The Cedars Assisted Living

Allegation investigated: Facility is in disrepair. Staff did not maintain facility at a comfortable temperature for residents. Staff did not ensure that the resident’s room was maintained free of malodors. Staff did not ensure that the resident’s bathroom was maintained in a clean condition.

On 8/26/26, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted subsequent complaint visit to investigate the allegations and to deliver the final report. Upon arrival, LPA met with facility Administrator Stephan Sarmazian and explained the reason for the visit. During today's visit, LPA Khurshudyan conducted physical plant tour to ensure health and safety of the residents are protected and the facility is in compliance with Title 22 Regulations. Between 11:40am to 12:30pm, LPA conducted interviews with ten (10) residents residing in the facility, three (3) staff members, and the Administrator. During the initial complaint visit conducted by LPA Antonia Alvizar-Ettima on 08/12/26, LPA requested and received copies of the facility resident and staff rosters. At approximately 11:40a.m., LPA and Administrator conducted a physical plant inspection. Continue on LIC9099-C Substantiated Allegation: Facility is in disrepair. Licensing Program Analyst (LPA) Khurshudyan conducted a complaint investigation regarding the allegation listed above. During the investigation, LPA conducted interviews with the Administrator, Staff, and Residents, and inspected the facility including the 1st and 2nd floor memory care areas. During the physical plant inspection, LPA observed areas of the facility requiring cleaning, repair, and /or maintenance including dirty walls and floors within the dementia Memory Care Unit. Interviews and observations supported concerns that the facility had not been consistently maintained in a clean, safe, and good state of repair. During the inspection, LPA observed that rooms 115 and 117 are currently under construction and was informed that the facility is undergoing a repair plan; however, the estimated completion time is approximately one year. Based on interviews conducted and LPA's observations there is sufficient information and evidence to support the allegation. Therefore, the allegation that the facility is in disrepair is substantiated. Allegation: Staff did not maintain facility at a comfortable temperature for residents. Licensing Program Analyst (LPA) Khurshudyan conducted a complaint investigation regarding the allegation listed above. The reporting party alleged that several rooms in the 1st and 2nd floor memory care units including rooms 109, 115, 125, and 226 were excessively hot and that residents reported feeling hot while lying in bed. During the investigation, LPA conducted interviews with the Administrator, Staff, Residents, and measured temperatures in resident rooms and common areas. LPA’s observations and / or temperature readings revealed that portions of the facility were maintained at an uncomfortably warm temperature. Resident interviews also corroborated concerns regarding excessive heat in their rooms. The facility was unable to demonstrate that comfortable temperatures were consistently maintained for residents during the period of 8/1/26 to 8/20/26. During the visit, LPA Khurshudyan observed that part of the facility does not have a central air conditioning system, and portable/mini-AC units are installed on the walls in the hallways and inside residents’ rooms. LPA checked the temperature inside the random residents’ rooms, which measured between 68°F and 70°F, a comfortable range. However, residents interviewed confirmed that past couple of weeks they have experienced hot temperature inside their rooms and the AC units were not working properly. Although, the hallway AC unit displayed a temperature of 62°F, LPA noted that it was not blowing cold air, and the hallway temperature was hot and uncomfortable. Based on interviews and LPA’s observations, there is sufficient evidence to support the allegation. Therefore, the allegation that staff did not maintain facility at a comfortable temperature for residents is substantiated. Continue on LIC9099-C Allegation: Staff did not ensure that the resident’s room was maintained free of malodors. Licensing Program Analyst (LPA) Khurshudyan conducted a complaint investigation regarding the allegation listed above. The Reporting Party alleged that a strong urine odor was present in resident room 109 during the investigation. LPA conducted interviews with the Administrator, Staff, Residents, and inspected resident room 109 and surrounding areas. LPA detected a strong urine and/or malodor in the resident’s room and surrounding areas. An interview with the Administrator revealed that there are plumbing issues in room 109 that are causing the odor. The Administrator also confirmed that the odor from the resident’s room had been addressed through routine cleaning and odor-control procedures; however, the plumbing still requires repair, and the flooring needs replacement, which is included in the facility’s remodeling plan. Based on interviews conducted and LPA's observations, there is sufficient evidence to support the allegation. Therefore, the allegation that staff did not ensure that the residence room was maintained free of malodors is Substantiated. Allegation: Staff did not ensure that the resident’s bathroom was maintained in a clean condition. Licensing Program Analyst (LPA) Khurshudyan conducted a complaint investigation regarding the allegations listed above. The Reporting Party alleged that fecal matter and a strong odor was observed in the bathroom associated with room 115. During the investigation, LPA conducted interviews with the Administrator, Staff, and Residents, and inspected room 115. LPA observed that room 115 is currently under construction and remodeling. An interview with the Administrator confirmed that visible fecal matter and/or soiled areas had previously been present in the resident’s room. Based on interviews conducted and LPA’s observations there is sufficient evidence to support the allegation. Therefore, the allegation that staff did not ensure that the resident's bathroom was maintained in a clean condition is Substantiated. Deficiencies were issued and recorded on LIC9099D. Exit interview conducted. Report signed and delivered. Appeal rights delivered.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 31-AS-20260811224400

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Sep 4, 2026

Maintenance and Operation(a)facility shall be clean, safe, sanitary and in good repair at all times[...] for...residents, employees and visitors (1)Floor surfaces [...] shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on inspection and observation the Licensee did not ensure that the facility is safe and sanitary and LPA observed evidence of disrepair and malodors in resident bedrooms. This poses apotential health, safety risk and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: The Administrator shall submit documentation of repair and the corrective measures taken to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(2) · Plan of correction due date: Sep 4, 2026

Maintenance and Operation(b)A comfortable temperature for residents shall be maintained at all times(2)The facility shall cool rooms to a comfortable range[...] This requirement is not met as evidenced by: Based on inspection and observation the Licensee did not ensure that the facility has proper operating AC unit and is in comfortable range of temperature, This poses apotential health, safety risk and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: The Administrator shall submit proof of repair of AC unit and the corrective measures taken to CCL by POC due date.

Type of visit: Case Management - Other

At 9:30am, Licensing Program Analysts (LPAs) Angela Panushkina and Perchui Milena Khurshudyan conducted an unannounced Case Management Visit. LPAs met with the Administrator, Stephan Sarmazian, and explained the reason for the visit. LPAs responded to facility to review Stipulation and Waiver which was ordered on 05/22/2026. LPAs reviewed Revocation of License on page 3. The revocation of this shall be Stayed ninety (90) days to facilitate the sale or transfer of the facility, subject to the limitations and conditions below. Respondent CEDARS understands that the facility license will be revoked at the end of the stay period and the license is not transferable to another party. Facility currently has an application with the Department name – Cedars Assisted Living. Licensee CEDARS ASSISTED LIVING INC. has applied for license on 02/26/2026 and is currently pending. LPAs reviewed page 4 of the Stipulation which allowed additional thirty (30) days in addition to the ninety (90) days reference in paragraph 2(A), he/she/they must make the request in writing during the initial 60 days of the stay. In no case shall the total number of days of the ninety (90) days stay exceed 120 days. The facility is currently cleared for 175 Non-Ambulatory, of which 8 may be bedridden in bedrooms 101, 103, 105,107,112,114 & 122. Approved for delayed egress (bedrooms 106-115, 117-120,123-129 & 226-240). Hospice waiver for 20 residents. It was determined that there is a "Clerical error" made, thirty (30) years ago. Due to the Fire Clearance Safety Regional Office (RO) is requesting for an additional monitoring on 2nd floor. LPAs informed the Administrator, as this is a Health and Safety issue, to provide a following Written Plan within 48-hours: Continue on LI809-C New facility sketch (room dimensions and water and gas shut off locations) to show Ambulatory only on the 2nd floor and room numbers for non-ambulatory and bedridden on the 1st floor. New LIC200 to reflect the correct number of non-ambulatory, ambulatory and bedridden. A list of people that need to be relocated (non-ambulatory and or bedridden on a 2nd floor). LPAs were informed that no bedridden residents currently reside on the 2nd floor. As for Non-ambulatory residents, the facility will submit Names and Room #'s of each resident by 5:00pm on 07/04/2026 Anticipated move for those residents will be as follows: LPAs were informed that the families/residents must be informed and upon approval the family/resident will coordinate and organize the transfer with the help of community. An addendum must be in place and attached to a current Admission Agreement, due to room changes and pricing. During today’s visit LPAs provided a copy of the Stipulation and Waiver, City of Los Angeles Certificate of Occupancy along with this report. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jul 2, 2026

Allegation investigated: Licensee is operating beyond the conditions and limitations specided on the license

Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conduced unannounced complaint visit the facility. LPA met with the Administrator and explained the purpose of the visit. It was alleged that the facility resident #1 ,(R1) was receiving in-house dialysis, which required a higher level of care. During this investigation at 12:45p.m., LPA inspected the facility including residents’ rooms. At 1:15p.m., LPA requested and reviewed R1s facility file, including but not limited to R1’s Physician Report, Needs and Services Plan, Identification Information, Resident Appraisal and other medical documents. At 1:25p.m., LPA spoke with three(3) facility staff including Administrator. Upon inspection of room #237, LPA observed the medical equipment for dialyses. Resident #1 residing in the room was not present due to being at the hospital. Therefore, LPA was unable to interview R1.Staff verified that R1 is receiving dialysis at the facility three (3) times a week. Cont. on LIC 9099-C Substantiated Cont. from LIC 9099 The services were ordered by R1’s family and provided by the Spectrum Dialysis Center. R1 was not receiving Home Health or Hospice services and was able to attend to dialysis center before. There were no changes in R1’s condition to allow them to receive the services in nonmedical settings. A review of R1’s facility file did not provide any information to verify the need to receive a Skilled Nursing Services, that should have been provided in the medical settings. No exception request was requested by the facility, prior to allowing R1 to receive dialysis in the facility. Overall investigation concluded that facility allowed R1 to receive medical services that shall be provided in medical setting. Therefore, based on inspection, observation and interviews, the allegation is SUBSTANTIATED at this time. Under Title 22, Division 6. Chapter 8 following citation was issued and recorded on LIC9099D. An immediate $500.00 civil penalty was issued to the facility due to allowing resident to receive Skilled Nursing Services, instate of arranging off– site outpatient medical services. Exit interview conducted, copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 31-AS-20260518100855

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87611(a) · Plan of correction due date: May 21, 2026

87611 General Requirements for Allowable Health Conditions (a) Prior to accepting or retaining a resident with an allowable health condition licensees … shall obtain Department approval: This requirement is not met as evidenced by. The Licensee allow R1, who was not receive home health or hospice services to receive dialysis in the facility, without seeking prior approval from the Licensing Agency. This poses an imminent health and safety hazard to residents in care.the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: Administrator contacted Spectrum Dialysis, CEO and cancelled Dialysis services for R1 at the facility. Spectrum was asked to pick up all Dialysis equipment from R1's room. POC was cleared during today's visit.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management visit regarding a recent incident report submitted February 20, 2026. The Serious Incident Report (SIR) states on February 20, 2026, multiple allegations of abuse involving staff member Claudia Sosa and three residents were reported by staff. The allegations include rough handling during personal care resulting in the resident crying out in pain, verbal abuse and intimidation causing emotional distress and fear of requesting assistance, and forceful feeding despite the resident's inability or refuse to eat. During interviews the Administrator stated facility took immediate action upon notification, initiated an internal investigation and suspended Claudia Sosa from duty. All responsible parties were notified. Facility reported the incident to the police, and a copy of the responding officers was provided. Subsequently, an in-service abuse and reporting training was completed by all staff. A review of facility files shows that Sosa was fingerprint cleared and completed all training. No health and safety hazards were noted during the visit. Nothing further at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 4, 2026

Allegation investigated: Resident sustained unexplained fractures while in care Resident sustained severe unexplained bruising while in care

On 02/24/26, at 11:35pm, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Resident Care Director Mary Jane Reyes. LPA explained the purpose of this visit was to deliver findings for this complaint. On 11/19/25, the complaint was referred to The Community Care Licensing Investigations Branch (IB) and accepted as a full investigation. It was assigned to Investigator, Christine Ferris. On 11/19/25, LPA Saucedo initiated the twenty-four (24) complaint investigation and asked for the census, staff, resident roster and obtained documents regarding R1- Resident Identification and Emergency Information, Physician’s Report, Resident Information Care Plan, Pre-placement Appraisal, Functional Capability Assessment, Resident Appraisal, Needs and Services Plan. LIC 9099C-continued Unsubstantiated On 11/19/25, IB subpoenaed medical records from two (2) different hospitals-Valley Presbyterian Hospital and California Hospital Medical Center. On 12/04/25, California Hospital Medical Center responded by saying, “they had no records for R1.” On 12/16/25, medical records were subpoenaed for R1 from Southern California Hospital at Hollywood and were received on 01/20/26. The medical records from Southern California Hospital at Hollywood show via X-rays that there were no fractures noted and no falls at the hospital were documented on 08/09/24. On 01/27/26, medical records were received from Valley Presbyterian Hospital. Regarding the allegation: Resident sustained unexplained fractures while in care. It is being alleged that resident #1 (R1) fractured their left arm and rib. The investigation revealed the following; During a record review per Southern California Hospital at Hollywood medical records, R1 was admitted to the hospital on 08/09/2024, X-rays were taken with no fractures noted and no falls at the hospital were documented. R1 was discharged back to Cedars Assisted Living on 08/15/2024. Per Valley Presbyterian Hospital medical records, R1 was admitted on 08/19/2024 and was diagnosed with multiple fractures “likely from an unwitnessed fall.” The fractures included an acute left wrist fracture, an acute left 10th displaced rib fracture, and a lumbar 1 vertebral body fracture of an indeterminate age. R1 was also noted to have bruising around their neck, chest, left hip, and left wrist. The cause of the fractures was unknown and the information regarding the bruising, which began at Southern California Hospital at Hollywood was not relayed to Valley Presbyterian Hospital. Staff at the facility denied R1 sustained any falls or incidents to explain the fractures prior to their hospitalization on 08/19/2024. On 12/10/25, IB Investigator interviewed five (5) facility staff and two (2) residents. Four (4) out of the five (5) caregivers stated, “that they did not witness and/or recall R1 having any falls, bruising and/or swelling while at the facility.” One (1) out of the five (5) staff stated, “they had just started working there within the last three (3) months and they did not know R1.” Two (2) out of two (2) residents stated, “that they were happy and felt safe at the facility.” There was no documentation, statements, or other evidence to show where, how, or when R1 sustained the fractures. Therefore, with no sufficient evidence found to substantiate the allegation, it is unsubstantiated. LIC 9099C-continued Regarding the allegation: Resident sustained severe unexplained bruising while in care. It Is being alleged that Resident #1 (R1) had bruises all over their body. The investigation revealed the following; During a record review per Southern California Hospital at Hollywood medical records, R1 was admitted to the hospital on 08/09/2024, notations of bruising on R1’s left jaw, neck, and right breast began on 08/13/2024, after their admission, with no notations of bruising upon R1’s admission. Per staff, R1 had no bruising prior to being admitted to Southern California Hospital at Hollywood and denied R1 had any falls or causes for bruising prior to their hospitalization but had bruising, and documented it, upon their return to the facility from the hospital on 08/15/2024. On 12/10/25, IB Investigator interviewed five (5) facility staff and two (2) residents. Four (4) out of the five (5) caregivers stated, “that they did not witness and/or recall R1 having any falls, bruising and/or swelling while at the facility.” One (1) out of the five (5) staff stated, “they had just started working there within the last three (3) months and they did not know R1.” Two (2) out of two (2) residents stated, “that they were happy and felt safe at the facility.” There is no evidence to show the bruising occurred at the facility, therefore, the allegation is unsubstantiated. Exit interview was conducted, no citation(s) were issued for the above allegation(s) and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 31-AS-20251118164042

Type of visit: Case Management - Other

On 02/24/26, at 11:35AM, Licensing Program Analyst (LPA) Gina Saucedo followed up on a Unusual Incident/Injury Report and SOC 341 that was received via Community Care Licensing Department dated of occurred-02/14/26: Resident #1 accused Resident #2 of rape, Proper measures and protocol were taken by the facility. R1 was taken to the Northridge Hospital via ambulance and 911 was called. R1 and R2's responsible parties were notified of the alleged incident. The administrator interviewed both R1 and R2 where R1 stated, "I consumed marijuana and I was hallucinating." R2 stated, "I do not speak to R1, I do not know R1's room location and that particular day I did not see R1 all day." Let it be noted, this is R1's second time that they have accused another resident of rape. R1's first allegation of rape similar situation was on 12/19/25 (at the same facility) and it was R1's same response, "I was high and I was hallucinating." On 02/24/26, LPA interviewed R1 and R1 stated, "Nothing happened that day." R1 continued to say, "I want to be high, I want to stop hearing voices, I want to change my social worker and I want to go to school." During the facility's further investigation and interviews with DMH-Department of Mental Health whom is responsible for R1 stated, "R1 has made similar allegations at their prior facilities." Let it be noted, DMH is currently finding another placement for R1 to live that will be more appropriate for R1. Exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Feb 24, 2026

Type of visit: Office

Case Management – Office Date: January 23, 2026 Time: 10:00 AM Location: Virtual An Office meeting was held virtually on January 23, 2026, at 10:00 AM to discuss a pending selling/change of ownership of Pasadena Villas (198603286), Melrose Villas (197609076), Melrose Chateau (197609724) and Cedars Assisted Living (197608267). Attendees: • Angela Whittaker – Regional Manager/South Woodland Hills • Troy Agard – Licensing Program Manager • Gina Saucedo – Licensing Program Analyst • David Sicarios- Licensing Program Manager • Tony Vasallo- Regional Manager/Monterey Park • Stephan Sarmazian-Vice President for Operations • Jai Chung-(Consultant) • Shawn Zhou – Chief Financial Officer (Consultant) 809-C continued Introductions were conducted at the beginning of the meeting. Regional Manager Angela Whittaker requested confirmation on whether the above facilities were being sold and/or if there would be a change of ownership in the near future. It was confirmed that there will be a future change of ownership for Cedars Assisted Living; however, because the facility is currently under revocation, the prospective owner is waiting for Legal to make a decision regarding the revocation action. The new owner is New Gen LLC, and the transaction will be a stock acquisition rather than a licensee change. The prospective owner plans to provide residents with a thirty (30) day notice and intends to submit a Community Care Licensing application on February 25, 2026. A copy of this meeting summary was emailed to all attendees listed above with signature on file.the state’s words, verbatim · CDSS document, Jan 23, 2026

Type of visit: Required - 1 Year

On 01/06/26 at 8:05AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA met with Resident Care Director Mary Jane Reyes and David Aguiniga, Administrator and disclosed the purpose of the visit. LPAs asked for the census, resident, and staff files. A physical tour was conducted at 8:10AM and observed the following: The entire facility has a total of 175 (one-hundred and seventy-five) beds. The facility is a two-story building. Both first floor and second floor are assisted living and memory care. The facility has two (2) memory care units: Evergreen located on the second floor and Willow located on the first floor. There is one (1) medication room on the second floor. The Evergreen Memory Care section of the facility has their own activity, television, dining hall area and patio area. The door has a code and delayed egress on the doors. Willow Memory Care also has its own activity, television, dining hall area and patio area. The assisted living side has their own activity room on the second floor, dining hall on the first floor and a television room on the first floor. The assisted living side has access to a huge patio area with proper seating for residents. There are two (2) elevators. There are three (3) stairways that have evacuation chairs. Random Bedrooms were randomly selected to tour and were observed to have furniture, lighting, bedding, and televisions. Random Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested randomly for and measured 105–110degree Fahrenheit. LIC 809C-continued Fire extinguishers were observed throughout the facility and were fully charged dated 11/2025. There are fire extinguishers upstairs, downstairs and in the kitchen area. Carbon Monoxide, fire sprinklers and fire alarms are located throughout the facility and are operable. Facility has one designated medication room that is inaccessible to residents where all the medication is stored and locked in the memory care side of the facility. There are always two (2) medical technicians staff in the facility to pass out medication. Common Areas: These include the dining areas, activities room, television rooms: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 68-72-degree Fahrenheit. There are several temperature thermostats throughout the facility including resident rooms. There are several common bathrooms throughout the upstairs and downstairs area. The staff and resident bathrooms are not shared. There are trash cans with lids and covid signs posted in the common bathrooms. Sufficient supplies of toilet paper and napkins observed. The facility has no body of water. There is a parking lot in the back of the facility. There is one (1) facility laundry area on the first level with chemicals inaccessible to the residents. The staff lounge is also located on the first level of the facility. The Kitchen: area was toured, and LPA observed sufficient supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The kitchen is located on the first floor. The assisted dining area has access to this kitchen, where at the time of the tour, different residents were observed having breakfast with proper feeding utensils/plates/cups. Next to the kitchen/dining room area is a vending machine for residents. Against the wall of the kitchen on your right-hand side is a Resident's Diet/Allergic Board and in the office area. LIC 809C-continued Resident records/Staff records: LPA conducted a complete file review of ten (10) resident records. Resident records were complete and updated. Staff records: LPA conducted a complete file review of six (6) staff records. Staff records were complete and updated. Administrative: The Insurance plan is dated as of 02/2026. There is an Emergency Disaster plan, Personal Right, Rights of Resident Council, YES, Licensee, Administrator Certificate and Ombudsman sign on your right-hand side at the entrance of the facility, Fire Drills conducted. The last fire drill was in October of 2025. Deficiencies/Citations: Window screens shall be clean and maintained in good repair and kitchen area did not have proper lightening. An exit interview was conducted, citation(s) were issued, appeals rights and a copy of this report was given to the David Aguiniga, Administrator.the state’s words, verbatim · CDSS document, Jan 6, 2026

Allegation investigated: Facility is in disrepair Staff did not ensure that facility is free of hazards Staff did not ensure that the facility is free of pests

On 12/22/25, at 1:14pm, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 12/22/25, LPA Saucedo asked for the census, staff, and resident rosters. On 12/22/25, at 1:14pm, LPA Saucedo conducted a physical tour, and interviewed staff. LIC 9099C-continued Substantiated Regarding the allegation: Facility is in disrepair. It is being alleged that several rooms'-baseboards, toilets, ceilings, and light fixtures need repairs. During LPA’s physical tour, LPA observed and obtained pictures of several rooms baseboards that were not stuck to the wall, toilets to be leaking, water damage to the wall and ceiling, a light fixture was exposed in one (1) of the resident's bathrooms. Be advised, these rooms were occupied by residents. Two (2) staff confirmed that they have seen the facility in disrepair in several rooms. Therefore, based on the LPA's observations, the allegation is SUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure that facility is free of hazards. It is being alleged that bathtub(s) lacked slip pads, some room floors were lifting with gaps/dents that may cause hazards to the residents. During LPA’s physical tour, LPA observed and obtained pictures of several rooms bathtubs not to have slip-resistant mats, some room floors were lifting with gaps/dents that may cause trip/fall hazards to the residents. Be advised, these rooms were occupied by residents. Two (2) staff confirmed that they have seen several rooms that are hazardous to the residents and to staff. Therefore, based on the LPA's observations, the allegation is SUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure that the facility is free of pests. It is being alleged that there were live roaches in some of the rooms. During LPA’s physical tour, LPA observed in one (1) of the rooms to have roaches. Be advised, this room was occupied by a resident. Two (2) staff confirmed that they have seen roaches/pests in several rooms. Therefore, based on the LPA's observations, the allegation is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, a civil penalty issued, appeal rights and a copy of this report was given to the Resident Care Director/Administrator.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 31-AS-20251217165129

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 12, 2026

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met by: Based on the LPA's observations the licensee/administrator failed to ensure that the facility was clean, safe, sanitary and in good repair at all times. This posed an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 22, 2025

Plan of correction: The licensee/administrator shall send a picture/repair paperwork to the LPA of repairs conducted. POC due date: 01/12/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(5)(A) · Plan of correction due date: Jan 12, 2026

Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows:(5)Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors.(A)All slip-resistant mats, strips, or flooring shall be in good repair and maintain slip-resistant properties. This requirement is not met by: Based on the LPA's observations the licensee/administrator failed to ensure that the facility was free of hazards. This posed an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 22, 2025

Plan of correction: The licensee/administrator shall send a picture/repair paperwork to the LPA of repairs conducted. POC due date: 01/12/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 12, 2026

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met by: Based on the LPA's observations the licensee/administrator failed to ensure that the facility was accorded safe, healthful and comfortable accommodations, furnishings and equipment. This posed an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 22, 2025

Plan of correction: The licensee/administrator shall send the Pest Control paperwork to the LPA showing that Pest Control has been providing services. POC due date: 01/12/26.

Type of visit: Case Management - Other

Licensing Program Analyst, Gina Saucedo arrived on 12/15/25 for an unannounced inspection to follow up on a substantiated allegation on a complaint investigation. On April 22, 2022, the Department concluded a complaint investigation regarding the following allegation: Resident sustained pressure injuries while in care. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, Section 87615(a)(1), Prohibited Health Conditions. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility failing to provide care and supervision, necessary to meet R1’s health care needs, resulting in serious bodily injury- two stage 3 pressure ulcers (injuries/wounds) that required hospitalization, surgical intervention (incisional debridement) and transfer to a higher level of care. Today, 12/15/25, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. Exit interview conducted. A copy of the report issued. Appeal rights provided, David Aguiniga, Administrator and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Dec 15, 2025

Allegation investigated: Staff do not provided food of quality

On 11/25/25, at 7:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Mary Jane Reyes, Resident Care Director. LPA explained the purpose of this visit was to gather more information and deliver findings for this complaint. On 11/19/25, LPA Saucedo conducted the initial visit. On 11/19/25, LPA Saucedo asked for the census, staff, and resident rosters. On 11/19/25, LPA Saucedo conducted a physical tour and interviewed staff. On 11/25/25, LPA Saucedo conducted another physical tour and interviewed residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff do not provide food of quality. It is being alleged that the meals provided are not healthy. During LPA's observations, LPA observed residents eating the food that was provided to them which was two (2) slices of English Muffins with scrambled eggs. Furthermore, cold and hot cereal was provided to them along with milk, juice and/or coffee. Some residents had extra food given to them such as bananas. Seven (7) residents were interviewed that confirmed they like the quality of food that is provided to them, they also confirmed that there has been a slight change in quality that has improved to their liking. Two (2) staff were observed working in the kitchen area. LPA observed the kitchen area to be clean and there was a display of resident diets such as residents that have certain allergies such as fish. Furthermore, there is a display in the front lobby saying, "Please, turn in Alternative Menu Slips Ahead of time." Therefore, based on the LPA's observation, resident and staff interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 31-AS-20251119100311

Type of visit: Case Management - Health Checks

On 11/25/25, at 9:32AM, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, case management visit and was greeted by Administrator, David Aguiniga. The visit is notifying the licensee of this case, referencing the complaint #31-AS-20210712154639, and that the Department is in the process of assessing an additional civil penalty under H&S Code 1569.49(f) for the allegation that a resident sustained pressure injuries while in care. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Nov 25, 2025

Allegation investigated: Staff does not provided residents with adequate amounts of food. Staff serve residents food of poor quality.

On 10/15/25, at 7:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Administrator, David Aguiniga. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 10/15/25, at 9:05am, LPA Saucedo asked for the census, staff, and client rosters. On 10/15/25, at 9:30am, LPA Saucedo conducted a physical tour, interview staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff does not provide residents with adequate amounts of food. It is being alleged that the amounts of food are not enough for each resident and sometimes they don’t have enough food for everyone. During LPA's observation, LPA observed residents asking for extra food and it was granted to them. LPA interviewed six (6) staff that confirmed when residents ask for extra food if they still feel hungry and/or believe the portions are not adequate they can request extra food and it is provided to them. LPA interviewed ten (10) residents that confirmed they can request for extra food. There is also snacks available to them and two (2) snack vending machines in the dining hall area. Therefore, based on the LPA's observation, resident and staff interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff serve residents food of poor quality. It is being alleged that the quality of food that is provided to the residents is of poor quality. During LPA's observations, LPA observed residents eating the food that was provided to them which was two (2) slices of pancakes and a sausage. Furthermore, cold and hot cereal was provided to them along with milk, juice and/or coffee. Some residents had yogurt for alternative food. Although, ten (10) residents were interviewed that do not like the food that is provided to them, they did state the quality is not the problem they would like a change in menu and other alternatives. Two (2) staff were observed working in the kitchen area, and stated the old food is thrown away and there is other foods given to the residents if they wish to eat at a later time or if they do not like the food that is given at the time of serving. Therefore, based on the LPA's observation, resident and staff interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 31-AS-20251014145356

Type of visit: Case Management - Other

On 10/15/25, at 7:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit. LPA conducted a physical tour and observed the following: One (1) Electrical plug against the wall was missing in the area where the residents watch television. In one (1) of the resident rooms there was a huge hole that needs repair where the back of the door when it is open has created a hole against the wall-Room 140 Upon observations of the kitchen/dining room area LPA observed two (2) caregivers giving/passing out food. LPA asked to see their file for sanitation-passing out of food and both caregivers did not have food sanitation training. In the absence of staff, staff providing the services shall be qualified under that duty. Upon speaking to some residents and conducting a physical tour, some resident did not have basic cable which is under their admission agreement where basic cable free. Residents stated it's been since 09/22/25 that the basic cable has been disconnected. LPA spoke to staff #1 (S1) and S1 stated, "it has been in process for a couple of weeks now to get resident's their cable back." Four (4) citations are being issued for four (4) observations during the physical tour. An exit interview was conducted, four (4) citation(s) were issued, and a copy of this report was given to the administrator with appeal rights provided.the state’s words, verbatim · CDSS document, Oct 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 29, 2025

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met by: Based on the LPA's observations the licensee/administrator failed to ensure that there was an electrical outlet missing in a common are and in one (1) of the residents room there was a huge hole behind their room door. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: Licensee/Administrator shall send a picture of the both repairs to LPA

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(f) · Plan of correction due date: Oct 29, 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 Based on the LPA's observations and resident interviews the licensee/administrator failed to ensure that there was basic cable provided to residents which states in their admission agreement that is included for free. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: Licensee/Administrator shall replace the basic cable for all residents which is included in their admission agreement and send a notice to LPA that basic cable has been restored.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Oct 29, 2025

87411 Personnel Requirements - General (d)All personnel shall be given on the job training or have related experience in the job assigned to them...(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met by: Based on the LPA's observations and resident interviews the licensee/administrator failed to ensure that appropriate care and supervision was given to other residents because two (2) caregivers were observed in the dining hall providing meals. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: Licensee/Administrator shall make sure that proper care and supervision is given to all residents by proper personnel and a new hiree needs to be hired in the kitchen area and all paperwork shall be sent to LPA upon hire and proper training given to other personnel providing food services.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87413(a)(1) · Plan of correction due date: Oct 29, 2025

87413 Personnel - Operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met by; Based on the LPA's observations and resident interviews the licensee/administrator failed to ensure that proper coverage is provided by personel with qualifications. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: Licensee/Administrator shall make sure that in the absence of any employee there shall be a personnel providing adequate services that is trained to perform tasks.

Allegation investigated: Facility staff does not ensure food is of good quality. Facility staff does not ensure the facility has sufficient amount of food for resident in care. Staff do not follow special dietary plans for residents in care

On 10/08/2025, Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to deliver findings for the above allegation(s). LPA Spaeth met with Mary Jane Reyes, the Resident Care Director. LPA explained the purpose of the visit was to deliver the findings. The investigation consisted of the following: On 5/01/2025, LPA Spaeth conducted an unannounced complaint investigation. LPA reviewed resident documents from 10:40 a.m. until 11:15 a.m. and received copies of the residents' records. LPA Spaeth interviewed 11 out of 107 residents (R1–R11) from 11:30 a.m. until 1:55 p.m. LPA also conducted an unannounced visit on 10/02/2025. LPA interviewed eight out of thirty-two residents (R12–R19) who require a special diet. Continued on 9099-C Unsubstantiated Regarding the allegation: Facility staff does not ensure food is of good quality. It is alleged the facility does not serve quality food and that it is not completely cooked. During interviews, 10 out of the 11 residents initially interviewed stated the facility serves food that is of good quality and is fully cooked. During interviews with staff, all denied the allegation. Eight residents were not interviewed regarding this allegation. Regarding the allegation: Facility staff does not ensure the facility has a sufficient amount of food for residents in care. It is alleged the facility runs out of food during some meals and during the afternoon snack time. During interviews, 10 out of the 11 residents initially interviewed stated there is sufficient food for them during snack and mealtimes. During interviews with staff, all denied the allegation. Eight residents were not interviewed regarding this allegation. During the facility tour, LPA observed a sufficient amount of perishable and non-perishable food supplies to meet the needs of the 113 residents. Regarding the allegation: Staff do not follow special dietary plans for residents in care. It is alleged alternative meals are not provided to residents who have dietary restrictions. During LPA’s subsequent visit, eight additional residents were interviewed. During the interviews, residents stated they are provided alternative meals related to their dietary needs. During LPA’s 10/02/2025 visit, LPA observed that two residents were served an alternative meal based upon their dietary needs. Based upon LPA’s interviews and observations the allegations are unsubstantiated. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 31-AS-20250425120215

Allegation investigated: Staff did not prevent residents from selling drugs on the premises. Staff did not prevent residents from using drugs on the premises.

On 09/23/25, at 8:15am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 09/23/25, LPA Saucedo asked for the census, staff, and resident rosters. On 09/23/25, at 8:35am, LPA Saucedo conducted a physical tour, interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not prevent residents from selling drugs on the premises. It is being alleged that people are selling drugs on the premises. LPA interviewed ten (10) residents that confirmed there are no residents selling drugs on the premises. In addition, LPA interviewed three (3) staff that confirmed they have not seen or heard any residents selling drugs on the premises. During LPA's physical tour, LPA did not observe any residents selling drugs on the premises. Therefore, based on the LPA's observation, resident and staff interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not prevent residents from using drugs on the premises. It is being alleged that people are using drugs on the premises. LPA interviewed nine (9) out of ten (10) residents that confirmed there are no residents using drugs on the premises. One (1) resident did state that the smell of drugs is coming from the memory care unit, the room that is next to them separated by the walls. In addition, this resident stated that residents come in and out of the memory care unit to do drugs and they can smell it in their room but did not know what type of drug it was. During LPA's physical tour, LPA did not observe any residents using drugs on the premises. In addition, LPA toured the memory care unit that is next to this resident's room and observed the room to be empty. Furthermore, LPA interviewed three (3) staff that confirmed they have not seen any residents using drugs on the premises and the staff also confirmed that residents cannot come in and out of the memory care unit which is secured. Therefore, based on the LPA's observation, resident and staff interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the resident care director.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 31-AS-20250922160334

Allegation investigated: Staff are not meeting residents' care needs.

This is an addendum to the previous licensing report delivered to the facility on 05/15/2025. On 08/19/25, at 9:15am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather additional information, interview staff and residents and deliver findings for this complaint. On 05/06/25, LPA Leizl DeLaCerra conducted an initial visit, interviewed staff and residents. On 05/15/25, LPA Leizl DeLaCerra delivered findings for this complaint. On 08/19/25, at 9:55am, LPA Saucedo conducted a physical tour and interviewed additional staff and residents and received relevant documentation. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff are not meeting residents' care needs. It is being alleged that the facility staff does not assist residents that were temporarily relocated from the Pasadena Villa Senior Facility (due to an emergency disaster). Furthermore, Residents needed to wait for Pasadena Villa Senior Facility staff to assist them. Due to the short notice of Pasadena Villa Senior Facility moving because of the fire evacuation, some residents were placed in rooms located in the memory care unit of the above facility and were told to wait for Pasadena Villa Facility staff to assist them. To investigate this allegation, on 5/06/2025 LPA DeLa Cerra between 10:30am to 11:55am conducted a physical plant tour, interviewed six (06) staff members and between 12:00pm to 1:30pm interviewed ten (10) residents and between 2:30pm to 3:10pm, LPA DeLa Cerra conducted a record review. LPA Dela Cerra’s observation, during the physical plant tour confirmed that the five (5) residents from Pasadena Villa Senior Living (198603286) temporarily placed in memory care were no longer present. Staff #1 (S1) further indicated that due to safety measures, the access code was not provided to the residents placed in the memory care unit. However, staff members from both facilities were always available to assist these residents in and out of memory care. Interviews with facility caregivers revealed that they were assisting all residents including those that were relocated from Pasadena Villa Senior Facility. Staff revealed that during certain incidents when a staff member was assisting temporary residents, which they are not familiar with, the staff member would also ask for assistance from the caregiver who was more knowledgeable of that resident so the appropriate care can be provided. LIC 9099C-continued During this visit, LPA Saucedo interviewed additional facility staff and residents. LPA Saucedo interviewed ten (10) residents from the above facility confirming that all caregivers were able to meet their needs. LPA Saucedo also interviewed four (4) staff that confirmed regardless of where the resident came from they were providing different types of care. Four (4) out of the four (4) staff also confirmed that due to safety measures, the access code was not provided to the residents placed in the memory care unit housed from Pasadena Senior Villa Facility but they were also able to call the front desk to let them in and out and also ask any staff available to let them in and out of the memory care area of the facility to have access to going outside, the dining area, and any other part of the facility. LPA Saucedo also conducted three (3) phone interviews with Pasadena Villa Senior Living (198603286) residents confirming that their needs were being met and while housed in memory care they were able to enter and leave when they wanted. Furthermore, LPA Saucedo interviewed two (2) Pasadena Villa Senior Living Facility staff via telephone that also confirmed any staff regardless from what facility they worked for were providing help to all residents. Let it be noted, that Pasadena Villa Senior Living staff and residents transferred back to Pasadena in April of 2025. LPA Saucedo also received a reporting log for maintenance that involved staff from both facilities being trained on the maintenance log in case any staff needed any repairs done to their room. Therefore, based on LPA Saucedo’s observations, interviews of staff and residents and record review allegation(s) is UNSUBSTANTIATED at this time. An exit interview conducted, and copy of the report was signed and given to the Resident Care Director.the state’s words, verbatim · CDSS document, Aug 19, 2025 · control 31-AS-20250429145855

Type of visit: Office

Case Management – Office Date: August 15, 2025 Time: 2:00 PM Location: Virtual An Office meeting was held virtually on August 15, 2025, at 2:00 PM to discuss a pending revocation action. Prior to the meeting, Stepan Sarmazian, Vice President of Operations, was provided with the 2023 Noncompliance Conference Summary. Attendees: • Angela Whittaker – Regional Manager • Troy Agard – Licensing Program Manager • Gina Saucedo – Licensing Program Analyst • Dr. Eyal Shtorch – Licensee • David Aguiniga – Administrator (introduced self and departed meeting) • Abdoulaye Niang – Chief Operating Officer (Consultant) • Shawn Zhou – Chief Financial Officer (Consultant) 809-C continued Introductions were conducted at the beginning of the meeting. The licensee and consultants expressed concern regarding the pending revocation action listed on Community Care Licensing's website. The Regional Manager clarified that the issue has been ongoing since 2021 and that a Noncompliance Meeting was held in 2023. The consultants were unaware of the incident that initiated the revocation action (pressure injuries sustained by a resident) but were familiar with the generator issues previously reported at the facility. Both the licensee and consultants expressed a strong desire to support the facility in remaining open and continuing to serve its residents. The Regional Manager noted that recommendations have been made to the legal team for probation in lieu of revocation, and a final decision is pending. The licensee’s consultant will provide an updated mailing address to the regional office, as the current address on file is no longer valid. A copy of this meeting summary will be emailed to all attendees listed above.the state’s words, verbatim · CDSS document, Aug 15, 2025

Allegation investigated: Staff hit resident. Staff did not safeguard resident's personal belongings. Staff left resident in soiled diaper for extended period of time. Staff made inappropriate comments towards resident.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegations. LPA met with Mary Jane Reyes and explained the reason for the visit. --- Staff hit resident. It was alleged that Staff #1 (S1) and Staff #2 (S2) came in Resident #1’s (R1) room and hit R1 in the head with own hand and no injuries noted. To investigate the allegation, on 04/24/2025 LPA interviewed three (03) staff from 11:00a.m. to 12:30p.m. and fifteen (15) residents from 12:30p.m. – 3:00p.m. During interviews with staff, all staff stated they have never forced R1 to hit themselves in the head with their own hand. During interviews with residents, one (01) resident stated they think staff hit them but not certain. (CONT. on LIC9099-C) Unsubstantiated All other residents stated they were not physically abused by staff or forced to abuse themselves. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. --- Staff did not safeguard resident's personal belongings. It was alleged that someone stole R1’s clothes and slippers. To investigate the allegation, on 04/24/2025 LPA requested documents at around 10:30a.m., interviewed three (03) staff from 11:00a.m. to 12:30p.m. and fifteen (15) residents from 12:30p.m. – 3:00p.m. A review of R1’s Safeguard Personal Valuables inventory does not show alleged missing items. During interviews with staff, all staff stated they did not take R1’s slippers or clothes. During interviews with residents, one (01) resident stated staff take their clothing items such as Garfield slippers, Scooby Doo slippers and workout clothes. All other residents stated their belongings have not gone missing. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. --- Staff left resident in soiled diaper for extended period of time. It was alleged that staff left R1 sitting in urine and poop for eight (08) hours. To investigate the allegation, on 04/24/2025 LPA interviewed three (03) staff from 11:00a.m. to 12:30p.m. and fifteen (15) residents from 12:30p.m. – 3:00p.m. During interviews with staff, all staff stated they check on and change incontinent residents every two (02) or as needed. Staff added residents are not left soiled for an extended time, that calls for service are answered within four (04) minutes. During interviews with residents, one (01) resident stated they are left soiled for an extended time. All other residents stated they are checked on often and all incontinent residents stated they are not left soiled for an extended time. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. (CONT. on LIC9099-C) --- Staff made inappropriate comments towards resident. It was alleged that staff S1 was standing at the end of the bed watching and laughing. To investigate the allegation, on 04/24/2025 LPA interviewed three (03) staff from 11:00a.m. to 12:30p.m. and fifteen (15) residents from 12:30p.m. – 3:00p.m. During interviews with staff, all staff stated they treat all residents with respect and dignity. Staff #1 (S1) added they do not taunt or laugh at residents. During interviews with residents, one (01) resident stated staff are not kind and taunt them. All other residents stated they are treated with respect and dignity. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 12, 2025 · control 31-AS-20250418110154

Type of visit: Case Management - Other

On 07/22/25, at 9:00am, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced case management visit following an inspection by the Los Angeles Fire Department (LAFD) on 07/17/25. LPA Saucedo met with Resident Care Director Mary Jane Reyes. The LAFD found five (5) violations during there inspection: -Systems out of service-Provide a fire watch due to deficient and/or out of service fire protection system. -Authority to require fire watch- Ordered to require and implement a Fire Watch. -Responsibility for instruction-Provide instructions to personnel performing Fire Watch. -Log book-Provide and maintain Fire Watch log book. -Specific duty requirements-Assigned Fire Watch personnel shall be thoroughly familiar with area patrolling, patrol area each 30-minutes. As of immediately, the facility needs to be on Fire Watch until the Reg 4 Generator test has passed. This is an immediate health and safety violation, placing hundreds of residents in serious and immediate danger. An exit interview was conducted, citation(s) were issued, appeal rights were provided, and a copy of this report was given to the resident care director.the state’s words, verbatim · CDSS document, Jul 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jul 23, 2025

87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met by: Based on the LPA's record review of the inspection by the Los Angeles Fire Department (LAFD) the licensee/administrator failed to ensure that the above facility is in violation of the Los Angeles Municipal Code of certain sections. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2025

Plan of correction: Licensee/Administrator has been conducting fire watch logs since 07/17/25 and has conducted a generator test that has been working. An In service attendance record was also conducted on 07/17/25 with staff. The POC was cleared at time of visit. POC Cleared 07/22/25

Allegation investigated: Staff not rotating resident resulting in pressure sores Staff not providing resident with food

On 07/14/25, at 9:55am, Licensing Program Analysts (LPAs) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather additional information, interview staff and residents and deliver findings for this complaint. On 05/21/25, LPA Saucedo conducted the initial visit. On 05/21/25, LPA Saucedo asked for the census, staff, and resident rosters. On 05/21/25, LPA Saucedo conducted a physical tour and interviewed staff. On 07/14/25, LPA’s Gina Saucedo and Angelica Segovia conducted another physical tour and interviewed additional staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff not rotating resident resulting in pressure sores. It is being alleged that resident #1 (R1) had pressure sores on their back, buttocks, and shoulders. LPA Saucedo requested medical records from Northridge Hospital and the medical records confirmed that R1 did not have any pressure sores. LPA Saucedo also called the skilled nursing where R1 is currently located, and they also confirmed R1 did not have any pressure sores, and they are not treating R1 for any pressure sores. R1 was also under Mensa Hospice care while at the facility, and they also confirmed that R1 did not have any pressure sores and/or was not being treated for any pressure sores. In addition, LPAs received R1’s hospice notes that indicated R1 did not have any pressure sores. Furthermore, LPAs conducted three (3) staff interviews that confirmed R1 did not have any pressure sores. Therefore, based on the LPA's record reviews, medical records, hospice notes and staff interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not providing resident with food. It is being alleged that resident #1 (R1) was not being provided with food. Since R1 was under the Mensa Hospice Care, LPAs reviewed hospice notes that confirmed mechanical soft diet (puree-smooth foods) was being provided to R1 because R1 could not have normal food. LPAs interviewed three (3) staff that confirmed that R1 could not intake any hard food so R1 was being provided puree food such as Ensure. LPA Saucedo requested medical records from Northridge Hospital and the medical records confirmed Northridge that R1 was put on Intravenous therapy (IV) fluids and was provided G-tube feeding while in the hospital because R1 could not swallow any solid foods and failed the hospital swallow study conducted by the GI consult-Gastroenterologist which allowed R1 to be put on a G-tube. Therefore, based on the LPA's record reviews/medical records, hospice notes and staff interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the resident care director. Regarding the allegation: Staff not providing resident with water. It is being alleged that resident #1 (R1) was not being provided with water. On May 4th, 2025, R1 was taken to Northridge hospital. Northridge medical records indicated that R1 was severely dehydrated and was thus admitted to the Intensive Care Unit (ICU). In addition, the Emergency Medical Services (EMS) that transported R1 to the hospital stated to the hospital that R1 was dehydrated. Furthermore, Intravenous fluid hydration had to be provided to R1 for the dehydration. Three (3) staff stated that they did not know R1 was dehydrated. Therefore, based on the LPA's record reviews/medical records and staff interviews conducted the allegation is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, appeal rights were provided, and a copy of this report was given to the resident care director.the state’s words, verbatim · CDSS document, Jul 14, 2025 · control 31-AS-20250520081630

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(B) · Plan of correction due date: Jul 15, 2025

87705(b)(B) Care of Persons with Dementia (b)Licensees shall be responsible for the following: (B) Recognizing symptoms that may create or aggravate behavioral expression, as defined in Section 87101, Definitions, including, but not limited to, dehydration, urinary tract infections, and problems with swallowing; and This requirement is not met by: Based on the LPAs Interviews the licensee/administrator failed to ensure the behavioral expressions of resident #1 (R1) having severe dehydration while at the facility. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 14, 2025

Plan of correction: Licensee/Administrator will provide a statement of understanding regarding the title 22 regulation of 87705 Care of Persons with Dementia: POC Cleared 07/15/25

Allegation investigated: Staff did not ensure resident's catheter needs were being met.

On 06/30/25, at 9:28am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 06/30/25, LPA Saucedo asked for the census, staff, and resident rosters. At 9:35am, LPA Saucedo conducted a physical tour and interviewed staff. LIC 9099C-continued Substantiated Regarding the allegation: Staff did not ensure resident's catheter needs were being met. It is being alleged that resident #1 (R1)’s catheter was plugged and R1 was experiencing urinary retention. LPA interviewed staff #1 (S1) and staff #2 (S2) who confirmed that R1 has a difficult time managing their catheter needs. LPA asked for Home Health, Hospice and/or skilled professional documentation that would show R1 was being helped/being provided assistance with their catheter. S1 and S2 confirmed that R1 was not under any skilled professional help. Let it be noted, that R1 is diagnosed with dementia, traumatic brain injury and altered mental status and is not physically and mentally capable of caring for their catheter. Additionally, LPA received R1’s Physician’s Report and Resident Appraisal. In addition, Valley Presbyterian Hospital confirmed that R1 now needed treatment for renal failure and UTI-Urinary Tract Infection. Therefore, based on the LPA's record reviews and staff interviews conducted the allegation is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, appeal rights were provided, and a copy of this report was given to the resident care director.the state’s words, verbatim · CDSS document, Jun 30, 2025 · control 31-AS-20250626103110

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87623(a)(1) · Plan of correction due date: Jul 1, 2025

(a) The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances: (1) If the resident is physically and mentally capable of caring for all aspects of the condition except insertion and irrigation. This requirement is not met by: Based on the LPA's Interviews the licensee/administrator failed to ensure that resident #1 (R1) was under the care of a skilled professional to help with their catheter. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: Licensee/Administrator will seek skilled professional help for Resident #1 (R1). The POC was cleared at time of visit. R1 is now under American Home care Health Services. POC Cleared 06/30/25

Allegation investigated: Staff are not meeting resident's care needs.

On 05/21/25, at 10:20 AM, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather additional information, interview staff and residents and deliver findings for this complaint. On 05/12/25, LPA Saucedo conducted the initial visit. On 05/12/25, LPA Saucedo asked for the census, staff, and resident rosters. On 05/12/25, LPA Saucedo conducted a physical tour and interviewed staff. On 05/12/25, LPA Saucedo requested hospital records from Northridge Hospital. LIC 9099C-continued Substantiated Regarding the allegation: Staff are not meeting resident's care needs. It is being alleged that staff are not providing adequate care and supervision to resident #1(R1). During LPA's record review of R1's medical records, It was revealed that R1 was severely dehydrated and had high levels of sodium resulting in hypernatremia. R1's sodium level was 176. Let it be noted, a normal sodium intake is between 136-145. LPA interviewed two (2) staff that confirmed that R1 was on Hospice. During LPA's record review of Hospice notes it showed that Hospice was at the facility every 14 (fourteen) days. LPA also interviewed Hospice Representative that stated R1 was not eating at the time of their last visit with them. During LPA's file review of R1 from the facility, it was observed that R1's last resident appraisal was completed on 11/30/2023. Based on the record reviews and staff/hospice interviews, it is being determined that the facility did not meet the resident's care needs therefore,the allegation(s) is SUBSTANTIATED at this time. A Civil Penalty of $1000.00 is being issued today, due to this being a repeat violation. Refer to LIC 421M. Exit interview conducted, appeal rights discussed, and a copy of the report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, May 21, 2025 · control 31-AS-20250509144659

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: May 22, 2025

§1569.269 Enumerated rights; severability(a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met by: Based on the LPA's Interviews the licensee/administrator failed to ensure the care, supervision and services of resident #1 (R1) while in the facility. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: Licensee/Administrator will provide dementia training to all staff on the care, supervision and services to all residents. POC Cleared 05/22/25

Allegation investigated: Staff are not meeting residents' care needs.

Licensing program Analyst (LPA) Leizl DeLaCerra conducted announced subsequent visit to the facility on 05/15/25 to deliver the findings. LPA met with the Resident Care Director and explained the purpose of the visit Allegation: Staff are not meeting residents' care needs. It was alleged that on 04/22/2025 a caregiver was mentioned that they could not assist a resident from Pasadena Villa, and that the resident needed to wait for Pasadena Villa staff to assist the resident. Also alleged on 01/13/2025, residents from Pasadena Villa, due to the short notice evacuation, some residents were put in the locked memory care unit rooms at Cedars Assisted Living and these residents were not allowed to have the code and were told to wait for Pasadena Villa staff to assist them. Also, on 1/13/2025, residents did not receive assistance and are made to wait longer to receive care for a Pasadena Villa staff. To investigate this allegation, LPA dela Cerra conducted an initial visit on 5/06/2025. On this initial visit, 05/06/2025 between 10:30am to 11:55pm LPA conducted a physical plant tour, interviewed six (06) staff members and between 12:00pm to 1:30pm interviewed ten (10) residents. Between 2:30pm to 3:10pm conducted and additional interview by phone and record reviews. Continue to LIC9099C Unsubstantiated LPA’s observation during the physical plant tour of the facility at 10:30am revealed that the five (5) relocated residents from Pasadena Villa who were placed temporarily in the memory care unit are no longer residing in these rooms. LPA de la Cerra conducted interviews with four (04) staff caregivers and interviews revealed that all facility staff caregivers were meeting resident’s needs, relocated residents and facility residents. Interviews with S1 and S6 revealed that Pasadena Villa residents were temporarily placed at Cedars Assisted Living at the beginning of 1/08/25, a policy was enforced during an emergency preparedness meeting on 1/09/25 that all caregivers from both facilities must assist all the residents, relocated residents and facility residents. Interviews with all staff members #S1 to S6 also revealed that certain incidents where a staff member was assisting a temporarily relocated resident of which they are not familiar with, the staff member do render aide to the temporary resident in need but caregiver would also call for assistance with a caregiver who was more knowledgeable of that particular resident so the appropriate care can be provided. Additionally, interview with S1 revealed that the five (5) relocated residents who were temporarily placed in the memory care unit, that the access code was not provided to these temporary residents due to safety concerns for the current residents in memory care unit, however staff members from both facilities were always available to assist these residents with access to their rooms. LPA de la Cerra’s interviews with eleven (11) facility residents revealed that staff caregivers are consistent in meeting residents’ needs. Additionally, S1 and S6 interviews confirmed that the Pasadena Villa residents who were temporarily staying at Cedars Assisted Living have been relocated back to Pasadena Villa on April 29, 2025. LPA’s review of a document that showed names of staff members who attended a meeting on 1/09/25 confirmed that the facility immediately held an emergency preparedness meeting to address to all staff members that all staff members from both facilities must assist and care for all the residents, the relocated residents and the current facility residents. Based on observation, inspection and record review, the facility staff responded to resident’s emergency call within reasonable time frame. Therefore, this allegation is deemed Unsubstantiated. Exit interview conducted, and copy of the report was signed and given to the Director.the state’s words, verbatim · CDSS document, May 15, 2025 · control 31-AS-20250429145855

Allegation investigated: Staff did not provide resident with copy of admission agreement Staff did not provide resident with itemized monthly statement Staff are not providing adequate food service to resident Staff are not providing laundry service to resident

On 05/05/25, at 09:40am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather additional information, interview staff and residents and deliver findings for this complaint. On 05/01/25, LPA Melissa Spaeth conducted the initial visit. On 05/05/25, LPA Saucedo asked for the census, staff, and resident rosters. On 05/05/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not provide resident with copy of admission agreement. It is being alleged that resident #1 (R1) did not receive a copy of their admission agreement. During LPA's record review, R1 signed their own paperwork on February 04, 2025. LPA received a copy of R1's admission agreement along with the itemized statement. LPA interviewed two (2) staff that confirmed R1 along with all residents get a copy of everything they sign when they arrive at the facility. Furthermore, the business manager confirmed they have given R1 copies of their admission agreement because they asked for it recently when R1 was told they never paid February's rent. During LPA's interview with R1, R1 did not remember if they got a copy of their admission agreement. LPA asked the business office to make another copy of R1's admission agreement and it was provided to R1 in front of LPA. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not provide resident with itemized monthly statement. It is being alleged that resident #1 (R1) did not receive an itemized monthly statement of services. The itemized monthly statement of services is provided under the admission agreement that was given to R1. Furthermore, R1 is under level 1. R1 is ambulatory and does not require any type of additional services. R1's monthly payment for rent is $700.00 for their portion to pay and the company Noble Quest pays their other portion but Noble Quest has not been approved yet. Let it be noted, R1 never paid for February's rent and now has an agreement with the business office to pay $104.00 per month for the next five (5) months. R1 paid $105.00 on April 15, 2025 for past rent for February. LPA received a copy of the Promissory Note that R1 signed on 04/30/25 and a copy of the receipt that was given to R1 regarding the $105.00 payment towards February's rent. Furthermore, the business office manager stated R1 paid the $105.00 in cash. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not providing adequate food service to resident. It is being alleged that resident #1 (R1) does not get meals and has to buy their own food. During LPA's interview with R1, R1 stated, they did not like the food at the facility and would continue to buy their own food. R1 also stated I have a microwave in my room. LPA stated to R1 that three (3) meals are served everyday and there is alternative menus if they do not like the food. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff are not providing laundry service to resident. It is being alleged that resident #1 (R1) is not receiving laundry services. During LPA's physical tour, the washers and dryers were working properly and were in use. During LPA's physical tour, R1 was returning from doing their own laundry and LPA helped R1 carry their laundry. During LPA's interview with R1, R1 stated, they would not be doing their laundry in the dirty washing machines and would instead like to do it themselves outside of the facility. LPA received the laundry schedule that states R1's laundry is done every Wednesday between 6:30am and 2:30 and informed R1 of this. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Exit interview conducted, and copy of the report was signed and given to the Resident Care Director.the state’s words, verbatim · CDSS document, May 5, 2025 · control 31-AS-20250429094041

Allegation investigated: Staff did not provide a safe environment for residents in care

On 05/05/25, at 09:40am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 05/05/25, LPA Saucedo asked for the census, staff, and resident rosters. On 05/05/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not provide a safe environment for residents in care. It is being alleged that resident #1 (R1) was molested at the above facility. LPA interviewed R1 via telephone at the Skilled Nursing Facility (SNF). Let it be noted, R1 has been at the SNF since January of 2025 and has not returned to the above facility. LPA asked R1 when did this incident happen and R1 did not know. LPA asked R1 who were the caregivers that entered their room and R1 did know. LPA asked were the caregivers providing help to you at the time of them entering your room and R1 stated they should not be in my room. LPA interviewed R1's roommate (resident #2-R2) and they stated that caregivers and housekeepers go in their room all the time to clean and provide services such as help with transfers from bed to wheelchair, showers, help changing their clothes. R2 also stated they have never had any issues with any of the caregivers and/or housekeepers that enter their room. LPA interviewed four (4) staff that confirmed that they would go in R1's room to provide services such cleaning, bathing, grooming, repositioning, and that both residents in that room were non-ambulatory and need help. Let it be noted, R1 was under Level 2 (two) care and needed assistance with different ADL-Activities of Daily Living. LPA interviewed nine (9) additional residents that confirmed they have not had any issues with any staff at the above facility. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Exit interview conducted, and copy of the report was signed and given to the Resident Care Director.the state’s words, verbatim · CDSS document, May 5, 2025 · control 31-AS-20250501102658

Allegation investigated: Staff did not provide medication assistance to resident in care resulting in hospitalization Staff did not provide foods of good quality to residents in care Staff left residents unattended

On 04/29/25, at 11:07am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Jolene Halog, Medication Technician. LPA explained the purpose of this visit was to gather additional information, interview staff and residents and deliver findings for this complaint. On 01/03/25, LPA Ngo-Castaneda conducted an initial complaint, asked for the census, staff, and resident rosters and conducted a physical tour. On 04/29/25, LPA Saucedo asked for the census, staff, and resident rosters. On 04/29/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not provide medication assistance to resident in care resulting in hospitalization. It is being alleged that resident #1 (R1) did not receive their blood pressure or diabetes medication on 01/01/25. During LPA’s record review, LPA obtained the medication administration record of R1 where it showed R1 took several medications the morning of 01/01/25 including their blood pressure and diabetes medication. LPA also interviewed staff #1 (S1) that provided the medication to R1, and the staff confirmed R1 took their medication. LPA interviewed ten (10) other residents and asked if their medication is provided to them every day and at their designated time and ten (10) residents confirmed that they do not have any problems with their medication being distributed to them. Based on the LPA's observations, record reviews, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not provide foods of good quality to residents in care. It is being alleged that the food at the above facility is horrible. LPA obtained the meal menus that are provided to the residents. In addition, there is an alternative menu provided to the residents to chose from other meals if they do not like what is being served and there is two (2) snack vending machines. LPA interviewed ten (10) residents that confirmed the food is either decent, and/or they do not eat meals at the facility because they have their own food in their room or some residents chose from the alternative menu. Based on the LPA's observations and record reviews, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff left residents unattended. It is being alleged that a resident was left unattended after complaining of not feeling well. LPA interviewed four (4) staff. (S1) stated they provided R1 with their medication and vitals that morning and observed R1 was fine and alert towards the end of their shift. (S2) stated they were called by a resident around 3:10pm regarding R1 had collapsed on the floor upstairs. S2 called (S3) and (S4) to let them know that R1 collapsed and was on the 2nd floor. S4 went to the 2nd floor, called 911 and performed CPR until 911 arrived. When 911 arrived, they continued giving R1 CPR until they were pronounced deceased at 4:02pm. LPA interviewed two (2) residents that confirmed they saw several staff helping R1. One (1) resident confirmed they saw two (2) staff giving R1 CPR-Cardiopulmonary resuscitation. LPA also confirmed with the Los Angeles Morgue to confirm that R1 died of natural causes. Based on the LPA's observations and record reviews, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to one of the Jolene Halog, Medication Technician.the state’s words, verbatim · CDSS document, Apr 29, 2025 · control 31-AS-20250102105433

Type of visit: Case Management - Other

On 4/29/25 at 09:50 AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced visit to the facility to conduct a Case Management visit. LPA was greeted by Jolene Halog, Medication Technician. LPA stated the reason for their visit. The purpose for the visit was to follow up on a self-reported SOC341 report on 4-25-25 which alleged that Resident #1 (R1) was sexually molested by caregivers. LPA spoke to R1 via telephone at the Skilled Nursing Facility (SNF). LPA asked R1 when this incident happened and R1 did not know. LPA asked R1 who were the caregivers and R1 did know. LPA asked were the caregivers providing help to you at the time and R1 stated, "no one should be in my room." Let it be noted, R1 has been at the SNF since January of 2025 and has not returned to the above facility. LPA interviewed two (2) staff that confirmed that they would go in R1's room to provide services such bathing, grooming, repositioning, and was non-ambulatory. R1 was under Level 2 (two) care and did need assistance with different ADL-Activities of Daily Living. Based on LPA's record review staff and resident interviews, a citation will not be issued. Exit interview conducted, and copy of the report was signed and delivered to the Jolene Halog, Medication Technician.the state’s words, verbatim · CDSS document, Apr 29, 2025

Allegation investigated: Staff did not prevent a resident from hitting another resident while in care Staff did not prevent a resident from threatening another resident while in care

On 04/16/25, at 11:20am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Administrator, Alexander Solorio. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 04/16/25, LPA Saucedo asked for the census, staff, and resident rosters. On 04/16/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not prevent a resident from hitting another resident while in care. It is being alleged that resident #1 (R1) was hit several times by resident #2 (R2) and staff did not prevent it. During LPA's interview with R1, R1 said the fight between them and R2 happened in the dining hall early in the morning before breakfast was being served. R1 admits to having an argument with R2 but did not expect R2 to hit them. R1 confirmed that two (2) staff responded to the incident and came to their aide and in addition, resident #3 (R3) told R2 to stop. LPA interviewed R3 and R3 stated, "they were sitting outside in the patio when they saw the commotion in the dining hall and told R2 to stop." R3 also stated that two (2) staff came to see what was happening. LPA attempted to interview another resident #4 (R4) but they did not see the incident. LPA interviewed two (2) staff that were present and said R2 did stop hitting R1 when they intervened. LPA received the Unusual Incident/Injury Report and SOC 341 that was sent to Community Care Licensing and the Local Police Department. Furthermore, LPA received an additional Unusual Incident/Injury Report for April 09, 2025, regarding R2 being sent to Los Angeles Department Medical Center (LADMC) for psychiatric evaluation therefore, R2 was not able to be interviewed and remains at LADMC. Let it be noted, R1, R2, R3 and R4 are residents from Pasadena Villa Senior Living (198603286) that are residing at Cedars Assisted Living because of the Fire Evacuations. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not prevent a resident from threatening another resident while in care. It is being alleged that resident #1 (R1) was threatened by resident #2 (R2) and staff did not prevent it. During LPA's interview with R1, R1 admitted that there was no staff or residents around when R2 threatened them. Let it be noted, R2 could not be interviewed due to them being sent to Los Angeles Department Medical Center (LADMC) for psychiatric evaluation. During LPA's interview with R3, R3 stated, "I saw R2 hitting R1 but never heard a threat." LPA attempted to interview another resident #4 (R4) but they did not see the incident or hear any threats from any residents. LPA interviewed two (2) staff that intervened when R1 was being hit but they confirmed they did not hear any threats being made by R2. Let it be noted, R1, R2, R3 and R4 are residents from Pasadena Villa Senior Living (198603286) that are residing at Cedars Assisted Living because of the Fire Evacuations. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Exit interview was conducted, no citation(s) were issued for the above allegation(s) and a copy of this report was given to the Administrator, Alexander Solorio.the state’s words, verbatim · CDSS document, Apr 16, 2025 · control 31-AS-20250410114746

Allegation investigated: Staff did not prevent residents in care from engaging in inappropriate interactions

On 04/16/25, at 8:40am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Administrator, Alexander Solorio. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 04/16/25, LPA Saucedo asked for the census, staff, and resident rosters. On 04/16/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not prevent residents in care from engaging in inappropriate interactions. It is being alleged that Resident #2 (R2) has been touching Resident #1 (R1) and telling them inappropriate things. LPA interviewed R1 and R1 denied that R2 touched them inappropriately and/or told them inappropriate things. R1 says that they talked to someone about R2, and it was taken out of context. R1 further explained that R2 is their friend and R2 has only touched their shoulder before and not anything else. LPA interviewed another resident # 3 (R3) whom is R1's roommate and says that R2 does come by sometimes and talk to them but has never touched them. When LPA spoke to R2, R2 stated R1 is their friend and they go to dialysis together in the same van but has never inappropriately touched them or said anything inappropriate to them. LPA interviewed resident #4 (R4) whom is from the Pasadena Villa Senior Living and they also stated they know R2 and R2 has never been inappropriate to them. LPA interviewed two (2) staff from Pasadena Villa Senior Living (198603286) and one (1) staff from Cedars Assisted Living. Let it be noted, R1, R2, R3 and R4 are Pasadena Residents that are currently residing at Cedars Assisted Living due to the Fire Evacuations. Both staff including the staff from Cedars Assisted Living has never received any information regarding R2 touching and/or saying anything inappropriate to anyone. Both staff from Pasadena Villa Senior Living did confirm that R1 and R2 are friends and have been seen talking to each other and dining together. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Exit interview was conducted, no citation(s) were issued for the above allegation(s) and a copy of this report was given to the Administrator, Alexander Solorio.the state’s words, verbatim · CDSS document, Apr 16, 2025 · control 31-AS-20250410161705

Allegation investigated: Staff does not have planned activities for the residents Staff does not meet the needs of the residents Staff are unable to properly lift a resident while in care

On 04/08/25, at 11:55am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Medication Technician, Jolene Halog. LPA explained the purpose of this visit was to interview staff, residents and deliver findings for this complaint. On 04/08/25, LPA Saucedo asked for the census, staff, and resident rosters. On 04/08/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff does not have planned activities for the residents. It is being alleged that there are no planned activities. During LPA's interview with resident #1 (R1), R1 stated the planned activities do not come to their room. LPA asked R1 if they were bedridden and R1 stated, "no." LPA advised R1 that the activities room is upstairs and there are different types of activities such as bingo, movies to watch, chair yoga, exercise sessions, coloring sessions conducted with different dates and times. During LPA's interview with the Activities Director, the Activities Director provided the LPA with three (3) calendars displaying the different times and dates and displaying the type of activity. The calendar was for the two (2) memory care areas and the Assisted Living area. During LPA's tour, LPA observed bingo, movies, a large television, coloring items, games and books in the Activities Room. Furthermore, LPA observed one (1) of the memory care areas having an activity session in the patio area. LPA interviewed nine (9) residents that confirmed there is different types of activities everyday. Therefore, based on the LPA's record review and observations, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff does not meet the needs of the residents. It is being alleged that Resident #1 (R1)'s needs are not being met. During LPA's interview with R1, R1 denied that their needs were not being met. R1 confirmed that everything they want takes some time to get but the staff do help them. Be advised, R1 is under Orange Home Health and receives medical and physical therapy. R1 also gets help from two (2) staff for different needs such as transferring from bed to wheelchair, showers, toiletry, dressing, grooming. LPA interviewed nine (9) residents that confirmed their needs are being met. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are unable to properly lift a resident while in care. It is being alleged that Resident #`1 (R1) cannot be lifted properly by staff. During LPA's interview with R1, R1 confirmed that staff do help them transfer from the bed to their electric wheelchair. LPA asked R1 how many staff do you need to help you and R1 stated, "one (1) or two (2) depends what they need help with." LPA interviewed two (2) staff that confirmed R1 always has two (2) staff helping them unless its a diaper change which one (1) staff can do that. Let it be noted, R1 is also under Orange Home Health. LPA asked R1 if they go outside and R1 stated, "yes, in my electric wheelchair." Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Exit interview was conducted, no citation(s) were issued for the above allegation(s) and a copy of this report was given to the Medication Technician, Jolene Halog.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 31-AS-20250407223612

Allegation investigated: Resident sustained multiple pressure injuries due to lack of care from staff

On 04/08/25, at 11:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Medication Technician, Jolene Halog. LPA explained the purpose of this visit was to deliver findings for this complaint. On 01/09/25, the complaint was referred to The Community Care Licensing Investigations Branch (IB) and accepted as a full investigation. It was assigned to Investigator, Edward Hector. On 01/09/25, LPA Angelica Segovia initiated the twenty-four (24) hour complaint investigation. LPA asked for the census, staff, resident roster and pertinent documents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Resident sustained multiple pressure injuries due to lack of care from staff. It is being alleged that resident #1 (R1) sustained multiple pressure injuries (including an unstageable ulcer on their left hip) while in care of the facility. On 01/23/25, at 07:29am, IB Investigator subpoenaed Kaiser Permanente’s, Release of Information (ROI) Unit, for the medical records of R1 but had to resend the subpoena on 01/24/25. The medical records were not received until 02/25/25. According to the medical records, R1 had a “history of unstageable pressure ulcer to right ankle and stage 3 pressure ulcer to left sacrum. On 01/23/25, at 10:51am, IB Investigator subpoenaed the Comcare Home Health main office for medical records of R1. On 02/14/25, multiple emails containing the home health records of R1 were received. According to the records, from November 7, 2024, to January 5, 2025, both home health nurse and facility caregivers confirmed that R1 would regularly move around, after being repositioned, and return to a position that was comfortable for them. The home health nurse advised that facility staff provided adequate supervision as evidence that they would come daily at “random” times and R1 always had a clean diaper, bed pad, and bed linens. Facility staff attributed to R1’s lack of healing to poor circulation of R1 being bed bound. There is not enough evidence to support the allegation that a lack of care caused R1 to develop pressure injuries. Therefore, based on the observation, record review, interviews conducted by the IB Investigator, the allegation is UNSUBSTANTIATED at this time. Exit interview was conducted, no citation(s) were issued for the above allegation(s) and a copy of this report was given to the Medication Technician, Jolene Halog.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 31-AS-20250109101010

Allegation investigated: Staff did not prevent the resident from being physically assaulted by another resident in care

On 04/08/25, at 9:05am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Medication Technician, Jolene Halog. LPA explained the purpose of this visit was to interview staff, residents and deliver findings for this complaint. On 04/08/25, LPA Saucedo asked for the census, staff, and resident rosters. On 04/08/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not prevent the resident from being physically assaulted by another resident in care. It is being alleged that resident #1 (R1) was assaulted by resident # 2 (R2) and staff did not prevent the assault. During LPA's interview with R1, R1 admitted that R2 and them were friends for a number of years and had met in college and took an English class together before meeting again at the above facility but eventually lost contact. Once they met again at the above facility, they became close friends again and even sat at the same dining table to eat. Let it be noted, both R1 and R2 lived in the assisted living area of the facility. R1 stated that they lost their friendship with R2 over a discussion about a female. R1 continued to say that R2 became very rude to them anytime they would see each other, R1 would just ignore them. R1 remembers the night of the incident, it was around 9:00pm or 10:00pm when R2 tried to come in their room but R1 was able to lock the door. R2 continuously kicked the door and the door eventually opened and R2 came into their room and started to hit them with a cart that R1 had in their room. After R2 hit them with the cart, R2 then picked up a vase and began to hit R1. R1 started yelling and that's when R1 remembers another resident came to help them. LPA asked R1 if they pressed their call button for help but R1 stated, "no, they just started yelling." Resident # 3 (R3) says they saw R2 pacing back and forth down the hallway before the incident happened but didn't mention it to anyone until R3 heard the yelling and R3 said by the time they got to R1's room, R2 started running away. R3 said staff was contacted and staff immediately came and called 911. R1 also confirmed that staff called 911 and they were taken to Northridge Hospital. LPA interviewed staff #1 (S1) and staff confirmed that when they were doing their night rounds they immediately responded and called 911 then R1 was transferred to the local hospital. The incident report was written, and a SOC 341 was also submitted and provided to the Ombudsman and a police report was obtained. LPA obtained the incident report along with the SOC 341. Let it be noted, R2 never returned back to the facility after this incident happened. LPA's interview with R1, R3 S1 and staff #2 (S2) confirmed that R2 never returned to the facility. Therefore, based on the LPA's record review, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Exit interview was conducted, no citation(s) were issued for the above allegation(s) and a copy of this report was given to the Medication Technician, Jolene Halog.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 31-AS-20250404135315

Allegation investigated: Staff does not ensure facility floor is kept in good repair for residents

On 04/02/25, at 8:40am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Medication Technian, Jolene Halog. LPA explained the purpose of this visit was to deliver findings for this complaint. On 04/02/25, LPA Saucedo asked for the census, staff, and resident rosters. On 04/02/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Substantiated Regarding the allegation: Staff does not ensure facility floor is kept in good repair for residents. It is being alleged that resident #1's (R1's) is in disrepair. During LPA's physical tour, LPA did observe R1's floor in disrepair with the wood laminate flooring lifting. LPA's physical tour consisted of fourteen (14) random rooms being toured and did not observe any other floors being in disrepair and/or lifting. LPA did interview R1 and R1 confirmed that their room floor was observed to be in disrepair several weeks ago and was told they would move rooms but never did. R1 will be temporarily moved to another room while repairs are being conducted. LPA interviewed two (2) staff that confirmed that R1's room floor is in disrepair and will be temporarily moved from their room while repairs are being conducted. Therefore, based on the LPA's observations, resident and staff interviews, the above allegation(s) above is SUBSTANTIATED at this time. Exit interview was conducted, a citation(s) was issued for the above allegation(s), the appeals rights and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Apr 2, 2025 · control 31-AS-20250401144855

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Apr 30, 2025

87303 (a)(1)-Maintenance:(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall...for the safety and well-being of residents, employees and visitors (1)Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not comply with the section cited above in one area/room that needs to be safe and repaired which poses a Potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: The licensee/administrator shall send a picture/repair paperwork to the LPA of repairs conducted. POC due date: 04/30/25.

Allegation investigated: Resident sustained a fracture while in care

On 03/26/25, at 9:20am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Administrator, Kandace Vergara. LPA explained the purpose of this visit was to deliver findings for this complaint. On 08/13/24, the complaint was referred to Investigations Branch (IB) and accepted as a full investigation. It was assigned to Veronica Padilla. On 08/14/24, LPA Gina Saucedo initiated the twenty-four (24) complaint investigation. LPA asked for the census, staff, resident roster and conducted a physical tour. LIC 9099C-continued Substantiated Regarding the allegation: Resident sustained a fracture while in care. It is being alleged that resident #1 (R1) sustained a cervical neck fracture. On 08/20/24, IB conducted a facility visit and received the following documents: August Staff Schedule, Staff Roster with contact information, Facility First Second Floor Facility Map, Daily Census, Unusual Incident/Injury Report, R1's File containing the following: Preplacement Appraisal Information, Functional Capability Assessment, Resident Appraisal, Appraisal /Needs and Services Plan, Personal Rights of Residents in Publicly Operated, House Rules, Guest Policy, Medication Disclosure and Policy, Private Caregiver, Home Health Agency, and Hospice Disclosure and Policy, Statement of Informed Choice, Unsupervised Absence Disclosure, Ambulation and Mobility, Dementia, Residence and Care Agreement, and Admission Agreement record review of hospital records from Kaiser Permanente. Furthermore, IB conducted interviews. On 10/08/24, IB conducted another facility visit and interviewed additional staff and was informed that R1 might have had an unwitnessed fall during the night that caused the cervical fracture. The investigation revealed the facility’s Neglect/Lack of Supervision contributed to the development of R1’s cervical fracture. Based on the observation of the IB Investigator, interviews conducted, and record review the allegation is SUBSTANTIATED at this time. An immediate Civil Penalty of $500.00 is being issued today, due to the staff’s negligence. Refer to LIC 421M. At this time, an Enhanced Civil Penalty (ECP) determination is pending and may be assessed at a later date. Exit interview conducted, appeal rights discussed, and a copy of the report was given to the administrator.the state’s words, verbatim · CDSS document, Mar 26, 2025 · control 31-AS-20240813145428

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Mar 27, 2025

§1569.269 Enumerated rights; severability(a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met by: Based on the Investigator's Interviews the licensee/administrator failed to ensure the care, supervision and services of resident #1 (R1) while in the facility. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Licensee/Administrator will provide training to all staff on mandatory reporting and the care, supervision and services to all residents. POC Cleared 03/27/25

Allegation investigated: Staff are not providing adequate laundry services for residents Staff do not keep the resident rooms free from odor

On 03/19/25, at 9:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Administrator, Kandace Vergara. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 03/19/25, LPA Saucedo asked for the census, staff, and resident rosters. On 03/19/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff are not providing adequate laundry services for residents. It is being alleged that resident #1's (R1's) clothing has not been washed since they arrived at the above facility. Let it be noted, that R1 was relocated from the Pasadena Fires (Pasadena Villa Senior Living Facility 198603286) and is residing at Cedars Assisted Living temporarily since 01/08/25. LPA conducted interviews with four (4) staff who informed LPA that the facility does provide laundry services on weekly basis to all residents in care. Additionally, LPA was informed that the facility has a set schedule for each of the facility rooms. LPA also reviewed the Admission Agreement from Cedars Assisted Living that confirmed laundry is part of basic services and are provided to all residents. During LPA’s physical tour, the laundry area that has washers and dryers were working and multiple baskets of resident clothes were also observed. LPA interviewed ten (10) residents that confirmed their laundry is washed on a weekly basis. Therefore, based on the LPA's observations, record review, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not keep the resident rooms free from odor. It is being alleged that resident #1 (R1)’s toilet is clogged and there is an odor in the room. Let it be noted, that R1 was relocated from the Pasadena Fires (Pasadena Villa Senior Living Facility 198603286) and is residing at Cedars Assisted Living temporarily since 01/08/25. During LPA's physical tour, LPA did not observe R1's toilet to be clogged and there was no odor in the room. LPA interviewed four (4) staff to confirm that housekeeping services are being provided and maintenance services if needed. LPA interviewed ten (10) residents that confirmed their toilet is working properly. Therefore, based on the LPA's observations, record review staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 31-AS-20250312120123

Allegation investigated: Resident sustained multiple unexplained injuries while in care. Residents are required to perform housekeeping duties.

On 03/11/25, at 9:20am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 03/11/25, LPA Saucedo asked for the census, staff, and resident rosters. On 03/11/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Resident sustained multiple unexplained injuries while in care. It is being alleged that resident #1 (R1) has received multiple, unexplained injuries. Let it be noted, that R1 was relocated from the Pasadena Fires (Pasadena Villa Senior Living Facility 198603286) and is residing at Cedars Assisted Living temporarily. LPA interviewed R1 and R1 said they fell by the patio area in between the dining hall and the inside bathroom but does not remember who helped them get up. LPA interviewed staff #1 (S1) and S1 stated that R1 was found by the bathroom in the hallway by the lobby. S1 also stated, they called 911 and R1 was taken to the hospital. Let it be noted, this is the first incident that involved a staff that works for Cedars Assisted Living and R1. Therefore, based on the LPA's record review, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Residents are required to perform housekeeping duties. It is being alleged that resident #1 (R1)’s room is not being cleaned. Let it be noted, that R1 was relocated from the Pasadena Fires (Pasadena Villa Senior Living Facility 198603286) and is residing at Cedars Assisted Living temporarily. LPA interviewed R1 that confirmed their room is not cleaned every day. LPA interviewed resident #2 (R2), R1's roommate to confirm if their room is being cleaned and R2 stated, "yes, it is cleaned weekly." LPA interviewed eight (8) more residents that confirmed their room is cleaned weekly not every day. LPA interviewed staff #2 (S2) and staff #3 (S3) that stated the rooms are assigned to be cleaned on a weekly basis not every day. In addition, they can request another cleaning that same week if there is an accident or mess. Let it be noted, that R1's room is being cleaned by S2 who is one (1) of the housekeepers that works with Pasadena Villa Senior Living. R1's and R2's room is scheduled to be cleaned every Sunday. During LPA's physical tour, LPA observed R1 and R2's room to be clean. Therefore, based on the LPA's record review, observations staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 31-AS-20250305101719

Allegation investigated: Staff do not answer residents calls for assistance timely

On 03/05/25, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 03/05/25, LPA Saucedo asked for the census, staff, and resident rosters. On 03/05/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff do not answer residents calls for assistance timely. It is being alleged that resident #1 (R1)'s call light is not being answered in a timely manner. During LPA's physical tour, LPA pressed random call light buttons to check if they were working and if staff would respond in a timely manner. The call light buttons that were pressed were working and staff responded within several minutes of pressing them. LPA interviewed R1 to check if they had any issues with their call light button and R1 stated, "no." LPA asked R1 when was the last time they pressed it for help and R1 stated, "this morning." LPA asked R1 if they can press their call light button to see if it was working and R1 stated, "of course." Two (2) staff responded to R1's room within minutes of pressing the call light button. LPA interviewed Staff #1 (S1) and Staff #2 (S2) to ask how long does it take to respond to a call light button and S1 and S2 confirmed that if they are nearby it is an immediate response if they are across the hallways a few minutes. LPA interviewed a total of eleven (11) non-ambulatory residents that confirmed their call light button works and staff respond within minutes of pressing it. Based on the LPA's observations, staff and resident interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Mar 5, 2025 · control 31-AS-20250228163035

Type of visit: Case Management - Incident

On 2/25/25 at 09:35 AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced visit to the facility to conduct a Case Management visit. LPA was greeted by Resident Care Director, Mary Jane Reyes and Administrator Alexander Solorio (Pasadena Administrator). LPA stated the reason for their visit. The purpose for the visit was to follow up on a self-reported incident (02-20-25) which alleged that Resident #1 (R1) was hit by a staff member on 02/19/25. LPA requested census, staff, and resident rosters. LPA reviewed R1's file obtained from Pasadena Villa Senior Living (198603286). LPA conducted a physical tour of the facility and interviewed staff and residents. LPA interviewed R1 regarding the incident and R1 revealed that their blanket was missing, they went retrieved it and went back into their room. When they went back into their room, staff #1 (S1) followed them, pulled the blanket from R1, pulled their hair and hit R1 in the chest area. S1 and S2 were interviewed by management staff and S1 and S2 had inconsistent stories. S1 is currently on administrative leave and S2 was removed from the Memory Care unit where R1 is currently residing. LPA interviewed S3 and S4 and both staff reported that when they arrived on shift that morning, R1 had reported the incident to them. S4 reported the incident to their management staff. The management staff interviewed R1 on the day of the incident, reported the incident via SOC341 to Community Care Licensing Department, Ombudsman, APS Police Department and R1's representative. The management staff also interviewed another staff-S5 who reported seeing S1 hit another resident recently which was reported on another SOC341. Resident #2 (R2) was interviewed but they did not confirm or deny any incident occurring. Let it be noted, R2 is in the Memory Care unit. Furthermore, management staff provided a mandated reporter training on 02/21/25 for all staff to report all incidents. LPA obtained a copy of the training. Based on LPA's record review staff and resident interviews, a citation will be issued on a 809-D Exit interview conducted, a citation(s) was issued, appeal rights and copy of the report was signed and delivered to the Resident Care Director.the state’s words, verbatim · CDSS document, Feb 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Mar 11, 2025

87468.1(a)(3) 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:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature..This requirement is not met as evidenced by: Based on the LPA's Interviews the licensee/administrator did not ensure that staff provide an environment free of punishment/intimidation/abuse of residents in care which poses an potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: The licensee/admnistrator shall immediately place the staff on administrative leave or/and discharge them from their work duties. POC Cleared 02/25/25

Allegation investigated: Staff hit resident in care Staff did not attend to resident's toileting needs in a timely manner Staff did not safeguard resident's personal belongings

On 02/05/25, at 9:35am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 02/05/25, LPA Saucedo asked for the census, staff, and resident rosters. On 02/05/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff hit resident in care. It is being alleged that one (1) of the nurses flicked a finger on resident #1 (R1)'s head. During the review of R1' file, LPA discovered that this incident occurred June 04, 2023. It was reported to the Ombudsman, West Valley Police and Community Care Licensing Department (CCLD) on June 05, 2023, through a SOC 341 report. The West Valley Police was called the day of the incident June 04, 2023. An Unusual Incident/Injury Report was also provided to CCLD. LPA interviewed R1, and R1 was able to tell LPA what happened and mentioned it was a long time ago. LPA interviewed nine (9) other residents that confirmed Staff #1 (S1) and Staff #2 (S2) have never hit them. LPA interviewed S1 and S1 remembers the day of the incident because they were accused of hitting a resident which could not have happened because they worked in a different area of the facility that day in memory care and not in assisted living where R1 resides. When LPA interviewed staff #3 (S3), S3 confirmed that the incident occurred a long time ago and the incident was not proven to be true, and all documentation was reported. Based on the LPA's observations and record reviews, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not attend to resident's toileting needs in a timely manner. It is being alleged that resident #1 (R1) is sitting in their own urine and feces all day. During LPA's interview with R1, R1 stated the caregivers only change them about three (3) times a day. During LPA's record review, LPA discovered that R1 is under the care of Orange Home Health for both medical and physical therapy. LPA obtained the Home Health schedule of R1. During LPA's physical tour, LPA observed R1 receiving services from Orange Home Health. During LPA's interview with two (2) staff, it was confirmed that R1 because of their incontinence, R1 gets changed several times a day and R1 can also request more incontinence changing if they need it. LPA interviewed nine (9) residents that confirmed their toileting needs are met in a timely manner. Based on the LPA's observations and record reviews, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff did not safeguard resident's personal belongings. It is being alleged that resident #1 (R1)'s clothes have been stolen. During LPA's record review of R1, LPA obtained the Client/Resident Personal Property and Valuables sheet from their file with their signature. During LPA's physical tour, LPA cross-referenced the items on the sheet with what was in R1's room. LPA took pictures of different items in R1's room. LPA also took pictures of Amazon packages that have been delivered to R1. LPA interviewed R1, and R1 stated they order a lot of items from Amazon and have a lot of clothing but don't know where their clothing is located in the room. LPA interviewed nine (9) other residents that confirmed they do not have any issue with the safeguarding of their personal belongings. LPA interviewed one (1) staff that confirmed that all Client/Resident Personal Property and Valuables sheet are obtained during resident intake and throughout their stay. Based on the LPA's observations and record reviews, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Resident Care Director..the state’s words, verbatim · CDSS document, Feb 5, 2025 · control 31-AS-20250204152339

Allegation investigated: Staff did not prevent residents from engaging in an altercation resulting in a fracture to resident in care

On 01/29/25, at 9:35am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather additional information, interview additional staff and residents and deliver findings for this complaint. On 01/02/25, this complaint was referred to the Investigations Branch (IB) but was returned to the Regional Office (RO) on 01/06/25 for investigation, due to it being the first incident of an altercation between the residents and there was no history of aggression based on both resident’s care plan. The staff also broke up the altercation and sought medical attention. On 01/03/25, LPA Ngo-Castaneda conducted an initial complaint and asked for the census, staff, and resident rosters. On 01/29/25, LPA Saucedo interviewed staff, residents and conducted a physical tour. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not prevent residents from engaging in an altercation resulting in a fracture to resident in care. It is being alleged that resident #1 (R1) got in an altercation with resident #2 (R2) and was punched in their face which resulted in a non-displaced fracture at the level of the base of the left mandibular incisor. An Unusual Incident/Injury Report was sent to Community Care Licensing Department (CCLD) on 12/31/24 reporting a physical altercation between R1 and R2 that took place on 12/30/24. An SOC 341 report was also provided to CCLD, the Ombudsman and West Valley Police Department. LPA interviewed two (2) staff that were present during the fight. Two (2) staff that were present during the incident reported that R2 hit R1 in the facial area and the fight was stopped immediately by separating the two (2) residents from each other. Let it be noted, both residents are non-ambulatory and are in wheelchairs. Staff #1 (S1) reported that R2 hit R1 in the mouth area while in the dining hall. S1 immediately moved R2 away from R1 and staff #2 (S2) took R2 back to their room. S1 then called staff #3 (S3) to report the incident and R1 was given an ice pack to put around their mouth area which was bleeding. R1 was sent to the hospital and West Valley Police Department took a report on 12/31/24 of what had occurred. During LPA's interviews, R1 was able to tell LPA non-verbally by pointing at their mouth area when asked what happened between them and R2. When LPA interviewed R2, R2 admitted to hitting R1 because R1 was yelling and screaming. LPA interviewed thirteen (13) residents that confirmed when an incident occurs staff are helpful to them, and the staff seek medical attention if it is needed. Based on the LPA's observations and record reviews, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) issued, and a copy of this report was given to the resident care director, Mary Jane Reyes.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 31-AS-20250102160228

Allegation investigated: Staff did not intervene when a resident-on-resident assault occurred

On 01/22/25, at 1:25pm, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director Mary Jane Reyes. LPA explained the purpose of this visit was to interview staff and residents and deliver findings for this complaint. Regarding the allegation: Staff did not intervene when a resident-on-resident assault occurred. It is being alleged that resident #1 (R1) was repeatedly hit on their head with a cell phone by another resident and staff did not intervene. LPA interviewed two (2) staff that confirmed that R1 was relocated from the Pasadena Fires (Pasadena Villa Senior Living Facility 198603286) and is residing at Cedars Assisted Living temporarily. Staff #1 (S1) confirmed that R1’s assault was reported and R1 was thus sent to the hospital for their injuries. S1 also confirmed that R1 was hit by another resident from the Pasadena Villa Senior Living Facility and not a Cedars Assisted Living resident. Therefore, based on the LPA's record review and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 22, 2025 · control 31-AS-20250121102152

Allegation investigated: Staff did not properly report incidents involving residents

On 01/22/25, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Resident Care Director Mary Jane Reyes. LPA explained the purpose of this visit was to deliver findings for this complaint. On 01/09/25, LPA Segovia conducted an initial complaint and asked for the census, staff, and resident rosters. Regarding the allegation: Staff did not properly report incidents involving residents. It is being alleged a Community Care Licensing (CCLD) employee confirmed no SOC 341 was received by the facility for this alleged abuse. On 01/30/24, LPA Saucedo investigated complaint # 31-AS-20240123163901 regarding an incident related to the SOC 341 that was allegedly not reported to licensing. In the complaint received on 01/23/24, was attached the SOC 341. In addition, there was an Unusual Incident/Injury Report sent to Community Care Licensing Department on 01/23/2024 by facility confirming the incident that took place. During an interview with the CCLD employee, they did not recall providing confirmation that an SOC 341 was or was not received. Therefore, based on the LPA's record review and staff interview the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 22, 2025 · control 31-AS-20250106131753

Type of visit: Case Management - Health Checks

On 1/17/25 Licensing Program Analyst, (LPA) Angelica Segovia, conducted an unannounced visit to the facility to check on the residents who were evacuated due to the current wildfires that took place. LPA was greeted by Activities Director, Tabetha Whitehall. LPA stated the reason for their visit. The Administrator from Pasadena Villa Senior Living, Alexander Solorio assisted with today’s visit. Resident Care Director, Mary Jane Reyes arrived shortly after. The facility accepted a total of forty-eight (48) residents from Pasadena Villa Senior Living (198603286), from the Monterey Park Regional Office. The facility had a mandatory evacuation due to the wildfires. The residents transported to this facility were transported with their medication and additional staff to assist. A physical plant tour was conducted to ensure the health and safety of residents. LPA observed the following: Relocated residents: Out of the forty-eight (48) residents, five (5) are in the Dementia Care unit of the facility, Willow on the first floor. Forty-three (43) residents are living in the Assisted Living Unit of the facility. Evacuated residents have been placed in appropriate shared or single rooms with proper bedding, nightstand, chair, and lighting. LPA observed bedding and furniture in proper condition. Sufficient supplies of hygiene observed for residents. All sharps and toxins observed locked and inaccessible to residents. LPA observed residents in various units such as: dining room, activity rooms, media room, and outside shaded areas with sufficient seating. LIC 809C-continued The Kitchen: LPA observed sufficient stock of seven (7) day non-perishable and two (2) day perishable foods. LPA observed such items as canned goods, bread, milk, eggs, and variety of meats. LPA observed additional chairs and tables had been ordered and placed in the dining area to accommodate the additional residents who were transferred. Administrator stated they were able to transfer food from their home facility to help accommodate during evacuation orders. LPA observed the weekly menu which showcased a variety of meal options for breakfast, lunch, and dinner. Fire drill: Last fire drill was conducted 10-5-2024. LPA observed multiple fire extinguishers located throughout the facility dated 11-13-24. The last annual was completed on 11-13-24. No immediate health or safety issues were observed during the annual. The Fire alarms and Carbon Monoxide detectors were last tested on 1-13-25 and noted to be in good condition and working properly. No immediate health and safety issues observed. Exist interview conducted and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Jan 17, 2025

Allegation investigated: Staff do not provide an appropriate sleeping arrangement for a resident Staff do not address a resident's change in medical condition Staff are mistreating a resident Staff do not provide comfortable accommodations for a resident

On 11/25/24, at 9:10am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 11/13/24, LPA Saucedo asked for the census, staff, and resident rosters. On 11/13/24, LPA Saucedo interviewed staff and conducted a physical tour. On 11/25/24, LPA Saucedo conducted another physical tour and interviewed additional staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff do not provide an appropriate sleeping arrangement for a resident. It is being alleged that resident #1 (R1) does not have a bed and that they have been sleeping on a chair. During LPA’s physical tour, LPA observed a bed in R1’s room and took a picture of it. During LPA’s interview with R1, R1 stated that they have a bed but not a bed like what they had at their previous facility which had handrails and would like a similar bed, therefore; they choose to sleep in a chair that was in the room. During LPA’s interview with Resident #2 (R2), R2 stated that the chair R1 is sleeping on belongs to them and R1 is choosing not to sleep on their bed. Let it be noted, R1 and R2 are roommates. Eleven (11) residents confirmed that they all have somewhere to sleep including a bed to sleep on. Two (2) staff confirmed that R1 does have a bed to sleep on. One (1) staff confirmed that when R1 arrived they did not bring a bed with them, so a bed was provided for them. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not address a resident's change in medical condition. It is being alleged that resident #1 (R1) is in pain, has several areas of their body swollen and uses their commode to help them stand on their feet. During LPA’s record review, R1 has several medical conditions including osteoarthritis and polyneuropathy and there has been no recent change in their medical condition. During LPA's physical tour of R1's room, R1 has a an adjustable walker to help them stand on their feet, they do not have to use a commode. LPA took a picture of the adjustable walker. During LPA’s interview with R1, R1 confirmed that their legs and feet were already swollen when they arrived at the above facility. R1 is currently at a skilled nursing facility due to their current medical condition being addressed at the above facility. Be advised, R1’s admission to the above facility was on 11/01/24 then had to be transferred to a hospital a couple days later due to unusual behaviors including a urinary tract infection. One (1) staff confirmed that on 11/09/24, R1 was sent to the hospital and was then transferred to a skilled nursing facility for treatment. Furthermore, another staff confirmed that when R1 arrived at the above facility, R1 had swollen legs and feet. Ten (10) out of eleven (11) residents confirmed that if changes occur to their medical condition it is addressed at the above facility. Therefore, based on the LPA's record reviews, staff, and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff are mistreating a resident. It is being alleged that resident #1 (R1) is not being treated well and has asked for a social worker. During LPA’s interview with R1, R1 stated they have a social worker but cannot get in contact with them since they arrived at the above facility. R1 wants to get in contact with them so they can receive everything they had the previous facility. R1 wants a bed with handrails, wants all their property from the previous facility and everything stated in their Assisted Living Waiver paperwork. One (1) staff confirmed that R1 has a social worker, but the social worker has not been returning their calls including R1’s calls. Furthermore, R1 will receive a new case worker since R1’s Assisted Living Waiver is being updated. Ten (10) out of eleven (11) residents confirmed that staff do assist and provide them with necessary help and do not mistreat them. Therefore, based on the LPA's record reviews, staff, and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not provide comfortable accommodations for a resident. It is being alleged that the room resident #1 (R1) is currently in has a freezing temperature. During LPA’s physical tour, LPA observed the room temperature in R1’s room to be with Title 22 regulations, it was 71 degrees in the room in which R1 shares with someone else. Furthermore, R1 and their roommate have a portable heater. Ten (10) out of eleven (11) residents confirmed that they are provided with comfortable accommodations. Ten (10) out of eleven (11) residents confirmed that they do not have any problems with their room temperature. Two (2) staff confirmed that room temperatures vary by resident’s room but also that the room temperature can be adjusted. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Nov 25, 2024 · control 31-AS-20241108145353

Allegation investigated: Unknown perpetrator physically abused resident in care. Resident sustained an injury while in care. Staff handled resident in a rough manner. Staff used inappropriate language toward resident. Staff did not ensure that facility was maintained clean and free of pests.

Licensing Program Analyst (LPA) Mariana Agban conducted a subsequent complaint investigation to investigate the allegations stated above. LPA met with Resident Care Director and the purpose of the visit was explained. Allegation: Unknown perpetrator physically abused resident in care. Allegation: Staff handled resident in a rough manner. The Complainant alleged that Facility staff had physically mistreated Resident #1 (R1). Alleged mistreatment included but was not limited to slapping R1 on the back of the head, bending R1’s fingers back, and throwing R1 onto R1’s bed as a method of transferring. Interviews with six (6) of 44 staff members and 13 of 134 residents did not identify any witnesses nor did they include any statements or information to corroborate the allegation. The information obtained was insufficient to confirm or deny the allegation and is therefore deemed Unsubstantiated at this time. (Continue on 9099C) Unsubstantiated Allegation: Resident sustained an injury while in care. The Complainant alleged that R1 sustained an injury to R1’s hand. Interviews with three (3) of 44 facility staff corroborate that there was an injury to R1’s hand. Staff #1 (S1) speculated the injury may have been caused when R1 slipped from R1’s wheelchair onto the floor. Interview with Staff#3 (S3) confirmed that R1 slid out of his chair during breakfast time at the dining room. LPA obtained a copy of the Special Incident Report (SIR) indicating the incident. Interviews with 13 of 134 residents did not identify any witnesses nor did they include any statements or information to corroborate the allegation. Therefore, the information obtained was insufficient to confirm or deny the allegation and is therefore deemed Unsubstantiated at this time. Allegation: Staff used inappropriate language toward resident. The Complainant alleged that Facility Staff had used language when speaking to R1 that would be considered insulting, offensive, and rude by a reasonable person. The language allegedly included profanity and raised voices. Interviews with 6 out of 44 staff members and 13 out of 134 residents of residents did not identify any witnesses nor did they include any statements or information to corroborate the allegation. The information obtained was insufficient to confirm or deny the allegation and is therefore deemed Unsubstantiated at this time. Allegation: Staff did not ensure that facility was maintained clean and free of pests. The Complainant alleged that when R1 was transferred to the memory care unit, R1 was placed in a bedroom that was visibly unclean and in need of repairs. The walls were described as having visible dried spit on them and the floor was patched with duct tape. There was also cockroach activity observed. R1 was moved to another bedroom due to a complaint by R1’s family member. Interviews with Staff 1 (S1) confirmed that they are aware of the pest situation in the facility. The facility has hired a pest control company, to work on the pest situation at the facility. LPA obtains proof of services from the pest control company that confirms the facility is actively working on the situation. Interviews with 13 residents revealed that the facility is successfully working on the pest issue and maintaining the facility clean and free of pets. Based on information obtained the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 31-AS-20230627165328

Allegation investigated: Facility is in disrepair

On 11/20/24, at 9:25am, Licensing Program Analysts (LPAs) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. On 11/20/24, LPA Saucedo asked for the census, staff and resident rosters. At 10:30am, LPA toured the physical plant. During the tour, residents and staff were interviewed. LIC 9099C-continued Unsubstantiated Regarding the allegation: Facility is in disrepair. It is being alleged that for several weeks the heaters have not been working at the above facility. During LPA's physical tour, LPA's entered several rooms and the temperatures were within Title 22 regulations. LPA took a picture of some of the temperatures which were 68, 69, and 77 degrees. In addition, all residents had portable heaters and/or wall heaters. Nine (9) out of ten (10) residents confirmed that they are provided with heat, are happy with the temperature and/or do not have an issue with the current temperature. Two (2) staff were interviewed and confirmed that the heaters have been working and the temperature can be adjusted at any time. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Nov 20, 2024 · control 31-AS-20241115142812

Type of visit: Required - 1 Year

On 11/13/24 at 9:40AM, Licensing Program Analysts (LPAs) Angelica Segovia and Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPAs met with Resident Care Director Mary Jane Reyes and disclosed the purpose of the visit. LPAs asked for the census, resident, and staff rosters. A physical tour was conducted at 11:10 AM and observed the following: The entire facility has a total of 175 (one-hundred and seventy-five) beds. The facility is a two-story building. Both first floor and second floor are assisted living and memory care. The facility has two (2) memory care units: Evergreen located on the second floor and Willow located on the first floor. There are two (2) medication rooms one on the first floor and one on the second floor. The Evergreen Memory Care section of the facility has their own activity, television, and dining hall area. The door has a code and delayed egress on the doors. Willow Memory Care also has its own activity, television, and dining hall area. The assisted living side has their own activity room on the second floor, dining hall on the second floor and a television room on the first floor. The assisted living side has access to a huge patio area with proper seating for residents. Random Bedrooms were randomly selected to tour and were observed to have appropriate furniture, lighting, bedding, and televisions. Random Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested randomly for and measured 105–118-degree Fahrenheit. Fire extinguishers were observed throughout the facility and were fully charged on green with different dates. There are fire extinguishers upstairs, downstairs and in the kitchen area. Carbon Monoxide and fire alarms are located throughout the facility and are operable. LIC 809C-continued Facility has two designated medication rooms that are inaccessible to residents where all the medication is stored and locked in the memory care side of the facility. There are always two (2) medical technician staff in the facility during the daytime for each side-memory care and assisted living. Common Areas: These include the dining areas, activities room, television rooms: All common areas were observed to be cleaned and properly furnished. Facility maintains a comfortable temperature of 69.-71-degree Fahrenheit. There are several temperature thermostats throughout the facility. There are several common bathrooms throughout the upstairs and downstairs area. The staff and resident bathrooms are not shared. There are trash cans with lids and covid signs posted in the common bathrooms. Sufficient supplies of toilet paper and napkins observed. The facility has no body of water. There is one facility laundry area on the first level with chemicals inaccessible to the residents. The staff lounge is also located on the first level of the facility. The Kitchen: area was toured, and LPAs observed sufficient supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The kitchen is located on the first floor. The assisted dining area has access to this kitchen, where at the time of the tour, different residents were observed having lunch with proper feeding utensils/plates/cups. Resident records: LPAs conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPAs conducted a complete file review of staff records. Staff records appeared to be complete and updated. Administrative: There is no annual fee that is due right now. The Insurance plan is dated as of 03/3025. There is an Emergency Disaster plan, Personal Right, Rights of Resident Council, YES, Licensee, and Ombudsman sign on your left-hand side at the entrance of the facility, Fire Drills conducted. An exit interview was conducted, no citations were issued, and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Nov 13, 2024

Allegation investigated: Staff did not seek timely medical attention for a resident in care Unqualified staff dispensing medication Staff not assisting resident with incontinence needs Staff did not assist resident with showering Staff not responding to resident's call button timely Staff did not afford resident respect in their relationship Staff not allowing POA into facility

On 10/30/24, at 8:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 07/25/2023, Licensing Program Analyst (LPA) Tuesday Cabiness initiated the complaint investigation. On 10/30/24, LPA Saucedo asked for the census, staff, and resident rosters. On 10/30/24, LPA Saucedo interviewed additional staff, residents and conducted a physical tour. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not seek timely medical attention for a resident in care. It is being alleged that staff did not immediately call 911 for a resident #1 (R1). R1 is no longer residing at the above facility. Ten (10) residents confirmed that staff do seek medical attention for them in a timely manner. Two (2) staff confirmed that it is staff’s duty to seek timely medical attention for each resident and ensure their well being. Furthermore, one (1) of the caregivers did state that when R1 would call for assistance in the middle of the night they would respond to them several times; In addition, they were the staff that called 911 and sent R1 to the hospital on July 13, 2023. LPA was able to confirm that an Unusual Injury/Incident report was sent to CCLD-Community Care Licensing Department regarding R1 seeking medical attention and the caregiver calling 911 for R1. Therefore, based on the LPA's record reviews, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Unqualified staff dispensing medication. It is being alleged that unqualified staff were dispensing incorrect medication. Three (3) staff confirmed that they do receive training to dispense medication. LPA was able to obtain training records for staff that dispense medication. LPA also confirmed that resident # 1 (R1) was under Palliative Care and Roze Room Palliative Care was distributing medication to R1 in addition to the staff working at the above facility. LPA obtained the Chart/Clinical notes provided by Roze Room Palliative Care regarding R1. Ten (10) residents confirmed that they do not have any issues with staff dispensing medication to them. Therefore, based on the LPA's record reviews, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff not assisting resident with incontinence needs. It is being alleged that staff was leaving resident #1 (R1) in soiled diapers. R1 is no longer residing at the above facility. Ten (10) residents that require incontinence needs were interviewed and confirmed that they are not left in soiled diapers. In addition, eight (8) of these residents receive home health/hospice care which provides that extra service of assisting the resident. LPA’s interview with Power of Attorney and Palliative Care notes confirmed that R1 did not want to accept hospice care. Two (2) staff confirmed that R1 was provided an extra staff from the above facility to help assist them with incontinence and other needs. Therefore, based on the LPA's record reviews, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. LIC9099C-continued Regarding the allegation: Staff did not assist resident with showering. It is being alleged that resident #1 (R1) did not shower for a month. R1 is no longer residing at the above facility. Ten (10) residents confirmed that they get a shower two (2) or three (3) times a week. Eight (8) out of these residents confirmed that they are provided help with showers from either home health or hospice care. LPA’s interview with Power of Attorney and record review confirmed that R1 did not want to accept hospice care but R1 was under Roze Room Palliative Care. Two (2) staff confirmed that R1 was provided an extra staff from the above facility to help assist them with their shower and other needs. Therefore, based on the LPA's record reviews, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff not responding to resident's call button timely. It is being alleged that staff were not responding to resident #1 (R1)'s call button in a timely manner. R1 is no longer residing at the above facility. Ten (10) residents confirmed that staff do respond to a resident’s call button in a timely manner. Three (3) staff confirmed that they respond to all call buttons in a timely manner. Therefore, based on the LPA's record reviews, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not afford resident respect in their relationship. It is being alleged that resident #1 (R1) was not shown respect in their relationships. R1 is no longer residing at the above facility. LPA spoke to R1’s Power of Attorney (POA) and POA confirmed that they had no issues visiting and/or having any relationship concerns when visiting or speaking to R1. LPA also confirmed with Roze Room Palliative Care about their visits and/or speaking with R1 at the above facility and they did not recall having any issues with the above facility. Two (2) staff confirmed that privacy is given to all residents. Ten (10) residents confirmed that they have no issues at the above facility with receiving visits or any type of relationships concerns. Therefore, based on the LPA's record reviews, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. LIC9099C-continued Regarding the allegation: Staff not allowing POA into facility. It was alleged that the staff were not allowing resident #1 (R1)’s Power of Attorney (POA) into R1’s room. R1 is no longer residing at the above facility. LPA spoke to R1’s POA and the POA confirmed that they were allowed to enter R1’s room with five (5) other people to retrieve all of R1’s belongings. LPA interviewed ten (10) residents that confirmed their POA and/or family members have rights to their room as long as they give them permission. Two (2) staff confirmed that if the permission is given by a resident to enter their room the staff will allow others to enter their room. Therefore, based on the LPA's record reviews, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 31-AS-20230721090852

Allegation investigated: Staff did not release resident's records upon request from the resident

On 10/21/24, at 8:55am, Licensing Program Analyst (LPAs) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 10/21/24, LPA Saucedo asked for the census, staff, and resident rosters. On 10/21/24, LPA Saucedo interviewed staff and residents and conducted a physical tour. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not release resident's records upon request from the resident. It is being alleged that one (1) of the resident’s requested their ALW-Assisted Living Waiver paperwork and it was not being provided to them. Nine (9) out of ten (10) residents confirmed that staff do assist and provide them with necessary paperwork with proper notification. Resident #1 (R1) did confirm that at the time that they requested their paperwork they were not at the above facility, and they requested their paperwork via telephone. Two (2) out of two (2) staff confirmed that paperwork is confidential, needs to be done in person and/or by written request and given proper notification time. One (1) staff confirmed that if requests are done over the phone, they do not know the person’s identity so the request must still be done via email/written request. LPA was able to confirm that R1 has not been at the above facility since 08/10/24. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Oct 21, 2024 · control 31-AS-20241015210021

Type of visit: Case Management - Deficiencies

On 10/14/24, at 12:45pm, Licensing Program Analysts (LPAs) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced case management visit and was greeted by Administrator, Kandace Vergara. LPA was advised that a nightstand was put in front of a resident’s bedding while the resident was sleeping on the bed. A picture was taken of this violation. Per the California Code of Regulations, Title 22, Division 6, Chapter 8 cited and noted on LIC 809D. Exit interview conducted, a citation(s) was issued, appeal rights and copy of the report was signed and delivered to the Administrator.the state’s words, verbatim · CDSS document, Oct 14, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5) · Plan of correction due date: Oct 14, 2024

Postural Support-87608(a)(5) (a)Based on the individual's preadmission appraisal, and subsequent changes...the facility shall provide assistance...to a resident who unable to do for himself/herself. Postural supports may be used under the following conditions.(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement is not met by: Based on the observation, the licensee/administrator did not ensure a resident was free of postural support that deprived resident of movement limitations at the above facility which poses a potential Health, Safety or Personal Rights risks to person in care.the state’s words, verbatim · CDSS document, Oct 14, 2024

Plan of correction: Licensee/Administrator shall remove the postural support that deprives the resident of movement limitations and send picture to LPA by POC 10/14/24. POC Cleared 10/14/24 at time of viist

Allegation investigated: Resident sustained multiple pressure injuries while in care Facility did not have sufficient staff to care for the residents Staff failed to observe the resident resulting to multiple falls Staff over medicated the resident in care Staff did not re appraise the resident regularly while in care

On 09/24/24, at 8:55am, Licensing Program Analyst (LPAs) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 08/27/2024, Licensing Program Analyst (LPAs) Gina Saucedo and Angelica Segovia initiated the complaint investigation. On 08/27/24, LPA Saucedo and LPA Segovia asked for the census, staff, and resident rosters. On 09/24/24, LPA Saucedo interviewed additional staff and residents, conducted a physical tour, gathered additional information, and delivered findings. LIC 9099-continued Unsubstantiated Regarding the allegation: Resident sustained multiple pressure injuries while in care. It is being alleged that resident #1 (R1) sustained multiple pressure injuries while in care. R1 is no longer residing at the above facility. While in care of the above facility, R1 received one (1) wound care on their sacro coccyx right buttocks sacral area, pressure ulcer stage 3 and received hospice care from “Mensa” with the son’s authorization. Mensa Hospice Care had case notes describing the wound and the care of the wound. One (1) out of ten (10) residents confirmed that they have been in the hospital for pressure injuries, but they were returned to the above facility after they got the care they needed and confirmed that they have a history of heel injuries. Three (3) out of three (3) staff confirmed that if any type of injury occurs especially injuries that have to do with wounds they are sent to the hospital and upon their return to the above facility the resident is cared for on the doctor’s orders. Hospice or Home Health is recommended for the resident depending on the type of injury and/or medical condition they have. The other residents confirmed they have not received any pressure injuries while in care. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Facility did not have sufficient staff to care for the residents. It is being alleged that resident #1 (R1) was not being provided staffing to meet their needs. R1 is no longer residing at the above facility. R1 was in the memory care section of the above facility where there are two (2) caregivers and one (1) housekeeper per shift. R1 was also put under Mensa Hospice Care on June 18, 2024, so their needs could be met and have an additional staff providing care to them. Four (4) out of ten (10) residents confirmed that there is a need for more staff, but their care might be slow, but it still gets done. Three (3) out of three (3) staff confirmed that there are several staff to help the residents. In addition, Hospice and Home Health are recommended for the resident’s that need extra care. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff failed to observe the resident resulting to multiple falls. It is being alleged that resident #1 (R1) fell multiple times and it resulted in stitches. R1 is no longer residing at the above facility. R1 fell twice since their stay at the above address. On 10/2023 and on 01/2023. Both falls were reported to CCLD-California Community Licensing Department and both times R1 was sent to the hospital. Northridge and Tarzana hospitals did not state that R1 needed any stitches for their fall and R1 was released back to the above facility. Ten (10) out of ten (10) residents confirmed that the staff have never failed to help them or left them unattended if they fell. Three (3) out of three (3) staff confirmed if a resident falls or an injury occurs with them the resident is transported to the hospital, an incident report is written, and sent to CCLD- California Community Licensing Department. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff over medicated the resident in care. It is being alleged that Resident #1 (R1) was sedated all day and would not get out of their bed. R1 is no longer residing at the above facility. R1’s paperwork confirms that R1 was bedridden and was taking multiple medications for their health. Ten (10) out of ten (10) residents confirmed that they have not been over medicated. Three (3) out of three (3) staff confirmed almost all their residents take medication and that the medication has different side effects and that to their knowledge a resident has not been sent to the hospital for being over medicated. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff did not reappraise the resident regularly while in care. It is being alleged that resident #1 (R1) was not appraised and reappraised to determine his or her individual needs and services. R1 is no longer residing at the above facility. R1 was admitted to the above facility in 2022. There was a pre-placement appraisal which indicated an ambulatory status on 05/2022. The Assisted Living Waiver indicates they had a history of falls which is dated 11/2022. R1’s Resident Information/Care Plan dated 08/2023 indicates they were now non-ambulatory, and their Physician Report 04/2023 also stated non-Ambulatory with history of falls. The updated paperwork from the hospitals showed R1 had become bedridden and there is an updated Resident Information/Care Plan that shows R1 was bedridden. The resident care director and administrator both stated that R1’s health had decreased while they lived at the above facility. On 09/14/23, R1 went to the hospital for a psychological evaluation and on 01/09/24, R1 went to the hospital again for a seizure. On 04/27/24, R1 was sent to the Northridge hospital, and they transferred R1 to a Woodland Hills Skilled Nursing Facility for further rehabilitation due to R1’s health. Woodland Hills Skilled Nursing discharged R1 back to the above facility in June 2024 with home health recommendation and R1 was placed under Hospice with son’s authorization on June 18, 2024. Ten (10) out of ten (10) residents confirmed that they are aware of their health changes, needs and services. Three (3) out of three (3) staff confirmed that the reappraisal happens when a resident’s health changes. The staff confirmed that the residents must go to the doctor for this to happen and the resident’s needs and services are then updated. One (1) of the staff also stated that R1’s health was deteriorating while in the care of the above facility. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Resident Care Director, Mary Jane Reyes.the state’s words, verbatim · CDSS document, Sep 24, 2024 · control 31-AS-20240826131516

Allegation investigated: Unlawful eviction Facility staff financially abuse resident

On 09/16/24, at 9:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director Mary Jane Reyes. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 11:05am, LPA toured the physical plant. During the tour, residents and staff were interviewed. 9099C-continued Unsubstantiated This is an amended copy of the report previously issued on 09/16/2024. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same. Regarding the allegation: Unlawful Eviction. It is being alleged that the resident is being evicted for non-payment of rent. Eight (08) out of nine (09) residents were able to confirm that they are aware of the admission agreement, and they are also aware of the eviction rules. LPA’s interview with Resident #1 (R1) confirmed that they have never paid rent. R1 believed that the Assisted Living Waiver was paying their rent. The Assisted Living Waiver was only paying $108.00 of the portion of R1’s rent. R1’s admission to the above facility was on 07/17/23 with a monthly rent of $1324.82. The accumulation of non-payment of rent is over $7389.92 which was given to R1 in the form of an eviction notice. In addition, the administrator provided the resident with the proper reasoning of eviction notice of non-payment on 06/07/24. On June 07, 2024, LPA received the appropriate eviction notice of R1 via fax through Community Care Licensing Department (CCLD). LPA’s interview with the administrator confirmed that R1 refused to get their help and help from the Assisted Living Waiver program to find a new place to live. A lawful detainer was also given to R1. Three (3) out of three (3) staff confirmed that they were present when they served R1 with the appropriate eviction notice. LPA review of R1's admission agreement shows the amount of the rent of 1324.82 for a shared room and the admission agreement describes the eviction notice. Therefore, based on the LPA's record reviews, staff and resident’s interviews the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Facility staff financially abuse resident. It is being alleged that unauthorized purchases were made to the resident’s medical card. Eight (08) out of nine (09) residents confirmed that they have never had any financial abuse from the above facility or any unknown charges to their medical card. LPA’s interview with Resident #1 (R1) confirmed that they did not have a receipt of the financial abuse. In addition, LPA spoke to a worker at United Medical Supplies that delivers all the supplies, creates invoices, and bills the residents at the above facility and the witness stated, no delivery, invoice or billing was made to R1 for any diapers, bed pans, and/or paste on R1's medical card. Two (2) out of two (2) staff confirmed that no residents have been billed for any unauthorized purchases on their medical card. Therefore, based on the LPA's record reviews, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Sep 16, 2024 · control 31-AS-20240913153942

Allegation investigated: Resident choked on food due to lack of supervision. Resident developed a UTI while in care.

Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to amend and conclude the investigation regarding the above allegations. LPA met with the Resident Care Director, Mary Jane Reyes and advised her of the allegations Resident chocked on food due to lack of supervision: In regards to the allegation, It was reported that on or around 5/21/2021 Resident 1 (R1) choked on their food because they were left eating unsupervised. R1 requires supervision during meals. Interviews were made with the administrator, Resident Care Director (RCD) and staff reveal that R1 was verbal, able to communicate their needs, required a mechanical diet, but was able to feed self, requiring no supervision. Information received by Investigations Branch (IB) received during their investigation indicated that R1 was total assist. This information received was outdated. During the course of LPA Cava’s investigation, updated information, pertaining to R1’s medical assessment and needs and services were received. Unsubstantiated This information reveal that, at admission to the facility, although R1 required a mechanical diet, R1 was able to feed self. In addition, R1’s post discharge papers from the rehabilitation center where R1 came from was also obtained. It indicates R1 can feed self and no longer requires services from the rehabilitation center, resulting in R1 being discharged to an assisted living. Moreover, this allegation held trial. R1’s family had to settle based on their attorney’s advice that “it was in the court’s opinion that the facility staff did all they possibly could have to prevent R1 from choking. Based on the information obtained, there wasn’t enough evidence to prove that R1 choked on food due to lack of supervision. Therefore, the allegation is deemed Unsubstantiated at this time. Resident developed a UTI while in care: In regards to the allegation, the initial investigation was made by LPA Alex Pitz on 02/10/22. Based on LPA Pitz’s interviews and record review, the allegation was Substantiated at that time. A further review of this allegation was made. Based on that review, there was no substantiative evidence available with regards to the allegation involving R1 developing UTI to prove the facility is at fault. Therefore, the allegation is changed to Unsubstantiated. RCD advised and a copy of this report issued.the state’s words, verbatim · CDSS document, Sep 5, 2024 · control 31-AS-20210527105206

Allegation investigated: Staff do not safeguard residents personal belongings Resident suffered a fall with injury due to staff negligence Staff did not seek timely medical attention for resident Staff do not provide feeding assistance to the resident Resident was abused and humiliated at the facility Staff did not provide proper medication assistance to the resident

Licensing Program Analyst (LPA) Antonia Alvizar - Ettima conducted unannounced complaint visit to the facility to complete investigation of the above noted allegations. LPA met with Resident Care Director, Mary Jane Reyes and explained the reason for the visit. Later Administrator Kandice Vergara joined us. During initial investigation conducted on 08/03/2023, at 10:45AM LPA request copies of the facility resident and staff roster. At 11:20AM LPA requested copies of resident #1 (R1) and resident #2 (R2s) records included but not limited to Identification and Emergency Information, Physician’s Report, Resident Appraisal, Needs and Services, Unusual Incident Reports, Inventory records for Personal Property and Valuables, Internal Notes and Medication Administration Records. Between 11:50AM – 2:50PM, LPAs interviewed the Resident Care Director (RCD), 2 staff assisting R1 and R2 and one (1) resident R2. At the time of investigation R1 was no longer in the facility. Prior to this visit on 08/06/24 at 8:45AM LPA reviewed all facility records received during initial visit. Unsubstantiated Staff do not safeguard residents personal belongings. It was alleged that the facility staff did not safeguard R1’s and R2’s personal belongings. Interviews revealed that in the memory care residents’ belongings are being safeguarded and valuables are stored in the locked cabinet by RCD, Staff revealed that R1’s and R2’s belongings and valuables were never inventoried by resident and/or responsible party. R1 had a watch, and it was stored in the locked cabinet and was given to R1’s responsible party when R1 was moving out of the facility. R2 reported missing bag with personal items and money. During the time of the incident R2 was going out in the community daily with a friend and returning to facility intoxicated. Staff conducted an internal investigation and did not find the missing bag. R2 informed a staff on 11/20/2023 that friend found R's bag and returned it. Staff was informed about the missing money and they offered to file a police report on R2’s behalf and R2 refused at that time. During this investigation at 3:15PM R2’s interview confirm that missing items were returned, and staff do safeguard resident’s personal belongings. Upon review of R1’s and R2’s records, LPA noted that both residents’ belongings were not recorded. Based on interviews and record review it was concluded that although the allegation may have happened, however, there is insufficient information to confirm the validity of the complaint. Therefore, the allegation is unsubstantiated at this time. Resident suffered a fall with injury due to staff negligence. Staff did not seek timely medical attention for resident. It was alleged that while staff was assisting R1, they "slipped" out of the staff's arms and fell hurting his elbow. R1’s elbow was dislocated, and staff did not take the resident to have his elbow looked at. Staff revealed that R1 never had dislocated elbow and did slipped out while assisted by staff. R1 never complain of the pain. Sometime in July 2023, R1 had unwitnessed fall. When R1 sits on the wheelchair, they suit themselves to the end of wheelchair and may easily loos the balance. R1 injured 2 fingers. Staff called emergency transportation and R1 was send to the hospital. At the time of investigation, R1 was no longer at the facility. LPA Alvizar - Ettima reviewed incident report, regarding R1’s unwitnessed fall. The report verified the information received from facility staff. Based on interviews and record review, there is insufficient information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. Continue on LIC 812c Staff do not provide feeding assistance to the resident. Concerns were addressed that R1 can't see, and the staff are supposed to assist the resident with feeding. The staff just blend up the resident's food and set it in front of them to eat. Interviews revealed that R1 had vision problem however did not require feeding assistance. R1 was hard of hearing. R1 did not like to eat breakfast, but they always ate lunch and dinner. Some time R1 would ask for oatmeal for breakfast and staff always brings the oatmeal for R1. A review of R1s records verified the information revealed from the staff. No information was revealed during this investigation to support the allegation. Therefore, the allegation is Unsubstantiated at this time. Resident was abused and humiliated at the facility. It was alleged that someone (unknown if it is staff or other residents) are coming into the R1’s room at night and "slapping" the resident upside the head and other times will hold the resident's nose and put their hand over the residents’ mouth. Staff denied entering residents’ rooms and humiliating R1 or other residents. Staff stated that residents supervised at night and no one is wondering or going to the other residents rooms. During this visit between 11:55a.m. – 1:00p.m. LPA interviewed eleven (11) residents and the residents denied being humiliated by the facility staff. A review of facility documents and internal incident log did not reveal any information to support the allegation, except that R1 had aggressive and disrespectful behavior towards facility staff and other residents. Based on interviews and record review there is insufficient information to verify the allegation. Therefore, the allegation is Unsubstantiated at this time. Staff did not provide proper medication assistance to the resident. It was alleged that the staff are not giving the resident (R1’s) medications. Staff interviews revealed that R1 always received their medications as prescribed. Since R1 was no longer in the facility LPA was unable to review R1’s medication supply. A review of R1’s medication Administration Records revealed that R1’s medication was dispensed as per doctor’s order. During this investigation, between 11:55a.m. – 1:00p.m. LPA Alvizar-Ettima spoke with eleven (11) residents and they did not have any concerns regarding their medication assistance. Based on interviews and record review there is no sufficient information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. Exit interview conducted. Copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Aug 6, 2024 · control 31-AS-20230728073109

Allegation investigated: Staff hit resident Staff speaks inappropriately to residents

On 07/30/24, at 9:55am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director Mary Jane Reyes. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 11:15am, LPA toured the physical plant. During the tour, residents and staff were interviewed. 9099C-continued Substantiated Regarding the allegation: Staff hit resident. It is being alleged that Staff #1 (S1) is aggressive to residents. Resident #1 (R1) was able to confirm that S1 hit them in the back of the neck, top of the head, and kicked them. Resident #2 (R2) confirmed that S1 choked them and Resident #3 (R3) was a witness to R2. Resident #4 (R4) confirmed that S1 grabbed and pulled them by the hand pushing them against a chair. Resident #5 (R5) suspects that they were hit behind the head by S1 because S1 was around them at the time but cannot confirm it because when they turned around from their wheelchair S1 was no longer around. LPA was able to confirm a cut behind the head of R5 and the Unusual/Incident/Injury Report. Seven (7) out twelve (12) residents have heard S1 being aggressive with other residents. Two (2) out of two (2) staff confirmed that they have received complaints about S1. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is SUBSTANTIATED at this time. Regarding the allegation: Staff speaks inappropriately to residents. It is being alleged that Staff #1 (S1) yells at residents. Twelve (12) out of twelve (12) residents confirmed that they have been yelled at and disrespected by S1. Two (2) out of two (2) staff confirmed that they have received complaints about S1. Furthermore, one (1) staff did confirm that S1 is impatient and yells at residents. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued for the above allegation(s), and a copy of this report was given to the Resident Care Director with the appeals rights.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 31-AS-20240724141451

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jul 31, 2024

87468.1(a)(3) 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:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature..This requirement is not met as evidenced by: Based on the LPA's Interviews the licensee/administrator did not ensure that staff provide an environment free of punishment/intimidation/abuse of residents in care which poses an Immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 30, 2024

Plan of correction: The licensee/admnistrator shall immediately place the staff on administrative leave or/and remove the staff from all care given to the residents.

Allegation investigated: Licensee did not provide responsible party prompt access to review all resident's records. Licensee did not respond to communications from resident representative.

On 7.15.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Mary Jane Reyes (S2) who is the Resident Care Coordinator of the facility. Initial visit was done by LPA Agban on 11.15.2023. With the assistance of the administrator, LPA took a tour of the physical plant at 10:10AM. At 10:30AM LPA requested the following documents: staff roster; resident roster, residents’ physician’s report, admissions agreement, appraisals, and other documents. LPA received copies of all the documents requested. LPA interviewed thirteen (13) residents out of one hundred twenty-four (124) residents and two (2) staff from 10:42AM until 12:15PM. LPA reviewed resident’s records at 12:20PM until 1:30PM. Allegation: Licensee did not provide responsible party prompt access to review all resident’s records Continue to LIC 9099-C Unsubstantiated It was alleged that the facility staff did not provide responsible party prompt access to review all resident’s records. Resident #1 (R1) had moved out of the facility and staff did not provide and transfer any of the financial records to the family. LPA interviewed residents, thirteen (13) out of one hundred twenty-four (124) residents and 2 staff. LPA interview S1 and S2 and stated that they had emailed the necessary records to the individuals who are only indicated in R1's file only. Based on LPA observation and review of the information received this allegation is unsubstantiated. Allegation: Licensee did not respond to communications from resident representative. It was alleged that the facility does not respond to communications from resident representative and block-off their number. R1 family has been trying to communicate and call the facility to obtain all the necessary documents. Interview with S1 and S2 stated they have no way of blocking a certain number since anyone can just call the office and can be helped. S2 also revealed that R1 family has their private number for them to call and communicate regarding R1's condition. Based on LPA's observation and review of the information received this allegation is unsubstantiated. Exit interview conducted. Report signed and delivered to the executive director.the state’s words, verbatim · CDSS document, Jul 15, 2024 · control 31-AS-20231106105909

Allegation investigated: Facility is financially abusing resident in care Unlawful eviction Facility did not cooperate with Ombudsman Representative

On 07/15/24, at 9:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Mary Jane Reyes, Resident Care Director. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 09/07/2022, Licensing Program Analyst (LPA) Wendell Smith and Joscelyn Martinez initiated the complaint investigation. On 07/15/24, LPA Saucedo asked for the census, staff, and resident roster. On 07/15/24, LPA Saucedo interviewed staff and residents and conducted a physical tour, gathered additional information, and delivered findings. LIC 90999C-continued Unsubstantiated Regarding the allegation: Facility is financially abusing resident in care. It is being alleged that the resident was not receiving their money from social security. Ten (10) out of twelve (12) residents confirmed that they oversee their own money. Two (2) out of two (2) staff confirmed that they were present at a meeting with resident #1 (R1)'s family and there was confirmation that R1's son was paying at the beginning and stopped paying the rent because the above facility was going to become the payee. There was also confirmation in one (1) of the meetings with the family that R1's friend assisted with their finances before the above facility became the resident’s payee. The above facility was given authorization to become R1's payee in May of 2021 and the application was finally processed in September 2021. The above facility did not officially become the payee for the R1 until May 13, 2022. Therefore, based on the LPA's record review, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Unlawful eviction. It is being alleged that there was an unlawful eviction that was issued to the resident which was an unlawful eviction. For several months there was nonpayment of rent and non-payment of basic needs. An eviction notice was issued on 07/08/2022. Two (2) out of two (2) staff denied the allegation that resident #1 (R1) was given an unlawful eviction. The administrator was able to provide the past due payments that were owed to the above facility. LPA interviewed ten (10) out of twelve (12) residents that were interviewed and denied the allegation that the facility issues unlawful evictions. Therefore, based on the LPA's record review, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Facility did not cooperate with Ombudsman Representative. It is being alleged that the facility staff (management staff) did not cooperate with Ombudsman Representative. The Ombudsman Representative made multiple phone calls and emails in which they were answered and in addition attended a meeting at the above facility on 03/16/2022 with the management staff and family members. Furthermore, the Resident Care Director and Administrator confirmed that they were also present at the meeting with the Ombudsman Representative and have the minutes to confirm their presence. Ten (10) out of twelve (12) residents confirmed that the facility does cooperate with the Ombudsman Representative and other representatives such as their case managers, family members and social workers. Therefore, based on the LPA's record review and staff interviews the above allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegations, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jul 15, 2024 · control 31-AS-20220902132402

Allegation investigated: Staff confiscated resident's personal belongings Staff refused to assist resident

On 07/08/24, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Mary Jane Reyes, Resident Care Director. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 07/03/2024, LPA Gina Saucedo initiated the complaint investigation. On 07/03/24, LPA Saucedo asked for the census, staff, and resident roster. On 07/03/24, LPA Saucedo interviewed staff and residents and conducted a physical tour. On 07/08/24, at 9:55am, LPA conducted another physical tour with Resident Care Director, gathered additional information and conducted more interviews. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff confiscated resident's personal belongings. It is being alleged that a staff took a resident’s belongings without permission. Twelve (12) out of twelve (12) residents confirmed that they have received new furniture within the last couple of weeks and that their personal belongings were not confiscated. Four (4) out of four (4) staff confirmed that new furniture has been bought for most of the residents to update the facility. During LPA's physical tour, LPA observed several residents that had new black furniture which included drawers, chairs and tables. In addition, LPA observed resident's personal belongings that were in boxes in their room while the new furniture was being set up. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff refused to assist resident. It is being alleged that staff declined to provide a service for a resident. Twelve (12) out of twelve (12) residents confirmed that staff do assist all residents in care with the help that they can provide. Resident #1 (R1) did confirm that at the time that they asked for help, the staff were busy and they did not wait for the assistance. Four (4) out of four (4) staff confirmed that they try their best to assist all residents in care. One (1) staff did confirm that if legal paperwork must be filled out or an appointment must be made, they will assist the resident as long as they have been given enough time. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegations, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jul 8, 2024 · control 31-AS-20240701082151

Allegation investigated: Staff disturb resident’s sleep Staff make inappropriate comments to resident

On 07/08/24, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Mary Jane Reyes, Resident Care Director. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 07/03/2024, LPA Gina Saucedo initiated the complaint investigation. On 07/03/24, LPA Saucedo asked for the census, staff, and resident roster. On 07/03/24, LPA Saucedo interviewed staff and residents and conducted a physical tour. On 07/08/24, at 9:55am, LPA conducted another physical tour with Resident Care Director, gathered additional information and conducted more interviews. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff disturb resident’s sleep. It is being alleged that resident's sleep is being disturbed. Twelve (12) out of twelve (12) residents confirmed that they have a roommate that is incontinent or/and that need help. In addition, Resident #1 (R1) has asked to be moved three times because they wanted to be closer to the Wi-Fi connection. R1's admission agreement also states that they have agreed to have a shared room. Four (4) out of Four (4) staff also confirmed that more than ninety-five percent of their residents require some type of help, and the caregivers/housekeepers will be in and out of the resident's room several times a day. During LPA's physical tour, LPA did observe several residents that require some type of help showering, in and out bed access, personal hygiene, hair care, wheelchair, walker and/or cane assistance. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff make inappropriate comments to resident. It is being alleged that staff are saying inappropriate comments to resident, trying to provoke them. Eleven (11) out of twelve (12) residents confirmed that staff speak to them in an appropriate manner. Four (4) out of four (4) staff confirmed that they try their best to help all residents in care and do not say inappropriate comments. During LPA's physical tour, LPA did not observe any staff saying inappropriate comments to the residents in care. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegations, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jul 8, 2024 · control 31-AS-20240702163246

Allegation investigated: Resident was not accorded dignity in relationships with staff, residents, and other persons Communications to the licensee from resident's representatives were not answered promptly and appropriately

On 07/03/24, at 8:55am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Activities Director, Tabetha Whitehall. LPA asked for the census, resident, and staff rosters. The Resident Care Director Mary Jane Reyes arrived about fifteen (15) minutes later. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 03/30/2022, Licensing Program Analyst (LPA) Joscelyn Martinez initiated the complaint investigation. On 07/03/24, at 8:55am LPA Saucedo asked for the census, staff, and resident roster, interviewed staff, residents and conducted a physical tour at 9:45am. LIC 9099C-continued Unsubstantiated Regarding the allegation: Resident was not accorded dignity in relationships with staff, residents, and other persons. It is being alleged that residents yell obscenities and vulgar things around visitors. Twelve (12) out of twelve (12) residents confirmed that they have not witnessed any residents yell obscenities and vulgar things around visitors and/or their family members. Five (5) out of five (5) staff also confirmed that they have not witnessed any residents yell obscenities and vulgar things around visitors and/or resident family members which is not allowed at the above facility. During LPA's physical tour, LPA did not observe any residents yelling obscenities and vulgar things. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Communications to the licensee from resident's representatives were not answered promptly and appropriately. It is being alleged that the administration did not return any emails pertaining to residents. Twelve (12) out of twelve (12) residents confirmed that they have not had any issues talking to the administration or any staff at the above facility including their family members being in contact with the administration. Five (5) out of five (5) staff confirmed that the residents and the resident family members can communicate with any staff including administration. One (1) of the management staff did confirm that they have stayed past their working schedule to talk to family members and the residents to resolve any issues and that residents including their family members and/or responsible party have the facility's phone number and email address if it is an emergency. The licensee did state that emails and phone calls are answered right away on a first come basis. During LPA's physical tour, LPA did observe the facility contact number and business cards at the lobby of the facility if any visitors and/or residents need to communicate with anyone. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegations, and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Jul 3, 2024 · control 31-AS-20220325133246

Allegation investigated: Facility does not ensure adequate storage for residents in care Facility is using residents closet to store facility supplies/items

On 06/19/24, at 8:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Activites Director, Tabetha Whitehall. Mary Jane Reyes, Resident Care Director arrived at 9:30am. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 06/11/2024, LPA Gina Saucedo initiated the complaint investigation. On 06/11/24, LPA Saucedo asked for the census, staff, and resident roster. On 06/11/24, LPA Saucedo interviewed some staff and residents and conducted a physical tour. On 06/19/24, at 9:35am, LPA conducted another physical tour with Resident Care Director, gathered additional information and conducted more interviews. LIC 9099C-continued Unsubstantiated Regarding the allegation: Facility does not ensure adequate storage for residents in care. It is being alleged that because a resident’s room is being used for storing items such as mattresses, wheelchairs, walkers, and old oxygen tanks it is leaving the resident with insufficient space for their personal belongings. Twelve (12) out of twelve (12) residents confirmed that they have adequate space for their personal belongings in their room. Four (4) out of four (4) staff also confirmed that a resident's room is not supposed to be used as storage as this takes up space for the resident's personal belongings. During LPA's physical tour, LPA did not observe any resident rooms to be occupied by storage items such as mattresses, wheelchairs, walkers and/or oxygen tanks. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Facility is using residents closet to store facility supplies/items. It is being alleged a resident’s closet is being used for storing items such as mattresses, wheelchairs, walkers, and old oxygen tanks. Twelve (12) out of twelve (12) residents confirmed that their closet in their room does not have any facility supplies/items. Four (4) out of four (4) staff also confirmed that a resident's closet is not supposed to store facility supplies/items. During LPA's physical tour, LPA did not observe any resident's closet to have facility supplies/items such as mattresses, wheelchairs, walkers and/or oxygen tanks. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegations, and a copy of this report was given to the Administrator. Regarding the allegation: Facility is in disrepair. It is being alleged that were several water leaks, including one in the ceiling near the dining area, several holes in the memory care hallway, and water damage to several baseboards in the residents’ rooms (specific rooms unknown) and a small hole in the elevator floor, which could pose a tripping hazard. Twelve (12) out of twelve (12) residents confirmed that they have seen the maintenance crew doing repairs throughout the facility, but they do not know the exact repairs being completed. Four (4) out of four (4) staff also confirmed that the maintenance crew are doing repairs throughout the facility including resident rooms, but they do not know the exact repairs being completed. During LPA's physical tour, LPA observed the maintenance crew doing several repairs throughout the facility including resident rooms. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued for the above allegation(s), Appeal Rights and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 31-AS-20240610110816

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 20, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on the LPA's observations, staff/ resident interviews, the staff did not ensure the residents to have good repair of different areas throughout the facility including rooms and common areas which poses an immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2024

Plan of correction: The licensee/admnistrator shall send pictures of repairs being completed by POC due date: 06/20/24.

Allegation investigated: Staff are not providing adequate housekeeping services to resident Staff are not ensuring that facility is free of odor

On 06/11/24, at 8:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Medical Technician, Joleen Halog. LPA disclosed the purpose of the visit. Medical Technician called the Resident Care Director and the Resident Care Director arrived at 9:20am. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 06/06/2024, LPA Gina Saucedo initiated the complaint investigation. On 06/06/24, LPA Saucedo asked for the census, staff, and resident roster. On 06/06/24, LPA Saucedo interviewed staff, residents and conducted a physical tour. On 06/11/24, at 10:35am, LPA conducted another physical tour with Resident Care Director and gather additional information. LIC 9099C-continued. Unsubstantiated Regarding the allegation: Staff are not providing adequate housekeeping services to resident. It is being alleged that the resident’s bathroom is not properly cleaned as there is urine, hair, and other debris on the floor. Twelve (12) out of twelve (12) residents confirmed that they have cleaning once a week. Four (4) out of four (4) staff also confirmed that they clean the facility on a daily basis. Four (4) out of four (4) staff confirmed that the rooms are cleaned on a weekly basis but if a resident wants additional cleaning, they can request for it. During LPA's physical tour, LPA observed housekeepers cleaning different rooms and caregivers providing resident services. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not ensuring that facility is free of odor. It is being alleged that the facility smells like urine. Twelve (12) out of twelve (12) residents confirmed that they have not smelled urine in the facility. Four (4) out of four (4) staff also confirmed that they have not smelled urine in the facility. During LPA's physical tour, LPA did not observe the smell of urine. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Resident Care Director. Regarding the allegation: Staff are not addressing the presence of roaches in the facility. It is being alleged that the facility is infested with roaches. Twelve (12) out of twelve (12) residents confirmed that they have seen roaches in their room and the common areas of the facility. Four (4) out of four (4) staff also confirmed that they have seen roaches throughout the facility. During LPA's physical tour, LPA observed roaches in several rooms, in resident drawers and in the common areas of the facility. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is SUBSTANTIATED at this time. Regarding the allegation: Staff are not ensuring that facility is clean. It is being alleged that the common areas of the facility are dirty. This allegation was recently addressed on 05-31-2024 with control number being 31-AS-20240531103114 and it was SUBSTANTIATED at the time. An exit interview was conducted, citation(s) were issued for the above allegation(s), and a copy of this report with the appeal rights was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Jun 11, 2024 · control 31-AS-20240604143032

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 12, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on the LPA's observations, staff/ resident interviews, the staff did not ensure the residents to have a clean and sanitary facility including rooms, common areas clean of roaches thus ensuring the facility was clean, which poses an immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2024

Plan of correction: The administrator/Licensee must at all times keep a facility free of roaches. The administrator/licensee is to show proof of pest control service/documentation and send to LPA by POC 06/12/2024

Allegation investigated: Staff failed to protect resident from assault

On 06/06/24, at 9:57am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by the Resident Care Director, Mary Jane Reyes. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 10:25am, LPA toured the physical plant. During the tour, twelve (12) residents and four (4) staff were interviewed. 9099C-continued Unsubstantiated Regarding the allegation: Staff failed to protect resident from assault. It is being alleged that the staff did not protect the resident from a fight that happened between them and another resident. Twelve (12) out of twelve (12) residents confirmed that they were present when the fight occurred between both residents. Twelve (12) out of (12) residents confirmed that resident #1 (R1) hit resident #2 (R2) and R2 defended themselves. Four (4) out of four (4) staff also confirmed that R1 has a history of yelling, screaming and being aggressive with others. Two (2) out of two (2) staff were present the day the incident occurred and wrote statements of what happened. The administrator confirmed that this type of behavior happened in the past and they have documentation of R1's behavior. During LPA's tour, LPA observed R1 during lunch time in the dining area, start to yell and scream at other residents for no reason while LPA was conducting resident interviews. In addition, LPA obtained the Unusual Incident/Injury Report of the day of the fight and the 911 incident case number. Therefore, based on the LPA's observations and documentation review, staff and resident’s interviews the above allegation(s) is unsubstantiated at this time. An exit interview was conducted, and a copy of this report was given to the Resident Care Director.the state’s words, verbatim · CDSS document, Jun 6, 2024 · control 31-AS-20240603145030

Allegation investigated: Staff did not meet resident’s hygiene needs Staff discarded resident’s clothing without consent of resident’s authorized representatives

On 06/03/24, at 10:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Director, Mary Jane Reyes. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 11:05am, LPA toured the physical plant. During the tour, twelve (12) residents and five (5) staff were interviewed. 9099C-continued Unsubstantiated Regarding the allegation: Staff did not meet resident’s hygiene needs. It is being alleged that the resident’s hair is unkept and dirty. Twelve (12) out of twelve (12) residents confirmed that their hygiene needs are met at the above facility and if they need anything extra they can request it from any of the staff. Five (5) out of five (5) staff also confirmed that the resident's hygiene needs are met based on their level of care; some residents need more help than others depending on the level of care that the individual has. During LPA's tour, LPA did not observe any resident needing hygiene care. Therefore, based on the LPA's observations, staff and resident’s interviews the above allegation(s) is unsubstantiated at this time. Regarding the allegation: Staff discarded resident’s clothing without consent of resident’s authorized representatives. It is being alleged that the resident’s clothing has been thrown away. Twelve (12) out of twelve (12) residents confirmed that they know the policy of personal property and valuables, theft and loss. Five (5) out of five (5) staff also confirmed they know they are to report immediate loss or damage to a resident's property/valuable to management staff. During LPA's record review, all residents have a Client/Resident Property Log in their file. Therefore, based on the LPA's observations and record review, staff and resident’s interviews the above allegation(s) is unsubstantiated at this time. An exit interview was conducted, and a copy of this report was given to the Resident Director. Regarding the allegation: Staff did not ensure to keep facility free of mold. It is being alleged that the above facility has mold. Twelve (12) out of twelve (12) residents did say that their room is cleaned on a weekly basis and they see different staff cleaning. Five (5) out of five (5) staff say that the rooms get cleaned weekly. During LPA's physical tour, LPA toured different rooms and was able to observe that some bathrooms were not clean and free of mold. Therefore, based on the LPA's observations, the above allegation(s) is SUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure to keep facility clean. It is being alleged that the above facility is filthy. Twelve (12) out of twelve (12) residents did say that the facility is cleaned on a daily basis and see different staff cleaning different areas. Five (5) out of five (5) staff say the facility gets cleaned everyday depending on the workers they have on a particular day. During LPA's physical tour, LPA toured different rooms and was able to observe that some rooms were not clean and in disrepair. Therefore, based on the LPA's observations, the above allegation(s) above is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) given, appeal rights, and a copy of this report was given to the Resident Director.the state’s words, verbatim · CDSS document, Jun 3, 2024 · control 31-AS-20240531103114

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a)(1) · Plan of correction due date: Jun 4, 2024

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times...(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on the LPA's observations, the staff did not ensure the residents to have a clean and sanitary bathroom free of mold, surface areas of bathroom need repair and light fixture needs a cover which poses an immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2024

Plan of correction: The administrator/Licensee must at all times keep a facility free of mold. At the time of visit there was a maintenance crew of three (3) individuals repairing/cleaning the bathroom and light fixture of resident #1(R1). POC CLEARED at time of visit-06/03/24

Allegation investigated: Staff do not ensure a resident's smoke alarm is properly operating

On 06/03/24, at 10:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Director, Mary Jane Reyes. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 11:05am, LPA toured the physical plant. During the tour, twelve (12) residents and three (3) staff were interviewed. 9099C-continued Unsubstantiated Regarding the allegation: Staff do not ensure a resident's smoke alarm is properly operating. It is being alleged that the smoke alarm in the resident’s room is always beeping and the beeping sound has been going on for at least the past 3 to 4 weeks. Twelve (12) out of twelve (12) residents were able to confirm that their smoke alarm works in their room and they have no issues with any beeping sound. Three (3) out of three (3) staff confirmed that if there is any issues with alarms beeping the maintenance staff will take care of it as soon as possible. During LPA's physical tour, there was no sound of any alarms beeping. LPA entered several of the rooms including Resident #1 and there was no beeping sound. Therefore, based on the LPA's observations, staff and resident’s interviews the above allegation(s) is unsubstantiated at this time. An exit interview was conducted, and a copy of this report was given to the Resident Director.the state’s words, verbatim · CDSS document, Jun 3, 2024 · control 31-AS-20240529125203

Allegation investigated: Illegal drug activities on the premises

On 05/22/24, at 12:37pm, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Administrator, Kandice Vergara. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to deliver findings for this complaint. On 12/26/2023, LPA Gina Saucedo initiated the complaint investigation. On 12/26/23, LPA Saucedo asked for the census, staff, and resident roster. On 12/26/23, LPA Saucedo interviewed staff and residents. On 12/26/23, the complaint was referred to Investigations Branch (IB) and it was accepted for investigation. The Investigator assigned was Lorraine Patterson. On 05/22/24, at 12:50pm, LPA conducted the physical tour. The investigation from Investigator Lorraine Patterson revealed the following: LIC 9099C-continued Unsubstantiated Regarding the allegation: Illegal drug activities on the premises. It is being alleged that there is illegal drug readily available, for free, and it's allowed, and no one does anything about the drugs and drug use in the facility. On 01/04/2024, IB Investigator Lorraine Patterson spoke to the reporting party (RP) via telephone. RP mention the facility was made aware of the drug use. On 01/10/24, IB investigator Patterson and Special Investigator Assistant (SIA) Rocio Flores conducted a physical tour along with staff and resident interviews. When investigator Patterson interviewed the Residential Care Director, they mentioned the house rules/policy and how drug use is a violation, and an eviction or warning can be issued to the resident. The Residential Care Director showed Investigator Patterson recent Unusual Injury/Incident reports and one (1) showed an eviction notice due to drug use in the facility. Investigator Patterson also reviewed Resident #1 (R1)’s file, previous complaints, and took some pictures of the no smoking signs and smoking areas. Investigator Patterson interviewed two (2) more staff that confirmed that they do not have any concerns relative to drug activity/use taking place on the premises and/or being provided for free and that illegal drugs are not permitted. Investigator Patterson interviewed three (3) out of three (3) residents that confirmed that they have not seen, heard and denied any drugs being used on premises, allowed, permitted, and or provided for free. Investigator Patterson attempted to interview three (3) out of three (3) additional residents that were not available and/or refused to speak to them. Based on the observation of the IB Investigator, interviews conducted, and record review, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, May 22, 2024 · control 31-AS-20231221160517

Allegation investigated: Residents are not provided with activities. Staff isolate residents. Staff do not maintain accurate records. Staff lock residents in their rooms.

At 1:00pm, Licensing Program Analyst (LPA) Angela Panushkina conducted a subsequent visit to deliver final findings.LPA met with the Administrator and explained the reason for the visit. During course of the investigation, interviews and record review were made. At 1:05pm, LPA requested resident and staff roster. At 1:10pm, LPA requested copies of pertinent information which include, but not limited to Facility Activity Program and Schedule relevant to the investigation. At approximately 1:15pm, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 1:20pm – 2:30pm, LPA interviewed the Administrator, Activity Director, two (2) staff, and eight (8) out of twelve (12) residents. Also, while interviewing residents, LPA randomly tested resident’s bedroom/unit doors, in an Assisted Living and Memory Care Unit. Continue on LIC9099-C Unsubstantiated Allegation: Residents are not provided with activities. It was alleged that during six random visits conducted from 09/17/21 - 03/16/22 the facility did not provide any Activity to the residents and no Activity schedule was available for review, upon request. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that the facility posts monthly Activity schedule for the residents in Memory Care Unit and Assisted Living. LPA was also informed that during the time mentioned above, the facility followed COVID protocol regarding minimizing big/long gatherings to protect residents health and well being. Moreover, interview with the Administrator revealed that Activities for the residents were never stopped completely. In addition, LPA was able to interview eight (8) out of twelve (12) residents and all residents interviewed expressed no concerns regarding the above allegation. Lastly, during todays visit, LPA observed thirteen (13) Memory Care Unit and twelve (12) Assisted Living residents engaging in a daily activity. Based on interviews, record reviews and LPA observation this allegation is deemed Unsubstantiated at this time. Staff isolate residents. It was alleged that the facility isolated residents between 09/17/21 - 03/16/22. To investigated this allegation, LPA conducted an interview with the Administrator and was informed that the facility always has enough staff members to provide care and supervision to residents in a Memory Care Unit. LPA was informed that due to Covid pandemic, frequent isolation was followed by the Department of Health. Interview with the Administrator also revealed that the facility staff respect all residents' personal rights and will attempt, but not force residents to commingle and or participate in certain activities. Moreover, interviews with two (2) staff members revealed that some residents, in a Memory Care Unit, like to be left alone. Although, the staff will redirect them to engage in communication or other activities, some residents may continue to and have a right to refuse. Lastly, during the visit, LPA observed staff members redirecting residents into common areas of the facility. Based on interviews, record reviews and LPA observation this allegation is deemed Unsubstantiated at this time. Continue on LIC9099-C Staff do not maintain accurate records. It was alleged that the facility Memory Care Unit has no rooms labeled with resident names and the census don’t match the residents who are actually in the room. To investigate this allegation, LPA conducted a tour in a Memory Care Unit on 05/16/24 and observed all resident rooms labeled with names, however, some labels are removed/torn/damaged. Interview with the Activity Director and two (2) staff members revealed that due to R1's mental condition, R1 remove/damage labels. However, once the staff is aware of that, they inform the management, and a new label is created and placed at the door. Interview with the Administrator revealed that residents would periodically remove the names from the individual rooms, however, that was never an issue for the facility staff to replace it with a new one. Administrator also informed LPA that R1 removes all labels and the facility is now working on replacing the labels with something different that cannot be damaged/torn/removed. Moreover, Administrator denied the above allegation and stated: “All resident names always matched/matches the facility census.” Lastly, during today’s visit, LPA confirmed that a Memory Care Unit residents, who are in the room, match with the facility census. Therefore, based on interviews, observation and record reviews, this allegation is deemed Unsubstantiated at this time. Staff lock residents in their rooms. It was alleged that residents in a Memory Care Unit are kept locked in their rooms. To investigate this allegation, LPA conducted an interview with the Administrator and an Activity Director. Both parties denied ever witnessing or hearing residents being locked in their rooms. LPA was informed that the doors can only be locked from inside by the resident. However, all staff members have a master key and can easily gain access. Interview with two (2) staff members revealed that a Memory Care Unit currently has five (5) wandering residents. LPA was also informed that when residents are out in common areas all resident doors are kept locked to prevent wandering residents from entering. Interview with two (2) staff and an Activity Director also revealed that all Memory Care Unit residents doors are always unlocked, when the resident is in the room, and the staff checks on them every hour. LPA visited five (5) random rooms and observed that the door has no auto lock and can easily be opened. However, the door is kept locked from the outside and only a staff member with master key can gain access. Therefore, based on interviews, observation and record reviews, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 16, 2024 · control 31-AS-20220415164023

Allegation investigated: Staff not safeguarding residents belonging. Resident does not receive packages in a timely manner. Facility has mold. Resident left in soiled diapers for extended amount of time.

At 1:00pm, Licensing Program Analyst (LPA) Angela Panushkina conducted a subsequent visit to deliver final findings.LPA met with the Administrator and explained the reason for the visit. Initial 10-day visit was conducted by LPAs Tan and Smith on 01/13/2022. During that visit, LPAs investigatied complaint control #31-AS-20220104133216 with similiar allegations. In addition, multiple visits were conducted by LPA Martinez ranging from March – October 2022. LPA Martinez conducted physical plant tour and LPA specifically toured R1’s bedroom. Moreover, on 06/30/2022, LPA Panushkina conducted a subsequent visit. During course of the investigation, interviews and record review were made. At 11:05am, LPA requested resident and staff roster. At 11:10am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Preplacement Appraisal, Continue on LIC9099-C Unsubstantiated relevant to the investigation. At approximately 11:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. LPA also conducted an interview with the Administrator, Resident Care Director, Wellness Coordinator, Maintenance Director, 11 out of 11 residents and reviewed facility records. Allegation: Staff not safeguarding residents belonging. It is alleged that on 11/27/2021 R1's family member could not find the soaps and tissues that were bought for R1 the week prior. To investigate this allegation, on 06/30/22, LPA conducted an interview with the Administrator, Resident Care Director and Wellness Coordinator. All parties interviewed confirmed that R1 would occasionally receive hygiene supplies, however, it was enough to last one week. An interview conducted with the Resident Care Director also revealed that no staff have lost, stolen or misplaced any of R1’s items. Administrator stated that staff would assist R1 with storing their hygiene supplies, and R1 would often state that their supplies would go missing. However, Administrator does not believe any staff have stolen any of R1’s items. Moreover, LPA conducted an interview 11 out of 11 residents. Ten (10) out of eleven residents, expressed no concerns regarding the above allegation and have not had any hygiene supplies missing/stolen. Based on interviews and LPA observation this allegation is deemed Unsubstantiated at this time. Allegation: Resident does not receive packages in a timely manner. It was alleged that the packages sent by R1's family were never provided to R1. To investigate this allegation, LPA conducted an interview with the Administrator, on 06/30/22, who stated that he had not heard complaints from any other resident. Administrator also stated that no staff have been noted to interfere with the resident’s mail. LPA interviewed the concierge who frequently works at the front desk. S1 stated that the mail is sorted into the resident’s individual mail box and is being picked up by residents twice a week. For some residents that are unable to come and pick up their mail/packages, the staff will deliver everything to their room during the day. Interviews with ten (10) out of eleven (11) residents revealed that they have never had any issues receiving their mail. Based on interview’s conducted this allegation is deemed Unsubstantiated. Continue on LIC9099-C Allegation: Facility has mold. It was alleged that R1's family member visited R1 (date unknown) and observed mold around the frame of the window. During the initial visit conducted by LPA Tan it was reported that LPA observed the room in which R1 stayed on 1/5/22 and LPA did not observe any mold in the room nor in R1's oxygen tube. Additionally, LPA Martinez conducted various onsite visits from March - October 2022, and LPA Martinez did not observe any mold on walls nor windows. LPA interviewed the Administrator, and Administrator stated that there were never any reports of mold on the walls or windows made by R1 or staff. Moreover, during 06/30/22 visit, LPA Panushkina conducted an interview with the Maintenance Director who also denied the above allegation. In addition, interviews with ten (10) out of eleven (11) residents revealed that they do not have issues with mold in the room. Lastly, during a physical plant tour, LPA did not observe any mold nor other, mold related issues in resident rooms. Due to interviews conducted, this allegation is deemed Unsubstantiated. Allegation: Resident left in soiled diapers for extended amount of time It was alleged that staff left R1 in a soiled diapers for an extended period of time. To investigate this allegation, LPA conducted an interview with R1 on 06/30/22 and was informed that R1 is being changed once or twice during a 24-hour time frame causing R1 to have a rash on bottom. However, interview with the Administrator, Resident Care Director, Wellness Coordinator revealed that the facility staff must change all incontinent residents every two (2) hours or as needed. Interview with three (3) staff members confirmed that during their shift they check/change incontinent residents at least 2-3 times or as needed. Moreover, five (5) incontinent residents interviewed stated that the staff has never left them unclean and that they are assisted to the restroom whenever they request to be taken and or being changed immediately upon request. Lastly, during the subsequent visit conducted on 06/30/22, LPA observed R1 just had a shower and LPA did not observe any strong smells of urine in R1's room. Based on interviews and LPA observation, there is not enough evidence to support the above allegation. Therefore, this allegation is deemed Unsubstantiated at this time. No deficiencies issued. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 16, 2024 · control 31-AS-20220104080541

Allegation investigated: Illegal eviction

On 05/13/24, at 9:55am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Activites Director, Tabetha Whitehall. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 10:25am, LPA toured the physical plant. During the tour, twelve (12) residents and three (3) staff were interviewed. Unsubstantiated Regarding the allegation: Illegal eviction. It is being alleged that a resident is saying staff is trying to make an example of them, to their peers and to their fellow patients by evicting them. Eleven (11) out of twelve (12) residents were able to confirm that they do not have any issues following the house rules. Eleven (11) out of the twelve (12) residents confirmed that they are aware of the admission agreement, and they also confirmed they are aware of the eviction rules. Two (2) residents confirmed that they have observed resident #1 (R1) using illegal drugs on facility grounds. LPA’s interview with R1 confirmed that their behavior did not comply with general policies of the facility. Two (2) out of three (3) staff confirmed that they were present when they serviced R1 with the appropriate eviction notice. Three (3) out of three (3) staff are aware of the house rules and eviction policy. On April 16, 2024, the resident director and the Activities director were witness to the resident signing the proof of service regarding eviction regarding illegal drug use in the facility. In addition, the administrator provided the resident with the proper reasoning of eviction explaining that drug use is a concern to health and safety code, there is a zero-tolerance policy for risking the lives of residents with this type of behavior. On April 17, 2024, LPA received the appropriate eviction notice of R1 via fax through Community Care Licensing Department (CCLD) and within the proper days of notice. On April 10, 2024, via fax/CCLD, LPA received an Unusual Incident/Injury reported stating that R1 refused to go to the hospital when the paramedics were called because R1 was overdosing on illegal drugs at the above facility and the paramedics had to administer Narcan. LPA’s interview with the administrator confirmed that placement has been found for R1 through the Assisted Living Waiver program. LPA also obtained R1’s admission agreement and house rules signed by R1 on 05/29/2023. Therefore, based on the LPA's record reviews, staff and resident’s interviews the above allegation(s) above is unsubstantiated at this time. An exit interview was conducted, no citations were issued for above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, May 13, 2024 · control 31-AS-20240508141207

Allegation investigated: Staff did not ensure that resident's personal possessions were safeguarded.

On 04/02/24, at 9:55am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Director Mary Jane Reyes. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 10:20am, LPA toured the physical plant. During the tour, twelve (12) residents and five (5) staff were interviewed. LIC 9099C-continued Unsubstantiated Regarding the allegation: It is being alleged that a resident's (R1) fanny pack disappeared from their room and reappeared weeks later with a large sum of money still missing. Eleven (11) out of twelve (12) residents were able to confirm that they have never had any items stolen from their room especially money. It was also confirmed that Eleven (11) out of twelve (12) residents are aware of the Theft and Loss Policy. In addition, five (5) out of five (5) staff are aware of the Theft and Loss Policy. Five (5) out of five (5) staff confirmed that they helped search for the missing items in (R1)’s room and documented it. LPA obtained all four (4) written documents and the Unusual Incident/Injury Report from the Resident Director that was sent to the Licensing Department stating the loss of the item(s). LPA also obtained R1's Client/Resident Personal Property and Valuables and the Cash Resources from the Admission Agreement stating that the facility does not maintain or supervise resident cash resources. LPA also reviewed the Theft and Loss Policy that was posted at the facility. Therefore, based on the LPA's interviews and observations the above allegation(s) above is unsubstantiated at this time. An exit interview was conducted, no citations were issued for the above allegation(s), and a copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Apr 2, 2024 · control 31-AS-20240327121941

Type of visit: Required - 1 Year

On 03/13/24 at 9:05AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Resident Care Director Mary Jane Reyes and disclosed the purpose of the visit. LPA asked for the census, resident, and staff rosters. A physical tour was conducted at 11:10 AM and observed the following: The entire facility has a total of 175 (one-hundred and seventy-five) beds. The facility is a two-story building: First floor and second floor: It is both assisted living and memory care. The facility has two (2) memory care units: Evergreen located on the second floor and Willow located on the first floor. There are two medication rooms one on the first floor and one on the second floor. The Evergreen Memory Care section of the facility has their own activity, television, and dining hall area. The door has a code and delayed egress on the doors. The other Memory Care-Willow also has its own activity, television, and dining hall area. The assisted living side has their own activity room on the second floor, dining hall on the second floor and a television room on the first floor. The assisted living side has access to a huge patio area with proper seating for residents. Random Bedrooms were randomly selected to tour and were observed to have appropriate furniture, lightening, bedding, and televisions. Random Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested randomly for and measured 105–118-degree Fahrenheit. LIC 809C-continued Fire extinguishers were observed throughout the facility and were fully charged on green with different dates. There are fire extinguishers upstairs, downstairs and in the kitchen area. Carbon Monoxide and fire alarms are located throughout the facility and are operable. Facility has two designated medication rooms that are inaccessible to residents where all the medication is stored and locked in the memory care side of the facility. There are always two (2) med-tech staff in the facility during the daytime for each side-memory care and assisted living. Common Areas: These include the dining areas, activities room, television rooms: All common areas were observed to be cleaned and properly furnished. Facility maintains a comfortable temperature of 69.-78-degree Fahrenheit. There are several temperature thermostats throughout the facility. There are several common bathrooms throughout the upstairs and downstairs area. The staff and resident bathrooms are not shared. There are trash cans with lids and covid signs posted in the common bathrooms. There is toilet paper and napkins. The facility has no body of water. There is one facility laundry area on the first level with chemicals inaccessible to the residents. The staff lounge is also located on the first level of the facility. The Kitchen area was toured, and LPA observed sufficient supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The kitchen is located on the first floor. The assisted dining area has access to this kitchen where at the time of the tour different residents were having lunch with proper feeding utensils/plates/cups. Administrative: There is no annual fee that is due right now. The Insurance plan is dated as of 07/2024. There is an Emergency Disaster plan, Personal Right, Rights of Resident Council, YES, Licensee, and Ombudsman sign on your left-hand side at the entrance of the facility, Fire Drill-February 19, 2024. An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Mar 13, 2024

Allegation investigated: Staff do not prevent residents from smoking in nonsmoking areas

On 03/12/24, at 8:50am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Resident Care Director Mary Jane Reyes. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather additional information, conduct more interviews and deliver findings for this complaint. On 07/05/2023, LPA Melissa Spaeth initiated the complaint investigation. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 9:30am, LPA toured the physical plant. During the tour, twelve (12) residents and three (3) additional staff were interviewed. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff do not prevent residents from smoking in nonsmoking areas. It is being alleged that facility staff are allowing residents to smoke in areas of the facility that are designated as nonsmoking. LPA was able to obtain three (3) different thirty (30) day eviction warning letters given to three (3) different residents warning them of House Rules/Facility Policy of The Community pertaining to no smoking in certain areas. During LPA’s physical tour, LPA was able to interview twelve (12) out of twelve (12) residents that have confirmed that they are aware of the non-smoking signs in several different areas of the facility. LPA interviewed smoking and non-smoking residents. LPA was able to observe six (6) different signs posted in different areas of the facility that stated "no smoking area". LPA obtained all six (6) pictures/postings: There was two (2) posted in the front of the facility. There was one (1) on the door of the dining hall, one (1) on a room door down the hallway displaying danger oxygen in use, One (1) against the wall of the patio area and another one (1) with a standing sign along the patio area. The resident care director also showed LPA where the residents are allowed to smoke. LPA took a picture of the designated smoking area for residents where there are several ash tray bins for cigarette butts. LPA was also able to interview three (3) additional staff that confirmed the smoking/non-smoking areas. Therefore, based on the LPA's interviews, observations, and record reviews the above allegation(s) above is unsubstantiated at this time.the state’s words, verbatim · CDSS document, Mar 12, 2024 · control 31-AS-20230630105843

Allegation investigated: Staff intimidating a resident Staff do not repositioned resident Staff do not assist resident with incontinence needs timely resulting in a rash Staff are not safeguarding a resident's property

At 4:45p.m. Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced complaint visit to deliver the finding for the above noted allegations. At 4:50p.m. LPA met with Resident Care Director, Mary Jane Reyes and explained the reason for the visit. During initial visit conducted on 02/25/22 at 9:25am Licensing Program Analysts (LPA) Shira Stamps conducted a physical plant tour, interviewed facility staff, and collected relevant records. During subsequent visit conducted on 03/14/22 at 10:30am LPAs Shira Stamps and Joscelyn Martinez arrived at the facility. LPAs conducted a physical plant walk through, interviewed additional staff and residents’, and collected relevant documents. Prior to this visit on 02/26/2024 LPA Antonia Alvizar-Ettima reviewed the information and the documents previously gathered by other LPAs on 02/25/22 and 03/14/2022. Unsubstantiated 1. Staff intimidating a resident. It was alleged that R1 was told by the administrative personnel that staff #1 (R1) is being written up for helping R1. During previously conducted interviews, the Wellness Coordinator and Administrator denied writing up S4. S4 was interviewed and denied being written up. R1 was unable to provide specific details to explain who told R1 that S4 will be written up and why? A review of facility records including S4’s file, did not reveal any sufficient information to support the allegation. Therefore, based on interviews and record review the allegation is unsubstantiated at this time. 2. Staff do not repositioned resident It was alleged that staff do not sit up or turn R1. Staff interviews revealed that residents are being repositioned every two (2) hours and after meals. All residents interviewed including R1 did not address any concerns about turning and reposition or transfer assistance. Resident #9 (R9) stated staff never reposition them. However, per resident’s file review R9 is not identified as a bedridden resident requiring turning and repositioning. A review of R1’s record revealed that R1 is non-ambulatory and does not require turning and repositioning in bed. Staff is assisting them to transfer in and out of bed. Based on interviews and record review, there is no sufficient information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. 3. Staff do not assist resident with incontinence needs timely resulting in a rash It was alleged that staff are changing R1 once or twice during a 24-hour time frame causing R1 to have a rash on bottom. Staff interviews revealed that incontinent residents are being changed three (3) to four (4) times a day or as needed. During facility internal investigation, R1 indicated to staff that they were changed, but not by S4. R1 was changed by another staff. Other residents revealed that staff changes them three (3) times a day, and more often if needed. A review of facility incontinent log supported the information provided by staff and residents. No information was available during this investigation to confirm the allegation. Therefore, the allegation is unsubstantiated at this time. 4. Staff are not safeguarding a resident's property It was alleged that staff are taking R1 over the counter medications and ointments. Staff revealed that R1 is the only resident that reports things missing. When residents’ things are missing the policy of theft is to investigate what resident brought and logged in. Staff also revealed that residents are not allowed to keep over the counter medications or ointments in their possession. The medication is distributed to the residents by the facility staff. R1 indicated that they were never given a paper to list their personal items. Other residents revealed that they never had their items go missing. A review of R1’s record revealed that R1 did not report their personal belongings. No supporting information was available during this investigation to verify the allegation. Therefore, based on interviews and record review, the allegation is unsubstantiated at this time. No immediate health and safety hazard is noted during this visit. Exit interview conducted with Resident Care Director, Mary Jane Reyes and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 26, 2024 · control 31-AS-20220223100228

Allegation investigated: Staff did not ensure that the facility was maintained free of pests.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with Resident Care Director, Mary Jane Reyes, and explained the reason for the visit. --- Staff did not ensure that the facility was maintained free of pests. It was alleged that Resident #1’s (R1) room and dresser had bugs. To investigate the allegation on 09/18/2023 LPA conducted physical plant tour at around 10:45 AM, interviewed 04 (four) staff at 11:45 AM, and interviewed 14 (fourteen) residents at 01:45 PM. During the physical plant tour, LPA did not observe pests or bugs in any of the rooms or dressers. During interviews with staff, Staff #3 stated that the facility does have a cockroach and mosquito issue and it is often rooms where residents take food to their rooms. All other staff stated that the facility has mosquitoes only. (CONT. LIC9099-C) Substantiated During interviews with residents, three (03) out of fourteen (14) residents stated that they have witnessed cockroaches in the facility. All other residents stated they do not feel that the facility has any insect or pest problems and have not witnessed any. Based on interviews, there is sufficient corroborating information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued. During interviews with staff, all staff stated that residents are changed a minimum three times per day and more if needed, that residents are checked on every two hours and bed pads are changed every morning and whenever soiled. Staff also stated that malodors are only present when resident relieve themselves and during changing which cannot be avoided, but rooms are cleaned and refreshed by cleaning and airing out. During interviews with residents, all residents stated that they are changed often, are not left soiled for an extended time and do not experience malodor in the facility. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 31-AS-20230914123856

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 5, 2024

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on interviews, one (01) staff and three (03) residents stated they've encountered cockroaches at the facility. This poses an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Although the facility hired a pest control company to service the facility for insects periodically, as a POC, the Administrator will schedule an appointment with pest control company and submit documentation as proof of service. The Administrator will also submit a written letter stating that they have reviewed Title 22 Div. 6 Ch. 8 of the CA Code of Regulations 87303(a) and, going forward, will adhere to the regulation.

Allegation investigated: Staff caused injury to resident Staff is physically abusive to residents Staff is verbally abusive to residents

On 01/30/24, at 0:855am, Licensing Program Analyst (LPA) Gina Saucedo conducted a subsequent, complaint investigation at the above facility to address the following allegation(s). LPA Gina Saucedo was met first by Mary Jane Reyes-Resident Care Director. LPA explained the purpose of this visit was to gather information, interviews and deliver findings for this complaint. The investigation consisted of the following: on 01/24/24, LPA Saucedo initiated a complaint investigation. On 01/30/24, at 9:20am, LPA Saucedo toured the physical plant and requested records. The following records were requested: staff roster and resident roster. Additional records were also obtained regarding R1 R2: Needs and services plan, physician report, Identification and emergency contact information, resident information/care plan, preplacement appraisal, functional capability assesment and resident appraisal. 9099C-continued Unsubstantiated Regarding the allegation: Staff caused injury to resident. It is being alleged that the staff threw resident on the floor, they hit something and sustained “laceration” between their eyes above their nose. According to the interviews that the LPA conducted from the staff and the injury report obtained, the resident fell to the floor hitting their forehead against one of the metal chairs while the staff was preventing them from leaving the memory care unit, but this was not due to staff throwing them on the floor. The interview with the LVN also confirmed that when they saw and gave aid to R1, the gash obtained on R1’s forehead was bleeding and they asked R1 about the injury. R1 stated they fell. LPA was able to obtain a picture of R1’ injury on their forehead. LPA’s interview with the alleged staff confirms that R1 fell to the floor hitting their head while they were trying to hold R1 against one of the chairs in the dining hall so R1 would not leave the memory care area of the facility. According to the resident care director, R1 has a history of trying to leave the facility and go home. LPA attempted to interview R1 but R1 could not describe what happened that day. LPA obtained R1’s records stating that R1 is sometimes confused/disoriented due to their diagnosis. Regarding the allegation: Staff is physically abusive to residents. It is being alleged that the staff hits residents and sprays residents with a water bottle. LPA was able to interview nine (9) out of eleven (11) residents and they all say that the staff does not physically abuse them. On the day of the incident, the alleged staff attempted to stop R1 from leaving the memory care unit but R1 became agitated. R1 has a history of wandering behavior. R1 wanted to leave the facility and continued to say they were leaving walking towards one of the exit doors. Once the alleged staff attempted to stop them from leaving the memory care unit, R1 fell to the ground and hit their head against the metal part of the chair. In addition, the LPA was also able to interview ten (10) out of eleven (11) staff that have confirmed that the alleged staff does not physically abuse the residents. Some staff also say that the alleged staff have trained them to do their job and have worked with that staff for many years with no issues. LPA was able to review the alleged staff’s file and made no observations of the staff being reprimanded for anything during their work history. LPA also interviewed the resident director and administrator where they state that there have been no reprimands and/or past allegations of this sort regarding the alleged staff. LPA was also able to obtain the police report where it states that R1 denied any abuse. LIC 9099C-continued Regarding the allegation: Staff is verbally abusive to residents. It is being alleged that the staff calls the residents inappropriate names. LPA was able to interview nine (9) out of eleven (11) residents and none of the nine (9) residents have heard or know of the staff being verbally abusive to them. In addition, the LPA was also able to interview ten (10) out of eleven (11) staff that have confirmed that the alleged staff does not verbally abuse the residents. They do admit that the alleged staff is very loud but that is the tone in their voice. Based on the LPA's interviews, observations, and record reviews all three allegation(s) above are unsubstantiated at this time. An exit interview was conducted, no citations were issued for the three (3) above allegations, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 31-AS-20240123163901

Allegation investigated: Facility staff have mismanaged resident's Social Security funding. Resident is not receivng their personal needs income as required. Resident's accounting records are not being maintained properly. Resident's Representative is not being communicated to by staff in a timely manner. Facility is preventing the Long Term Care Ombudsman from resolving complaints involving resident. Facility is preventing the Long Term Care Ombudsman from examining resident's records at the facility.

Licensing Program Analysts (LPAs) Chris Alemoh and Michael Cava conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegations. LPAs met with the administrator, Kandace Vergara, and advised her of the complaint. Today's investigation consisted of an interview with the administrator and record review. A physical plant inspection was also made. Facility staff have managed resident's Social Security funding/Resident is not receiving their personal needs income as required/Resident's accounting records are not being maintained properly: In regards to the allegation, it was reported that facility started the process to become payee for Resident 1 (R1) on or around July 2021. Since that time, R1 stopped receiving their personal needs money and all social security payments. As a result, R1's family and friends were using their own money to purchase R1's personal items since there is no money being given to the resident. Unsubstantiated On or around March 3, 2022, LTCO met with R1 and confirmed that R1 had "no idea" where their money was and had not received "any money in a very long time". According to the administrator, the facility didn't handle R1's finances until June 1, 2022. Prior to that, R1's monies were deposited directly into their personal bank account. R1's family would then pay the facility, via check, their rent on the due date. Facility only received payment from May 2021 to July 2021, and then stopped receiving rental payment from R1's family. The last payment received from R1 was June 1, 2022, for $626.21. R1 left the facility after June 1, 2022. R1 currently has an overdue balance of approximately $14,980. Review of R1's records indicate that R1's monthly rent is $1070 per month. The statements from the business office confirm that payment was only received from May 2021 to July 2021. LPAs also reviewed a letter from Social Security Administration indicating that R1's SSI will be sent to the facility as of June 1, 2022. Based on the information received, it could not be proven that facility staff have managed R1's Social Security funding, R1 is not receiving their personal needs income as required and R1's accounting records are not being maintained properly. Therefore, the allegations are deemed Unsubstantiated at this time. Resident's Representative is not being communicated to by staff in a timely manner: In regards to the allegation, it was reported that no one from the facility had informed R1 or their family about R1's account and or rent being behind and not receiving monies for their Personal Needs Income (PNI). According to the administrator, the facility didn't help handle R1's finances until June 1, 2022. R1 is in the Assisted Living Waiver program (ALW). Although finances weren't being handled by the facility, email notification was getting sent to the ALW program and R1's family, advising them of R1's overdue payments. Review of R1's records confirm notification was getting sent. LPAs obtained copies of these email notification. Based on the information obtained, there was insufficient evidence to prove that R1's representative is not being communicated in a timely manner. Therefore, the allegation is deemed Unsubstantiated at this time. Facility is preventing the Long Term Care Ombudsman from resolving complaints involving resident/Facility is preventing the Long Term Care Ombudsman from examining resident's records at the facility: In regards to the allegations, it was reported that the facility has willfully interfered, impeded, and prevented the ombudsman from resolving the resident's complaints. The facility has also willfully prevented and interfered with examination of the resident's personal records in order to carry out the ombudsman's responsibilities. Interviews with the administrator and Staff 1 (S1) deny the allegation. Both stated they cooperated with the ombudsman's investigation. Pursuant to WIC, medical or personal records of a patient could only be provided by the facility to any entity only with the expressed written consent of the patient/resident. Administrator stated that they received instruction not to provide any resident's personal and/or medical information/document to anyone without the consent of the resident. Based on the information obtained, there was insufficient evidence to prove that the facility is prevented the Long Term Care Ombudsman from resolving complaints involving resident and the facility prevented the Long Term Care Ombudsman from examining resident's records at the facility. Therefore, the allegations are deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Oct 4, 2023 · control 31-AS-20220608164259

Allegation investigated: Staff are selling illicit drugs. Residents in care are using illicit drugs. Staff failed to seek timely medical treatment. Staff did not provide proper food service to resident in care Staff is verbally abusive to resident in care Staff did not safeguard resident's personal belongings

At 10:30am, Licensing Program Analysts (LPAs) Angela Panushkina, Leslie Ngo-Castaneda and Huma Rahimi, conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs met with the Administrator and explained the reason for the visit. During course of the investigation, interviews and record review were made. At 10:35am, LPAs requested resident and staff roster. At 10:40am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:50am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:40am – 1:10pm, LPAs interviewed the Administrator, Resident Care Manager, three (3) staff and eleven (11) out of fourteen (14) residents residents. Continue on LIC9099-C Unsubstantiated Allegation: Staff are selling illicit drugs. To investigate this allegation LPAs conducted interviews with eleven (11) out of fourteen (14) residents and ten (10) out of fourteen residents denied ever witnessing facility staff selling illicit drugs. One (1) out of fourteen (14) residents informed LPAs that the facility staff sells illicit drugs. However, the resident never witnessed nor was able to provide a specific staff name. In addition, LPAs conducted Interviews with the Administrator, Resident Care Manager and three (3) staff members and all staff denied the above allegation. Therefore, based on interviews, LPAs did not have sufficient evidence to prove the allegation, and it’s UNSUBSTANTIATED at this time. Allegation: Residents in care are using illicit drugs. To investigate this allegation LPAs conducted interviews with eleven (11) out of fourteen (14) residents and ten (10) out of fourteen (14) residents denied ever using or witnessing other residents using illicit drugs. One (1) out of fourteen (14) residents informed LPAs that the facility residents use illicit drugs. However, the resident never witnessed nor was able to provide a specific resident name. In addition, LPAs conducted Interviews with the Administrator, Resident Care Manager and three (3) staff members and all staff denied witnessing residents using illicit drugs. LPAs were informed by the Administrator that due to weed being legal to use, the facility has one resident that uses weed in designated area only. Therefore, based on interviews, LPAs did not have sufficient evidence to prove the allegation, and it’s UNSUBSTANTIATED at this time. Allegation: Staff failed to seek timely medical treatment. To investigate this allegation LPAs conducted interviews with eleven (11) out of fourteen (14) residents informed LPAs that they feel very secured at this facility and that the staff always provides immediate assistance in case of an emergency. Moreover, LPAs conducted Interviews with the Administrator, Resident Care Manager and three (3) staff members and were informed that residents involved in any incident are assessed by the MedTech immediately to determine if 911 needs to be contacted. Therefore, based on interviews, LPAs did not have sufficient evidence to prove the allegation, and it’s UNSUBSTANTIATED at this time. Allegation: Staff did not provide proper food service to resident in care. To investigate this allegation, LPAs conducted interviews with eleven (11) out of fourteen (14) residents revealed that the facility provides three (3) meals and snacks in between every day. Moreover, LPAs were also informed that the staff will provide an extra meal upon request. During todays interview with R1, LPAs Continue on LIC9099-C witnessed a staff member bring lunch (soup, vegetables, toast, dessert, etc.) into R1's room. LPAs also witnessed R1 refused the lunch and requested the staff for the Peanut Butter and Jelly. Lastly, interviews with the Administrator, Resident Care Manager and three (3) staff members never had any concerns and that the staff will also customize food being served upon resident's request. Based on the information gathered during this visit, this allegation is deemed Unsubstantiated at this time. Allegation: Staff is verbally abusive to resident in care To investigate this allegation LPAs conducted interviews with eleven (11) out of fourteen (14) residents informed LPAs that they have not experienced or observed any facility staff to be verbally abusive to themselves or any other residents. Interviews of residents also revealed that they can always talk to staff without fear of retaliation or abuse. Several residents also indicated that facility staff are approachable, friendly, and nice. Moreover, LPAs conducted Interviews with the Administrator, Resident Care Manager and three (3) staff members and all staff denied the above allegation. LPAs were also informed that as soon as the staff observes resident being aggressive/combative/behavior episode, etc. they immediately call for help and change the staff member to avoid any complication. Therefore, based on interviews, LPAs did not have sufficient evidence to prove the allegation, and it’s UNSUBSTANTIATED at this time. Allegation: Staff did not safeguard resident's personal belongings During today's investigation, LPAs conducted interviews with eleven (11) out of fourteen (14) residents and ten (10) out of fourteen (14) residents expressed no concerns regarding this allegation. In addition, LPAs were informed that no personal belongings have been taken from them, and whatever was accidentally misplaced during the laundry, the resident received there belongings in a timely fashion. Moreover, interviews with R1 revealed that he/she observed one some of his/her clothes on another resident. However, R1 was unable to identify the resident nor provide specific items were missing. Lastly, interviews with the Administrator, Resident Care Manager and three (3) staff members revealed that a lot of times residents will misplace their belongings and find it later. Therefore, the allegation, resident's personal belongings were taken by staff, is deemed UNSUBSTANTIATED at this time. No Deficiencies cited during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 4, 2023 · control 31-AS-20230928082308