The Gardens at Northridge

Allegation investigated: Staff did not provide adequate supervision to prevent harm by another resident resulting in a fracture. Staff did not intervene to prevent inappropriate physical contact between residents.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility, met with Cynthia Lara-Vargas, and explained the reason for the visit. --- Staff did not provide adequate supervision to prevent harm by another resident resulting in a fracture. It was alleged that Resident #1 (R1) was pushed down by Resident #2 (R2) at the facility causing injury. To investigate the allegation, on March 18, 2026, LPA requested documents at around 9:30 a.m. and interviewed three (03) staff from 10:30a.m. – 12:00p.m., seven (07) residents from 12:00p.m. to 2:30p.m. On April 24, 2026, LPA interviewed an additional three (03) residents at around 01:30p.m. A review of the Serious Incident Report states on December 12, 2025, resident was observed on the floor and per R1, was walking using their walker and when R1 felt someone touch them from behind, they tried to turn around to see, lost their balance and fell. R1 complained of pain on the right shoulder and emergency services were contacted. (CONT. on LIC9099-C) Unsubstantiated A review of the Department’s incident report log shows there were no incident reports for R2 prior to this alleged incident. A review of physician’s reports and needs and service plan for R1 states resident is level two (02) with Mild Cognitive Impairment, is able to translocate and able to perform activities of daily living with some assistance. R1 is unable to leave the facility unassisted. A review of physician’s reports and needs and service plan for R2 states resident is a level one (01) with Mild Cognitive Impairment, disorientation with days of the week, however, all other behavioral expressions state that R2 has impulse control, does not hallucinate, elope or wander. R2 is also ambulatory and able to leave the facility unassisted. A review of the staff schedule for December 19, 2025 shows there were at least four (04) caregivers and two (02) MedTechs per shift. During interviews, all staff stated they did not witness the incident but were in the area, approximately twenty (20) feet from the incident, and immediately went to R1’s aid and called for emergency services. Staff #1 (S1) and Staff #2 (S2) stated when they asked the residents, R1 explained they were touched on the shoulder and lost balance when trying to look back. Staff added all residents are checked on at minimum every two (02) hours. During interviews with residents, R1 stated they were feeling dizzy that day and R2 was always too excited to get their attention and tapped R1 on the shoulder. R1 explained that the fall was a result of trying to look back at the same time. R1 added R2 would wait by the doorway to get an opportunity to speak with R1 and found it strange. R1 explained the tap may have been too hard and could have been gentler in trying to get their attention. R1 added R2 has a relationship partner now and is no longer a bother. R1 feels there is adequate supervision in the facility. R2 stated they have never physically assaulted anyone. All other residents stated they have never experienced an altercation with R2 or witnessed R2 having any physical alterations with other residents. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not intervene to prevent inappropriate physical contact between residents. It was alleged that R2 kissed R1 on the forehead on December 17, 2025, got super close, and made R1 uncomfortable. To investigate the allegation, on March 18, 2026, LPA requested documents at around 9:30 a.m., interviewed three (03) staff from 10:30a.m. – 12:00p.m., seven (07) residents from 12:00p.m. to 2:30p.m. On April 24, 2026, LPA interviewed an additional three (03) residents at around 10:30a.m. (CONT on LIC9099-C) A review of the Department’s incident report log shows there were no incident reports for R2 prior to this alleged incident. A review of physician’s reports and needs and service plan for R2 shows resident is a level one (01) with Mild Cognitive Impairment, disorientation with days of the week, however, all other behavioral expressions state that R2 has impulse control, does not hallucinate, elope or wander. During interviews, all staff stated they are not aware of R2 kissing R1 on the forehead or aware of R2 making R1 feel uncomfortable. During interviews with residents, R1 stated R2 kissed them on the forehead and made them uncomfortable. R1 added they feel safe in the community around R2 as they are no longer pursuing a relationship. R2 stated they do not recall kissing R1 on the forehead. All other residents stated they feel safe in the community and have not witnessed any inappropriate contact between R2 and R1. Based on interviews and record review, 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, Apr 24, 2026 · control 31-AS-20251220163614

Allegation investigated: Staff neglect led to resident death Staff did not adequately address resident's fall risk

On 03/23/26, at 11:36am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Lisa Villasenor, Executive Director. LPA explained the purpose of this visit was to deliver findings for this complaint. On 12/03/25, the department initiated the twenty-four (24) complaint investigation and asked for pertinent records. LIC 9099C-continued Unsubstantiated On 12/19/25, The department requested medical records from Northridge Hospital Medical Center and Health Corners Hospice Medical Records, California Department of Public Health Death Certificate and Los Angeles County Medical Examiner-Coroner Records. On 12/22/25, medical records from Northridge Hospital Medical Center were received. On 12/29/25, Health Corners Hospice Medical Records were received. On 01/12/26, the California Department of Public Health Death Certificate was received and on 01/26/26 the Los Angeles County Medical Examiner-Coroner Records were received. Regarding the allegation: Staff neglect led to resident death. It is being alleged that staff did not properly address resident #1 (R1)’s fall risk, which led to their death. The investigation included interviews with facility staff, residents, R1’s daughter, R1’s nurse practitioner, and physician, as well as a review of medical, coroner, and facility records. R1 entered the facility on 08/12/2025 and had two unwitnessed falls before their death on 09/23/2025. The first fall on 08/22/2025 caused a sprained ankle; the second on 09/19/2025 caused an intracranial hemorrhage. Post Fall Assessments were completed after each incident, and R1’s Needs and Services Plan documented their need for assistance with ambulation and all activities of daily living (ADLs). R1’s resident assessment, completed before admission, also addressed these needs. After the first fall, a staff member placed a foam mat around R1’s bed as a precaution. Staff consistently reported they were aware of R1’s fall risk. On the evening of the second fall, another staff member monitored R1’s due to their restlessness and checked on them frequently; R1 was found on the floor approximately 15 minutes after being returned to bed. 911 was called immediately. Hospital and coroner records confirmed an intracerebral hemorrhage from a ground-level fall. R1’s physician, and R1’s nurse practitioner, and facility staff explained that falls cannot be entirely prevented in seniors with their conditions. Based on the precautions taken and the available evidence, the fall was determined to be accidental, and the allegations of neglect/lack of supervision were found to be unsubstantiated. LIC 9099C-continued Regarding the allegation: Staff did not adequately address resident's fall risk. It is being alleged that resident #1 (R1) fell twice and the facility did not address R1’s fall risk. The investigation examined the allegation that staff neglect resulted in R1’s death. The investigation included interviews with facility staff, residents, and R1’s medical providers, as well as a review of medical, coroner, and facility records. Following both falls, staff implemented additional safety measures. R1’s physician stated, “that seniors, especially those with the medical conditions R1 suffered from, such as Dementia, were at increased risk of sustaining a fall that could be fatal.” R1’s Nurse Practitioner and facility staff all explained that it was impossible to prevent all falls. Due to all the precautions taken prior to R1 sustaining their fall, R1’s fall was determined to be an accident rather than the result of neglect. Therefore, the allegation of questionable death caused by falls were found to be 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 Executive Director.the state’s words, verbatim · CDSS document, Mar 23, 2026 · control 31-AS-20251203094203

Allegation investigated: Staff did not safeguard resident's personal belongings. Staff financially abused resident.

On 10/13/25, at 8:55am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Cinthia Lara-Vargas, Resident Services Director. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 10/01/2025, Licensing Program Analyst (LPA) Gina Saucedo initiated the complaint investigation. On 10/01/25, LPA Saucedo asked for the census, staff, resident rosters, conducted a physical tour and gathered documents. On 10/13/25, LPA Saucedo interviewed additional staff and residents, conducted another physical tour, gathered additional information, and delivered findings. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not safeguard resident's personal belongings. It is being alleged that the facility staff did not safeguard resident #1 (R1)’s personal belongings. During LPA’s interview with R1, R1 stated,” that they do not need help safeguarding their personal belongings and any other services. R1 continued to say that even though they can only see from one (1) eye they are independent.” LPA asked if they received a SPV- Safeguards for Resident Cash, Personal Property, and Valuables form when they first arrived at the facility and R1 stated, “yes.” LPA received and reviewed R1’s Safeguards for Resident Cash, Personal Property, and Valuables and it was noted that R1 had a PC/desk chair, love seat and chair, bed/dresser, bedside table, several pieces of insured jewelry and it was signed on 04/25/25 by R1. When LPA conducted a physical tour of R1’s room, all the items noted on the SPV form were in R1’s room including a Capital One credit card that R1 stated, “there was a fraudulent, unauthorized charge but I still have my card with me.” Four (4) staff were interviewed regarding R1’s belongings and confirmed that R1 safeguards their own personal belongings and R1 is very independent. LPA interviewed seven (7) other residents that confirmed that they have not had any missing items from their personal belongings. 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 financially abused resident. It is being alleged that fraudulent, unauthorized charge, was made to resident #1 (R1)’s credit card. When LPA interviewed R1, R1 stated, “at 6:50am on September 28, 2025, a staff entered their room and R1 told them to leave. Then at 7:01am, R1 noticed that someone had attempted to use their credit card because they received a fraudulent alert via email asking them if they had authorized a payment in the amount of $398.15 which was declined. R1 continued by saying that they immediately pressed their pendant that is on their neck and a staff member named Kathy came in to help them search for their purse which was on the bed and Kathy returned the $4.00 cash that was also previously missing from their purse.” When LPA was interviewing R1, LPA asked R1 if all their credit cards were in their purse and R1 stated, “I have everything nothing is missing.” LPA observed several credit cards and cash in R1’s purse. LIC 9099C-continued During the investigation, LPA was made aware that the staff that R1 had mentioned was working that day. Staff #1 (S1) works in the memory care area of the facility. LPA interviewed S1 and asked if they had any encounters with R1 and S1 stated, “no, I work in the Memory Care area so I don’t go to the Assisted Living Area unless there is a major problem.” In addition, LPA spoke to R1’s son via telephone and R1’s son stated, “that R1 makes a lot of purchases online.” Furthermore, LPA obtained the pendant, alarm history for R1 and of R1’s room number for September 28th 2025. R1 pressed their pendant three (3) times on September 28, 2025. It was at 12:07pm, 4:47pm and 6:00pm. There was no pendant pressed from R1 and R1’s room at 7:01am on September 28, 2025 which R1 stated. Four (4) staff also confirmed that R1 does not need any help with any services except for taking out the trash and removing/making up their bed which is until 11:00am or so when R1 wakes up. Staff #2 (S2) stated that on September 28, 2025, R1 made another report at 7:00pm that their credit card was used for $46.01 online again for VIP GOATED which is for video games. In addition, LPA interviewed Staff # 3 (S3) that was assigned to R1’s room on September 28, 2025 and S3 stated, “they did not go to R1’s room until 12:00pm or so when R1 pressed their pendant.” S3 then helped R1 find their purse and credit cards because R1 is blind in one (1) eye R1 needed help locating their purse and the S3 stated, “that R1 had some money in their purse with all their credit cards, no credit cards were missing because R1 specifically asked them to check for a specific credit card which was also there.” 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, and a copy of this report was given to the executive director.the state’s words, verbatim · CDSS document, Oct 13, 2025 · control 31-AS-20250930212739

Type of visit: Required - 1 Year

On 07/29/25 at 8:10 AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. LPA Saucedo met with Executive Director, Lisa Villasenor and Cinthia Lara Vargas-Resident Service Director and disclosed the purpose of the visit. LPA asked for the census, resident, and staff files. At 9:45 AM a physical tour was conducted for both the Assisted Living Area and Memory Care Area: The entire facility has a total of 135 (one-hundred and thirty-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 one (1) memory care units which is located on the back section of the facility and the assisted living is in the front section and upstairs. The memory care area can hold up to twenty-four (24) rooms and the Assisted Living area can hold up to 115 (one-hundred fifteen) rooms. The memory care door has a code and delayed egress on the doors. The Memory Care area of the facility has its own laundry room, living room/activity area, dining hall area, enclosed patio area, a common shower room that any resident can use and a medication room. All hand sanitizers and fire extinguishers in this area are covered so residents cannot have access to them only visitors and/or staff. The assisted living side has their own activity room, salon, library, dining hall, two (2) patio areas with proper seating for residents and two (2) laundry areas one (1) upstairs and one (1) downstairs. Besides the large industrial washers and dryers that residents cannot use, there are two (2) other laundry rooms that can be used by residents. There are also two (2) elevators throughout the facility. LIC 809C-continued Random Bedrooms were randomly selected to tour and were observed to have appropriate furniture, proper lights, bedding, televisions, closets and pull cord alarms. Random Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested randomly for and measured 118–120-degree Fahrenheit. There are two (2) medication rooms one (1) on the first floor and one (1) on the second floor. The medication is locked and inaccessible to the residents. They are also medication carts in the Wellness centers. Fire extinguishers were observed throughout the facility and were fully charged on green with different dates such as September and October 2025. There are fire extinguishers upstairs, downstairs and in the kitchen area. Carbon Monoxide and fire sprinklers are located throughout the facility. 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 74.-79-degree Fahrenheit. There are several temperature thermostats throughout the facility. There are several common bathrooms throughout the upstairs and downstairs area. There are trash cans with lids and covid signs posted in the common bathrooms. There is toilet paper and napkins. There are also pull cords in these bathrooms. The facility has no bodies of water. There is a water fountain next to the memory care area. The mailbox for residents is also located in this area. There is also a salon and spa room in this area of the facility. Next to the salon and spa room is the Activities Room. There is also a library area in this section of the facility leading to the memory care. There is a bathroom with a large shower area upstairs that can be used for wheelchair accessible residents. The exit stairways upstairs all have evacuation chairs. There are several hand sanitizers against the wall throughout the facility. There is a theater upstairs. There are two (2) laundry rooms for resident use in the assisted area of the facility. There is one (1) downstairs on your left hand side of the entrance of the facility and there is another one (1) upstairs on your left hand side. LIC 809C-continued 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 breakfast with proper feeding utensils/plates/cups. The kitchen area has a first aid kit and CPR-Cardiopulmonary resuscitation kit against the wall. Against the wall of the kitchen on your right-hand side is a Resident's Diet Board. Administrative: The Insurance plan is updated- 10/2025. There is an Emergency Disaster plan, House Rules, Rights of Resident Council, YES sign, Resident Rights, Facility Sketch, Ombudsman and Theft and Loss Policy against the wall on your left-hand side of the facility near the entrance of the memory care. The last fire drill/evacuation drill/Theft and Loss was conducted in June 2025. In August there is a new company that has being hired to do drills named Southwest Fire. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the executive director.the state’s words, verbatim · CDSS document, Jul 29, 2025

Allegation investigated: Licensee did not provide adequate notice of fee increase to resident’s representative. Licensee did not ensure facility was maintained in good repair. Staff did not ensure hazardous equipment was inaccessible to resident.

On 02/24/25, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Executive Director, Lisa Villasenor. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 02/24/25, LPA Saucedo asked for the census, staff, and resident rosters. On 02/24/25, LPA Saucedo conducted a physical tour and interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Licensee did not provide adequate notice of fee increase to resident’s representative. It is being alleged that the representative did not get notice of the rent increase. LPA spoke to resident #1 (R1) who resides in the Assisted Living Area of the facility and asked if they received a sixty (60) day notice for rent increase. Let it be noted, R1 is self-Independent, ambulatory and alert. In addition, the R1's representative changed their address and did not notify the facility. R1 stated they do not always check their mailbox but maybe they did receive it. LPA spoke to staff #1 (S1) who confirmed R1 received a sixty (60) day notice for the rent increase. LPA obtained a copy of the sixty (60) that was issued to R1 on April 29, 2024 to be effective August 01, 2024. Based on the LPA's observations and record reviews, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Licensee did not ensure facility was maintained in good repair. It is being alleged that three or four months ago there was an issue with the lock on the door to resident #1 (R1)’s room and the door frame broke. LPA interviewed resident #`1 (R1) who confirmed that when their door lock broke it was repaired right away along with the door frame. R1 stated I have not had any issues coming in and out of that room. LPA spoke to Staff #`1(S1) that confirmed R1's door was repaired right away and R1 was given the option to move rooms when it was being repaired but refused to move out of that room. S1 also stated, R1 has not had issues coming in and out of their room. LPA also interviewed Staff #2 (S2) who confirmed R1's door was repaired as soon as they got the work order for repair and R1 has not complained since the repair was completed. During LPA's physical tour, LPA took a picture of R1's door and was able to observe R1 go in and out of their room without any issues. Based on the LPA's observations, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure hazardous equipment was inaccessible to resident. It is being alleged that resident #1 (R1)’s central air conditioning and heating has not worked for at least one (1) year so staff placed a space heater and window Air Conditioner (AC) unit in the room which is hazardous to R1. Let it be noted that R1 is in the assisted living area of the facility, alert and Independent. LPA interviewed R1 who agreed that they want to continue having their space heater and window Air Conditioner in their room because they can change the temperatures when they want but they cannot manage the central air conditioning provided by the facility. R1 stated I want to keep both air conditioner and space heater that was provided to me. LPA spoke to Staff #1 (S1) that confirmed R1 does not want to return the space heater or have the air conditioner on the window removed from their room. 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 and a copy of this report was given to the Executive Director. Regarding the allegation: Licensee charged resident for services not received. It is being alleged that resident #1 (R1) was charged for services they did not receive. R1 moved into the facility in October of 2022 and was documented as being Independent for services meaning R1 did not need help with any type of extra services. In addition, R1 is documented as ambulatory and self-independent on his Identification. LPA interviewed staff # 1 (S1) and Staff # 3 (S3) and both confirmed R1 was Independent and did not need any type of extra services. LPA reviewed R1's file and R1 was shown as being Independent not needing any type of services but there were charges of $500.00 under level one care for seventeen (17) months. LPA interviewed R1 and R1 confirmed that they have recently received medication management but was not receiving these services before. The above facility had R1 labeled as receiving level one care since November of 2022 but the level one care plan's effective date was not supposed to take effect until 06/2024 when R1 starting receiving level one care. Based on the LPA's observations, staff and resident interviews conducted the allegation is SUBSTANTIATED at this time. Regarding the allegation: Licensee did not provide resident’s representative with an itemized statement of charges. It is being alleged that due to all the billing discrepancies, the itemized statement of all of the charges were wrongly documented. LPA interviewed staff #1 (S1) and staff #3 (S3) and both confirmed that Resident #1 (R1)'s itemized statement was not correctly documented. LPA obtained and reviewed the documentation that shows the itemized statement of charges being provided to R1 and resulted in discrepancies. The discrepancy amount is $5250.00 that needs to be reimbursed. Based on the LPA's observations and record reviews, staff interviews conducted the allegation is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, appeals right was provided and a copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Feb 24, 2025 · control 31-AS-20250219151035

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(C) · Plan of correction due date: Mar 10, 2025

87507 Admission Agreements (g) Admission agreements shall specify the following:(3)Payment provisions, including the following: (C) Any fee that is charged prior to or after admission, shall be clearly specified... This requirement was not met by: Based on the observations, interviews and record reviews, the licensee/administrator did not ensure a resident being charged for services at the above facility that were not being provided which poses potential Health, Safety or Personal Rights risks to person in carethe state’s words, verbatim · CDSS document, Feb 24, 2025

Plan of correction: The Licensee/Administrator shall reimburse/provide credit to the resident/resident's representative for the services that were being charged but not received in the amount of $5250.00 POC Due Date:03/10/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(A) · Plan of correction due date: Mar 10, 2025

87507Admission Agreements(g)..shall specify the following:(3) Payment provisions, including the following: (A) Rate for all basic services which the facility is required to provide..Basic services rate(s), including: 1.A comprehensive description of any items and services.. This requirement is not met by: Based on the observations, interviews and record reviews, the licensee/administrator did not ensure a resident's billing statement to be corrent which poses potential Health, Safety or Personal Rights risks to person in carethe state’s words, verbatim · CDSS document, Feb 24, 2025

Plan of correction: The Licensee/Administrator shall document all services being provided to the resident properly and itemized in the forthcoming biling statements. POC Due Date:03/10/25.

Allegation investigated: Staff hit resident

On 10/28/24, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Executive Director, Lisa Villasenor. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 10/28/24, LPA Saucedo asked for the census, staff, and resident rosters. On 10/28/24, LPA Saucedo interviewed staff and residents and conducted a physical tour. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff hit resident. It is being alleged that resident #1 (R1) was hit by a caregiver while they were being changed. Nine (09) out of nine (09) residents confirmed that they do not have any issues with any staff and that they have not been hit by any staff. Furthermore, R1 was not able to recall being hit by any staff. Four (4) staff confirmed that R1 is aggressive, yells a lot and has hit several staff. Two (2) staff were able to confirm that R1 hit them recently while they were helping R1 change their clothing. LPA obtained an Unusual Incident/Injury Report where it states that R1 hit a staff on 10/22/24. 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 Executive Director.the state’s words, verbatim · CDSS document, Oct 28, 2024 · control 31-AS-20241024162643

Allegation investigated: Staff did not prevent a resident from falling and sustaining injuries while in care Staff illegally evicted a resident in care

On 10/22/24, at 9:45am, Licensing Program Analysts (LPAs) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Executive Director, Lisa Villasenor. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 10/22/24, LPA Saucedo asked for the census, staff, and resident rosters. On 10/22/24, LPA Saucedo interviewed staff and residents and conducted a physical tour. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not prevent a resident from falling and sustaining injuries while in care. It is being alleged that one (1) of the residents has had multiple falls and sustained injuries while in care. LPA's reviewed Resident #1 (R1)’s file and proper documentation was sent to CCLD-Community Care Licensing Department regarding R1’s falls and injuries. On 06/30/24, it was reported that R1 was laying on the floor next to their sofa area complaining of their forehead hurting and was sent to the hospital for an ankle injury. On 10/08/24, R1 had fallen and was sent to the hospital resulting in a tear near their left eye. On 10/08/24, R1 was sent again for the same injury due to their eye not getting properly treated. Furthermore, R1's resident plan shows R1 is a fall risk. Three (3) staff confirmed that R1’s health has been deteriorating. R1 was ambulatory and is now non-ambulatory and needs help with assisted daily living activities. Nine (9) out of nine (9) residents confirmed that emergency calls are made for them, and they are sent to the hospital if they feel ill or sustain any injuries. 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 illegally evicted a resident in care. It is being alleged that resident #1 (R1) is being evicted. LPA confirmed with three (3) staff that R1 is not being evicted but the staff also confirmed that R1’s health and behavior has changed within the last couple of months. Since June of 2024, R1 has been at two (2) different Skilled Nursing Facilities. R1 was sent to a Skilled Nursing Facility in June and was allowed to return to the above facility. R1 returned to the hospital again in October and the hospital transferred R1 to another Skilled Nursing Facility. R1 continues to be the Skilled Nursing Facility and has not returned back to the above facility. Nine (9) out of nine (9) residents confirmed that they are aware of the eviction process, reasons for eviction and are not aware of any residents being illegally evicted. 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 22, 2024 · control 31-AS-20241016115656

Allegation investigated: Staff abandoned resident Staff made inappropriate comments towards resident

On 08/20/24, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Administrator, Lisa Villasenor. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 07/31/2024, Licensing Program Analyst (LPA) Gina Saucedo initiated the complaint investigation. On 07/31/24, LPA Saucedo asked for the census, staff, resident rosters, conducted a physical tour and gathered documents. On 08/20/24, LPA Saucedo interviewed additional staff and residents, conducted a physical tour, gathered additional information, and delivered findings. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff abandoned resident. It is being alleged that the resident cannot return to the above facility. Resident #1 (R1) was not allowed to come back to the facility because their level of care had changed. R1 got a stroke on 06/14/24, attended West Valley Subacute and Nursing Center for rehabilitation and would still need additional care. R1's level of care changed from being ambulatory and Independent to non-ambulatory and needing assistance in various areas such as moving around the facility, assistance with medication and way of communicating. Social Services Director of West Valley Subacute and Nursing Center advised R1 that a Board and Care would be a better fit for R1 because of their change in health; thus, higher level of care and R1 agreed. Furthermore, the Social Services Director of West Valley Subacute and Nursing Center and R1 toured a Board and Care in which R1 agreed to reside in. The Board and Care received R1 on 07/15/24. R1's original Preplacement Appraisal Information, Resident Appraisal and Physician's Report for Residential Care Facilities for the Elderly has shown the change in level of care. The administrator of the Board and Care in which R1 resides now also stated, "R1 toured the facility and agreed to reside here." LPA interviewed eight (8) out of eight (8) residents who confirmed that they have been allowed to return to the above facility from a hospital stay and have not been abandoned. Three (3) out of three (3) staff confirmed that R1's level of care had changed and that R1 was denying the help of receiving services prior to getting the stroke such as needing mobile assistance and while they were at West Valley Subacute and Nursing Center, R1 also denied additional services for full recovery such as therapy sessions and getting assistance in bathing, creating a potential hazard to themselves. Therefore, based on the LPA's staff and resident interviews, observations, and record reviews the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff made inappropriate comments towards resident. It is being alleged that the staff told the resident that they do not want them at the above facility. LPA interviewed eight (8) out of eight (8) residents that confirmed they have never had any staff say inappropriate comments to them. Three (3) out three (3) staff confirmed that they would never say anything inappropriate to any of the residents. Therefore, based on the LPA's staff and resident interviews, observations 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.the state’s words, verbatim · CDSS document, Aug 20, 2024 · control 31-AS-20240725162258

Type of visit: Case Management - Other

This is an amended copy of the report previously issued on 08/08/24. After review of this case management, it was determined corrections to the verbiage was warranted. On 08/08/24, at 11:35am Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced Case Management. LPA Saucedo met with the Business Manager, Claudia Rosas who informed the LPA, Executive Director, Lisa Villasenor was on vacation from 08/07/2024-08/15/2024. The reason for the visit was explained. It was brought to the Regional Office’s (ROs) attention that the facility is no longer operating as a Continuing Care Retirement Community (CCRC). LPA inquired about the current operational status of the facility’s as a CCRC or a Residential Care Facilities for the Elderly (RCFE). Villasenor contacted LPA Saucedo telephonically and spoke briefly with LPA and disclosed that there are currently 38 residents that are CCRC clients. LPA Saucedo then conducted interviews with Business Manager, Claudia Rosas and Marketing Director, Malcolm Adams 11:50am-12:20pm. Their employment with the facility started in May 2024. Per a review of the data on the facility’s computer, LPA Saucedo was informed there is a total of forty-one (41) CCRC residents and the current census is ninety (90). LPA reviewed fourteen (14) of forty-one (41) CCRC residents’ files. The facility was able to provide copies of the admissions agreements/continuing contract contracts on the forty-one (41) existing residents identified as CCRC residents. Since his employment, Adams indicates that his marketing efforts are on the Memory Care and Assisted Living beds. Claudia shared a brochure that Adams uses to market these beds, and the only copy of admission agreement that she has used since her employment with the facility. Both interviewees acknowledged having limited or no information on the operational status of the facility as a CCRC. LPA will share information obtained today with the Continuing Care Contracts Bureau (CCCB). On behalf of the CCCB, this is another reminder to the Licensee to submit the following items to CCCB no later than 8/9/2024: 1. Proof of all current marketing materials for CCRC contracts. 2. Copies of executed CCRC contracts for any residents who moved in on or after 8/9/22. 3. Copies of all agreements offered to incoming residents. 4. Copies of the annual report for Fiscal Year (FY) 22/23 and FY 23/24. And exit interview was conducted, a copy of this report was provided to Claudia Rosas, Business Manager.the state’s words, verbatim · CDSS document, Aug 8, 2024

Type of visit: Required - 1 Year

On 07/10/24 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 Administrator, Lisa Villasenor and disclosed the purpose of the visit. LPA asked for the census, resident, and staff files. A physical tour was conducted at 11:30 AM and observed the following: The entire facility has a total of 135 (one-hundred and thirty-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 one (1) memory care units which is located at the back section of the facility and the assisted living is in the front section and upstairs. The memory care area can hold up to twenty-four (24) rooms and the Assisted Living area can hold up to 115 (one-hundred fifteen) rooms. The memory care door has a code and delayed egress on the doors. The Memory Care area of the facility has its own laundry room, living room area, dining hall area, enclosed patio area and a common shower that everyone uses. The assisted living side has their own activity room, salon, library, dining hall, two (2) patio areas with proper seating for residents and two (2) laundry areas one (1) upstairs and one (1) downstairs. There are chemicals that are inaccessible to the residents that are located in the laundry area with the washers and dryers. There are two (2) elevators throughout the facility. Random Bedrooms were randomly selected to tour and were observed to have appropriate furniture, proper lights, bedding, and televisions. LIC 809C-continued 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. There are two (2) medication rooms one (1) on the first floor and one (1) on the second floor. The medication is locked and inaccessible to the residents. 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. 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 72.-78-degree Fahrenheit. There are several temperature thermostats throughout the facility. There are several common bathrooms throughout the upstairs and downstairs area. 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. 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 updated- 10/2024. There is an Emergency Disaster plan, House Rules, Rights of Resident Council, YES sign, Ombudsman and Theft and Loss Policy against the wall on your left-hand side of the facility near the entrance of the memory care. 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, Jul 10, 2024

Allegation investigated: Resident's room is not being cleaned Staff are unable to communicate with residents due to language barrier

On 03/26/24, at 8:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by the Executive Director-Lisa Villasenor. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information and deliver findings. On 03/26/2024, at 8:35am, LPA Saucedo asked for the census, resident, and staff roster. The Executive Director-Lisa Villasenor met with LPA Saucedo to conduct the physical tour at 8:45am. During the tour, LPA interviewed eight (08) residents and five (5) staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Resident's room is not being cleaned. It is being alleged that RP/Resident #1 (R1) stated their room is not being cleaned. LPA interviewed seven (7) out eight (8) residents that confirmed that their room is cleaned on a weekly basis, and they have no issues with the caregivers or/and housekeepers. LPA interviewed five (5) out of five (5) staff that confirmed they have tried to clean R1's room and R1 does not let them enter their room. LPA was able to confirm that R1 keeps a note on their door by the doorknob that says, "no walk-in maintenance or anyone." LPA was also able to confirm during the physical tour that R1 blocks their door from being opened with the bathroom door and clothing items hanging on a rope. LPA obtained a picture of both the note on the door and the door being blocked from opening. LPA also obtained a note from one of the housekeepers that stated from room 281 not to clean on 03/16/24. Room 281 is a single, room occupied by R1. LPA was able to ask one of the housekeepers to clean R1's room with permission of the executive director; thus, making an exception to clean their room on their non-cleaning day and R1 declined the cleaning services on 03/26/24. Therefore, based on the LPA's interviews, observations, and record reviews the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are unable to communicate with residents due to language barrier. It is being alleged that the RP/Resident #1 (R1) mentioned that the staff do not speak English, which impedes their ability to communicate with them. LPA interviewed seven (7) out eight (8) residents that confirmed that there is no language barrier with the housekeepers, caregivers, or maintenance. All the staff can communicate with the residents and our able to speak English. LPA also confirmed with R1 if they can speak English and R1 said, “I can speak English and Spanish.” LPA interviewed five (5) out of five (5) staff that confirmed they speak both English and Spanish. The maintenance director also confirmed that they specifically hired one (1) person to enter R1’s room that spoke only English and R1 has now declined to have that person help them. LPA was able to interview the person that got hired specifically to help R1 and they stated, "R1 does not want my services anymore." Therefore, based on the LPA's interviews, observations, and record reviews 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, Mar 26, 2024 · control 31-AS-20240320161123

Allegation investigated: Staff are not adhering to residents' admission agreement

On 02/26/24, at 12:49pm, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by the Executive Director-Lisa Villasenor. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather more information and deliver findings. On 02/21/2024, LPA Saucedo initiated the complaint investigation. On 02/26/24 at 12:49pm, LPA Saucedo asked for the census, resident, and staff roster. The Executive Director-Lisa Villasenor met with LPA Saucedo to conduct the physical tour at 12:55pm. During the tour, LPA interviewed ten (10) residents and four (4) staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff are not adhering to residents' admission agreement. It is being alleged that residents other than the memory care unit were given a notice that the facility will be charging the residents for services that were previously included in their rent and care fees. The notice states that there are new charges regarding the basic laundry services, 1 load per week, will cost $100 per month, and 2 loads per week will cost $200. The notice also states that the facility will no longer be taking out residents' trash and will no longer be making resident’s' beds daily. During the tour, LPA conducted four (4) out of five (5) staff interviews and ten (10) resident interviews. All four (4) staff confirmed that there will be new charges added as of March 01, 2024, for certain services provided. Three (3) out of five (5) staff were present at the council meeting when this was mentioned to the residents that attended January 29th. Seven (7) out of ten (10) residents confirmed that they do not agree with the new changes that will occur on March 01, 2024. All seven (7) residents state that it is unsanitary and for some residents dangerous to do their own basic housekeeping. Seven (7) out of ten (10) residents state that trash and bed making should be provided daily and there should be no extra charge for personal laundry being done. LPA was able to review ten (10) resident files. Ten (10) out of ten (10) files under the admission agreement/continuing care residence and services agreement stated under accommodations and services (pages 2-4) that a thirty (30) day written notice shall be given to residents in advance. It also states that, “As part of your Monthly Fee, you will receive the basic housekeeping services set forth in Appendix B. Other housekeeping services are available for an extra charge as set forth in Appendix C, personal laundry along with other items may be washed at the Community’s laundry facilities on a first-come first serve basis. Personal laundry service is offered at an additional charge (see Appendix C).” LPA was able to obtain the notice that was given to the residents dated December 20, 2023, that states the charges of laundry and that states trash and bed making will no longer be including daily. The notice was given within the guidelines of the thirty (30) day written notice which is stated in the admission agreement. The LPA was also able to obtain where it states under the admission agreement that laundry besides bed linens if personal is offered at an additional charge. The notice that was given to the residents stated the same thing. The executive director did confirm that bed linens is free of charge but not personal laundry. The executive director also stated that there are available washers and dryers that the residents can use upstairs and downstairs for a small fee for personal use and that the facility will provide free detergent. LPA was also able to obtain Appendix A under the Resident Handbook Including Rules and Regulation page 8 stating that Housekeeping/Laundry is included weekly in their package not stating daily. Therefore, based on the LPA's interviews, observations, and record reviews 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, Feb 26, 2024 · control 31-AS-20240216130953

Allegation investigated: Facility is not recognizing resident's current Power of Attorney status

At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina, and Gina Saucedo conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPAs met with the Executive Director and explained the reason for the visit. During course of the investigation, interviews and record review were made. At 10:05am, LPAs requested resident and staff roster. At 10:10am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, R1’s notarized Power of Attorney (POA) etc., relevant to the investigation. At approximately 10:15am, LPAs 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 10:30am – 11:30am, LPAs interviewed the Executive Director, Resident Service Director and Resident #1 (R1). Continue on LIC9099-C Unsubstantiated It was alleged that the Facility is not recognizing resident's current Power of Attorney (POA) status and R1 is being placed in a Memory Care Unit against his/her will. To investigate this allegation, LPAs conducted review of R1’s Power of Attorney (signed and dated on 09/09/2002) and a Physician’s Report (signed and dated on 04/27/2023). Review of R1's Physician's Report indicated that R1 is diagnosed with Dementia and can not leave unassisted. Interview with the Executive Director and Resident Service Director revealed that upon admission, the facility will assess the resident and review their Physician's Report in order to determine if the resident will be placed in a Memory Care Unit or Assisted Living. In addition, interview with the Executive Director and Resident Services Director revealed that upon admission the resident/family/conservator will provide the facility with any legal documents (if any) the facility always recognizes residents POA’s/Conservator, etc. and when a copy is provided, the facility files the document in resident’s individual files. Lastly, LPAs attempted to conduct an interview with R1, but due to R1's medical condition LPAs were unable to receive necessary information. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegation is Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 21, 2023 · control 31-AS-20231116114248

Allegation investigated: Staff failed to keep resident's room clean Staff failed to provide a safe and comfortable environment for resident Staff neglected resident while in care

Licensing Program Analyst (LPA) Gary Tan, Gina Saucedo and Leslie Ngo-Castaneda conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Resident Services Director Cynthia Vargas and explained the reason for the visit. LPAs conducted a physical plant tour at 9:30 AM, requested copies of facility documents at 10:00 AM and interviewed residents and staff between 10:13 AM to 1:15 PM. Regarding the allegation that the facility staff failed to keep resident's room clean, it was alleged that Resident #1 (R1)'s room was not maintained. LPAs' observation during physical plant tour today at 9:30 AM revealed that the six (6) random bedrooms visited at the memory care unit were all clean and well organized. LPAs' interview with eight (8) random residents from Assisted Living sections or 10% of the current census revealed that eight (8) out of eight (8) residents interviewed stated that their room were cleaned regularly by the staff. LPA's interview with staff on 06/13/23 between 10:30 AM to 1:00 PM and today between 10:13 AM and 1:15 PM confirmed that Memory Care housekeeper clean residents' room with the help of care staff on a daily basis (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Regarding the allegation Staff failed to provide a safe and comfortable environment for residents, it was alleged that R1's bedroom had urine all over the floor which may have led to R1 having a fall. LPA's interview with four (4) staff on 06/13/23 between 10:30 AM to 1:00 PM revealed that R1 had just an onset of incontinence and not yet used to wearing diapers and kept on removing it once the staff put it. Further interview also revealed that staff check on R1 on an hourly basis but refused a lot of care and assistance from staff. Regarding the allegation that Staff neglected resident while in care, it was alleged that R1 was found inside own bathroom covered in urine and had dried fecal matter on legs. LPA's interview with four (4) staff on 06/13/23 between 10:30 AM to 1:00 PM revealed that R1 had just an onset of incontinence and not yet used to wearing diapers and kept on removing it once the staff puts it. Further interview also revealed that staff check on R1 on an hourly basis but refused a lot of care and assistance from staff. Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 31, 2023 · control 31-AS-20230609122426