Silverado Rolling Hills

Allegation investigated: Staff handled resident in a rough manner, resulting in bruising Staff did not properly report incident Staff do not have the required training

On 07/08/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced Complaint Visit to the facility listed above. LPA met with Christina Hale, Executive Director, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During the initial visit conducted on 04/29/2026, LPA inspected the facility, interviewed Staff S1-S9, and received documents pertinent to the investigation. LPA received and reviewed the following documents, Staff Roster, Resident Roster, Admission Agreement (dated 10/14/2025) , Progress Notes (dated 11/04/2025 to 02/20/2026), Resident Incident Logs, electronic Medication Administration Record (eMAR), Routine Wellness Observation Results (dated 01/29/2026), Nursing Admission Evaluation Results (dated 10/16/2025 and 02/12/2026), Health and Service Evaluation Results (dated 10/21/2025), Physician’s Report (dated 10/08/2025), Unusual Incident/Injury Report (dated 02/25/2026 & 02/12/2026), and eight (8) staff Relias Transcripts. During today’s visit, LPA interviewed Residents R2-R8 and Residents Responsible Party W2-W4. Unsubstantiated The investigation revealed the following: Allegation: Staff handled resident in a rough manner, resulting in bruising The allegation alleges that a resident had unexplained bruising, and the family thinks the resident was handled in a rough manner. During the facility visit, LPA observed residents being assisted with transferring and ambulating. LPA observed staff’s hands were properly placed while assisting to ensure safe ambulation and a safe transfer. During record review, LPA received and reviewed eight (8) staff’s Relias Transcripts and observed eight (8) out of eight (8) staff have received training in Performing Safe Transfers. In reviewing the Service Plan, LPA observed R1 “requires frequent “hands on assistance with transfers and/or change in position. During interviews with Staff S1-S9, were asked if they have or have observed staff handle a resident in a rough manner, nine (9) out of nine (9) stated no, they have not observed staff handling a resident in a rough manner. Additionally, Staff S1-S9, were asked what they would do if they observed staff handling a resident, nine (9) out of nine (9) stated they would step in to take over assistance and would report it. During interviews with Residents R2-R8, were asked if they have been handled by staff in a rough manner, seven (7) out of seven (7) stated no, staff have not handled them in a rough manner. During interviews with resident’s Responsible Party W2-W4, were asked if they have any concerns regarding their resident being handled in a rough manner, three (3) out of three (3) stated no, they have no concerns regarding their resident being handled in a rough manner. Allegation: Staff did not properly report an incident The allegation alleges that when the family was notified of a resident’s fall, they were not informed the resident sustained an injury. During record review, LPA received and reviewed resident R1’s Admission Agreement that on page 6, under F. Notification of Resident Representative Upon Significant Change of Condition states that states “In the event that you experience a significant change in condition or require emergency medical attention, Silverado will attempt to contact your designated resident representative by telephone within twelve (12) hours. LPA received and reviewed the Progress Notes and observed on 02/02/2026 R1 experienced a fall and it was noted that R1’s the Responsible Party was notified in person. Additionally, on 02/05/2026, R1 was placed on Alert Charting, and the Progress Notes indicate R1’s Responsible Party was Made aware of this and was on their way to the facility. LPA received and reviewed three Unusual Incident/Injury Report’s faxed to Community Care Licensing (CCL), regarding R1. The first fax was received on 02/03/2026 at 5:00pm, regarding R1 experiencing a fall resulting in an injury 02/05/2026 at 4:21pm, regarding R1 experiencing abdominal pain and being transferred to the Emergency Room. The third fax was received on 02/13/2026 at 12:55pm regarding R1 experiencing a change of condition on 02/12/2026. During interviews with Staff S1-S9, were asked if residents’ families are notified of all incidents, nine (9) out of nine (9) stated yes, families are notified of any incidents regarding their resident. Additionally, Staff S1-S9, were asked if incidents were reported to Community Care Licensing, nine (9) out of nine (9) stated yes, incidents are reported to Community Care Licensing. During interviews with Residents R2-R8, were asked if their family is notified of any incidents, seven (7) out of seven (7) stated to their knowledge their responsible parties are notified of any incidents. During interviews with resident’s Responsible Party W2-W4, were asked if they have any concerns regarding incidents being reported to them, three (3) out of three (3) stated they are informed by staff of all incidents. Allegation: Staff do not have the required training The allegation alleges that staff lack the required training to know how to respond to incidents. During the facility visit, emergency personnel (911) were called to evaluate a resident and transfer the resident to the emergency room. LPA observed staff were trained on when to call emergency personnel, how to support the resident while awaiting emergency personnel, and the documents prepared and ready to go when emergency personnel arrived. During record review, LPA received and reviewed staff Relias Transcripts for eight (8) staff. LPA observed eight (8) out of eight (8) staff have received between 25.25 hours and 51.97 hours for training since 04/01/2025. During interviews with Staff S1-S9, were asked if they received training regarding assisting resident, nine (9) out of nine (9) stated yes, they have received training regarding assisting residents. During interviews with Residents R2-R8, were asked if they feel staff are trained to assist residents, seven (7) out of seven (7) stated yes, they believe staff are properly trained. During interviews with residents’ Responsible Party W2-W4, were asked if they have any concerns regarding staff training, three (3) out of three (3) stated no, they have no concerns regarding staff training. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. LPA did not observe or cite any deficiencies. An exit interviews was conducted with Christian Hale, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 11-AS-20260422095123

Type of visit: Case Management - Annual Continuation

On 05/29/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Required 1-year Annual Visit- Continuation. LPA met with Executive Director, Christina Hale, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is a Residential Care Facility for the Elderly serving residents aged 60 and over. The facility has a Fire Clearance for 68 Bedridden residents with a total capacity of 68. The facility has an approved hospice waiver for thirty (30). Medications LPA observed Centrally Stored Medications secured in locked medication carts, secured in locked Medication Rooms, and are inaccessible to residents. LPA observed Centrally Stored Medications in their original packaging. LPA reviewed the Centrally Stored Medications and electronic Medication Administration Record (eMAR) for seven (7) residents. LPA observed seven (7) out of seven (7) resident’s Centrally Stored Medications are consistent with properly documented records. Files LPA reviewed the files for seven (7) residents. LPA observed seven (7) out of seven (7) residents files contain the required documents. LPA reviewed the files for five (5) staff and the administrator. LPA observed the administrator and staff file have the required documents, certification, clearance, and training. The administrator’s Administrator Certificate, number 7039235740, is valid till 08/21/2026. LPA observed Licensing Fees are current. Safety LPA observed smoke and carbon monoxide detectors are operable. LPA observed multiple fully charged fire extinguishers, last serviced on 04/10/2026. LPA observed the last Emergency Drill was conducted on 05/13/2026. LPA observed the last Fire Prevention Inspection was conducted by the Torrance Fire Department on 05/30/2026. The Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC-610E) was observed posted in the lobby and was last updated on 07/22/2025. LPA observed evacuation chairs at each staircase. The facility has a working landline telephone. LPA observed all required posting, posted throughout the facility. LPA received and reviewed the facility’s liability insurance through Acord valid till 07/07/2027. Infection Control In the lobby, LPA observed Visitor Sign-In Logs and hand sanitizer. LPA observed hand sanitizer throughout the facility. LPA observed infection control signs posted throughout the facility. LPA observed a 90-day supply of Personal Protective Equipment (PPE). During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Chritina Hale, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 29, 2026

Type of visit: Required - 1 Year

On 05/28/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Required 1-year Annual Visit. LPA met with Executive Director, Christina Hale, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is a Residential Care Facility for the Elderly serving residents aged 60 and over. The facility has a Fire Clearance for 68 Bedridden residents with a total capacity of 68. The facility has an approved hospice waiver for thirty (30). Physical Plant/Structure The facility is a two-story building in a commercial area. The facility consists of the following: the entrance area has a lobby with a sitting area, meeting room, conference room, restroom, administrative offices, and reception area. The first floor has 15 resident rooms with bathrooms, an activity area, dining area, television area, sitting area, bistro area, quite room for physical therapy, linen storage room, supply room, housekeeping storage room, salon, restroom, Activity Director office, medication room, industrial kitchen, staff lounge area, and enclosed patio. The second floor has 32 resident rooms with bathrooms, an activity area, dining area, television area, sitting area, bistro area, linen storage room, supply room, housekeeping storage area, spa, restroom, Health and Wellness director office, medication room, and Wellness Office. During the facility inspection, LPA did not observe any bodies of water on the premises. The outside patio area has tables, chairs, and umbrellas available for residents’ use. The gates exiting the patio are egressed and work properly. All outside walkways were observed clean, clear, and free of obstructions, debris, and hazards. All windows, screens, and blinds were observed to be in good repair. Resident Rooms LPA inspected five (5) resident rooms, room 111, 114, 211, 214, and 220, and observed them clean and in good repair. LPA observed all resident rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. Residents have the option to furnish their room how they would like, or the facility has furniture available if residents need it. LPA observed the beds have the required linens including a mattress cover, fitted sheet, flat sheet, blanket, comforter, and pillows. Residents do have the option to use their personal linens, or the facility has a supply of linens available. LPA observed an additional supply of linens in a linen storage room. All linens and mattresses were observed in good repair. The water temperature in residents’ bathrooms measured 108.9- degrees, 110.1- degrees, 112.2- degrees, 112.9- degrees, and 113.2- degrees Fahrenheit. All residents’ rooms were observed with ample lighting. Kitchen LPA observed the industrial kitchen clean and sanitary during time of visit. LPA observed all appliances operable and in good repair. LPA observed an ample supply of cookware, dishware, and cutlery in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods were observed properly dated, labeled, packaged, and stored. The freezer temperature measured -1-degrees Fahrenheit, and the refrigerator temperature measured 3-degrees Fahrenheit. LPA observed knives and sharps secured and are inaccessible to residents. LPA observed menus posted in the dining rooms. The first and second floor Bistro areas were observed clean and sanitary. LPA observed a supply of snacks and drinks available for residents at any time. LPA observed cleaning supplies secured in locked storage rooms and are inaccessible to residents. All trash cans were observed with tight fitting covers. Common Rooms LPA observed all common rooms have ample seating to accommodate residents. LPA observed dining areas have ample tables and chairs to accommodate residents. In the activity areas, LPA observed tables and chair available to accommodate residents. LPA observed an ample supply of arts, crafts, exercise equipment, games, and activities stored in a storage room on the first and second floor. LPA observed a daily and monthly activity schedule posted in the activity areas. The facility was observed appropriately furnished during the time of visit. All walkways and hallways in the facility were observed clean, clear, and free of hazards and obstructions. The facility was kept at a comfortable temperature. All rooms and hallways were observed with ample lighting. Due to time constraints, LPA will return at a later date to complete the Annual Inspection. During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Christina Hale, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 28, 2026

Allegation investigated: Facility staff handled client in a rough manner

On 04/07/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Administrator, Chistina Hale, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA observed lunch and activities, and interviewed Residents R1-R5. During the initial visit conducted on 02/17/2026, LPA inspected the facility, interviewed Staff S1-S10, interviewed resident’s Responsible Party W2-W5, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Staff Schedule, Identification & Emergency Form, Physician’s Report, Charting Notes, Unusual Incident Report (SIR), Initial Psychiatric Evaluation, NurseDX Results Fax, Service Care Plan, staff’s Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders, and Staff Training Logs. The investigation revealed the following: Unsubstantiated Allegation: Facility staff handled client in a rough manner The allegation alleges a resident was beaten up and had their fingers twisted during a fight with four (4) perpetrators in their room. During the facility inspection, LPA observed staff assisting residents with transferring and escorting. LPA observed staff placing hands in appropriate places to minimize any injuries. During record review, LPA received and reviewed Resident R1’s Charting Notes dated 02/09/2026, that states a body check was conducted on R1 for a skin assessment and no bruising or lacerations were noted on the body. On 02/10/2026, R1’s physician and psychiatrist were notified. A review of recent behavioral expressions and of medications was conducted, and an adjustment of medications was ordered. LPA received and reviewed Staff S1, S4-S10‘s Relias Transcript that indicates Staff have received training regarding the following Alzheimer’s Disease and Related Disorders: Psychosocial Needs, Care For Residents with Varying Dementias, Recognizing a Change in Condition, Transferring Safety, Mandated Reporting-Elder and Dependent Abuse and Neglect in CA, Preventing, and Recognizing, and Reporting Abuse. During interviews with Staff S1-S10, were asked if they have handled a resident in a rough manner, ten (10) out of ten (10) stated they have not handled a resident in a rough manner. Additionally, Staff S1-S10, were asked if they have observed staff handling a resident in a rough manner, ten (10) out of ten (10) stated they have not observed staff handling residents in a rough manner. During interviews with Residents R1-R5, were asked if they have been handled in a rough manner by staff, five (5) out of five (5) stated they have not been handled in a rough manner. Additionally, Residents R1-R5 were asked if they have observed staff handle a resident in a rough manner, five (5) out of five (5) stated they have not observed staff handle a resident in a rough manner. During interviews with resident’s Responsible Party W2-W5, were asked if they have observed staff handle a resident in a rough manner, four (4) out of four (4) stated they have not observed staff handle a resident in a rough manner. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. During today’ visit LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator Christina Hale, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 11-AS-20260210093238

Allegation investigated: Staff worked while under the influence of drugs, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care Staff did not maintain facility free from hazards, resulting in a resident sustaining an injury Staff spoke inappropriately to resident Staff handled resident in a rough manner Staff did not properly report incident(s)

On 04/07/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Administrator, Christina Hale, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA inspected the facility, interviewed Staff S1-S6, interviewed Residents R1-R6, and interviewed resident Responsible Party’s W1-W3. During the initial visit conducted on 03/19/2026, LPA inspected the facility with the Director of Plant Operations (S3), interviewed Staff S1-S3, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Unusual Incident/Injury Reports (dated 02/19/2026, 02/09/2026, and 02/06/2026), resident R1’s Progress Notes (dated 01/10/2026 to 03/19/2026), Resident Incident Log (dated 01/01/2026 to 03/19/2026), Maintenance Report Log (dated 04/08/2025 to 03/18/2026), Maintenance Incident Statement (dated 03/11/2026 and 03/12/2026), Unsubstantiated staff Alcohol and Substance Abuse Policy in the employee handbook, Associate Acknowledgement of policy (dated 04/30/2025, 02/23/2013, and 03/14/2025), and Torrance Police Department Case Information (dated 03/03/2026 and 03/13/2026). The investigation revealed the following: Allegation: Staff worked while under the influence of drugs, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care. The allegation alleges that staff are working while impaired, narcotics have fallen out of a staff’s pocket, and staff were observed getting high during a break. During record review, LPA received and reviewed the Alcohol and Substance Abuse Policy on page 40 of the Employee Handbook signed and dated by staff when they are hired. It states “the purpose of this policy is to inform every associate that Silverado does not condone or tolerate alcohol or drug use in the workplace. During interviews with Staff S1-S6, were asked if they have worked while under the influence, six (6) out of six (6) stated they have not worked while under the influence. Additionally, Staff S1-S6 were asked if they have observed staff working while under the influence, six (6) out of six (6) stated no, they have not observed staff working while under the influence. During interviews with Resident R1-R6, were asked if they have observed staff working while under the influence, five (5) out of six (6) stated they have not seen staff working while under the influence. One resident did not answer. During interviews with resident responsible party W1 -W3, were asked if they have observed staff working while under the influence of a mind altering substance, three (3) out of three (3) stated no, they have not observed staff working while under the influence. Allegation: Staff did not maintain facility free from hazards, resulting in a resident sustaining an injury. The allegation alleges that multiple exit doors are nonfunctional and a resident fell after tripping on a wet floor sign and fan. During the facility inspection, LPA tested all exit doors and observed the egress system and doors function properly and open as required. LPA observed the access hatches to the roof were closed and properly secured. Additionally, LPA was informed the carpets were just cleaned and LPA observed signs for “Wet Floors,” and fans against the walls in the hallways, not blocking the walkway. LPA observed all walkways and hallways were clean, clear, and free of hazards, debris, and obstructions. LPA received and reviewed Maintenance Logs that indicates what was reported that need fixed, and when and who repaired it. During interviews with Staff S1-S6, were asked how they ensure the facility is kept free from hazards, six (6) out of six (6) stated rounds are done multiple times a day by the maintenance director, and the directors to ensure there are no hazards. Additionally, Staff S1-S6, were asked if there have been any issues with the exit doors, six (6) out of six (6) stated there have been no issues with the egressed exit doors. During interviews with Residents R1-R6, were asked how the staff ensure the facility is free from hazards, five (5) out of six (6) stated the staff make sure walkways are clear, they pick up papers on the floor, and the staff will walk with the residents to make sure they get there safe. Additionally, Residents R1-R6, were asked if there have been any issues with the exit doors or the exit doors being left open, five (5) out of six (6) no, there have been no issues with the doors. One resident did not answer. During interviews with resident responsible party W1 -W3, were asked if staff ensure the facility is free from hazards, three (3) out of three (3) stated they have not observed any hazards at the facility. Allegation: Staff spoke inappropriately to a resident The allegation alleges staff spoke inappropriately to a resident, calling them an idiot and cussing at them. During the facility visit, LPA observed staff’s interactions with residents during meals, providing assistance, and activities. LPA observed the staff speaking respectfully to residents. During record review, LPA received and reviewed staff’s signed and dated Statement Acknowledging Requirements to Report Suspected Abuse of Dependent Adults and Elders. LPA received and reviewed staff’s Relias Transcript that include training regarding Resident Rights, Mandated Reporting-Elder and Dependent Abuse and Neglect in CA, and Silverado Communicated with Resident Living with Dementia. Additionally, LPA received and reviewed staff’s General Standard of Conduct on page 14 of the employee handbook that states the following infractions may result in disciplinary action, up to and including immediate termination of employment: “insubordination or other malicious or threatening conduct;” and “intentional or negligent violation of safety or health standard.” During interviews with Staff S1-S6, were asked if they have spoken to a resident in an inappropriate manner or have heard a staff speaking to a resident in an inappropriate manner, six (6) out of six (6) stated no, they have not spoken to a resident inappropriately or heard staff speak inappropriately to a resident. During interviews with Residents R1-R6, were asked if staff have spoken to them or another resident inappropriately, five (5) out of six (6) stated no. One (1) resident did not answer. During interviews with resident’s Responsible Party W1-W3, were asked if they heard staff speaking inappropriately to any resident, three (3) out of three (3) stated no. Allegation: Staff handled resident in a rough manner The allegation alleges that while assisting a resident up from a fall the staff handled them in a rough manner. During the facility visit, LPA observed staff assisting residents with transferring from the wheelchair to their bed. LPA observed staff using appropriate hand placement while assisting with transferring a resident. During record review, LPA received and reviewed staffs signed and dated Statement Acknowledging Requirements to Report Suspected Abuse of Dependent Adults and Elders. Additionally, LPA received and reviewed staff’s General Standard of Conduct on page 14 of the employee handbook that states the following infractions may result in disciplinary action, up to and including immediate termination of employment: “insubordination or other malicious or threatening conduct;” and “intentional or negligent violation of safety or health standard.” LPA received and reviewed staff’s Relias Transcript that include training regarding Resident Rights, Mandated Reporting-Elder and Dependent Abuse and Neglect in CA, and Silverado Communicated with Resident Living with Dementia. During interviews with Staff S1-S6, were asked if they have or have observed staff handle a resident in a rough manner, six (6) out of six (6) stated no, they have not. During interviews with Residents R1-R6, were asked if staff have handled them in a rough manner, five (5) out of six (6) stated no, they have not been handled in a rough manner. During interviews with resident’s Responsible Party W1-W3, were asked if they have observed staff handle a resident in a rough manner, three (3) out of three (3) stated no they have not. Allegation: Staff did not properly report incidents The allegation alleges that incident reporting was not done regarding the residents fall. LPA received and reviewed Resident Incident Log from 01/01/2026 to 03/31/2026, that indicates R1 was observed on the floor on 02/12/2026. Additionally, LPA received and reviewed Resident R1’s Progress Notes from 01/01/2026 to 03/31/2026 that indicates on 02/12/2026 R1 was observed on the floor, was assessed by LVN, assisted to a standing position, and R1 ambulated to their room without assistance. LPA observed R1’s Responsible Party was notified and R1 was on Alert Charting and had additional monitoring till 02/15/2026. Additionally, LPA received and reviewed Unusual Incident/Injury Report’s submitted to Community Care Licensing (CCL) for the month of February. The incident reports are regarding residents who were observed on the floor and were transferred to the Emergency Room for additional assessment. During interviews with Staff S1-S6, were asked if all incidents are reported to CCL, six (6) out of six (6) stated all incidents that require first aid, a transfer to the hospital, refusal of transfer to the hospital, or incidents that interrupts daily operation is reported to licensing. During interviews with Residents R1-R6 were asked if to their knowledge are incidents reported to CCL, five (5) out of six (6) stated yes, they are. One (1) resident did not answer. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. LPA did not observe or site any deficiencies. An exit interview was conducted with Administrator, Christina Hale, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 11-AS-20260310113943

Allegation investigated: Facility staff does not ensure resident is provided adequate supervision resulting in resident having multiple falls while in care.

On 02/05/2026, Licensing Program Analyst, Wendy Gibbs, conducted a subsequent unannounced Complaint Visit to the facility listed above. LPA met with Administrator, Christina Hale, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During the initial visit conducted on 01/08/2026, LPA inspected the facility, interviewed Staff S1, S2, S4-S6, interviewed residents Responsible Party W1 and W2, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Report, Needs and Service Plan, Fall Assessment, Admission Agreement, Fall Plan, Hospice Plan, incident reports, and Charting Notes. During a subsequent visit conducted on 01/23/2026, LPA inspected the facility, interviewed Residents R2-R6, and interviewed resident’s Responsible Party W3-W5. During today’s visit, LPA interviewed Staff S3, S7 and S8, received training logs for Staff S3-S8, and in-service logs. The investigation revealed the following: Unsubstantiated Allegation: Facility staff does not ensure resident is provided adequate supervision resulting in multiple falls while in care. The allegation alleges a resident experienced three (3) falls from their bed during the month of December 2025. During the facility inspection, LPA observed staff escorting residents to meals, activities, and the restrooms. LPA observed some residents have hip protectors on. LPA observed in rooms 101, 225, and 116, the beds are on the lowest setting and there are fall mats to the side of the beds. During record review, LPA received and reviewed the Staff Schedule that indicates there are two (2) caregivers and a nurse working the NOC shift. LPA received and reviewed Staff S3-S8 training logs that indicate they have received the following training on Relias within the last year, Silverado Fall Management for Residents with Dementia, Slip, Trip, and Fall Prevention, and Minimizing Slips, Trips, and Falls. LPA received and reviewed in-service logs that indicate staff received training regarding Hip Saver, Fall/Injury Management, Prevention, and Precautions. LPA received and reviewed Incident Forms dated 12/02/2025 and 12/21/2025, that indicated Resident R1 was observed on the floor. The reports state there were “no signs of injury” and R1 was “unable to verbalize what occurred.” One report stated R1 was assisted back to bed and “magnet bed alarm was placed.” Additionally, LPA received and reviewed R1’s Nursing Admission Evaluation Results and Service Plan, dated 11/10/2025, that indicates R1 has a history of falls, but not within three (3) months of the assessment. LPA observed R1 uses ambulatory aids such as a walker or cane, and “may require hands on assistance by staff” when ambulating and transferring, and “cues for safety.” In R1’s Charting Notes, LPA observed S2 and W1 met on 12/23/2025 to discuss implementation of a second alarm in addition to the tag alarm. During interviews with Staff S1-S8, were asked if they feel there is enough staff on each shift to provide adequate supervision to prevent or minimize falls, seven (7) out of eight (8) stated yes, they feel there is enough staff to provide adequate supervision to minimize falls. During interviews with Residents R2-R6, they were asked if they feel there is enough staff to provide adequate supervision to prevent or minimize falls, five (5) out of five (5) stated yes, they believe there is enough staff to provide adequate supervision. Additionally, Residents R2-R6 were asked if the facility take precautions to minimize falls, four (4) out of five (5) stated yes, the facility takes precautions to minimize or prevent falls. One (1) resident stated they do not have any concerns regarding falls. During interviews with Resident’s Responsible Parties W1-W6, they were asked if staff provide adequate supervision to prevent or minimize falls, five (5) out of six (6) stated yes, they believe there is enough staff to provide adequate supervision to prevent or minimize falls. Additionally, six (6) out of six (6) stated the facility takes precautions to minimize or prevent falls. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. LPA did not observe or cite any deficiencies during today’s visit. An exit interview was conducted with Executive Director, Christina Hale, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 5, 2026 · control 11-AS-20260102134450

Allegation investigated: Staff are not providing adequate care and supervision to residents in care.

On 01/23/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced Complaint Visit to the facility listed above. LPA met with Christina Hale, Administrator, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: Durning today’s visit, LPA inspected the facility, interviewed Residents R1-R5, interviewed Staff S3-S9, interviewed residents Responsible Party W1-W5, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Maintenance Daily Task Schedule, resident Physician’s Report, resident Service Plan, and resident Assessment. During the initial visit conducted on 01/22/2026 LPA interviewed Staff S1-S2 and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Staff Schedule (January 2026), Staff Assignment Sheets (January 1 – January 22, 2026), Hospice List, and Shower Log (January 2026), The investigation revealed the following: Unsubstantiated Allegation: Staff are not providing adequate care and supervision to residents in care The allegation alleges that due to the lack of staffing, residents are dirty and do not receive assistance with showers, wheelchairs are not clean, and staff do not perform hand hygiene between assisting residents. During the facility inspection, LPA observed five (5) caregivers and two (2) nurses on during the AM shift. On the first floor, LPA observed residents involved in activities with the Engagement Assistants, while the Caregiver was assisting a resident in their room, and the Nurse was supervising a few residents in the sensory area. On the second floor, LPA observed 14 residents participating in an activity with an Engagement Assistant, six (6) other residents were in another activity area with an additional Engagement Assistant. LPA observed Caregivers going into residents’ rooms and providing assistance. LPA observed residents well kept in clean clothing and well groomed. LPA observed resident’s wheelchairs were clean. During record review, LPA received and reviewed the Staff Schedule and observed during the AM and PM shift there are five (5) caregivers and two (2) nurses scheduled. During the NOC shift there are two (2) caregivers and one (1) nurse scheduled. Additionally, LPA received and reviewed the Staff Assignment Sheet and observed Caregivers currently provide care to seven (7) to nine (9) residents. During interviews with Staff S1-S9, were asked if they feel there is enough staff on during each shift, nine (9) out of nine (9) stated yes, they feel there are enough staff on each shift. Additionally, four (4) out of nine (9) staff stated there are certain times when they could use an additional caregiver, mainly during the NOC shift, in the morning, and during meals. During interviews with Residents R1-R5, were asked if they feel there is enough staff on shift to provide care to residents, five (5) out of five (5) stated yes, they feel there is enough staff on shift to provide care. Additionally, one (1) out of five (5) stated they could use and additional caregiver on the first floor. Durning interviews with Residents Responsible Party’s W1-W5, were asked if they believe there are enough staff on each shift to provide care to the residents, five (5) out of five (5) stated yes, they feel there is enough staff on shift. Additionally, three (3) out of five (5) stated they believed they would benefit with adding an additional staff to assist. During record review, LPA received and reviewed the resident’s Shower Log for January 2026. LPA observed that residents are scheduled to be assisted with showering two (2) or three (3) times a week and one (1) resident daily. Upon review of the log, LPA observed staff sign-off of showered or refused, is consistent with the scheduled numbers of showers per week. During interviews with Staff S1-S9, were asked how often residents are assisted with bathing/showering, nine (9) out of nine (9) stated residents are scheduled to be assisted with bathing 2 to 3 times a week. During interviews with Residents R1-R5, were asked how often they are assisted with bathing, five (5) out of five (5) stated they are assisted with showering at least two (2) times a week. Durning interviews with Residents Responsible Party’s W1-W5, were asked how often their resident is assisted with bathing, five (5) out of five (5) stated they are scheduled at least two (2) to three (3) times a week for a shower. Additionally, five (5) out of five (5) stated they do not have any concerns regarding their residents not receiving showers. LPA received and reviewed the Maintenance Daily Task Schedule that indicates wheelchairs are power washed on the last Wednesday of every month. During interviews with Staff S1-S9, were asked if residents wheelchairs are cleaned, nine (9) out of nine (9) stated yes, wheelchairs are wiped down with sanitizing wipes when a resident is transferred out of it or when they have an accident or spill something. Additionally, nine (9) out of nine (9) stated they are power washed and dried monthly. During interviews with Residents R1-R5, were asked their wheelchairs are cleaned, two (2) out of five (5) stated yes, their wheelchairs are cleaned and sanitized regularly. Additionally, three (3) out of five (5) residents do not require a wheelchair. Durning interviews with Residents Responsible Party’s W1-W5, were asked if their residents wheelchairs are clean, four (4) out of five (5) stated yes, their residents’ wheelchairs are kept cleaned. One (1) stated their resident does not require a wheelchair. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator Christina Hale and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 23, 2026 · control 11-AS-20260113144511

Type of visit: Case Management - Incident

On December 30, 2025, at approximately 12:30 pm, Licensing Program Analyst- LPA Alfonso Iniguez conducted an unannounced Case Management/Incident visit at the facility. LPA Iniguez met with Christina Hale, Facility Administrator, and explained the purpose of the visit. On December 29, 2025, the Regional Office received a Report of Suspected Dependent Adult/Elder Abuse (SOC 341). The report indicated that on December 27, 2025, the facility was notified by (W#1) that (R#1) had reported being sexually assaulted by an unknown individual on the night of December 26, 2025. The facility promptly assessed (R#1) and notified their physician, POA, the Torrance Police Department, and CCLD. On December 30th, 2025, LPA Iniguez gathered the following documents: Staff roster dated: 7/18/25, resident roster dated:12/29/25, (R#1) resident identification and emergency information worksheet dated:11/8/2024, copy of (R#1) Physician Orders for Life-Sustaining Treatment (POLST) dated:7/13/22, copy of (R#1)’s identification cards, copy of (R#1) resident appraisal or LIC 603A, and a copy of (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A dated:12/5/25. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. In addition, LPA Iniguez together with the facility administrator conducted a Health and Safety check of the facility. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Christina Hale, Facility Administrator.the state’s words, verbatim · CDSS document, Dec 30, 2025

Type of visit: Prelicensing

On 05/02/2025 at 9:00AM, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an announced Pre-Licensing visit to the facility listed above. LPA met with Administrator Taylor Giunto and Administrator Trainee Christina Hale, and the purpose of today’s visit was explained. An application was submitted to CCLD on 07/09/24 for a Change of Ownership. The facility is a Residential Care Facility for the Elderly serving residents aged 60 and over. The facility was granted Fire Clearance on 03/15/2025 for 68 Bedridden residents with a total capacity of 68. Physical Plant/Structure The facility is a two story building in a commercial area. The facility consists of the following: the entrance has a lobby with a sitting area, restroom, meeting room, sitting room, administrative offices, and reception area. The first floor has 15 resident rooms with bathrooms, an activity area, dining area, television area, sitting area, bistro area, quite room for physical therapy, linen storage room, supply room, housekeeping storage room, salon, restroom, Activity Director office, medication room, industrial kitchen, staff lounge area, and enclosed patio. The second floor has 32 resident rooms with bathrooms, an activity area, dining area, television area, sitting area, bistro area, linen storage room, supply room, housekeeping storage area, spa, restroom, Health and Wellness director office, medication room, and Wellness Office. During the facility inspection, LPA did not observe any bodies of water on the premises. The outside patio area has tables, chairs, and umbrellas. The gates exiting the patio are egressed and work properly. All outside walkways were observed to be clean, clear, and free of obstructions, debris, and hazards. All windows, screens, and blinds were observed to be in good repair. Resident Rooms LPA inspected all resident rooms and observed them to be clean and in good repair. LPA observed all resident rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. Residents have the option to furnish their room how they would like, or the facility has furniture available if residents need it. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Residents do have the option to use their personal linens, or the facility has a supply of linens available. LPA observed an additional supply of linens in a linen storage room. All linens and mattresses were observed in good repair. All resident rooms were observed with ample lighting. Kitchen LPA observed the industrial kitchen to be clean and sanitary during time of visit. LPA observed all appliances to be operable and in good repair. LPA observed an ample supply of cookware, dishware, and cutleries in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods were observed properly dated, labeled, packaged, and stored. The freezer temperature measured -2-degrees Fahrenheit, and the refrigerator temperature measured 39-degrees Fahrenheit. LPA observed knives and sharps to be secured and are inaccessible to residents. LPA observed menus posted in the dining rooms. The first and second floor Bistro areas were observed clean and sanitary. LPA observed a supply of snacks and drinks available for residents at any time. LPA observed cleaning supplies to be secured in a locked storage room and are inaccessible to residents. All trash cans were observed with tight fitting covers. Common Rooms LPA observed all common rooms to have ample seating to accommodate residents. LPA observed dining areas to have ample tables and chairs to accommodate residents. In the activity areas, LPA observed tables and chair available to accommodate residents. LPA observed an ample supply of arts, crafts, exercise equipment, games, and activities stored in a storage room on the first and second floor. LPA observed a daily and monthly activity schedule posted in the activity areas. The facility was observed appropriately furnished during the time of visit. All walkways and hallways in the facility were observed to be clean, clear, and free of hazards and obstructions. The facility was kept at a comfortable temperature. All rooms and hallways were observed to have ample lighting. Files LPA observed resident medical files secured in the locked wellness room and are inaccessible to residents. Resident Administrative files were observed secured in a locked cabinet in an administrative office. LPA observed staff files secured in a locked cabinet in an administrative office. The facility does not handle resident’s finances. Medications LPA observed medications secured in locked medication cart on each floor. Medications are inaccessible to residents. LPA observed medications to be in their original packaging. LPA observed a fully stocked First Aid kit with a current manual, in both medication rooms. LPA observed additional First Aid supply secured in the medication room. Safety LPA tested smoke detectors on each floor and carbon monoxide detectors in each resident unit and found them to be operable. The facility has fire doors that are triggered to close automatically when the fire alarm goes off. LPA observed multiple fully charged fire extinguisher last serviced on 03/09/25, throughout the facility. The Fire Safety Inspection was conducted by the Torrance Fire Department on 03/13/25. The last emergency drill was conducted on 02/04/25. LPA observed an evacuation chair at the top of the stairwell LPA observed the facility’s Emergency and Disaster Plan posted and last updated on 08/01/24. LPA observed emergency flashlights with every fire extinguisher. The generator was tested and ran. LPA observed logs indicating the generator is ran monthly for 30 minutes. The facility has a working landline telephone. LPA observed all required posting, posted throughout the facility. LPA tested the signal system by pressing resident’s pendants. LPA received and reviewed a copy of the liability insurance through Acord. LPA and Administrator reviewed and discussed Component III. LPA did not observe or cite any technical advisory deficiencies. An exit interview was conducted with Administrator Taylor Giunto and Administrator Trainee Christina Hale and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 2, 2025