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 Kris Ann Joy Resuento- Business Office Director who was informed of the purpose of the visit The facility is licensed to serve (138) elderly adults aged 60 and above, of which (40) may be non-ambulatory on 1st and 2nd floor. Facility has an approved hospice waiver for (8). The facility is a 4- story structure located in a residential neighborhood. It consists of (79) bedrooms throughout the 4 floors, (8) common area bathrooms, (79) full private bathrooms, shaded area. 1st Floor: Lobby, Receptionist desk, library, activity room, storage, salon, dining room, administrators’ office, kitchen, laundry room, linen closet, The 2nd Floor consists of patio, Medication room, janitor's closet,linen closet. The 3rd floor has residents rooms and linen closet. 4th floor has a visiting area and linen closet. Internet service and land line were observed. At 10:00 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. LPA also conducted an audit of three (3) residents’ medications, and it appears that residents are given their medications as prescribed by their physicians. At 12:15 PM, LPA Allen and Joy 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. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was a 5-day supply of perishable and a 7day supply of non-perishable food items available, which was adequately maintained/stored. There was a menu available for review which coincides with what is being served. 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 Joy Resuento-Business Office Director at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 17, 2026

Allegation investigated: Lack of care and supervision resident is left unattended. Staff do not ensure provision of care and supervision to meet client needs. Staff did not report incidents to family. Staff shove food into resident mouth.

*This report supersedes the report dated 07/01/2026 to add additional information and interviews.* On 7/01/26, the department conducted an initial complaint visit to the facility and was greeted by Memory Care Coordinator, Sandy Iraheta, and Robin Culver, Executive Director. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff, and deliver findings for the allegations mentioned above. The investigation consisted of the following: On 7/22/26, the department conducted a subsequent visit the facility to interview residents about the complaint. The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S5) and residents (R2-R6). The department received the following documents: Resident Roster (Date: No Date), Staff Roster (Dated: 06/18/2026), ID Emergency Information (Dated:12/02/2024), Physician’s Report (Dated:10/23/2025), Service Plan (Dated: 02/06/2026), Resident Assessment (Dated: 02/06/2026), Death Report (Dated: 03/25/2026), and Preplacement Appraisal (Dated: 12/02/2024) from the facility. Report Continued On LIC9099-C Unsubstantiated The investigation revealed the following: Allegation#1- Lack of care and supervision resident is left unattended. The details of the complaint alleged that the facility’s staff leaves the resident (R1) unsupervised in the dining area when they need full assistance with feeding and mealtime support. It was reported that staff wheels the resident (R1) into the dining room and leaves them unsupervised while eating. On 7/01/2026, from 1:40pm-4:00pm, the department interviewed staff (S1-S5) and on 7/22/2026 from 10:00am-11:00am the department interviewed residents (R2-R6) regarding the allegation. R1 could not be interviewed because the resident has passed away. 5 of 5 staff denied the allegation that Lack of care and supervision resident is left unattended. All of the staff stated that the resident did need full assistance with feeding and meal support. Staff further stated that the resident was never left unattended and that there is always a caregiver available for those residents who need to be monitored while eating. The department reviewed the Service Plan (Dated: 02/06/2026), Physician’s Report (Dated:10/23/2025), Resident Assessment (Dated: 02/06/2026), and observed that the resident did need full assistance with eating and meal support. The department interviewed 5 of 5 staff and all staff stated that (R1) was never alone while eating and full assistance and meal support was given at all times. The department interviewed residents (R2-R6) ) about the allegation and 5 of 5 residents that were interviewed denied that due to lack of care and supervision they have been left unattended. When asked if staff has ever left you unattended for long periods of time or if you have witnessed staff leaving other residents unattended for long periods of time when they needed care and supervision, they stated no. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Lack of care and supervision resident is left unattended. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued On LIC9099-C Allegation#2-Staff do not ensure provision of care and supervision to meet client needs. The details of the complaint alleged that the facility’s staff shoves food into the residents’ mouth, then walks away and leaves them unsupervised. It was reported that the resident chokes while eating because staff is not there to monitor the resident. On 7/01/2026, from 1:40pm-4:00pm, the department interviewed staff (S1-S5) and on 7/22/2026 from 10:00am-11:00am the department interviewed residents (R2-R6) regarding the allegation. R1 could not be interviewed because the resident has passed away. 5 of 5 staff denied the allegation that Staff do not ensure provision of care and supervision to meet client needs. All of the staff stated that they have not witnessed or heard of any staff member shoving food into (R1s) mouth and then leaving them unsupervised and to choke on their food. Staff stated that (R1) needed full assistance with eating and meal support and that a caregiver was with (R1) at all times while they were eating and that the resident has never choked on their food. The department interviewed residents (R2-R6) about the allegation and 5 of 5 residents that were interviewed stated that the staff does ensure provision of care and supervision is provided. When asked if staff provides you with the provision of care and supervision to meet your needs, they all stated yes. The department did not observe any incident reports of choking for (R1). The department reviewed the Resident Assessment (Dated: 02/06/2026), and Service Plan (Dated: 02/06/2026) and observed that the resident did need full assistance with eating and meal support. The department interviewed 5 of 5 staff and all denied that the resident was ever left alone and had no knowledge of (R1) choking on their food. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure provision of care and supervision to meet client needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation#3-Staff did not report incidents to family. The details of the complaint alleged that the facility staff did not report choking incidents to the family involving the resident. It was reported that the resident chokes while eating because staff is not there to monitor the resident. On 7/01/2026, from 1:40pm-4:00pm, the department interviewed staff (S1-S5) and on 7/22/2026 from 10:00am-11:00am the department interviewed residents (R2-R6) regarding the allegation. Report Continued On LIC9099-C R1 could not be interviewed because the resident has passed away. 5 of 5 staff denied the allegation that Staff did not report incidents to family. All staff stated that there has never been any incidents of the resident choking. Staff also stated that the family was always notified of any incidents involving (R1) and their care at the facility. But added that there was not a report of the resident choking because they have no knowledge of the incident, therefore a report was never sent to the family. The department interviewed residents (R2-R6) about the allegation and 5 of 5 residents that were interviewed stated that the staff does report incidents to their doctor and family. The department did not observe any incident reports of choking for (R1). Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff did not report incidents to family. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation#4-Staff shove food into resident mouth. The details of the complaint alleged that the facility staff shove food into the residents’ (R1) mouth and leaves without making sure the resident swallows their food. It was reported that the resident was having a hard time breathing because their mouth was stuffed with food. On 7/01/2026, from 1:40pm-4:00pm, the department interviewed staff (S1-S5) and on 7/22/2026 from 10:00am-11:00am the department interviewed residents (R2-R6) regarding the allegation. R1 could not be interviewed because the resident has passed away. 5 of 5 staff denied the allegation that Staff shove food into resident mouth. All of the staff stated that the staff has never shoved food into (R1s) mouth and never observed the resident having a hard time breathing because their mouth was full of food. Staff stated that (R1) needed full assistance with eating and mealtime support and that a caregiver was always present when they were eating. The department interviewed residents (R2-R6) about the allegation and 5 of 5 residents that were interviewed stated that they have never witnessed staff shoving food into a resident’s mouth. The department did not observe any incident reports of (R1) having breathing problems because of food related issues. Report Continued On LIC9099-C Based on interviews, there is insufficient evidence to support the allegation that Staff shove food into resident mouth. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were found and no citations were issued for this complaint investigation. An exit interview was conducted with Robin Culver, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 11-AS-20260629130547

Allegation investigated: Staff did not provide resident with proper notice regarding move. Staff did not provide resident with proper admissions agreement.

**This report does not supersede the previous report delivered on 02/25/2026 and is used only to clarify findings**. On 07/08/2026 between 10:20 AM and 2:35 PM, Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit regarding the allegations listed above. LPA met with Administrator Robin Culver, and the purpose of the visit was explained. The investigation consisted of the following: On 02/25/2026, LPA Watson obtained copies of the following documents: Resident Roster dated 11/24/2024, Staff Roster dated 11/18/2024, Resident Lease Agreement for R1 dated 05/01/2026, Physician’s Report for R1 dated 07/24/2025, CONTINUED ON LIC9099 - C Unsubstantiated Notice to Move Letter dated 02/05/2026, Medical Assessment dated 05/30/2026, and cell phone correspondence dated 02/27/2026. On the same date, LPA Watson conducted interviews with Staff #1–5 (S1–S5) and Residents #1–5 (R1–R5). On 07/08/2026, the department conducted additional interviews with Staff #1–3 and Staff #5 (S1–S3 and S5). An attempt was made to interview Staff #4, however S4 was not present and is no longer working at the facility. LPA Watson toured the facility with Administrator Culver and observed the facility to be clean and in good repair. Investigation revealed the following: Allegation: Staff did not provide R1 with proper notice regarding move. This allegation asserts that R1 did not provide proper notice of a room change, that the notice was undated, and that staff attempted to move R1 while he was ill. On 07/08/2026, the department interviewed Administrator Robin Culver (S1). S1 reported that staff provided proper notice to R1 and all affected residents. S1 stated all residents received 30 day notice of the renovation project and that R1 was granted an additional week to relocate. S1 clarified that the renovations were limited to flooring and painting and did not constitute major construction. On 07/09/2026, the department obtained and reviewed the Notice to Move Letter issued to R1 on 02/05/2026. The notice showed it was hand delivered to all residents on the first floor, informing them of the planned relocation to the fourth floor due to remodeling. Interviews with S1 and R1 confirmed that although the notice was provided on 02/05/2026, R1 was the last resident to relocate and did not move until 05/02/2026. On 02/25/2026, LPA Watson interviewed Staff #1–5 and Residents #1–5. Out of those interviewed 5 out of 5 staff denied the allegation, and 4 out of 5 residents denied the allegation. On 07/08/2026, additional interviews were conducted with Staff #1–3 and #5. Out of those interviewed 4 out of 4 staff interviewed denied the allegation. CONTINUED ON LIC9099-C Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or could be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. Allegation: Staff did not provide R1 with proper admissions agreement. This allegation asserts that R1 was not provided with an admission agreement containing required information, specifically late fee disclosures and notice of resident rights. On 07/08/2026, the department interviewed Administrator Robin Culver (S1). S1 stated that R1 received a proper and updated Admission Agreement that included required elements such as late fee information and notification of resident rights. S1 explained that the facility follows all terms outlined in R1’s Admission Agreement. On 07/09/2026, the department reviewed R1’s signed Resident Lease Agreement. Under Section 1.2, the agreement states that a $250.00 late fee will be added if payment is not received by the 6th day of each month. Section 10.1 indicates that the resident or responsible party received a copy of the Resident Personal Rights. Based on this review, the department concluded that the admission agreement contains all required information, including late fee disclosure and notice of resident rights. On 02/25/2026, LPA Watson interviewed Staff #1–5 and Residents #1–5. Out of those interviewed 5 out of 5 staff denied the allegation, and four out of five residents denied the allegation. On 07/08/2026, additional interviews were conducted with Staff #1–3 and #5. Out of those interviewed, 4 out of 4 staff denied the allegation. Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or could be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. An exit interview was conducted with Administrator Robin Culver, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 11-AS-20260219145659

Allegation investigated: Lack of care and supervision resident is left unattended. Staff do not ensure provision of care and supervision to meet client needs. Staff did not report incidents to family. Staff shove food into resident mouth.

On 7/01/26, the department conducted an initial complaint visit to the facility and was greeted by Memory Care Coordinator, Sandy Iraheta, and Robin Culver, Executive Director. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S5). The department received the following documents: Resident Roster (Date: No Date), Staff Roster (Dated: 06/18/2026), ID Emergency Information (Dated:12/02/2024), Physician’s Report (Dated:10/23/2025), Service Plan (Dated: 02/06/2026), Resident Assessment (Dated: 02/06/2026), Death Report (Dated: 03/25/2026), and Preplacement Appraisal (Dated: 12/02/2024) from the facility. Report Continued On LIC9099-C Unsubstantiated Allegation#4-Staff shove food into resident mouth. The details of the complaint alleged that the facility staff shove food into the residents’ (R1) mouth and leaves without making sure the resident swallows their food. It was reported that the resident was having a hard time breathing because their mouth was stuffed with food. On 7/01/2026, from 1:40pm-4:00pm, the department interviewed staff (S1-S5) regarding the allegation. R1 could not be interviewed because the resident has passed away. 5 of 5 staff denied the allegation that Staff shove food into resident mouth. All of the staff stated that the staff has never shoved food into (R1s) mouth and never observed the resident having a hard time breathing because their mouth was full of food. Staff stated that (R1) needed full assistance with eating and mealtime support and that a caregiver was always present when they were eating. They stated further that it is not their policy to force feed any of the residents. The department did not observe any incident reports of (R1) having breathing problems because of food related issues. Based on interviews, there is insufficient evidence to support the allegation that Staff shove food into resident mouth. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were found and no citations were issued for this complaint investigation. An exit interview was conducted with Memory Care Coordinator, Sandy Iraheta, and a hard copy of this Complaint Investigation Report was provided. The department did not observe any incident reports of choking for (R1). The department reviewed the Resident Assessment (Dated: 02/06/2026), and Service Plan (Dated: 02/06/2026) and observed that the resident did need full assistance with eating and meal support. The department interviewed 5 of 5 staff and all denied that the resident was ever left alone and had no knowledge of (R1) choking on their food. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure provision of care and supervision to meet client needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation#3-Staff did not report incidents to family. The details of the complaint alleged that the facility staff did not report choking incidents to the family involving the resident. It was reported that the resident chokes while eating because staff is not there to monitor the resident. On 7/01/2026, from 1:40pm-4:00pm, the department interviewed staff (S1-S5) regarding the allegation. R1 could not be interviewed because the resident has passed away. 5 of 5 staff denied the allegation that Staff did not report incidents to family. All staff stated that there has never been any incidents of the resident choking. Staff also stated that the family was always notified of any incidents involving (R1) and their care at the facility. But added that there was not a report of the resident choking because they have no knowledge of the incident, therefore a report was never sent to the family. The department did not observe any incident reports of choking for (R1). Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff did not report incidents to family. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued On LIC9099-C The investigation revealed the following: Allegation#1- Lack of care and supervision resident is left unattended. The details of the complaint alleged that the facility’s staff leaves the resident (R1) unsupervised in the dining area when they need full assistance with feeding and mealtime support. It was reported that staff wheels the resident (R1) into the dining room and leaves them unsupervised while eating. On 7/01/2026, from 1:40pm-4:00pm, the department interviewed staff (S1-S5) regarding the allegation. R1 could not be interviewed because the resident has passed away. 5 of 5 staff denied the allegation that Lack of care and supervision resident is left unattended. All of the staff stated that the resident did need full assistance with feeding and meal support. Staff further stated that the resident was never left unattended and that there is always a caregiver available for those residents who need to be monitored while eating. The department reviewed the Service Plan (Dated: 02/06/2026), Physician’s Report (Dated:10/23/2025), Resident Assessment (Dated: 02/06/2026), and observed that the resident did need full assistance with eating and meal support. The department interviewed 5 of 5 staff and all staff stated that (R1) was never alone while eating and full assistance and meal support was given at all times. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Lack of care and supervision resident is left unattended. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation#2-Staff do not ensure provision of care and supervision to meet client needs. The details of the complaint alleged that the facility’s staff shoves food into the residents’ mouth, then walks away and leaves them unsupervised. It was reported that the resident chokes while eating because staff is not there to monitor the resident. On 7/01/2026, from 1:40pm-4:00pm, the department interviewed staff (S1-S5) regarding the allegation. R1 could not be interviewed because the resident has passed away. 5 of 5 staff denied the allegation that Staff do not ensure provision of care and supervision to meet client needs. All of the staff stated that they have not witnessed or heard of any staff member shoving food into (R1s) mouth and then leaving them unsupervised and to choke on their food. Staff stated that (R1) needed full assistance with eating and meal support and that a caregiver was with (R1) at all times while they were eating and that the resident has never choked on their food because staff was not doing their job. Report Continued On LIC9099-Cthe state’s words, verbatim · CDSS document, Jul 1, 2026 · control 11-AS-20260629130547

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 #2 through #6 (R1-R6) and Staff #1 through Staff #3 (S1-S3). (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 serious breach of privacy and potentially leading to legal consequences. 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 #3 (S1-S3). Three (3) of the three (3) staff members could not support this claim. (S2) confirmed that an external vendor performed a live performance at one time that included comedy and music for the residents at memory care. (S1-S3) 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 content from Instagram, Facebook, and YouTube, featuring Residents #1 in the video. (S1-S3) confirmed the resident's identity and reported that (R1) has a Media Release Form authorizing the use of photos, newsletters, bulletin boards, and social media pages on file. On June 4, 2026, between 01:00 PM and 01:57 PM, the Department interviewed resident members identified as Resident #2 through Resident #6. Five (5) out of Five (5) could not corroborate this claim. None of the residents recalls encountering any guests or vendors taking photographs or videos. They stated they had never witnessed an outside vendor recording images or videos of residents without their consent. All residents confirmed signing the Media Release Form and stated they had no concerns about their images being shared on social media platforms. Resident #1 (R1) is unavailable for an interview due to the resident's death. (Evaluation Report continues LIC 9099-C) The Department reviewed the Media Release Forms for Resident #1, #2, and #3 (dated 12/02/24, 06/04/25, and 03/12/25) 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 the facility's activities calendar (dated 06/01/25 through 06/30/26) and found no entries for external vendor 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 (1) resident was resident featured in social media posting. 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-20260529144201

Type of visit: Case Management - Deficiencies

On 05/26/2026 at 2:00pm, the Department conducted an unannounced case management deficiencies at the facility listed above. During the complaint investigation for 11-AS-20260521081210, the Department observed Staff # 2 (S2) was not associated to the facility at the time of unannounced complaint investigation. As a result, civil penalties are being assessed and a deficiency is being cited under California Code of Regulation Title 22, Division 6, Chapter 8 are being cited on the LIC 809-D. Exit interview conducted with Maria Mesplie (Medtech) and a copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, May 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: May 27, 2026

Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2)Obtain a California clearance or a criminal record exemption as required by the Department Based on observation and interview, S2 Linda Calixte was not associated to the facility as the time of unannounced complaint investigation which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: The facility shall associate staff 2 in Guardian and submit proof of update via email at zina.brown@dss.ca.gov by POC due date.

Allegation investigated: Staff did not prevent resident from developing pressure injuries. Staff do not ensure that residents’ incontinent care needs are met. Staff do not assist resident with eating. Staff do not assist resident with ambulation. Staff do not observe resident for change in condition. Staff are not following resident's care plan. Staff do not report incidents to appropriate parties. Licensee does not ensure that staff have required training.

On 03/13/2026, the department conducted an unannounced subsequent complaint investigation visit to deliver findings for the allegations listed above. LPA met with Memory Care Coordinator, Sandy Iraheta, and was granted access into the facility. The investigation consisted of the following: On 2/6/26, at 9:30am, the department conducted an initial complaint visit to the facility and was greeted by Sandy Iraheta, Memory Care Director. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, and interview staff and residents. The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4) and residents (R1-R6). The department received the following documents: Resident Roster (Date: No Date), Staff Roster (Dated: 01/31/2026), Resident Notes (06/23/2025-02/05/2026)... Report Continued On LIC909-C Unsubstantiated Face Sheet/ID Emergency Information (Dated: 02/26/2026), Resident Lease Agreement (Dated: 06/05/2025), Addendum Note (Dated:02/13/2025), Feeding Abilities Note (Dated: 12/05/2025), Physician’s Report (Dated: 10/23/2025), Service Plan (Dated: 01/08/2026), Physician Orders for Life Sustaining Treatment (Dated: 09/15/2024), Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26), In-Service Training (Dated: 2025), and Resident Assessment (Dated: 02/06/2026) from the facility. The investigation revealed the following: Allegation #1- Staff did not prevent resident from developing pressure injuries. The details of the complaint alleged that the facility staff did not prevent the resident (R1) from developing pressure injuries. It was reported that R1 developed pressure injuries in their groin and thigh areas because staff leave R1 in soiled diapers for extended periods of time, staff do not rotate R1 or ambulate R1. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation that Staff did not prevent resident from developing pressure injuries. All staff stated that R1 is not being treated for wound care for pressure injuries. They stated that to their knowledge R1 does not have any pressure injuries. They also stated that R1 is receiving two-person full assistance with bathing, dressing, toileting, mobility support, and repositioning every two hours to prevent bedsores and does not have any pressure injuries. They also state that R1 is assisted with ambulation, changed regularly, and does not sit in soiled diapers for extended periods of time. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that they have not developed any pressure injuries due to neglect from the staff. They also stated that the staff are attentive to their needs and are happy with the care and supervision that is given by the staff. The department reviewed the Physician’s Report (Dated: 10/23/2025), Service Plan (Dated: 01/08/2026), Resident Assessment (Dated: 02/06/2026), Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26), and Face Sheet/ID Emergency Information (Dated: 02/26/2026) and did not observe any evidence of pressure injuries noted for R1. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff did not prevent resident from developing pressure injuries. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued On LIC9099-C Allegation #2- Staff do not ensure that residents’ incontinent care needs are met. The details of the complaint alleged that the facility staff do not ensure R1’s incontinent care needs are met. It was reported that the facility staff leave R1 in soiled diapers for extended periods of time. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation that Staff do not ensure that residents’ incontinent care needs are met. All staff stated that the allegation was not true and they have never left R1 in soiled briefs for an extended period of time. They state that all residents who are incontinent are checked on and changed every two hours or more depending on the resident and their care needs. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that their incontinent needs are being met timely by the staff and have no complaints. The department reviewed the Service Plan (Dated: 01/08/2026), Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26), and the Physician’s Report (Dated: 10/23/2025) and did not observe any lack in care or assistance in incontinence care. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure that residents’ incontinent care needs are met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3- Staff do not assist resident with eating. The details of the complaint alleged that the facility staff do not assist R1 with eating. It was reported that R1 chokes while eating because staff shoves food into R1’s mouth, then walks away and leaves R1 unsupervised. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation Staff do not assist resident with eating. All staff stated that they do assist the resident with eating and it is in R1s service plan for full assistance with feeding and mealtime support. However, they state the family tells them it would be beneficial if R1 was able to feed R1s self. They stated that the family stressed that R1 be given utensils and allowed R1 to feed themselves. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that they do not need assistance with eating. Report Continued On LIC9099-C The department reviewed the Service Plan (Dated: 01/08/2026), Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26), Resident Notes (06/23/2025-02/05/2026), Feeding Abilities Note (Dated: 12/05/2025), and Physician’s Report (Dated: 10/23/2025) and observed that there was communication between the facility and the family encouraging independence on the part of R1 to feed themselves. The department also observed that the Physician’s report states that the resident is able to feed themselves. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not assist resident with eating. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #4- Staff do not assist resident with ambulation. The details of the complaint alleged that the facility staff do not rotate or assist R1 with ambulation. It was reported that staff do not turn or reposition R1 causing pressure injuries. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation Staff do not assist resident with ambulation. All staff stated that it was not true. They stated that they transfer R1 from their bed to their wheelchair and assist with Activities of Daily Living every day. All staff further stated that they follow R1s service plan which includes full assistance with bathing, dressing, grooming, toileting, transfer, and mobility. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that they do not need assistance with ambulation but are confident that staff would assist them if they were needed. The department reviewed the Physician’s Report (Dated: 10/23/2025), Service Plan (Dated: 01/08/2026), Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26), and Resident Assessment (Dated: 02/06/2026) and did not find any evidence that the facility was not adhering to the service plan. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not assist resident with ambulation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued On LIC9099-C Allegation #5- Staff do not observe resident for change in condition. The details of the complaint alleged that the facility staff do not observe changes in R1’s condition. It was reported that R1 had a fever, low oxygen level and that R1 couldn't breathe. During the incident, a witness observed R1 having food shoved into R1’s mouth and R1 was having a hard time breathing but staff did not notice any of the changes in R1’s condition. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation Staff do not observe resident for change in condition. All staff stated that they are all trained to notice changes in a resident’s condition and would act accordingly if changes were noticed. 4 out of 4 staff stated that R1 has not had any incidents of choking or were aware of any to their knowledge. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that they were confident that staff would notice if they had a change in condition. The department reviewed the Physician’s Report (Dated: 10/23/2025), Service Plan (Dated: 01/08/2026), and Resident Assessment (Dated: 02/06/2026) and did not observe any incidents or observations that the resident was at risk for choking or has had a change in condition. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not observe resident for change in condition. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #6- Staff are not following resident's care plan. The details of the complaint alleged that the facility staff are not following R1’s care plan. It was reported that R1 has a care plan regarding the placement and cleaning of R1’s dentures. However, staff are not correctly putting R1’s dentures into R1’s mouth or cleaning their dentures. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation Staff are not following resident's care plan. All staff stated that the resident does have a service plan that involves cleaning and changing R1s dentures. They all stated that they are adhering to the service plan and are in constant contact with the family about R1s dental care. The department interviewed residents (R1-R6) about the allegation and 3 of 6 residents that were interviewed stated that they have a service plan and the staff are adhering to it. While two other residents stated they did not have a specific service plan that should be followed. Report Continued On LIC9099-C The department reviewed the Service Plan (Dated: 01/08/2026) and interviewed staff and did not observe or find any evidence that the facility did not follow the service plan. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff are not following resident's care plan. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #7- Staff do not report incidents to appropriate parties. The details of the complaint alleged that R1 choked while eating and that staff did not report the choking incidents to the family. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation Staff do not report incidents to appropriate parties. All staff stated that R1 has not had any incidents of choking at the facility to their knowledge. Staff further stated that any incidents involving the residents are reported as required by Community Care Licensing. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that the staff does let their responsible parties know if they have an incident in the facility. The department reviewed the Resident Notes (06/23/2025-02/05/2026), Face Sheet/ID Emergency Information (Dated: 02/26/2026), and Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26) and did not observe any evidence that the resident had a choking incident or a history of choking. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not report incidents to appropriate parties. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #8- Licensee does not ensure that staff have required training. The details of the complaint alleged that the facility staff do not have the required training to follow R1’s care plan. It was reported that a staff member stated that they have not received proper training to assist with correctly placing R1s’ dentures in their mouth. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation Licensee does not ensure that staff have required training... Report Continued On LIC9099-C All staff stated that they do have training in caring for R1 and in taking care of R1s dentures. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that they believe the staff does have sufficient training to take care of them and their service needs. The department reviewed the In-Service Training (Dated: 2025), Resident Notes (06/23/2025-02/05/2026), and Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26) and observed that the facility was in contact with the family and following the request for the care of R1’s dentures as well as had other required training for the position. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Licensee does not ensure that staff have required training. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued for this complaint investigation. An exit interview was conducted with Sandy Iraheta, Memory Care Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Mar 13, 2026 · control 11-AS-20260130115632

Allegation investigated: Staff did not administer medication to resident. Facility does not have adequate food service. Staff is not meeting resident's overall needs.

On 03/05/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to The Pinnacles at Burton and was greeted by Administrator Robin Culver (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S3, residents R1-R6. LPA Calderon obtained the following records: Physician report (dated 07/24/2025 and 02/23/2026), Menu for March 2026 and activities schedule for March 2026, MAR for 3 residents. Toured the facility with S1 to include the dining area and common areas. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff did not administer medication to residents. This complaint alleged that the facility did not administer medicated to R1. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions between staff and residents. LPA Calderon noted staff giving medications to residents in care. Records review indicate the following: reviewed MAR for residents indicates that the medication given to residents is given in the correct amount. R1 is not a resident, and no records could be found. Physician report (dated 02/23/2026) indicates that residents self-medicate. Interviews indicate the following: S1 indicates that staff follows the physician report for residents and they follow the MAR. Staff S2-S3 state that staff do not overmedicate residents. 3 of 3 staff deny the allegation. R1 could not answer any questions as residents do not exist. R2-R6 indicates that staff follow the residents MAR. 5 out of 6 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not administer medication to residents” is found to be UNSUBSTANTIATED. Regarding the Allegation: Facility does not have adequate food services. This complaint alleged that the facility did not feed residents. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions between staff and residents. LPA Calderon noted staff cleaning the facility. LPA Calderon witnessed staff serving residents’ breakfast. LPA Calderon inspected the kitchen area and noted 2 days and 7 days of food. Records review indicate the following: Reviewed March Menu, appears well balanced meals served to residents in care. Interviews indicate the following: S1 states that the facility serves 3 meals per day and snacks. S1 indicates that no residents go hungry. 3 out of 3 staff deny the allegation. R1 could not answer any questions as R1 does not exist and does not live at the facility. 5 out of 6 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “facility does not have adequate food services” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff do not meet residents’ overall needs. This complaint alleged that the facility did not meet residents’ overall needs. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions between staff and residents. LPA Calderon noted staff cleaning the facility. LPA Calderon witnessed staff serving residents’ breakfast. LPA Calderon witnessed activities being done in the activities room. Records review indicate the following: Reviewed the activities schedule for March 2026. Appears well balanced activities being given to residents. Interviews indicate the following: S1 states that the facility meets residents’ overall needs by giving meals, cleaning, activities and medications. 3 out of 3 staff deny the allegation. R1 could not answer any as R1 does not exist and does not live at the facility. 5 out of 6 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff is not meeting resident’s overall needs” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Robin Culver (S1).the state’s words, verbatim · CDSS document, Mar 5, 2026 · control 11-AS-20260303101629

Allegation investigated: Staff did not provide resident with proper notice regarding move. Staff did not provide resident with proper admissions agreement.

On 02/25/26 between 08:45 and 04:00 PM Licensing Program Analyst (LPA) Troy Watson conducted an initial complaint visit regarding the allegation above. LPA met with Administrator Robin Culver and the purpose of today’s visit was explained. The investigation consisted of the following: On 02/24 /26 LPA Watson obtained copies of the following documentation: Staff Roster, Resident Roster, Resident Lease Agreement dated 05/01/2026, Physicians Report dated 07/24/2025 and Notice to Move Letter dated 02/05/2026. On 02/24/2026 LPA Watson conducted interviews with Staff#1-5 (S1-S5) and Residents #1-5(R1-R5). LPA Watson toured the facility with Administrator Robin Culver and found the facility to be clean and in good repair. The investigation revealed the following: CONTINUED ON LIC9099-C Unsubstantiated Allegation 1: Staff did not provide R1 with proper notice regarding move. The allegation alleges that staff did not provide R1 with proper notice regarding a room move, including issuing undated notice and attempting to move the resident while he was ill. LPA Watson interviewed Administrator (A1) Robin Culver regarding whether staff provided the resident with proper notice prior to the room change. A1 explained that residents are being relocated due to ongoing construction and remodeling of the first floor units, which includes bathroom renovations, new carpet installation, interior painting, and repair of any unit damage. A1 stated that a letter was distributed to all first floor residents on 02/05/26 informing them that the facility was restarting the final stage of construction in the North Building, including the first floor remodel. Residents were also verbally informed that they would not incur any expenses related to the move and that the facility would provide boxes and assistance. Residents were advised they would receive 24 hours’ notice and that the actual move would be completed within one day. A1 acknowledged that the printed letter does not show a date; however, the electronic file indicates, when hovered over on her computer, that the letter was drafted and distributed on 02/05/2026. On 02/24/2026 LPA Watson conducted interviews with Staff#1-5 (S1-S5). Out of those interviewed 5 out of 5 staff members denied the above allegation. On 02/24/2026 LPA Watson conducted interviews with Residents #1-5(R1-R5). Out of those interviewed 4 out of 5 Residents denied the above allegation. LPA Watson obtained and reviewed the notice to move letter, and it showed that R1 was informed of the room move and LPA Watson observed that R1 had not yet moved from his room as of 02/25/2026. Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation : Staff did not provide R1 with proper admissions agreement. The allegation alleges that staff did not provide R1 with a proper admissions agreement, that lacked required information such as late fees and a notice of resident rights. CONTINUED ON LIC9099-C LPA Watson interviewed Administrator (A1) Robin Culver regarding whether staff provided R1 with the proper admissions agreement. A1 stated that R1 refused to move, reporting that he was sick and had not been given enough time or notice. A1 explained that due to R1’s hoarding behaviors and other mental health issues, he appeared unable to process the information about the move or participate in the required timeframe. R1 was third on the list to be relocated, and although a fully furnished, brand new unit was prepared for him, he repeatedly provided reasons why he could not move. A1 clarified that the move was not optional because all first floor residents had to be relocated for construction scheduled to begin on 03/01/2026. Staff continued to postpone R1’s move to accommodate him, but he remained unable to accept or complete the relocation process. On 02/24/2026 LPA Watson conducted interviews with Staff#1-5 (S1-S5). Out of those interviewed 5 out of 5 staff members denied the above allegation. On 02/24/2026 LPA Watson conducted interviews with Residents #1-5(R1-R5). Out of those interviewed 4 out of 5 Residents denied the above allegation.Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with the Resident Service Coordinator Sandy Iraheta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 11-AS-20260219145659

Type of visit: Office

On February 24, 2026, an office meeting was held to discuss Complaint 11-AS-20250909091421. The attendees included Licensing Program Manager (LPM) Janae Hammond, Licensing Program Analyst (LPA) Ernand Dabuet, Executive Director Robin Culver, Resident Coordinator Sandy Iraheta and Chief Executive Officer Jason Reyes. During the meeting, the Licensing Program Manager (LPM) reviewed the details of the complaint. On September 9, 2025, the Department confirmed allegation of neglect and a lack of care and supervision. The facility staff failed to provide adequate supervision, which resulted in the resident eloping on multiple occasions and sustaining serious bodily injuries. When the findings were delivered on September 17, 2026, the Department indicated that an enhanced civil penalty determination was pending under Health and Safety Code Section 1569.49(f) for Serious Bodily Injury. The Department is currently reviewing the complaint for an enhanced civil penalty for serious bodily injury as per H&S 1569.49(f). The total civil penalty has been set at $10,000 for serious bodily injury. Additionally, there is a discussion on the use of video surveillance within the facility. During the meeting Technical Support Program (TSP) was offered to the Executive Director. At this time the Department will follow up in a later date to see if the facility wants to participate in the program. An exit interview was conducted with Robin Culver, and a copy of this report was emailed to Jason Reyes..the state’s words, verbatim · CDSS document, Feb 24, 2026

Allegation investigated: The Administrator does not ensure that residents receive proper care. Facility staff do not ensure their is a sufficient amount of incontinence supplies available for resident use.

On 02/12/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint investigation for the allegations listed above. LPA met with Director, Robin Culver, and Resident Care Coordinator, Sandy Iraheta. LPA explained the purpose of the visit and was granted entry to the facility. The investigation consisted of the following: On 01/02/26, LPA Gonzalez collected the following documents: staff roster, resident roster, and the staff schedule for the months of November 2025, and December 2025. Additionally, LPA interviewed staff #1-#4 (S1-S4), conducted a tour of the facility, inspected resident rooms, and the med-tech room. Furthermore, on 02/12/26, LPA Gonzalez conducted interviews with resident #1-#5 (R1-R5), and staff #5 (S5). Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: The Administrator does not ensure that residents receive proper care. It is being alleged that the memory care department is severely understaffed. It is also being alleged that Memory Care Director, Sandy Iraheta provides little support or guidance during short-staffed situations. On 01/02/26, LPA conducted interviews with S1-S4, and on 02/12/26, LPA conducted an interview with S5. Of those interviewed, 4 out of 5 staff could not corroborate with the allegation. 2 out of 5 staff said they believe the facility is understaffed. On 02/12/26, LPA Gonzalez conducted interviews with R1-R5. Of those interviewed, 5 out of 5 residents could not corroborate the allegation. On 02/12/26, LPA Gonzalez conducted a review of the facility’s Personnel Report LIC 500 and staff schedule for the moths of November-December 2025 revealed the facility had sufficient staff to tend to the resident’s needs. Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Facility staff do not ensure there is a sufficient amount of incontinence supplies available for resident use. It is being alleged that there is an inadequate amount of essential care supplies, particularly incontinence products. On 01/02/26, LPA Gonzalez conducted interviews with S1-S4, and on 02/12/26, LPA conducted an interview with S5. Of those interviewed, 5 out of 5 staff denied the allegation. Interviews conducted with S1 and S5 revealed that residents are responsible for providing their own personal supplies. S1 and S5 reported that the facility maintains emergency supply available if a resident is in need. Continued on LIC9099-C On 02/12/26, LPA Gonzalez conducted interviews with R1-R5. Of those interviewed 5 out of 5 residents could not corroborate with the allegation. On 01/02/26, LPA Gonzalez conducted a tour of the facility and inspected resident rooms and the med-tech room. During the inspection, LPA observed an adequate supply of essential care products, including hygiene items and incontinence care products, maintained in the med-tech room. Based on observation, and interviews conducted, there is insufficient evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 11-AS-20251226142640

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

On 10/31/2025 at approximately 10:00 AM, LPA Jose Anguiano conducted a subsequent visit to deliver findings regarding the above allegations and met with the Medical Technician Danna Romero. Investigation consisted of the following: On 10/08/2025 at approximately 10:00 AM, Licensing Program Analyst (LPA) Jose Anguiano conducted a complaint investigation regarding the above allegations. LPA met with Resident Care Coordinator Sandy Iraheta. The investigation consisted of the following: LPA Anguiano toured the facility, interviewed (5) staff members (S1–S5), and (5) residents (R1–R5). LPA also conducted a review of facility records. LPA collected the following documentation: Physician’s reports for five (5) residents identified as potential victims. Care plans and medication records that may explain the presence of bruising. Observation reports for the month of September related to incidents involving the identified residents. Please see report continuation on LIC9099-C Unsubstantiated Face sheets for (5) residents. The facility’s personnel report and resident roster. Investigation revealed the following: Regarding the allegation "Residents sustained unexplained injuries": It was alleged that residents were observed with injuries for physical abuse. Interviews conducted with (5) staff and (5) residents revealed that none of the residents denied sustaining injuries; however, all injuries discussed were explained and attributed to known causes. Staff confirmed that any injuries were addressed appropriately. LPA observations during multiple visits revealed that no residents were observed with visible injuries at the time of inspection. Record reviews—including incident reports, care plans, observation logs, and hospital summaries—showed that all injuries were documented with corresponding explanations and follow-up. On 10/11/2025, LPA requested physician notes and hospital records. Additionally, LPA was informed and documented internally by administrator—that one resident refused medical attention. The resident’s Power of Attorney (POA) was notified and agreed with the decision to decline treatment. Documentation also confirmed that family members or responsible parties were notified in a timely manner. Additionally, LPA reviewed documentation and spoke directly with family members of residents involved. Family members confirmed being informed of the incidents and were aware of the care provided. On 10/11/2025, LPA requested physician notes and hospital records. LPA was informed—and it was documented internally—that one resident refused medical attention. The resident’s Power of Attorney (POA) was notified and agreed with the decision to decline treatment. Based on the evidence gathered, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. Regarding the allegation "Staff did not prevent resident from injuring another resident": It was alleged that staff failed to intervene in an incident where one resident injured another. LPA observations revealed no indication of staff shortages or lack of supervision during the visits. Record reviews revealed that although one resident has verbally directed inappropriate or insulting language toward other residents and staff, the behavior is well-documented internally. Records show that the resident’s family has been notified, hourly safety checks are conducted, medical adjustments have been made, and all three shifts of caregivers assist with ADLs, redirect the resident, and help de-escalate behaviors as needed. Interviews with residents and staff revealed that no resident had injured another. Please see report continuation on LIC9099-C In fact, one resident shared that staff actively prevent such incidents by locking the elevator to certain floors at specific times of the day to limit unsupervised movement and reduce the risk of resident-to-resident contact. Based on the evidence gathered, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. No deficiencies were cited during this visit. An exit interview was conducted with the Medical Technician Danna Romero, and a copy of this report, along with the Appeal Rights, was provided.the state’s words, verbatim · CDSS document, Oct 31, 2025 · control 11-AS-20250929141743

Type of visit: Case Management - Deficiencies

On 10/31/2025, around 10:00AM Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced case management visit to the facility and met with Medical Technician Danna Romero. The investigation revealed that the administrator failed to comply with Title 22 regulations, resulting in a deficiency. This noncompliance poses a potential health and safety risk to residents in care and constitutes a violation of Section 87211(a)(1)(D), which pertains to reporting requirements. On 10/08/2025, Licensing Program Analyst (LPA) observed that three residents (R1–R3) experienced unwitnessed falls on 09/11/2025, 09/12/2025, and 09/13/2025, respectively. These incidents were not reported to the Department as required. The Department determined that the facility was not in compliance with Title 22 regulations and was cited under Section 87211(a)(1)(D) – Reporting Requirements. This citation includes a civil penalty. Based on interviews, observations, and record reviews, the licensee was found to be in violation of the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8. Deficiencies were issued, and an exit interview was conducted with Medical Technician Danna Romero. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Oct 31, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 7, 2025

Reporting Requirements...licensee shall furnish to…licensing...A written report…submitted...of the occurrence of any of the events...(D) Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidence by: Based on LPA interviews conducted and record reviews, the Licensee failed to report incidents involving Residents (R1-R3) injuries, and hospitalization. This violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2025

Plan of correction: The licensee agrees to develop and implement a Plan of Correction to ensure that all Unusual Incident Reports are submitted to the Community Care Licensing Division (CCLD) in a timely manner.

Allegation investigated: The facility staff failed to provide adequate supervision resulted in the resident eloping. The facility does not have an auditory device or other staff alert feature to monitor exits.

On September 17, 2025, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Robin Culver, Executive Director and Sandy Irahta Resident Coordinatorr, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above. The investigation included interviews, a collection of records, and a tour of the facility. Interviews were conducted with Staff #1 through Staff #3 (S1-S3), Resident #1 (R1) and Witness #1 (W1). The Department reviewed several documents, including the Facility Resident Roster (dated 09/12/25), Facility Personnel Roster LIC 500 (dated 09/11/25 & 09/15/25), and (R1's) Physicians Report LIC 602 (dated 02/24/25), as well as other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED FOLLOWING: Allegation #1: The facility staff failed to provide adequate supervision resulted in the resident eloping. The complaint alleges that the facility staff failed to provide adequate supervision for Resident #1 (R1), which led to (R1) eloping from the premises. It was reported that staff were unaware of (R1's) disappearance on September 7, 2025, until staff began checking the facility for (R1). According to the report, the Beverly Hills Fire Department discovered (R1) on the sidewalk with injuries. (R1) had a laceration on the right eyebrow and multiple skin tears on the right elbow. No additional information about this situation was provided. On September 12, 2025, between 10:18 AM and 12:15 PM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) out of the three (3) staff members validated the incidents with Resident #1 (R1) eloping from the facility on September 7, and a subsequent elopement on September 8, 2025. All staff statements confirmed through the Facility End of Shift Reports (dated September 7, 2025, and September 8, 2025). (R1) exited the facility unattended by utilizing the fourth-floor exit stairwell, navigating through the main floor corridor and kitchen entry hallway, and ultimately leaving through the rear receiving/delivery service and exterior gated door into the alley. (S1) reported that (S1) only became aware of (R1's) disappearance during routine room checks. (R1) was last seen around 2:30 AM on September 7, 2025, outside the facility. According to (S1), (R1) sustained injuries during the elopement incident, having fallen and suffered injuries to the head, hand, and elbow. (R1) received medical treatment at Cedars Sinai for injuries and was discharged later that day. (S2) reported that (R1) was unaccounted for and on September 8, 2025, between 9:30 PM and 11:30 PM, and was seen wandering outside the facility by neighboring vendors. (S2) mentioned that (R1) managed to leave the facility through the kitchen rear doors that had an egress bar with no sensory alarm in place. (S2) reported that law enforcement was notified, but later, (R1) returned to the facility on (R1's) own and was found in another resident's room on the first floor. During evening shifts, the facility typically has three to four staff members, while night shifts are covered by only two staff members. According to (S1 and S2), they felt understaffed on the days when (R1) elopement occurred both times. Additionally, there are no surveillance cameras installed on the premises, according to (S3). (Evaluation Report continues LIC 9099-C) On September 12, 2025, between 11:45 AM and 12:00 PM, the Department interviewed resident identified as Resident #1 (R1). (R1) acknowledged that (R1) left the facility and sustained injuries, which required hospital treatment. While (R1) could not provide additional details about the incidents, (R1) remembered leaving the facility unattended. During the interview with (R1), noticeable injuries and visible signs of trauma on the face, elbows, and hands. On September 12, 2025, between 12:16 PM and 12:33 PM, the Department interviewed witness identified as the power of attorney to (R1) as Witness #1 (W1). (W1) verified that facility staff notified (W1) of incidents involving (R1) by telephone communication. (W1) indicated that (R1) is medically assessed with wandering and elopement behaviors. (W1) clarified that (R1) being new to the facility is being triggered by the unfamiliar environment and may frequently attempt to leave. (W1) mentioned that during the medical assessment intake (W1) was disclosed to the facility of (R1’s) wandering behavior. A review of Resident #1 (R1's) Physician's Report LIC 602 (dated 02/24/25), Preplacement Appraisal Information LIC 603A (dated 02/22/25), and Service Plan (dated 09/02/25) indicated that (R1) requires assistance due to memory impairment and needs special observation or night supervision due to confusion, forgetfulness, or wandering. The facility’s evaluation of (R1) in Memory Care is Level 4, which is to provide advanced care related to wandering and elopement, offering high-level, round-the-clock support. A review of (R1’s) prescribed medications indicated that (3) three out of the three (3) medications cause side effects of wandering/elopement behaviors (ref: National Institute of Health NIH). Further examination of (R1's) Cedars Sinai Medical Records (dated 09/06/25 and 09/08/25) confirmed that (R1) sustained injuries from a fall, including abrasions, skin tears, and facial lacerations. Additionally, a review of Personnel Report LIC 500 (dated 09/11/25 & 09/15/25) revealed the facility had insufficient staffing with only one med-tech and caregiver on NOC shift schedule. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Allegation #3: The facility does not have an auditory device or other staff alert feature to monitor exits. The complaint details allege that the facility lacks an auditory device or staff alert system to monitor exits. Reports indicate that residents tend to wander around the unit, but the staff are often unaware when residents leave the building. There are no wander guard systems in place, and staff do not have any means to be alerted if a resident exits the facility. No additional information about this situation was provided. (Evaluation Report continues LIC 9099-C) On September 12, 2025, between 10:18 AM and 12:15 PM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) out of the three (3) staff could not validate this claim. All staff confirmed that each floor has two fire exit doors, each equipped with a keyless alarm control keypad that leads to a stairwell. When the egress bar is activated, an auditory alert system will sound off an alarm. In the main lobby, a security panel displays information about the condition of each exit door, indicating whether it is open, bypassed, or tampered with. Additionally, the main lobby door is locked during nighttime hours. However, it is important to note that neither the rear receiving/delivery door nor the exterior gated rear door is equipped with any sensory alarms. (S1) noted the incident when (R1) eloped from the facility during night shift of September 7, 2025, no exit door alarms sounded off and no indication on the security panel displays. (S1-S3) verified that the facility does not have surveillance cameras for added security. The Department reviewed the (R1’s) Admissions Agreement (dated 08/29/25) including Delayed Egress Consent Form that Memory Care is a secured unit with Delayed Egress Alarms located at each exit door. Further review of the Facility Interior Floor Plan locations of all exit doors. On September 12, 2025, the Department conducted an inspection of the Fire Exit Doors on the fourth floor where (R1) managed to exit both incidents September 7, 2025, and September 8, 2025, and observed both exit doors did not sound off the alarm when the egress bar was triggered. A facility pass code had to be keyed by a staff for the doors to work properly for the auditory alarm system to work. The Department further observed the kitchen double doors and receiving/delivery door had a delayed egress bars but had no alarm. Based on the information gathered, there is sufficient 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. (Evaluation Report continues LIC 9099-C) California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099D). *Immediate Civil Penalty issued* An exit interview was conducted with Robin Culver, and copies of the reports were provided. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”the state’s words, verbatim · CDSS document, Sep 17, 2025 · control 11-AS-20250909091421

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Sep 18, 2025

87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided... when such observation reveals unmet... When changes such as... deterioration of mental ability or a physical health condition... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician. This requirement is not met as evidenced by: Based on interviews, observation and record reviews, the Licensee was aware of (R1's) history of wandering behavior failed to ensure proper supervision and sustained serious injuries. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: Licensee/Administrator shall have a written plan to ensure that in addition to the resident's needs and services plan a specific plan is drafted for each resident's change in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The plan must be submitted by POC date 09/18/25 to ernand.dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 1, 2025

87411 Personnel Requirements - General (a) Facility personnel...shall be sufficient in numbers...to provide the services...to meet resident needs. Additional staff... employed...to perform...maintenance...and grounds. This requirement is not met as evidenced by: Based on LPAs observation and record reviews, the licensee did not ensure sufficient staff were present at the facility for NOC shift. This violation poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: Licensee/Administrator have spoken and have agreed that management will hire an overnight staff in order to attend to residents' needs while in care. An updated LIC 500 will be sent to ernand.dabuet@dss.ca.gov by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(d) · Plan of correction due date: Oct 1, 2025

87705 Care of Persons with Dementia (b)Licensees shall be responsible for the following...(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement... This requirement is not met as evidenced by:Based on LPA's observation, interviews, and record reviews. Liccensee failed to equip the kitchen and receiving/delivery exit doors with auditory devices. This violation poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: Licensee/Administrator have spoken and have agreed an auditory device will be install in all exit doors. Proof of invoice/receipt sent to ernand.dabuet@dss.ca.gov by POC due date.

Type of visit: Case Management - Deficiencies

On September 17, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit to the facility in connection with complaint # 11-AS-20250909091421. The LPA met with Executive Director, Robin Culver and the Resident Coordinator, Sandy Iraheta, and explained the purpose of the visit. The Department determined the facility was not incompliance with Title 22 Regulations and were cited as follows: · 87466 – Observation of the Resident · 82711(a)(1)(D) - Reporting Requirements · 87705(b)(d) - Care of Person with Dementia · 87411(a) – Personnel Requirements-General The investigation revealed that the administrator did not comply with Title 22 regulations, leading to several deficiencies being identified, along with a civil penalty. This poses a potential health and safety risk to the residents in care and violates section 87405(b)(2), which pertains to Administrator Qualifications and Duties. Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies are issued and an exit interview is conducted with Robin Culver. A copy of this report is provided along with the appeal rights.the state’s words, verbatim · CDSS document, Sep 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(b)(2) · Plan of correction due date: Oct 1, 2025

87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on interview and record reviews the Licensee/Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: LIcensee/Admnistrator will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. Plan of correction will be submitted by POC due date: 10/01/25.

Allegation investigated: The facility did not report the incident to Licensing.

On September 12, 2025, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Sandy Iraheta, Resident Coordinatorr, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, a collection of records, and a tour of the facility. Interviews were conducted with Staff #1 through Staff #3 (S1-S3), Resident #1 (R1) and Witness #1 (W1). The Department reviewed several documents, including the Facility Resident Roster (dated 09/12/25), Facility Personnel Roster (dated 09/11/25), and (R1's) Physicians Report LIC 602A (dated 02/24/25), as well as other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #2: The facility did not report the incident to Licensing. The complaint alleges that the staff did not report incidents involving Resident #1 (R1) to Community Care Licensing. According to the reports, the facility failed to inform the appropriate authorities about (R1) eloping from the premises and subsequent hospitalization. No further information regarding this situation was provided. On September 12, 2025, between 10:18 AM and 12:15 PM, 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 the incidents with Resident #1 (R1) eloping from the facility on September 7 and September 8, 2025. All staff statements were verified through the Facility End of Shift Reports (dated 09/06/25 through 09/08/25). (S3) admitted that the facility has not submitted an Unusual Incident Report (LIC 624) to Community Care Licensing regarding incidents involving (R1). According to the internal Facility End of Shift Reports, Resident #1 (R1) experienced an unwitnessed fall and was hospitalized on September 6, 2025. The following day, (R1) had another incident involving elopement, which resulted in injuries and another hospitalization on September 7, 2025. On September 8, 2025, (R1) eloped once more, prompting the dispatch of law enforcement. On September 12, 2025, between 12:16 PM and 12:33 PM, the Department interviewed witness identified as the power of attorney to (R1) as Witness #1 (W1). (W1) verified that facility staff notified (W1) of incidents involving (R1) by telephone communication. On September 12, 2025, the Department verified with the Community Care Licensing Regional Office that there have been no Unusual Incident Reports submitted for (R1). Based on the information gathered, there is sufficient 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 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 with Sandy Iraheta, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Sep 12, 2025 · control 11-AS-20250909091421

From the deficiency page — Deficiency type: Type A · Section cited: CCR 82711(a)(1)(D) · Plan of correction due date: Sep 13, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...of the occurrence of any of the events... (D) Any incident which threatens the welfare, safety or health of any resident...,or unexplained absence of any resident. This requirement was not met as evidence by: Based on LPA interviews conducted and record reviews, the Licensee failed to report incidents involving (R1's)wandering, injuries, or hospitalization. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 12, 2025

Plan of correction: Licensee agrees that a Plan of Correction will be submitted to CCLD by 09/13/25 with Unusual Incident Reports LIC 624 involving (R1) incidents 09/06/25, 09/07/25 and 09/08/25 to (CCL). POC must be fax to 424-544-1016.

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

Allegation investigated: Staff are mismangaing residents medications. Staff do not ensure resident is provided a comfortable temperature. Staff does not ensure resident's medical needs are being met.

***This report supersedes the original report delivered on 7/3/2025. On 8/21/2025,LPA arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 07/3/2025. *** On 7/3/2025, at 10:10 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a complaint investigation and deliver findings for the alleged allegations. LPA identified herself to Chanel Sanchez-Administrator who was informed of the purpose of the visit. The investigation consisted of the following At 10:30 AM, LPA obtained the following documents for Resident 1 (R1) Unsigned admissions agreement, Pre-assessment dated 6/20/2025, Identification and Emergency/Information dated 6/25/2025, Medication list for June and July 2025 (MARs),Staff and Resident roster dated 7/1/2025, Move-in notes dated 6/30/2025, End of shift notes from 6/26/2025 to 7/1/2027,Cedars-Sinai After Visit Summary dated 6/27/2025, Valley Vista Nursing and Transitional Care notes/reports dated 11/12/2024, 4/2/2024, Continued Unsubstantiated 6/26/2025, and discharge report dated 6/26/2025, Physician's Report including doctor's visit/Emergency room visits dated 12/15/2024, Southern California Hospital at Culver City patient order history dated 6/18/2025, Home health notes dated 4/20/2025, and card from the Los Angeles Police Department. LPA also conducted interviews with Staff members 1-4 (S1-S4) and Residents 1- 5 (R1-R5). LPA attempted to interview R1 who was not at the facility during the investigation. The investigation revealed the following: #1 Allegation: Staff are mismanaging residents medications. At 11:00 AM, LPA conducted interviews with four (4) staff members (S1-S4), and 4 out of 4 staff members stated R1 was being assisted with their medications but had refused on several occasions which were documented at the time of refusals. LPA reviewed R1's facility file and records, which revealed that R1 had been assisted with their medications as prescribed by their physician but revealed R1 had refused medications on several occasions. LPA conducted interviews with Resident 1-4 (R1- R4) 3 out of 4 stated stated they have received their medications daily and they do not think their medications are mismanaged by anyone. LPA attempted to interview R1 at the time of the visit but they were not available during the visit. #2 Allegation: Staff do not ensure resident is provided a comfortable temperature. At 1:25 PM, LPA conducted interviews with four staff members 1-4 (S1-S4) and 4 out of 4 stated the temperature in R1's room would be warm from time to time but assistance would be given by showing R1 how to turn on the air conditioning unit (AC) in the room. During the tour of R1's room the AC was operating when turned on and cool air was felt. LPA also conducted interviews with Resident 1- 4 (R1- R4) LPA was unable to interview R1 at the time of the visit and 3 out of 4 stated their AC units are working and they have not experience any problems with their AC unit. LPA did not observe thermostats in any of the residents rooms 302,308, 311, 312, 318, and 319 but LPA did observe working AC units that were turned on and in working conditions dispensing cool air. During the tour of the facility LPA observed the thermostats ranged from 75-76 degrees. Continued.. #3 Allegation: Staff does not ensure resident's medical needs are being met LPA conducted interviews with four (4) staff members 1-4 (S1-S4), and 4 out of 4 staff members stated R1 and all residents are assisted with their medical needs daily but there were occasions when R1 would refuse help from staff members. Staff also stated scheduling and transportation is provided. LPA also conducted interviews with Resident 1-4 (R1- R4) LPA was unable to interview R1 at the time of the visit. 3 out of 4 residents stated staff members assist them with their medical needs. They were asked if appointments are required does the staff members assist them and their reply was yes. Additionally they were asked if their AC units in their rooms work and they all replied yes. Based on interviews conducted, documents reviewed and observations the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Chanel Sanchez- Administrator at conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 11-AS-20250627133928

Type of visit: Required - 1 Year

On 08/06/2025 Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Chanel Sanchez, as the purpose of the visit was explained. The facility is licensed to serve (138) elderly adults ages 60 and above, of which (40) may be non-ambulatory on 1st and 2nd floor. Facility has an approved hospice waiver for (8). The facility has a remaining balance of $991.00, facility fee was partially paid on 07/15/25. Liability insurance is active (LTP-00307-25-07 EXP:3/1/2026). The facility is a 4- story structure located in a residential neighborhood. It consists of (79) bedrooms throughout the 4 floors, (8) common area bathrooms, (79) full private bathroom, shaded back yard, front yard, 1st Floor: Lobby, Receptionist desk, library, activity room, storage, salon, dining room, administrators office, kitchen, laundry room, linen closet, The 2nd Floor consist of: patio, Medication room, janitor's closet, linen closet, 3rd floor has a linen room, 4th floor has a visiting area and linen closet. Internet service, and land line were observed. No firearms are stored at facility and no bodies of water present. Exit, walkways and/passageways, are free of debris and/or hazards. LPA conducted a records review of 4 staff records, 5 resident records, and 5 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 03/23/25, fire extinguishers fully charged and located throughout the facility, carbon monoxide and smoke detectors are interconnected and operational. Auditory alarms/pull cords were observed to be operable. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2025

Allegation investigated: Staff are mismangaing residents medications. Staff do not ensure resident is provided a comfortable temperature. Staff does not ensure resident's medical needs are being met.

On 7/3/2025, at 10:10 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a complaint investigation and deliver findings for the alleged allegations. LPA identified herself to Chanel Sanchez-Administrator who was informed of the purpose of the visit. The investigation consisted of the following At 10:30 AM, LPA obtained the following documents for Resident 1 (R1) Unsigned admissions agreement, Pre-assessment dated 6/20/2025, Identification and Emergency/Information dated 6/25/2025, Medication list for June and July 2025 (MARs),Staff and Resident roster dated 7/1/2025, Move-in notes dated 6/30/2025, End of shift notes from 6/26/2025 to 7/1/2027,Cedars-Sinai After Visit Summary dated 6/27/2025, Valley Vista Nursing and Transitional Care notes/reports dated 11/12/2024, 4/2/2024, 6/26/2025, and discharge report dated 6/26/2025,Physician's Report including doctor's visit/Emergency room visits dated 12/15/2024, Southern California Hospital at Culver City patient order history dated 6/18/2025, Home health notes dated 4/20/2025,and card from the Los Angeles Police Department. Continued ..... Unsubstantiated LPA also conducted interviews with Staff members 1-4 (S1-S4) and Residents 1- 5 (R1-R5). LPA attempted to interview R1 who was not at the facility during the investigation. The investigation revealed the following: #1 Allegation: Staff are mismanaging residents medications. At 11:00 AM,LPA conducted interviews with four (4) staff members (S1-S4), and 4 out of 4 staff members stated R1 was being assisted with their medications but had refused on several occasions which were documented at the time of refusals. LPA reviewed R1's facility file and records, which revealed that R1 had been assisted with their medications as prescribed by their physician but revealed R1 had refused medications on several occasions. LPA conducted interviews with Resident 1-5 (R1- R5) LPA was unable to interview R1 at the time of the visit. and R2-R4 stated they have received their medications daily and they do not think their medications are mismanaged by anyone. #2 Allegation:Staff do not ensure resident is provided a comfortable temperature. At 1:25 PM, LPA conducted interviews with four staff members 1-4 (S1-S4) and 4 out of 4 stated the temperature in R1's room would be warm from time to time but assistance would be given by showing R1 how to turn on the air conditioning unit (AC) in the room. During the tour of R1 room the AC was operating when turned on and cool air was felt. LPA also conducted interviews with Resident 1-5 (R1- R5) LPA was unable to interview R1 at the time of the visit and R2-R4 stated their AC unit was working and they have not experience any problems with their AC unit. During the tour of the facilities rooms LPA did not observe thermostats in any of the residents rooms 302,308, 311, 312, 318, and 319 but LPA did observe working AC units that were turned on and in working conditions dispensing cool air. During the tour of the facility LPA observed the thermostats ranged from 75-76 degrees. Continued.. #3 Allegation: Staff does not ensure resident's medical needs are being met LPA conducted interviews with four (4) staff members 1-4 (S1-S4), and 4 out of 4 staff members stated R1 and all residents are assisted with their medical needs daily but there were occasions when R1 would refuse help from staff members. Staff also stated scheduling and transportation is provided. LPA also conducted interviews with Resident 1-5 (R1- R5) LPA was unable to interview R1 at the time of the visit and R2-R4 stated staff members assist them with their medical needs. They were asked if appointments are required does the staff members assist them and their reply was yes. Based on interviews conducted, documents reviewed and observations the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Chanel Sanchez- Administrator at conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jul 3, 2025 · control 11-AS-20250627133928

Type of visit: Case Management - Other

On 01/10/25 Licensing Program Analyst (LPA), Yolanda Rosser conducted an unannounced case management visit regarding the relocation of 30 residents from Ceila- #198320375, located at 17310 W. Vereda Dela Montura Pacific Palisades, CA 90272.to the facility listed above due to the mandatory evacuation Fire Advisory. LPA met with Administrator, Chanel Sanchez and Allie Davidov from both facilities and explained the purpose of the visit. During the visit, LPA conducted a health and safety check and no concerns observed. LPA reviewed and obtained resident and staff rosters for both facilities. Last Fire Drill was conducted on 12/12/24. Per interview with the licensee, 30 residents have been relocated to Pinnacle at Burton Way. the facility has sufficient beds, hygiene supplies, beddings, linens, and everyone has a designated room and bathroom. The dining room is large enough to accommodate all residents. The kitchen has sufficient two - day perishable and seven -day perishable food supplies. Medications, MARS's and files of the Palisade Villa residents have been transferred to and stored in a locked cabinet. 16 ambulatory and 14 non-ambulatory. The Licensee stated both facilities use the same vendors, pharmacy and home health health agencies, which allows them to provide the same level of continued care for the residents. There is sufficient staffing available to provide care for residents of both facilities. It has been verified that a routine Fire Inspection and testing was completed on 12/12/25 and a fire drill was conducted on 12/12/25. The Licensee confirmed that all families, responsible parties, DMH, regional centers for Ciela have been notified about the relocation either via calls, texts, or emails. The licensee stated that current Pinnacle at Burton Way will not share rooms with Ciela residents. An exit interview was conducted and a copy was provided to Administrator.the state’s words, verbatim · CDSS document, Jan 10, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA)/ Yolanda Rosser conducted a case management visit to follow-up on an incident report dated 5/8/24. LPA Rosser met with Administrator/ Chanel Ann Sanchez and explained the purpose of today's visit. The incident report was regarding 50 missing Oxycodone 325 mg tablets belonging to Resident #1 (R1) and subsequent police visit regarding the missing medication. LPA Rosser interviewed the Administrator/ Chanel Ann Sanchez, LVN/ Shirley Gonzalez, and Resident #1 (R1). LPA Rosser obtained copies of R1's facility file, medication administration Records for April 2024-June 2024, narcotic count audit forms, police incident report number, and Medical-Technician training verification. LPA Rosser found R#1 handles all medical and ordering medications independently. LPA found R#1 places orders for a surplus for Oxycodone 325 mg. The facility stores R#1’s medication and administered medications to R#1 who experiences a chronic pain condition. LPA Rosser found the facility conducts medication audits during shift changes as a measure to safeguard medication. The audits are conducted by the incoming Medical Technician and outgoing Medical-Technician at the end of shifts. The audits did not include the surplus medications as they are not administered until a depletion of medication occurs. On 5/7/24, a medication audit of surplus medication occurred, and 50 Oxycodone 325 mg tablets were missing from R#1’s surplus and on 5/8/24 an audit was conducted, and 195 Oxycodone 325 mg tablets were missing from R#1’s surplus. On 5/9/24 law enforcement was notified of the missing tablets and visited the facility on 5/9/24. The police department recorded the incident and no follow-up occurred. LPA Rosser found the department did not receive an Unusual Incident Report was submitted for the 5/8/24 audit results and missing tablets. During this visit, LPA Rosser inspected the storage of medications and found medications are properly stored as well as inaccessible to Residents. LPA found Medication Administration Records utilized and completed. LPA found the facility has protocols in place to safeguard medications by conducting audits at the beginning and end of each shift. During this visit, LPA Rosser conducted an interview with R#1 who states they were informed of the missing tablets from their surplus medication on hand and missing medications reported to local law enforcement. R#1 stated the missing tablets did not interfere with their medication regimen. LPA Rosser conducted interviews with LVN/ Shirley Gonzalez and Administrator/ Chanel Ann Sanchez who stated they are unable to confirm how the medication went missing and Medical Technician training occurred after the incident. Additionally, the facility requested assistance from the corporate Registered Nurse to evaluate the system of medication facilities administration and make recommendations that are now employed as additional measures to safeguard medication. LPA interviewed LVN, Shirley Gonzalez who indicated that she contacted the pharmacy and R#1 physician to report the missing medication, R#1 had surplus medications on hand. At this time no citations have been issued and an exit interview was conducted with the Administrator. The Administrator was provided a copy of this report.the state’s words, verbatim · CDSS document, Oct 30, 2024

Allegation investigated: Staff are not feeding a resident in care. Staff are neglecting the residents in care.

On 10/22/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Channel Sanchez /Administrator. LPA explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), and Residents interviews (R#1-R#6). LPA obtained and reviewed the following documents: Client’s roster, Personnel roster, (R#1-R#4) Identification and Emergency Information, (R#1-R#4) Admissions agreements, (R#1-R#4) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#4) Needs and Services Plan, (R#1-R#4) Medication Administration Record (MAR) for the month of October 2024, copies of facility menu for 2 months. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff are not feeding a resident in care. The details of the complaint alleged that facility staff are not feeding the residents in care. During the records review, LPA Iniguez reviewed copies of two months of the facility menu. LPA noted that the facility serves a variety of three meals per day: breakfast, lunch, and dinner. In addition, LPA observed that the meals meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. During an Interview with the Administrator (A#1), she stated that the facility offers three meals per day: breakfast, lunch, and dinner plus snacks. In addition, (A#1) stated that the meals provided by the facility are nutritious and well-balanced. During interviews with residents (R#1-R#6), (6) out of (6) stated that the facility serves three meals per day plus snacks; also, they stated that the meals served by the facility are nutritious. During interviews with staff (S#1-S#4), (4) out (4) stated that the facility serves three meals per day and snacks; also, they stated that the meals are nutritious. Evaluation Report continues LIC 9099-C Allegation: Staff are neglecting the residents in care. The details of the complaint alleged that facility staff are neglecting residents in care. During the records review, LPA Iniguez reviewed the facility Personnel Report or LIC 500. LPA noted that there are two to three MedTech and a nurse available caregiver from Monday to Sunday for 24 residents in care total, and one caregiver available during the weekend. During an interview with the administrator (A#1), she stated that three caregivers, MedTech and a nurse, are at the facility every day. She also stated that the facility staff is not neglecting the residents in care. During interviews with residents (R#1-R#6), (6) out of (6) stated that there is enough staff to take care of them and the rest of the residents, and they also stated that the facility staff has never neglected them. During interviews with staff (S#1-S#4), (4) out (4) stated that there are always three caregivers and a MedTech taking care of the residents. Also, they stated that they had never neglected a resident in care. Evaluation Report continues LIC 9099-C During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Channel Sanchez /Administrator.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 11-AS-20241016015919

Type of visit: Required - 1 Year

On 07/29/2024, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Chanel Ann Sanchez/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (138) elderly adults ages 60 and above, of which (40) may be non-ambulatory on 1st and 2nd floor. Facility has an approved hospice waiver for (3). The facility is a 4- story structure located in a residential neighborhood. It consists of (79) bedrooms, (8) common area bathrooms, (79) full private bathroom, shaded back yard, front yard, 1st Floor: Lobby, Receptionist desk, library, elevator activity room, storage, salon Administrators office, kitchen, laundry room, linen closet, PPE storage, 2nd Floor: patio, card room, janitor's closet, linen closet, 3rd Floor; linen closet, storage, janitor's closet, electrical closet. LPA Richard toured the physical plant with Administrator. There were no bodies of water or obstructions on the premises. A total of (7) 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: #101, #106, #201, #217, #308, #403, #420; call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 120.5F° – 118.2F°. The rooms temperature ranged from 76F°– 78F°. Evaluation Report continues on LIC 809-C Richard 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 and were operable. The last Fire/Disaster Drills were conducted on 06/27/24. Working landline phones are available on-site. A review of (5) residents' service files (R1-R5) and (5) staff personnel files (S1-S5) and Medication Administration Records (MAR) were maintained in order. 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 were posted throughout the facility. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Administrator/Chanel Sanchezthe state’s words, verbatim · CDSS document, Jul 29, 2024

Allegation investigated: Staff did not ensure facility elevator is in good repair resulting in resident sustaining an injury. Staff did not inform resident's responsible party.

On 07/17/2024 at around 10:20 AM Licensing Program Analyst (LPA), Leandro conducted a complaint investigation regarding the allegations listed above. LPA met with Administrator, Chanel Ann Sanchez and the purpose of the visit was explained. The investigation consisted of the following: During today’s investigation LPA, and Administrator conducted a tour of the facility which included checking the facility elevators. LPA interviewed 1 out of 24 residents and 4 out of 32 staff. LPA reviewed resident census, personnnel report, Resident 1’s records, and elevator maintenance information. Unsubstantiated The investigation revealed the following: Regarding the allegation “Staff did not ensure facility elevator is in good repair resulting in resident sustaining an injury,” it is being alleged that Resident 1 (R1) sustained a laceration on her leg via elevator on 07/06/2024, due to elevator being in disrepair. LPA observed elevator being in good repair. Interviews conducted indicated that the elevator has recently received maintenance. Records review indicated that elevator has undergone inspection by the City of Los Angeles Department of Building and Safety on 07/02/2024. 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 inform resident's responsible party” it is being alleged that staff did not inform R1’s responsible party (family) of the injury. Interviews conducted revealed that R1’s family member had been notified the day of the incident. Record review revealed that R1’s family member had been notified the day of the incident. 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. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Jul 17, 2024 · control 11-AS-20240709163834