Sunrise Assisted Living of Hermosa Beach

Allegation investigated: Staff administered the incorrect medication to a resident in care.

On 5/5/2026, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met Judith Uy Villaruz/Executive Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Executive Director Interview (A#1), Staff Interviews (S#1-S#2). LPA gathered the following documents: copy of client roster and staff roster dated:5/4/26, copy of Unusual Incident Report or LIC 624 dated 4/25/26 and copy of (R#1) Medical Assessment for Residential Care Facilities for the Elderly or LIC 602A dated:3/9/2026. Evaluation Report continues LIC 9099-C Substantiated Investigation Revealed the Following: Allegation: Staff administered the incorrect medication to a resident in care. The details of the complaint alleged that facility staff gave the wrong medication to (R#1) On May 5, 2026, at approximately 10:00 a.m., during the records review, the Department observed a copy of the Unusual Incident Report (LIC 624) dated April 25, 2026. The report states that on April 24, 2026, (S#1) approached (R#1) in the first-floor reading room and asked if they were (R#2). According to the report, (R#1) confirmed the identification. The report further indicates that shortly thereafter, upon returning to the medication cart on the second floor, (S#1) realized that medications intended for (R#2) had been administered to (R#1). In addition, the Department reviewed a copy of (R#1)’s Medical Assessment for Residential Care Facilities for the Elderly (LIC 602A), dated March 9, 2026, which indicates that (R#1) is not able to self-administer their medications due to cognitive impairment. On May 5, 2026, at approximately 10:30 a.m., the Department interviewed the facility administrator (A#1). (A#1) stated that (S#1) is a part‑time care manager who had not been working at the facility since late February 2026. (A#1) reported that new residents, including (R#1), were admitted during that period, and (S#1) was not familiar with (R#1). According to (A#1), on April 25, 2026, (S#1) went to administer medications to (R#1) but did not find them in their room. (S#1) observed (R#1) in the reading room and asked if they were (R#10). (A#1) stated that (R#1) responded “yes,” and (S#1) proceeded to administer (R#10)’s medications to (R#1). (A#1) reported that after returning upstairs to document in the Medication Administration Records (MARs), (S#1) saw (R#1) and realized the wrong medications had been administered. (A#1) stated that following the incident, (S#1) notified the wellness director, the resident care director, and the hospice agency providing services to (R#1). (A#1) further reported that the facility notified (R#1)’s physician, responsible representatives, and the licensing department. Evaluation Report continues LIC 9099-C On May 5, 2026, the Department could not interview staff (S#1) because they were not on duty at the facility. The Department attempted to contact (S#1) via telephone; however, (S#1) did not answer the call. On May 5, 2026, at approximately 11:30 a.m., the Department interviewed facility staff (S#2). (S#2) stated that on April 25, 2026, (S#1) asked them how (R#1) ambulates. (S#2) reported that when they asked why, (S#1) stated, “I think I gave the wrong medication to (R#1).” (S#2) stated that after receiving this information, staff immediately monitored (R#1) throughout the day and notified (R#1)’s responsible representatives, physician, and hospice agency. During this investigation, The Department found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Judith Uy Villaruz/Executive Administrator. Investigation Revealed the Following: Allegation: Staff are not completing medication logs. The details of the complaint alleged that facility staff are not completing medication logs. On May 5, 2026, at approximately 10:00 a.m., during the records review, the Department observed copies of the Medication Administration Records (MARs) for residents (R#1) through (R#4) dated February, March, and April 2026. The Department noted that there were no discrepancies in the residents’ medication intake records for those months. On May 5, 2026, at approximately 10:30 a.m., the Department interviewed the facility administrator (A#1). When asked to describe the facility’s process for ensuring that medication administration logs are completed at the time medications are provided to residents, (A#1) stated that it is the facility’s practice for Med Techs to document the medication administration immediately after providing medications to residents. In addition, when asked what systems or oversight practices the facility uses to verify that staff are documenting all administered, refused, or held medications on the Medication Administration Records (MARs), (A#1) stated that the resident care director conducts quality-assurance reviews of completed MARs. Moreover, when asked how the facility addresses missing or incomplete entries on a medication log and ensures corrective action is taken, (A#1) stated that the issue is brought back to the staff member who administered the medications to determine why the entry was not completed. On May 5, 2026, at approximately 10:30 AM, during interviews with residents in care (R#2-R#9), (8) out of (8) stated that staff stay with them when assisting with their medications. Residents also stated that they have observed staff writing information down or using a chart after providing medications. In addition, (8) out of (8) residents reported that they have not experienced a time when they did not receive the medication they were expecting or received later than usual. Evaluation Report continues LIC 9099-C On May 5, 2026, at approximately 11:30 AM, during interviews with facility staff (S#1-S#2), (2) out of (2) stated that their usual process after assisting a resident with medication. Staff stated that they ensure the resident takes the medication, provide sufficient water, ensure the resident is not choking, and confirm that no medication is left unattended. Staff reported that once the medication is administered and the resident’s identity has been verified, they document the administration on the Medication Administration Records (MARs). In addition, when asked how they document medications that are refused, delayed, or unavailable, staff stated that if a medication is refused, they offer it up to three times and explain the benefits of the medication while also informing the residents of their right to refuse. Staff reported that refusals are documented on the MARs and that the residents’ physicians and responsible representatives are notified. Moreover, when asked how the facility ensures that all medication entries are completed for the shift, (2) out of (2) staff stated that documentation is completed in the electronic system, which indicates when a medication has been administered. Staff also reported that the service care coordinator conducts regular quality-assurance reviews of the MARs. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Judith Uy Villaruz/Executive Administrator.the state’s words, verbatim · CDSS document, May 5, 2026 · control 11-AS-20260430170307

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 25, 2026

87465 Incidental Medical and Dental Care a) A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: Based on interviews and records review, facility staff (S#1) failed to ensure that (R#1) received their own prescribed medications when (S#1) administered medications intended for another resident (R#2). This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: Licensee will adhere to Title 22 at all times. The Executive Director stated that, as a Plan of Correction-POC, (S#1) will receive disciplinary action related to the medication error. The facility will also conduct an in service training for staff on proper medication management and dispensing procedures. Proof of correction will be submitted to the Department by the POC due date.

Type of visit: Required - 1 Year

On 05/01/26, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual visit using the CARE Inspection Tool. LPA met with Executive Director Judith Uy Villaruz and explained the purpose of today’s visit. The facility is licensed to serve one hundred forty-two (142) non-ambulatory residents, of which six may be bedridden. The facility has a hospice waiver for ten residents. During today’s visit, LPA toured the inside and outside of the facility. Due to insufficient time, an annual continuation is required. An exit interview was conducted and a copy of this report was reviewed and discussed with the Executive Director Judith Uy Villaruz.the state’s words, verbatim · CDSS document, May 1, 2026

Allegation investigated: Facility does not have hot water.

On 01/15/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Executive Director Judith Uy-Villaruz and the purpose of the visit was explained. Investigation consisted of the following: On 12/31/2025, LPA obtained Personnel Report, Register of Residents, Staff Schedule, December 2025 Shower Schedule, Email Correspondence, Contractor Estimate, Agreement, and Purchase Order. LPA interviewed Staff #1 – 6, Residents #1 – 6, and measured water temperatures on the first and second floor. On 01/15/2026, LPA interviewed Staff 1 – Staff 2, Staff 6, Resident #7 – 9, and Witness #1 and received Smiley App Correspondence. Investigation revealed the following: Allegation: Facility does not have hot water. Continue to LIC9099-C. Substantiated Regarding the allegation, “facility does not have hot water,” it is being alleged that showers were not provided to residents from 12/20/2025 – 12/25/2025. Record review of Broadway National Estimate (08/15/2025) revealed staff was to arrive onsite AFTER normal business hours. Project will take approximately (7-9) nights to complete. In order to complete the work safely and efficiently, a temporary shutdown of the water supply will be required. To prevent disruption to daily operations, all work will be scheduled to take place after hours. Record review of email correspondence (12/25/2025 12:59 PM) revealed the facility restored its hot water. Interview with Witness #1 indicated the project was expected to be completed in a week-long job, staff worked day and night, and hot water was to be intermitted. Interview with Staff #1 – 2 indicated the work was to be completed in one day. Staff #1 indicated there was a leak in the old tank and the work to replace it was expected to take a day. However, complications arose, and a second contractor was hired to finish the work. As a result, hot water was provided from kettles so residents could receive/take hot sponge baths. Plus some residents went to their family’s home to shower. Interview with Staff #8 indicated hot water from kettles was offered to some residents but not all. Some residents said they would wait. Eight out of eight staff interviews (S1 – S8) indicated that the facility was without hot water for four to five days due to the replacement of a hot water tank. Five out of eight residents (R1 – R8) interviews, including spouses, indicated they were unable to shower, was not presented with alternatives or did not receive shower assistance/sponge bath according to schedule. Regarding the allegation, “facility does not have hot water,” based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, plans of correction developed, and a copy of this report with the appeal rights was provided to Executive Director Judith Uy-Villaruz.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 11-AS-20251224160908

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(3) · Plan of correction due date: Feb 2, 2026

(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident... This requirement was not met as evidence by: Based on resident interviews, five out of eight residents (R1-R8), indicated they were unable to shower, was not presented with alternatives or did not receive shower assistance/sponge bath according to schedule due to lack of hot water. This posed a potential health and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: As of 12/25/2025 12:59 PM, residents have been able to shower with hot water and receive bathing assistance according to schedule and an email notice was sent to families. LPA was provided with a copy of the email.

Allegation investigated: Staff did not seek medical attention for resident in care

*This report supersedes the investigation report dated 11/20/2025. A subsequent visit was conducted on 12/19/2025 to re-deliver findings in the report. This report supersedes the previous report, the complaint investigation findings for the above allegation does change.* On 12/19/2025, the department was greeted by the Administrator, Judith Uy-Villaruz and the purpose of the visit was explained. On 11/20/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced continuation complaint investigation visit regarding the allegations listed above. LPA met with the Senior Executive Director, Cortez Jordan, and the purpose of the visit was explained. LPA was granted entry to the facility. Substantiated Investigation consisted of the following: On 07/09/2025, interviews were conducted, a tour of the Reminiscence Neighborhood was conducted, records were gathered. Interviews conducted consisted of 7 resident interviews [Resident 2 (R2) to Resident 8 (R8) were interviewed] and 6 staff interviews [Staff 1 (S1) to Staff 6 (S6) were interviewed]. Facility records were gathered which consisted of Resident Roster dated 07/01/2025; Personnel Report; Abuse, Neglect & Exploitation – Prevention, Reporting and Investigation Facility Policy, Unusual Incident/Injury Report dated 06/11/2025; Staff Certificates of Completion for Abuse & Neglect Prevention; and Reminiscence Neighborhood Residents Emergency Contact Information. On 07/10/2025, Witness 1 (W1) was interviewed. On 08/28/2025, Witness 2 (W2) was interviewed. On 11/20/2025, interviews were conducted, and records were reviewed. Interviews conducted consisted of 1 staff [Staff 2 (S2) was interviewed] and 7 witness interviews [Witness 3 (W3) to Witness 9 (W9) were interviewed]. Records reviewed consisted of pertinent Resident 1’s (R1) records. The investigation revealed the following: Allegation: “Staff did not seek medical attention for resident in care”, it is being alleged that staff did not seek emergency medical attention for R1 on 06/08/2025 which included calling 9-1-1. Interviews conducted revealed the following: Interviews conducted with R2 to R8 revealed the following: 7 out of 7 residents denied the allegation, moreover, residents indicated that if they required medical attention staff would assist them. Interviews conducted with W1 and W3 to W9 revealed the following: 7 out of 8 witnesses denied the allegation and 1 out of 8 witnesses agreed with the allegation. Moreover, 1 out of 8 witnesses indicated that when they observed R1 on 06/08/2025 it seemed as if R1 had been physically assaulted, R1 had bruises on their eyes and face, they observed blood in R1’s room, they were informed by facility staff that R1 had a broken tooth, they took R1 to urgent care (not facility staff). Interviews conducted with S1 to S6 revealed the following: 6 out of 6 staff denied the allegation. Furthermore, staff indicated that on 06/08/2025 the following occurred: Around 8:30 AM facility staff assessed R1 and determined that R1 had a cold sore, R1’s doctor was notified and responsible person. Around 10:45 AM to 11:00 AM R1 was reassessed by Staff 2 (S2) and facility staff observed that R1 had a crack tooth, one tiny tear outside the mouth and one inside the mouth; R1 was asked if they fell but they indicated that they did not fall; R1 could not explain what happened; R1’s room was searched and staff found droplets of blood and concealed wadded up paper towels under the couch; R1’s responsible person was contacted and notified with an update. Staff were unsure how R1 sustained an injury / it was an un-witnessed incident. A theory that staff came up with is that R1 slept on their couch next to their coffee table and R1 fell on the corner of the coffee table. R1’s responsible person came to the facility past 1:00 PM and with the guidance of S2 took R1 to urgent care. Additionally, staff explained that 9-1-1 nor non-emergency ambulance were called because R1 was acting like their normal self, did not express signs of pain, was alert, and did not have a serious life-threatening injury. Moreover, S2 explained that 9-1-1 is called when residents have an un-witnessed fall and head injury. Records reviewed revealed the following: “Statement of Event” written by facility staff on 06/2025 revealed that on 06/08/2025 the following occurred: 5 staff indicated that R1 was assessed by facility staff and R1 was taken to urgent care. Staff 7 (S7) wrote that they assessed R1 around 8:00 AM and “saw open skin (wound) no presence of blood no broken tooth." Just an open white in color open wound…R1 is asked what happened but R1 is unable to answer…no signs of discomfort…around 11:00 AM S2 re-assess R1 and informs S7 that R1 “might had a fall and hit themselfon the edge of the table that was same level of the couch.” Staff 8 (S8) wrote that around 8:30 AM they assessed R1 and observed with “a big lump on thei lip (the left) and a bruise on their chin”…R1 was asked if they hurt themselves and R1 indicates no… “the nurse looked at it” and indicates that it looks like a cold sore “since the resident had a cut from the inside of the lip. When the nurse lifted R1’s lip it did hurt the resident. I did notice a chipped tooth as well.” Staff 9 (S9) wrote that they observed R1 at around 9:00 AM and saw that R1’s “right upper lip swollen and a bruise on their right side”…R1 was assessed by facility staff and staff determined that R1 had a cold sore on the right upper lip. Unusual Incident/Injury Report (UIR) dated 06/11/2025 revealed the following: R1 was reported to have a swollen lip and cracked tooth; R1 was evaluated by facility staff and taken to the emergency room. Fax records dated 06/08/2025 revealed the following: facility staff faxed R1’s doctor four times. R1’s Physicians Report revealed the following: R1’s primary diagnosis is Alzheimer’s Dementia. R1’s mental condition is confused and disorientated. Substantiated: Based on interviews and records R1 sustained an un-witnessed fall which resulted in a head injury because R1 was observed with a chipped tooth, a cut inside their mouth, a cut outside their mouth, swollen lip, and bruise on their chin. Additionally, R1’s room was searched and staff found droplets of blood in the room. Also, due to R1’s diagnosis they had difficulties expressing the events that occurred that led to their head injuries and expressing if they were in pain or not. Moreover, staff theorized that R1 slept on their couch and fell on the corner of their coffee table and sustained said injuries. Furthermore, R1 was incorrectly assessed around 8:00 AM with a cold sore and then correctly assessed around 11:00 AM but the facility did not seek emergency medical attention for R1. The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator, Judith Uy-Villaruz. Investigation consisted of the following: On 07/09/2025, interviews were conducted, a tour of the Reminiscence Neighborhood was conducted, records were gathered. Interviews conducted consisted of 7 resident interviews [Resident 2 (R2) to Resident 8 (R8) were interviewed] and 6 staff interviews [Staff 1 (S1) to Staff 6 (S6) were interviewed]. Facility records were gathered which consisted of Resident Roster dated 07/01/2025; Personnel Report; Abuse, Neglect & Exploitation – Prevention, Reporting and Investigation Facility Policy, Unusual Incident/Injury Report dated 06/11/2025; Staff Certificates of Completion for Abuse & Neglect Prevention; and Reminiscence Neighborhood Residents Emergency Contact Information. On 07/10/2025, Witness 1 (W1) was interviewed. On 08/28/2025, Witness 2 (W2) was interviewed. On 11/20/2025, interviews were conducted, and records were reviewed. Interviews conducted consisted of 1 staff [Staff 2 (S2) was interviewed] and 7 witness interviews [Witness 3 (W3) to Witness 9 (W9) were interviewed]. Records reviewed consisted of pertinent Resident 1’s (R1) records. The investigation revealed the following: Allegation: “Staff did not prevent resident from being hit at the facility by an unknown individual”, it is being alleged that R1 was hit by an unknown individual. Interviews conducted with R2 to R8 revealed the following: 7 out of 7 residents denied the allegation, moreover, residents indicated that no one has ever hit them in the facility. Interviews conducted with W1 to W9 revealed the following: 7 out of 8 witnesses denied the allegation and 1 out of 8 witnesses agreed with the allegation; 8 witnesses indicated that they have never seen a resident being physically hit by another person; W2 goes on to explain that a police investigation was conducted in the facility regarding the allegation and it was unknown if R1 was hit by an individual or if R1 fell on the corner of their coffee table, W2 explains that no individual was arrested due to the allegation and there was not sufficient evidence to indicate that an individual hit R1. Interviews conducted with S1 to S6 revealed the following: 6 out of 6 staff denied the allegation, furthermore, staff indicated that they have not seen or heard that R1 was physically hit by an individual, S1 goes on to explain that the Hermosa Beach Police came to the facility, conducted an investigation, requested video footage of the facility and sign in and sign out records of the facility. Records reviewed of the Hermosa Beach Police Department DR# 25-0001355-Crime / Incident Report dated 06/11/2025 regarding the incident with R1 revealed the following: The Hermosa Beach Police Department were unable to determine if an unknown individual hit R1 or if R1 fell. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not report incident to appropriate parties”, it is being alleged that R1’s appropriate parties were not contacted. Interviews conducted with R2 to R8 revealed the following: 7 out of 7 residents denied the allegation, moreover, residents indicated staff contact their family members. Interviews conducted with W1 and W3 to W9 revealed the following: 7 out of 8 witnesses denied the allegation and 1 out of 8 witnesses agreed with the allegation; 7 witnesses indicated that staff contact them when necessary and W1 indicated that facility staff contacted them when R1 had an incident. Interviews conducted with S1 to S6 revealed the following: 6 out of 6 staff denied the allegation, furthermore, staff indicated that R1’s responsible person was contacted and their medical provider. S1 indicated that the facility did not submit an SOC341 Report of Suspected Dependent Adult-Elder Abuse because they did not think nor have evidence that R1 was a victim of elder abuse. Unusual Incident/Injury Report (UIR) dated 06/11/2025 revealed the following: R1 was reported to have a swollen lip and cracked tooth; R1 was evaluated by facility staff and taken to the emergency room; the UIR was faxed to the department. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with the Administrator, Judith Uy-Villaruz.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 11-AS-20250703084105

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Jan 8, 2026

Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above in not calling 9-1-1 for an unwitnessed fall that lead to head injuries, staff observed R1 with head injuries such as a swollen lip, chip tooth, cut inside their mouth, cut outside their mouth, droplets of blood in R1’s room, which could have led to an imminent threat to R1’s health, which posed a potential health, safety risk to person in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: The Administrator has agreed to re-read Incidental Medical and Dental Care 87465 (g) and also read PIN 25-06-ASC Subject: Calling 9-1-1 In Residential Care Facilities for the Elderly (RCFE) which provides facilities with guidance with 87465 (g). The Administrator has agreed to apply said PIN to in service staff trainings when calling 9-1-1. Proof of correction email staff trainings of when to call 9-1-1 to Socorro.Leandro@dss.ca.gov

Allegation investigated: Staff did not seek medical attention for resident in care Staff did not prevent resident from being hit at the facility by an unknown individual Staff did not report incident to appropriate parties

On 11/20/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced continuation complaint investigation visit regarding the allegations listed above. LPA met with the Senior Executive Director, Cortez Jordan, and the purpose of the visit was explained. LPA was granted entry to the facility. Unsubstantiated Investigation consisted of the following: On 07/09/2025, interviews were conducted, a tour of the Reminiscence Neighborhood was conducted, records were gathered. Interviews conducted consisted of 7 resident interviews [Resident 2 (R2) to Resident 8 (R8) were interviewed] and 6 staff interviews [Staff 1 (S1) to Staff 6 (S6) were interviewed]. Facility records were gathered which consisted of Resident Roster dated 07/01/2025; Personnel Report; Abuse, Neglect & Exploitation – Prevention, Reporting and Investigation Facility Policy, Unusual Incident/Injury Report dated 06/11/2025; Staff Certificates of Completion for Abuse & Neglect Prevention; and Reminiscence Neighborhood Residents Emergency Contact Information. On 07/10/2025, Witness 1 (W1) was interviewed. On 08/28/2025, Witness 2 (W2) was interviewed. On 11/20/2025, interviews were conducted, and records were reviewed. Interviews conducted consisted of 1 staff [Staff 2 (S2) was interviewed] and 7 witness interviews [Witness 3 (W3) to Witness 9 (W9) were interviewed]. Records reviewed consisted of pertinent Resident 1’s (R1) records. The investigation revealed the following: Allegation: “Staff did not seek medical attention for resident in care”, it is being alleged that staff did not seek appropriate medical attention for R1. Interviews conducted with R2 to R8 revealed the following: 7 out of 7 residents denied the allegation, moreover, residents indicated that if they required medical attention staff would assist them. Interviews conducted with W1 and W3 to W9 revealed the following: 7 out of 8 witnesses denied the allegation and 1 out of 8 witnesses agreed with the allegation. Interviews conducted with S1 to S6 revealed the following: 6 out of 6 staff denied the allegation, furthermore, S1, S2, S3 and S5 indicated that R1 was assessed for medical attention by facility staff, R1’s doctor was notified and R1 received medical attention by medical providers. “Statement of Event” written by facility staff on 06/2025 revealed the following: 5 staff indicated that R1 was assessed by facility staff and R1 was taken to urgent care. Unusual Incident/Injury Report (UIR) dated 06/11/2025 revealed the following: R1 was reported to have a swollen lip and cracked tooth; R1 was evaluated by facility staff and taken to the emergency room. Fax records dated 06/08/2025 revealed the following: facility staff faxed R1’s doctor four times. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not prevent resident from being hit at the facility by an unknown individual”, it is being alleged that R1 was hit by an unknown individual. Interviews conducted with R2 to R8 revealed the following: 7 out of 7 residents denied the allegation, moreover, residents indicated that no one has ever hit them in the facility. Interviews conducted with W1 to W9 revealed the following: 7 out of 8 witnesses denied the allegation and 1 out of 8 witnesses agreed with the allegation; 8 witnesses indicated that they have never seen a resident being physically hit by another person; W2 goes on to explain that a police investigation was conducted in the facility regarding the allegation and it was unknown if R1 was hit by an individual or if R1 fell on the corner of their coffee table, W2 explains that no individual was arrested due to the allegation and there was not sufficient evidence to indicate that an individual hit R1. Interviews conducted with S1 to S6 revealed the following: 6 out of 6 staff denied the allegation, furthermore, staff indicated that they have not seen or heard that R1 was physically hit by an individual, S1 goes on to explain that the Hermosa Beach Police came to the facility, conducted an investigation, requested video footage of the facility and sign in and sign out records of the facility. Records reviewed of the Hermosa Beach Police Department DR# 25-0001355-Crime / Incident Report dated 06/11/2025 regarding the incident with R1 revealed the following: The Hermosa Beach Police Department were unable to determine if an unknown individual hit R1 or if R1 fell. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not report incident to appropriate parties”, it is being alleged that R1’s appropriate parties were not contacted. Interviews conducted with R2 to R8 revealed the following: 7 out of 7 residents denied the allegation, moreover, residents indicated staff contact their family members. Interviews conducted with W1 and W3 to W9 revealed the following: 7 out of 8 witnesses denied the allegation and 1 out of 8 witnesses agreed with the allegation; 7 witnesses indicated that staff contact them when necessary and W1 indicated that facility staff contacted them when R1 had an incident. Interviews conducted with S1 to S6 revealed the following: 6 out of 6 staff denied the allegation, furthermore, staff indicated that R1’s responsible person was contacted and their medical provider. S1 indicated that the facility did not submit an SOC341 Report of Suspected Dependent Adult-Elder Abuse because they did not think nor have evidence that R1 was a victim of elder abuse. Unusual Incident/Injury Report (UIR) dated 06/11/2025 revealed the following: R1 was reported to have a swollen lip and cracked tooth; R1 was evaluated by facility staff and taken to the emergency room; the UIR was faxed to the department. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Resident Care Director, Lennora Folkes.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 11-AS-20250703084105

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced annual required visit with the primary focus on infection control measures and using the new CARE Inspection Tool. LPA Bunker met with Executive Director Anita Csukardi to explain the purpose of today's annual inspection. There are currently seventy-seven residents in placement. The facility's annual fees are current. The following 12 Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant & Environmental Safety, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/Incident Reports, Disaster Preparedness, and Residents with Special Health Needs. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." Ms. Csukardi and LPA Bunker toured the facility. The facility is a two-story building located in a commercial business area. It consists of a Memory Care Unit on the first floor with 15 apartment suites each, with its own bathroom, and an Assisted Living Unit on the second floor with 65 apartment suites, also with private bathrooms. The facility includes the following amenities and areas: a receptionist area, lobby, discovery room, bistro, reading area, parlor, living rooms, dining rooms, kitchens, a coordinator's office, mechanical closet, 4 public restrooms, life skills room, hair salon, Bathtique, activity room, Wellness office, and 3 laundry rooms, Additional features include a parking garage and an indoor/outdoor activity area with a shaded patio furnished with tables and chairs. See continued LIC809-C page 2 Continued LIC809-C page 2 Documents have been posted, as mandated, on the bulletin board in the lobby area. The following Title 22 regulated areas were audited and found to be in compliance: The facility telephones are working. Bedrooms: The apartment suites meet the required standards for furniture, safety, privacy, and comfort. Bathrooms: The bathrooms are clean and operational, and residents are provided with the necessary personal accommodations with non-skid surface mats ensuring safety and privacy. Linen and Supply: The facility has an adequate supply of linen. Kitchen and Food Service: The kitchen is adequately equipped for food preparation and service. A review of the food service revealed an ample supply of perishable and nonperishable food, stored appropriately. Medication Storage and Management: Medications are centrally stored in a locked Med Cart on each floor with up-to-date records, ensuring proper storage and documentation. Common Areas: The Living rooms, dining rooms, and common areas are well-maintained, free of potential hazards, and meet the cleanliness standards necessary for the safety and well-being of residents. Safety Equipment and Measures: The facility is equipped with fully stocked first aid kits with manuals, functional hardwired, smoke and carbon monoxide detectors, and the fire extinguishers are compliant and have been properly charged. The hot water temperature is measured at 113.3 degrees and is maintained within the standard range of 105-120 degrees Fahrenheit. Emergency Preparedness: All exit doors are in compliance, the resident's bedroom windows are equipped with sliding window locks without thumbscrews, and the facility conducted a fire drill on May 08, 2025. Environmental Safety: The yard is free from debris and hazards, trash cans are covered, and no firearms or bodies of water are present on the premises. Hazardous items are kept inaccessible to residents. Staff Training: Staff members have received training on reporting dependent adult and elder abuse. Administrative Compliance: The Administrator Certificate is current and expires July 29, 2026, The HIV/TB requirements have also been verified. See continued LIC809-C page 3 Continued LIC9099-C page 3 A copy of the Facility Evaluation Report LIC809, and LIC809-Cs, was provided to Executive Director Anita Csukardi. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, May 21, 2025

Type of visit: Required - 1 Year

On 04/18/2024 at 8:00 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA España verified that the facility has an approved mitigation plan report. LPA España was granted access and allowed to enter the facility to conduct the inspection. LPA met with Anita Csukardi, Executive Director and explained the purpose of the visit. There are Seventy-Eight (78) residents in the facility, 61 residents are ambulatory, and 16 are non-ambulatory. The facility is a two-story structure with underground parking located in a residential neighborhood. The facility consists of (94) bedrooms, (99) full bathrooms including common area restrooms, 1st floor consist of: lobby, bird room, TV room, copy room, storage room, fire control room, dining room, bistro, kitchen, main laundry room, chemical room, resident laundry room, staff lounge, physical therapy/gym room, 2 lounge areas. Reminiscence Unit: storage room, electrical room, chemical closet, laundry room, living room /office, life skill area, kitchenette, dining room, bathtique, and balcony. 2nd floor: Resident laundry room, lounge, hair salon, activity room, storage area, electrical room, housekeeping room, bathtique, medication room, and lounge. Shaded middle patio, enclosed front porch area, underground parking (P1.) LPA and Executive Director Anita Csukardi, toured the facility inside and out. LPA observed all walkways to be clean, clear and free from obstructions, hazards and debris. LPA did not observe any bodies of water on the premises. LPA observed the facility to be in good repair. LPA toured rooms on both floors and found they contained the required furniture. All rooms were spacious and had storage to accommodate resident’s belongings. LPA observed ample lighting in rooms. Resident's have the option to furnish rooms with their own belongings. LPA checked bathrooms in rooms toured and public restrooms. All bathrooms observed were clean and sanitary. All showers were free of mold and mildew. LPA observed all bathrooms to have secured handrails and not skit mats or chairs for the shower. LPA observed the kitchen to be clean and sanitary. LPA observed a 3-day supply of perishable foods and 7-day nonperishable foods. LPA observed all appliances to be in good repair. LPA observed an ample supply of cutleries, pots and pans to be in good repair. All knives and sharps are secured and inaccessible to residents. All beds observed had the required linens, including mattress cover, fitted sheets, blankets, comforters, pillows, and pillowcases. Residents had an ample supply of personal hygiene supplies.LPA toured all common rooms and areas. All walkways and hallways were clean, clear, and free of hazards and obstructions. LPA observed ample seating to accommodate residents in all common rooms. The facility was maintained at a comfortable temperature. LPA observed ample lighting in all walkways and common rooms. LPA observed resident’s doing activities, playing games, and watching music performers. All smoke detectors and carbon monoxide detectors are in compliance and operational. LIC809C Continued LPA observed the First aid kit and found it to fully stocked of the required items, with manual. There are no firearms or ammunition stored at the facility. All hazardous toxins are inaccessible to residents. LPA observed all exits, walkways and/or passageways to be clean, clear, and free of debris and hazards. All medications are stored in the Med Room and are secured and inaccessible to residents. LPA reviewed medications for Six (6) out of Seventy-Eight (78) residents and matched them to the eMARs. LPA observed all medications to be in their original packaging. LPA reviewed Eight (8) out of Seventy-Eight (78) residents files and found they contained the required documentation. LPA reviewed the executive directors and 7 Staff files and found they contained the required documents, training and certification. LPA reviewed and received a copy of the facilities Liability Insurance, Plan of Operations (Dementia plan, Admission policies and Incidental Medical and Dental Care), activity schedule, meal menu, resident and family council meeting notice and notes, Advertisement and marketing/promotional material, and admission/intake packet. LPA conducted 7 interviews with residents. All residents had nothing but good things to say about the facility and staff. LPA conducted 4 interviews with staff. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time. The generator is tested and ran weekly. LPA reviewed the facility’s Emergency and Disaster Plan (LIC610E). LPA observed all required postings. LIC809C Continued Fire alarm system is monitored by private company and was last inspected on March 13, 2024. LPA observed (12) fire extinguishers fully charged last serviced on 02/05/2024 The last emergency drill was conducted on 04/18/2024. There was one Technical Assistance provided on today's visit. Resident Rights/Information - Technical Assistance: 87468(c)(2)(A) An exit interview conducted with Anita Csukardi, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 18, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained a pressure injury while in care.

On 11/2/2023 at 1:00 PM, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent complaint visit to deliver the complaint investigation finding of the allegation listed above. LPA conducted a risk assessment with Administrator Eric Mensah who stated the facility is free of Covid-19. LPA explained the purpose of the visit to Administrator Mensah. Investigations consisted of the following: On 8/7/2020, LPA Montoya conducted a virtual visit and obtained staff roster, resident roster and resident’s (R1) service records. On 12/6/2021, LPA Montoya interviewed staff and residents. LPA obtained additional pertinent records from the facility. REPORT CONTINUED IN LIC 9099C Substantiated INVESTIGATIONS REVEALED THE FOLLOWING: Allegation: Resident sustained a pressure injury while in care It is alleged resident sustained a pressure injury while in care. Based on records review, Admission Agreement indicates R1 was admitted to the facility on 5/14/2020. Physician’s Report dated 5/11/2020 and the facility’s Progress Notes dated 5/14/20 indicate R1 has a history of deep tissue pressure injury on the right lateral heel, stage not noted. R1 is non-ambulatory. R1’s Medication Administration Record (MAR) shows facility staff administered Venelax topical ointment from 5/14/2020 through 7/6/2020, 2x day on R1’s right heel for suspected deep tissue pressure injury. During the Torrance Memorial Home Health Nurse’s visit on 5/17/2020, home health nurse instructed caregivers on resident’s Stage 1 Pressure Ulcer to Right Heel to keep off pressure, leave open to air and other measures to prevent skin breakdown. The facility’s progress notes dated 5/17/2020 indicates home health nurse verbalizes nurses will continue to visit once a week and the facility staff/caregivers will continue to assist R1 with repositioning four times per shift and floating right heel on pillow. On 5/22/2020, the facility’s progress notes indicate R1 had a quarter sized open area with surrounding redness on coccyx, care team to continue to apply barrier cream and reposition resident and home health nurse is to visit on 5/23/2020. On 5/31/2020, the facility’s progress notes and the home health notes revealed R1 had developed an open bed sore on the coccyx area. According to the department’s records review, there were no records that R1 received wound care for coccyx from Home Health and no records were found that facility staff repositioned R1 between 5/23/2020 and 5/30/2020. In addition, there was no evidence that the facility made attempts to follow-up on the request for home health services or medical assessment for R1’s coccyx during this period. However, home health continued in providing wound care to RI's right heel. On 6/2/2020, a new home health service for R1's coccyx commenced and it was revealed that R1 developed an unstageable pressure injury on coccyx. On 6/28/2020, Home health notes show R1’s pressure injury in coccyx was at Stage 3 and it progressed to Stage 4 on 7/12/2020. Based on interviews conducted with four out of eight staff (S1, S2, S4 & S8), R1 developed a pressure injury while in care. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met: Due to neglect/lack of supervision, Resident #1 developed an unstageable pressure injury on coccyx, therefore the above allegation “Resident sustained a pressure injury while in care” is found to be SUBSTANTIATED. REPORT CONTINUED IN LIC 9099-C Pursuant to Title 22 Division 6 of the California Code of Regulations, following deficiency was cited (refer to LIC 9099-D). Civil penalty assessed. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, “a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to Administrator Eric Mensah.the state’s words, verbatim · CDSS document, Nov 2, 2023 · control 11-AS-20200805163559

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87612(a)(11) · Plan of correction due date: Nov 3, 2023

87612 Restricted Health Conditions (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (11) Wound care as specified in Section 87631. This requirement was not met as evidenced by: According to the department’s review, there were no records that R1 received wound care for coccyx from Home Health and no records were found that facility staff repositioned R1 between 5/23/2020 and 5/30/2020 after facility staff found on 5/22/2020 that R1 sustained a quarter sized open area with surrounding redness on coccyx and it developed to an open bed sore on 5/31/2020. In addition, there was no evidence that the facility made attempts to follow-up on the request for home health services or medical assessment for R1’s coccyx during this period. However, home health continued in providing wound care to RI's right heel. On 6/2/2020, a new home health service for R1's coccyx commenced and it was revealed that R1 developed an unstageable pressure injury on coccyx. On 6/28/2020, Home health notes show R1’s pressure injury in coccyx was at Stage 3 and it progressed to Stage 4 on 7/12/2020. Based on interviews conducted with four out of eight staff (S1, S2, S4 & S8), R1 developed a pressure injury while in care. This poses an immediate health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 2, 2023

Plan of correction: At the time of visit, R1 was no longer living in the facility. Administrator Mensah agreed to adhere to the section cited herein and shall submit a self-certification of understanding the Section above. The administrator shall conduct an in-service training on this section to all care staff. POC shall be submitted to Lourdes.montoya@dss.ca.gov by the POC due date, 11/3/2023.