The Pinnacles at Burton

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct an annual inspection. LPA was greeted by Anna Ter Akopyan Care Coordinator who was informed of the purpose of the visit. The facility is licensed to serve (40) ambulatory and (160) non-ambulatory elderly adults ages 60 and above. The facility is approved for (6) hospice residents. Currently, the facility has (5) residents on hospice care. The facility is a four story building structure located in a residential neighborhood. It consists of (37) bedrooms, (47) bathrooms, lobby, office, tea room, activity room, dining room, living area, activity room, laundry room, commercial kitchen, storage, beauty shop, medication room, synagogue room, library, and linen closets. and outside patio area. At 2:25 AM, LPA also reviewed six (6) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings which appeared to be up to date. LPA reviewed six (6) residents’ files for admission agreements, updated physician reports, and needs and services plan which appeared to be up to date. At 3:15 PM, LPA Allen and Anna toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of six (6) bedrooms and six (6) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were in good condition and operational. The water temperature ranged from 105°F to 120 °F. LPA observed that the facility appeared to be clean, sanitary, and appropriately furnished. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was a 5-day supply of perishable and a 7day supply of non-perishable food items available, which was adequately maintained/stored properly. There was a menu available for review. The fire extinguishers, carbon monoxide detectors and smoke detectors were fully charged and operable. The last Fire/Disaster drills were conducted on 6/12/2026. An exit interview was conducted, and this report was discussed and provided to Anna Ter Akopyan Care Coordinator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 17, 2026

Allegation investigated: Staff do not ensure that outside vendors maintain resident privacy during the provision of services.

On June 4, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial unannounced complaint visit. Robin Culver, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, inspection of the facility, and a collection of documents. The Department reviewed the Resident Roster (dated 06/04/26), Personnel Report LIC 500 (05/29/26), Welcome to Pinnacles at Burton Package, Media Release Form, activities calendar from (dated 06/01/25 through 06/30/26) and other pertinent records associated with this complaint. Interviews conducted with Resident #1 through #7 (R1-R7) and Staff #1 and Staff #2 (S1-S2). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff do not ensure that outside vendors are not video recording/taking pictures of residents. It is alleged that an external vendor recorded audio and images of residents without their consent and shared them online, in violation of residents’ rights. Additionally, it is claimed that the facility staff failed to prevent the vendor from recording the residents. It is reported that these events occurred sometime between 2024 and 2025. On June 4, 2026, between 9:45 AM and 10:15 AM, the Department conducted an interview with staff members identified as Staff #1 and Staff #2 (S1-S2). Two (2) of the Two (2) staff members could not support this claim. (S2) confirmed that an external vendor performed only a live performance at one time that included comedy and music for the residents at the assisted living side. (S1-S2) emphasized that photography is strictly permitted only with prior approval and requires signed Media Release forms. Furthermore, (S1) stated that there have been no complaints regarding vendors posting online images or videos of residents without their consent, as the facility was previously unaware of any such incidents. The facility clearly requests consent for photography at the time of move-in. There have been no complaints from residents or their families concerning unauthorized recordings, and the staff typically recognized that recording residents is prohibited and/or necessitates consent from residents or their families. The Department presented social media from Instagram, Facebook, Titok and YouTube and (S1-S2) identified Resident #1, #2, and #3 (R1--R3) featured in videos. (S1-S2) stated they have Media Release Forms authorizing photos, newsletters, bulletin boards, or social medial pages on file. On June 4, 2026, between 10:25 AM and 02:17 PM, the Department interviewed resident members identified as Resident #1 through Resident #7. Seven (7) out of seven (7) could not support this claim. None of the residents remember seeing any visitors or vendors taking photos or videos. They stated that they had never seen an external vendor capturing images or videos of residents without permission. All residents verified signing a Media Release Form and claimed having no issues concerns of their images posted on social media platforms. (R1-R3) reviewed the video shared on social media and found it engaging. They felt that their rights were not infringed upon in any way. (Evaluation Report continues LIC 9099-C) The Department reviewed the Media Release Forms for Resident #1-#3 (R1-R3) (dated 04/20/23, 08/30/23 and 02/01/24) revealed verified authorization to use photograph and video images on social media platforms. A review of Welcome to Pinnacles at Burton Package included Media Release Form (page 16) provided to all residents during admission. Further review of facilities’ the facility's activities calendar from (dated 06/01/25 through 06/30/26) and found no entries for external vendor admissions or live events during this period. A supplementary record review and found one time invoice for comedy performances from external vendor. The invoice dated April 11, 2025, one hour event. Further review of social media links from You Tube, Instagram, and Titok identified (3) residents were residents featured in social media postings. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with ROBIN CULVER, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 11-AS-20260529092931

Allegation investigated: Staff did not present the resident’s advance directive form to the responding emergency medical personnel. Staff did not follow resident’s hospice care plan.

On November 16, 2025, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Robin Culver, Executive Director greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above. The investigation included a collection of records, and a tour of the facility. The Department reviewed several documents, including the Facility Resident Roster (dated 11/06/25 & 10/09/25), Personnel Report (dated 10/07/25), and (R1's) Physicians Report LIC 602A (dated 02/04/25), Service Plan (dated 02/05/25), Resident Assessment (dated 06/29/25), Physician Orders for Life Sustaining Treatment (dated 02/05/25), Cedars Sinai Medical Records (dated 10/10/25) and Comfort Hospice Care Records and other records pertinent to this complaint. Interviews conducted with Staff #1-#3 (S1-S3), Residents #1-#7 (R1-R7), and Witness #1 (W1). (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not present the residents’ advance directive form to the responding emergency medical personnel. The complaint alleges that the staff failed to provide Resident #1's (R1) directive form to the emergency medical personnel. Reports indicate that (R1) experienced chest pains on October 6, 2025, and was transported to Cedar Sinai by Emergency Medical Technicians (EMT) without a Physician's Orders for Life-Sustaining Treatment (POLST) form. As a result, because no (POLST) form to indicate "Do Not Resuscitate," (R1) underwent repeated cardiac diagnostic testing over several days. On November 6, 2025, between 09:30 AM and 11:15 AM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) out of the three (3) staff members were able to validate Resident #1 (R1) was transported to Cedar Sinai without a (POLST) or an Advance Directive form was provided to the (EMT). (S1) admitted to having failed to provide a (POLST) form when presented with a copy. (S1) explained that the documents given to the (EMT) included only a Face Sheet Emergency Information and a Verification of Medication Order form, which only listed medications (dated 07/08/24). (S1) understood that it was an unintentional mistake, given the urgency of the situation. In that moment, (S1) genuinely believed that (R1) was experiencing cardiac arrest and felt it was crucial to get (R1) the immediate medical attention needed. On November 6, 2025, between 11:16 AM and 11:31 AM, the Department interviewed resident member identified as Resident #1 (R1). (R1) confirmed that (R1) left the facility and was transported by (EMT) to the hospital. However, (R1) does not remember the details of that incident. (R1) recalled experiencing deep, sharp chest pains, and (S1) took the necessary steps to ensure immediate medical attention was provided. On November 6, 2025, between 11:32 AM and 01:30 PM, the Department interviewed resident members identified as Resident #2 through Resident #7 (R2-R7). Six (6) out of six (6) resident members cannot support this claim. All residents reported being hospitalized, and hospital staff received the necessary documentation to treat them properly. A review of (R1’s) Face Sheet and Emergency Info (dated 10/07/25 and 10/16/25), Service Plan (dated 02/05/25 and 06/29/25), Resident Assessment (dated 06/29 25), Physician’s Report LIC 624A (dated 02/24/25), and Unusual Incident Report LIC 624 (dated 10/07/25). (Evaluation Report continues LIC 9099-C) Further review of the Physician Orders for Life-sustaining Treatment (POLST) (dated 02/05/25) indicate in section A Cardiopulmonary Resuscitation (CPR) box was checked off - Do Not Attempt Resuscitation/DNR (allow Natural Death) was selected. Based on the information gathered, there is enough evidence to support the allegation mentioned above. Allegation #2: Staff did not follow resident’s hospice care plan. The complaint alleges that the staff failed to follow Resident # 1’s (R1) hospice care plan. Reports claims that (R1) Resident is enrolled in hospice and that hospice protocol requires that hospice be notified as a part of the decision to seek medical intervention. Further reports stated that facility staff contacted hospice after the resident was transported to Cedars Sinai Hospital on October 6, 2025. On November 6, 2025, between 09:30 AM and 11:15 AM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) of the three (3) staff members confirmed that Resident #1 (R1) was transported to Cedar Sinai Hospital. Comfort Hospice Care was contacted after the fact, once (R1) was already being transported by Emergency Medical Technician services (EMT). Staff member (S1) was responsible for the emergency incident involving (R1), who was claimed to have failed to adhere to hospice care protocols by not contacting Comfort Hospice Care before calling 9-1-1. (S1) believed (R1) was in cardiac arrest and felt it was vital to get immediate medical help, unintentionally bypassing hospice protocols. On November 6, 2025, between 11:16 AM and 11:31 AM, the Department interviewed resident member identified as Resident #1 (R1). (R1) confirmed to be receiving hospice care when hospitalized. Unfortunately, (R1) does not have any recollection of the events from that day. (R1's) hospitalization was due to severe chest pains, and (R1) can only remember the intensity of the discomfort (R1) experienced. (S1) was there to ensure that (R1) received immediate medical attention during this difficult time. On November 6, 2025, between 11:32 AM and 01:30 PM, the Department interviewed resident members identified as Resident #2 through Resident #7 (R2-R7). Six (6) out of six (6) resident members cannot support this claim. All residents had no issues or concerns about this matter, as the staff followed their care plans accordingly. On November 14, 2025, between 04:30 PM and 04:47 PM, the Department interviewed staff member of Comfort Hospice Care identified as Witness #1 (W1). (W1) confirmed that the facility staff failed to adhere to the care plan. (Evaluation Report continues LIC 9099-C) The facility is instructed to contact the hospice agency first, rather than calling 9-1-1, in the event of a medical emergency or death. According to (W1), Comfort Hospice Care was notified only after (R1) was already admitted to the Emergency Department. A review of (R1’s) Face Sheet and Emergency Info (dated 10/07/25 and 10/16/25), Service Plan (dated 02/05/25 and 06/29/25), Resident Assessment (dated 06/29 25), Physician’s Report LIC 624A (dated 002/24/25), and Unusual Incident Report LIC 624 (dated 10/07/25). Further review of Comfort Hospice Plan of Care (dated 03/2024) revealed that hospice service “may require procedures performed in a hospital outpatient setting, and that Comfort Hospice Care will arrange for these services as needed, as indicated on the plan of care”. Based on the information gathered, there is enough evidence to support the allegation mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegations are found to be SUBSTANTIATED. An exit interview was conducted with Robin Culver, and copies of the reports were provided. INVESTIGATION REVEALED THE FOLLOWING: Allegation #3: Staff mismanaged resident’s medication. Allegation#4: Staff did not properly report the resident’s incident to the resident’s authorized representative. The complaint alleges that staff mishandled Resident #1's (R1) medication and failed to inform (R1’s) authorized representative about an incident involving (R1). Reports indicate that staff administered “Nitroglycerin”, prescribed by (R1's) cardiologist, before (R1’s) hospice designation. Incident report show (R1's) initial vital signs recorded a blood pressure of 95/55, but this was omitted from the initial incident report; only the readings taken after administering “Nitroglycerin” were noted. After receiving “Nitroglycerin” twice, (R1's) blood pressure dropped to 78/53, resulting in a hypertensive condition, and (R1) was sent to the hospital. On November 6, 2025, between 09:30 AM and 11:15 AM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) of the three (3) staff members disputed both allegations. They confirmed that Resident #1 (R1) experienced chest pains that felt like stabbing sensations in the chest and radiated around the neck at a pain level of 10 out of 10. (R1) was given "Nitroglycerin" as a PRN medication prescribed by (R1's) primary physician from Comfort Hospice Care. The staff also stated that the information provided in the incident report to (R1's) authorized representative was accurate. (S1) indicated that they followed (R1's) medication plan by administering "Nitroglycerin" in an emergency setting to relieve chest pain and improve circulation. (S1) reported that when "Nitroglycerin" was given, (R1's) blood pressure was measured, with the systolic blood pressure (SBP) exceeding 90 mmHg. (S1) stated that the incident report submitted to the authorized representative and Community Licensing is accurate, and that no amendments have been made to the reports. On November 6, 2025, between 11:16 AM and 11:31 AM, the Department interviewed resident member identified as Resident #1 (R1). (R1) reported experiencing chest pains that radiated in (R1's) back and neck. Although (R1) does not remember much about the incident, (R1) recalls being assisted by (S1), who provided pain medication that did not ease (R1's) symptoms. Despite that, (R1) was grateful that (S1) was there to take urgent measures and get medical assistance. (Evaluation Report continues LIC 9099-C) On November 6, 2025, between 11:32 AM and 01:30 PM, the Department interviewed resident members identified as Resident #2 through Resident #7 (R2-R7). Six (6) out of six (6) resident members cannot validate these claims. (R2-R7) stated medications have been handled appropriately, and there have been no reports of incorrect or unreported medication to their authorized representatives. On November 14, 2025, between 04:30 PM and 04:47 PM, the Department interviewed staff member of Comfort Hospice Care identified as Witness #1 (W1). According to (W1), Nitroglycerin is included in (R1's) prescribed medications. Comfort Hospice Care prescribes it as needed (PRN), starting July 8, 2024, for use at the first sign of an attack. It can be repeated every 5 minutes up to 3 times in 24 hours, with a maximum of 3 tablets per dose. (W1) indicated that (S1) took the appropriate actions by administering Nitroglycerin to (R1), who was experiencing chest pain attacks, on October 6, 2025. A review of (R1’s) Face Sheet and Emergency Info (dated 10/07/25 and 10/16/25), Service Plan (dated 02/05/25 and 06/29/25), Resident Assessment (dated 06/29 25), Physician’s Report LIC 624A (dated 02/24/25), and Unusual Incident Report LIC 624 (dated 10/07/25). Further review of Comfort Hospice Plan of Care (dated 03/2024), Cedars Sinai Medical Records (dated 10/10/25), End of Shift Report (dated 10/06/25 – 10/14/25) and Physician Orders for Life-Sustaining Treatment (POLST) (dated 02/05/25). Further review of Medication Administration Record (dated 10/1/25 -10/31/25) verified that Nitroglycerin is prescribed by Comfort Hospice Care. Based on the information gathered, there is not enough evidence to support the allegations mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. An exit interview was conducted with Robin Culver, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Nov 16, 2025 · control 11-AS-20251010143113

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87469(c)(1) · Plan of correction due date: Nov 30, 2025

87469 Advanced Directives and Requests Regarding Resuscitative Measures (c) If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following: (1) Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel and identify the resident as the person to whom the order refers. This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee failed to provide (R1's) Advanced Directives/POLST to EMT on 10/06/25 which lead to hospitalization. This violation poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2025

Plan of correction: Licensee will ensure to review Title 22 Reg 87469 and submit in writing that it's been review and will comply. Licensee will conduct hospice staff training and submit completed sign in sheet of attendees by POC 11/30/25 to ernand.dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(d) · Plan of correction due date: Nov 30, 2025

87633 Hospice Care of Terminally Ill Residents (d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times. This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee failed to follow the hospice care plan, as required, by not contacting hospce first during an emergency on 10/06/25 and instead calling 9-1-1, resulting in R1's hospitalization. This violation poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2025

Plan of correction: Licensee will ensure to review Title 22 Reg 87633 and submit in writing that it's been review and will comply. Licensee will conduct hospice staff training and submit completed sign in sheet of attendees by POC 11/30/25 to ernand.dabuet@dss.ca.gov

Allegation investigated: Residents sustained unexplained injuries. Staff did not prevent resident from injuring another resident.

On 09/24/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the allegations listed above. LPA met with the Robin Culver, Executive Director, and explained the purpose of the visit. LPA was granted access to the facility. The investigation consisted of the following: LPA Gonzalez requested and reviewed the staff roster, and resident roster. LPA observed that residents #1-#3 (R1-R3) were not listed on the roster and their service files are not in this facility. An interview conducted with staff #1 (S1) Robin Culver who informed LPA that R1-R3 are not residents at this facility. Based on the information gathered, this alleged violation is determined to be unfounded. An exit interview was conducted and a copy of the report was provided to Robin Culver. Unfoundedthe state’s words, verbatim · CDSS document, Sep 24, 2025 · control 11-AS-20250916105842

Type of visit: Case Management - Annual Continuation

On July 16, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual continuation visit. LPA met with Executive Director Chanel Sanchez. LPA explained the purpose of today’s visit. The facility is licensed to serve (40) ambulatory and (160) non-ambulatory elderly adults ages 60 and above. The facility is approved for (6) hospice residents. Currently, the facility has (3) residents on hospice care. The facility is a four story building structure located in a residential neighborhood. It consists of (37) bedrooms, (47) bathrooms, lobby, office, tea room, activity room, dining room, living area, activity room, laundry room, commercial kitchen, storage, beauty shop, medication room, synagogue room, library, and linen closets. and outside patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #112; #122; #123; #224; #232; #236; #301; #303, and #316. The water temperature range from 105.6 - 115.6 degrees F. and room temperature range from 70 - 73 degrees F., call buttons, and smoke and carbon monoxide are all in operating condition. LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged. Evaluation Report continues on LIC 809C During the visit LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters, including the Activities Calendar and Food Menu, were posted. The facility included stairway evacuation chairs in all the stairwells. Advisory Notes Issued (see LIC 9102) No Deficiencies were identified during this inspection visit. An exit interview was conducted, and a copy of this report was provided to Chanel Sanchez.the state’s words, verbatim · CDSS document, Jul 16, 2025

Allegation investigated: Staff did not ensure the kitchen area was kept clean and free of pests.

On July 1,2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an intial visit to gather information regarding the above allegation. LPA met with Executive Director Chanel Sanchez, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #6 (S1-S6) and resident members #1 to #7 (R1-R7). List of documents reviewed/obtained Register of Facility Residents LIC 9020 (dated 07/01/25), Personne Report (dated 07/01/25), Weekly Menu (dated 07/01/25 through 07/31/25), Western Exterminator Pest Management Maintenance Agreement (dated 3/3/25), Service Inspection Report from (04/07/25 to 06/18/25) ,and other records pertinent to this complaint. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not ensure the kitchen area was kept clean and free of pests. The complaint alleges that the facility staff does not ensure the kitchen area is kept clean and free of pests. It is reported that the kitchen consistently produces food contaminated by pests and appears to lack adequate cleaning of the kitchen area, as evidenced by contaminated food served to residents in care. No further details have been provided concerning this allegation. On July 1, 2025, between 09:50 AM and 11:45 AM, the Department interviewed staff members identified as Staff # through Staff #6. (S1-S6). Four (4) out of the six (6) staff members could not validate this allegation. (S1) stated they were not aware of any incident’s pest infestation in the kitchen that had been reported, and no residents reported needing medical attention due to food contamination. (S5-S6) claimed to have observed pests in the kitchen, but that was several months ago; it was not a frequent occurrence, but rather occasional. According to (S1-S6), a reputable pest control company provides weekly spray services in the kitchen. Since these services started, the pests have not returned. (S2-S6) reported that the kitchen staff practices safe handling procedures, which include regular hand washing, preventing cross-contamination, thoroughly cooking and reheating food, and maintaining food at safe temperatures. They clean and sanitize surfaces and equipment frequently, doing so three times daily, and store food properly while adhering to health and safety protocols. The kitchen staff has completed OSHA and Safety Training, as well as Food Safety training for food handlers. (S2-S6) emphasized that servers must wear appropriate, clean uniforms, aprons, hair restraints, and gloves. Furthermore, (S2-S3) clarified that contaminants are carefully managed and are never served to the residents in their care. Ensuring the safety and well-being of the residents is their top priority. In addition, the facility is overseen by a Certified Nutrition Specialist who conducts monthly inspections to ensure compliance with regulations, as stated by (S2-S3). On July 1, 2025, between 10:15 a.m. and 11:15 a.m., the Department interviewed the resident members identified as Resident #1 through Resident #7 (R1-R7). Five (5) out of the seven (7) resident members could not corroborate this allegation. (R1-R7) emphasized that they have consistently observed the kitchen staff practicing safe food handling and have not been served contaminated meals. (R1-R7) praised the kitchen staff and servers as courteous, efficient, and providing excellent service. (Evaluation Report continues LIC 9099-C) (R1-R2) have noticed pests in the dining area, but it has been a long time since they last witnessed them due to regular pest control spraying. A review of the facility’s Weekly Menu (dated 07/01/25 through 07/31/25), Training Topics, revealed staff have completed courses on OSHA & Safety, Food Safety, Kitchen Safety, Appearance Guidelines, Customer Expectations and Special Diet Considerations and Certification Board for Nutrition Specialist revealed the facility staff are fully trained and being monitored for regularly compliance. A review of the Western Exterminator Pest Management Maintenance Agreement (dated 3/3/25) and the Service Inspection Report from (04/07/25 to 06/18/25) confirms that the facility has a pest control agreement with weekly services. The Department's inspection included the commercial kitchen, dining room, laundry room, kitchen staff area, and janitor storage. No remnants of pest activity were observed. Additionally, the Department noted that kitchen staff were wearing gloves, hair restraints, aprons, and clean uniforms. The food supply was managed with appropriate dates to prevent spoilage and stored at the correct temperatures, by Title 22 regulations. Moreover, the Department observed the presence of additional supplies, including food thermometers, gloves, cleaning and sanitation supplies (such as spray bottles and brushes), food preparation tools (such as cutting boards and labels), storage containers, including aprons and masks. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with the Executive Director Chanel Sanchez, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 11-AS-20250627135310

Type of visit: Required - 1 Year

On June 5, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Executive Director Chanel Sanchez. LPA explained the purpose of today’s visit. The facility is licensed to serve (40) ambulatory and (160) non-ambulatory elderly adults ages 60 and above. The facility is approved for (6) hospice residents. Currently, the facility has (3) residents on hospice care. The facility is a four story building structure located in a residential neighborhood. It consists of (37) bedrooms, (47) bathrooms, lobby, office, tea room, activity room, dining room, living area, activity room, laundry room, commercial kitchen, storage, beauty shop, medication room, synagogue room, library, and linen closets. and outside patio area. A review of Fire & Earthquake Drills were completed for AM, PM and NOC shift on 03/11/25 and 03/23/25. Several working landline phones are available on-site. An audit of resident's service records for resident #1-#6 (R1-R6) and staff personnel records for staff #1-#5 (S1-S5) were accurate and complete. The facility is current on Community Care Licensing annual fees. The facility has a current administrator certificate on file for Chanel Sanchez #7013559740 valid between 07/07/2023 07/06/2025. The facility has a Liability Insurance Certificate coverage for 03/01/25 through 03/01/26 - LTP 00307-25-07. Due to time constraints, an additional visit is needed for the annual continuation inspection. No deficiencies cited during this inspection visit. An exit interview was conducted, and a copy of this report was provided to Chanel Sanchez.the state’s words, verbatim · CDSS document, Jun 5, 2025

Allegation investigated: Staff did not seek timely emergency medical treatment for resident. Staff did not notify resident's responsible party of change in resident's condition.

On March 21, 2025, California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent visit to gather information regarding the above allegations. LPA met with Chanel Sanchez, Executive Director, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #5 (S1-S5), and resident members #1 to #7 (R1-R7). List documents reviewed/obtained Resident Roster (dated 2/11/25 and 03/12/25), Personnel Report LIC 500 (dated 01/22/24 and 03/17/25), (R1)'s Medication List (dated 02/05/25), Service Plan (dated 11/05/24 and 02/05/25), Physicians Report LIC 602 (dated 05/20/24 and 02/04/25), Residential Agreement (dated 07/11/24), Progress Report (dated01/26/25 through 02/10/25), Cedars Sinai Medical Records (dated 01/29/25 through 02/01/25), and other pertinent documents associated with this complaint. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not seek timely emergency medical treatment for resident. Allegation #2: Staff did not notify resident's responsible party of change in resident's condition. The complaint alleged that the facility staff did not seek timely emergency treatment and did not notify Resident #1 (R1)’s responsible party of change in condition. It is reported on January 25, 2025 (R1) had an unwitnessed fall and hit (R1’s) head on the bathroom tub. On January 27,2025, (R1) was found incoherent and with loss of conciseness and in both incidents no medical attention was provided. On February 11, 2025, between 10:15 AM and 12:40 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the three (3) acknowledge the incidents occurred with (R1). (S1-S3) claimed the standard procedures are that when a fall occurs, the care staff performs a triage, an assessment is done, and if necessary, 911 is dispatched. (S1-S2) stated that medical attention is requested if the fall involves a head injury. After a fall, the registered nurse monitors the resident for seven consecutive days. (S1) claimed was unaware of the fall on January 25, 2025, while (S2) was not on duty and was only made aware of the incident by staff. (S1-S2) both admitted that medical attention was required as the fall with (R1) involved a head impact. On March 21, 2025, between 12:15 PM and 12:55 PM, the Department interviewed a staff member identified as Staff #4 and Staff #5. Two (2) out of the two (2) staff members (S4-S5) stated they was aware of (R1)’s fall and no medical attention was provided ordered by (R1). (S4) stated that the family representative of (R1) was notified and refused medical attention following the fall. (S4-S5) reported caregivers are trained to respond to resident falls. The on-duty supervisor assesses the resident and decides if medical attention is needed, especially in head impact cases. Two (2) out of the two (2) staff members identified as Staff #2 and Staff #4 were only made aware of (R1) 's change in medical condition on January 28, 2025, by (R1) 's family representative who informed them about the resident's change in condition. (S2 and S4) claimed they did not notice (R1)'s decline or seek medical attention until the family representative informed them that (R1) was incoherent and had lost consciousness. On March 21, 2025, between 10:00 AM and 11:07 AM, the Department conducted interviews with resident members identified as Resident #1 through Resident #7 (R1-R7). Four (4) out of the seven (7) residents reported experiencing falls while in care at this facility. They indicated that they received appropriate care from staff and did not require any medical attention. (Evaluation Report continues LIC 9099-C) INVESTIGATION REVEALED THE FOLLOWING: Allegation #3: Staff did not provide resident with food. Allegation #4: Staff did not provide resident with fluids. The complaint alleged that the facility staff did not provide Resident #1 (R1) adequate food and fluids. (R1)'s recent hospitalization required monitoring of food and fluid intake. No additional information was provided concerning these allegations. On February 11, 2025, between 10:15 AM and 12:40 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the (3) staff members denied the claim. (S1-S3) explained that (R1) receives three meals daily without a special diet. Along with the meals, a variety of liquid fluids are provided. All residents are offered a daily 60 oz pitcher of drinking water. According to (S1), the meals are both nutritious and have been approved by dieticians at Calson Management. (S1-S3) reported with (R1)'s recent hospitalization, (R1) was medically reassessed, and the service plan was updated. (R1) returned from the hospital on February 1, 2025, and was monitored by care staff daily through February 10, 2025. On March 21, 2025, between 12:15 PM and 12:40 PM, the Department interviewed a staff member identified as Staff #5. (S5) claimed to be one of the primary care staff for (R1) and verified that (R1) was being monitored routinely after (R1)'s hospitalization. (S5) claimed that it was challenging oftentimes when it came to meals as (R1) preferred only a Cheeseburger, and if (R1) was not provided that request, they would refuse to eat. (S5) also stated that (R1) preferred only to drink sodas and that water was not of preference and would have to make (R1) must do better on water intake. On March 21, 2025, between 10:00 AM and 11:07 AM, the Department interviewed resident members identified as Resident #1 through Resident #7 (R1-R7). Seven (7) out of the seven (7) residents claimed to have no issues or concerns with lack of meals and fluids. (R1-R7) all verified the facility provided three meals daily and fluids are provided with meals. (R1-R7) confirmed that care staff provided residents with daily water pitcher and it refilled in the afternoon. (R1) reported to have a preference for cheeseburger and soda for liquid drinks and claimed (R1) needed to better at consuming water. (Evaluation Report continues LIC 9099-C) The Department reviewed (R1)'s Progress Notes (dated 01/26/25 through 02/10/25) and revealed that (R1) was being monitored for food and liquid consumption. A review of (R1's) Physicians Report LIC 602 (dated 05/20/24 and 02/04/25) and Service Plan (dated 11/05/24 and 02/05/25) made no indication that (R1) is on a special diet. An additional review of the facility's menu (dated 03/01/25 through 03/31/25) revealed that certified board nutrition specialists approve meals. Upon further review of (R1)'s Medication List (dated 02/05/25), it was noted that two (2) of the nine (9) prescribed medications has side effects related to loss of appetite (ref. National Institutes of Health). The Department observed (R1) was supplied with a bedside water pitcher on both visits on February 11, 2025 and March 21, 2025. Based on the gathered information, insufficient evidence supports the stated allegations. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted with Chanel Sanchez, and copies of the reports were provided. Resident #1 (R1) recalled having a fall but did not believe that medical attention was necessary at the time. However, (R1) did remember hitting their head on the bathroom tub during the fall. Six of the seven residents, identified as Resident #2 through Resident #7, stated that the staff are attentive in observing any decline or change in a resident's condition. (R1) mentioned being hospitalized after the fall, but only after a family representative requested medical attention. (R1) noted a change in condition due to symptoms of a urinary tract infection that staff should have noticed. The Department reviewed (R1)'s Progress Notes (dated 01/26/25 through 02/10/25) and revealed that had fall with head impact on January 26, 2025 and 911 was not ordered. It also revealed that on January 28, 2025, facility staff was ordered by the family representative to call for paramedics due to the change with (R1)'s condition. Further review of (R1)'s Medication List (dated 02/05/25) revealed nine (9) out of the nine (9) prescribed medications all had side effects of dizziness, anxiety, confusion, seizure or fainting (ref National Institute of Health) symptoms could contribute to falls. Upon reviewing the available information, it is evident that the facility failed to comply with its established fall prevention protocols. In this instance, immediate medical attention was not sought for resident (R1) following a fall that resulted in a significant head impact. Such an oversight in care is concerning, as prompt hospitalization could have revealed that the resident may have been experiencing a urinary tract infection. This condition can lead to further complications if left untreated. This lapse underscores the critical importance of adherence to safety guidelines and the need for timely intervention. Based on observations, interviews, and record reviews, the preponderance of evidence standard for "NEGLECT and LACK OF CARE AND SUPERVISION" has been met. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted with Chanel Sanchez, the Executive Director. During the interview, a hard copy of the report and information on appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 21, 2025 · control 11-AS-20250204170433

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Mar 28, 2025

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat... an apparent life-threatening medical crisis... This requirement was not met as evidence by: Based on observation, interviews, and record reviews (R1) suffered head impact due to a fall and no medical attention was provided with a 911. This violaiton poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2025

Plan of correction: Licensee shall provide staff with training on imminent threat health conditions. Licensee will provide copies of training materials and sign in sheet to CCL by POC 03/28/25 date to ernand.dabuet@dss.ca.gov * Corrected during the visit with training conducted on 02/20/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Mar 28, 2025

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental..., that appropriate assistance is provided when such observation reveals unmet needs... This requirement was not met as evidence by: Based on observation, interviews, and record reviews (R1) suffered head impact and a change of conditon was not observed for decline in health condition. This violaiton poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2025

Plan of correction: Licensee shall provide staff with training on observation of the residents. Licensee will provide copies of training materials and sign in sheet to CCL by POC 03/28/25 date to ernand.dabuet@dss.ca.gov * Corrected during the visit with training conducted on 02/20/25.

Allegation investigated: Licensee did not provide copies of resident records in a timely manner.

On 3/19/2025 at approximately 10:40 AM, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Chanel Sanchez / Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interview (S#1) and Witnesses Interview (W#1). LPA obtained and reviewed the following documents: Resident Roster, Personnel Roster and (W#1) electronic records request. Evaluation Report continues LIC 9099-C Substantiated Investigation Revealed the Following: Allegation: Licensee did not provide copies of resident records in a timely manner The details of the complaint alleged that facility staff did not provide copies of (R#1)’s records in a timely manner. On March 19, 2025, at approximately 1:30 PM, LPA Iniguez observed the e-fax cover sheet from (W#1) dated 2/24/25 at around 5:30 PM. This cover sheet requested records regarding (R#1), and the e-fax transmission was successful. On March 13, 2025, at approximately 1:00 PM, during an interview with witness 1 (W#1), (W#1) stated that they represent (R#1)’ Power of Attorney (W#2). On February 24, 2025, they had requested copies of (R#1)’s file from the facility, but the facility had not responded to their request. (W#1) reported that they called the facility on March 5, March 6, March 7, March 10, March 11, and March 12 to follow up on the records, but the facility did not address their requests. On March 13, a facility staff member emailed (W#1) partial records related to (R#1). However, (W#1) has still not received the complete records they requested. On 3/19/2025, at approximately 10:30 AM, LPA contacted (W#1). He asked them if the facility had sent them all the required records. (W#1) stated no, "I have only partial records, not everything we have requested". Evaluation Report continues LIC 9099-C On March 19, 2025, at approximately 11:15 AM, during an interview with Executive Director (A#1), she stated that she was not aware of (W#1)’s records request regarding (R#1), however, (A#1) stated that as 3/18/25, they send some of the records to (W#1). In addition, (A#1) stated that she will send all the records today. On March 19, 2025, at approximately 11:45 AM, during an interview with facility staff (S#1). They mentioned that they had received a records request from (W#1) and were currently working on it since they had just located (R#1)’s records. (S#1) also noted that they had already sent some records to (W#1) on March 18, 2025. During this investigation, LPA found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Chanel Sanchez/Executive Director.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 11-AS-20250312101947

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Mar 24, 2025

87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential.(1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidence by: Based on a review of records and interviews, the facility staff failed to ensure (R#1)'s designated representative did not get their records upon request. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2025

Plan of correction: Licensee will ensure to follow Tittle 22 Regualtions at all times. As plan of correction, facility will send (R#1)'s requested records to (W#1). Proof of correction will be confirmed with (W#1) before poc due date.

Allegation investigated: Staff does not administer residents medication as prescribed. Staff does not maintain residents hygiene. Staff left resident soiled in urine and feces. Staff did not provide medical attention to resident after fall. Staff does not ensure resident has running water

On 2/13/2025, the Department of Social Services (DSS) - Community Care Licensing Division (CCLD) staff conducted an unannounced complaint visit at this facility. CCLD staff explained the purpose of the visit to the Executive Director/Administrator, Chanel Sanchez. The investigation consisted of the following: On 8/13/2024, the department toured the facility, interviewed staff and residents, and collected facility records. On 2/11/2025, the department toured the facility, interviewed 7 residents and 5 staff, and collected facility records such as resident and personnel roster, resident records, and facility records. On 2/13/2025, the department reviewed Medication Administration Records (MARs), Facility Shower Schedule and delivered findings. Unsubstantiated The investigation revealed the following: Regarding the allegation “staff does not administer residents medication as prescribed”, it is being alleged that staff administers residents’ medication 2 hours after prescribed scheduled time. Interviews conducted revealed the following: 7 out of 7 residents denied the allegation and 5 out of 5 staff denied the allegation. Records reviewed of MARs do not indicate that medications were provided after prescribed scheduled time. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “staff does not maintain residents hygiene”, it is being alleged that residents hygiene is not being maintained. Records reviewed of Facility Shower Schedule revealed the following: the facility has a shower schedule for residents in care. Interviews conducted revealed the following: 7 out of 7 residents denied the allegation and 5 out of 5 staff denied the allegation. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “staff left resident soiled in urine and feces”, it is being alleged that residents are left in soiled diapers for long periods of time. Interviews conducted revealed the following: 7 out of 7 residents denied the allegation and 4 out of 5 staff denied the allegation. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff did not provide medical attention to resident after fall”, it is being alleged that after resident(s) fell staff did not provide medical attention. Interviews conducted revealed the following: 7 out of 7 residents denied the allegation and 5 out of 5 staff denied the allegation. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff does not ensure resident has running water”, it is being alleged that staff is aware that resident(s) do not have running water in their apartment(s) and the facility has done nothing to fix the problem. Interviews conducted revealed the following: 7 out of 7 residents denied the allegation and 5 out of 5 staff denied the allegation. Observations revealed the following: 7 out of 7 resident apartments had running water. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with the Executive Director/Administrator, Chanel Sanchez. The investigation revealed the following: Regarding the allegation “staff does not keep facility free of pests”, it is being alleged that the facility has vermin. Observations revealed the following: a live vermin (cockroach) was observed in the kitchen area as well ad dead vermin. Pest control records for the year of 2024 revealed the following: pest control comes to the facility at least once a month or more and provides services; pest control also provides recommendations in each visit and indicates if it is pending or completed as well as states the severity of the recommendation; pest control record dated 12/2/2024 has recommendations dating back to 4/5/2023 and under General Comments it states “Cockroach activity has worsened in kitchen”. Regarding the allegation “staff does not keep facility free of pests”, the preponderance of the evidence standard has been met therefore the allegation is substantiated. Deficiencies cited based on observation and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director/Administrator, Chanel Sanchez.the state’s words, verbatim · CDSS document, Feb 14, 2025 · control 11-AS-20240808094537

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Mar 4, 2025

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in having evidence of vermin in the kitchen area, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Feb 14, 2025

Plan of correction: The Administrator has agreed to complete the recommendations provided by their pest control company. The Administrator will email Facility Pest Control Plan and Steps they have taken to minimize vermin in facility to Socorro.Leandro@dss.ca.gov.

Type of visit: Required - 1 Year

On 06/14/24, Licensing Program Analyst (LPA), David España conducted an unannounced annual visit using the full CAREs tool. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection. LPA was met by Chanel Sanchez; Administrator and the purpose of today’s visit was explained. Currently there are 62 residents, 11 are ambulatory and 51 of are non-ambulatory.The facility is a 4-story building structure located in a residential neighborhood. It consists of (37) bedrooms, (47) bathrooms, lobby floor contains: front desk, office, tearoom, activity room, dining room, living room, TV room, laundry room, kitchen/ food storage, 2 elevators, and common restrooms. The 1st residential floor contains arts/crafts room, beauty shop, medication room, 2 storage rooms, janitor closet, 1 linen closet, outside seating patio with chairs and umbrellas, and common restrooms. The 2nd floor residential floor contains common restrooms, synagogue, janitor closet, PPEs storage room # 214, linen closet, and janitor's closet. The 3rd floor residential floor contains common restroom, library, janitor closet, 1 storage closet, and 1 linen closet. LIC809 (cont) The front of the building is landscaped and there is a basement garage. The last fire drill was conducted on 05/14/2024. LPA and Chanel Sanchez, Administrator toured the kitchen, first floor and second floor. LPA tour inside and out grounds with Chanel Sanchez, Administrator. Six rooms were toured at the time of visit. All the rooms toured were occupied by residents. Each room had the required furniture, including a bed, chair/couch, dresser, nightstand, lamp and ample closet space. Residents have the option to furnish rooms with their own belongings or keep the furnishings that is in the unit. LPA did not observe any deficiencies; therefore, no citations were issued at this time. An exit interview was conducted with Chanel Sanchez; Administrator and copy of report provided.the state’s words, verbatim · CDSS document, Jun 14, 2024

Allegation investigated: Staff do not provide adequate food service to residents. Staff do not ensure the facility is clean. Staff do not administrer residents' medications as prescribed Staff do not ensure residents have adequate night time supervision.

On 12/07/23, Licensing Program Analyst (LPA) Antonine Richard conducted an initial complaint investigation for the allegations listed above. LPA was greeted by receptionist Tony Mitchell. Administrator Bernice Pulanco arrived shortly and later joined by Regional Executive Director Robin Culver with the visit. LPA explained the purpose of today's visit. The investigation consisted of the following: LPA Richard toured the physical plant with the Regional Executive Culver and Pulanco. LPA Richard reviewed and requested copies of staff and client's records. LPA interviewed six residnts,(R1-R6) and six staff (S1-S6). LPA Richard requested and reviewed and collected facility documents. Resident Information sheet, roster, MAR, Menu for the month, General Cleaning Schedule. Unsubstantiated The investigation revealed the following: Regarding allegations: Staff do not provide adequate food service to residents. On 12/07/23, LPA interviewed six staff (S1-S6) about the allegation above, all six staff agreed the allegation is not true, some of the resident like to have a portion of food served to them. The staff also reported they do ask the residents if they like to have more food. During today investigations, LPA and Administrator observed residents having breakfast, the proportion of the food served was adequate a lot. Based on Observation and interviews there is not sufficient evidence to support the alleged allegation: There is not preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation staff do not provide adequate food service to residents is unsubstantiated. Regarding allegation: Staff do not ensure the facility is clean. On 12/07/23, LPA interviewed six staff(S1-S6) all staff indicated that residents bedrooms were sanitary, during the investigation, LPA observed the residents bedrooms, bed sheets, the floor, the wall are cleaned. The water fountain in lobby and in the dining room had no mold, stain, and calcium surrounding the water faucet. About the allegation above all the staff agreed the allegation is not true. LPA interviewed six Residents (R1-R6), all residents stated the facility is in sanitary condition. Based on observation, interviews there is not sufficient evidence to support the alleged allegation, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation staff do not ensure the facility is clean is Unsubstantiated. Regarding allegation: Staff do not administer residents' medications as prescribed. On 12/07/23, LPA interviewed six staff (S1-S6), 3 out 6 staff stated that they assisted with the medications the way the doctor prescribed the medication. LPA interviewed the nurse (S6) stated all the medications are being recorded and signed in the MAR after the medication have been administered. LPA reviewed the records (MAR) and found it to be in order. LPA Interviewed six residents (R1-R6) 4 out 6 residents stated they don't need assistance with their medications. However, if they do need help the nurse does help them. The Residents (R2-R3) stated they do not have a problem how the facility administers its medications. Based on records reviewed and interviewed there is not sufficient evidence to support the alleged allegation there is not a preponderance of evidence to prove the allegation staff do not administer residents medications as prescribed. Therefore the allegation is Unsubstantiated. Regarding allegation: Staff do not ensure residents have adequate nighttime supervision. On 12/07/23, LPA Richard interviewed six staff (S1-S6) Interviews conducted with both administrators, S1 – S2, stated that there is night supervision. There are 2 care givers, 1 Med aide, and the Nurse supervisor is on call for the night shift. There is also someone at the front desk until 10:00 PM every day. Interviews with residents (R1-R6), did not know about night supervision. LPA Richard reviewed the staff schedule, front desk schedule, and Med aide schedule. there is enough night time supervision at the facility. Based on interviewed, records reviewed There is enough night supervision for the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the alleged allegation staff do not ensure residents have adequate night time supervision is unsubstantiated. An exit interview was conducted with Bernice Pulanco, Administrator, and Robin Culver, Regional Executive Director, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 7, 2023 · control 11-AS-20231129152826