service to residents to meet their specific needs. Kitchen staff are informed daily for any changes to a resident’s dietary requirements from the facility nurse. Furthermore, they offer alternatives upon request from a resident. Although, the facility does follow dietary needs of the residents, the facility staff did not take an appropriate action when R2 denied and controlled R1’s food. LPA conducted a review of R1’s file and found no documented evidence that R2 had any legal authority for the purpose of decision making on behalf of R1. Based on interviews and record review, this allegation is SUBSTANTIATED. Staff did not safeguard resident's personal belongings It is alleged that R1’s wheelchair was either missing or stolen at the facility. To investigate this allegation LPA conducted interviews with Executive Director and staff. It was revealed that R2 left their wheelchair out of their room. The facility staff removed the wheelchair for being a potential hazard and placed it in the storage room to safeguard without notifying R1 and R2. Upon R2’s request, the facility returned the wheelchair back to R1. Additionally, during the initial visit on 02/20/2024, LPA observed the wheelchair in R1’s and R2’s room and R2 informed LPA that their wheelchair was returned as soon as they requested. Although facility returned R1’s wheelchair, interviews with eight (8) out of ten (10) residents revealed that that staff did not safeguard other personal items/belongings and were reported missing. Based on interviews and information gathered, this allegation is SUBSTANTIATED. Deficiency cited on LIC9099-D. Exit Interview conducted, appeal rights explained and copy of this report signed and delivered. Staff are not providing resident with a comfortable environment: It is alleged that the facility does not provide adequate cooling in the summer and heating in the winter which is uncomfortable. During the initial visit on 02/20/2024, and today’s subsequent visit, LPAs toured R1’s and R2’s room and random rooms in the facility and found the overall room temperature comfortable enough and compliant to regulation to at least 68 degrees Fahrenheit. Based on LPAs observation during initial visit and today’s visit this allegation is unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jul 16, 2024 · control 31-AS-20240215114434

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 17, 2024

Maintenance and Operation: a) The facility shall be clean, safe, sanitary and in good repair.... Maintenance shall include provision of maintenance ....... and visitors. This requirement is not met as evidenced by: Based LPA observation licensee did not comply with the section sited above by having bed bugs in random rooms, and as well resident's rooms were not being cleaned on regular basis which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: The licensee addressed the issue with bed bugs by hiring pest control compnay. Moreover, a new maintainence supervisor was hired in place to ensure housekeeping services are being met. POC cleaed during today's visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jul 17, 2024

Incidental Medical and Dental Care: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation....shall do so directly or make arrangements for this service. This requirement is not met as evidenced by: Based on LPA interviews with residents licensee did not comply with the section sited above by not providing transportation to residents in timely manner which caused hospitalization of a resident which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: The Licensee addressed the issue by providing third party transportation to residents in care. Additionally, Executive Director is helping with transportation as neccessary. POC cleared during today's visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Nov 14, 2024

Safeguards for Resident Cash, Personal Property, and Valuables: (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables... This requirement is not met as evidenced by: Based on interviews, licensee did not comply with the section sited above. Eight (8) out of ten (10) residents confirmed their personal items/belongins gone missing, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: The Licensee/Administrator will conduct an in-service training with all staff regarding this Section. Proof of training will be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87461.8(a)(3) · Plan of correction due date: Nov 14, 2024

Personal Rights: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) be free from punishment... ...interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on LPAs interviews and observation, licensee did not comply with the section cited above by allowing R2 to make a decision on R1's behalf (regarding food) without being a conservator. This poses/posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Licensee/Administrator agreed to conduct in-service training to all staff regarding this Section and proof of training will be submitted to LPA by POC date.

Allegation investigated: Licensee/Administrator made misleading representation of the facility

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced complaint visit to the facility to investigate the above allegations at 10:45 am. LPA met with the administrator Adam Syncheff and disclosed the purpose of the visit. LPA Smith conducted interview with staff two (2), reviewed facility files, and request documents relevant to the investigation between 11:00- 1:20 pm. Licensee/Administrator made misleading representation of the facility It was alleged that the licensee/administrator made misleading representation of the facility. and the facility Garden of Palms LA is operating as Savant. Details of the complaint reveal staff are representing themselves as employees of Savant, wearing T-shirts advertising Savant Senior Living. Licensing Program Manager (LPM) Naira Margaryan called the facility and the reception staff responded to the call stating, "Savant West Hollywood - How can I help you"? during complaint intake to collect additional information. During a previous visit to the facility Substantiated (cont from 9099) conducted by LPA Tihesha Smith on 06/16/2024 unrelated to current complaint LPA observed the signage on the building was rename from Gardens of Palm LA to Savant West Hollywood Senior Living. During today’s visit LPA observed staff in Savant shirts and folders bearing the Savant name. Interview with the administrator revealed that the name change was handled at the corporate level. The vice president of the facility was contacted by the administrator via telephone. interview with the vice president of operations for the facility revealed the name change paperwork is drafted but waiting for signatures from the Chief Executive Officer of the company and has not been sent to the Licensing Department for initial review and approval. Based on interviews, there is sufficient evidence to support the allegation Licensee/Administrator made misleading representation of the facility. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency cited on 9099D Exit interview conducted/Copy of report given.the state’s words, verbatim · CDSS document, Jun 28, 2024 · control 31-AS-20240621110324

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Jul 3, 2024

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility of any of the services provided by the facility. This requirement was not met: Based on observation and interviews the Licensee changed name and singage to building without following appropriate protocol with the CCLD. This poses a potential risks to residents in care.the state’s words, verbatim · CDSS document, Jun 28, 2024

Plan of correction: The Licensee will contact LPA to discuss plan of correction. POC due date:07/03/24

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 safeguard resident's personal belongings

Licensing program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility to deliver findings. The administrator was not present at the facility. LPA met with staff and disclosed the purpose of the visit. Facility did not safeguard resident's personal belongings It was alleged that facility did not safeguard resident's personal belongings. Resident # 1 (R1) states that their passport and computer were missing when they returned to the facility 01/04/24. During initial visit on 01/09/24, LPA Smith conducted a short tour of the facility, interviewed staff, Resident #1 (R1), and review facility records reviewed from approximately 12:05 pm to 1:00 pm. R1 is no longer a resident at the facility. During today's visit, LPA Smith interviewed staff, residents and requested records. During interview with R1 on 01/09/24, R1 revealed was homeless prior to admission to facility. When LPA asked R1 about their belongings, R1 was unable to give the color of their (Cont to 9099C) Unsubstantiated (Cont. from 9099) passport book or give the make, model, and color of the computer that was allegedly missing. LPA ended the interview with R1 when R1 began to have a behavior episode. Interviews with five (5) of five (5) available staff reveal the facility and or staff does not safeguard residents’ personal belongings as each resident’s belongings are stored in their own rooms. Interviews with (6) of eleven (11) residents revealed personal belongings are stored in their rooms not by facility and they have not had any of their belongings missing at the facility. Two (2) of eleven (11) residents revealed had some items misplaced but items were later found in their room. Based on interviews, there is insufficient evidence to support the allegation Facility did not safeguard resident’s personal belongings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted/Copy of report given.the state’s words, verbatim · CDSS document, Jun 16, 2024 · control 31-AS-20240104170516

Allegation investigated: Staff do not ensure that resident has a working call button

Licensing Program Analyst (LPAs), Abeye Duguma, conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Regional Director, Nirjara Acharya, and explained the reason for the visit. --- Staff do not ensure that resident has a working call button It was alleged that facility does not have a consistently functioning call button. To investigate the allegation, on 02/27/2024, LPA conducted a physical plant tour at around 9:30 AM, interviewed three (03) staff from 10:30 AM to 12:00 PM and interviewed eleven (11) residents from 12:00 PM – 3:00 PM. During the physical plant tour, LPA observed maintenance worker fixing and testing the call button system. During interviews with staff, all staff stated the facility was experiencing issues with the call button system for a few days but that the issue was resolved, and they are currently testing the system. (CONT. on LIC9099-C) Substantiated During interviews with residents, seven (07) out of eleven (11) residents stated they have experienced problems with the call button and believed that it was not working. The remaining four (04) out of eleven (11) residents stated they are unaware as they do not use the call button for assistance. 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 health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued. During interviews with residents, all residents stated that it takes staff between five (05) to ten (10) minutes. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff are unable to communicate with residents due to a language barrier It was alleged that there are many incidents of communication issues because staff do not understand what the residents are asking for. To investigate the allegation, on 02/27/2024, LPA interviewed three (03) staff from 10:30 AM to 12:00 PM and interviewed eleven (11) residents from 12:00 PM – 3:00 PM. During interviews with staff, all staff stated they can effectively communicate with residents to meet their needs. During with residents, all residents stated they do not have issues with communication and staff are able to meet their needs. Based on interviews, there is enough not information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not assist resident with incontinence needs It was alleged that Resident #1 (R1) is not checked on every two hours and not being changed. To investigate the allegation, on 02/27/2024, LPA interviewed three (03) staff from 10:30 AM to 12:00 PM and interviewed eleven (11) residents from 12:00 PM – 3:00 PM. During interviews with staff, all staff stated they check all incontinent residents every two (02) hours or more frequently if needed. During interviews with residents, eight (08) out of eleven (11) residents stated they are checked on every two (02) hours. The remaining three (03) residents stated they do not require incontinent care. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (CONT. on LIC 9099-C) --- Staff do not ensure that the facility remains free of odors It was alleged that visitors can smell that R1 has not been changed. To investigate the allegation, on 02/27/2024, LPA conducted a physical plant tour at around 9:30 AM, interviewed three (03) staff from 10:30 AM to 12:00 PM and interviewed eleven (11) residents from 12:00 PM – 3:00 PM. During the physical plant tour, LPA did not experience any mal odor. During interviews with staff, all staff stated the only time that mal odor exists is when residents are in the process of relieving themselves or when they are changed. Staff added that after changing, the rooms are aired out. During interviews with residents, all residents stated they do not experience mal odor in the facility. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not follow resident's care plan It was alleged that R1 is supposed to have their legs elevated but staff are not doing it. To investigate the allegation, on 02/27/2024, LPA interviewed three (03) staff from 10:30 AM to 12:00 PM and interviewed eleven (11) residents from 12:00 PM – 3:00 PM. During interviews with staff, all staff stated that Resident #1’s (R1) legs are being elevated, but that R1 moves their legs after a short time. During interviews with R1, they stated that staff are following the request of having their feet elevated but after a while, they put their feet down and reposition however they please. All other residents stated that the facility is following their care plan. 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. Copy of this report issued.the state’s words, verbatim · CDSS document, May 9, 2024 · control 31-AS-20240222123534

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 9, 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, the residents' call buttons were not in working order which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Facility was not issued a POC as the call button system was repaired, tested and observed to be in working order.

Allegation investigated: Due to insufficient staffing the food served to the residents gets cold.

Licensing Program Analysts (LPAs) Gary Tan and Liezel Dela Cerra conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPAs met with Executive Director Adam Syncheff and explained the reason for the visit. LPA conducted physical plant tour at 10:00 AM, requested copies of facility documents at 10:24 AM and interviewed staff and resident between 11:00 AM to 1:00 PM. Regarding the allegation that due there is insufficient staffing the food served to the residents get cold. LPAs' record review at 12:32 PM revealed that there are three (3) servers scheduled at every meal. LPAs' interview with the Executive Director at 11:00 AM confirmed that there are always two (2) servers during meals and the dishwasher also acts as a server during meals. Further, about thirty (35) residents out of the current census are on Memory Care unit and had their caregivers and activity staff act as servers with average of four (4) servers every meal on their own. Moreover, about fifteen (15) residents from Assisted Living are being served trays every meal, leaving about fifty (50) to fifty (55) five residents are being served every meal on the dining area. Unsubstantiated (continued from LIC 9099) LPAs observed that there are three (3) servers serving food during today's lunch at 12:15 PM. LPAs' interview with eleven (11) residents today between 11:00 AM to 1:00 PM revealed that nine (9) out of eleven (11) residents stated that the food was served to them on time or within five (5) minutes upon seating. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Feb 27, 2024 · control 31-AS-20240223154316

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 do not prevent resident from entering other resident's room Staff do not prevent inappropriate interactions between residents

This amendment is correct the finding from Needs Further to Unsubstantiated. Licensing Program Analysts (LPAs) Abeye Duguma, conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with Executive Director, Adam Syncheff, and explained the reason for the visit. ---Staff do not prevent resident from entering other resident's room It was alleged that Resident #2 (R2) goes into Resident #1's (R1) room and says inappropriate things. To investigate the allegation, LPA interviewed three (03) staff and eleven (11) residents. During interviews with staff, two (02) out of three (03) staff stated that they are not aware of any complaints from the R1, have never heard R2 saying inappropriate things to R1 and that the relationship between the two is cordial and consensual. One (01) out of three (03) staff stated they are not aware of R2 going into R1 room and saying inappropriate things. (CONT. on LIC 9099-C) Unsubstantiated During interviews with residents, all residents stated that residents do not go into their rooms and say inappropriate things. R1 added that R2 does not go into their room and say inappropriate things. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff do not prevent inappropriate interactions between residents It was alleged that Resident (R1) is being sexually harassed by Resident #2 (R2). To investigate the allegation, LPA interviewed three (03) staff and eleven (11) residents. During interviews with staff, two (02) out of three (03) staff stated they are aware of their friendship and that any interactions between the two are consensual. One (01) out of three (03) staff stated that they are not aware of their relationship. During interviews with residents, all residents stated they have never been sexually harassed by residents. R1 added that all interactions with R2 are consensual and welcomed. 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. Copy of this report issued.the state’s words, verbatim · CDSS document, Feb 27, 2024 · control 31-AS-20240222123534

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 do not prevent resident from spitting on surfaces in common areas.

This report supersedes the previous report issued on 02/20/2024 to change the findings. An appeal was granted and the citation 87303(a)(1) is dismissed. On 02/20/24, at 09:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by the Executive Director-Adam Syncheff. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, interviews and deliver findings for this complaint. The investigation consists of the following: On 02/20/24 at 09:25am, LPA Saucedo asked for the census, resident, and staff roster. At 09:46am, LPA Saucedo conducted the physical tour. During the tour, ten (10) residents and six (6) staff were interviewed. LIC 9099C-continued Unsubstantiated This report supersedes the previous report issued on 02/20/2024 to change the findings. An appeal was granted and the citation 87303(a)(1) is dismissed. Regarding the allegation: Staff do not prevent resident from spitting on surfaces in common areas. It is being alleged that Resident #1 (R1) is spitting on the floors in the hallway, lobby and the dining room table, and facility staff are not doing anything to stop R1 from such behavior. During the tour, ten (10) residents and six (6) staff were interviewed. Nine (9) out of ten (10) residents confirmed that R1 does spit around the dining room table where they have breakfast, lunch and dinner. Moreover, R1 spits on napkins and tosses the napkins in the bowls where the residents are eating from. In addition, R1 spits inside the bowls if there is no napkins available. Furthermore, the residents also have seen R1 spit on the floor inside the lobby and outside lobby area. Interviews with six (6) out of six (6) staff members, also confirmed that R1 spit in the dining room area while eating. However, one (1) out of six (6) staff members informed LPA that when the facility staff members attempts to redirect and or communicate with R1, R1 behavior immediately changes and R1 starts screaming and speaking in their native language. The medical technician staff and the Memory Care Director confirmed that when they see R1 spitting they try to redirect R1 or give R1 a cup to spit in. Although the interview with the Executive Director revealed that R1 had been constantly reminded that they have an unacceptable behavior and it has to stop, R1 ignored and continued with this behavior due to language barrier. R1's facility file record review revealed that R1 is ambulatory and has no mental issues. Therefore, based on the LPA's interviews and record review the above allegation(s) above is Substantiated at this time. An exit interview was conducted, one citation was issued for the above allegation(s) on the LIC 9099-D, and a copy of this report was given to the executive director with the appeal rights. Be advised, the above is the original report and it was amended on 12/01/25, to dismiss original findings. The executive director has been advised of appeal being granted and changes of report.the state’s words, verbatim · CDSS document, Feb 20, 2024 · control 31-AS-20240212161217

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Mar 7, 2024

87303 (a)(1)The facility shall be clean, safe, sanitary and in good repair at all times...(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on the LPA's interviews the licensee/administrator did not ensure one out of one resident at the facility to be clean and sanitary at all times which poses an potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 20, 2024

Plan of correction: The licensee/admnistrator agreed to schedule an appointment with R1's doctor and show documentation of what is going to be done to resolve this problem. POC due date: 03/07/24.

Allegation investigated: Unlawful eviction

On 02/08/2024 at 10:40 am Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit to investigate the above stated allegation. LPA met with Executive Director, Adam Syncheff, and explained the reason for the visit. As part of this investigation, at 11:55 am, LPA conducted a physical plant tour. LPA interviewed with the Executive Director, and three (3) other facility staff members. Additionally, from 12:00 pm to 1:00 PM, LPA interviewed eleven (11) residents in care. At 1:10 pm, LPA also obtained and reviewed copies of pertinent documents relevant to the investigation. Regarding the allegation: Unlawful eviction. It’s being alleged a facility staff asked R1 to leave the facility and not return. Per interviews and record review, the investigation revealed that the eviction is for a 30-day notice issued on 01/25/2024 for failure to pay. Continue on LIC 9099C Unsubstantiated The eviction notice was submitted to R1 and they were advised to vacate within 30 days after being served with the notice. A review of the eviction letter indicates that R1 is late in rent from 12/01/2023 through 01/31/2024 in the amount of $2,767.05, and an additional charge of Room and Board in the amount of $1398.07. LPA observed R1 is still living at the facility, currently, and has not been evicted yet. During an interview with R1 they denied the allegation and stated in summary they were the one who checked themselves into a hotel. Based on LPA's interviews conducted, record review and observation, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given.the state’s words, verbatim · CDSS document, Feb 8, 2024 · control 31-AS-20240130111847

Allegation investigated: Staff are not addressing residents' health conditions while in care.

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegation. LPA met with Wellness Director Jessica Perez and explained the reason for the visit. LPA conducted physical plant tour at 9:50 AM, requested copies of facility documents relevant to the investigation at 10:18 AM and interviewed staff and residents between 10:30 AM to 1:00 PM. It was alleged that Resident #1 (R1) is being treated poorly by the caregiver and R1's health conditions are worsened daily. LPA's record review today at 1:00 PM revealed that R1 was admitted at the facility on 04/20/23 and immediately admitted to Hospice services on the same day of admission at the facility. Further review also revealed that R1 was on Assisted Living Waiver (ALW) and currently on Home Health services. Moreover, the facility had an internal log for all the Hospital visits, Skilled Nursing Facility discharges, Hospice and Home Health agencies visits and caregiver logs for all any unusual incident about R1 including but not limited to R1's refusal to shower, hospitalization and the likes. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) LPA's interview with three (3) staff today between 10:30 AM to 1:00 PM revealed that R1 is living with Resident #2 (R2) in the same room, and they always call if they need anything. They are on tray service but always buy their own food delivered to their room. All three (3) staff interviewed denied mistreating and/or treating R1 and R2 poorly. LPA's interview with a total of nine (9) residents on 09/26/23 and three (3) additional residents today between 10:30 AM to 1:00 PM revealed that twelve (12) out of twelve (12) residents interviewed stated that the staff are respectful and provided all the care they need. Based on the information gathered during today and prior visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jan 16, 2024 · control 31-AS-20230914123412

Allegation investigated: Staff unlawfully evicted a resident

Licensing Program Analysts (LPAs) Abeye Duguma and Christopher Alemoh conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with Executive Director, Adam Syncheff, and explained the reason for the visit. --- Staff unlawfully evicted a resident. It was alleged that facility refused to take Resident #1 (R1) back. To investigate the allegation, on 12/28/2023 LPA requested records at 10:00 AM and interviewed three (03) staff from 10:30 AM – 12:00 PM. The facility’s Functional Capability Assessment records stated that R1’s needs would not be safely met, R1 has a history of violence, and that resident requires close supervision for medication management and mental health observations. (CONT on LIC 9099-C) Unsubstantiated During interviews with staff, all staff stated R1 is currently in a mental health facility after physically assaulting staff and that, based on R1’s preliminary assessment, R1 will not be readmitted to the facility at this time as they pose an immediate danger to self and others. Based on interviews and record review, 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, Dec 28, 2023 · control 31-AS-20231219140004

Allegation investigated: Staff did not properly address multiple residents falls at facility.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with Executive Director, Rina Hirsch, and explained the reason for the visit. --- Staff did not properly address multiple residents falls at facility. It was alleged that the facility is not doing anything to prevent residents from falling. To investigate the allegation, on 11/29/2023, LPA reviewed Incident Report records at 10:30 AM and interviewed three (03) staff from 11:30 AM – 1:00 PM. A review of recent Incident Reports shows that facility reported three (03) fall incidents in November 2023, eleven (11) in October 2023, five (05) in September 2023 and six (06) in August 2023. (CONT. on LIC 9099-C) Unsubstantiated During this period, (03) three residents experienced more than one fall incident and according to facility staff, clients were hospice residents, and all available measures and precautions were exercised. During interviews with staff, all staff stated that the local fire department’s complaint of frequent falls and increased 911 calls is directly correlated to the increase in the facility’s census from forty-eight (48) residents to ninety-six (96) residents. All staff added that facility takes all necessary steps to mitigate falls such as adjusting their beds, removing any obstacles, reviewing medications, providing extra care and support, alerting all staff, encouraging residents to request for assistance to move about, requesting mats from Home Health, checking for loose clothing, increasing the frequency of how often they are checked on, continuous reminders to use their walkers, notify and follow-up with physicians and nurse practitioners. Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 29, 2023 · control 31-AS-20231121153310

Allegation investigated: Staff refused to accept resident back from hospital

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Executive Director Rena Hirsch and explained the reason for the visit. LPA conducted physical plant tour at 9:45 AM, requested copies of facility documents relevant to the investigation at 10:00 AM and interviewed staff between 10:00 AM to 11:20 AM. It was alleged that the facility was refusing to accept Resident #1 (R1) back from the hospital upon being discharged. LPA's record review today at 11:20 AM revealed that R1 will be released today from the hospital and LPA's interview with the administrator today at 11:45 AM also revealed that she will accept R1 upon release. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 3, 2023 · control 31-AS-20230929161909