Sunrise of Beverly Hills

Type of visit: Annual/Random

On August 29, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual inspection for 1 Year Required. LPA Dabuet met with Assisted Living Coordinator Nancy Maya and explained the purpose of the visit. The facility is licensed to serve non-ambulatory adults aged 60 and over, with a total capacity of (127) residents, including (9) who may be bedridden. Additionally, the facility is approved to care for up to (20) hospice residents. Currently, there are (5) residents receiving hospice care. The facility is a five-story building situated in a commercial neighborhood. It features (80) resident units, each with a private bathroom. The facility includes several amenities, such as a gym and physical therapy room, a bistro, a formal dining room, a theater, and a restaurant-style kitchen. There are also two elevators for easy access throughout the building. Additionally, a large patio is located on the fifth and fourth floors, and several seating areas are on the first floor. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. Units were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected units: #117; #127; #209; #220; #314; #327; #503; and #522 in assisted living and #402 and #419 in memory care. The water temperature ranges from 106.9- 114.8 degrees F.; room temperature ranges from 70- 76 degrees F.; call buttons and smoke and carbon monoxide detectors are all in operating condition. LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. (Evaluation Report continues LIC 809-C) A commercial kitchen was inspected, and there is sufficient perishable and non-perishable food available and properly stored. All fire extinguishers were charged. A review of Fire Drills was completed on 08/12/26 at 3 PM. Several working landline phones are available on-site. A review of Medication Administration Records found to be in order and accurate. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, as well as sanitizing stations in common areas and restrooms. All mandated inspection control posters, including the Activities Calendar and Food Menu, were posted. The facility included stairway evacuation chairs in all the stairwells. An audits of residents' service records for residents #1-#5 (R1-R5) and staff personnel records for staff #1-#5 (S1-S5) were accurate and complete. The facility is current on Community Care Licensing annual fees. The facility has a current administrator certificate on file for Sean Taghizadeh, #6740, valid as of 05/29/2026. The facility has a Certified Liability Insurance Certificate, policy #7850, effective 09/01/25 through 09/01/26. The facility has the current Emergency and Disaster Plan, LIC 610E, on file. No Deficiencies were identified during this inspection visit. An exit interview was conducted, and a copy of this report was provided to Sean Taghizadeh. Note: due to technical difficulties, you were unable to generate an electronic inspection tool and instead used a printable/PDF version.the state’s words, verbatim · CDSS document, Aug 29, 2026

Allegation investigated: Resident sustained unexplained injuries while in care Staff did not properly report an incident involving a resident Staff allowed a resident to be soiled Staff did meet a resident's incontinence needs Staff did not prevent a resident from entering another resident's bedroom.

On August 5, 2026, Licensing Program Analyst (LPA) Antonine Richard conducted a follow-up visit to interview additional staff members and residents regarding the LPA Iniguez complaint visit created on June 18, 2026 (Complaint Number: 11-AS-20260202103336). During today's visit, LPA Richard met with Sean Taghizadeh, the Executive Director, and explained the purpose of the visit. On August 5, 2026, LPA Richard interviewed 3 staff members (S1-S3) and one resident (R2) and observed other residents in the Reminiscence area. After the interviews and observations, the report created on June 18, 2026, remained unchanged. For details on deficiencies, refer to the LIC9099D created on June 18, 2026. An exit interview was conducted. A copy of this report was provided to the Executive Director, Sean Taghizadeh. Substantiatedthe state’s words, verbatim · CDSS document, Aug 5, 2026 · control 11-AS-20260202103336

Allegation investigated: Resident sustained unexplained injuries while in care Staff did not properly report an incident involving a resident Staff allowed a resident to be soiled Staff did meet a resident's incontinence needs Staff did not prevent a resident from entering another resident's bedroom

On 6/18/2026, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met Sean Tahizadeh/Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: the department conducted the following interviews: former Administrator Interview (A#1). The department gathered the following documents: copy of client roster and staff roster dated:5/11/26, copies of emails between (R#1)’s representative and facility, and copy of (R#1)’s Special Incident Report dated 1/22/2026. Evaluation Report continues LIC 9099-C Substantiated Investigation Revealed the Following: Unexplained Injuries While in Care The details of the complaint alleged that (R#1) sustained unexplained injuries while in care. On 5/12/26, during the records review, the Department obtained evidence that showed (R#1) sustained injuries to the knees and shoulder while in the care of staff. Interviews and email correspondence indicated that (R#1) was being assisted in the bathroom by (S#1) when the fall occurred, and that family-reviewed video footage showed (S#1) entering (R#1)’s room alone despite a documented two-person assist requirement. In addition, the evidence showed that (S#1) did not disclose the fall for approximately 36 hours and provided an account inconsistent with the injuries observed (“fell on their bottom”). Moreover, the evidence demonstrates that facility leadership acknowledged that (S#1) was placed on leave pending investigation and subsequently terminated. In addition, the Department reviewed a copy of the Special Incident Report dated 1/22/2026; the Department noted that the report documented that (R#1) “slid down to the ground” while being assisted in the restroom, that (R#1) later complained of pain to both knees and the left arm, and that staff requested medical evaluation due to ongoing pain. On May 14, 2026, during an interview with former facility administrator (A#1), he stated that he was informed by the Registered Nurse one day after the incident that (R#1) had leaned against the wall and slowly slid to the floor while being assisted in the bathroom. He reported that (R#1)’s service plan identified them as requiring a two-person assist for toileting, and that facility Registered Nurse and Reminiscence Coordinator were dispatched for immediate assessment and follow-up. In addition, (A#1) further stated that surveillance footage later provided by (R#1)’s representative showed only (S#1) entering the room and assisting (R#1) to the bathroom where the incident occurred. He reported that, following review of the incident, all Reminiscence staff were re-in serviced by the Reminiscence Care Coordinator regarding the requirement to follow resident care plans, specifically related to two-person assist interventions. Evaluation Report continues LIC 9099-C Staff Did Not Properly Report an Incident The details of the complaint alleged that staff failed to properly report an incident involving (R#1). On 5/12/26, during the records review, the Department obtained evidence reflecting that the fall occurring on January 19 was not reported by the assigned caregiver, and the family learned of the incident only after observing injuries the following morning. Further evidence showed that the staff failed to notify management or the family and that the incident remained undisclosed for more than 24 hours. Facility leadership did not dispute the failure to report and indicated that the matter was under internal review. In addition, the Department reviewed a copy of the Special Incident Report dated 1/22/2026; the Department noted that the report acknowledged a delay in reporting and properly documenting the incident involving (R#1), including the statement: “There was a delay in reporting incident and documenting properly.” On May 14, 2026, during an interview with former facility administrator (A#1), he stated that (S#1) was disciplined for failure to follow the resident’s care plan and for the delay in reporting the incident, and that (S#1)’s employment was ultimately terminated. Resident Was Left Soiled The details of the complaint alleged that (R#1) was left soiled while in care. On 5/12/26, during the review of the records, the Department obtained evidence indicating that paramedics returned (R#1) to her room late at night and that the staff member who received her placed her in bed without checking her condition. The following morning, the morning lead discovered (R#1) soaked in urine, with a strong ammonia odor present in the room, and contacted the family. The facility acknowledged communication gaps among staff regarding (R#1)’s return and did not dispute the family’s account. Evaluation Report continues LIC 9099-C On May 14, 2026, during an interview with former facility administrator (A#1), he stated that after reviewing surveillance footage provided by (R#1)’s representative, it appeared that paramedics transferred (R#1) from the gurney to her bed upon return to the community. He reported that staff appeared focused on ensuring (R#1) was positioned comfortably in bed; however, it did not appear that staff checked for the presence or condition of a continence product at that time. Staff Did Not Meet Resident’s Incontinence Needs The details of the complaint alleged that staff did not meet (R#1)’s incontinence needs. On 5/12/26, during the records review, the Department obtained evidence indicating that (R#1) experienced repeated episodes of dry briefs despite known incontinence, and staff did not identify or report signs of urinary retention or constipation. (R#1) was later hospitalized with severe fecal impaction causing urinary obstruction, requiring inpatient treatment. It was reported that toileting and hydration protocols previously discussed with the facility were not implemented. The facility did not dispute the account and acknowledged ongoing concerns regarding care coordination. In addition, the Department reviewed a copy of the Special Incident Report dated 1/22/2026; the Department noted that the UCLA Emergency Room report documented constipation. On May 14, 2026, during an interview with former facility administrator (A#1), he stated that resident care plans are reviewed during weekly care meetings and are also discussed during daily shift crossovers to ensure staff remain aware of individualized care needs. (A#1) explained that care plans are accessible to staff through their individual electronic tablets for both review and documentation purposes. Evaluation Report continues LIC 9099-C Staff Did Not Prevent Resident from Entering Another Resident’s Bedroom The details of the complaint alleged that staff failed to prevent another resident from entering (R#1)’s bedroom. On 5/12/26, during the records review, the Department obtained information that showed staff did not prevent another resident from entering (R#1)’s bedroom. Email documentation shows that a male resident entered (R#1)’s room late at night wearing only undergarments and got into bed with her. Staff reportedly had difficulty removing the resident without waking (R#1). The family reported that the room was normally locked due to known wandering behavior but was not secured on the night of the incident. Facility leadership acknowledged the event and agreed to provide an overnight caregiver at the facility’s expense as a temporary safety measure. On May 14, 2026, during an interview with former facility administrator (A#1), he stated that that Sunrise’s expectation regarding resident room access is consistent throughout both daytime and nighttime hours, and that resident rooms in the Reminiscence unit are to always remain unlocked. He reported that he was informed by (R#1)’s representative the morning after the incident that another resident had entered (R#1)’s room and laid down next to her in bed. He stated that (R#1)’s representative advised she had reviewed surveillance footage related to the incident and shared the footage with him. During this investigation, LPA found 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 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 Sean Tahizadeh/Executive Director.the state’s words, verbatim · CDSS document, Jun 18, 2026 · control 11-AS-20260202103336

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Jul 13, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable... This requirement was not met as evidence by: Based on records review, the facility staff failed to ensure (R#1) received the level of assistance required by their individualized care plan. Documentation showed that (S#1) assisted (R#1) in the bathroom without the required two person assist. In addition, the facility staff failed to assist (R#1) with their toileting needs. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: Licensee will adhere to Title 22 at all times. As plan of correction the facility will conduct an all staff in-service to review residents care plans. A copy of the in-service meeting will be email to LPA Iniguez.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jun 29, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement was not met as evidence by: Based on records review, the facility staff failed to ensure that (S#1) did not notify facility leadership or (R#1)’s responsible party of the fall, and the incident remained undisclosed for more than 24 hours. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: Licensee will adhere to Title 22 at all times. As plan of correction the facility will conduct an all staff in-service regarding reporting any incidents before the end of the shift. A copy of this in-service will be sent ot by email to LPA Iniguez.

Allegation investigated: Staff did not ensure supervision was provided to resident resulting in multiple fractures from a fall. Staff did not ensure resident received medical attention in a timely manner. Staff did not observe changes in residents physical health. Staff did not ensure reporting requirements were followed

On 4/27/2026 LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Sean Taghizadeh/Executive Director LPA explained the purpose of this visit. Investigation Consisted of: the department conducted the following interviews: Administrator Interview (A#1), Facility Staff Interviews (S#1-S#4), Witnesses Interviews (W#1-W#4) and Residents Interviews (R#1-R#9). The department gathered the following documentation: Copy of (R#1) hospital medical records dated:10/23/25 and copies of (R#1)’s interdisciplinary notes from facility, various dates, copy of (R#1) facility notes, various dates, and copy of (R#1) incident report dated:10/23/2025. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff did not ensure supervision was provided to resident resulting in multiple fractures from a fall. The details of the complaint alleged that facility staff did not ensure supervision was provided to (R#1) resulting in multiple fractures from fall. On October 20, 2025, during the records review, the Department observed documentation consistent with the facility’s reporting of the incident and subsequent monitoring of (R#1). On the same date, (R#1) sustained an unwitnessed fall. The facility caregiver conducted rounds at approximately 06:00 a.m. and observed (R#1) in bed, asleep. At approximately 06:40 a.m., during the second rounds, (R#1) was discovered on the bathroom floor of their bedroom and was assessed by the facility nurse with no visible injuries noted. (R#1) was placed on observation. On October 21, 2025, (R#1) appeared to have some pain, and the facility requested X-rays, which were pending from the medical doctor. On October 22, 2025, (R#1) had a visible change in condition and was unable to bear weight, collapsing into the arms of a caregiver. (R#1) was transported to the local hospital and admitted to the emergency room, where they were diagnosed with a large left pneumothorax, moderate left pleural effusion, and mildly displaced left posterolateral fourth through seventh rib fractures. Based on the information reviewed and interviews conducted, there was no evidence that the facility neglected (R#1)’s care. On October 20, 2025, during interviews with witnesses (W#1–W#4), (4) out of (4) stated they had no concerns regarding the care provided to residents in care, including (R#1). Witnesses reported that during their visits, (R#1) appeared well and that they had never observed any indication of neglect by the facility. Witnesses further stated that (R#1) was consistently clean, groomed, and in good spirits. One witness reported making unannounced visits and stated they had never observed neglect of care toward any residents. Another witness stated they had never seen any signs of abuse or neglect by the facility. A witness also stated they had no concerns regarding the care provided, had never had any inclination of neglect, and was satisfied with the type of care the facility provided. Evaluation Report continues LIC 9099-C On October 20, 2025, during interviews with facility staff (S#1–S#4), (4) out of (4) stated that they had no concerns regarding the care provided to residents in care, including (R#1). Staff reported that they had not observed any signs of neglect, abuse, or unexplained injuries and stated that residents appeared well cared for, clean, and appropriately supervised. In addition, (4) out of (4) facility staff further stated that the facility followed established procedures for monitoring residents and responding to changes in condition. Allegation: Staff did not ensure resident received medical attention in a timely manner The details of the complaint alleged that facility did not ensure (R#1) received medical attention in a timely manner. On October 20, 2025, during the records review, the Department observed documentation consistent with the facility’s reporting of the incident and subsequent monitoring of (R#1). On the same date, (R#1) sustained an unforeseen, unwitnessed fall. Facility caregivers conducted rounds at approximately 06:00 AM and observed (R#1) in bed, asleep. At approximately 06:40 AM, (R#1) was discovered on the bathroom floor of her bedroom. (R#1) was assessed by the facility nurse, who noted no signs of injury or indications of a possible fracture. (R#1) was placed under observation for any change in condition. On October 21, 2025, (R#1) appeared to be in pain, and the facility requested X-rays to be completed. The facility arranged for (R#1) to be transported to the local hospital for further evaluation. Allegation: Staff did not observe changes in residents physical health. The details of the complaint alleged that facility did observe (R#1)’s changes in physical health. On April 27, 2026, during the records review, the Department observed copies of (R#1)’s facility staff notes. The Department noted multiple documented changes in condition for (R#1), including an entry dated 10/23/2025 in which staff reported (R#1)’s “color was off” and that the resident “was not making any sense,” after which 911 was called and (R#1) was transported to Cedars ER. The Department also noted documentation of unwitnessed falls on 10/20/2025 and 10/04/2025, with post-fall evaluations and notifications to (R#1)’s responsible party and physician. Evaluation Report continues LIC 9099-C Additional health status notes reflected a broken or missing lower front tooth on 10/5/2025 and a nosebleed on 9/16/2025, both with notifications to the responsible party and physician. On April 27, 2026, during an interview with the Executive Director (A#1), he stated that the facility’s procedures for observing, monitoring, and documenting changes in residents’ physical health, including (R#1), involve the care team documenting observations electronically in their tablets and informing their supervisor when they notice any significant changes in a resident’s condition. (A#1) further stated that when a change in condition or incident requires an incident report, the care team contacts the family or responsible party and documents the incident. He stated that incident reports are then reviewed by the nurses to ensure appropriate follow-up and reporting. On 4/27/2026, the Department could not speak with (R#1) as they no longer reside at the facility. The Department attempted to contact (R#1) using the phone number on file; however, the Department could not reach them. On April 27, 2026, during interviews with residents in care (R#2 through R#9), (8) out of (9) stated that when they are not feeling well or when something about their health changes, staff usually notice and check on them. In addition, residents also stated that staff appear aware of how they are doing day to day, including their energy, appetite, and mobility, with residents reporting that staff “come every day. On April 27, 2026, during interviews with facility staff (S#1 through S#4), (4) out of (4) staff stated that they monitor residents, including (R#1), for changes in their physical condition by conducting daily checks with the care team and observing for changes in mobility, appetite, hygiene, or overall appearance. Staff stated that they document any observed changes. In addition, (4) out of (4) staff further stated that when they notice a change in a resident’s physical health, they are expected to notify the family or responsible party immediately and notify the resident’s physician. Evaluation Report continues LIC 9099-C Allegation: Staff did not ensure reporting requirements were followed The details of the complaint alleged that facility did report to (R#1) representatives on their events. On April 27, 2026, during the records review, the Department evaluated whether staff followed required reporting procedures for changes in condition and incidents involving (R#1). The Department noted multiple entries in which staff documented changes in condition and completed required notifications. This included an entry dated 10/23/2025 in which staff reported that (R#1)’s “color was off” and that the resident “was not making any sense,” after which 911 was called and (R#1) was transported to Cedars ER, with notifications made to the responsible parties and the primary care physician. In addition, the Department observed a copy of (R#1)’s incident report dated 10/23/2025 and noted that when (R#1) sustained a fall on 10/20/2025, the facility informed (R#1)’s representative and the Department. On April 27, 2026, during an interview with the Executive Director (A#1), he stated that the facility ensures staff follow mandated reporting requirements through online training and in-service trainings provided as needed. (A#1) further stated that the facility reported incidents involving (R#1) to the resident’s representatives and that a copy of the LIC 624 was provided, along with documentation in the notes indicating when the responsible party was informed. On 4/27/2026, the Department could not speak with (R#1) as they no longer reside at the facility. The Department attempted to contact (R#1) using the phone number on file; however, the Department could not reach them. On April 27, 2026, during interviews with residents in care (R#2 through R#9), (8) out of (9) residents stated that when something changes with their health, staff talk to them or let them know if they are informing anyone about it. in addition, residents also stated that if they tell staff they are not feeling well or need help, staff follow up with them or notify someone else as needed. Evaluation Report continues LIC 9099-C On April 27, 2026, during interviews with facility staff (S#1 through S#4), (4) out of (4) staff stated that the facility’s procedures for reporting changes in condition, incidents, or unusual observations begin with the caregiver identifying the concern and initiating an alert. Staff stated that after an alert is initiated, they notify the party responsible and the resident’s physician and then follow any instructions provided by the physician. In addition, (4) out of (4) Staff further stated that when they report a concern or change in a resident’s condition, the information is communicated to the appropriate individuals by updating the resident’s care plan and notifying the resident’s family, such as when a resident sustains a fall. During this investigation, the Department 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 Sean Taghizadeh/Executive Director.the state’s words, verbatim · CDSS document, Apr 27, 2026 · control 11-AS-20251112141341

Type of visit: Case Management - Incident

On 3/27/2026, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced Case Management visit to Sunrise of Beverly Hills. The purpose of today’s visit is to serve an ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY for staff #1. LPA met with James Howland/Executive Director and explained the purpose of today’s visit. California Department of Social Services determined that staff #1 violated California Code of Regulations Title 22. Government Code 11522 was also issued, informing the licensee that an excluded person may petition for reinstatement to the Department one year after the effective date of the exclusion order. LPA delivered copies of the immediate exclusion letters for the following facility to James Howland/Executive Director. Staff #1 (S1) were not present at the facility at the time of the visit. Staff #1 was mailed the Immediate Exclusion Order letter and Government Code 11522. The Administrator read the Immediate Exclusion from Facility Order and acknowledged understanding the immediate exclusion order and that the mentioned staff is not allowed to be physically present at the facility. An exit interview was conducted with James Howland/Executive Director and copies of Order to Licensee/Facility of Immediate Exclusion from Facility and Government Code 11522 were provided. The report was signed by James Howland/Executive Director and copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 27, 2026

Type of visit: Case Management - Other

On August 15, 2025 Licensing Program Analyst (LPA) Deborah Lee conducted a Case Management visit to facility listed above. LPA Lee met with Jim Howland, Executive Director and explained the purpose of the visit. On July 23, 2025 LPA Inguez conducted a Case Management visit as part of complaint investigation (11-AS-20250716110807) where the facility's elevator had been in disrepair since June 26, 2025. Today's visit serves as a follow up and to see if there are protocols in place to ensure safety of residents in care.. Jim Howland informed LPA that there was a conference call with Elevator company OTIS and facility personnel and Resident Council president on 8/14/25 to resolve the issue. As of today 8/15/25, 2 of the 3 elevators are now working with the expectation of the 3rd being repaired and completed today 8/15/25. OTIS repair company is currently on site.In the event that the elevator is not repair, Executive Director will notify Community Care Licensing. There are no safety concerns to report at this time, as the Sunrise senior community is following their safety procedures put in place. No deficiencies cited during today's visit. Exit interview conducted and report provided to Executive Director Jim Howland.the state’s words, verbatim · CDSS document, Aug 15, 2025

Allegation investigated: Facility staff does not ensure elevators are in good repair

On 7/30/25, at approximately 10:00 AM, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met with Jim Howland/Executive Director. LPA explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Executive Director(A#1), Residents (R#1-R#5), Witnesses(W#1-W#2) and Elevator Technician (E#1). LPA obtained and reviewed the following documents: Resident’s Roster dated:7/30/25, Personnel Roster dated:7/30/2025 and a Health and Safety Check of the facility elevators. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Allegation: Facility staff does not ensure elevators are in good repair. The details of the complaint alleged that the elevator that works in the facility closes for residents without stopping. On July 30, 2025, at approximately 12:30 PM, during a health and safety inspection of the facility elevators, LPA Iniguez observed residents using the elevator to return to their rooms after lunch. He noted that the elevator doors did not close abruptly or quickly on them. On July 30, 2025, at approximately 10:30 a.m., the Executive Director (A#1) reported that the first elevator has been out of service for over 30 days. This elevator is located inside the facility and is responsible for transporting residents between the bottom floor and the fifth floor. (A#1) mentioned that two technicians are currently working on it. He also noted that, prior to July 25, 2025, he was unaware of issues with the second elevator until a family member alerted him that it was closing quickly on people. Following this report, (A#1) requested that repairs be made. The elevator company was onsite on July 25 and July 26, and they are now working on fixing the broken elevator as well as inspecting the second one. On July 30, 2025, at approximately 10:30 am, during an interview with the facility maintenance director (S#1), he acknowledged that one of the elevators is currently out of service. However, he noted that the working elevator does not close quickly on people. On July 30, 2025, at approximately 11:00 am, during an interview with residents who live on the second floor (R#1-R#5), (5) out of (5) stated that the elevator door had never closed on them quickly before. Evaluation Report continues LIC 9099-C On July 30, 2025, at approximately 2:00 pm, during an interview with witnesses (W#1-W#2), (2) out of (2) stated that the times they come and visit their family at the facility, they have never experienced the elevator door closing on them quickly. On July 30, 2025, at approximately 3:00 PM, during an interview with the elevator technician (E#1), they explained the operation of the elevator's door system. The elevator has a built-in timer that allows the door to remain open for approximately 10 seconds after closing. If someone needs to hold the door for another person to enter, the door can remain open for up to 20 seconds. After this time, the door will attempt to close, bypassing the infrared sensors until it shuts completely. If the door does not close completely, it will reopen and shut off the electrical system until a technician can reboot it. LPA Iniguez inquired whether there are any safety hazards associated with the elevator door closing on someone. (E#1) reassured that there are no safety hazards, as the force exerted by the door is less than 15 pounds, which complies with state regulations. During this investigation, LPA did not find sufficient evident 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 JIM Howland/Executive Director.the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 11-AS-20250728144911

Type of visit: Required - 1 Year

On 7/30/2025, Licensing Program Analyst (LPA) Iniguez and Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with James Howland Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (127) non ambulatory elderly adults ages 60 and above, of which (9) can be bedridden. The facility has an approved hospice waiver for (20). The facility has 80 units, and approximately 86-bathrooms, is five stories tall with a basement garage. The facility is a beige in color structure with a gym/ physical therapy room, bistro, formal dining room, theater, a restaurant style kitchen, and two elevators. There is a large patio area on the 3rd floor and other sitting areas on the 1st floor. LPA Iniguez and the Executive Director toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (10) bedrooms and (10) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113.5°F to 115.2°F, and the room temperature ranged from 75°F to 76°F. During the visit, LPA's observed that the facility was clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 7/28/25. LPA Villegas conducted a review of (4) residents' service files and (4) staff personnel files were maintained in order. LPA reviewed (4) Medication Administration Records (MARs) and found no discrepancies. LPA Iniguez reviewed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. Liability insurance is active (XSLG48928079). Facility Annual Fess current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Executive Director James Howland.the state’s words, verbatim · CDSS document, Jul 30, 2025

Allegation investigated: Staff do not ensure elevator is in good repair

On 7/23/25, at approximately 9:30 AM, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met with Melon Rivera/Executive Director. LPA explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Executive Director(A#1). LPA obtained and reviewed the following documents: Resident’s Roster dated:7/23/25, Personnel Roster dated:7/23/2025, and copies of email chain of communication between facility and OTIS Elevators: various dates. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Allegation: Staff do not ensure elevator is in good repair. The details of the complaint alleged that the facility is doing nothing to fix the elevator that is in disrepair. On July 23, 2025, at approximately 9:30 AM, during an interview with the Executive Director (A#1), it was reported that an elevator broke down on June 26, 2025, and requires a valve replacement due to overheating. (A#1) mentioned that they are still awaiting the delivery of the part needed to repair the broken elevator. Currently, only one of the two elevators is operational. Furthermore, (A#1) stated that the facility has an open contract with OTIS Elevators. Because they manufacture elevators, the facility is unable to hire a different repair company. On July 23, 2025, at approximately 10:30 AM, during a records review, LPA Iniguez observed copies of emails exchanged between (A#1) and OTIS Elevators. On June 26, 2025, (A#1) reported a malfunctioning elevator via a phone call. The same day, a technician from OTIS Elevators arrived to assess the situation and subsequently shut down the elevator. On June 27, 2025, (A#1) followed up with an email indicating that a technician had come the previous day and shut down one of the elevators. (A#1) emphasized the need for assistance regarding this issue. Later that day, the account manager for OTIS Elevators responded to (A#1)’s email, stating that the technician had reported the problem was due to an overheated valve that needed replacement. To prevent future occurrences, they planned to install two oil coolers in the elevators. Additionally, LPA Iniguez noted that the facility communicated with the repair company via email on the following dates: June 30, July 1, July 9, July 10, July 16, July 18, July 20, and July 21, 2025. These emails documented the facility's efforts to resolve the elevator issue as promptly as possible. Evaluation Report continues LIC 9099-C During this investigation, LPA did not find sufficient evident 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 Melon Rivera/Executive Director.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 11-AS-20250716110807

Type of visit: Case Management - Deficiencies

On July 23, 2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a case management visit. LPA Iniguez met with Melon Rivera, the Executive Director, to explain the purpose of the visit. During this visit, which was part of a complaint investigation (11-AS-20250716110807), it was discovered that the facility's elevator had been in disrepair since June 26, 2025. The facility had not reported this issue to the department. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See page D for more information. -Reporting Requirements-Type B Citation. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Melon Rivera/Executive Director.the state’s words, verbatim · CDSS document, Jul 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 25, 2025

87211 Reporting Requirements a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by: Based on observation and interviews, facility staff failed to report to the department that one of the elevators was in disrepair since 6/26/25. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2025

Plan of correction: Licensee will adhere to Title 22 at all times. As Plan of Correction, administrator will provide an Unusual Inident Report to the that will include guidance received from the fire department and a sefety action plan. POC will be sent via email to LPA Iniguez before POC due date.

Type of visit: Case Management - Incident

On July 23, 2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a case management visit. LPA Iniguez met with Melon Rivera, the Executive Director, to explain the purpose of the visit. On July 19, 2025, the Department received an Unusual Incident Report (LIC 624) via fax. The report states that on 7/15/25, the facility received an anonymous call reporting an allegation of physical abuse that happened about a month ago regarding (R#1). Before this report, a Report of Suspected Dependent Adult/Elder Abuse or SOC 341 was submitted to the Department on 7/16/25. This report indicated that on 6/4/2025, the suspected abuser (S#1) encountered resistance while assisting (R#1) with their peri-care. (R#1) locked their legs during the hygiene session, and (S#1) was observed to use additional force to complete the peri-care. Another facility staff member (S#2) was present during this incident and noted a nonverbal response from (R#1). On July 23, 2025, Licensing Program Analyst LPA Alfonso Iniguez gathered additional documentation related to this visit. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Melon Rivera/Executive Director.the state’s words, verbatim · CDSS document, Jul 23, 2025

Type of visit: Case Management - Incident

On January 31, 2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a case management visit. LPA met with Zach Howell, the executive director, and explained the purpose of the visit. On 1/25/25, the Regional Office received an Unusual Incident/Injury Report or LIC 624 and a Report of Suspected Dependent Adult/Elder Abuse or SOC 341 regarding a facility resident in the assisted living (R#1) and a friend of theirs were found in bed by two facility staff. Facility staff promptly notified Beverly Hills Police Department Case Number 25-4314. After the investigation, police stated they believed it was a consensual encounter. On 1/31/2025, LPA Iniguez visited the facility, gathered documentation, interviewed (R#1) and conducted a Health and Safety Check at 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 Zak Howell/Executive Director.the state’s words, verbatim · CDSS document, Jan 31, 2025

Allegation investigated: Staff did not ensure residents room was kept clean. Staff did not provide shower assistance to resident in care. Resident was not provided good quality food.

On January 14,2025, an associate from the California Department of Social Services/Community Care Licensing (CDSS/CCL) conducted a subsequent, unannounced complaint visit. The Senior General Manager, Zachary Michael Howell, greeted the associate. The associate explained that the purpose of this visit was to investigate the allegations mentioned above. The investigation included a tour of the facility, interviews, and the collection of records. Interviews were conducted with staff members #1 to #6 (S1-S6) and residents #1 to #7 (R1-R7). The associate reviewed several documents, including the Personnel Report LIC 500 (dated 10/23/24), the Facility Roster (dated 01/10/25), the Resident Council Meeting (dated 12/17/24), the Facility Shower Schedule Log (dated: 01/01/25-01/10/25), the Housekeeping Staff Schedule, Facility Daily Menu, Dietitian's Quarterly Assurance Report (dated 10/03/24), and (R1-R7) Facility Face Sheets. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not ensure residents room was kept clean. The complaint alleged that the facility does not keep residents' rooms clean. It is reported that staff do not maintain the upkeep of the resident's refrigerator, which contained old food that smelled with odor. It is also noted that the staff would stack cleaned, laundered clothes on top of dirty ones. No further details were provided regarding this issue. On January 10, 2025, between 9:15 AM and 10:50 AM, the Department interviewed all three staff members identified as Staff #1, Staff #2, and Staff #3 regarding the allegation, which they claimed was fabricated. Staff #1 and Staff #2 mentioned that the facility employs four housekeepers, and each staff member is responsible for cleaning an entire floor. They stated that housekeeping and laundry services are included as part of the living accommodations outlined in the Residency Agreement, with services provided once a week or as needed. Staff #1 and Staff #3 noted that the housekeeping team is responsible for the upkeep and cleaning of the refrigerator. However, it was reported that residents often refuse housekeeping services, including the cleaning of refrigerators and the disposal of expired food items. In such cases, Staff #3 stated they would notify the maintenance coordinator and the front desk. Staff #4 confirmed that laundry services are also provided once a week or as needed. Residents are instructed to prepare their dirty clothes in a laundry bag and place it outside their door on designated laundry days. The clean, laundered clothes are returned in bags marked with the date, room number, and a “Clean” label. Staff #4 noted that the clean laundry is never placed on top of the dirty clothes. On January 10 and 14, 2025, between 10:20 AM and 11:20 AM, the Department conducted interviewed (7) out of (7) residents, identified as R#1 through R#7. None of the residents could verify the allegations made. R#1 - R#7 reported that the housekeeping and laundry staff provided adequate services. They confirmed that housekeeping is performed once a week, and they also stated that it is the residents' responsibility to maintain their rooms in a clean and sanitary condition, which includes keeping the refrigerator clean. Additionally, R#1 through R#7 expressed that they had no issues or concerns regarding the handling of their laundry. (Evaluation Report continues LIC 9099-C) The Department's review of the facility's housekeeping schedule revealed that staff members service rooms once a week. According to the facility's Residency Agreement, Article VI, Section A, subsections #1 and #2 specify that laundry and housekeeping services are included in the living accommodations. It also states that under "Housekeeping," residents are responsible for keeping their suites clean and sanitary. On January 10 and 14, 2025, between 9:30 AM and 11:20 AM, the Department inspected rooms #116, #119, #202, #211, #212, #218, and #317. The inspections noted that these rooms and refrigerators were maintained orderly, clean, and sanitary. Based on the gathered information, insufficient evidence supports the stated allegation. Allegation #2: Staff did not provide shower assistance to resident in care. The complaint indicated that facility staff did not provide shower assistance to residents in care. It was reported that a resident had not received a shower in over a week. No further details were provided regarding this issue. On January 10, 2025, between 9:15 AM and 10:50 AM, the Department interviewed (2) out of (2) staff members, identified as Staff #1 and Staff #6, who claimed that the allegation was false. They stated that residents are being assisted with bathing as part of their Personal Assistance and Care. According to the residents' care plans, assistance is provided with activities of daily living, including bathing, dressing, ambulating, and help with medications and scheduling medical and dental appointments. Staff #1 and Staff #6 disputed the claim that a resident had gone without bathing services for over a week. Staff #6 noted that residents receive bathing assistance ranging from once a week to daily services, depending on each resident's care plan. Additionally, if a resident refuses bathing, the lead care manager will offer sponge baths as an alternative. On January 10 and 14, 2025, between 10:20 AM and 11:20 AM, the Department interviewed (7) out of (7) residents, identified as R#1 through R#7, who could not validate the allegation. R1 through R7 reported no complaints or concerns regarding bathing assistance and expressed satisfaction with the services provided by the staff. (Evaluation Report continues LIC 9099-C) A review of the Residency Agreement, specifically Article VI, Section B regarding Services to Residents in the Community, revealed that bathing is included as an essential service offered. An audit of the resident Shower Log (dated 01/01/25 - 01/10/25) confirmed that residents were assisted with bathing once a week, or on all seven days. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation #3: Resident was not provided good quality food. The complaint states that the facility does not provide high-quality food to its residents. Many residents have expressed their dissatisfaction with the food quality, although no further details were provided regarding this issue. On January 10, 2025, between 9:15 AM and 10:20 AM, the Department interviewed (2) out (2) staff members, identified as Staff #1 and Staff #5, who both claimed that the allegation was false. They indicated that the facility employs registered dietitians who assess the nutritional needs of the residents and monitor their meal plans. Additionally, Staff #1 and Staff #5 mentioned that Crandall Corporate Dietitians oversee the meals and conduct quarterly audits to ensure compliance. According to Staff #1 and Staff #5, the meals served to residents meet health standards, are of good quality, and provide adequate portions. Staff #5 specifically remarked that no substandard meals are served. Furthermore, the facility offers meal substitutes and can accommodate residents with special dietary restrictions. S1 and S6 claimed the food supply is provided Sysco a reputable company. On January 10 and 14, 2025, between 10:20 AM and 11:20 AM, the Department interviewed (7) out of (7) residents, identified as R#1 – R#7, who could not corroborate this allegation. R1-R7 reported that the meals served are high-quality and adequately cooked. In addition, the facility offers meal substitute options and caters to residents with special diet restrictions. The Department reviewed the lunch served on January 10, 2025, which provided a healthy and balanced diet consisting of protein, carbohydrates, fats, and vegetables. An examination of the facility's Daily Menu (dated 01/10/25) and the Crandall Corporate Dietitian Assisted Living Quarterly Audit Report (dated 10/03/24) indicated that the facility meets standards with a Meal Service rating of 100%, a Nutritional Assessment score of 83%, and an overall Quality Control Compliance rating of 97%. (Evaluation Report continues LIC 9099-C) On January 14, 2025, the Department conducted an inspection of the food supply. The Department found that the food was stored safely and prepared using proper hygiene practices. The items were labeled correctly, and all foods were maintained at safe temperatures. Additionally, a review of the facility’s Resident Council Meeting notes (dated 12/17/24) highlighted that dining services were discussed, and there were no complaints or concerns raised about the meals. Based on the gathered information, there is insufficient evidence to support the stated allegation. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted with Zachary Howell, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 11-AS-20250102134203

Type of visit: Case Management - Other

On November 7,2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management visit. LPA met with Zach Howell/Executive Director and the purpose of the visit was explained. On September 18, 2024, during a subsequent complaint visit to another Residential Care Facility for the Elderly (RCFE), the Department found that the facility's surveillance cameras in the common areas were equipped with audio recording capabilities. This practice violated the privacy rights of the residents. Additionally, LPA Iniguez noted that the facility was not adhering to section 1569.153 of the Health and Safety Code regarding the admission of new residents. On November 7, 2024, LPA Iniguez and Executive Director Zach Howell reviewed the video surveillance cameras together. LPA Iniguez noted that the system does not have audio capabilities. Additionally, they reviewed a total of (7) residents' files and confirmed that the facility is in compliance with Section 1569.153 of the Health and Safety Code. 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 this Case Management report was provided to Zach Howell / Executive Director.the state’s words, verbatim · CDSS document, Nov 7, 2024

Allegation investigated: Staff did not ensure that a resident's incontinence needs were met Staff do not answer a resident's call button in a timely manner Staff do not monitor a resident for change in condition

**This amended LIC9099, dated 12/09/2024, supersedes the original LIC9099, dated 10/03/2024** Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Thursday, October 03, 2024, upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a risk assessment. Based on the evaluation, the facility is cleared of COVID-19 infection. LPA Bunker met with The facility Nurse Liza Bond. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: Interviews were conducted with staff members 1-3 (S1-S3) and residents 1-7 (R1-R7). LPA Bunker asked pertinent questions relevant to the nature of the complaint. S1-S3 and R2-R7 stated that staff ensure that a resident's incontinence needs are met, that the resident's call button is answered in a timely manner, and that the staff monitors residents for changes in their condition. During visits, we toured the facility, including buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats or concerns. No evidence of neglect or abuse was observed during these visits on October 02, 2024, and October 03, 2024. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 LPA Bunker requested a copy of the personnel report, and resident roster, and reviewed the resident files, including the physician's report, medical records, admission agreement, identification and emergency information, medication records, medication administration records (MARs), medication logs, medical assessments, consent forms, incident reports, appraisal & needs service plan. LPA Bunker requested copies of supporting documents. S1-S2 stated that R1 handles its own medications and medical appointments. Allegation #1: Staff did not ensure that a resident’s incontinence needs were met Interviews with staff members S1-S3 (S1-S3) stated that there was no indication in R1's medical records that R1 was experiencing incontinence need. S1-S3 stated that R1 was not receiving incontinence assistance per the resident's needs and services plan. S1-S3 stated that R1’s undergarments were dry, and there was no evidence of R1 sitting in urine overnight. S1-S3 stated that R1 does not receive one-on-one care and that R1 had accidentally fallen after sliding from her bed, which was positioned low to the floor as per the resident’s preference. S1-S3 stated that prior to the fall, staff had just left R1’s room, and R1 was doing well. Shortly after the fall, a family member called to inform staff. While S3 was still on the phone with the family member, S3 proceeded to R1’s room to provide assistance, and staff promptly called for additional help. The Care Manager responded immediately. S3 stated that a complete body check was conducted for injuries, but at first, R1 refused the body check. Staff observed a discoloration on R1’s left leg. It was unclear whether the discoloration resulted from the fall or was present prior to the fall. S1-S3 stated that R1 reported feeling fine, declined hospital care, and refused medical treatment. S3 states that she and the Care Manager assisted R1 back to bed. The family, responsible party, and physician were promptly notified. S1-S3 emphasized that the fall could not have been prevented by staff. S1-S3 stated that they have maintained open communication with the family and their leadership team, including lengthy meetings lasting up to four hours. S1-S3 stated the facility operates 24/7, 365 days a year, ensuring resident safety at all times. Allegation #2: Staff do not answer a resident's call button in a timely manner S1-S3 stated staff consistently respond to residents’ call buttons in a timely manner. The facility adheres to a 10-minute response window or less for assisting residents once a call is placed, whether via the call button or pendant. S1-S3 stated it did not take an hour to help the resident. S1-S3 stated that S3 was in the resident's room when the resident was on the phone with her family member. S1-S3 stated that S3 did respond to the resident's pendant alarm promptly. R2-R7 stated that staff always answer a resident's call button in a timely manner. S1-S3 and R2-R7 denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation #3 Staff do not monitor a resident for changes in condition S1-S3 stated the facility staff monitors residents' changes in condition. S1-S3 the care staff will alert the Registered Nurse if a resident needs assistance. R2-R7 stated staff monitor residents for changes in condition. When a resident goes to the doctor the Wellness Department provides residents with an envelope for the doctor to complete as a follow-up on the resident's medical condition. S1-S3 and R2-R7 denied the allegation. Investigation revealed the following: Staff members 1-3 (S1-S3) interviewed stated that on September 23, 2024 R1's undergarments were dry, and R1 had not sat in urine for 24 hours. R1 agreed that her undergarments were not wet, and she did not sit in urine for hours. R1 physician's report states that R1 has no bowel or bladder impairment and is capable of self-care. S1-S3 stated that on the morning of September 24, 2024, at 4:48 A.M., R1 had accidentally fallen after sliding from her bed. R1 mentioned that after the fall, it took approximately one hour to reach her phone for assistance because it was out of her immediate reach. S1-S3 stated that S3 went to R1's room immediately and R1 did not wait an hour for assistance. S1-S3 stated there were four staff on duty when the incident occurred. S1-S3 stated that S3 responded immediately during both incidents. S1-S3 explained that R1 does not receive one-on-one care and that prior to the fall, staff had just left the resident's room, and R1 was doing well and in stable condition. Shortly after the fall, S3 received a call from R1’s family member informing them of the incident. While still on the phone with the family member, S3 proceeded to R1’s room to provide assistance. S3 stated that she promptly called for help, and the Care Manager responded immediately. Together, S3 and the Care Manager conducted a thorough body check on R1 for injuries, observing a discoloration on R1’s left leg. However, it was unclear whether the discoloration resulted from the fall or was present beforehand. S3 stated they assisted R1 back to bed while still on the phone with the family member. R1 declined medical treatment and refused further assistance. S1-S3 indicated that the fall was unavoidable, as there were no witnesses to the incident, either from staff or residents. Regarding the call button allegation, S1-S3 and R2-R7, stated that the call buttons are answered in a timely manner. S1-S3 stated that the facility adheres to a 10-minute or less response window for assisting residents once a call is made, whether through the call button or pendant. S1-S3 also stated that they monitor residents’ conditions, and any changes are promptly reported to the Registered Nurse (RN) for further action. See continued LIC9099-C page 4 Continued LIC9099-C page 4 S1-S3 emphasized that Sunrise of Beverly Hills operates on a 24/7 basis. R2-R7 stated that staff members are consistently available to assist and expressed satisfaction with their living conditions at the facility. S1-S3 and R2-R7 stated that the accommodations provided are comfortable and that the staff is dedicated to ensuring the safety and well-being of all residents. All allegations were denied by S1-S3 and R2-R7. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-Cs, was provided to Assisted Living Coordinator Nancy Maya. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 11-AS-20240925120845

Allegation investigated: Staff did not ensure the facility a/c was not in disrepair. Staff are not providing a comfortable environment for residents.

On 9/10/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Zachary Howell /Administrator. LPA explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Resident’s interviews (R#1-R#6) and Staff Interviews (S#1-S#6). LPA obtained and reviewed the following documents: Resident’s roster and a health and safety check of the facility common areas. This report continues on LIC 9099C... Unsubstantiated Investigation Revealed the Following: Allegation: Staff did not ensure the facility a/c was not in disrepair. The details of the complaint alleged that the facility’s Air-conditioned unit in the common areas is not working. During a health and safety check of the facility, LPA Iniguez inspected the facility's common areas; LPA measured the temperature with a digital thermometer and recorded the following numbers: facility dining room= 78.1F°, 1st-floor hallways= 73.1F°, Bistro area=77.0F°, theater room= 75.3F°, Activities room= 73.4F°, 4th-floor dining room= 69.9F°, 4th floor TV room=69.8F° and fitness center=74.3F°. LPA Iniguez did not observe an overall facility temperature over 85.0F°. During an interview with the administrator (A#1), (A#1) stated that the air-conditioned unit is working now, and there's just a water leak in the bistro. In addition, (A#1) stated that the AC was never broken; it was not cooling enough in the bistro area but never got over 85F. Also, (A#1) stated that in the event of the AC breaking down, the facility has portable AC units that can be supplemented until the central AC unit gets fixed. During interviews with residents (R#2-R#6), (6) out of (6) residents stated that the Air-conditioned (AC) in their room is working, and they have not noticed in the common areas that the (AC) is not working at all. During interviews with staff (S#1-S#5), (5) out (5) facility staff stated that the facility (AC) is working correctly; it is just the Bistro area that sometimes gets warm, but still the (AC) works in that area. This report continues on LIC 9099C... Allegation: Staff are not providing a comfortable environment for residents. The details of the complaint alleged that facility staff is are not providing a comfortable environment for residents in care. During a health and safety check, LPA Iniguez observed the facility's (AC) unit working correctly. The facility's overall temperature was 74.5F°. LPA Iniguez did not observe the facility providing an uncomfortable environment to residents in care. During an interview with the administrator (A#1), he stated that they provide a comfortable environment for residents in care. During interviews with residents (R#2-R#6), (6) out of (6) residents stated that the facility is providing a comfortable environment for them. During interviews with staff (S#1-S#5), (5) out (5) facility staff stated that the facility is providing a comfortable environment to the residents in care. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. 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 Zachary Howell /Administrator.the state’s words, verbatim · CDSS document, Sep 10, 2024 · control 11-AS-20240909135942

Type of visit: Required - 1 Year

On 7/10/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Zachary Howell /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (127) non ambulatory elderly adults ages 60 and above, of which (9) can be bedridden. The facility has an approved hospice waiver for (20). The facility has 80 units, and approximately 86-bathrooms, is five stories tall with a basement garage. The facility is a beige in color structure with a gym/ physical therapy room, bistro, formal dining room, theater, a restaurant style kitchen, and two elevators. There is a large patio area on the 3rd floor and other sitting areas on the 1st floor. LPA Iniguez and the Executive Director toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (10) bedrooms and (10) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113.5°F to 115.2°F, and the room temperature ranged from 75°F to 76°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 6/28/24. A review of (5) residents' service files and (6) staff personnel files were maintained in order. LPA reviewed (5) Medication Administration Records (MARs) and found no discrepancies. LPA Iniguez reviewed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA. Facility Annual Fess current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Zachary M Howell / Executive Director.the state’s words, verbatim · CDSS document, Jul 10, 2024

Allegation investigated: Staff do not ensure that resident's medical condition is properly managed. Staff do not assist resident with hygiene needs. Staff do not ensure that resident's dietary needs are met.

On 05/09/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a complaint visit to deliver findings regarding the above allegations. LPA Richard met with Resident Care Director Liza Bond. Later was joined with Administrator Hawell Zachary and Assisted Living Coordinator Nancy Maya. The investigation consisted of the following: On 05/09/2024, LPA Richard toured the facility. LPA Richard reviewed and requested, staff and resident's records, LIC 602, and the daily assignment sheets, Physician Report, Resident Scheduled menu. LPA requested copies of supporting documents. LPA interviewed five (R1-R5) Residents, and five staff (S1-S5). LPA Richard requested and copies of supporting documents. Reviewed and collected facility documents. This report is continued, please see LIC9099C. Unsubstantiated Allegation 1: Staff do not ensure that residents’ medical condition is properly managed. It is alleged that staff do not ensure that a resident’s medical condition is properly managed resulting in the resident was admitted to the hospital due to a blood sugar of 40. The investigation revealed that on 05/09/24, LPA Richard interviewed the Resident Care Director Liza Bond, (RCD) regarding the above allegation, the (RCD) denied the allegation above. The (RCD) stated that, blood sugars are checked according to the Doctors orders, and can be checked from 1 time a day to 2 times a day. The (RCD) stated that R1 was diagnosed with type 2 diabetes at the time of admission. LPA reviewed and obtained resident R1’s physician’s medication management dated from 10/05/23 to 04/15/24, and there was no instruction about having R1 blood sugar checked. On 04/15/24, R1 physician increase R1 medication without any mentioned of any new order of needing to check the blood sugar. LPA interviewed five staff (S1-S5) regarding the above allegation, 3 out of 5 staff interviewed did not assist with medication administration, 1 of the 5 staff interviewed denied the above allegation. Staff S1 interviewed, stated that blood sugars are checked and documented daily according to doctors’ orders. On 05/09/24 LPA interviewed with residents (R2-R6) regarding the above allegation, 2 out of 5 residents interviewed were unable to provide information regarding allegation above, 3 out of 5 residents interviewed reported the facility do not conducted any blood sugar for them. Records reviewed during the investigation showed that LPA did not find sufficient evidence to support the allegation that staff do not ensure resident's medical condition is properly managed. Continued LIC 9099-C Based on interviews there is not sufficient evidence to support the allegation that Staff do not ensure that a resident's medical condition is properly managed. 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. Regarding the allegation 2: Staff do not assist resident with hygiene needs. It is alleged that staff do not assist resident with hygiene needs resulting in “resident appeared dirty, not being clean and greasy”. The investigation revealed that the facility provides showering assistance to resident in care. Records reviews indicate that there is a resident shower schedule and notes indicating if client refused or accepted to take a shower. During interviews with the staff (S1-S5), 5 out of 5 stated that the residents shower regularly. The staff stated that resident R1 constantly refused their help. All the staff stated that R1 wakes up early, around 6:00 am, and wears the same clothing as the day before. When staff tried to help and change the clothing, R1 refused. LPA interviewed five residents (R2- R6), 4 out of 5 indicated that they did not need assistance with hygiene and shower. Only 1 out of 5 residents stated that the staff helped with showering and dressing. R2, R5, R4 and R6 stated they do not require assistance with showering, brushing their teeth, and getting dressed. LPA reviewed the resident R1 Needs of service plan. R1 are scheduled to shower two times a week. LPA reviewed the shower scheduled from 04/10/24 to 04/27/24. The schedule showed R1 was scheduled and was assisted with taking a shower. LPA Richard reviewed the residents shower schedule for the month of March 2024, and observed that all residents have received their scheduled shower. Continued LIC9099-C Resident R3 stated that the staff does assist with grooming and bathing and that they are happy with the care and supervision given. Sometimes the staff provide verbal assistance on how to proper brushed teeth and comb their hair. LPA could not interview R1 because R1 was out of the facility. Based on the information gathered, interviewed and records reviewed, LPA did not find sufficient evidence to support the allegation staff did not assist resident with hygiene needs. Based on interviews, and records reviewed there is not sufficient evidence to support the allegation that Staff did not assist resident with hygiene. 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. Regarding the allegation 3: Staff do not ensure that resident’s dietary needs are met. It is alleged that the staff do not ensure that resident’s dietary needs are met, resulting of resident missing meals. The investigation revealed that the facility served three meals per day to the residents in care. Records reviews showed the facility have a special diet menu for the resident who doctor’s order special meals. LPA interviewed five residents (R2-R6) and five staff (S1-S5), regarding the allegation. During the interviews with five residents (R2-R6) 5 out of 5 stated they are served three meals daily plus snacks. Residents (R2- R6) stated they are not on a special diet and have no issues with getting their meals. LPA interviewed five staff (S1-S5), and 4 out of 5 stated that three meals are prepared and served to all residents daily. Continued LIC9099-C The staff (S1, S3, S4) stated that two snacks were offered daily for every resident. Staff (S2-S5) stated the kitchen prepares special diet foods for diabetes clients with the physician orders. Staff (S2) stated there is a menu of residents with special diet needs that are met with each meal. LPA reviewed and obtained menu various meal. LPA reviewed physician’s orders from 10/05/23, to 04/15/24; and there was no instruction about having R1 on a special dietary menu. LPA reviewed resident R1’s scheduled meals from 04/10/24 to 04/29/24 before R1 went to the hospital on 04/30/24, the resident R1 was provided breakfast, lunch, and dinner. All the staff and residents stated if a resident is on a special diet staff is following their physician's orders. Residents and staff stated the facility is providing proper food service. The residents who were interviewed were content with the food that has been served to them. The menus are written at least five weeks in advance and copies of the menus are posted in the facility dining room, activity room and copies are also, kept on file. The staff stated they also have daily menu. During the investigation, LPA did not find sufficient evidence to support the allegation staff do not ensure resident’s dietary needs are met. Based on LPA observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies cited. Exit interview conducted and a copy of this report was provided to the Assisted Living Coordinator Nancy Maya.the state’s words, verbatim · CDSS document, May 9, 2024 · control 11-AS-20240503093132

Allegation investigated: Staff yelled at resident. Staff did not provide assistance to resident in a timely manner resulting in resident urinating. Staff forced residents to eat in their bedroom. Insufficient staffing to escort residents to the dining room.

On 04/09/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit to deliver findings regarding the above allegations. LPA Richard met with Director Sales Theresa Mack and Liza Bond Resident Care Director. Later was joined with Assisted Living Coordinator Nancy Maya. The investigation consisted of the following: On 04/09/2024, LPA Richard toured the facility inside and out with Director Sales Theresa Mack LPA Richard reviewed and requested, staff and resident's records, LIC 602, and the daily assignment sheets. LPA interviewed five (R1-R7) Resident, and five staff (S1-S5). LPA Richard requested and reviewed and collected facility documents. This report is continued, please see LIC9099C. Unsubstantiated The investigation revealed the following: Allegation: “Staff yelled at residents.” Interviews were conducted with staff (S1-S5) and Residents (R1-R7) and found there’s no evidence to corroborate the allegation mentioned above. During interviews with residents and staff, no one can verify that “Staff yelled at residents”. (R1-R7) have made statements that the staff is very respectful towards residents and have not observed any yelling. (S1-S5) stated that communication with residents is conducted properly. Interviews with Residents (R2, R4) stated that they have had some loud talking in the past with staff due to the residents having a hard time hearing staff when talking to them. However, (R1-R7), stated that some of the residents would yell at the staff when they don’t get what they want. Residents also stated that some of the residents have a hard time hearing the staff, the staff need to speak little bit louder to the residents. Interviews conducted with Residents in Care (R1-R7) stated that staff generally treat residents with respect, and do not yell or raise their voice towards residents. (R1-R7) stated that they have not witnessed staff yelling at other residents. Staff (S1-S5) interview stated that they do not yell at residents. LPA did not observe any staff yell at residents while conducting interviews. Based on LPA observation, and interviews conducted there is no evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. The investigation revealed the following: Allegation: Staff did not provide assistance to resident in timely manner resulting in resident urinating. During the interviews with residents (R1-R7) 7 out of 7 residents stated that they were assisted in a timely manner. 4 out of 7 residents stated they have had no issues or concerns with incontinent care and in some cases do not require assistance with daily activities. An interview with (R5) resident stated that staff was available to assist after activating the call button in eight (8) to (10) minutes, sometimes R5 stated that if R5 don’t press call button on time then accident could happen. The resident (R5) stated the staff is very efficient of checking if they need help. The resident (R2-R6) noted that the staff responds promptly when called within (5) to 10 minutes. The Department tested (R7’s) call button on 04/09/24 and observed the equipment to be operable. LPA interviews Staff (S1-S5) stated that residents are monitored every two hours for each shift or as needed when the call button is activated. (S1-S5) stated that for every shift the residents that require assistance and are not independent are being monitored every two hours during each shift and the facility maintains a daily monitoring log for each resident for each shift. Staff (S1-S5) denied having a resident not assisted in resulting in resident urinating. The staff (S1-S5) reported even in the busiest times, the resident is assisted within 8 minutes. The care manager is alerted when a resident activates the call button and the care manager response immediately in the order it was received. The staff (S1-S5) does not recall having not assisting the residents in timely manner resulting in resident urinated on themselves. Based on the interviews conducted, observation and records review LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. The investigation revealed the following: Allegation: Staff forced resident to eat in their bedroom. During the interviews with residents (R1-R7), 7 out 7 residents stated that they are not forced to eat in their bedroom. Residents also stated that they most like to stay in their bedroom to watch TV, and they sometimes don’t like going down in the dining room to eat so they asked the caregiver to bring the food to their room. LPA interviews staff (S1-S5), all the staff stated that after they help the resident with their morning routine, they usually asked them if they were coming down to the dining room for breakfast or lunch. The staff stated that the facility allows the residents to come down or stay in their rooms. The assistant coordinator (S1) stated that some of the residents want to be in their room most of the time to eat, watch television, or be on the phone, this is their choice, they have rights we have to obey them. Staff (S1) stated that the facility encourages resident to leave their bedrooms and come to the dining room to eat with other residents. Based on the interviews conducted, observation and records review LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. The investigation revealed the following: Allegation: Insufficient staffing to escort resident to the dining room. Interviews with Resident’s (R1-R7), seven (7) out of seven (7) stated that they received assistance when needed and the facility have enough staff to assist them. Additionally, six (6) out of seven (7) residents stated that the facility has enough staff to provide care to the residents. During the interview with Staff (S1-S5) 5 out of 5 stated that they could provide care and help resident with daily activities. Additionally, Staff stated there are four (4) staff on duty during the day and evening shift, and four on the night. Depending on the facility census, the facility staffing may fluctuate. Staff (S1-S5) stated that if they needed help to escort the resident to the dining room, they would call other staff from another location to come and assist. Staff (S1-S5) stated that sometimes they are the ones who asked residents if they want to go downstairs to eat in the dining room today. During the time of the visit, LPA observed all resident cares was being met, the residents did not have to wait before they received assistance. LPA reviewed the Staff Roster and observed there are four (4) staff and administrator who work regularly. During the investigation, LPA was unable to find any evidence to support the allegation. Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted. A copy of this report was provided to Assisted Living coordinator Nancy Maya. .the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 11-AS-20230418105343