Terraza Court Senior Living

Allegation investigated: Facility is not meeting the residents dietary restrictions.

On 08/06/2026 at 11:50am, the Department conducted an subsequent visit at the facility listed above to deliver the investigation findings. The Department met with Michell Brown (Wellness Director) and explained the purpose of the visit. The investigation consisted of the following: On 07/23/2026, the Department conducted interviews with A1, Staff (S1 - S10) and Resident (R1 -R10 ) between the hours of 10:55am - 4:23pm. The Department requested and obtained the following documentation such as staff roster (dated 05/19/2026), resident roster (dated 07/06/2026) LIC 601 Identification and Emergency Information (dated 07/22/2025), LIC 602A Physician Report (dated 07/21/2025), LIC 603 Preplacement Appraisal Information(dated 07/22/2025), Assessment (02/01/2026), Admission Agreement (dated 07/22/2025), List of Residents with Dietary Need & Restrictions (on 07/23/2026) and Weekly Menus (dated 7/12/2026 - 8/8/2026). Substantiated The investigation revealed the following: Allegation: Facility is not meeting the residents dietary restrictions. It was alleged that a resident with health issues was being served food that was not healthy for the resident’s condition, and that the facility was not following the dietary orders provided by the resident’s physician. On 07/23/2026 between the hours of 1:30pm - 2:00pm the Department interview the Administrator (A1) in regards to the allegation. A1 denied the allegation and stated dietary orders are received from physicians, communicated to culinary staff, documented on the kitchen whiteboard, and implemented through substitute meals and updates provided by the wellness and executive directors. On 07/23/2026 between the hours of 9:50am - 3:02pm and on 08/06/2026 between the hours of 12:09pm - 12:18pm, the Department interview 10 staff in regards to the allegation. 10 out of 10 staff did not confirm nor deny the allegation. Of the 10 staff who did not confirm nor deny the allegation: 3 staff mentioned working in memory care with R1 resides in assisted living, 4 staff have knowledge of R1 having restriction but did not report unmet dietary needs and 3 staff are not aware of R1's restrictions. On 07/23/2026 between the hours of 10:46am - 4:25pm the Department interview 9 residents in regards to the allegation. 2 out of 9 residents confirmed the allegation. R1 reported receiving multiple meals that did not meet their extensive dietary restrictions and stated accommodations promised at admission were not implemented. R9 reported receiving meals inconsistent with their pre-diabetic dietary needs, including excessive starches and inconsistent delivery of fruit and salad, and expressed concern that the meals may affect their A1C. 7 out of 9 residents did not confirm nor deny the allegation reported no dietary restrictions or no issues with the meals that are provided. On 07/23/2025 between the hours of 1:00pm - 2:00pm, the Department conducted a record review and observed the following: According to the Residence and Care Agreement (dated 07/22/2025) which states e. meals section it states 1. Dining Room: We will serve three (3) nutritionally balanced meals and snacks daily to resident at the Community. These meals and snacks are included in your monthly fee. We will also accommodate some special diets, if prescribed by your physician as a medical necessity. Investigation findings continue on LIC 9099-C On 07/23/2026, the Department conducted a record review and observed the following: A1 provided a photo of the whiteboard in the kitchen which consist of a list of resident who have dietary needs /restriction. However on the date of 07/23/2026, the facility did not have Resident 1 (R1) dietary needs/restrictions listed. A1 stated that the whiteboard need to be updated with additional information in regards to other residents who have dietary restrictions and needs. According to the LIC 602 Medical Assessment for Residential Care Facilities for the Elderly (dated 07/21/2025) on page 3 of 9 in the Results of Exam for Other Medical Conditions states yes R1 does have prospective resident medical conditions such as unspecified protein-calorie malnutrition On page 4 of 9 in section In the allergies section it states yes resident has allergies such as Azithromycin, chlordiazepoxide, clonazepam, diazepam, erythromycin, metronidazole sulfa antibiotics, corn, wheat, wheat bran, cotrim and iodine contrast 1. Over Physical Health e. Special Diet in the explain such it say NAS (no added salt). On LIC 603 Preplacement Appraisal Information (dated 07/22/2025) in the health section it states no sugar, no flour, dairy besides yogurt, pork, red meat, spaghetti, wheat, gluten, fruit juice fruits, corn and peanuts. In the services needed section is yes is checked for special diet/observation. A assessment (dated 02/01/2026) indicate a condition/need for Candida Diagnosis requires culinary as the lead department for a special diet applicable across all daily meals. On 08/06/2026,between the hours of 12:20pm – 1:20pm, the Department conducted a tour of the kitchen and observed R1’s room number listed with the notation “protein and veggies only.” The Department also reviewed the alternative menu options posted. The alternative menu included items containing ingredients prohibited for R1, such as flour, wheat, gluten, dairy, pork, red meat, pasta, fruit, sugar, sauces, corn, and peanuts. The alternative menu items include cheese quesadilla, pastrami sandwich with fries, hamburger with fries, turkey burger with fries, blt with chips, chicken salad sandwich, plant-based chicken cultlet, pasta with plant-based meatballs and marinara, vegan cheese quesadilla and veggie sandwich which does not met R1’s documented dietary restrictions. Furthermore, the facility provided no documentation showing how modified alternative meals were prepared to comply with physician-ordered diets for R1 and other residents with dietary restrictions Investigation findings continue on LIC 9099-C Based on the Department's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. Exit interview conducted with Michell Brown (Wellness Director) .the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 11-AS-20260717133308

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Sep 3, 2026

However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal. This requirement was not met by: based interviews, records review & observation the facility failed to meet R1's dietary restrictions/needs as identified in the LIC 603 & LIC 625. The kitchen dietary list & alternative menu options failed to reflect or support these restrictions, posing a potential risk to R1's health and safety.the state’s words, verbatim · CDSS document, Aug 6, 2026

Plan of correction: The licensee will create & maintain an updated & current dietary restriction list for all residents with dietary needs from the residents LIC 602, LIC 603 & LIC 625, develop menus that support each resident’s documented restrictions, and keep a daily log of meals served to residents with dietary residents with dietary needs. Proof of correction will be submitted to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Allegation investigated: Staff did not prevent a resident from causing another resident to sustain a fracture while in care.

On July 19, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted a subsequent an unannounced complaint visit. Queen Esther Blake, Activities Assistant, greeted the LPA. Ms. Blake contacted Linda Poythress, Executive Director by telephone and (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, record reviews, and a tour of the facility. Investigation conducted by Investigator Dennis Douglas of the CDSS Investigation Branch. Interviews with Staff member S#1 - S#6 (S1-S6). The Department reviewed several documents, including the Facility Resident Roster (dated 03/05/26), Personnel Report LIC 500 (dated 02/28/26), (R1’s and R2’s) Physicians Report LIC 602 A (dated 010/02/24 and 01/02/25), Appraisal/Needs & Service Plan LIC 625 (dated 06/03/24, 07/22/24, 09/20/24 and 01/02/25), Hospice Care Notes (dated 01/01/26 – 03/06/26), Medication Administration Record (dated 02/01/26 – 02/28/26), County of Los Angeles Death Certificate (dated 05/28/26) and Culver City Police Station Report (#26001152). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION: Staff did not prevent a resident from causing another resident to sustain a fracture while in care. It is alleged that the facility staff did not prevent a resident from causing another resident to suffer a fracture while under their care. Reports indicate that on March 1, 2026, Resident #1 (R1) was physically assaulted by Resident #2 (R2). Specifically, (R2) threw (R1) against the wall, causing (R1) to fall and break a hip. Additional reports state that (R1) passed away five days after the incident, on March 6, 2026. The incident was reported to the Culver City Police Department, though no further details have been provided. On April 30, 2026, May 13, 2026, and May 29, 2026, between 02:00 PM and 03:20 PM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Four (4) out of six (6) staff members could not corroborate this claim. (S2) was not working on the day of the incident, and (S6) became aware of it only after the incident occurred. According to (S1, S4, and S5), both residents were in the dining area of the memory care unit on March 1, 2026, when the incident took place. (S1, S4, and S5) explained that (R1) was trying to read a book that belonged to (R2), which (R2) had left on a table. (R2) became agitated when (R1) attempted to take (R2's) book, leading (R2) to push (R1) away. As a result of this push, (R1) fell to the floor, as confirmed by both (S4 and S5), who witnessed the incident. (S4) claimed to have been able to shield (R1) from striking (R1's) head against the wall; however, (R1) still fell and impacted (R1's) buttocks. Meanwhile, (S3) learned about the incident from (S4 and S5) and acknowledged that after being notified, the responsible party for (R1) was contacted. The staff were instructed not to call 9-1-1 and were advised to leave (R1) on the floor, with the understanding that the responsible party would place (R1) back in bed. The staff followed the directives given by the responsible party. (S3) reported that hospice was contacted and arrived at approximately 3:45 PM on March 1, 2026. (S3) also noted that the facility did not have any surveillance cameras that could have captured the incident. (S2-S6) acknowledged that (R1) exhibited wandering behaviors and would often roam throughout the memory unit, occasionally entering other residents' rooms, with staff members shadowing (R1) during these times. They also confirmed that (R2) had no prior incidents of aggression towards other residents and had not been involved in any physical altercations. (Evaluation Report continues LIC 9099-C) The Department reviewed hospice care notes dated from January 1, 2026, to March 6, 2026. During this time, Resident #1 (R1) was receiving hospice care. Hospice nurses were contacted and arrived at the facility the same day, accompanied by the responsible party. (R1) was not taken to the hospital; instead, hospice nurses treated (R1) at the facility in the following days. (R1) passed away at the facility five days later, on March 6, 2026, while under the care of the hospice staff. Reports also indicated that (R1) was regularly administered pain medication to alleviate (R1’s) discomfort until (R1’s) passing on March 6. A further review of Resident #2 (R2's) "Resident Assessment/Service Plan (dated January 2, 2025) indicated that (R2) "may exhibit physically or verbally aggressive behavior" and might present "agitated or anxious behavior." This assessment also highlighted a "change of condition" relative to (R2’s) prior plan, (dated September 20, 2024). It was further revealed that (R2) had been prescribed antipsychotic and antidepressant medication. Nevertheless, (R2’s) Medication Administration Record (dated February 1, 2026 to February 28, 2026) showed that (R2) did not miss any doses in the weeks leading to the incident. Further review of (R1’s) copy of the County of Los Angeles Death Certificate (dated May 28, 2026) listed "Blunt Trauma" as the cause of death. However, hospice care notes indicated that before the incident on March 1, 2026, (R1) had been diagnosed with "end-stage" Alzheimer's Disease and "advanced" Major Neurocognitive Disorder. It was noted that (R1) was very frail, weak, and debilitated, with poor prognosis. The objective of (R1’s) hospice care treatment was to ensure (R1) had comfort during that time. The Department reviewed the Culver City Police Station Report (#26001152) and verified that the statements from all parties involved were accurate and consistent with the incident reporting. No charges were filed for elder abuse. Based on the gathered information, it appeared that the facility was unaware of any previous instances involving Resident #1 and Resident #2 involving physical altercations or assaults and that staff acted promptly when the incident occurred. There is insufficient evidence to corroborate the 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. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted with QUEEN ESTHER BLAKE, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Jul 19, 2026 · control 11-AS-20260306170519

Allegation investigated: Facility staff abandoned resident at the hospital

On 06/15/2026 at 8:45am, the Department conducted an initial complaint visit at the facility listed above. The Department met with Linda Poythress (Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 06/15/2026, the Department conducted interviews with A1, Staff (S1 - S6) and Residents (R1 - R10) between the hours of 09:00am - 12:00pm. The Department requested and obtained the following documentation such as staff roster (dated 05/19/2026), resident roster (dated 06/15/2026) SOC 341 Report of Suspected Dependent Adult/Elder Abuse (dated 04/13/2026 & 04/24/2026), Resident 1's documentation such as LIC 602A Medical Assessment for Residential Care Facilities for the Elderly (dated 06/04/2026, 03/31/2025, & 02/25/2026 ), UCLA Health Patient Summary (date of service 06/05/2026), Resident Assessment/Service Plan (Dated February 2026), Resident Return from Extended Leave Policy & Procedure, Staff Memory Care Schedule (June 2026), Pre-and Re-Assessment(dated 05/26/2026), Discharge Summary (dated 06/10/2026) and Communication Logs (April 2026 - June 2026) Unsubstantiated The investigation revealed the following: Allegation: Facility staff abandoned resident at the hospital. It was alleged that the facility did not ensure the resident’s return from the hospital after resident was medically cleared, resulting in the resident remaining at the hospital for an extended period. On 06/15/2026, between the hours of 09:00am – 09:15am, the Department conducted an interview with A1. A1 denied the allegation and stated she was notified by the Memory Care Director that R1 had been admitted to the hospital on a 5150 hold. A1 reported becoming aware of R1’s medical clearance approximately two weeks after 05/03/2026 when contacted by a social worker from UCLA Santa Monica. A1 stated R1 had been transferred between multiple hospitals and that the facility experienced delays in receiving the required medical documentation. A1 reported the facility completed an assessment prior to R1’s return and maintained ongoing communication with the hospital through multiple phone calls until the updated LIC 602 and clinical information were received. A1 stated the facility’s policy requires a 72 hour alert period to monitor residents returning from hospitalization and reported that R1 adjusted well upon returning. A1 stated the plan is for R1 to remain at the facility. On 06/15/2026, between the hours of 10:15am – 12:00pm, the Department conducted 6 staff interviews in regards to the allegation. 3 out of 6 staff denied the allegation and stated they had not heard any discussion about R1 being refused return to the facility. 3 out of 6 staff were unaware of the allegation and reported they were not aware of R1’s hospitalization or return status due to working in the assisted living unit while R1 resides in the memory care unit. On 06/15/2026, between the hours of 9:24am – 11:15am, the Department conducted 10 resident interviews in regards to the allegation. 10 out of 10 residents denied the allegation and stated they were not aware of any residents who had been hospitalized and experienced difficulty returning to the facility. Of the 10 residents, 9 residents reported having been hospitalized while residing at the facility for various reasons, including stroke/high blood pressure (R2), diabetes (R3), a busted lip requiring stitches (R4), a medication change (R5), a broken leg (R6), an infection (R8), surgery (R9), and a fall requiring stitches (R10). All 9 residents confirmed they were able to return to the facility without issue. While 1 resident (R7) reported no history of hospitalization. Investigation findings continue on LIC 9099-C On 06/15/2026, between the hours of 1:30pm – 2:40pm, the Department conducted a records review and observed the following: the facility’s Resident Return from Extended Leave Policy & Procedure states that residents returning from hospitalization or any absence exceeding seven (7) days must be assessed prior to readmission, and the facility may require updated medical documentation to determine whether it can safely meet the resident’s needs. R1’s Pre- and Re-Assessment (dated 05/26/2026) documented traumatic brain injury, mental health challenges, memory loss, behavioral triggers, a history of aggression, and the need for assistance with activities of daily living and medication management. The communication log reflected ongoing contact between the facility and UCLA from 05/04/2026 through 06/06/2026, including repeated requests for updated clinical information and the LIC 602. Documentation showed the facility received the updated LIC 602 on 06/04/2026, completed the assessment on 05/26/2026, and confirmed R1’s return hospital on 06/05/2026. Hospital records (dated 06/08/2026) indicated R1 was medically cleared, stable for discharge, and appropriate for return to the facility. R1’s LIC 602 (dated 06/04/2026) listed diagnoses of acute psychosis, schizophrenia, and traumatic brain injury and confirmed R1 required staff assistance with medication administration. Based on information gathered through interviews and record reviews, there is not enough 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 isUNSUBSTANTIATED. Exit interview conducted with Michelle Brown (Wellness Director) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 15, 2026 · control 11-AS-20260609085800

Allegation investigated: Staff do not allow resident to return to facility.

On 05/20/26 at 10:00 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Executive Director Linda Poythress (staff #1/S1) as the purpose of today’s visit was explained. The investigation consisted of the following: On 05/20/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, Pre-appraisal dated:04/01/25, Admission agreement dated: 04/01/25, Physicians reports dated: 02/25/26 and 03/31/25, Service plan dated: 04/20/25, Medication list, Facility notes dated 04/04/2026- 05/15/2026, and copies of SOC 341's dated: 04/13/26 and 04/24/26. On 05/20/26 from 10:30 am- 11:30 am LPA conducted Interviews with Residents #2-7 (R2-R7). LPA unable to interview R1 as R1 is currently not receiving services at the facility. On 05/20/26 from 12pm- 1pm LPA conducted interviews with staff #1-6 (S1-S6), and conducted a review of documents obtained. Unsubstantiated The investigation revealed the following: Allegation: Staff do not allow resident to return to facility. It is being alleged that the facility is refusing to accept back a resident who has been medically cleared to be discharged back to the facility for care. On 05/20/26 from 10:30 am- 11: 30 am LPA conducted Interviews with R2-R7 regarding the allegation above. 2 of the 6 residents interviewed denied the allegation above and reported having no issues returning to the facility after hospitalization. 4 of the 6 residents interviewed reported having no knowledge of the allegation above as they have not been hospitalized since their admission to the facility. On 05/20/26 LPA Villegas was unable to interview R1 due to diagnosis. Additionally, 6 of the 6 residents interviewed reported they are happy with the care being provided at the facility. On 05/20/26 from 12pm- 1pm LPA conducted interviews with S1-S6 regarding the allegation above. 4 of the 6 staff interviewed denied the allegation above. 1 of the 6 staff interviewed reported having no knowledge of the allegation above. 1 of the 6 staff interviewed confirmed the allegation above and reported that if the resident is reassessed and the residents care needs cannot be met at the facility, the facility will not accept a resident back. Additionally, 4 of 6 staff report that the facility can no longer meet the care needs of a resident, the facility will accept a resident back until proper placement is found. 2 of the 6 staff interviewed indicated that a former facility staff reported conducting a reassessment for R1 but there is no documentation available to prove that the assessment was done. On 05/20/26 LPA conducted a review of documents obtained for R1, LPA did not observe a reassessment nor an eviction notice on file. Per facility notes dated: 05/04/26, 05/08/26, and 05/11/26 per Hospital social worker R1 was not ready for discharge. Per facility note dated: 05/12/26, facility asked hospital social worker for SNF referral to assure medication compliance as R1 was placed on new meds due to physical behaviors, and to ensure safety for all Terraza Court residents. Per note Social worker agreed to SNF referral. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 11-AS-20260513124515

Allegation investigated: Licensee is retaining a resident whose needs cannot be met Staff do not prevent a resident from harming other residents

On 05/05/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Administrator, Linda Poythress, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: LPA inspected the facility, interviewed Staff S1-S_, interviewed Resident R2-R12, and received and reviewed pertinent documents. The following documents were received and reviewed Staff Roster, Resident Roster, Medical Assessment for Residential Care Facilities for the Elderly (dated 03/31/2025 & 03/18/2026), RCFE Service Plan- Department & Shift Task Delegation (updated 04/03/2026), Resident Assessment/Service Plan (dated 04/04/2025), resident Notes (from 12/18/2025 to 04/20/2026), In-Service Sign-In Sheets and material (dated 06/2025 and 11/2025), Report of Suspected Dependent Adult/Elder Abuse -SOC341 (dated 04/24/2026 & 04/13/2026), Unusual Incident/Injury Report (dated 04/08/2026 & 06/23/2025), and Tolwin Psychiatric Medical Group – Evaluation and Follow-Up ( dated 08/05/2025 and 04/07/2026). Unsubstantiated The investigation revealed the following: Allegation: Licensee is retaining a resident whose needs cannot be met The allegation alleges there is a resident who was improperly accepted in the facility’s Memory Care Unit, whose needs cannot be met due to an additional diagnosis of mental illness. During record review, LPA received and reviewed Resident R1’s Medical Assessment for Residential Care Facilities for the Elderly (dated 03/31/2025 & 03/18/2026), that indicates R1 was admitted to the facility with the initial diagnosis of Mild Cognitive Impairment (MCI). As of 03/18/2025 R1 has a dual diagnosis of MCI and a mental disorder. LPA observed on the Medical Assessments no aggressive behavior was indicated and no behavioral expressions indicated. LPA received and reviewed an Evaluation, through Tolwin Psychiatric Medical Group, conducted on 08/05/2025 that states staff reported R1 has not exhibited behavioral disturbances requiring intervention. Additionally, LPA received and reviewed a Follow-Up Evaluation, through Tolwin Psychiatric Medical Group, conducted on 04/07/2026 that states “no behavioral problems or safety concerns were reported. R1 remains directable though unpredictable at times.” Both reports indicate R1 was cooperative, guarded, and calm. LPA received and reviewed Resident Assessment/Service Plan, dated 04/05/2025, that indicates R1 may exhibit physically or verbally aggressive behavior and agitated or anxious behavior. Additionally, R1 may exhibit behaviors requiring staff intervention/redirection once per shift. During interviews with Staff S1-S6, were asked if they feel R1 requires a higher level of care, six (6) out of six (6) stated yes, after the past 6 weeks, they believe R1 requires a higher level of care. Additionally, during interviews with S1 and S2 stated they have been working with R1’s psychiatrist and case manager to find a more appropriate placement for R1. During interviews with Residents R2-R12, were asked if they have any concerns regarding them or a resident requiring a higher level of care, eleven (11) out of eleven (11) stated no, they have no concerns regarding a resident requiring a higher level of care. Allegations: Staff do not prevent resident from harming other residents The allegation alleges an ongoing risk from a resident who is attacking staff and other residents. During record review, LPA received and reviewed staff Orientation/In-Service Sign-In Sheets for Training staff received in June 2025 and November 2025. The topic for the training in June 2025 was Behavior + Interventions in Dementia and the topic for the November 2025 training was Behavior Management & Dementia. LPA received and reviewed Resident R1’s Medical Assessment for Residential Care Facilities for the Elderly (dated 03/31/2025 & 03/18/2026), that does not indicate Aggressive Behavior as a Behavioral Expression. LPA received and reviewed the RCFE Service Pan – Department & Shift Task Delegations (updated 04/03/2026) that indicates for Behavior Monitoring that staff on “all shifts” should “stop and watch” resident. During interviews with Staff S1-S6, were asked how they prevent and/or minimize altercations between residents, six (6) out of six (6) stated there is continuous supervision of residents in common areas, provide activities, and provide them space to calm down. During interviews with Residents R2-R12, were asked if staff have precautions in place to minimize and/or prevent altercations between residents, eleven (11) out of eleven (11) stated yes staff take precautions to prevent altercations. Additionally, Residents R2-R12 were asked if they feel safe living in this facility, eleven (11) out of eleven (11) stated yes, they feel safe living in this facility. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator, Linda Poythress, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 5, 2026 · control 11-AS-20260427101612

Allegation investigated: Staff are not responding to resident's call button Staff are not following resident's dietary plan

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 2/12/26. On 2/12/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Wellness Director, Michelle Brown and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 2/12/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, weekly menus, Medical Assessment for Residential Care facilities for the Elderly (LIC 602A) and Resident Service Plan. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 8 (S1 – S8), and Resident -1 – Resident - 6(R1-R6). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff are not responding to resident's call button. It is being reported that staff are not responding to the residents calls in a timely manner. LPA Felisa Shirley interviewed S1 – S8 and was told when a resident pulls the call cord, the alert is sent to the front desk/receptionist. On 2/12/26, LPA Shirley was working in the Administrator’s office located next to the front desk in the lobby. LPA Shirley heard the receptionist calling staff on the walkie constantly relaying call request from the residents. During the tour to R1’s room on 2/12/26, LPA Shirley pulled the call cord at 11:19am. At 11:25pm there was a knock on the door, then the responding staff announced herself then walked in the room. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 6(R1 – R6). Of those who interviewed 5 out of 6 denied the allegation. One stated that they go down to the front desk on their own. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not responding to resident's call button,” therefore, the allegation is unsubstantiated. Allegation: Staff are not following resident's dietary plan. It is being reported that staff are ignoring resident’s special diets. R1 is also concerned that she is not receiving fresh fruit and vegetables. Upon LPA Shirleys arrival to this facility on 2/12/26, LPA observed oranges in the snack area located in front of the elevators in the lobby. LPA Shirley reviewed the tour to the February 2026 weekly menu and observed that fruit and vegetables are offered daily. Upon LPA Shirleys kitchen, LPA observed a large whiteboard posted in the kitchen which listed room numbers and corresponding special diets. LPA Shirley observed R1’s room number listed on table of dietary plans. During the interview with R1, she stated that her dietary requirements are not always consistently followed by the staff. con'd on 9099-C LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 6(R1 – R6). Of those who interviewed 5 out of 6 has a regular diet, one stated sometimes yes, sometimes no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not following resident's dietary plan,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Executive Director, Linda Poythress..the state’s words, verbatim · CDSS document, May 4, 2026 · control 11-AS-20260206162139

Allegation investigated: Staff do not safeguard resident's belongings Staff speak inappropriately to resident Staff are not meeting resident's dietary needs

On 04/30/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Terraza Court Senior Living and was greeted by Administrator Linda Poythress (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S3, residents R1-R11. LPA Calderon obtained the following records: Physician report (dated 05/20/2025), Admission Agreement (dated 05/20/2025), Incident reports (dated 03/06/2026), Menu and alternative menu for R1. Toured the facility with S1 The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff do not safeguard residents belonging. This complaint alleged that the facility staff stole personal items from R1 room. Records review indicate the following: Physician report (dated 05/20/2025) indicates that R1 has health issues and cognitive issues. Interviews indicate the following: R1 states that R1 purchased items from Amazon and staff have stolen R1 personal items. R1 has no proof and did not file a police report. R2-R11 deny the allegation. S1 indicates that none of S1 staff would steal items from R1 room. S2-S3 deny the allegation. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; "The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.” therefore, the allegation of “Staff do not safeguard residents belongings” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff speak inappropriately to residents. This complaint alleged that the facility staff speak to R1 inappropriately. Records review indicate the following: Physician report (dated 05/20/2025) indicates that R1 has health issues and cognitive issues. Interviews indicate the following: R1 states that staff yell and curse at R1 unless R1 purchases items from Amazon for staff. R2-R11 deny the allegation. S1 indicates that none of S1 staff would yell or curse at R1. S1 indicates that none of S1 staff would take items from R1. S2-S3 deny the allegation. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; "The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.” therefore, the allegation of “Staff speak inappropriately to residents” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not meeting residents’ dietary needs. This complaint alleged that the facility staff are not feeding R1 meals. Records review indicate the following: Physician report (dated 05/20/2025) indicates that R1 has health issues and cognitive issues. Reviewed facility menu and vegan menu for residents in care. Menus offer a wide range of food for residents to eat. LPA Calderon toured the kitchen and noted a wide range of food offered to residents in care. Interviews indicate the following: R1 states that R1 is vegan and staff do not offer R1 any options. R1 indicates that R1 has seen the alternative vegan menu and none of the food is offered to residents in care. R2-R11 deny the allegation. S1 indicates that R1 changed to vegan and staff offered R1 a vegan menu but R1 refuses to eat any of the food. S2-S3 deny the allegation. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; "The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.” therefore, the allegation of “Staff are not meeting residents dietary needs” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Linda Poythress (S1).the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 11-AS-20260423151419

Allegation investigated: Facility staff handled resident in a rough manner. Facility staff did not treat resident with dignity.

*This report does not supersede the previous report dated 10/23/2025 but is used to clarify findings*. On 04/30/2026 at approximately 10:00 AM, Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit to the facility listed above to deliver findings. LPA met with the Administrator Linda Poythress and the purpose of the visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: On 10/23/2025, between 09:32 AM – 04:59 PM, the Department requested, reviewed, and obtained the Resident Roster, Staff Roster, Psych Evaluation Report dated 10/13/2025, Resident Rights Training Log dated 06/24/2025. CONTINUED ON LIC9099-C Unsubstantiated On 10/23/2025, between 09:32 AM – 04:59 PM, the Department conducted interviews with Residents #2 through #7 (R2–R7). An attempt was made to interview Resident #1 (R1); however, R1 was no longer at the facility at the time of interviews. The Department conducted interviews with Staff #1–#5 (S1–S5). The Department toured the facility with Wellness Director Michelle Brown and observed the facility to be clean and in good repair. Allegation: Facility staff handled residents in a rough manner. It is alleged that staff accused R1 of damaging facility property and stealing money from another resident, resulting in an invasive bodily search and handling R1 in a rough manner. On 10/23/2025, between 09:32 AM – 04:59 PM, the Department interviewed Administrator Brittany Cavanaugh (A1). A1 denied that staff handled residents in a rough manner, denied that physical searches occurred, and denied any verbal abuse or accusations of stealing money. A1 stated that in instances where a resident was suspected of having another resident’s belongings, staff verbally asked the resident about the item and retrieved it without incident. A1 stated that staff were trained in personal rights. On 10/23/2025, between 09:32 AM – 04:59 PM, the Department conducted interviews with Staff #1–#5 (S1–S5). Out of those interviewed, 5 out of 5 denied the allegation. On 10/23/2025, the Department conducted interviews with Residents #2–#7 (R2–R7). Out of those interviewed, 6 out of 6 denied the allegation. On 04/30/2026, between and 10:00AM – 11:00PM the Department obtained and reviewed the Resident Rights Training Log dated 06/24/2025, which showed that staff received training on the proper handling of residents which included dignity in care, restraints, behavior management, resisting care, and aggression. During the facility tour conducted on 10/23/2025, the Department did not observe any instances of residents being handled in a rough manner. The Department requested, but did not receive, any incident reports indicating that staff handled R1 in a rough manner or violated R1’s personal rights. Based on record reviews, staff and resident interviews, and observations, there is insufficient evidence to support the allegation: "Facility staff handled residents in a rough manner." Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, this allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: Facility staff did not treat residents with dignity. It is alleged that staff spoke to and treated the residents in a manner that was undignified and violated R1’s personal rights. On 10/23/2025, between 09:32 AM – 04:59 PM, the Department interviewed Administrator Brittany Cavanaugh (S1). S1 stated that residents are always treated with dignity and respect. The Department asked whether S1 or any staff member had an altercation with a resident at the facility. S1 answered no. On 10/23/2025, between 09:32 AM – 04:59 PM, the Department conducted interviews with Staff #1–#5 (S1–S5). Out of those interviewed, 5 out of 5 denied the allegation. On 10/23/2025, the Department conducted interviews with Residents #2–#7 (R2–R7). Out of those interviewed, 6 out of 6 denied the allegation. On 04/30/2026, between and 10:00AM – 11:00PM the Department obtained and reviewed the Resident Rights Training Log dated 06/24/2025, which showed that staff received training on the proper handling of residents which included dignity in care, restraints, behavior management, resisting care, and aggression. During the facility tour conducted on 10/23/2025, the Department did not observe any instances of residents being handled in a rough manner. The Department requested, but did not receive, any incident reports indicating that staff did not treat R1 with dignity or violated R1’s personal rights. Based on record reviews, staff and resident interviews, and observations, there is insufficient evidence to support the allegation: "Facility staff did not treat residents with dignity." Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, this allegation is Unsubstantiated. An exit interview was conducted with the Administrator Linda Poythress and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 11-AS-20251015125106

Type of visit: Office

On 04/10/2026 at 10:00 AM, an office visit was held by the El Segundo Adult and Senior Care Regional Office. During the meeting the following people were present: Janae Hammond (Regional Manager), Ulysses Coronel (Licensing Program Manager), Regina Cloyd (Licensing Program Analyst), Brittany Kavanaugh (Regional Director), and Linda Poythress (Executive Director) to address repeated fire clearance violation. On 09/24/25, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a case management visit to the facility. During the visit, LPA requested a resident roster and list of residents who were bedridden. Upon review of the roster, LPA observed Resident was residing on floor two and is bedridden. The current facility fire clearance indicates that floor on is cleared for bedridden residents. Floor two is cleared for non-ambulatory residents. On 03/12/26, Licensing Program Analyst (LPA) Regina Cloyd conducted an annual During record review, Resident #1 (R1) and Resident #2’s (R2) physician report revealed both residents as bedridden due to physical and mental condition. The facility's fire inspection (07/03/2024) special conditions states bedridden residents are only permitted to be on the first floor. Review of Resident Roster (03/11/2026) revealed R1 and R2 in rooms on the second floor. A discussion was had about the past visits, the significance of adhering to the fire clearance, Executive Director monitoring change of conditions (ambulatory status), an ambulatory audit conducted by the facility, and the Regional Office following up with the Fire Department to clarify the facility current Fire Inspection Report (STD 850) on file. An exit interview was conducted and a copy of this report was provided to the Regional Director Brittany Kavanaugh.the state’s words, verbatim · CDSS document, Apr 10, 2026

Type of visit: Case Management - Other

On 4/1/26, Licensing Program Analyst (LPA) Felisa Shirley arrived at this facility to conduct a case management on complaint #11-AS-20260206162139 investigated on 2/12/26. On 4/1/26, LPA Shirley reviewed the Medical Assessment for Residential Care facilities for the Elderly (LIC 602A) and Dietary Order Clarification. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1, Staff 2 and Staff 4 and Resident 1 – Resident 6 (R1 – R6). No deficiencies were issued. An exit interview was conducted, and a copy of this report was left with the Executive Director, Linda Poythress whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Apr 1, 2026

Allegation investigated: Staff are not responding to resident's call button. Staff are not following resident's dietary plan.

On 2/12/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Wellness Director, Michelle Brown and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 2/12/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, weekly menus, Medical Assessment for Residential Care facilities for the Elderly (LIC 602A) and Resident Service Plan. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 8 (S1 – S8), and Resident -1 – Resident - 6(R1-R6). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff are not responding to resident's call button. It is being reported that staff are not responding to the residents calls in a timely manner. LPA Felisa Shirley interviewed S1 – S8 and was told when a resident pulls the call cord, the alert is sent to the front desk/receptionist. On 2/12/26, LPA Shirley was working in the Administrator’s office located next to the front desk in the lobby. LPA Shirley heard the receptionist calling staff on the walkie constantly relaying call request from the residents. During the tour to R1’s room on 2/12/26, LPA Shirley pulled the call cord at 11:19am. At 11:25pm there was a knock on the door, then the responding staff announced herself then walked in the room. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 6(R1 – R6). Of those who interviewed 5 out of 6 denied the allegation. One stated that they go down to the front desk on their own. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not responding to resident's call button,” therefore, the allegation is unsubstantiated. Allegation: Staff are not following resident's dietary plan. It is being reported that staff are ignoring resident’s special diets. R1 is also concerned that she is not receiving fresh fruit and vegetables. Upon LPA Shirleys arrival to this facility on 2/12/26, LPA observed oranges in the snack area located in front of the elevators in the lobby. LPA Shirley reviewed the February 2026 weekly menu and observed that fruit and vegetables are offered daily. Upon LPA Shirleys tour to the kitchen, LPA observed a large whiteboard posted in the kitchen which listed room numbers and corresponding special diets. LPA Shirley observed R1’s room number listed on table of dietary plans. During the interview with R1, she stated that her dietary requirements are not always consistently followed by the staff. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 8(R1 – R8). Of those who interviewed 5 out of 6 has a regular diet, one stated sometimes yes, sometimes no. Con'd on 9099-C Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not following resident's dietary plan,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Wellness Director, Michelle Brown.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 11-AS-20260206162139

Allegation investigated: Staff did not ensure that resident received medical care in a timely manner.

On 1/30/26, at 9:30am, the department conducted an initial complaint visit to the facility and was greeted by Maria Garcia, Business Office Manager, and later joined by Michelle Brown, Wellness Director. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegation(s) mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4) and residents (R1-R10). The department received the following documents: Resident Roster (Date: 01/29/2026), Staff Roster (Dated: 01/29/2026), Face Sheet/ID Emergency information (Dated: 04/11/2025), Physician’s Report (Dated: 04/08/2025), Appraisal & Needs Service Plan (Dated: 05/02/2025), Pre-Placement Appraisal (Dated:04/11/2025), Admission Agreement (Dated: 04/11/2025), After Visit Summary Cedars-Sinai (Dated: 11/23/2025), and Incident Report (Dated: 01/26/2026) from the facility. Report Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation- Staff did not ensure that resident received medical care in a timely manner. The details of the complaint alleged that the facility did not get the resident medical care in a timely manner. On 1/30/2026, from 9:30am-3:00pm, the department interviewed staff (S1-S4) regarding the allegation. 4 of 4 staff denied the allegation that Staff did not ensure that resident received medical care in a timely manner. All staff stated that the facility does call for emergency services in a timely manner whenever the resident has needed assistance on previous hospital visits and currently. Staff stated that the resident was recently being transported in their wheelchair when their body began to shake. They stated the caregivers lowered the resident out of their wheelchair to the ground, 911 was called, the executive director was notified, and the caregivers stayed with the resident until paramedics arrived. They stated that the resident was assessed by paramedics and taken to So Cal Culver City emergency room. Staff stated that when the resident was observed possibly having a seizure, 911 was called immediately. The department interviewed residents (R1-R10) about the allegation and 10 of 10 residents that were interviewed stated that they have not had any issues with getting medical attention in a timely manner. They state that whenever they need or ask for medical services to be called, the staff always calls immediately. The department reviewed the After Visit Summary Cedars-Sinai (Dated: 11/23/2025), Incident Report (Dated: 01/26/2026), Physician’s Report (Dated: 04/08/2025), Appraisal & Needs Service Plan (Dated: 05/02/2025), and Pre-Placement Appraisal (Dated:04/11/2025). The department did not find any evidence in the interviews or records that would suggest that the facility failed to ensure that the resident received medical care in a timely manner. Based on interviews, and records reviewed, there is insufficient evidence to support the allegation that Staff did not ensure that resident received medical care in a timely manner. 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 for this complaint investigation. An exit interview was conducted with Michelle Brown, Wellness Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 11-AS-20260122123623

Allegation investigated: Staff do not ensure resident's hygiene needs are met

On 1/26/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Wellness Director, Michelle Brown and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 1/26/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Identification and Emergency Information, Physician’s Report, RCFE Service Plan, Resident Appraisal, Appraisal Needs and Services, Laundry Schedule, and Shower Schedule. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 6 (S1 – S6), and Resident -1 – Resident -8 (R1-R8). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff do not ensure resident’s hygiene needs are met It is being reported that a resident was not groomed properly. On 1/26/26, LPA Felisa Shirley reviewed the resident’s Laundry List and observed that R1’s laundry is cleaned on Thursdays. On 1/26/26, interviews with S1 -S6 stated, R1 showers on their own. Staff stated that staff stands by and assist as R1 needs and request. Per review of R1’s Appraisal/Needs and Services plan dated 5/17/24, staff should assist as needed in the process of Activities of Daily Living, ADL’s. LPA Shirley interviewed R1 and he stated that assistance is not needed by the staff as R1 showers and grooms himself. LPA interviewed staff 1 – staff 6 (S1 – S6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed Resident 1 – Resident 8(R1 – R8). Of those who interviewed 4 out of 8 denied the allegation and 4 showers on their own. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure resident's hygiene needs are met,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Wellness Director, Michelle Brown.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 11-AS-20260121093218

Type of visit: Required - 1 Year

On 01/17/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff , Wellness Director Michelle Brown, and spoke with Executive Director Brittany Kavanaugh. During today's visit, LPA toured the facility and tested water temperatures in eleven resident bathrooms, reviewed eight resident records, menu, activities schedule, observed lunch and social activities, tested signal system, interviewed the Chef, reviewed nine staff records, emergency disaster plan, infection control plan, plan of operation, liability insurance, and observed dinner. Due to insufficient time, an annual continuation is required. An exit interview was conducted and a copy of this report was left with staff and emailed to the Executive Director Brittany Kavanaugh.the state’s words, verbatim · CDSS document, Jan 17, 2026

Allegation investigated: Facility staff did not assist resident with transferring as needed Facility staff did not assist resident with incontinence care as needed Facility staff did not notify the fire authority within 48 hours of retaining a resident who is bedridden

*THIS REPORT SERVES TO CLARIFY INVESTIGATION FINDINGS AND HAS BEEN CREATED TO SUPERSEDE THE LIC9099 AND LIC9099-C REPORTS CREATED ON 09/25/2025. ALTHOUGHT THIS REPORT SUPERSEDES THE PREVIOUS REPORT, THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME. * On 12/18/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent Complaint Visit to deliver a superseded LIC9099 report. LPA met with Business Manager, Maria Garcia, and the purpose of today’s visit was explained. LPA was granted entry into the facility. During a subsequent visit conducted on 09/25/2025, LPA interviewed Residents R2-R11, and received and reviewed Resident Assignment, and Outside Agency/Service Documentation. During the initial visit conducted on 09/24/2025, LPA inspected the facility, interviewed Staff S1-S7, interviewed Resident R1, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Bedridden Resident List, notification letter to the local fire department informing them of a bedridden resident, Staff Training Logs, Resident R1 Physician’s Unsubstantiated Report, Resident R1's Physician's Orders, Needs and Service Plan, Assessment, and Admission Agreement. The investigation revealed the following: Allegation: Facility Staff did not assist resident with transferring as needed The allegation alleges there is not a sling for the Hoyer lift to transfer residents. During record review, LPA received and reviewed a staff Training Log, dated 04/2025, on the topic of Hoyer Lift Training from PSL Hospice. Additionally, LPA received and reviewed a six (6) page handout on How to Use a Hoyer Lift. LPA received and reviewed an invoice from Omni Care that a sling was ordered on 08/26/2025. During the facility tour, LPA observed a sling for the Hoyer lift, and lifts are operational. Additionally, LPA was shown slings that are available and was informed some residents do not like those slings and do not want them to be used when transferring them. During interviews with Staff S1-S7, were asked if bedridden residents are assisted with transferring from their bed to chair, seven (7) out of seven (7) stated yes, bedridden residents are assisted with transferring from their bed to chair. Additionally, seven (7) out of seven (7) stated the bedridden resident often refuses to transfer from their bed to the chair. Staff S1-S7 were asked if there were any issues with the Hoyer lift, seven (7) out of seven (7) stated no, there have been no issues with the Hoyer lift. Three (3) out of seven (7) stated when one of the residents was transferred to the hospital, the resident’s personal Hoyer sling did not return with them. Additionally, six (6) out of seven (7) staff stated the facility has multiple slings available for use. During interviews with Residents R1-R11, were asked if they are assisted with transferring when needed and wanted, five (5) out of eleven (11) stated yes, they are assisted with transferring when requested. One (1) resident stated, “I don’t trust the slings, so I don’t get up.” Another resident stated they are not going to wait around for them to come, and that they are self-reliant and don’t really need them. Four (4) residents stated they do not require assistance with transferring. Allegation: Facility staff did not assist resident with incontinence care as needed The allegation alleges that a residents incontinent needs are not being met. During record review, LPA received and reviewed Assigned Resident list of residents who requires additional assistance that includes a bed bath, incontinent care, and grooming. LPA reviewed staff training conducted on Relias and observed Caring for Incontinent Residents was completed by staff. During interviews with Staff S1-S7 were asked how often incontinent residents are assisted with changing or checked to see if they need changing, seven (7) out of seven (7) stated they check residents every two (2) hours unless the resident requires more frequent checks. During interviews with Residents R1-R11, were asked if staff assist them with incontinence, seven (7) out of eleven (11) stated staff assist them with incontinence. Two (2) out of eleven (11) stated they do not require assistance with their incontinence but know staff will be there to assist if they need assistance. Two (2) out of eleven (11) stated they do not require assistance with incontinence. Additionally, Residents R1-R11 were asked if they have been left in a soiled diaper or briefs for an extended period of time, seven (7) out of eleven (11) stated they have not been left in soiled diapers for an extended period of time. Allegation: Facility staff did not notify the fire authority within 48 hours of retaining a resident who is bedridden The allegation alleges that the facility is not notifying the local fire department of a resident who is bedridden. During an interview with Staff S1, was asked if notice is sent to the Culver City Fire Department informing them within 48 hours of retaining a resident who is bedridden according to the regulations, S1 stated yes a letter notifying them is sent within 48 hours. During record review, S1 provided LPA with a copy of two (2) letters that were faxed to the Culver City Fire Department dated 04/25/2025 and 09/01/2025 and the fax receipt. LPA observed the letters are updated lists of residents who are on hospice, receive Oxygen, and who are bedridden, and their room number. Staff S1 informed LPA that when the list is updated whether removing a person or adding a person it is sent to the Fire Department. . During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are unsubstantiated. An exit interview was conducted with Business Manager, Maria Garcia, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 11-AS-20250915160928

Allegation investigated: Staff do not ensure facility has current fire extinguishers. Facility is malodorous. Staff do not ensure facility is properly maintained.

On 12/4/25, at 9:30am, the department conducted an initial complaint visit to the facility and was greeted by Michelle Brown, Wellness Director. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4) and residents (R1-R8). The department received the following documents: Resident Roster (Date: No Date), Staff Roster (Dated: No Date), House Keeping Schedule (Dated: December 2025), Laundry Schedule (Dated: December 2025), A & A Fire Protection Invoice (Dated: 10/15/24), House Keeping Daily Checklist (Dated: November/December 2025), Maintenance and House Keeping Work Order Log (Dated: November 2025), RCFE Caregiver Morning Shift Workflow (Dated: 6:00am-2:00pm), RCFE Caregiver Morning Shift Workflow (Dated: 2:00pm-10:00pm), and RCFE Caregiver Morning Shift Workflow (Dated: 10:00pm-6:00am) from the facility. Report Continued On LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Staff do not ensure facility has current fire extinguishers. The details of the complaint alleged that the facility does not ensure that fire extinguishers are properly maintained. It was reported that the fire extinguishers have not been serviced or replaced for several years. On 12/4/2025, from 9:30am-3:00pm, the department interviewed staff (S1-S4) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not ensure facility has current fire extinguishers. All staff stated that the fire extinguishers were recently serviced and that they have not observed any that were outdated. The department reviewed the A & A Fire Protection Invoice (Dated: 10/15/24) and observed that they were serviced on 10/15/2024. The department toured the facility and observed that there was a total of 16 fire extinguishers throughout the facility that were recently serviced on 12/2/2025 and all were fully pressurized. Three in the lobby, two in the kitchen, three on the first floor, three on the second floor, three in the garage, one in the storage room, and one in the elevator mechanical room. The facility has not received an invoice for the current year. Based on observation, interviews, and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure facility has current fire extinguishers. 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 #2- Facility is malodorous. The details of the complaint alleged that the facility is malodorous. It was reported that the facility smells of incontinence, especially on the first floor and in memory care. On 12/4/2025, from 9:30am-3:00pm, the department interviewed staff (S1-S4) and residents (R1-R8) regarding the allegation. 4 of 4 staff denied the allegation that the Facility is malodorous. All staff that were interviewed stated that the facility ensures that the building is free from foul odors like urine, incontinence, and hygiene-related odors on all floors. They further stated that the facility has a housekeeping checklist that the housekeepers follow as well as a caregiver workflow schedule to ensure the facility is cleaned and has no lingering smells. The department interviewed residents (R1-R8) about the allegation and 8 of 8 residents that were interviewed stated that they have not smelled any foul odors that lingers for a long time in the facility. The department reviewed the RCFE Caregiver Morning Shift Workflow (Dated: 6:00am-2:00pm), RCFE Caregiver Morning Shift Workflow (Dated: 2:00pm-10:00pm), and RCFE Caregiver Morning Shift Workflow (Dated: 10:00pm-6:00am) and the House Keeping Daily Checklist (Dated: November/December 2025) and observed that the facility has a round the clock schedule of staff that are tasked at making sure the facility remains clean. Report Continued On LIC9099-C The department toured the entire facility (lobby, first floor, memory care, second floor, kitchen and garage area) and did not observe any foul odors like urine, incontinence, and hygiene-related odors throughout the facility. Based on observation, interviews, and records reviewed, there is insufficient evidence to support the allegation that Facility is malodorous. 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 #3- Staff do not ensure facility is properly maintained. The details of the complaint alleged that the facility is not properly maintained. It was reported that the breaker boxes (electrical panels) are outdated and need to be repaired. On 12/4/2025, from 9:30am-3:00pm, the department interviewed staff (S1-S4) and residents (R1-R8) regarding the allegation. 4 of 4 staff denied the allegation that the Staff do not ensure facility is properly maintained. Staff stated that they have not had any issues with the electrical system or breaker boxes in the facility. Staff maintained that all breaker boxes (electrical panels) were in working order. The department interviewed residents (R1-R8) about the allegation and 8 of 8 residents that were interviewed stated that they have not had any electrical issues in their rooms or noticed any electrical problems in the facility. The department reviewed the Maintenance and House Keeping Work Order Log (Dated: November 2025), Laundry Schedule (Dated: December 2025), A & A Fire Protection Invoice (Dated: 10/15/24), House Keeping Daily Checklist (Dated: November/December 2025), Maintenance and House Keeping Work Order Log (Dated: November 2025), RCFE Caregiver Morning Shift Workflow (Dated: 6:00am-2:00pm), RCFE Caregiver Morning Shift Workflow (Dated: 2:00pm-10:00pm), and RCFE Caregiver Morning Shift Workflow (Dated: 10:00pm-6:00am) and did not observe any deficiencies in the way the facility was maintained. The department toured the facility and observed 10 breaker boxes (electrical panels) and observed that they were all in working order and not outdated or in need of repair. The department further observed that the facility was well maintained inside and outside of the facility. Based on observation, interviews, and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure facility is properly maintained. 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 citations were issued. An exit interview was conducted with Michelle Brown, Wellness Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 11-AS-20251125080321

Allegation investigated: Facility is not adhering to their plan of operation.

On 11/5/25, at 10:00am, the department conducted an initial complaint visit to the facility and was greeted by Brittany Kavanaugh, Executive Director. The department explained the purpose of this visit is to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegation mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and resident (R1). The department received the following facility documents: Resident Roster (Date: 11/05/2025), Staff Roster (Dated:10/23/2025), Physician Report (Dated: 03/21/2025), ID/Emergency Information (Dated: 04/01/2025), Preplacement Appraisal Information (Dated: 04/01/2025), Appraisal & Needs Service Plan (Dated: 04/20/2025), Psychiatric Evaluation (Dated: 08/05/2025, 09/02/2025, 10/01/2025), Clinical Requisition (Dated: 07/20/2025, 09/03/2025), RCFE Plan of Operation Addendum (Dated: 10/30/2025), and Unusual Incident Reports LIC624 (Dated:06/23/2025, 10/26/2025 ) from the facility. Report Continued on LIC909-C Unsubstantiated The investigation revealed the following: Allegation- Facility is not adhering to their plan of operation. The details of the complaint alleged that the facility is not adhering to their plan of operation by having a resident that may need a higher level of care. It was reported that the resident is residing in memory care and does not seem to be correctly placed, as they seem to suffer from psych related issues as opposed to age related memory loss. Consequently, it was reported that the residents in the memory care wing may be at risk, as they are not able to defend themselves. On 11/5/2025, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and resident (R1) regarding the allegation. 4 of 4 staff denied the allegation that Facility is not adhering to their plan of operation. All staff (S1-S4) stated they are adhering to their plan of operation and that R1 does not have a mental disorder diagnosis and is appropriately placed in the facility. Staff stated that R1 does not require 24-hour or skilled nursing care and is placed in memory care due to their physician’s diagnosis. Staff also stated that R1 has continued to take their medications as prescribed. The department interviewed resident (R1) about the allegation and the resident stated that they were happy with the care and supervision provided by the staff and that they did not have any problems with living at the facility. The department reviewed the Physician Report (Dated: 03/21/2025), Psychiatric Evaluation (Dated: 08/05/2025, 09/02/2025, 10/01/2025), Preplacement Appraisal Information (Dated: 04/1/2025), Appraisal & Needs Service Plan (Dated: 04/2025), and Unusual Incident Reports LIC624 (Dated:06/23/2025, 10/26/2025). The department did not observe in any of the medical documents that the resident may have been placed at the facility incorrectly. Additionally, the department did not observe that the resident has a psychiatric diagnosis and that the facility has regular psychiatric evaluations of the resident. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility is not adhering to their plan of operation. 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 citations were issued. An exit interview was conducted with Brittany Kavanaugh, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 11-AS-20251027134919

Allegation investigated: Facility staff handled resident in a rough manner. Facility staff did not treat resident with dignity.

On 10/23/2025 Licensing Program Analyst (LPA) Troy Watson conducted an initial complaint visit to the facility listed above. LPA met with Administrator Brittany Cavanaugh, and the purpose of the visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: On 10/23/2025 LsPA Watson requested, reviewed and obtained the following: Resident Roster, Staff Roster, Psych Evaluation Report,Facility Agreement Form and Unusual Incident Report. On 10/23/2025 LPA Watson conducted interviews with Resident #2 - Residents #7 (R2-R7). An attempt to interview Resident#1 (R1) was made but the resident was no longer at the facility during the time of interviews. LPA Watson conducted interviews with Staff#1 – Staff #5 (S1-S5). LPA Watson to ured the facility with the Wellness Director Michelle Brown and found the facility clean and in good repair. CONTINUED ON LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Facility staff handled residents in a rough manner. On 10/23/2025 LPA Watson interviewed Staff #1-Staff #5 (S1-S5). Of those interviewed, 5 out of 5 staff denied the above allegation. On 10/23/2025 LPA Watson interviewed Residents #2 – Residents #7 (R2-R7). An attempt to interview Resident#1 (R1) was made but R1 was no longer at the facility at the time of the interviews. Of those interviewed 6 out of 7 denied the above allegation. LPA Watson completed interviews with 6 residents at the facility and every resident interviewed was asked the question, have you ever been handled by the staff in a rough manner, and all residents interviewed answered no. LPA Watson interviewed 5 staff members at the facility listed above and all staff members were asked, have you handled the residents in a rough manner, and all staff interviewed answered no. Based on record reviews, staff and client interviews and observations there is insufficient evidence to support the allegation: “Facility staff handles residents in a rough manner” 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: Facility staff did not treat residents with dignity. On 10/23/2025 LPA Watson interviewed Staff #1-Staff #5 (S1-S5). Of those interviewed, 5 out of 5 staff denied the above allegation. On 10/23/2025 LPA Watson interviewed Residents #2 – Residents #7 (R2-R7). An attempt to interview Resident#1 (R1) was made but the R1 was no longer at the facility at the time of the interviews. Of those interviewed 6 out of 7 denied the above allegation. LPA Watson completed interviews with 6 residents at the facility and every resident interviewed was asked the question does the facility staff treat you with dignity and respect and everyone interviewed answered yes. LPA Watson interviewed 5 staff members at the facility listed above and all staff members were asked, are the residents treated with dignity and respect and all residents interviewed answered yes. Based on record reviews, staff and client interviews and observations there is insufficient evidence to support the allegation: “Facility staff did not treat residents with dignity” 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 with the Wellness Director Michelle Brown, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 11-AS-20251015125106

Allegation investigated: Staff did not ensure that resident was receiving catheter care

On 10/17/2025, at 9:45 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met with Michell Brown-Wellness Director who was informed of the purpose of the visit. The investigation consisted of the following: On6/23/2025 at 9:00 AM, LPA Allen obtained pertinent documents for Resident 1(R1) Admissions Agreement, Home Health Resident Assessment Plan dated 4/20/2025, Physicians Report dated 3/4/2025. Patient Orders dated 6/14/2025, Connect HealthCare Notes dated 4/25/25, 4/29/25, 5/1/25, 5/6/25,5/12/25,5/20/25, and 5/27/25. These records revealed that staff members are educated about providing catheter care/cleaning on each visit. Dazzle Health P.C. dated 3/22/25 and 3/27/25, Dignity Health-California records, Hospital Medical Center record dated 12/15/24. Identification and Emergency Information, Pre-appraisal, telecommunication device notification dated 3/7/2025, Staff training dated 6/11/2025, Medication list, Notes including doctors’ visit/Emergency room visits date 12/15/2024, Continued..... Unsubstantiated Southern California Hospital at Culver City patient order history dated 6/18/2025, and home health notes dated 4/20/2025-5/27/2025 and LPA Allen also conducted an interview with R1. The investigation revealed the following: On 06/26/2025, LPA reviewed R1’s home health notes dated 04/20/2025 – 05/27/2025, which revealed that facility staff ensured R1 received catheter cleaning/care from Terraza Court facility staff, in addition to care provided by Connect HealthCare. Connect HealthCare notes dated 04/25/2025, 04/29/2025, 05/01/2025, 05/06/2025, 05/12/2025, 05/20/2025, and 05/27/2025 were reviewed. Connect HealthCare documentation further indicated that both caregivers and patient were educated and informed about catheter cleaning/care and demonstrated comprehension of the information provided during each visit.Records also revealed that R1 has a history of medical complications due to manipulating the catheter against medical advice. At 10:00 AM on 10/17/2025, LPA conducted interviews with Residents 1- 7 (R1–R7). Of those interviewed, 1 out of 7 residents stated they receive assistance with catheter cleaning/care and understand the information provided by the nurse during visits. R2, R3, and R4 also stated that staff members assist them with their care. LPA attempted to interview R5, R6, and R7; however, they were unable to engage in a clear conversation. LPA also interviewed Staff Members 1- 6 (S1-S6) Of those interviewed, 6 out of 6 staff members stated that residents are assisted with their care needs, including catheter cleaning/care. Staff also reported understanding their responsibilities when providing catheter cleaning/care and confirmed they comprehend the information provided by the nurse during visits. Additionally, staff acknowledged that if further medical care is needed by a medical professional residents are either sent out for medical visits or home health professionals are contacted for facility visits. LPA also observed training documents for catheter cleaning/care signed by staff members dated 6/11/2025. Records revealed that R1 received catheter cleaning/care from both medical professionals and facility staff from the date of admission on 03/10/2025 until the discharge date of 09/08/2025 from Connect Healthcare. Continued Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. which means 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. An exit interview was conducted, during which this report was discussed and provided to Michelle Brown- Wellness Director at the conclusion of the visit, along with appeal rights.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 11-AS-20250616185252

Allegation investigated: #1-Allegation: Resident was physically abused while in care #4- Allegation: Staff had inadequate record keeping for a resident

This report supersedes the original report delivered on 6/23/2025.On 10/17/2025, LPA arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 6/23/2025. Upon arrival LPA was assisted by Michelle Brown-Wellness Director. On 6/23/2025, at 11:15 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met Brittany Kavanaugh-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 04/15/2025 at 10:15 AM, LPA Allen obtained and reviewed files for Resident 1 (R1), which included face sheet dated, medication list, appraisal dated 4/20/2025, needs and services plans, physicians report, admissions agreement with personal property valuables list, staff and client roster dated April 2025, police report dated 4/6/2025, and after office visit medical summary dated 4/6/2025. Continued Substantiated LPA Allen also conducted interviews with Staff 1- Staff 5 (S1 – S5), Residents 1 (R1), Witness 1 (W1) and attempted to interview Resident 2 (R2) along with observations of R1 physical signs of physical abuse, LIC624 dated 4/7/2025, interviews with Deeyanna Banda and Administrator Brittany Kavanaugh. Investigation revealed the following: #1-Allegation: Resident was physically abused while in care On 4/15/2025, at 11:15 AM, LPA interviewed Staff 1- 5 (S1–S5). of those interviewed 5 out of 5 staff members reported that they did not witness R1 being physically assaulted by R2 and were unable to establish a timeline for the alleged incident. However, each staff member stated that they observed unexplained bruises on R1’s face immediately upon entering R1's room. Additional bruising to R1's abdomen was noted by staff within a few hours. LPA Allen also interviewed R1, who stated that R2 punched them in the face, mouth, and stomach. On 4/16/2025, at 3:00 PM, LPA received and reviewed the Culver City Police Department (CCPD) report. The report confirmed that R1 reported being physically assaulted by R2. The medical assessment revealed R1 sustained abrasions to the face, a swollen left eye, injuries to the upper and lower lip, a skin tear on the left elbow, a hematoma to the head, neck and back pain upon palpation, chest pain, and bruising to the stomach. R2 admitted to the assault during their interview with CCPD and was subsequently arrested. R1 was transported by EMS to the Emergency Room (ER) for further evaluation. LPA attempted to conduct a file review for R2 but was unable to do so, as the facility failed to complete a pre-admission assessment to determine the resident’s care and supervision needs. Based on observations, staff interviews, and records reviewed, it was determined that the facility failed to provide proper supervision of R2, resulting in the assault on R1 and causing R1 to sustain multiple injuries. #4- Allegation: Staff had inadequate record keeping for a resident- On 4/15/2025, at 11:15AM, LPA interviewed Staff 1- 5 (S1-S5), of those interviewed 5 out of 5 stated upon the paramedic’s arrival, no records or medical information were available for residents R1 or R2. Continued The interviews conducted with Memory Care Director Deeyanna Banda and Administrator Brittany Kavanaugh both stated that no records had been prepared for either resident prior to the altercation. When LPA arrived at the facility and inquired about the absence of records, Deeyanna and Brittany explained that R1 and R2 were newly admitted as displaced individuals who arrived without any identification, medical history or documentation. As a result, their files were not created until after the incident occurred. Based on the evidence gathered during the investigation of record review, interviews and observations the above allegations are found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report was discussed and provided to Brittany Kavanaugh- Administrator, at the conclusion of the visit with appeal rights. Per Administrators’ approval, Joseph Wieder was authorized to sign the report.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 11-AS-20250407120939

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a) · Plan of correction due date: Sep 30, 2025

87468.2 -Additional Personal Rights of Residents in Privately Operated Facilities.(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, or sexual abuse. This requirement was not met as evidenced by: Based on record review, interviews and observations the licensee failed to comply with the section above by not providing proper supervision which resulted in R1 being assaulted by R2 on 4/6/2025 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2025

Plan of correction: The licensee has agreed to provide training to all staff members regarding the personal rights of all residents in care which should include a statement of understanding signed by all staff members. This information will be emailed to LPA by the POC date of 06/25/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a) · Plan of correction due date: Sep 30, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: which poses an immediate health, safety or personal rights risk to persons in care. During LPA Allen investigation the Adminstrator did not have R1 or R2 files availiable for paramedics or LPA during investigation visit.the state’s words, verbatim · CDSS document, Oct 17, 2025

Plan of correction: The licensee has agreed to provide a complete file for R1and R2. along with a statement of understanding of the cited regulations to ensure that all residents files are availiable at all times. This information will be emailed to LPA by the POC date of 06/25/2025

Allegation investigated: Facility staff did not assist resident with transferring as needed Facility staff did not assist resident with incontinence care as needed Facility staff did not notify the fire authority within 48 hours of retaining a resident who is bedridden

On 09/25/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Wellness Director, Michelle Brown, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA interviewed Residents R2-R11, and received and reviewed Resident Assignment, and Outside Agency/Service Documentation. During the initial visit conducted on 09/24/2025, LPA inspected the facility, interviewed Staff S1-S7, interviewed Resident R1, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Bedridden Resident List, notification letter to the local fire department informing them of a bedridden resident, Staff Training Logs, Resident R1 Physician’s Report, Resident R1 Physician's Orders, Needs and Service Plan, Assessment, and Admission Agreement. The investigation revealed the following: Unsubstantiated Allegation: Facility Staff did not assist resident with transferring as needed The allegation alleges there is not a sling for the Hoyer lift to transfer residents. During record review, LPA received and reviewed a staff Training Log, dated 04/2025, on the topic of Hoyer Lift Training from PSL Hospice. Additionally, LPA received and reviewed a six (6) page handout on How to Use a Hoyer Lift that was provided to staff. LPA received and reviewed an invoice from Omni Care that a sling was ordered on 08/26/2025. During the facility tour, LPA observed a sling for the Hoyer lift, and lifts are operational. Additionally, LPA was shown slings that are available but was informed some residents do not like these slings and do not want them to be used when transferring them. During interviews with Staff S1-S7, were asked if bedridden residents are assisted with transferring from their bed to chair, seven (7) out of seven (7) stated yes, bedridden residents are assisted with transferring from their bed to chair. Additionally, seven (7) out of seven (7) stated their bedridden resident refuses transferring from their bed to the chair. Staff S1-S7 were asked if there have been any issues with the Hoyer lift, seven (7) out of seven (7) stated no, there have been no issues with the Hoyer lift. Three (3) out of seven (7) stated when one of the residents was transferred to the hospital, the Hoyer sling did not return with them. During interviews with Residents R1-R11, were asked if they are assisted with transferring when needed and wanted, two (2) out of eleven (11) stated no, they are not assisted with transferring when requested. Allegation: Facility staff did not assist resident with incontinence care as needed The allegation alleges that a residents incontinent needs are not being met. During record review, LPA received and reviewed Assigned Resident list of residents who requires additional assistance that includes a bed bath, incontinent care, and grooming. On the Assigned Resident list there are reminders to check on residents every 2 hours and to care for incontinent needs when needed. LPA reviewed staff training conducted on Relias and observed Caring for Incontinent Residents was completed. During interviews with Staff S1-S7 were asked how often incontinent residents are assisted with changing or checked to see if they need changing, seven (7) out of seven (7) stated they check residents every two (2) hours unless they require more frequent checks. During interviews with Residents R1-R11, were asked if they are assisted with incontinence frequently, one (1) out of eleven (11) stated they are not assisted with incontinent care regularly. Additionally, Residents R1-R11 were asked if they have been left in a soiled diaper or briefs for an extended period of time, eight (8) out of eleven (11) stated they have not been left in soiled diapers for an extended period of time. Three (3) out of eleven (11) residents stated they do not receive assistance with incontinent care. Allegation: Facility staff did not notify the fire authority within 48 hours of retaining a resident who is bedridden The allegation alleges that the facility is not notifying the local fire department of a resident who is bedridden. During an interview with Staff S1, was asked if notice is sent to the Culver City Fire Department informing them within 48 hours of retaining a resident who is bedridden according to the regulations, S1 stated yes a letter notifying them is sent within 48 hours. During record review, S1 provided LPA with a copy of two (2) letters that were faxed to the Culver City Fire Department dated 04/25/2025 and 09/01/2025 and the fax receipt. LPA observed the letters are updated lists of residents who are hospice, receive Oxygen, and who are bedridden, and their room number. Staff S1 informed LPA that when the list is updated whether removing a person or adding a person. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated. During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Wellness Director, Michelle Brown, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 11-AS-20250915160928

Type of visit: Case Management - Deficiencies

On 09/24/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a case management visit to the facility listed above. LPA met with Memory Care Director, Deeyanna Banda, and the purpose of today’s visit was explained. LPA was granted entry into the facility. During today’s visit, LPA requested a resident roster and list of residents who are bedridden. Upon review of the roster, LPA observed Resident R1 is residing on floor two and is bedridden. The current facility fire clearance indicates that floor on is cleared for bedridden residents. Floor two is cleared for non-ambulatory residents. Based on the information the facility is not in compliance with the approved fire clearance. An immediate Civil Penalty was assessed during today’s visit. Deficiency cited under California code regulation Title 22, Division 6, Chapter 8. An exit interview was conducted with Memory Care Director, Deeyanna Banda, and a copy of this report and the Appeals Rights were provided.the state’s words, verbatim · CDSS document, Sep 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Sep 25, 2025

87202 Fire Clearance (a)All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2)Bedridden persons This requirement is not met as evidence by: Based on records review and observation resident R1 is residing on the 2nd floor and is bedridden. This poses an immediate Health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2025

Plan of correction: MCD S1 stated Resident R1 will be moved to floor one which is cleared for bedridden residents. LPA will conduct a visit to ensure the move was made. CivilL Penalty Assessed

Allegation investigated: Staff did not seek medical attention for resident in care in a timely manner. Staff did not ensure that resident was provided with a comfortable environment whle in care.

On 9/16/2025 at approximately 10:00 AM, LPA Alfonso Iniguez conducted a subsequent unannounced complaint visit. LPA Iniguez met with Deeyanna Banda/Med Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Care MC Director Interview (A#1), Residents Interviews (R#1-R#7) and Staff Interview (S#1-S#2). LPA obtained and reviewed the following documents: Resident Roster dated: 8/7/25, Staff Roster dated: 8/7/25, copy of (R#1)’s Unusual Incident Report dated: 3/8/25, copy of (R#1)’s, copy of facility staff (S#2) email regarding (R#1)’s incident dated:3/10/25, copies of facility progress notes dated: 3/6/25 and 3/8/25, copy of Med Tech Communication Log dated: 3/7/25, copy of (R#1) resident assessment dated: 3/7/25, copy of (R#1)’s discharge hospital records dated:3/7/25, copy of (R#1)’s Physicians Report for Residential Care Facilities for The Elderly (RCFE) or LIC 602A dated:3/7/25. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff did not seek medical attention for residents in care in a timely manner. The details of the complaint alleged that facility staff did not seek medical attention for (R#1) in a timely manner. On September 16, 2025, at approximately 10:30 a.m., during the records review, LPA Iniguez observed a copy of the Culver City Fire Department Incident Report dated 3/7/25. LPA Iniguez observed that the report states that on the night of 3/7/25 at approximately 11:31 p.m., the emergency department was dispatched to the facility regarding (R#1). When the emergency department arrived at (R#1)’s room, emergency personnel spoke with (R#1), who denied any medical complaint. (R#1) stated that they were very uncomfortable because they needed an adjustable bed, and the facility did not have one. Emergency personnel took (R#1) to the hospital. On August 7, 2025, at approximately 10:00 AM, during an Interview with the Administrative Assistant (A#1), she stated that (R#1) was only one day with us at the facility. (R#1) was taken to the hospital for further care and evaluation. In addition, (A#1) stated that the facility did not use Uber or Lyft to transfer (R#1) to the hospital; the emergency department came on the night of 3/7/25 and took them back to the hospital. On August 7, 2025, at approximately 11:25 am, Licensing Program Analyst-LPA Alfonso Iniguez contacted former resident (R#1), they answered the call and LPA Iniguez introduced himself, (R#1) stated that they do not have time to take the call since they are at the hospital and they do not want to talk about it. LPA Iniguez thanked (R#1) for their time and ended the call. Evaluation Report continues LIC 9099-C On August 7, 2025, at approximately 12:00 PM, during an interview with residents in care (R#2-R#7), (6) out of (7) stated that they feel the facility staff are trained in case they need emergency medical services. In addition, (6) out of (7) residents in care stated that they feel the facility staff will call the emergency department in case they need it. On August 7, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#2), (2) out of (2) stated that (R#1) was only one night at the facility and they did not attempted to take them to the hospital using an Uber or Lyft, the emergency department came an took (R#1) to the hospital. Allegation: Staff did not ensure that residents were provided with a comfortable environment while in care. The details of the complaint alleged that (R#1) spent the night on their wheelchair. On September 16, 2025, at approximately 10:30 a.m., during the records review, LPA Iniguez observed a copy of the hospital discharge records dated 3/7/25. LPA Iniguez observed that (R#1) did not have an order for a hospital bed. On August 7, 2025, at approximately 10:00 AM, during an Interview with the Administrative Assistant (A#1), she stated that (R#1)’s bed was clean and in good condition when they arrived at the facility; it was not soiled. In addition, (A#1) stated that (R#1) did not sleep in their wheelchair the whole night. When (R#1) arrived at the facility, they requested a hospital bed. We told (R#1) that such a bed is considered medical equipment and needs a doctor’s order. When (R#1) found out we could not provide the hospital bed that night, they refused to use the facility bed. Later that night, facility staff informed me that (R#1) slept on the facility’s bed. Evaluation Report continues LIC 9099-C On August 7, 2025, at approximately 11:25 am, Licensing Program Analyst-LPA Alfonso Iniguez contacted former resident (R#1), they answered the call and LPA Iniguez introduced himself, (R#1) stated that they do not have time to take the call since they are at the hospital and they do not want to talk about it. LPA Iniguez thanked (R#1) for their time and ended the call. On August 7, 2025, at approximately 12:00 PM, during an interview with residents in care (R#2-R#7), (6) out of (7) stated that the facility provides a comfortable environment for them and the rest of the residents in care. In addition, (6) out of (7) residents in care stated that they feel comfortable living at the facility. On August 7, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#2), (2) out of (2) stated that (R#1)’s bed was clean and in good condition when they arrived at the facility; it was not soiled and they did not sleep in their wheelchair the whole night. 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 Michelle Brown/Wellness Director.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 11-AS-20250310122319

Allegation investigated: Staff did not assist a resident in care with transportation.

On 09/03/25 Licensing Program Analyst (LPA) Mario Leon conducted an initial complaint visit at the facility. LPA was met by staff one, Michelle Brown (S1), and the purpose of the visit was explained. The investigation consisted of the following: between 09:50AM and 10:50AM LPA requested the staff and resident rosters and three (3) resident files which include Admission Agreements (dated: various), Physician's reports (dated: various) and one (1) notification to residents (dated: 05/01/25). LPA conducted interviews with residents #1-#5 (R1-R5) and staff #1-#5 (S1-S5) and LPA toured the facility. The investigation revealed the following: Regarding the allegation, “staff did not assist a resident in care with transportation”, it is being alleged that the facilities’ vehicle is inoperable which has resulted in personal rights violation for resident(s) in care. Between 11:05AM and 3:15PM, LPA interviewed R1-R5 and S1-S5. Three (3) out of five (5) residents and all five (5) staff have denied the allegation has taken place. All five staff have informed LPA that residents are provided transportation when transportation is necessary. S5 has stated that numerous automotive shops have denied service to the van, but that a transmission shop in Burbank has accepted to inspect the van's transmission (dated: 09/05/25). Report continues, please see LIC9099-C. Unsubstantiated Record reviews revealed that a notification regarding the facility's van being out of service (dated 05/01/25). Within this notification there are written regulation(s) regarding scheduling and distance, to be provided by Uber and Access, which has been provided to residents and their responsible parties, on 05/01/25. Based on record reviews and interviews conducted, 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 that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 11-AS-20250827130833

Allegation investigated: Licensee did not ensure that resident was reassessed as necessary while in care.

On August 22, 2025, Licensing Program Analyst (LPA) Pamela Bunker conducted a subsequent visit to gather information regarding the above allegations. LPA met with Michelle Brown, Wellness Director, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On August 22, 2025, the following documents were reviewed and/or obtained as part of the investigation: Personnel Report (dated 08/22/2025), Resident Roster (dated 08/22/2025), Special Incident Reports (dated 10/24/2024), Admission Agreement (dated 03/15/2022) Identification and Emergency Information (dated 03/16/2022), Physician’s Report (dated 07/13/2022, 07/25/2023 & 10/02/2024), Medical Assessment (dated 03/09/2022), Medication Administration Records (MARs) (dated 10/24/2024 & 11/20/2024), Appraisal & Needs and Services Plan (dated 05/14/2024), Functional Capability Assessment (dated 07/13/2022), Preplacement Appraisal Information (dated 07/13/2022), Personal Rights (dated 03/12/2022), Consent Forms (date 03/12/2022), Resident Assessment (dated 03/15/2022), See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 3 AL Advantage Resident Assessment (dated 02/24/2022 & 03/09/2022). Interviews were conducted with Staff Members #1–6 (S1–S6) and Resident #2-6 (R2-R6) Resident #1 (R1) was unavailable for an interview as they no longer reside at the facility. R1 passed away on December 21, 2024, after transferring to another care facility. The investigation revealed the following. Allegation: Licensee did not ensure that the resident was reassessed as necessary while in care. LPA interviewed Staff #1–6. All six staff members (6 out of 6) stated that the facility staff ensure residents are reassessed as necessary while in care. 6 out of 6 staff members also reported that there was no reason for the resident to be reassessed, as the previous assessment was up to date and there had been no change in R1's condition requiring reassessment. All six (6 out of 6) staff members denied the allegation. A review of R1’s file, including the Physician’s Report (dated 07/13/2022, 07/25/2023 & 10/02/2024), Medical Assessment (dated 03/09/2022), Medication Administration Records (MARs) (dated 10/24/2024 & 11/20/2024), Appraisal & Needs and Services Plan (dated 05/14/2024), Functional Capability Assessment (dated 07/13/2022), Preplacement Appraisal Information (dated 07/13/2022), and Resident Assessment (dated 03/15/2022) did not indicate resident need to be reassessed. The resident did not have a change in condition. LPA interviewed Residents #2-6 (R2–R6). Five (5 out of 6) residents stated that staff ensure residents are reassessed when needed during their care. Five (5 out of 6) residents denied the allegation. 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-C was provided to the Wellness Director, Michelle Brown. An exit interview was conducted. No deficiencies were cited.the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 11-AS-20250714101031

Allegation investigated: Staff did not safeguard residents personal belongings.

On 08/21/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the allegation mentioned above. LPA met with Wellness Director, Michelle Brown, and explained the purpose of the visit. LPA was granted access to the facility. The investigation consisted of the following: LPA requested the staff and resident rosters. Reviewed five (5) resident files and collected the following records: ID and Emergency Information, Residence and Care Agreements, Move in Records (Face Sheets), Resident Personal Property and Valuables, Theft and Loss Policy, and Unusual Incident/Injury Report (dated: 07/09/25). LPA conducted interviews with residents #1-#7 (R1-R7) and staff #1-#6 (S1-S6). Additionally, LPA conducted a tour of the facility. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not safeguard residents personal belongings. It is being alleged that someone is going into the residents and stealing their belongings. On 08/21/25, between 11:00 AM and 12:30 PM, LPA conducted interviews with S1-S6. Of those interviewed, 6 out of 6 staff denied the allegation. 4 out of 6 staff said that they were not aware of any resident reporting any missing items, and 2 out of 6 staff said they were aware of a resident reporting a stolen item. S1-S2 stated that when a resident reports a missing or stolen item, they will do a sweep and look for the item, they will talk with staff and other residents to see if they know anything about the missing item, and that they will involve the police if they feel the need to. On 08/21/25, between 1:30 PM and 3:00 PM, LPA conducted interviews with R1-R7. Of those interviewed, 7 out of 7 residents denied the allegation. 6 out of 7 residents said they haven’t had an issue with their personal belongings missing or stolen. 7 out of 7 residents said they believe they are responsible for keeping their valuables safe and secure. A review of Unusual Incident/Injury Report dated 07/09/25 revealed that on 07/08/25 a resident informed staff that their debit card was stolen and used at a local 7-11. Staff spoke with that residents Power of Attorney (POA), and they provided the exact timing and amounts of the transactions. Staff went to the 7-11 and confirmed that it was the residents roommate who had used the debit card. Staff called Culver City Police Department, and an investigation was conducted. Staff offered the to relocated the resident (victim) to a private room. Although it did happen, the facility took the proper steps and called law enforcement, reported it to Community Care Licensing Department (CCLD), and other applicable agencies. Based on observation, interviews conducted, and a review of records, there is insufficient 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 unsubstantiated. An exit interview was conducted, and a copy of this reportthe state’s words, verbatim · CDSS document, Aug 21, 2025 · control 11-AS-20250812110146

Allegation investigated: Staff did not provide resident medication as prescribed.

On 06/27/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegation(s). LPA met with Wellness Director Michelle Brown and the purpose of the visit was explained. LPA spoke with Executive Director over the phone. LPA conducted a subsequent visit on 07/10/25, 07/11/25 and 08/08/25 and met with the Wellness Director. Investigation consisted of the following : On 06/27/25, LPA obtained Resident Rosters, Staff Roster, Elevator Invoices, Assisted Living and Memory Care Activity Schedule (January 2025 – June 2025), and Fire Drill Reports. LPA interviewed six (6) staff (S2 – S7) and toured the facility (stairwells 1 and 2), elevator, common areas, and outdoor patios. LPA received resident records via email on 07/07/25 – 07/09/25. On 07/10/25, LPA interviewed Staff #8 (S8), seven residents (R1 – R7), and Witness #1 (W1). On 07/11/25, LPA interviewed two staff (S9 – S10), five residents (R5, R8 – R11), and Witness #2. On 07/14/25, Executive Director emailed Medication Administration Records for five residents. Continue to LIC9099-C. Substantiated On 08/01/25, Executive Director emailed August 2025 Activity Calendar and medication discontinuation and refill rosters for five residents. On 08/08/25, LPA conducted four (4) staff (S9 – S12) interviews and obtained identification and emergency information and needs and services plans for five memory care residents. LPA toured the common areas of the facility. Investigation revealed the following Allegation: Staff did not provide resident medication as prescribed Record review of the facility’s Plan of Operation indicated that "medication refills will be obtained in a timely manner to ensure residents have all physician ordered medication available. 1) The designated staff member contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to running out of a medication, unless medication is on a cycle refill with the pharmacy…. 2) If necessary, the prescribing physician is contacted for a new order. 3) Medications are never allowed to run out unless directed to by the physician (obtain this direction in writing). Record review of R1’s February 2025 Medication Administration Record (MAR) revealed that medication A was out of stock as of 02/20/25, medication B as of 02/22/25, medication C and D as of 2/23/25, and medication E and F as of 02/26/25. Record review of R1’s refill order did not provide a refill date request for medication A and B. Medication C, D, and E refills were requested on 02/21/25. Medication F refills was requested on 02/26/25. Record review of R4’s July 2025 MAR revealed medication A was missed on 7/2, 7/6, 7/8, 7/10, 7/12, and was requested to be refilled on 07/17/25. Medication B was missed on 7/4, 7/6, 7/10 and requested to be refilled on 7/17/25. Record review of R5’s July 2025 MAR revealed medication A was unavailable from 07/09/25 – 07/13/25 and the request for refill was submitted 07/16/25. Medication B was missed 07/03/25, 07/09-07/10, 07/12-07/13 AM and 07/07, 07/09 - 07/12 PM and was requested to be refilled on 07/16/25. Medication C was missed on 7/2 - 7/3, 7/6 - 7/7, 7/9 - 7/12. Record review of R12’s March 2025 MAR revealed R12’s medication A – G was out of stock as of 03/19/2025. Record review of R14’s May 2025 MAR revealed medication A was missed on 5/1 - 5/4, 5/6 - 5/11, 5/13, 5/15 - 5/19, 5/21 - 5/24, 5/29 - 5/31 and medication B was missed on 5/1, 5/5-5/7, 5/10, 5/13, 5/17-5/19, and 5/24. Regarding the allegation, “Staff did not provide resident medication as prescribed” based on record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6 and Chapter 8 on the attached LIC 9099D. An exit interview was conducted, plans of correction developed, and a copy of this report with appeals was provided to the Wellness Director Michelle Brown.the state’s words, verbatim · CDSS document, Aug 8, 2025 · control 11-AS-20250625130052

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Aug 19, 2025

87208 Plan of Operation (a) The licensee shall ... operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49... This requirement was not met as evidence by: Based on record review, the Licensee did not follow its plan of operation: medication policy (medication refills) for Residents #1, 4, 5, 12, and 14 which poses a potential health risk for resident in care. Plan indicates medications are never allowed to run out and refills will be ordered 7 days in advanced.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: The Licensee will submit a plan of correction to regina.cloyd@dss.ca.gov by the POC due date.

Allegation investigated: Staff did not ensure that residents were provided adequate supervision.

On 06/27/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit on to gather information regarding the above allegation(s). LPA met with Wellness Director Michelle Brown and the purpose of the visit was explained. LPA spoke with Executive Director over the phone. On 07/10/25, LPA conducted a subsequent visit and met with the Wellness Director. On 07/11/25, LPA conducted a subsequent visit and met with the Wellness Director. Investigation consisted of the following : On 06/27/25, LPA obtained Resident Rosters, Staff Roster, Elevator Invoices, Assisted Living and Memory Care Activity Schedule (January 2025 – June 2025), and Fire Drill Reports. LPA interviewed six (6) staff (S2 – S7) and toured the facility (stairwells 1 and 2), elevator, common areas, and outdoor patios. LPA received resident records via email on 07/07/25 – 07/09/25. On 07/10/25, LPA interviewed Staff #8 (S8), seven residents (R1 – R7), and Witness #1 (W1). On 07/11/25, LPA interviewed two staff (S9 – S10), five residents (R5, R8 – R11), and Witness #2. Continue to LIC9099-C. Unsubstantiated Regarding the allegation, “Staff did not ensure that residents were provided adequate supervision,” it is being alleged that on several occasions, wheelchair-bound residents were placed in front of the television area for hours without checking on them regularly. LPA observed staff supervision during group activities in the large common area on the ground floor and in the theater room and dining room with memory care residents. Two out of two staff interviews denied the allegation. Four out of five resident interviews denied the allegation. Witness #2 was unaware. Regarding the allegation, “Staff did not ensure that residents were provided adequate supervision,” based on interviews and observations, the Department found no evidence to support the allegation mentioned above. 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. An exit interview was conducted and a copy of this report was provide to the Wellness Director Michelle Brown.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 11-AS-20250625130052

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

Allegation investigated: Staff did not ensure resident was assisted in a timely manner. Staff do not provide activities for residents. Facility elevator is in disrepair. Facility does not conduct emergency drills as required.

On 06/27/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit on to gather information regarding the above allegation(s). LPA met with Wellness Director Michelle Brown and the purpose of the visit was explained. LPA spoke with Executive Director over the phone. On 07/10/25, LPA conducted a subsequent visit and met with the Wellness Director. Investigation consisted of the following : On 06/27/25, LPA obtained Resident Rosters, Staff Roster, Elevator Invoices, Assisted Living and Memory Care Activity Schedule (January 2025 – June 2025), and Fire Drill Reports. LPA interviewed six (6) staff (S2 – S7) and toured the facility (stairwells 1 and 2), elevator, common areas, and outdoor patios. LPA received resident records via email on 07/07/25 – 07/09/25. On 07/10/25, LPA interviewed Staff #8 (S8), seven residents (R1 – R7), and Witness #1 (W1). Continue to LIC9099-C. Unsubstantiated Regarding the allegation, “Staff did not ensure resident was assisted in a timely manner,” it is being alleged that Resident #2 (R2) was not ready for scheduled pick-up on 06/24/25. Record review of R2’s Physicians’ Report revealed that R2 is able to dress and groom self, able to communicate, and leave the facility unassisted. Interview with Wellness Director indicated that R2 is independent. Wellness Director indicated that when a resident is independent, appointments are not tracked unless the facility is providing transportation. Four out four staff interviews (S2 – S5) indicated that staff communicate with each other to have the resident prepared for timely pick-ups. One out two resident interviews (R3 – R4) indicated that staff have them prepared for pick-ups. Three out of three resident interviews (R1- R2, R7) indicated that they are independent. Witness #1 indicated that resident is assisted in a timely manner. Regarding the allegation, “Staff did not ensure resident was assisted in a timely manner,” based on interviews and record review, the Department found no evidence to support the allegation mentioned above. 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. Regarding the allegation, “Staff do not provide activities for residents,” it being alleged that on several occasions, wheelchair-bound residents were placed in front of the television for an extended period of time instead of being engaged in other activities. Record review of January through March 2025 activity schedule revealed that activities were scheduled from 9:00 AM – 6:30 PM from Sunday through Tuesday, Thursday, and Saturday. Activities were scheduled from 9:00 AM – 8:00 PM on Wednesdays and Fridays. Record review of April - June 2025 activity schedule revealed that activities were scheduled from 9:00 AM – 6:30 PM from Sunday through Tuesday and Thursday through Saturday. Activities are scheduled from 9:00 AM – 6:00 PM on Wednesdays. Five out five staff interviews (S2 – S6) indicated that residents in wheelchairs are provided with activities. Interview with the Activities Director indicated that all residents in wheelchairs or diagnosed with dementia are encouraged to participate in events and outings. Seven out seven resident interviews (R1 – R7) indicated that staff provides residents with activities. Witness #1 indicated that the facility provides activities. LPA observed residents engaged in activities located in the common areas. Regarding the allegation, “Staff do not provide activities for residents,” based on interviews, record review, and observations, the Department found no evidence to support the allegation mentioned above. 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. Continue to LIC9099-C. Regarding the allegation, “Facility elevator is in disrepair,” it is being alleged that the elevator was not working in early June 2025. Record review of elevator service contract revealed that the facility has a maintenance service agreement throughout 2025. Interview with the Maintenance Director indicated that the elevator was operable in June and whenever there is an issue, it is resolved right away. Four out four staff interviews (S2 – S3, S5, S7) indicated that the elevator was operable in June. LPA observed a evacuation wheelchair in stairwell 1 and 2. Four out five resident interviews (R1 – R3, R5, R7) indicated that the elevator was operable in June. R4 and R6 were unaware if the elevator was or was not operable. Witness #1 indicated that the elevator was operable in June. Regarding the allegation, “Facility elevator is in disrepair,” based on interviews, record reviews, and observations, the Department found no evidence to support the allegation mentioned above. 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. Regarding the allegation, “Facility does not conduct emergency drills as required,” it is being alleged that the facility has never conducted a fire drill. Record review of fire drill report revealed that seven residents and staff participated in a drill on May 25, 2025 in the evening. Fifteen residents participated in the fire drill on February 12, 2025 in the morning. The document also revealed that some residents did not want to participate. Six out six staff interviews (S2 – S7) indicated that the facility conducts drills. Witness #1 indicated that W1's father does not participate in fire drills. Three out five resident interviews (R1, R3, R5 – R7) indicated that the facility has fire drills. Two out of two residents (R2, R4) were unaware if the facility conducted fire drills. Regarding the allegation, “Facility does not conduct emergency drills as required,” based on interviews, record reviews, and observations, the Department found no evidence to support the allegation mentioned above. 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. No deficiencies were issued. An exit interview was conducted and a copy of this report was provide to the Wellness Director Michelle Brown.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 11-AS-20250625130052

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: #2 Allegation- Resident was sexually abused while in care #3 Allegation- Staff did not properly report an incident involving a resident

***This report supersedes the original report delivered on 06/23/2025. At 3:20 PM On 7/3/2025, the LPA arrived at the facility to deliver the corrected 9099, obtaining signatures of the authorized representative on the original report issued on 06/23/2025. *** Upon arrival Joseph Wieder was not avaliable to sign the report and Deeyanna Banda memory care director was authorized to sign. On 6/23/2025, at 11:15 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met Brittany Kavanaugh-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 04/15/2025 at 10:15 AM, LPA Allen obtained and reviewed files for Resident 1 (R1), which included face sheet, medical assessment dated 4/20/2025 , appraisal, needs and services plan, physicians report dated 2/7/2025, admissions agreement with personal property valuables list, staff and client roster dated April 2025, police report dated 4/6/2025 and UCLA Health after visit medical summery dated 4/6/2025, SOC341 and SIR 624 date 4/7/2025. Unsubstantiated Investigation revealed the following: #2 Allegation- Resident was sexually abused while in care On 4/15/2025 LPA conducted interviews with staff members S1- S5 and 5 out of 5 staff members stated they did not witness or hear R1 being sexually abused by R2. Staff members stated when R1 was observed they only saw visible abrasions to their face and later that evening during their scheduled shower time R1 was observed with abdominal bruising which was reported. LPA interviewed R1, who stated they were not sexually assaulted by R2 only physically punched in their face and stomach. LPA Allen also obtained and reviewed a copy of R1’s medical summary, which did not indicate any evidence of sexual assault. LPA Allen also interviewed W1, who stated upon arriving to the facility, both R1 and R2 were questioned, and R1 denied ever being sexually assaulted by R2. LPA attempted to interview R2; however, R2 was not present at the facility during the investigation. #3 Allegation- Staff did not properly report an incident involving a resident On 4/15/2025, LPA conducted interviews with Staff 1- Staff 5 (S1 – S5) and 5 out of 5 staff members stated R1 was observed with visible abrasions to their face and body which was immediately reported, documented, and management was informed of the incident the same day. The police were also contacted the same day and upon their arrival both residents were interviewed and R2 admitted to physically assaulting R1 and they were taken into custody. The Administrator- Brittany Kavanaugh and facility staff self- reported the incident by calling the police, completing the SOC341 and the Unusual incident report LIC624 and sent R1 to the hospital for assessment. Based on the evidence gathered during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Deeyanna Banda at the conclusion of the visit with appeal rights. Per Administrators approval Deeyanna Banda was authorized to sign the report.the state’s words, verbatim · CDSS document, Jul 3, 2025 · control 11-AS-20250407120939

Allegation investigated: Staff did not prevent a resident from sustaining a fracture while in care. Staff did not prevent resident from eloping from the facility.

*** THIS REPORT SUPERSEDES REPORT DATED 04/17/2025 TO INCLUDE ADDITIONAL INFORMATION. THE FINDINGS REMAIN THE SAME. ** On April 17, 2025, Licensing Program Analyst (LPA) Pamela Bunker conducted a subsequent visit to gather information regarding the above allegations. LPA met with Memory Care Director, Denyanna Banda, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On April 17, 2025, the following documents were reviewed and/or obtained as part of the investigation: Personnel Report, Resident Roster, Special Incident Reports, Admission Agreement, Identification and Emergency Information, Physician’s Report, Medical Assessment, Medication Administration Records (MARs), Appraisal & Needs and Services Plan, Functional Capability Assessment, Preplacement Appraisal Information, Consent Forms, and UCLA Medical Center Records. Interviews were conducted with Staff Members #1–5 (S1–S5) and Residents #2–8 (R2–R8). Resident #1 (R1) was unavailable for an interview as they no longer reside at the facility. R1 passed away on December 21, 2024, after transferring to another care facility. Unsubstantiated Continued LIC9099-C page 2 The investigation revealed the following: Allegation 1: Staff failed to prevent a resident from sustaining a fracture while in care. It was alleged that on October 24, 2024, R1 exited the facility, began walking backward, and subsequently fell, sustaining a hip fracture. R1 was transported to the emergency room and diagnosed with the injury. LPA interviewed Staff #1–5. 1 out of 5 staff members stated they were not present during the incident and could not provide details. 4 out of 5 staff members confirmed they were present and described that R1 was attempting to leave the memory care unit. R1 exited through a secured door and began walking backward, which led to the fall. Staff arranged transport to the hospital for medical evaluation. LPA interviewed Residents #2-8 (R2–R8), and 7 out of 7 residents denied the allegation. LPA conducted a tour of the physical plant, but no surveillance cameras were observed. A review of R1’s file, including the Physician’s Report, Needs and Services Plan, and Preplacement Appraisal, did not indicate a documented history of falls. An incident report was submitted to Community Care Licensing (CCL) for the incident that occurred. Based on the investigation, there is not enough evidence to support that staff failed to supervise R1, resulting in the resident sustaining a fracture. 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. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation 2: Staff failed to prevent a resident from eloping from the facility. It was alleged that on October 24, 2024, R1 exited the facility without staff supervision. LPA interviewed Staff #1–5. 1 out of 5 staff members was not present during the incident but reported hearing that R1 never left the facility premises. 4 out of 5 staff members confirmed their presence during the incident and stated that while R1 exited the memory care unit, the resident did not leave the facility grounds and was under supervision at all times. LPA interviewed residents #2-8 regarding the allegation, 7 out of 7 residents denied the allegation. LPA conducted a tour of the physical plant and observed the facility's memory care unit is located on the second floor of the building. Based on LPA’s observation if a resident exits the memory care unit they would be in the hallway and would need to take an elevator down from the second floor to completely exit the facility premises. Based on the investigation there is no evidence to support R1 eloped from the facility grounds. 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-C, was provided to the Memory Care Director Denyanna Banda. An exit interview was conducted. No deficiencies were cited.the state’s words, verbatim · CDSS document, Jun 26, 2025 · control 11-AS-20241107165127

Allegation investigated: #1-Allegation: Resident was physically abused while in care. #4- Allegation: Staff had inadequate record keeping for a resident.

On 6/23/2025, at 11:15 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met Brittany Kavanaugh-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 04/15/2025 at 10:15 AM,LPA Allen obtained and reviewed files for Resident 1 (R1), which included face sheet dated, medication list, appraisal 4/20/2025, needs and services plans , physicians report, admissions agreement with personal property valuables list, staff and client roster,April 2025, police report dated 4/6/2025,and after visit medical summery dated 4/6/2025. LPA Allen also conducted interviews with Staff 1- Staff 5 (S1 – S5), Residents 1 (R1), Witness 1 (W1) and attempted to interview Resident 2 (R2) along with observations of R1 physical signs of physical abuse,LIC624 dated 4/7/2025,SOC341dated 4/7/2025 and interviews with Deeyanna Banda and Administrator Brittany Kavanaugh Substantiated Investigation revealed the following: #1-Allegation: Resident was physically abused while in care On 4/15/2025, at 11:15AM, LPA interviewed Staff 1- Staff 5 (S1-S5), and 5 out of 5 stated they did not witness R1 being physically assaulted by R2 and were unable to establish a timeline for the alleged incident. However, all (5) five staff members reported noticing unexplained bruising on R1's face immediately after going into their room. Staff also stated they observed additional abdominal bruising within hours. LPA Allen interviewed R1 with the assistance of S2 as a translator. When asked if R2 physically abused them while in care, R1 stated that R2 had punched them in the face, mouth, and stomach. LPA attempted to interview R2, but they were not present at the facility during the investigation. LPA Allen obtained a police report reflecting R1 was physically assaulted while in care. LPA Allen also interviewed W1, who stated that upon arriving at the facility, R1 and R2 were questioned and R2 admitted to attacking R1 and was immediately taken into custody. Paramedics were called, and R1 was transported to the Emergency Room (ER) for further observation and determined that R1 was physically assaulted by R2. #4- Allegation: Staff had inadequate record keeping for a resident- On 4/15/2025, at 11:15AM, LPA interviewed Staff 1- Staff 5 (S1-S5), and 5 out of 5 stated upon the paramedic’s arrival, no records or medical information were available for residents R1 or R2. The interviews conducted with Memory Care Director Deeyanna Banda and Administrator Brittany Kavanaugh both stated that no records had been prepared for either resident prior to the altercation. When LPA arrived at the facility and inquired about the absence of records, Deeyanna and Brittany explained that R1 and R2 were newly admitted as displaced individuals who arrived without any identification, medical history or documentation. As a result, their files were not created until after the incident occurred. Based on the evidence gathered during the investigation, the above allegation is found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report was discussed and provided to Brittany Kavanaugh- Administrator at the conclusion of the visit with appeal rights. Per Administrators approval Joseph Wieder was authorized to sign the report. Investigation revealed the following: #2 Allegation- Resident was sexually abused while in care On 4/15/2025 LPA conducted interviews with staff members S1- S5 and 5 out of 5 staff members stated they did not witness or hear R1 being sexually abused by R2. Additionally, none of the staff members were able to corroborate the allegation or establish a timeline for the alleged assault that could have happened. LPA interviewed R1, who stated that they had not been sexually assaulted by R2 only physically punched in their face and stomach. LPA attempted to interview R2; however, R2 was not present at the facility during the investigation. LPA Allen also obtained and reviewed a copy of R1’s medical summary, which did not indicate any evidence of sexual assault. LPA Allen also interviewed W1, who stated that upon arriving to the facility, both R1 and R2 were questioned, and R1 denied ever being sexually assaulted by R2 additionally, R2 did not confirm or deny the sexual allegation took place. Based on the evidence gathered during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Brittany Kavanaugh Administrator at the conclusion of the visit. #3 Allegation- Staff did not properly report an incident involving a resident On 4/15/2025, LPA conducted interviews with staff members S1- S5. 5 out of 5 staff members stated they did not witness or hear of an occurrence that R1 was being sexually abused by R2. The staff members stated that when R1 was observed wit visible abrasions to their face and body it was immediately reported and documented to management the same day. The police was also contacted the same day of the incident and upon arrival they interviewed R1, R2 and staff members. Although staff and residents were interviewed a timeline could not be established as to determine when the incident occurred and the incident was self reported by facility management, the police was called , and Department of Social Services was contacted and facility staff provided the LIC624 and SOC341. Based on the evidence gathered during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Joseph Wieder at the conclusion of the visit with appeal rights. Per Brittany Kavanaugh.the state’s words, verbatim · CDSS document, Jun 23, 2025 · control 11-AS-20250407120939

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jun 25, 2025

87468.2 -Additional Personal Rights of Residents in Privately Operated Facilities.(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: which poses an immediate health, safety or personal rights risk to persons in care. The staff could not provide details of the time of the assult of R1 and R2.the state’s words, verbatim · CDSS document, Jun 23, 2025

Plan of correction: The licensee has agreed to provide training to all staff members regarding the personal rights of all residents in care which should include a statement of understanding signed by all staff members. This information will be emailed to LPA by the POC date of 6/25/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jun 25, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: which poses an immediate health, safety or personal rights risk to persons in care. During LPA Allen investigation the Adminstrator did not have R1 or R2 files availiable for paramedics and incomplete files during LPA visit.the state’s words, verbatim · CDSS document, Jun 23, 2025

Plan of correction: The licensee has agreed to provide a complete file for R1and R2. along with a statement of understanding of the cited regulations to ensure that all residents files are availiable at all times. This information will be emailed to LPA by the POC date of 6/25/2025.

Allegation investigated: Resident fell while in care due to staff neglect. Staff did not respond to resident's requests for assistance in a timely manner. Staff are not feeding resident food according to their special diet/restrictions. Staff mismanage resident's medications.

On June 13, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted a complaint visit regarding the above allegations. LPA Lee met with Brittany Kavanaugh, Executive Didrector, and Deeyanna Banda Memory Care Director and explained the reason for the visit. The investigation consisted of the following: On June 13, 2025, LPA obtained and reviewed Resident Rosters (dated 1/1/25-6/13/2025), staff roster (no date). LPA conducted interviews with 4 staff including Executive Director (A1, S1-S3). The investigation revealed the following: Page 1 of 3 Unfounded Allegations: Resident fell while in care due to staff neglect. Staff did not respond to resident's requests for assistance in a timely manner. Staff are not feeding resident food according to their special diet/restrictions. Staff mismanage resident's medications The complaint alleges the following: On Sunday before Memorial Day, R1 fell off of the toilet because staff took too long to respond to R1’s call for assistance, R1 pulled the emergency “lever” [call button], but staff didn’t respond for two hours, the facility does not adhere to R1’s dietary preferences/restrictions and the facility did not refill R1’s medication when it ran out. On 6/13/25 between 8:42am-10:00am LPA conducted interviews with Deeyanna Banda, Memory Care Director (A1), and Brittany Kavanaugh Executive Director (S1) who denied the allegations stating that R1 is not a resident of the facility and has never been a resident of the facility. Additionally, LPA interviewed S2-S3 regarding the allegations and they also denied the allegations stating that R1 is not a resident of the facility. On 6/13/25, LPA obtained/reviewed staff rosters dated (1/1/25-6/13/25) and R1's name was not listed on either roster which corroborated staff's report that R1 is not nor has been a resident of the facility. This agency has investigated the complaint alleging: Resident fell while in care due to staff neglect; Staff did not respond to resident's requests for assistance in a timely manner; Staff are not feeding resident food according to their special diet/restrictions; and Staff mismanage resident's medications. Page 2 of 3 We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint No deficiencies cited during today's visit Exit interview conducted and copy of report provided to Deeyanna Banda, Memory Care Director.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 11-AS-20250606170327

Allegation investigated: Staff do not ensure that residents' are being accommodated concerning room and roommate choices

On 06/13/2025 at around 3:30 PM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding the allegation listed above. LPA met with Wellness Director Michelle Brown and the purpose of the visit was explained. LPA was granted entry to the facility. Substantiated Investigation consisted of the following: On 06/12/2025, interviews were conducted, resident rooms were toured, and records were gathered. Interviews conducted consisted of 10 resident interviews [Resident 1 (R1) to Resident 10 (R10) were interviewed] and 8 staff interviews [Staff 1 (S1) to Staff 8 (S8) were interviewed]. The tour consisted of 9 resident rooms. Resident 1 to Resident 5’s (R5) records were gathered which consisted of Admission Agreements, Physicians Report, 30-day notice letter, Care Plan, and other pertinent information. Facility records were gathered which consisted of Resident Roster and Staff Roster. On 6/13/2024, interviews were conducted. Interviews conducted consisted of 5 witness interviews [Witness 1 (W1) to Witness 5 (W5) were interviewed], 2 informal conversations with staff [S8 and Staff 9 (S9)], and 1 attempted interview with Staff 10 (S10). Continuation to next page. Investigation revealed the following: Allegation: “Staff do not ensure that residents' are being accommodated concerning room and roommate choices”, it is being alleged that during the admission process residents agreed to be in a private room without a roommate and now the facility has informed them that they will be having a roommate through a 30-day notice letter. Interviews conducted with R1 to R10 revealed the following: 4 out of 10 residents agreed with the allegation; 6 out of 10 residents do not know if the above allegation occurred and/or have not heard residents or staff complaining about the above allegation. Resident 1 to R4 indicated that during their admission process they informed facility staff that they wanted to be in a private room without a roommate and facility staff agreed. Resident 3 indicated that they have not received a 30-day notice indicating that they are eligible for a roommate. Interviews conducted with W1 to W5 revealed the following: 5 out of 5 witnesses indicated that their loved ones (residents) are in a private room. 5 out of 5 witnesses are unaware that residents have a received a 30-day notice indicating that they are eligible for a roommate. Witness 1 is the responsible person and/or Power of Attorney (POA) for R4. Witness 2 and W3 are the responsible person and/or POA for R3. Witness 3, W4, and W5 indicated that they were in the admission agreement meeting with S10 and they informed them that they wanted a private room, no roommates. S10 agreed and informed them that they would have their own private room. Furthermore, on 05/23/2025 Witness 3 (W3) received a phone call from S10 asking for a favor by having a roommate and W3 and R3 declined the offer. Continuation to next page. Interviews conducted with S1 to S8 revealed the following: 1 out of 8 staff denied the allegation and 7 out of 8 staff do not know if the above allegation occurred and/or have not heard residents or staff complaining about the above allegation. The department attempted to interview S10 but was unsuccessful. Records reviewed of Admission Agreements of R1, R3, and R4 revealed the following: there is no mention of roommates potentially moving into their rooms nor residents agreeing to have a roommate. Staff 10 signed the Admission Agreements for R1, R3, and R4. Witness 2 signature is on R3’s Admission Agreement. Observations of nine resident rooms on 06/12/2025 reveled the following: 7 out 9 residents do not have roommates. Records reviewed of a 30-day notice indicating that they are eligible for a roommate for R1 to R4 do not confirm that residents nor responsible person/POA received the notice. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on observations, interviews, record reviews, and analysis, the preponderance of evidence standard has been met; therefore, the allegations that are determined Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted, and Wellness Director Michelle Brown was provided with a copy of this report and appeals rights. Investigation consisted of the following: On 06/12/2025, interviews were conducted, resident rooms were toured, and records were gathered. Interviews conducted consisted of 10 resident interviews [Resident 1 (R1) to Resident 10 (R10) were interviewed] and 8 staff interviews [Staff 1 (S1) to Staff 8 (S8) were interviewed]. The tour consisted of 9 resident rooms. Resident 1 to Resident 5’s (R5) records were gathered which consisted of Admission Agreements, Physicians Report, 30-day notice letter, Care Plan, and other pertinent information. Facility records were gathered which consisted of Resident Roster and Staff Roster. On 6/13/2024, interviews were conducted. Interviews conducted consisted of 5 witness interviews [Witness 1 (W1) to Witness 5 (W5) were interviewed], 2 informal conversations with staff [S8 and Staff 9 (S9)], and 1 attempted interview with Staff 10 (S10). Continuation to next page. Investigation revealed the following: Allegation: “Staff altered resident's admission agreement.” Interviews conducted with R1 to R10 revealed the following: 1 out of 10 residents agreed with the allegation and 9 out of 10 residents do not know if the above allegation occurred and/or have not heard residents or staff complaining about the above allegation. Interviews conducted with W1 to W5 revealed the following: 5 out of 5 witnesses do not know if the above allegation occurred and/or have not heard residents or staff complaining about the above allegation. Interviews conducted with S1 to S8 revealed the following: 1 out of 8 staff denied the allegation and 7 out of 8 staff do not know if the above allegation occurred and/or have not heard residents or staff complaining about the above allegation. Records reviewed of Admission Agreements of R1 to R4 revealed the following: there is no evidence indicating that the admission agreements were altered. 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 Wellness Director Michelle Brown was provided with a copy of this report.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 11-AS-20250606161738

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jun 16, 2025

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidence by: Based on interviews and records review the licensee did not provide the 30-day notice to responsible persons/POAs and R3, the licensee did not follow their admission agreement for R1, R3, and R4 in informing them that they might potentially have a roommate.the state’s words, verbatim · CDSS document, Jun 13, 2025

Plan of correction: The licensee will recall 30-day notices for R1, R3, and R4. Licensee will create a plan to stay in compliance with CCR87507(f) to Socorro.Leandro@dss.ca.gov .

Allegation investigated: Facility overcharged resident. Facility staff is not answering communications from resident’s representative. Facility staff has not provided a copy of admission agreement to resident's responsible person.

On June 11, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a visit to gather information regarding the above allegations. LPA met with BRITTANY KAVANAUGH the Executive Director, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of interviews, and records were collected with staff members #1 to #2 (S1-S2) and resident member #1(R1). List of documents reviewed/obtained Resident Roster (dated 06/11/25), Facility Staff Roster (dated 06/11/25), (R1)'s Physicians Report LIC 602A (dated 03/19/25), Resident Appraisal (dated 03/19/25), Identification and Emergency Information LIC 601 (dated 03/19/25), and other pertinent documents associated with this complaint. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Facility overcharged resident. The facility is accused of overcharging Resident #1 (R1) for services. According to the report, (R1) moved into the facility on April 8, 2025, and was billed for the entire month. (R1) has two charges listed for May 5, 2025, and May 19, 2025. It is reported that (R1) receives SSI/SSP income and should only be charged $1,420.07 monthly. A review of Resident #1's (R1) Admissions Agreement (dated March 19, 2025) shows that (R1) 's representative signed the agreement on that date. On page six, Section VI - Fees Subsection A – Monthly Fee indicated $1292.40 for fee for residential services for (R1). On June 11, 2025, between 10:00 AM and 10:15 AM, the Department interviewed a resident member identified as Resident #1 (R1). (R1) claimed not to know the financial intricacy and was uninterested. (R1) stated that (R1) 's family representative handles finances and payments. On June 11, 2025, between 10:15 AM and 11:00 AM, the Department interviewed staff members identified as Staff #1 and Staff #2 (S1-S2). (S1) verified that (R1)’s resident agreement signing of documents were performed on March 19, 2025. However, the (R1) did the fully take possession of a room until April 8, 2025. (S1-S2) stated that (R1) should have not been charged the full amount of $1,292.40 from April 1, 2025, through April 7, 2025. (S1) was unaware for the reported duplicate charges for May 5, 2025, and May 19, 2025. (S2) assumed the duplicate charge was for the preadmission for the month of March 2025 but later discovered that (R1) did not occupy the room for the March and should have not be charged the duplicate amount of $1292.40 in May 2025. (S1-S2) both verified there is an error in billing, and it was not intentional. The Department reviewed invoices Facility Transaction Log (dated June 11, 2025) from March 1, 2025, through June 5, 2025, and revealed (R1) was billed for March 2025. Payments for April 2025 were applied to the March 2025 invoice, leaving (R1)’s account in the rears. Individual invoices from March through June indicate being paid in full. Nonetheless, the invoice for May 2025 did not list itemized services or charges to indicate the two charges for May 2025. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-C) Allegation #2: Facility staff is not answering communications from resident’s representative. It is alleged that the facility staff is not responding to communications from Resident #1 (R1)'s representative. It has been reported that Staff #1 (S1) has not addressed the issue of (R1) being overcharged twice for the month of May 2025 for services. On June 11, 2025, between 10:00 AM and 10:15 AM, the Department interviewed resident member identified as Resident #1 (R1). (R1) claimed to have no knowledge of any issues with the charges for services. (R1) is unaware if any facility staff have had any communication regarding this matter with (R1)’s family representative. On June 11, 2025, between 10:15 AM and 11:00 AM, the Department interviewed staff members identified as Staff #1 and Staff #2 (S1-S2). (S1) acknowledged several text messages from (R1) 's representative in late May 2025. (S1) stated in the text messages that (S1) responded to the text messages to (R1) 's representative with messages from May 26, 2025, through May 28, 2025, of the following: "I will call you back in a few minutes," "In a signing, will call you back shortly," and "I will call you back shortly." Despite earlier assurances, (S1) confessed to neglecting the follow-up call to (R1)’s representative, which had been promised. (S2) claimed was unaware of any issues or concerns related to (R1). The Department reviewed the text communication logs between (S1) and (R1) 's family representative. It was confirmed that (S1) had a text exchange from May 26, 2025, to May 28, 2025. The last recorded text to (S1) by (R1) 's representative was on June 4, 2025, requesting an update. (R1)'s representative has sent an email but has not received a response. Additionally, (R1) 's representative is requesting a callback. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Allegation #3: Facility staff has not provided a copy of admission agreement to resident's responsible person. It has been reported that the facility staff did not provide a copy of the admission agreement contract to the responsible person for Resident #1 (R1). Specifically, Staff #1 (S1) has not supplied a copy of the signed admission agreement for (R1) since (R1)’s admission in April 2025. (Evaluation Report continues LIC 9099-C) A review of Resident #1's (R1) Admissions Agreement, (dated March 19, 2025), shows that (R1)'s representative signed the agreement on that date. However, (R1) did not officially enter Terraza Court Senior Living until April 8, 2025. Additionally, the Agreement contract Appendix A through L records were not signed until April 28, 2025. On June 11, 2025, between 10:00 AM and 10:15 AM, the Department interviewed resident member identified as Resident #1 (R1). (R1) does not remember the exact date of admission but believes it was in April 2025. (R1) mentioned being present when (R1)'s representative signed the contract documents during the intake process. (R1) stated that (R1) did not receive a copy of the admissions contract, as a family member with power of attorney handles it. On June 11, 2025, between 10:15 AM and 11:00 AM, the Department interviewed staff members identified as Staff #1 and Staff #2 (S1-S2). (S1) confirmed to have been responsible staff who process the intake/admission for (R1). (S1) clarified that (R1) and (R1)'s family representative was present during the initial signing of the resident's agreement on March 19, 2025, along with the Community Care Licensing documents. However, (R1) did not officially move into the facility until April 8, 2025, and the remaining sections of the agreement, Appendix A through L, were not signed until April 28, 2025. In admission (S1) acknowledged that (S1) had not provided a copy of the resident's Admissions Agreement to (R1)'s family representative after (R1) signed the records. (S2) stated they were unaware that the Admissions Agreement had not been given to (R1)'s representative. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on observations, interviews, record reviews, and analysis, the preponderance of evidence standard has been met; therefore, the allegations that are determined Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted, and Executive Director BRITTANY KAVANAUGH was provided with a copy of this report and appeals rights.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 11-AS-20250606092721

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(b) · Plan of correction due date: Jun 18, 2025

Personal Rights (a) Residents in residential care facilities for the elderly shall have personal rights...(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: This requirement is not met as evidence by: Based on interview and record review, the licensee failed to provide a copy of the signed admission agreement to the resident's representative in a timely manner. This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee will review Title 22 Reg 87468 and submit a copy of the resident's admission agreement to (R1)'s representative. A proof of a receipt must be sent to LPA Dabuet: ernand.dabuet@dss.ca.gov by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Jun 18, 2025

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: (9)To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidence by: Based on interview and record review, the licensee failed to communicate with with family representative promptly and appropriately. This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee will review Title 22 Reg 87468.1 and submit proof of a receipt indicating the the representative was notify and explained the billing error and refund or credit is applied. Proof of correction must be sent to ernand.dabuet@dss.ca.gov by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(B)(4) · Plan of correction due date: Jun 18, 2025

Admission Agreements (B) Rate for additional items and services, including: 4.If the licensee offers additional items and/or services that were not available at the time the admission agreement was signed, a list of these services and charges shall be provided to the resident or the resident’s representative. This requirement is not met as evidence by: Based on record review and interview, licensee failed to provide a list of services/charges to the resident's representative for the overcharge fees for May 2025. This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee will review Title 22 Reg 87507 and ahere to the regulations. Licensee will correct overcharge fees/billing error and apply a refund or credit to the resident's account. Proof of correction receipt must be submitted to ernand.dabuet@dss.ca.gov by due date.

Allegation investigated: Staff did not provide adequate care and supervision to a resident

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 1/15/25. On 1/15/25, Licensing Program Analyst, (LPA) Felisa Shirley conducted a subsequent unannounced visit to this facility. LPA was met by Executive Director, Brittany Kavanaugh and explained the purpose of the visit is to investigate and deliver findings for the allegation mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 12/2/24, LPA Shirley spoke to facility Executive Director, Brittany Kavanaugh and reviewed facility records. LPA requested and received copies of staff and resident rosters, shower schedule, and special incident reports involving Resident 1 (R1), Admissions Agreement, Emergency Contacts, Physician’s report, 10/30/24, preplacement appraisal12/2019, Appraisal/Needs and Services Plan, 5/17/24 Staff Schedule, Resident Assessment, and Assessment for Medication Self-Management. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not provide adequate care and supervision to a resident ON 12/2/24 LPA Felisa Shirley reviewed facility records. Per incident report dated 11/5/24, On 11/3/24 R-1 fell in the shower and was found the next morning by facility staff. LPA conducted a review of Appraisals/Needs and Services dated 5/17/24, which shows that R-1 was independent and did not require assistance with their activities of daily living such as bathing, grooming and able to feed herself. It was noted that staff should promote independency where tolerated. Per R-1’s Physician Report dated 10/30/24, R-1 was non-ambulatory, and was able to bathe, dress and groom themself. LPA Shirley observed that none of the records stated R1 was a fall risk. Per facilities Assisted Living Shower Sheet, R-1 is not listed as needing assistance with bathing. On 1/15/25 LPA Shirley reviewed staff schedule for the dates of 11/3/24 and early hours of 11/4/24. Per the schedule, there were 5 staff scheduled between the hours of 2pm and 6:30am. ON 12/2/24 LPA Shirely interviewed Facility Administrator Brittany Kavanaugh. Per interview with Administrator, R-1 was not a fall risk and walked with the assistance of a walker. No unsteadiness was noted in her gait. On 12/2/24, LPA Shirley interviewed staff 1 thru staff 10(S-1 thru S-10), of those interviewed, 9 out of 10 denied the allegation with 1 staff answering with something other than confirming or denying the allegation. On 12/2/24, LPA Shirley interviewed residents 2 thru resident 7 (R-2 thru R-7), of those interviewed, 6 out of 6 answered denied the allegation. LPA was attempted to interview R-1 but was unable as they were hospitalized. Con'd on 9099-C Based on interviews, available evidence, 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 unsubstantiated. There were no deficiencies cited. A copy of this report was provided to the Executive Director Brittany Kavanaugh. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, May 28, 2025 · control 11-AS-20241126115531

Allegation investigated: Staff did not meet a resident's indwelling urinary catheter needs while in care Staff did not provide adequate transportation for a resident

On 05/14/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Terraza Court Senior Living and was greeted by Manager Michele Brown (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the finding pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S5, resident R1-R8. LPA Calderon obtained the following records: Admission Agreement (dated 04/22/2025), Physician Report (dated 04/22/2025), Providence Hospital Records (dated 05/11/2025), written statement from staff (dated 05/10/2025) for R1. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff did not meet a residents indwelling urinary catheter needs while in care. This complaint alleged that the facility did not fix or replace R1 catheter that was dislodged. Record review indicate the following: Admission agreement does not indicate that the facility is licensed to care for resident with catheter needs. Physician report indicates that R1 has health issues. Interviews indicate the following: 5 out of 5 staff deny the allegation. 5 out of 5 staff indicate the facility is not licensed or have staff that can take care of residents with catheter needs. 5 out of 5 staff indicate that home health care or hospice takes care of resident with catheter needs. R1 indicates that R1 does not remember having any issues or being taken to the hospital. 7 out of 8 residents indicate no need for home health care of hospice to take care of their needs. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not meet a residents indwelling urinary catheter needs while in care” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff did not provide adequate transportation for a resident. This complaint alleged that the facility did not provide transportation for R1 to be taken to the hospital. Record review indicate the following: Admission agreement indicates page 4-part g “transportation” we will make available to residents or otherwise assure the provision of scheduled transportation to the nearest appropriate health facilities for medical and dental appointments. Reviewed S5 written statement for the incident that happened on 05/10/2025. S4 indicates that R1 was having health issues and S4 called 911. S4 indicates that the fire department refused to transport R1 for a non-emergency call. Interviews indicate the following: 5 out of 5 staff indicated that the facility does supply residents with transportation to the hospital, doctor office or dentist office. 5 out of 5 staff indicate that the fire department refused to transport R1 on 05/10/2025 for a non-emergency call. R1 does not remember being transported to the hospital. 7 out of 8 residents indicate that the facility does supply them with transportation to the hospital or for medical needs. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not provide adequate transportation for a resident” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report were provided to the Manager Michele Brown (S1).the state’s words, verbatim · CDSS document, May 14, 2025 · control 11-AS-20250512114149

Allegation investigated: Lack of supervision resulted in resident eloping

On (04/23/25 at approx.11:00AM), Licensing Program Analyst (LPA’s) Yolanda Rosser and Alphonso Iniguez conducted a(n) initial visit on to gather information regarding the above allegation. LPA’s met with (Brittany Kavanaugh, Administrator and the purpose of the visit was explained. LPA’s was granted entry to the facility. Investigation consisted of the following: On 04/23/25 LPA’s reviewed/obtained: Resident Roster (dated 04/18/25), staff roster (dated 04/23/25), (R1) Unusual Incident Report/Injury Report (dated 04/10/25), (R1)Physician’s Report for Residential Care Facilities for the Elderly (dated 03/25/25) and (R1) Durable Power of Attorney (dated 05/25/24). LPA’s conducted the following interviews: Administrator Interview (A1), Resident 1 interview (R1) and Facility Staff interviews (S1-S4). Evaluation report continues on LIC 9099-C Unsubstantiated Investigation revealed the following: Allegation: Lack of supervision resulted in resident eloping The detail of the complaint alleges (R1) was found wandering on the street unassisted. On 04/23/25 at approximately 2:00pm, LPA Rosser reviewed (R1) Unusual Incident /Injury Report dated 04/10/25, was having a behavioral episode, facility staff was always by (R1) side. (R1) decided to go out of the facility into the street, facility staff followed (R1) closely and redirected (R1) back into the facility. In addition, LPA Rosser observed (R1) Physician’s Report for Residential Care Facilities for the Elderly (dated 03/25/25). On the form it is marked that (R1) Secondary diagnosis impedes with her cognitive ability and it is not marked as a primary diagnosis. On 04/23/25 at approximately 11:30 AM, during an interview with the Administrator, (A1), stated staff contacted her to inform that (R1) had a behavioral episode and ran into the street followed by facility staff (S4) who redirected (R1) back into the facility. In addition, (A1) stated that (R1) was never alone when they went out into the street. On 04/23/25 at approximately 1:15 PM, during an interview with (R1) stated that they don’t recall the incident. However, (R1) stated they don’t go out of the facility alone, and they are always with someone. On 04/23/25 at approximately 12:15PM, during interviews with facility staff (S1-S4), (4) out (4) stated that they witnessed (R1) have a behavioral episode and intervened when (R1) ran into the street and redirected (R1) back into the facility. In addition, (4) out of (4) facility staff stated that (R1) was never alone when they ran outside Evaluation report continues on LIC 9099-C During this investigation, LPA found 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 Brittany Kavanaugh/Administrator.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 11-AS-20250414111153

Allegation investigated: Staff are not providing resident's responsible party with requested records.

On 03/12/2025 Licensing Program Analyst (LPA) Troy Watson conducted a subsequent visit to deliver findings to the facility mentioned above. LPA met with the Administrator Brittany Kavanaugh and explained the purpose of the visit. LPA was granted entry into the facility. The investigation consisted of the following:On 12/12/2024 the department conducted interviews with staff members 1-2 (S1-S2). LPA requested and reviewed the resident's records and asked for copies of the following documents: Personnel report, Resident Roster, Special Incident Reports, Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Medication Logs, Appraisal Need and Services Plan, Safeguards for Cash Resources, Preplacement Appraisal Information, Safeguards for Property Valuables, Personal Rights, and Consent Forms. CONTINUED ON LIC9099-C Unsubstantiated Investigation revealed the following: Allegation: Staff are not providing the resident's responsible party with the requested records. 12/12/2024 the department spoke with Administrator Brittany Kavanaugh. Per administrator, facilities legal team had received certified mail from a Law Office requesting a resident's medical records. Administrator stated Terraza Court Senior Living's legal team replied to the law office and sent them the requested documents.On 12/12/2024 facility provided LPA Bunker with copies of the documents that was submitted to the law office as well as email correspondence dated 11/07/2024 at 1:26 P.M., 11/12/2024 at 10:34 A.M., 12/02/2024 at 8:52 A.M.,and on 01/03/2025 at 9:03 A.M.. On 02/26/2025 LPA Bunker contacted the law office via telephone and confirmed the documents had been received. Based on interviews conducted, the department did not find 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 unsubstantiated. There were no deficiencies cited. An exit interview was conducted with the Administrator Brittany Kavanaugh and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 11-AS-20241203134527

Allegation investigated: Staff did not provide adequate care and supervision to a resident

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 1/15/25. On 1/15/25, Licensing Program Analyst, (LPA) Felisa Shirley conducted a subsequent unannounced visit to this facility. LPA was met by Executive Director, Brittany Kavanaugh and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 12/2/24, LPA Shirley spoke to facility Executive Director, Brittany Kavanaugh and reviewed facility records. LPA requested copies of staff and resident rosters, Shower schedule, and special incident reports involving R-1. LPA also interviewed staff 1 thru staff 10 and residents 2 thru resident 7. LPA received copies of residents, Admissions Agreement, Emergency Contacts, Physician’s report, preplacement appraisal, Appraisal/Needs and Services Plan, Staff Schedule, Resident Assessment, and Assessment for Medication Self-Management. Con'd on 9099-C Unsubstantiated Allegation: Staff did not provide adequate care and supervision to a resident. On the evening of 11/3/24, R1 sat on the edge of the shower chair and accidentally fell in the shower and was found at 6:15am the next morning attempting to get up from the bathroom shower floor by S9. S9 went to R1’s room to check on the resident and remind her to come to breakfast. S9 immediately assisted the resident as R1 stated she was cold and stated that she could not reach the pull cord. The responsible party stated that R1 had been shouting for help since 6pm the evening before but no one heard her. Per S9, R1 stated that she did not want to go to see doctor but S9 advised her that she should be checked out by a doctor. S9 promptly called for assistance, and Med Tech S-3 responded immediately. The Med Tech called 911 without delay, and the resident was transported to Southern California Hospital at Culver City. The resident’s responsible party was notified. Per S2, R1 does not receive one-on-one care. R1 is independent and is residing in the Assisted Living unit of the facility. S1 stated that resident is ambulatory, uses a walker, not a fall risk and does not show signs of being unsteady. LPA Felisa Shirley toured the facility with S2 and went to R1’s room to verify if the pull cord worked. LPA Shirley pulled the pull cord in the bathroom located between the toilet and the shower. Once the cord was pulled, the unit displayed the word, HELP! LPA Shirley then heard on S2’s walkie and the caregiver's walkie in the hallway, that the staff at the front desk received an alert from R1’s room. Upon review of shower list, R1 was not on the shower list as per R1’s physician’s report and Needs and Service plans she is able to dress and groom herself. There is not a Medication Administration Record, (MAR) for R1. Per resident’s physicians report, Needs and Service Plans, Resident Assessment, and Assessment Con'd on 9099-C for Medication Self-Management, R1 was independent and able to administer her own prescription medications. LPA Felisa Shirley spoke with the responsible party and they stated that R1 did not like to be disturbed during the night when she slept. LPA Shirley spoke with and interviewed staff 1 thru staff 10 (S-1 thru S-10). LPA ask, does staff provide adequate care and supervision to residents in care? Of those interviewed, 9 out of 10 answered yes. One staff answered, sometimes. LPA Shirley interviewed residents 2 thru resident 7 (R-2 thru R-7). R1- was not available for interview. LPA ask, does staff provide adequate care and supervision to residents. Of those interviewed, 6 out of 6 answered yes. 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 unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to the Executive Director Brittany Kavanaugh. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 11-AS-20241126115531

Type of visit: Case Management - Incident

On 01/14/25 Licensing Program Analyst (LPA), Yolanda Rosser arrived at Terraza Court for an unannounced Case Management visit to follow up on a incident report received 12/03/24. LPA, Rosser introduced herself and met with Brittany Kavanaugh, Executive Director and explained purpose of visit. LPA, Rosser later met with Deeyanna Banda, Memory Care Director (MSG). LPA Rosser explained the purpose of the visit. Census is 79 of which 22 in Memory Care Unit. LPA toured facility. LPA Rosser obtained and reviewed Personnel File for (S4) hire date 11/15/24 as a Caregiver. Criminal Background clearance was located in the file. (S4) application indicates job history, one previous employer since 03/24 Dental Front Office (position). Upon interview of Staff #2 (S2) Reference(s) were verified. The Incident report indicated staff (S4) was verbally abusive to Resident #1 (R1) in memory care. (S3) reported incident to (S2). LPA interviewed (S1) who did not witness incident and is unfamiliar with (S4). (S2) indicated (S4) was soft spoken and no indications of aggression was witnessed. The day of incident, (S4) was working an evening shift, which is not the normal shift of 6am - 2pm. (R1) was trying to leave memory care to find her parents. (R1) became agitated when (S4) tried to stop her from leaving memory care. (R1) called (S4) Fat, (S4) became very upset and began to verbally abuse her. (S4) referred to (R1) as "ugly bitch", "you need to get your ass back in memory care". (S2) indicated staff and resident were separated for the rest of the evening to ensure (S4) did not take things any further than a verbal altercation. continued on 809C (S2) indicated a no tolerance policy for any type of abuse with residents. (S4) called out the following day after the incident and was subsequently terminated. (S3) was not working at the time of this visit therefore I was unable to obtain interview. (R1) was unable to be interviewed based up memory level. A copy of this report was provided to Executive Director.the state’s words, verbatim · CDSS document, Jan 14, 2025

Allegation investigated: Staff did not prevent a resident from sustaining a fracture while in care. Staff did not prevent resident from eloping from the facility.

*** This amended complaint report dated 04/17/2025, supersedes the original report dated 11/14/2024***On 04/17/2025, Licensing Program Analyst (LPA) Pamela Bunker conducted a subsequent visit to gather information regarding the above allegations. LPA met with Michelle Brown, Director of Wellness, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On 04/17/2025, documents were reviewed/obtained: Personnel report, Resident Roster, Special Incident Reports, Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Appraisal & Needs Service Plan, Functional Capability Assessment, Preplacement Appraisal Information, Consent Forms, and UCLA Medical Center Record. Interviews were conducted with staff members 1-4 (S1-S4) and residents 2-8 (R2-R8). Resident 1 (R1) was unavailable for an interview and no longer resides at the facility. R1 passed away on 12/21/2024, after relocating to another facility. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 LPA and staff toured the facility's buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. No evidence of neglect or abuse was observed during these visits. Investigation revealed the following: Allegation: Staff did not prevent a resident from sustaining a fracture while in care. It was alleged that on 10/24/24, the resident got out of the facility and fell while walking backward. The resident was taken to the emergency room, where the resident was found to have a hip fracture. 4 out of 4 staff interviewed stated that R1, who has Dementia and Parkinson's and experiences tremors, suddenly began walking backward, repeatedly saying that someone was kidnapping their daughter. As R1 attempted to turn around, the resident accidentally tripped over their own foot and fell on their back. S2-S4, (3 out of 4) stated that the incident happened so quickly that they could not have prevented R1 from falling. Interviews with staff members 1-4 (S1-S4) reported that on October 24, 2024, at approximately 9:50 P.M., R1 experienced an accidental fall and sustained a fracture while in care. S1-S4 reported that Residents 1 and 2 (R1 & R2) were wandering in the Memory Care Unit when R2 triggered the egress door alarm, and it went off. Staff immediately responded, running to the door to assist and redirect the two residents. The Med Tech immediately called Emergency 911 services without delay, contacted the resident’s responsible party, Power of Attorney(POA), and the physician was notified. 3 out of 4 assured that no one pushed R1, emphasizing that staff were present to assist and care for both residents the entire time, and R1 was transported to UCLA Medical Center per the daughter's request. According to S1-S4, the fall was unavoidable, and the staff was present the entire time. 4 out of 4 staff members stated that R1 was not considered a fall risk. R1 was ambulatory and had no history of falls. The facility did not have any surveillance camera footage of the incident. Interviews with Residents 2-8 (R2-R8). 7 out of 8 indicated that none of them witnessed the fall or any other instance of a resident falling or attempting to leave the facility. R2-R8 expressed that they feel safe, are happy with the care and supervision provided, and believe that the staff are doing a wonderful and great job. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Residents R2-R8 stated that staff members are consistently available to assist and expressed satisfaction with their living conditions and the care provided. Both S1-S4 and R2-R8 state that the accommodations provided are comfortable and that the staff is dedicated to ensuring the safety and well-being of all residents. Staff 1-4 (4 out of 4) stated that the Special Incident Report was submitted, and the resident's family, Power of Attorney (POA), responsible party, physician, Community Care Licensing, and all appropriate agencies were notified in a timely manner. S1-S4 and R2-R8 denied the allegation. Investigation revealed the following: Allegation: Staff did not prevent a resident from eloping from the facility. It was alleged staff did not prevent a resident from eloping from the facility and the resident was able to get out of the facility. Interviews with staff members 1-4 (S1-S4) 4 out of 4 staff stated that R1 never eloped from the facility but was only five steps in front of the Memory Care Unit door. 4 out of 4 staff stated that at no point did the resident leave the building, and staff remained present to provide assistance throughout the incident. S1-S4 emphasized that the facility operates on a 24/7 basis, ensuring that residents are never left unattended. Interviews with Residents 2-8 (R2-R8). 7 out of 8 indicated that none of them witnessed any resident eloping from the facility. They expressed feeling safe, and satisfied with the care and supervision provided, and believe that the staff is doing great and wonderful job and maintaining a secure, comfortable environment. S1-S4 and R2-R8 denied the allegation. The medical records from UCLA stated staff is not at fault for the resident's fall. The facility reported the special incident in a timely manner to Community Care Licensing and all the appropriate agencies stating the resident had accidentally fallen. The facility had no surveillance cameras to capture the fall. See continued LIC9099-C page 4 Continued LIC9099-C page 4 Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. Although the allegations 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 allegations is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to the Wellness Director Michelle Brown. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 11-AS-20241107165127

Type of visit: Prelicensing

On 10/2/24 Licensing Program Analyst (LPA) Alfonso Iniguez conducted a pre-licensing Change of Ownership evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with Executive Director: Brittany Kavanaugh. The licensee has applied for a license to serve (170) elderly residents age range 60 and over. The fire clearance is approved for (170) non-ambulatory of which (10) may be bedridden. Non-ambulatory and bedridden are only permitted on the first floor. Approved hospice waiver for (10). The facility consists of the following: The first-floor Lobby/receptionist area, Executive Director's office, Business office, copy area, Marketing office, living room, library/activity room, cafe/bistro/latte/water area, public/visitor restrooms, hair salon, life enrichment/activity office, storage rooms, dining room, commercial kitchen, staff restrooms, commercial laundry room, resident's laundry room, Director of Nursing office, medication room, employee's lounge, emergency food, mechanical room, electrical room, 3 storage rooms, and attached underground security parking garage. The second floor consists of resident's bedrooms and bathrooms, storage closets, and patio. The Memory Care Unit (MCU) consists of bedrooms and bathrooms, resident's laundry room, dining room/activity room, small kitchen, living room/TV room, shower room, Memory Care Coordinator office, small living room, storage room, and MCU patio. The third floor consisted of bedrooms and bathrooms, resident's laundry room, small living room/TV room. Report continues LIC 809C. The following was observed during this visit: MEDICATIONS There are locked storage areas for Resident medications. PHYSICAL PLANT Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 85°F. degrees. Areas of potential hazard are well-lit. Smoke alarms operate properly. Carbon monoxide detectors operate properly. BEDROOMS There is a space for client’s own furniture that will accommodate a bed, a chair, a nightstand, a lamp, reading lights and a chest of drawers. BATHROOMS There is at least (1) toilet and washbasin per six (6) clients, family, and personnel. There is at least (1) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is between 105F°. and 120F°. Bathrooms are located inside clients’ bedrooms. There are nightlights in the hallways outside non-private bathrooms. SUPPLIES There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths. Report continues LIC 809C. FOOD SERVICE Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A seven (7) day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. RECORDS A review of (5) residents' service files and (5) staff personnel files was maintained in order. LPA reviewed (5) Medication Administration Records (MARs) and found no discrepancies. ADMINISTRATION The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. DELAY EGGRESS and SECURE PERIMETER Delay egresses are located on the 2nd floor memory care entry. Report continues LIC 809C. MISCELLANEOUS There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for commercial laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. Copy of liability insurance will be email to LPA during this visit. During this pre-licensing inspection, LPAs did not find corrections were needed. LPA Iniguez conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAU Analyst. Exit interview conducted with Brittany Kavanaugh/Executive Director.the state’s words, verbatim · CDSS document, Oct 2, 2024

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: CHOW Capacity: 170 Census (if any clients in care): 70 COMP II Participants: Baruch Berkowitz (applicant/licensee), Brittany Kavanaugh (administrator) Interview Method: Microsoft Teams On 07/31/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jul 31, 2024