The Plaza at Westwood

Type of visit: Required - 1 Year

On 06/12/26, Licensing Program Analysts (LPAs) Regina Cloyd and Pamela Bunker conducted an unannounced annual visit using the CARE Inspection Tool. LPAs met with Administrator Luz Rose and explained the purpose of today’s visit. The facility is licensed to serve one hundred thirty-six (136) non-ambulatory residents of which six may be bedridden. The facility has a hospice waiver for twelve (12) residents. Six residents are bedridden and eight residents are currently receiving hospice services. Annual Fees are current. The facility is a three-story building with 68 resident bedrooms, and 74 bathrooms. The first floor consists of a lobby area, laundry facility, staff break room, hair salon and an adjacent parking structure. The second and third floors consist of residential rooms. The second floor also consists of the dining room, kitchen, outdoor shaded patio/courtyard area with tables and chairs, activity room, medication room and the Administrator’s office. The third floor consists of resident rooms and storage. Administrator accompanied LPA inside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards. Continue LIC809-C. Resident bedrooms (202, 207, 217, 226, 307, 317, 330, 335) had bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, a non-skid mat was in place, and water temperature measured between 113.1 – 119.8-degree Fahrenheit. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Extra comforters and linen are stored in the employee locker room on the third floor. LPA tested emergency pull cords (rooms 226 and 307) and phone calls to the front desk (room 330 and 335). Door Guardians are mounted near the exits. Common areas were clean and clear of hazards. Doorways were free of obstructions. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives were kept in a secure kitchen. Emergency supply is stored in a room across from room 227. First aid kit with handbook was available in the MedTech room. Fire extinguishers were observed on each floor. Los Angeles Fire Department conducted a fire alarm test on 04/20/26. Two stairwells include evacuation chairs. Seven staff records were reviewed; seven out of seven staff records had the required criminal record clearances or criminal record exemptions. Seven resident records were reviewed; seven out of seven resident records had medical assessments and pre-appraisal or reappraisals. Three residents’ medication was reviewed. An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Administrator Luz Rose.the state’s words, verbatim · CDSS document, Jun 12, 2026

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure that facility has adequate lighting. Staff did not prevent facility from being in disrepair. Staff are not serving an adequate amount of food portions to residents in care.

On 05/07/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Selena Cruz, Assistant Administrator, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA interviewed Staff S7, and delivered findings. During a subsequent visit conducted on 03/27/2026, LPA inspected the facility, watched lunch service prepared and served, interviewed Staff S1-S6, interviewed Resident’s R2-R7, and received a Staff Roster, Resident Roster, Maintenance Logs, and Kitchen Santation Checklist. During the initial visit conducted on 12/30/2025, LPA received and reviewed documents pertinent to the investigation. The documents consist of: Staff Roster, Resident Roster, Admission Agreement, House Rules, Needs and Service Plan, Physician’s Report, and Menu. The investigation revealed the following: Unsubstantiated Allegation: Staff did not ensure that facility has adequate lighting The allegation alleges that the smoking area does not have adequate lighting causing a resident to fall and hit their head. During the facility inspection, LPA observed all walkways, hallways, common areas, and parking garages have adequate lighting. During record review, LPA received and reviewed an Unusual Incident/Injury Report, dated 08/22/2025, indicating R1 experienced a fall while in the garage and hit their head. Additionally, LPA received and reviewed Maintenance Logs and did not observe any Notes/Comments regarding the lighting being out or inadequate in the parking garages. During interviews with Staff S1-S7, were asked if all areas in the facility, including the packing garages, have adequate lighting, seven (7) out of seven (7) stated yes, all areas have adequate lighting. During interviews with Residents R2-R7, were asked if they feel all walkways, common areas, and the garages have ample lighting, six (6) out of six (6) stated yes, all areas are well lit. Allegation: Staff did not prevent facility from being in disrepair The allegation alleges a pipe was broken and caused water to get on the floor. During the facility inspection, LPA observed walls and floors in good repair. LPA did not observe any water damage on the walls, ceilings, or floor. During record review, LPA received and reviewed Maintenance Logs that indicate repairs have been made on the pipes. On 11/02/2025, maintenance checked the shower in R1’s room due to the water not draining. According to the notes, “the shower pipe was checked and everything works fine.” Maintenance explained to R1’s private caregiver why the water is retained in the shower and showed how to run the water to ensure it drains properly. On 02/27/2026, maintenance checked on a reported leak in room 205. Maintenance reported the carpet was wet and needed to be replaced. Resident R2, was relocated to another room. On 03/04/2026, maintenance replaced the carpet with flooring. On 03/05/2026, maintenance removed the sink, cabinets, shower, lower walls, to ensure the leak was fixed and ensure no damage was sustained, and then replaced it. During interviews with Staff S1-S7, were asked if there have been any ongoing issues with the plumbing, seven (7) out of seven (7) stated no, there have been no ongoing issues with the plumbing. Additionally, S1 stated they have had a few instances where residents have flushed underwear or diapers down the toilet, which has caused plumbing issues in the past but nothing maintenance could not fix. During interviews with Residents R2-R7, were asked if they felt the facility is in disrepair, four (4) out of six (6) stated no, the facility is not in disrepair. Two (2) out six (6) stated the plumbing will sometimes back up. Additionally, Resident R2-R7 were asked if there has been any flooding or molding, six (6) out of six (6) stated no, there has been no flooding or mold. Two (2) out of six (6) residents stated there have been leaks but they were fixed right away and the area was cleaned and scrubbed to help minimize the possibility of mold. One (1) out of six (6) residents stated they once left their window open while it was raining, staff noticed it, had the area cleaned, and staff scrubbed the walls to minimize the possibility of mold. Allegation: Staff are not serving an adequate amount of food portions to residents in care. The allegation alleges that the facility is serving small portions of food. During the facility inspection, LPA observed the lunch service being served. LPA observed kitchen staff using 4-ounce ice cream scoopers to serve sides and they received 2 to 3 chicken tenders, depending on the resident’s request. LPA observed chicken salad and sandwiches available if a resident wanted an alternative meal. Residents were provided with a second serving if they requested. Posted on a wall in the kitchen, LPA observed a chart with Serving Size Recommendations. During record review, LPA received and reviewed R1’s Admission Agreement, dated 08/30/2022, that states on page 3, listed under Basic Service Included in the Monthly Fixed Fees: “Food and Dietary Service – Three nutritional meals daily and available snacks throughout the day.” During interviews with Staff S1-S6, were asked if residents are provided with an ample amount of food throughout the day, six (6) out of six (6) stated yes, residents are provided with an ample amount of food including breakfast, lunch, dinner, and snacks. During interviews with Residents R2-R7, were asked if they are provided with three meals and snacks daily, six (6) out of six (6) stated yes, they receive enough food throughout the day. Additionally, residents R2-R7 were asked if they receive an adequate portion of food during meals, six (6) out of six (6) stated yes, they receive adequate portions. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are unsubstantiated. LPA did not observe or cite any deficiencies. An exit interview was conducted with Selena Cruz, Assistant Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 7, 2026 · control 11-AS-20251224100506

Allegation investigated: Staff interfered with resident doing their own laundry. Staff do not treat resident with dignity and respect.

On 04/20/26, Licensing Program Analyst (LPA), Elvira Gonzalez, conducted an unannounced complaint visit to the facility listed above. LPA met with Administrator, Luz Rose, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: On 04/20/26, the department requested the staff roster, resident roster, and Resident Laundry Schedule. The department conducted a review of resident #1’s (R1’s) service records and requested a copy of the following documents: Admission Agreement, Personal Rights, Facility House Rules, Identification and Emergency Information, Appraisal/Needs and Services Plan, and Physician’s Report. Additionally, the department conducted a tour of the facility, interviewed staff #1-#5 (S1-S5), and residents #1-#6 (R1-R6). Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff interfered with resident doing their own laundry. It is alleged that staff are prohibiting a resident from doing their own laundry despite there being no restriction or limitation preventing the resident from independently performing this task. On 04/20/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. An interview with S1 revealed that no resident, including R1 has informed them that they no longer wish to receive laundry services or that staff have denied them the ability to complete their own laundry. An interview with S2 revealed that staff follow a Resident Laundry Schedule, under which residents’ laundry is completed at least once per week. S2 stated that if a resident no longer wishes to receive laundry services, the resident must inform administration staff so that the residents name can be removed from the laundry schedule. On 04/20/26, the department conducted interviews with R1-R6. Of those interviewed, 5 out of 6 residents could not corroborate the allegation. 5 out of 6 residents said they are satisfied with the services being provided to them. On 04/20/2026, during a review of records, the Department did not identify any documented restriction or limitation preventing R1 from independently completing their own laundry. The Department also reviewed the facility’s Resident Laundry Schedule (updated 04/16/2026) and observed that resident laundry is completed at least once per week. Additionally, the Department observed that R1 is scheduled to receive laundry services on Fridays. On 04/20/2026, the Department conducted a tour of the facility and observed a sign posted on the laundry room door indicating that residents and independent caregivers are permitted to do their own laundry on Sundays and Mondays between 8:00 a.m. and 6:00 p.m. Based on observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Continued on LIC9099-C Allegation: Staff do not treat resident with dignity and respect. It is being alleged that staff yelled at a resident. On 04/20/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. On 04/20/26, the department conducted interviews with R1-R6. Of those interviewed, 5 out of 6 residents denied the allegation and reported feeling respected and are treated with dignity. Based on observation, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Luz Rosethe state’s words, verbatim · CDSS document, Apr 20, 2026 · control 11-AS-20260414151645

Allegation investigated: Staff illegally evicted a resident in care.

On 03/27/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Administrator, Luz Rose, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA inspected the facility, interviewed Staff S1-S6, interviewed Resident’s R2-R7, and received a Staff Roster, Resident Roster, Maintenance Logs, and Nutritionist Review. During the initial visit conducted on 12/30/2025, LPA received and reviewed documents pertinent to the investigation. The documents consist of: Staff Roster, Resident Roster, Admission Agreement, House Rules, Needs and Service Plan, Physician’s Report, and Menu. The investigation revealed the following: Unsubstantiated Allegation: Staff illegally evicted a resident in care. The allegation alleges that a resident received a wrongful eviction notice due to smoking in their room and being abusive. LPA received and reviewed the eviction notice issued on 12/23/2025 and effective on 01/23/2026. During review of the eviction LPA observed the 30-day Eviction Notice included the effective date, specific Facility House Rules being violated listed in the Admissions Agreement and House Rules and the incidents, resources available to assist in alternative housing and care option, the right to file a complaint with Community Care Licensing’s and the Long-Term Care Ombudsman’s contact information, and the Health and Safety Code section 1569.683(a)(4). LPA received and reviewed letters given to the Administrator and Property Manager of complaints regarding a resident smoking in their room on the second floor and having to smell it and be exposed to it. LPA received and reviewed written notices to the resident and the Responsible Party of the resident’s violation of the House Rules. Additionally, LPA received and reviewed the House Rules signed by the resident during move-in, on 08/30/2022) that state on page 1, “3. Disruptive or violent behavior whether it is verbal or physical abuse towards staff or other residents is unacceptable…A second incident may result in a written warning that any continued disruptive or violent behavior can result in a notice of eviction.” On page 2 of the House Rules states “17. Smoking is not permitted inside the facility. There is a designated area in the back patio where smoking is allowed.” LPA received and reviewed Unusual Incident/Injury Report’s (dated 09/14/2025, 10/04/2025, 10/06/2025, 10/07/2025, 10/29/2025, 10/30/2025, 11/14/2025, 11/15/2025, 12/17/2025, and 12/21/2025) regarding resident R1 smoking in their room. LPA additionally received Unusual Incident/Injury Reports (dated 08/09/2025 and 09/18/2025) regarding R1 arguing and yelling at other residents and then going to the resident’s room to yell and argue with them. LPA received and reviewed resident R1’s Admission Agreement, signed and dated 08/30/2022, that states on page 9 to 10, under 31. Eviction Procedure, that states “The licensee may upon 30-day written to the resident, evict the resident for one or mor of the following reasons: Failure of resident to comply with general policies of facility (said general policies must be in writing, for making it possible for residents to live together and must be made part of the Admission Agreement).” During interviews with Resident R1-R7, were asked if they were issued an eviction notice due to violating House Rules, six (6) out of seven (7) stated they have not been issued an eviction notice for violating House Rules. One (1) out of eight (8) stated they were given an eviction notice for smoking in their room and they have quite a week ago. During interviews with Staff S1-S6, were asked if any residents have been issued an eviction notice in the past four months, six (6) out of six (6) stated Resident R1 was issued an eviction notice due to violating House Rules and smoking in their room. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. Due to insufficient information available at this time, the above allegation needs further investigation. An exit interview was conducted with Administrator, Luz Rose, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 11-AS-20251224100506

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: Resident sustained multiple pressure injuries due to lack of care from staff Staff did not ensure that resident's hygiene needs were met.

On 01/07/2026, At 10:00 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct interviews and deliver the findings for the allegations listed above. LPA Allen met with Theresa Cruz-Pascual and she was informed of the purpose of the visit. The investigation consisted of the following: Interviews with staff members 1-6 (S1-S6) and Residents 1-7 (S1-S7). A review of Resident 1(R1) file which consisted of Marlora Post Acute Rehabilitation Hospital dated 5/10/2025, UCLA-discharge instructions dated 1/15/2023-1/17/2023 that includes Home Health Service Agency Accute Care UCLA Health Inc. Medlife Supply Orders dated 1/5/2023, after visit care dated 11/8/2022, with medication list, Pre-placement appraisal dated 6/10/2022 and 8/30/2022, Needs and service plan dated 8/30/2022, Physicians Report dated 8/30/2022, Admissions agreement dated 8/30/2022, Identification and emergency information dated 10/7/2022, Intra Care Home Health Providers Inc. Continued.... Unsubstantiated Notes and UCLA internal Medicine & Pediatrics Progress Notes Post-discharge follow-up dated 5/8/2025. The investigation revealed the following: Allegation 1: Resident sustained multiple pressure injuries due to lack of care from staff. On 09/24/2025, LPA conducted phone interviews with staff members 1-6 (S1-S6) and 6 out of 6 staff members stated Resident 1 (R1) was regularly assisted by staff with care for pressure injuries whenever R1 allowed assistance. Staff also reported that on several occasions, R1 refused and discontinued wound care services provided by Intra Care Home Health Providers Inc. On 01/07/2026, LPA conducted interviews with Residents 1-7 (R1–R7) and 6 out of 7 residents stated that they have never sustained multiple pressure injuries, either in the past or currently, while at the facility due to lack of staff care. These residents also expressed confidence that if they were to develop pressure injuries, staff would provide appropriate care. LPA attempted to interview R1; however, R1 no longer resides at the facility. Allegation 2: Staff did not ensure that resident's hygiene needs were met. On 09/24/2025, LPA conducted phone interviews with staff members 1-6 (S1-S6) and 6 out of 6 staff stated staff members ensure all residents’ hygiene needs are met, including those of Resident 1 (R1). LPA also reviewed documentation indicating that R1 refused and terminated care services provided by Intra Care Home Health Providers Inc. Additionally,6 out of 6 staff stated R1 was assisted with hygiene needs whenever R1 allowed staff to help. On 01/07/2026, LPA attempted to interview R1; however, R1 no longer resides at the facility. Residents R2, R3, R4 and R5 stated that they currently do not require assistance with hygiene needs but expressed confidence that staff would assist them if needed. Residents R6 and R7 stated that staff members assist them with hygiene needs as scheduled and/or as needed. continued... LPA reviewed documentation from Intra Care Home Health Providers Inc. and UCLA Internal Medicine & Pediatrics Progress Notes. Post-discharge follow-up dated 05/08/2025 indicating that R1 declined and terminated services from the home health agency. Records also confirmed that residents in care are receiving hygiene assistance from facility staff. Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met. Which means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Luz Rose Administrator at the conclusion of the visit with the appeal rights.the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 11-AS-20250611154001

Allegation investigated: Facility staff failed to properly supervise a resident.

On 12/02/25, LPA Gonzalez conducted an unannounced subsequent complaint visit to further investigate the above-mentioned allegation. LPA met with Administrator, Luz Rose, and explained the purpose of the visit. LPA was granted access to the facility. The investigation consisted of the following: On 08/05/25, LPA Gonzalez requested the following documents: staff roster, and resident roster. LPA reviewed R1’s service file and requested copies of the following documents: Admission Agreement, Identification and Emergency Information, Physician’s Report, Appraisal / Needs and Services Plan, Preplacement Appraisal Information, Resident Appraisal, Advance Health Care Directive Form, email correspondence between staff and R1's responsible party, Private Attendant (PA) notes for the months of June and July 2025, and R1’s Care Plan. Additionally, LPA conducted interviews with witness #1 (W1), staff #1-#6 (S1-S6), and residents #1-#6 (R1-R6). Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Facility staff failed to properly supervise a resident. It is being alleged that R1 is supposed to receive 16 hours of one-on-one care a day and is often left unattended. It is also being alleged that staff is sleeping while caring for R1. On 08/05/25, LPA Gonzalez conducted a review of records and revealed the following: A Care Plan for R1 notes that R1 requires total care, including feeding with aspiration precautions, and 24-hour supervision to ensure safety. A review of the facility’s Periodic Check Sheets (for the dates of 05/27/25 – 07/28/25) revealed that R1 was receiving around the clock care from facility and agency staff. On 08/05/25, between 11:20 AM and 01:30 PM, LPA Gonzalez conducted interviews with S1-S6. Of those interviewed, 6 out of 6 staff denied the allegation. 5 out of 6 staff said that R1 has not been left unattended by staff, and 1 out of 6 staff said they did not know if R1 has been left unattended by staff. 4 out of 6 staff said that no staff has been observed sleeping in R1’s room, and 2 out of 6 staff said that staff has been observed sleeping in R1’s room. An interview with Luz Rose, Administrator, revealed that it was brought to her attention that a staff member was observed sleeping in R1’s room while they were supposed to be caring for them. Luz Rose said that the caregiver in question was from an agency and not one of her caregivers at the facility. Furthermore, Luz Rose said they handled this matter immediately after becoming aware of it, and said the facility is no longer dealing with that agency. On 08/05/25, between 01:40 PM and 03:00 PM, LPA Gonzalez conducted interviews with R1-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. 6 out of 6 residents said they are receiving assistance as needed from staff. 6 out of 6 residents said facility staff are meeting their needs as far as care. 5 out of 6 residents said they are receiving the services they signed up for, and 1 out of 6 residents said they sometimes receive the services they signed up for. 5 out of 6 residents said they are happy with the care and supervision the staff is providing them, and 1 out of 6 residents was unable to answer due to intense emotional distress. Continued on LIC9099-C On 08/05/25, LPA Gonzalez and Theresa Pascual toured the facility and inspected R1’s bedroom #320. LPA observed R1 laying down on their bed and watching TV. LPA observed a caregiver sitting on the chair next to R1 and engaging and caring for the resident. LPA observed R1’s room to be clean and sanitary. Based on observation, interviews conducted, and a review of records, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of this report was provided to Administrator, Luz Rose.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 11-AS-20250728155456

Allegation investigated: Staff did not address a resident's change in medical condition

On 10/17/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to The Plaza at Westwood and was greeted by Administrator Emma Luz (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S4, resident R1-R6. LPA Calderon obtained the following records: Email from resident family members (dated 10/09/2025), Incident report (dated 10/05/2025), Physician Report (dated 01/31/2025), Needs and Service Plan (dated 04/30/2025), UCLA Medical Center (dated 10/03/2025) for R1. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff did not address the residents’ change in medical conditions. This complaint alleged that the facility staff did not update R1 medical condition. LPA Calderon noted staff serving breakfast to residents. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions. Reviewed incident report (dated 10/05/2025), report indicates that R1 had an unwitnessed fall and was taken to the hospital. The report does suggest that R1 family was advised of the incident. The Physician Report (dated 01/31/2025) and Needs and Service Plan (dated 04/30/2025) indicates that R1 lives independent life and has cognitive issues. UCLA Hospital report (dated 10/03/2025) indicates that R1 was evaluated for skin tears to the right forearm falling out of bed. 4 out of 4 staff deny the allegation. R1 cannot be interviewed due to not being in 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 did not address a residents change in medical condition” 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 Emma Luz (S1).the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 11-AS-20251010121004

Allegation investigated: Staff do not accord dignity to resident in care. Staff are not preventing resident in care from harassing other resident in care.

On 08/29/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Administrator Assistant, Selena Cruz, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During the initial visit conducted on 08/28/2025, LPA inspected the facility, interviewed Staff S1, interviewed Residents R1-R7, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, resident’s Admission Agreement, resident’s Personal Rights of Residents in Privately Operated Residential Care Facilities for the Elderly, the Plaza at Westwood General Facility Information and House Rules, Identification and Emergency Information, Appraisal/Needs and Services Plan, resident’s Physician’s Report, staff Training Logs (dated 03/18/2025, and Unusual Incident/Injury Report (dated 08/09/2025 and 08/15/2025). During today’s visit LPA interviewed Staff S2-S7 and received and reviewed additional documents. The document received and reviewed was an Internal Incident Report (dated 08/09/2025), and meeting notes between S1 and R1 (dated 08/11/2025). Unsubstantiated The investigation revealed the following: Allegation: Staff do not accord dignity to resident in care The allegation alleges that a resident tried to see the administrator and the door was closed and locked by staff and the administrator has not spoken to the resident about the incidents that have occurred at the facility. LPA received and reviewed staff In-Service Training Logs, regarding the Personal Rights of Residents signed and dated 03/18/2025. During the facility tour, LPA observed the Personal Rights of Residents posted in the hallway. LPA received and reviewed R1’s Personal Rights of Residents in Privately Operated Residential Care Facilities for the Elderly signed and dated on 08/20/22, that states on page 2, they have the right “to be accorded dignity in their personal relationships with staff, residents, and other persons.” LPA received and reviewed documentation of S1 and R1 discussing the incidents that occurred that are signed and dated 08/19/2025. During interviews with Staff S1-S7, were asked if residents are treated with dignity, seven (7) out of seven (7) stated residents are treated with dignity. During interviews with Residents R1-R7 were asked if they are treated with dignity by staff, seven (7) out of seven (7) stated yes, they are treated with dignity by staff. Additionally, two (2) out of the seven (7) stated some of the staff can be rude. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff are not preventing resident in care from harassing other resident in care. The allegation alleges that a resident is being harassed by other residents who are making false allegations about them. During record review, LPA received and reviewed residents General Facility Information and House Rules provided to residents upon move-in, that states in number 3. “Disruptive or violent resident behavior: Disruptive or violent behavior whether it is verbal or physical abuse towards staff or other residents is unacceptable. The facility administrator will arrange a meeting with the resident and their responsible party to discuss any incident to ensure that such actions do not happen again. A second incident may result in a written warning that any continued disruptive or violent behavior can result in a notice of eviction.” Additionally, LPA received and reviewed incident reports dated 08/09/2025 and 08/15/2025, regarding police officers responding to the facility due to interactions between R1-R3. On 08/09/25, staff S8 heard R1 and R2 yelling at each other in R2's room. According to R1 and R2, they were arguing about money, towels, and a walker. S8 separated the residents and escorted R1 to their room. At 10:50PM S3 reported police had arrived. Police spoke with residents and staff. The police officers determined it was a civil matter and recommended staff to keep the residents separated. On 08/15/2025 at 8:45PM, R3 spoke with S4. R3 told S4 they wanted to call the police because they were afraid of R1. S4 told R3 that it's their right to call and make a report. During an interview with S4, stated R3 told them they were afraid R1 was going to hit them. Police officers came to the facility and spoke with residents involved in the incident. During interviews with Staff S1, stated Residents R1-R3 have been advised not to interact with one another, and that staff are present in common areas and during activities to ensure residents do not have a confrontation. During interviews with Staff S1-S7, were asked how they ensure a resident does not harass another resident, seven (7) out of seven (7) stated they provide supervision to residents while in common area, and if residents have an issue with another resident staff speak with them to resolve the issue or to ensure it does not escalate. During interviews with Residents R1-R7, were asked if they have been harassed by another resident, five (5) out of seven (7) stated no, they have not been harassed by a resident. Additionally, Residents R1-R7, were asked if staff prevent residents from harassing other residents, six (6) out of seven (7) stated yes, staff are there to prevent incidents and ensure there is no harassment. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Administrator Assistant, Selena Cruz, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 29, 2025 · control 11-AS-20250821121316

Allegation investigated: Staff physically abused resident

***This report supersedes the original report delivered on 7/16/2025. On 8/13/2025, At 2:36PM LPA arrived at the facility to deliver the corrected 9099, providing clarification to the original report issued on 7/16/205 *** On 07/16/2025 At 8:20 PM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver the findings for the allegation listed above. LPA Allen called the facility at the entry gate introduced herself to the receptionist Afsaneh Zarabi and explained the purpose of the visit and was allowed entry into the facility. LPA met by Theresa Cruz-Pascual- Wellness Director. The Administrator Luz Rose arrived around 10:10 AM. The investigation consisted of the following: Interviews with Residents 1-6 (R1- R6), Staff members 1-6 (S1- S6), a tour of the facility and observations of 3 residents’ rooms/bathrooms. Continued..... Unsubstantiated LPA obtained and reviewed the resident roster dated 7/16/2025, staff roster, shower schedule for June 30- July 16, 2025, and staff RCA assignment dated 7/11/2025 which is only adjusted when the census changes. The investigation revealed the following: #1 Allegation: Staff physically abused resident At approximately 10:15 AM, the Licensing Program Analyst LPA attempted to interview Resident 1 (R1) on two separate occasions during the investigation; however, R1 was unwilling to participate in an interview. LPA successfully conducted interviews with Residents 2, 3, and 4 (R2, R3, R4), 3 out of the 6 stated they have not experienced any form of abuse by staff members. LPA attempted to interview Residents 5 and 6 (R5, R6), but they were unavailable at the time of the investigation. Residents R2-R4 also permitted LPA to observe their showers, which were equipped with shower heads attached to cords. No health or safety concerns were observed during the inspection. LPA conducted interviews with Staff 1 - 6 (S1–S6). 6 out of 6 staff members stated they have not witnessed or experienced any type of abuse involving residents by any staff member. While S1–S6 acknowledged hearing gossip regarding the allegation of abuse involving R1, therefore they could not confirm if the alleged abuse took place or not. Additionally, 6 out of 6 staff members noted that R1 can sometimes be challenging to assist with Activities of Daily Living (ADLs). In these situations, alternate measures are taken to ensure R1 receives the necessary care, including reassigning another staff member to assist with the residents’ needs. S1 confirmed that R1 had accused them of abuse. In response, S1 stated they immediately reported the allegation to the Administrator, and alternate measures were implemented to ensure R1 received assistance from a different staff member. At approximately 11:30 AM, LPA obtained and reviewed documentation indicating that Staff 1 (S1) attempted to assist Resident 1 (R1) with their ADLs and at the time of the incident the administrator assigned another staff member to assist R1 and implemented an alternate caregiver to prevent future occurrences. Continued Based on the evidence gathered during the interviews, records reviewed, and observations during the investigation, 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 violations did or did not occur. An exit interview was conducted, and this report was discussed and provided to Luz Rose Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 11-AS-20250709094026

Allegation investigated: Staff physically abused resident

On 07/16/2025 At 8:20 PM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver the findings for the allegation listed above. LPA Allen called facility at entry gate introduced herself to the receptionist Afsaneh Zarabi and explained the purpose of the visit and was allowed entry into the facility. LPA met by Theresa Cruz-Pascual- Wellness Director. The Administrator Luz Rose arrived around 10:10 AM. The investigation consisted of the following: Interviews with Residents 1-6 (R1-R6),Staff members 1-6 (S1- S6), a tour of the facility and observations of 3 residents’ rooms/bathrooms. LPA obtained the resident roster dated 7/16/2025, staff roster, shower schedule for June 30-July 16, 2025, and staff RCA assignment dated 7/11/2025 which is only adjusted when the census change. Continued.... Unsubstantiated The investigation revealed the following: #1 Allegation: Staff physically abused resident At 10:15 AM, LPA conducted interviews with three residents (R2, R3, R4), who stated they had not been physically abused in any way by a staff member. R2, R3 and R4 also allowed LPA to observed their showers that were installed with shower heads with cords and there were health & safety concerns. LPA attempted to interview R1 twice during the investigation, but R1 was unwilling to be interviewed. Additionally, LPA attempted to interview R5 and R6, but they were unavailable. LPA also conducted interviews with Staff 1- Staff 6 (S1-S6), and 6 out of 6 staff members stated they have not witnessed, experienced, or heard of any resident being physically abused in any way by a staff member. S1-S6 also mentioned that R1 can sometimes be challenging to assist with their (ADLs) Assistance Daily Living, In such instances, alternate measures are taken to ensure R1 receives the necessary assistance. At 11:30 LPA reviewed documents and it was observed that R1 did received assistance from S1 which did not involve physical abuse. The incident was documented and reported to the responsible administrative staff and Community Care Licensing. An alternate plan was immediately implemented to prevent future occurrences. Based on the evidence gathered during the interviews and observations during the investigation, 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 violations did or did not occur. An exit interview was conducted and this report was discussed and provided to Luz Rose Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jul 16, 2025 · control 11-AS-20250709094026

Allegation investigated: Staff not allowing resident to sit with significant other. Staff made inappropriate comments regarding resident.

***This report supersedes the original report delivered on 5/13/2025. On 6/18/2025 at 12:29 PM,LPA Allen arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 5/13/2025.*** LPA met with Luz Rose Administrator and she was informed of the purpose of the visit. On 05/13/2025 At 8:45 PM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver the findings for the allegations listed above. LPA Allen was met by Theresa Cruz-Pascual. LPA Allen introduced herself and explained the purpose of the visit and was allowed entry into the facility. Around 9:30 AM Luz Rose, Administrator arrived, and she was informed of the purpose of the visit. The investigation consisted of the following: Interviews with Staff members 1-7 (S1- S7), Residents 1-7 (R1-R7), a tour of the facility and observations. Continued.... Unsubstantiated The investigation revealed the following: Allegation 1: Staff not allowing resident to sit with significant other. At 10:15 AM, LPA conducted interviews with residents #1 – resident #7 (R1–R7), and 6 out of 7 residents stated they are free to sit with whomever and wherever they choose while dining. However, because not all residents get along, staff members make efforts to accommodate those who prefer to dine in groups or alone. This approach helps prevent potential conflicts among residents while providing seating options. R1 and R2 were asked if this was a reoccurring situation and their reply was it has happened only once.. LPA also conducted interviews with Staff #1 – Staff #7 (S1- S7), and 7 out of 7 staff members stated residents are allowed to sit wherever and with whomever they prefer in the dining area. Some residents prefer specific seating arrangements, either alone or with others, and staff members attempt to fulfill their requests. Staff stated residents have not been told others cannot dine with them. However, if concerns arise, seating adjustments may be made to de-escalate potential confrontations at that time. During LPA’s visit, LPA observed R1 and R2 dining together during lunch. LPA also observed other residents dinning alone and in groups. There was no visible indication that residents were assigned specific seating. Based on the evidence gathered during the interviews and observations during the investigation, 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 violations did or did not occur. Continued.... The investigation revealed the following: Allegation 2: Staff made inappropriate comments regarding resident LPA conducted interviews with Residents #1 – Resident #7 (R1–R7), and 6 out of 7 residents stated they have not heard any staff members saying inappropriate remarks concerning any resident. When R1 was asked whether inappropriate statements had been made directly to them and their response was no someone told them what the staff member said about them. LPA clarified by asking did the staff member say the inappropriate comment to them directly and their response was no. LPA also conducted interviews with Staff #1 – Staff #7 (S1- S7), and 7 out of 7 staff members stated they have not made inappropriate comments regarding any resident. The staff member's have also said residents have not complained to them about any staff member making inappropriate comments towards residents. During the tour of the facility LPA also observed residents visiting each other’s rooms. Based on the evidence gathered during the interviews and observations during the investigation, 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 violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Luz Rose-Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 11-AS-20250506131114

Allegation investigated: Staff did not accept resident back into care following hospitalization. Staff did not treat resident with dignity or respect. Staff left resident in soiled diapers for an extended period of time.

On05/19/2025, at 10:39 am Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit in order to deliver investigation findings. LPA met with Teresa Pascual (Wellness Director), and explained the purpose of the visit. The investigation consisted of the following: On 11/04/2024, LPA Brown interviewed the Administrator (A1), staff members (S1-S5), and residents (R2-R8). LPA requested the resident and staff roster, resident files for R1-R7, including Admission Agreement, Pre-Placement Appraisal, Resident Appraisal, Appraisal/ Needs and Service Plan, Unusual Serious Incident Reports, List of Incontinence Residents, Incontinence Logs (dated 08/01/2024 – 10/31/2024), and LIC 602 Physician’s Report for RCFE. LPA was not able to interview Resident #1 (R1) since the resident no longer resides at the facility and LPA was unable to locate the resident after multiple attempts. Report continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation 1: Staff did not accept resident back into care following hospitalization. It was alleged that Resident #1 was refused re-admission following hospitalization. On 11/04/2024 at 9:45 AM, LPA interviewed A1, who denied the allegation, stating that R1 needed more care but was not refused re-admission. Between 11:45 AM - 1:00 PM, LPA interviewed 5 staff members regarding the allegation: 2 of 5 staff denied the allegation. 3 of 5 staff were unaware of the situation. Between 10:00 AM - 11:30 AM, LPA interviewed 7 residents: 0 out of 7 residents confirmed the allegation. 2 out of 5 residents were unsure or unaware of the situation. 5 out of 7 residents denied the allegation. LPA reviewed records and did not observe any documentation to support the allegation. Based on interviews conducted an records reviewed there is no evidence to support the allegation, therefore the allegation is unsubstantiated. Allegation 2: Staff left residents in soiled diapers for an extended period of time. It was alleged that incontinent residents were not changed in a timely manner. On 11/04/2024 at 9:45 AM, LPA interviewed A1, who denied the allegation. Between 11:45 AM - 1:00 PM, LPA interviewed 5 out of 5 staff denied the allegation. Between 10:00 AM - 11:30 AM, LPA interviewed 7 residents: 4 out of 7 residents were independent and did not require incontinence care. 3 out of 7 residents who required incontinence care denied the allegation. LPA reviewed incontinence logs and observed documentation of care being provided every two hours. Based on interviews conducted an records reviewed there is no evidence to support the allegation, therefore the allegation is unsubstantiated. Report continues on LIC 9099-C Allegation 3: Staff did not treat residents with dignity or respect. It was alleged that staff mistreated residents. On 11/04/2024 at 9:45 AM, LPA interviewed Administrator (A1), who denied the allegation. Between 11:45 AM - 1:00 PM, LPA interviewed 5 staff: 4 out of 5 staff denied the allegation. 1 out of 5 staff acknowledged witnessing mistreatment. Between 10:00 AM - 11:30 AM, LPA interviewed 7 residents: 4 out 7 residents confirmed the allegation. 3 out of 7 residents denied the allegation. LPA reviewed records but did not observe documentation supporting the allegation. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be UNSUBSTANTIATED. No citations were issued for this complaint. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Teresa Pascual, Wellness Director.the state’s words, verbatim · CDSS document, May 19, 2025 · control 11-AS-20240506161638

Allegation investigated: Staff retaliate against residents in care. Staff yell at resident(s) in care. Facility is in disrepair. Staff verbally abuse resident(s) in care. Staff harass resident(s) in care. Staff discriminate against resident in care. Staff steal resident(s) personal belongings while in care.

On 05/19/2025, at 10:39 am, Licensing Program Analyst (LPA) Zina Brown conducted a complaint visit to the facility and was greeted by Teresa Pascual, Wellness Director. The department explained the purpose of this visit is to deliver findings for the allegations mentioned above. The investigation consisted of the following: An initial complaint visit was completed by the department on 08/21/2024, during the visit the department interviewed staff and obtained facility files. A subsequent visit was completed by the department on 11/04/2024 and the department interviewed staff (S1-S5) and residents (R1-R6). The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm. The department received the following: Resident Roster (Dated: 11/04/2024), Staff Roster (Dated: No Date), Maintenance log (Dated: Various Dates), and Theft and Loss Policy (Dated: No Date) were obtained from the facility. Unsubstantiated Allegation #8 - Licensee is not ensuring that resident(s) are provided with hot water while in care. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 3 of 5 staff denied the allegation that Licensee is not ensuring that resident(s) are provided with hot water while in care. Most of the staff stated that they have no knowledge of any issues with the hot water in the facility. While another staff stated that it takes a little while for the water to heat up, but it does. The department interviewed residents (R1-R6) about the allegation and 3 of 6 residents denied the allegation. Half of the residents interviewed stated that they do not have a problem with getting hot water, while the other half stated that it takes a while for the water to heat up in the facility. On 05/19/2025 between the hours of 10:52am - 11:50am LPA checked the water temperature in the following resident rooms: Room 225 (108.F), Room 224 (106.2F), Room 215 (106.8F), Room 207(101.7F), Room 208 (99.3F), Room 211 (98.6F), Room 320 (104.F) and Room 309 (96.4F). Based on LPAs observations and interviews there is sufficient evidence to support the allegation that the Licensee is not ensuring that resident(s) are provided with hot water while in care the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. A deficiency has been issued for this allegation. An exit interview was conducted, and a hard copy of this Complaint Investigation Report with Appeal Rights was provided to Teresa Pascual, Wellness Director. Allegation #1- Staff retaliate against residents in care. It is alleged that the resident is concerned with retaliation if they were to make a complaint against the facility. It was reported that residents are afraid of reporting and are leaving the facility. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that the Staff retaliate against residents in care. All staff (S1-S5) stated that they have never retaliated against any residents in care and that they try to resolve any issues the residents may have and foster an open-door policy with respect to complaints and other issues in the facility. The department interviewed residents (R1-R6) about the allegation and 4 of 6 residents denied the allegation. The majority of residents interviewed stated that they have not been retaliated against because they made a complaint and felt comfortable voicing their concerns about issues in the facility without fear of retaliation. Based on interviews conducted, there is insufficient evidence to support the allegation that the Staff retaliate against residents in care. 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 yell at resident(s) in care. It is alleged that the staff in the facility yell and scream at residents and make it unbearable to live there. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that Staff yell at resident(s) in care. All staff (S1-S5) stated that they have never yelled at any resident and are unaware of any staff that has yelled at residents. Staff further stated that if residents are upset or uncooperative they get the family involved to diffuse any misunderstandings before it escalates. The department interviewed residents (R1-R6) about the allegation and 4 of 6 residents denied the allegation. The majority of residents interviewed stated that they have not experienced being yelled at by the staff. They further state that the staff treats them with dignity and respect. Based on interviews conducted, there is insufficient evidence to support the allegation that Staff yell at resident(s) in care. 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 - Facility is in disrepair. It is alleged that the facility is in disrepair and there are problems with the water lines. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that Facility is in disrepair. All staff (S1-S5) stated that the facility is not in disrepair and that some rooms are in the process of upgrading some of the flooring, repainting rooms, and fixing waterlines in the facility. The department interviewed residents (R1-R6) about the allegation and 3 of 6 residents denied the allegation. The majority of residents interviewed stated that they believed the facility was not in disrepair and are happy with the way the facility looks. The department toured the facility and observed that several rooms were being remodeled and new waterlines were purchased and were being installed. The department did not observe the facility to be in disrepair. Based on observations and interviews conducted, there is insufficient evidence to support the allegation that Facility is in disrepair. 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 verbally abuse resident(s) in care. It is alleged that the facility staff abuses the residents verbally, while living at the facility. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that Staff verbally abuse resident(s) in care. All staff (S1-S5) stated that they have not verbally abused any of the residents and the facility does not allow staff to treat the residents in such a way. They state that the residents have personal rights and one of those rights are not to be spoken to without respect and never yelling at them. The department interviewed residents (R1-R6) about the allegation and 4 of 6 residents denied the allegation. The majority of residents interviewed stated that they have not been verbally abused or yelled at by the staff. They further state that the staff has always spoken to them in a respectful manner. Based on interviews conducted, there is insufficient evidence to support the allegation that Staff verbally abuse resident(s) in care. 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 #5- Staff harass resident(s) in care. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that Staff harass resident(s) in care. All staff (S1-S5) stated that they have not harassed any resident and are unaware of any other staff that has harassed a resident at the facility. They further state that they have taken personal rights training and harassment of any kind is not accepted at the facility. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents denied the allegation. The majority of residents interviewed stated that they have not been harassed by the staff. Based on interviews conducted, there is insufficient evidence to support the allegation that Staff harass resident(s) in care. 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 discriminate against resident in care. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that Staff discriminate against resident in care. All staff (S1-S5) stated that they have no knowledge of anyone discriminating against any resident living at the facility. They further state that no one has reported being harassed to them. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents denied the allegation. The majority of residents interviewed stated that they have not been discriminated against by any staff member. Based on interviews conducted, there is insufficient evidence to support the allegation that Staff discriminate against resident in care. 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 steal resident(s) personal belongings while in care. It is alleged that the facility staff and caregivers discriminate against the resident in care at the facility. On 08/21/24 the department interviewed staff (S1-S5) and residents (R1-R6) from 9:00am-2:00pm about the allegation. 5 of 5 staff denied the allegation that Staff steal resident(s) personal belongings while in care. All staff (S1-S5) stated that they have no knowledge of anyone stealing resident’s belongings. They further state that sometimes residents will misplace their items and when they go to investigate the items are found. The department interviewed residents (R1-R6) about the allegation and 4 of 6 residents denied the allegation. The majority of residents interviewed stated that they have not been a victim of theft in the facility. Based on interviews conducted, there is insufficient evidence to support the allegation that Staff steal resident(s) personal belongings while in care. 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. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Teresa Pascual, Wellness Director.the state’s words, verbatim · CDSS document, May 19, 2025 · control 11-AS-20240813131630

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: May 26, 2025

Maintenance and Operation Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents shall be...attain a temperature of not less than 105 degree F... and not more than 120 degree F .. This requirement is not meet as evidence by Based on interview & observation, LPA checked the water temp in Rooms 207 (101.7F), 208 (99.3F), 211 (98.6F), 320 (104.F) & 309 (96.4F) which is not within required range as documented in Title 22 regulation which poses an Health & Safety risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2025

Plan of correction: The licensee will ensure that maintenance supervisor will inspect the water boiler & will continue to test the water temperature to ensure it is within required range 105F - 120F (per Title 22) throughout all the facility resident rooms 207, 208, 211, 320, and 309, etc. Submit proof of correction to zina.brown@dss.ca.gov by POC due date.

Allegation investigated: Staff did not accept resident back into care following hospitalization. Staff did not treat resident with dignity or respect. Staff left resident in soiled diapers for an extended period of time.

On05/19/2025, at 10:39 am Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit in order to deliver investigation findings. LPA met with Teresa Pascual (Wellness Director), and explained the purpose of the visit. The investigation consisted of the following: On 11/04/2024, LPA Brown interviewed the Administrator (A1), staff members (S1-S5), and residents (R2-R8). LPA requested the resident and staff roster, resident files for R1-R7, including Admission Agreement, Pre-Placement Appraisal, Resident Appraisal, Appraisal/ Needs and Service Plan, Unusual Serious Incident Reports, List of Incontinence Residents, Incontinence Logs (dated 08/01/2024 – 10/31/2024), and LIC 602 Physician’s Report for RCFE. LPA was not able to interview Resident #1 (R1) since the resident no longer resides at the facility and LPA was unable to locate the resident after multiple attempts. Report continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation 1: Staff did not accept resident back into care following hospitalization. It was alleged that Resident #1 was refused re-admission following hospitalization. On 11/04/2024 at 9:45 AM, LPA interviewed A1, who denied the allegation, stating that R1 needed more care but was not refused re-admission. Between 11:45 AM - 1:00 PM, LPA interviewed 5 staff members regarding the allegation: 2 of 5 staff denied the allegation. 3 of 5 staff were unaware of the situation. Between 10:00 AM - 11:30 AM, LPA interviewed 7 residents: 0 out of 7 residents confirmed the allegation. 2 out of 5 residents were unsure or unaware of the situation. 5 out of 7 residents denied the allegation. LPA reviewed records and did not observe any documentation to support the allegation. Based on interviews conducted an records reviewed there is no evidence to support the allegation, therefore the allegation is unsubstantiated. Allegation 2: Staff left residents in soiled diapers for an extended period of time. It was alleged that incontinent residents were not changed in a timely manner. On 11/04/2024 at 9:45 AM, LPA interviewed A1, who denied the allegation. Between 11:45 AM - 1:00 PM, LPA interviewed 5 out of 5 staff denied the allegation. Between 10:00 AM - 11:30 AM, LPA interviewed 7 residents: 4 out of 7 residents were independent and did not require incontinence care. 3 out of 7 residents who required incontinence care denied the allegation. LPA reviewed incontinence logs and observed documentation of care being provided every two hours. Based on interviews conducted an records reviewed there is no evidence to support the allegation, therefore the allegation is unsubstantiated. Report continues on LIC 9099-C Allegation 3: Staff did not treat residents with dignity or respect. It was alleged that staff mistreated residents. On 11/04/2024 at 9:45 AM, LPA interviewed Administrator (A1), who denied the allegation. Between 11:45 AM - 1:00 PM, LPA interviewed 5 staff: 4 out of 5 staff denied the allegation. 1 out of 5 staff acknowledged witnessing mistreatment. Between 10:00 AM - 11:30 AM, LPA interviewed 7 residents: 4 out 7 residents confirmed the allegation. 3 out of 7 residents denied the allegation. LPA reviewed records but did not observe documentation supporting the allegation. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be UNSUBSTANTIATED. No citations were issued for this complaint. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Teresa Pascual, Wellness Director.the state’s words, verbatim · CDSS document, May 19, 2025 · control 11-AS-20240506161638

Allegation investigated: Staff not allowing resident to sit with significate other. Staff made inappropriate comments regarding resident.

On 05/13/2025 At 8:45 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver the findings for the allegations listed above. LPA Allen was met by Theresa Cruz-Pascual. LPA Allen introduced herself and explained the purpose of the visit. Around 9:30 AM Luz Rose, Administrator arrived, and she was informed of the purpose of the visit. At 10:15 AM, LPA conducted interviews with Residents #1 – #7 (R1-R7), and 6 out of 7 residents stated they are free to sit with whomever and wherever they choose while dining. However, since not all residents get along, staff members make efforts to accommodate those who prefer to dine in groups or alone. This approach helps prevent potential conflicts among residents while providing seating options. During LPA’s visit, LPA observed R1 and R2 dining together during lunch and noted residents visiting each other’s rooms. Additionally, 6 of the 7 residents stated staff members have not made inappropriate remarks concerning any resident. Continued..... Unsubstantiated LPA also conducted interviews with staff #1 – #7 (S1- S7), with all seven (7) staff members stating residents are allowed to sit wherever and with whomever they prefer in the dining area. Some residents prefer specific seating arrangements, either alone or with others, and staff members attempt to fulfill their requests. Staff confirmed that residents have not been told others cannot dine with them. However, if concerns arise, seating adjustments may be made to de-escalate potential confrontations. Additionally, all seven (7) staff members stated they have not made inappropriate comments regarding residents, nor have they been informed by residents about staff making inappropriate remarks concerning any resident. Based on the evidence gathered during the interviews and observations during the investigation, 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 violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Luz Rose-Administrator at the conclusion of the visit. LPA also conducted interviews with staff #1 – #7 (S1-S7), with all seven staff members stating that residents are allowed to sit wherever and with whomever they prefer in the dining area. Some residents prefer specific seating arrangements, either alone or with others, and staff members attempt to fulfill their requests. Staff confirmed that residents have not been told others cannot dine with them. However, if concerns arise, seating adjustments may be made to deescalate potential confrontations. Additionally, all seven staff members stated they have not made inappropriate comments regarding residents, nor have they been informed by residents about staff making inappropriate remarks concerning any resident. Based on the evidence gathered during the interviews and observations during the investigation, 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 violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Luz Rose-Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 13, 2025 · control 11-AS-20250506131114

Allegation investigated: Staff do not keep a resident's room free from mold and chemicals Staff do not properly maintain a resident's room Staff verbally abused a resident while in care Staff do not seek emergency assistance for the residents Staff abused the residents while in care Staff did not safeguard a resident's personal belongings Staff unlawfully evicted a resident Staff refused to provide requested documentation to requesting agencies

On 3/27/25 at 10:00am, Licensing Program Analyst (LPA) Sparkle Day conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. This report supersedes the report dated 3/14/2024, the purpose of this amendment is to provide clarification on the circumstance surrounding the allegations. although this report supersedes the previous report the complaint investigation findings remain the same: Unsubstantiated. LPA met with Theresa Pascual, Wellness Director who allowed entry into the facility and was later met by Administrator Luz Rose who assisted with the visit. The investigation of this complaint consisted of the following: On 3/14/24 LPA David Espana conducted an unannounced complaint visit and met with Executive Director,Luz Rose and the following was conducted: LPA Espana conducted interviews of staff and residents. LPA Espana toured the facility and received the following documents: Staff and Resident roster, SIR reports, physician reports, ALW appraisal, Summons for eviction. During todays visit LPA Sparkle Day toured the facility including rooms#226,224,207,206,341,340 ,335,333,324 and 322. LPA interviewed staff and residents and received copy of court order for Unsubstantiated eviction of resident #1. Allegation #1: Staff do not keep a residents room free from mold and chemicals. It is alleged that a resident lives in a room with mold and chemicals. On 3/27/25 at around 11:45am LPA interviewed the Administrator regarding the allegation, Administrator denied the allegation and stated there is no mold or chemicals in any of the rooms. On 3/27/25 between 12:00pm-1:30pm LPA Day interviewed 6 clients and 6 of the 6 clients denied the allegation. On 3/27/25, between 1:30 pm-2:30pm LPA interviewed 5 staff regarding the allegation. 5 of 5 staff interviewed denied the allegation. All interviewed including staff and residents were consistent in their statements that they have not seen nor smelled mold or chemicals in their rooms. On 3/27/25 during the visit LPA toured the facility and observed 10 rooms and did not observe any mold or chemicals . Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation #2: Staff do not properly maintain a residents room. It is alleged that maintenance in residents room is not properly handled . On 3/27/25 at betwenn 12:00pm - 1:30 pm LPA Day interviewed 6 clients and 6 of the 6 clients denied the allegation. On 3/27/25, between 1:30pm-2:30pm LPA interviewed 5 staff regarding the allegation. 5 of 5 staff interviewed denied the allegation. All interviewed including staff and residents were consistent in their statements that residents rooms are cleaned daily, which consists of: taking out trash, vacuum floors, making bed and cleaning bathroom .Deep cleaning is once a week, which consists of: Everything in daily cleaning plus: changing lining, cleaning windows and mirrors ,mopping floors and dusting .On 3/27/25 during the visit LPA toured the facility and observed 10 rooms and found the rooms to be cleaned and in order. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Allegation #3 :Staff verbally abused a resident while in care It is alleged that resident is being verbally abused by the entire staff including caregivers and managers. On 3/27/25 between 12:00pm - 1:30 pm LPA Day interviewed 6 clients and 6 of the 6 clients denied the allegation. Stating they have not witnessed any staff verbally abusing any resident. On 3/27/25, between 1:30 pm-2:30pm LPA interviewed 5 staff regarding the allegation. 5 of 5 staff interviewed denied the allegation and state they have not witnessed any staff being verbally abusive to any resident Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Allegation #4: Staff do not seek emergency assistance for the residents It is alleged that resident do not feel safe as the facility refuses to call 911 for anybody. On 3/27/25 at between 12:00pm - 1:30 pm LPA Day interviewed 6 clients and 6 of the 6 clients denied the allegation. On 3/27/25, between 1:30 pm -2:30 pm LPA interviewed 5 staff regarding the allegation. 5 of 5 staff interviewed denied the allegation .All interviewed including staff and residents were consistent in their statements that if emergency assistance is needed for residents the staff call immediately. On 3/27/25 during the visit LPA reviewed SIRs for the last 3 months ( January 2025 - March 2025) and found the Emergency Assistance was called (4) times. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Allegation #5: Staff abused the residents while in care It is alleged that it was witnessed of a caregiver abusing 2 patients. On 3/27/25 between 12:00pm - 1:30 pm LPA Day interviewed 6 clients and 6 of the 6 clients denied the allegation. Stating they have not witnessed any staff abusing any residents. On 3/27/25, between 1:30 pm -2:30 pm LPA interviewed 5 staff regarding the allegation. 5 of 5 staff interviewed denied the allegation and state they have not witnessed any staff being abusive to any resident. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Allegation #6: Staff did not safeguard a residents personal belongings It is alleged that some of residents possessions were removed from their room. On 3/27/25 between 12:00pm - 1:30 pm LPA Day interviewed 6 clients and 6 of the 6 clients denied the allegation. Stating they have not had any of their personal belongings missing from their rooms. On 3/27/25, between 1:30 pm -2:30 pm LPA interviewed 5 staff regarding the allegation. 5 of 5 staff interviewed denied the allegation and state they have not heard of anything missing from a residents room Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Allegation #7: Staff unlawfully evicted a resident It is alleged that a resident was illegally evicted and possessions removed from their room. On 3/27/25 between 12:00pm - 1:30 pm LPA Day interviewed 6 clients and 6 of the 6 clients denied the allegation. Stating they have no knowledge of any residents being evicted. On 3/27/25, between 1:30 pm -2:30 pm LPA interviewed 5 staff regarding the allegation. 4 of 5 staff interviewed denied the allegation and state they had no knowledge of a resident being unlawfully evicted. The Administrator informed LPA Day that resident #1 was evicted per court order and not unlawfully. LPA Day obtained a copy of the court order and found it to be proper and within Title 22 guidelines. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Allegation #8: Staff refused to provide requested documentation to requesting agencies. It is alleged that staff refuse to provide documentation needed to social security and other agencies. On 3/27/25 between 12:00pm - 1:30 pm LPA Day interviewed 6 clients and 6 of the 6 clients denied the allegation. Stating they have not encountered the staff not providing documentation to any of the Agencies that would request anything of them pertaining to any resident.. On 3/27/25, between 1:30 pm -2:30 pm LPA interviewed 5 staff regarding the allegation. 5 of 5 staff interviewed denied the allegation and state they have not witnessed any staff not providing requested documentation to any agency upon their request. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATEDthe state’s words, verbatim · CDSS document, Mar 27, 2025 · control 11-AS-20240311144357

Type of visit: Required - 1 Year

On 3/27/2025, At 1:14 PM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced annual comprehensive inspection. Upon arrival LPA called the facility introduced herself, explained the purpose of the visit and was granted access into the facility gates. LPA was greeted by Alzaneh Zerabi- Receptionist upon entering the facility. LPA was greeted by the Luz Rose-Administrator who was informed of the purpose of the visit. The facility is licensed to serve 136 non- ambulatory residents of which 6 may be bedridden. The facility has an approved hospice waiver for 12 residents. Currently there are six (6) bedridden, five (5) residents are on hospice. There are currently no residents who have dementia, and five (5) residents are receiving home health services. The facility does not handle any of the residents’ money. The current census is 64. At 1:40 PM, LPA reviewed seven (7) residents files for admission agreements, updated physician reports, needs and services plans all of which were all current. LPA also reviewed seven (7) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings which were all current. At 2:55 PM, LPA conducted a random audit of seven (7) residents Medication Administration Records (MARS) which appeared residents have been given their medications as prescribed by their physicians. At 3:15 PM,LPA and Luz Rose-Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of seven (7) bedrooms and seven (7) bathrooms and the bathrooms were found to be clean and operational. The bedrooms have the required furniture which appeared to be in good repair. The rooms also have adequate lighting, and storage for the residents’ personal belongings. LPA toured the kitchen and dining area and there was sufficient seating for dining. There was a menu available for review. LPA observed a 5-day supply of perishables and a 7-day supply of non-perishable food available for the residents in care which was adequately maintained. All fire extinguishers were fully charged and operable. The last fire inspected was on 3/17/2025 and the smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 115.5°F to 116.2°F throughout the facility and the temperature ranged from 74°F to 78°F. During the visit, LPA observed that the facility was clean, sanitary, and appropriately furnished. LPA also, observed cleaning supplies, toxins, and sharp objects were stored inaccessible to residents in care. Based on the observations made during today’s visit, no deficiencies were cited. An exit interview was conducted, and this report was discussed and provided to Luz Emma Rose-Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Mar 27, 2025

Allegation investigated: Staff do not provide resident with laundry service. Staff do not provide resident with housekeeping service. Staff do not ensure that resident receives mail when delivered to facility. Staff did not ensure that resident received medical care. Staff do not ensure that facility is maintained in good repair.

*This amendment serves to clarify the complaint allegations, it does not supersede the report delivered on 3/17/2025* On 03/17/2025 at 10:30 AM the Department conducted a subsequent complaint visit to the facility to deliver findings for the allegations listed above.The Department was met by Luz Rose, the Administrator and the purpose of today’s visit was explained.The Department was granted access and allowed to enter the facility. INVESTIGATION CONSISTED OF THE FOLLOWING: On 05/22/2024 The department requested, received, and reviewed copies of the following documents: Staff and Resident Rosters, emergency and ID Sheet, Laundry list, Housekeeping-Room, and cleaning list. On 05/15/2024 and 05/22/2024 The department toured facility grounds and viewed rooms toured Room 212, Room 337, Room 335, Room 327 & 328, Room 304, Room 318, Room 316 & 317, and Room 315. The department interviewed staff 1-staff 6 (S1-S6) and resident 1-resident 8 (R1-R8) CONTINUED ON LIC9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff do not provide resident with laundry service. On 05/15/2024 the department and Maria Theresa Pascual Wellness Director toured the facility. The department observed laundry area, service schedules, staff members schedules and services provided. On 05/15/2024, during interviews with 6 staff the department asked if staff laundry services were provided at the facility. Of those interviewed, 6 out of 6 staff stated they provide laundry services to all residents at the facility. On 05/15/2024, the department interviewed 8 residents. Of those interviewed, 8 out of 8 residents stated that laundry services were provided daily, weekly, twice a week, and as often as needed. Of those interviewed, 8 out of 8 residents who stated that they were happy with the laundry service, and they are receiving daily housekeeping, and the caregivers are doing an excellent job. Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. 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, therefore the allegations are Unsubstantiated. Allegation: Staff do not provide resident with housekeeping service. On 05/15/2024 the department toured facility from 10:00 am-1:12 pm and observed Room 212, Room 337, Room 335, Room 327 & 328, Room 304, Room 318, Room 316 & 317, and Room 315. The department observed all rooms to have housekeeping schedules posted which included daily cleaning of bathrooms. On 05/15/2024, The department interviewed 6 staff, of those interviewed 6 out of 6 staff stated there are 4 housekeeping staff on alternate schedules to service all rooms daily. Of those interviewed, 6 out of 6 staff stated the facility provides housekeeping services to residents. On 05/15/2024, The department interviewed 8 residents of those 8 out of 8 reported they had no concerns as their rooms are serviced daily or as needed and did not feel neglected. CONTINUED ON LIC9099-C Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. 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, therefore the allegations are Unsubstantiated. Allegation: Staff do not ensure that resident receives mail when delivered to facility. On 05/15/2024, The department interviewed Maria Theresa Pascual, Wellness Director who stated, that the facilities contact residents when they receive mail, as the concierge desk must notify the resident who must come down and receive their mail. If the resident is not able to come down, the staff will wait for family or resident. On 05/15/2024 The department interviewed 8 residents of those interviewed, 8 out of 8 residents stated that mail is received including packages and USPS Mail. On 05/15/2024, The department interviewed 8 out of 8 residents. Of those interviewed, 8 out of 8 stated deliveries arrive and staff notifies residents to pick up their packages which residents receive on a timely manner. On 05/15/2024 the department interviewed 6 staff members. Of those interviewed, 6 out of 6 staff members interviewed disagreed with the allegation. Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. 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, therefore the allegations are Unsubstantiated. Allegation: Staff did not ensure that resident received medical care. On 05/15/2024, The department interviewed Maria Theresa Pascual, Wellness Director who stated the facility ensures that residents receive medical care. On 05/15/2024, The department interviewed 6 staff of those interviewed, 6 out of 6 stated that residents’ medical care is not mismanaged. On 05/15/2024, The department interviewed with 6 out of 6 staff who stated that they ensure that resident received medical care. On 05/15/2024, The department interviewed 8 residents of those interviewed, 8 out of 8 residents stated that they disagreed with the allegation. Of those interviewed, 8 out of 8 residents stated satisfaction with the medical care they received and felt that their health needs were consistently addressed. CONTINUED ON LIC9099-C Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. 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, therefore the allegation is Unsubstantiated. Allegation: Staff do not ensure that facility is maintained in good repair. On 05/15/2024, The department and Maria Theresa Pascual, Wellness Director toured the facility grounds and noted the facility looks clean, indoor, and outdoor passageways were free of obstructions, lights all operated properly, as did sinks and toilets and beds had all required linens. On 05/15/2024, The department interviewed 8 residents of those interviewed, 8 out of 8 stated they believed the facility was maintained well and that the facility was in good repair. On 05/15/2024, The department interviewed 6 staff of those interviewed, 6 out of 6 staff stated that facility is in good repair and well maintained. Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. 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, therefore the allegation is Unsubstantiated. There were no deficiencies cited. An exit interview was conducted with the administrator Luz Rose and a copy of the Complaint Investigation Report LIC9099, and LIC9099-Cs, was provided to facility staff. CONTINUED ON LIC9099-Cthe state’s words, verbatim · CDSS document, Mar 17, 2025 · control 11-AS-20240509122945

Allegation investigated: Staff did not accept resident back into care following hospitalization.

**This report supersedes the previous report dated 10/25/24 to add additional information in the Complaint Investigation Report. ** On 3/7/25, at 12:00pm, the department conducted an unannounced subsequent complaint visit to add additional information in the complaint report. LPA was met by Administrator, Luz Rose, and the purpose of the visit was explained. On 10/25/2024 the Department conducted a subsequent complaint visit to the facility to deliver findings for the allegations listed above. The Department was met by Luz Rose, Administrator, and the purpose of today’s visit was explained. The Department was granted access and allowed to enter the facility. Complaint Investigation Report Continued On LIC9099-C Substantiated The investigation consisted of the following: On 02/22/2024 and 03/28/2024, from 9:30am -11:00am, the department requested and received the following documents: Staff and Resident rosters, SIR reports, Physician's report, ALW appraisal, Summons for Eviction for residents, records from Southern California Hospital at Culver City, and other pertinent records associated with this complaint. The department conducted interviews with witnesses (W1-W3), residents (R1-R8) and staff (S1-S8). On 03/7/25, the department conducted interviews with (S1, S2, and S9). Investigation Revealed the Following: Allegations #1: Staff did not accept resident back into care following hospitalization. The details of the complaint alleged that the facility did not accept a resident back into care following their hospitalization. On 02/22/2024 and 03/28/2024, from 9:30am -11:00am, the department interviewed staff (S1-S8) and residents (R1-R8) and witnesses (W1-W3). On 3/7/25, from 12:00pm-1:00pm, the department interviewed S1, S2, and S9 regarding the allegation. 3 of 9 staff interviewed corroborated the allegation that Staff did not accept resident back into care following hospitalization. While 6 of 9 staff had no knowledge of the incident. 3 of the 9 staff that corroborated the allegation stated that the reason the resident was not admitted back to the facility was because the resident needed a higher level of care that the facility could not give. 3 of 3 witnesses interviewed corroborated the allegation Staff did not accept resident back into care following hospitalization, stating there was an issue with the resident returning to the facility. The department interviewed residents R1-R8 about the allegation that Staff did not accept resident back into care following hospitalization. 7 of 8 residents interviewed stated they had no knowledge of the incident. Whereas 1 of 9 residents refused to be interviewed. The department reviewed all documents received from the facility and found that the facility did not follow proper procedures according to Title 22 regulations when it comes to residents who need a higher level of care. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not accept resident back into care following hospitalization, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Citations were issued on this visit. Note: *Citations not cleared by the due date will have a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. If the facility plans to appeal, the plan of corrections must still be completed by the due date. An exit interview was conducted, appeal rights were printed and discussed with Luz Rose, Administrator, and a hard copy of this Complaint Investigation Report was provided. The department interviewed residents R1-R8 about the allegation that Staff attempted to administer resident’s medication by force. 7 of 8 residents interviewed stated that the facility does not force them to take their medication. The department reviewed all documents received from the facility and found no evidence that the facility forces residents to take their medication. Based on interviews and observations there is insufficient evidence to support the allegation Staff attempted to administer resident’s medication by force. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued. An exit interview was conducted and discussed with Luz Rose, Administrator, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Mar 7, 2025 · control 11-AS-20240213144456

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(1-5) · Plan of correction due date: Mar 14, 2025

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) ... This requirement was not met as evidence by: Based on interviews and analysis, the administrator did not take the appropriate reappraisal steps by documenting the re-appraisal and formerly evicting the resident. R1 was displaced at the hospital because the resident needed a higher level of care. This is a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: Administrator will review Title 22 regulations section 87224 and will outline a plan on how to adhere to eviction procedure and re-evaluate residents to reflect Title 22. Administrator will send copy by POC due date of 3/14/2025, to LPA Perry Scott by email at perry.scott@dss.ca.gov

Allegation investigated: Staff steal resident(s) personal belongings while in care.

On 02/13/25, the department conducted an unannounced complaint visit to investigate the above-mentioned allegation and deliver findings. The department met with Wellness Director, Teresa Pascual, and the purpose of the visit was explained. The investigation consisted of the following: The department reviewed client files, and requested, and received the following documents: staff roster, resident roster, and copies Admissions Agreement, Physician Report, Record of Resident’s Safeguarded Cash Resources, Resident Personal Property and Valuables, Personal Rights, Personal Property Procedures, Grievance Procedure, Facility Information and House Rules, Identification and Emergency Information, Appraisal Needs and Services Plan, Preplacement Appraisal Information for R1. Additionally, the department conducted interviews with staff #1-#5 (S1-S5), residents #2-#6 (R2-R6) and attempted to interview R1. Furthermore, the department conducted a tour of the facility with Teresa Pascual. Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Staff steal resident(s) personal belongings while in care. It is being alleged that staff have been stealing money from a resident since they arrived at this facility. Based on interviews conducted, 5 out of 5 staff denied the allegation. 5 out of 5 stated that they respect the residents and their personal belongings. An interview with S1 revealed that R1 has not recently or in the past reported to management about any money and/or items missing or stolen by any staff member. Based on interviews conducted 5 out of 6 residents interviewed denied the allegation. 5 out 6 residents interviewed stated that staff have never stolen any money from them. 5 out of 6 residents interviewed stated that they didn't know of any staff member stealing from R1. 5 out of 6 residents interviewed stated that staff treat them with dignity and respect, and are respectful of their belongings. 5 out 6 residents interviewed stated they are satisfied with the services being provided to them. Based on the information gathered, interviews conducted, and records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with Wellness Director, Teresa Pascual, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 13, 2025 · control 11-AS-20250206155838

Allegation investigated: .Staff did not accept resident back into care following hospitalization. 2.Staff attempted to administer resident’s medication by force.

On 10/25/2024 the Department conducted a subsequent complaint visit to the facility to deliver findings for the allegations listed above. The Department was met by Luz Rose Executive Director, Administrator and the purpose of today’s visit was explained. The Department was granted access and allowed to enter the facility. The investigation consisted of the following: The department requested and received the following documents: Staff and Resident roster, SIR reports, physician's report, ALW appraisal, Summons for Eviction for residents, records from Southern California Hospital at Culver City, and other pertinent records associated with this complaint requested. A tour of the facility was conducted 02/27/2024. The department conducted interviews with witnesses #1 - witnesses #3 (W#1-#3), residents #1 - residents #8 (R#1-R#8) and staff #1 - staff #8 (S#1-S#8). CONTINUE REPORT TO LIC9099C Unsubstantiated Investigation Revealed the Following: Allegations: Staff did not accept resident back into care following hospitalization. On 02/22/2024 and 03/28/2024, the department interviewed Luz Rose, Administrator who was asked if staff did not accept resident back into care following hospitalization, and the Administrator stated there were no concerns or issues. Per the Administrator, Luz Rose, they had a resident that required a higher level of care. On 02/22/2024 and 03/28/2024, the department interviewed staff 2-staff 8 (S2-S8) regarding the allegation staff did not accept resident back into care following hospitalization, of those interviewed S2-S8 stated there were no concerns about resident being let back into the facility after hospitalization. On 02/22/2024 and 03/28/2024, the department interviewed witnesses #1 - witnesses #3 (W#1-#3). Of those interviewed W1-W3 stated there was an issue accepting resident back into facility after hospitalization. On 02/22/2024 and 03/28/2024, the department interviewed residents #1 - residents #8 (R#1-R#8). Of those interviewed 8 out of 8 stated they did know of anyone resident who has not been accepted back into the facility following hospitalization. The department attempted to interview R9, but they refused. On 02/22/2024, 03/28/2024 and 10/21/2024, the department conducted record reviews. Records show communication between facility, hospital, and a skilled nursing facility. Based on interviews and observations there is insufficient evidence to support the allegation: Staff did not accept resident back into care following hospitalization. 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. CONTINUE TO LIC9099C Allegation: Staff attempted to administer resident’s medication by force On 02/22/2024 and 03/28/2024, the department interviewed Luz Rose, Administrator who was asked if staff attempted to administer resident’s medication by force, and the Administrator stated there were no concerns or issues. Per Luz Rose staff does not administer resident’s medication by force. On 02/22/2024 and 03/28/2024, the department interviewed staff 2-staff 8 (S2-S8) about staff attempting to administer resident’s medication by force, of those interviewed S2-S8 stated the staff does not administer resident’s medication by force. On 02/22/2024 and 03/28/2024, the department interviewed residents #1 - residents #8 (R#1-R#8). The department attempted to interview R9, but they refused. Of those interviewed 8 out of 8 stated they did know of any resident that had been administered medication by force. Based on interviews and observations there is insufficient evidence to support the allegation: Staff attempted to administer resident’s medication by force. 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 with Luz Rose Executive Director and a copy of this report and appeals rights provided.the state’s words, verbatim · CDSS document, Oct 25, 2024 · control 11-AS-20240213144456

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Luz Emma Rose, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 136 non- ambulatory residents of which 6 may be bedridden. The facility has an approved hospice waiver for 12 residents. Currently(4) residents or on hospice, (2) residents have dementia and (7) are receiving Home health services. The facility does not handle any of the residents’ money. LPA and Administrator toured the facility @ approximately 1:00pm Structure/Physical Plant: The facility is a three-story building with 68 resident-bedrooms, and 74-bathrooms. 1st floor consists of a lobby area, laundry facility, staff break room , hair salon and an adjacent parking structure. The 2nd floor and 3rd floor consists of residential rooms. The 2nd floor also consists of the dining room, kitchen, outdoor shaded patio,courtyard area with tables and chairs, Activity room and medication room and Administrator office. The 3rd floor consists of resident rooms and storage. Outdoor passageways, walkways, driveways, steps, and patios are free from obstructions, hazards, or debris. LPA did not observe any bodies of water on the premises. Bedrooms During today's visit, LPA inspected rooms 203, 206, 211, 337, 342, 332 and 322. The Resident bedrooms are spacious and easily accommodate furnishings. All bedrooms were observed to have the required furniture per Title 22.. Bathrooms: Facility has approx. 74 bathrooms (68 full baths and 6 half). Bathrooms were observed to have a working toilet, wash basin and shower. All handrails were securely attached. LPA observed a non-skid mat and chair in showers. The water temperature measured between 108 degrees and 115-degrees Fahrenheit Linens & Hygiene Supplies: LPA observed an ample supply of linens including , and hygiene supplies for residents Kitchen LPA inspected the kitchen. During today’s inspection, LPA observed all appliance to be in good working order including stove burners, oven, microwave, freezer, and refrigerator. The refrigerator and freezer are maintained at the correct temperate for food storage. LPA observed a 3-day supply of perishable and a 7-day supply of non-perishable foods. All food was observed to be properly stored and labeled. Common Rooms LPA inspected all common rooms. In the dining room LPA observed ample seating to accommodate residents. A menu was posted at the entrance of the dining room and at the tables. LPA observed residents playing bingo in the activity room. The facility has board games, books, and other recreational materials for the client's use as well as an activity calendar. Residents are provided with a monthly activity calendar, and they are posted by the elevator on all floors. LPA observed all hallways, walkways, to be clean, clear, and free of obstructions or hazards. The facility was maintained at a comfortable temperature. Safety LPA observed multiple fully charged fire extinguishers mounted throughout the facility. There is a backup generator. The dual smoke/carbon monoxide detectors are hardwired and interconnected were operational and linked to LAFD. The system was last inspected and tested on 3/16/24 by LAFD. All required documents are posted according to Title 22. The First Aid Kit was inspected and contained the required items and a manual. LPA tested the landline and found it to be fully operational. All toxins and cleaning supplies are secured in a locked storage room on the 1st floor and are inaccessible to residents. At approximately 11:00 am LPA observed all centrally stored medication to be in their original packaging. LPA reviewed the medications and MARs for 10 residents. All medications are secured in the Medication Room and are locked in a med cart. LPA reviewed the files for 10 residents and 5 staff and found they contained the required documents. LPA interviewed 5 residents and 7 staff. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies, therefore no citations issued at this time. An exit interview was conducted and a copy of the Facility Evaluation Report was provided to the Administrator Luz Rose..the state’s words, verbatim · CDSS document, May 30, 2024

Allegation investigated: Staff do not keep a resident's room free from mold and chemicals Staff do not properly maintain a resident's room Staff verbally abused a resident while in care Staff do not seek emergency assistance for the residents Staff abused the residents while in care Staff did not safeguard a resident's personal belongings Staff unlawfully evicted a resident Staff refused to provide requested documentation to requesting agencies

** This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 03/14/2024. ** On 03/14/2024 at 8:00 am Licensing Program Analyst (LPA) David España conducted an unannounced complaint subsequent visit to Plaza at Westwood to initiate investigation for the above-mentioned complaint allegations and was greeted by Executive Director, Luz Rose. LPA explained the purpose of this visit is to gather information and conduct interviews with staff for the allegations mentioned above. The investigation consisted of the following: LPA Espana conducted interviews with residents and staff. LPA Espana requested and received the following: Staff and Resident roster, SIR reports, physician's report, ALW appraisal, Summons for Eviction and other pertinent records associated with this complaint where gathered. A tour of the facility was conducted on 03/13/2024 and 03/14/2024. Continue LIC9099C on next page Unsubstantiated Allegation: Staff did not safeguard a resident's personal belongings. On 03/13/2024 LPA España interviewed the Administrator who stated that they are aware of residents' personal rights and confirmed that no personal belongings are missing. They also stated that staff are not stealing residents' belongings. LPA España interviewed 6 residents, of those interviewed 6 out of 6 stated they were aware of their personal rights and reported no missing belongings or theft by staff. LPA España interviewed 6 staff members, of those interviewed, 6 out of 6 who confirmed their awareness of residents' rights and denied any involvement in theft. Based on interviews and observations there is insufficient evidence to support the allegation: Staff did not safeguard a resident's personal belongings. 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 abused the residents while in care. On 03/13/2024 LPA España interviewed 6 staff members of those interviewed 6 out of 6 denied the above allegation and reported being unaware of any resident being physically abused while in care. LPA España interviewed 6 residents of those interviewed, 6 out of 6 denied the allegation. LPA conducted a file review and there were no incident reports on file for the above allegation staff abused residents while in care. Based on interviews and observations there is insufficient evidence to support the allegation: Staff abused the residents while in care. 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 do not properly maintain a resident's room. On 03/13/2024, LPA España interviewed the Administrator and confirmed that maintenance oversees the housecleaning schedule, which includes daily cleaning of residents' bedrooms, except when refused. The facility employs 3 housekeepers and plans to hire more. LPA Espana interviewed 6 staff members regarding the allegation. All 6 stated housekeeping services where available to residents daily. LPA Espana interviewed 6 residents, who all indicated that housekeeping is available on weekdays and weekends. Based on interviews and observations there is insufficient evidence to support the allegation: Staff do not properly maintain a resident's room. 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. The investigation revealed the following: Allegation: Staff do not keep a resident's room free from mold and chemicals. On 03/13/2024, LPA España inspected the facility's grounds. LPA Espana toured 10 rooms and did not find any mold or chemicals present. The Executive Director, Luz Rose, stated there were no mold or chemicals present. LPA España interviewed 6 staff members and 6 residents of those interviewed, all stated they had no issues with mold or chemicals. Both the 6 staff and the 6 residents disagreed with the allegation, consistently stating that there were no problems with mold or chemicals in the facility. Based on interviews and observations there is insufficient evidence to support the allegation: Staff do not keep a resident's room free from mold and chemicals. 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 do not seek emergency assistance for the residents. On 03/13/2024 LPA Espana interviewed Executive Director, Luz Rose, who explained that staff immediately call EMS and document incidents in SIRs when emergency assistance is needed. The facility contacts relevant parties, such as the resident's physician and family. A pull cord system alerts staff when a resident requires immediate help, and caregivers check on residents every two hours. On 3/13/2024 LPA España interviewed 6 staff members of those interviewed, 6 confirmed that the facility promptly calls EMS and provides necessary medical care. LPA España interviewed 6 residents of those interviewed, 6 stated that they feel confident in the facility's prompt response to emergencies. Based on interviews and observations there is insufficient evidence to support the allegation: Staff do not seek emergency assistance for the residents. 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 verbally abused a resident while in care. On 03/13/2024 LPA España interviewed 6 of those interviewed, all 6 staff members reported no incidents of abuse in 2024, with any aggressive acts documented in Unusual Incident Reports. LPA España interviewed 6 staff of those interviewed 6 stated that any mistreatment is immediately reported to relevant authorities. LPA España interviewed 6 residents of those interviewed, 6 revealed no concerns or experiences of verbal abuse, and they believed the allegation lacked merit. LPA España 6 residents, of those interviewed, 6 denied witnessing or being involved in any abuse incidents. Based on interviews and observations there is insufficient evidence to support the allegation: Staff verbally abused a resident while in care. 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 unlawfully evicted a resident. On 03/13/2024, LPA España interviewed Administrator who explained that evictions occur only for reasons such as unpaid rent, not taking medications, or multiple incidents with documented warnings. They noted that the last eviction notice was given in 2023, and that resident still resides at the facility. LPA España interviewed 6 staff members of those interviewed, all 6 stated no awareness of any unlawful evictions. LPA Espana interviewed 6 residents of those interviewed, all 6 stated no awareness of any unlawful evictions. Based on interviews and observations there is insufficient evidence to support the allegation: Staff unlawfully evicted a resident. 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. THIS PAGE IS INTENTIONALLY LEFT BLANK THIS PAGE IS INTENTIONALLY LEFT BLANK Allegation: Staff refused to provide requested documentation to requesting agencies On 03/13/2024 LPA España interviewed 6 staff of those interviewed, 6 staff revealed no awareness of such incidents, and 6 staff believed management addresses all requests. LPA interviewed 6 residents of those interviewed, 6 stated they had no awareness of such incidents, and 6 residents believed management addresses all requests. A file review found no incident reports supporting the allegation. Based on interviews and observations there is insufficient evidence to support the allegation: Staff refused to provide requested documentation to requesting agencies. 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 were no deficiencies cited on today's visit. An exit interview with Luz Rose Executive Director and a copy of this report provided. THIS PAGE IS INTENTIONALLY LEFT BLANKthe state’s words, verbatim · CDSS document, Mar 14, 2024 · control 11-AS-20240311144357

Allegation investigated: Facility staff do not ensure resident's room is maintained clean.

On 01/18/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with Administrator, Luz Rose, and the purpose of today's visit was explained. During today's visit LPA toured the facility with administrator, interviewed staff (S1-S7), interviewed residents (R1-R7), and reviewed and received documents pertinent to the investigation. Documents reviewed and received include Staff Roster, Resident Roster, Deep Cleaning Schedule (Cleaner #1 and #2), Admission Agreement, Resident's Physician’s Report, and Needs and Service Plan. The investigation revealed the following: Continued on LIC9099-C Unsubstantiated Allegation: Facility staff do not ensure resident’s room is maintained clean. The allegation alleges resident’s room is dirty, unsanitary, and cluttered to the point that is a safety issue for the resident. During the facility tour, LPA observed the facility to be clean and sanitary. LPA inspected seven (7) resident rooms, including 213, 214,304,306,314, 315, and 316/317. LPA observed all rooms inspected to be clean and in good repair. All walkways and hallways in the facility and resident rooms were observed to be clean, clear, and free of obstructions, hazards, and debris. LPA reviewed the facility Admission Agreement that on page 3 states under Basic Housekeeping: Resident room will be cleaned once (1) per week. Residents are encouraged to keep their room I good order. Additionally, under General Facility Information and House Rules number 7 Housekeeping and Laundry service: states “Resident rooms are cleaned weekly and include dusting, furniture polish, and vacuuming and air freshener as needed. Personal laundry is provided a minimum of once a week or as needed. Bed linen and towels are changed weekly as part of the basic service.” LPA received and reviewed the Deep Cleaning Schedule for Cleaner #1 and #2 that shows what rooms require a deep cleaning and on which day it is to be done. During interviews with Staff (S1-S7), seven (7) out of seven (7) stated rooms are cleaned daily which include trash removal, bathroom wipe up, and linen change if needed and once a week each room is deep cleaned which include dusting, vacuuming, bathroom cleaning, mopping, and linen change. Staff (S1- S7) stated there are one (1) to three (3) residents who do not want staff to come in and clean their rooms, that they take care of it themselves. Additionally, Staff S4, S5, and S6 stated when we knock on their doors for housekeeping service, the resident’s will give them their trash to take out and they would provide them with new towels and anything else they need or want. During interviews with Residents (R1-R7) four (4) out of seven (7) stated housekeeping comes in and does a daily cleaning of making the bed, taking out the trash, put things away, wipe the toilet, and change linens if needed and that a deep cleaning is done once a week. Additionally, during interviews with Residents (R1, R4, and R5) three (3) out of three (3) stated there is housekeeping available but they prefer to clean their rooms and do their laundry themselves. During file review, LPA observed that Residents (R1, R4, and R5) are independent residents. Based on interviews conducted, observations, and record review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. LPA did not observe or cite any deficiencies during today’s visit. An exit interview was conducted with Administrator, Luz Rose, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 18, 2024 · control 11-AS-20240111085000

Allegation investigated: Staff leaves residents soiled for an extended period of time. Facility has a malodorous odor. Facility is in disrepair. Facility has pests.

On 10/07/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced visit at this facility and was greeted by Executive Director Luz Rose. LPA explained the purpose of this visit is to gather information and conduct interviews with staff for the allegations mentioned above. The investigation consisted of the following: LPA investigated the allegations mentioned and conducted interviews with residents, staff and witness. Staff and Resident roster, SIR reports, physician's report, ALW appraisal, Summons for Eviction for resident #1 (R1) and other pertinent records associated with this complaint. A tour of the faclity was conducted 09/07/23, 10/06/23 and 10/07/23. (Evalution Report continues on LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #5: Staff leaves residents soiled for an extended period of time. The details of this complaint alleged staff leave residents in soiled diapers for an extended period. The complainant did not have further details nor granted names of residents involved. Interviews were conducted on 10/06/23 between 10:00 a.m. and 11:15 a.m. with staff. There were (6) out of (6) staff #1-#6 (S1-S6) who were unable to validate this allegation. (S1-S4) denied neglect or lack of supervision of residents in care and has not observed any residents left in soiled diapers for an extended period and body checks are conducted during change of diapers and showers. (S3-S4) reported residents are monitored every two hours around the clock by each shift or as needed for incontinence care. The Department interviewed (8) residents on 09/07/23 between 10:00 am - 2:45 pm. (7) out of (8) residents #2-#8 (R2-R8) reported having no issues with incontinence care. (R2-R8) reported that staff are attentive and responsive to their needs and have no knowledge of any residents neglected in care. On 09/07/23 at 10:00 am resident #1 (R1) was interviewed and was unable to provide names of residents that have been neglected in care or staff involved. During the investigation (S1) revealed that there are (3) to (4) care staff for the a.m. shift, (2) to (3) care staff for the p.m. shift, and (3) care staff for the NOC shift. (S1) reported that Med-techs are also cross-trained as caregivers during staffing shortages. Based on the information gathered, there is no evidence to support the allegation mentioned above. Allegation #6: Facility has a malodorous odor. Allegation #7: Facility is in despair. The details of this complaint alleged that resident #1 (R1’s) room emitted a malodorous odor and its condition was in disrepair. The complainant reported (R1’s) toilet, sink, and faucet do not work and that a foul-smelling chemical surrounds (R1’s) room. (Evaluation Report continues LIC 9099-C) The Department at 10:00 am interviewed resident #1 (R1). (R1) claimed to have a foul smell coming through the air conditioning system and from the wood floors. (R1) claimed that mold was under the wood floors, and it presented a hazardous smell. (R1) also complained that the bathroom faucet, toilet, and air vent were not in working condition. (R1) stated maintenance has neglected to repair these items. The Department inspected (R1’s) room and it appeared to be cluttered and in disarray condition. The Department tested the bathroom toilet, faucet, and vent and found all to be in working condition. The air conditioning system is brand new and was replaced in August 2023 according to staff #6 (S6) as (R1) made multiple work requests for maintenance to inspect the AC system. The Department inspected (R1’s) room and found no sign of malodorous odor or mold. The Department interviewed (8) residents on 09/07/23 between 10:00 am - 2:45 pm. (7) out of (8) residents #2-#8 (R2-R8) report they are pleased with the upkeep of the facility and stated their rooms and common areas are not neglected. (R2-R8) added they have not observed the facility in a malodorous odor that would be considered offensive. These residents (R2-R8) who resided on the same floor had proximity to (R1’s) room could not validate these allegations. Interviews were conducted on 10/06/23 between 10:00 a.m. and 11:15 a.m. with staff. There were (6) out of (6) staff #1-#6 (S1-S6) who were unable to authenticate these allegations. (S5) reported that (R1) did not allow entry into the room, making (R1’s) room unavailable for cleaning for five months. (S5) claimed housekeeping services are conducted daily with once-a-week deep cleaning in all of the resident’s rooms. (S6) stated that (R1) did not allow maintenance inside the room making it unworkable to do maintenance services and that no work order had been placed for bathroom repairs. (S6) reported the last maintenance service conducted for (R1’s) room was in August 2023 when the new A/C system was installed. (S1-S4) confirmed that (R1) prohibited all staff from entering the room when (R1) is not present or absent, making upkeep problematic. (S2) claimed the gas company had investigated the chemical foul-smelling odor in (R1's) room and found it invalid with a receipt of an invoice. During the visits on 09/07/23, 10/06/23, and 10/0723, the Department observed housekeeping, janitorial, and maintenance services being conducted. Based on the information gathered, there is no evidence to support the allegation mentioned above. Allegation #8: Facility has pests. It is alleged that the facility has pests. The complainant reported the facility has some type of cockroaches. An area of the facility, date, or time when the issue occurred was not provided by the complainant. (Evaluation Report continues LIC 9099-C) There is uncertainty as to whether the issue has been discussed with management. The investigation revealed the facility did not pest during visits on 09/07/23, 10/06/23 and 10/07/23. The facility appeared to be in an organized, clean, and sanitary condition. The management is ensuring the facility is being treated on an ongoing basis by a reputable pest control company with an annual agreement contract. Proof of an annual service contract was provided by management. The Department inspected the entire facility including commons areas, the kitchen, the dining room, and the laundry room. Resident rooms inspected were #341, #214, #228, and #338 all showed no signs of pests. Interviews were conducted on 10/06/23 between 10:00 a.m. and 11:15 a.m. with staff. There were (6) out of (6) staff #1-#6 (S1-S6) who were unable to verify this allegation for accuracy. The Department interviewed (8) residents on 09/07/23 between 10:00 am - 2:45 pm. (7) out of (8) residents #2-#8 (R2-R8) reported having no concerns or issues with pests in their rooms or common areas. (R2-R8) reported that they have observed pest control services being performed within the facility at times. (R1) stated cockroaches were observed in the building, but was unable to explain where or when the pests were found. Therefore, based on all the information obtained during the investigation, there is no evidence to corroborate the allegation mentioned above. Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. 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, therefore the allegations are Unsubstantiated. An exit interview was conducted with Luz Rose, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Oct 7, 2023 · control 11-AS-20230829161007

Allegation investigated: Staff handles residents in a rough manner. Staff do not treat residents with dignity and respect. Staff locked the resident out of the room. Staff removed and withheld resident’s personal belongings without consent.

On 10/06/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced visit at this facility and was greeted by Executive Director Luz Rose. LPA explained the purpose of this visit is to gather information and conduct interviews with staff for the allegations mentioned above. The investigation consisted of the following: LPA investigated the allegations mentioned and conducted interviews with residents, staff and witness. Staff and Resident roster, SIR reports, physician's report, ALW appraisal, Summons for Eviction for resident #1 (R1) and other pertinent records associated with this complaint. A tour of the faclity was conducted 09/07/23 and 10/06/23. (Evalution Report continues on LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff handles residents in a rough manner. The details of this complaint alleged that staff handles residents in a rough manner. The complainant reported that residents have been observed mistreated by staff. The complainant did not go into details about the allegation who was involved or the time the incidents occurred. The Department interviewed (8) residents on 09/07/23 between 10:00 am - 2:45 pm. (7) out (8) residents #2-#8 (R2-R8) reported having no issues with staff. (R2-R8) were all complimentary of the staff and stated the staff conducted themselves professionally. On 09/07/23 at 10:00 am resident #1 (R1) was interviewed and unable to provide names of staff or residents or when events were witnessed. Interviews were conducted on 10/06/23 between 10:00 a.m. - 11:15 a.m. with staff. There were (6) out of (6) staff #1-#6 (S1-S6) who were unable to validate this allegation. (S3-S4) stated that residents in care are vulnerable and that staff are mindful of their interactions with residents. (S1) stated the facility is monitored 24/7 with a surveillance camera to capture any activities and incidents. Based on observation during the visits on 09/07/23 and 10/06/23, the Department observed the staff professionally interacting with residents. Therefore, based on all the information obtained during the investigation, there is no evidence to support the allegation mentioned above. Allegation #2: Staff do not treat residents with dignity and respect. The Department interviewed (8) residents on 09/07/23 between 10:00 am - 2:45 pm. (7) out (8) residents #2-#8 (R2-R8) claimed to have no problems with staff. On 09/07/23 at 10:00 am resident #1 (R1) was interviewed named (R2-R3) was not treated with graciousness by staff. (R1) did not elaborate on which staff was involved or when events were witnessed. (R2-R3) described staff to be helpful, thoughtful, and kind and did not have issues with staff. Interviews were conducted on 10/06/23 between 10:00 a.m. and 11:15 a.m. with staff. There were (6) out (6) staff #1-#6 (S1-S6) who declared this allegation is untrue. (Evaluation Report continues LIC 9099-C) (S1) reported staff have completed mandatory training courses dealing with Ethics and Code of Conduct, Diversity and Inclusion, and Bullying and Harassment. The facility has zero tolerance for any intolerable behavior. Based on observation during the visits on 09/07/23 and 10/06/23, the Department observed the staff professionally interacting with residents. Therefore, based on all the information obtained during the investigation, there is no evidence to corroborate the allegation mentioned above. Allegation #3: Staff locked the resident out of the room. he complainant claimed resident #1 (R1) was locked out of the room. The complainant reported on 05/25/23 (R1) was locked out of (R1's) room and law enforcement was dispatched for assistance. According to the facility's records, (R1) was admitted on 10/20/21 with no Admissions Agreement signed by the resident. (R1) refused to sign any documentation involving (R1) as resident at this facility. Facility records revealed (R1) was served with a 30-day Notice to Vacate in February 2023 for non-payment of services. In addition, a Summon of Eviction to appear in the Superior Court in California, County of Los Angeles on 08/28/23 was served. On 09/07/23 at 10:00 am resident #1 (R1) was interviewed about this matter and expressed being locked out by staff and did not have access to the room. (R1) admitted to only paying rent for (2) months and has refused to pay rent thereafter. (R1) could not give further details on the incident nor was able to provide names of staff involved in the 05/25/23 incident. Interviews with staff #1-2 (S1-S2) on 10/06/23 between 10:00 am and 11:15 am verified (R1) was given an Eviction Notice and Summons of Eviction to appear in court. (S1-S2) provided copies of legal documents stating the reason for (R1's) eviction was for failure to pay rent from 03/01/22 - 02/01/23 for a total unpaid services of $21, 869.13. (S1-S2) denied this accusation and claimed that (R1) was never locked out of (R1's) room on 05/25/23. Facility incident reports revealed (27) incidents involving (R1) for inappropriate behavior or for failure to adhere to the rules and regulations. Incident reports disclosed on 01/26/23 and 08/17/23 (R1) accused the staff of the same practice. There was no incident report for 05/25/23 to valid this incident happened nor a police report on record. Based on observation during the visits on 09/07/23, 10/06/23, and 10/07/23, the Department observed (R1) has maintained residency at this facility with no interruptions. (R1) continues to have access to all the amenities the facility has to offer which includes care and supervision. Therefore, based on all the information obtained during the investigation, there is no evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099) Allegation #4: Staff removed and withheld resident’s personal belongings without consent. The details of this complaint alleged staff had removed (R1's) personal property without consent. The complainant claimed that (R1's) personal property was removed from (R1's) room without approval. (R1's) property items were removed by the former administrator. According to the complainant, all of (R1's) property were stored away in storage. The Department interviewed (8) residents on 09/07/23 between 10:00 am - 2:45 pm. (7) out (8) residents #2-#8 (R2-R8) reported to have no problems with their personal property. (R2-R8) indicated they are independent and are capable of safeguarding their property including their finances. On 09/07/23 at 10:00 am resident #1 (R1) was interviewed and claimed that at some point several months back items were missing including jewelry from when (R1's) personal items were stored away in storage. (R1) could not elaborate on what exactly items were missing or provide demonstrative evidence. Interviews were conducted on 10/06/23 between 10:00 a.m. and 11:15 a.m. with staff. There were (6) out (6) staff #1-#6 (S1-S6) all unable to validate this claim. (S1-S2) reported that the former administrator did not authorize staff to remove any of (R1's) property items from (R1's) room. (S1-S2) added that no one is allowed access to (R1's) room as (R1) prohibited entry. (S4) claimed that (R1) has a hidden camera and can monitor activities inside and outside of (R1's) room. (S1) claimed that the facility does have a storage area for residents. (R1's) service records did not include itemized documentation of (R1's) personal values on a LIC 621 Safeguards for Property/Valuable as (R1) refused to provide any records. Therefore, based on all the information obtained during the investigation, there is no evidence to corroborate the allegation mentioned above. Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. 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, therefore the allegations are Unsubstantiated. An exit interview was conducted with Luz Rose, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 11-AS-20230829161007

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 10/06/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with Executive Director Luz Rose and explained the purpose of the visit. During an investigation visit on 10/06/23 associated with complaint #11-AS-20230829161007, LPA was informed that incidents involving resident #1 (R1) were not reported to Community Care Licensing (CCL) on a LIC 624. According to the facility's internal incident reports, there were a total of (27) incident reports from 12/17/21 through 09/17/23. The facility issued the 30-day Notice to Vacate to (R1). A copy of the Eviction Notice was sent to (CCL) on 02/15/23. Licensing Program Manager Ulysses Coronel notified in writing the facility failed to meet Title 22 Division 6 Chapter 8, Article 04 Operating Requirements, 82744 Eviction Procedures is not met. In the letter, it stated that the facility in not in compliance with Title 22 Regulations 87244(d)(1)(A-D). The facility needed to make the necessary corrections and resubmit for approval. The facility never resubmitted with the corrections and just proceeded with the eviction. The facility did not allow for the Department to investigate the reason for the Eviction Procedures. The notice was determined to be invalid. Based on the information provided by the administrator, the facility violates the California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D). An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Luz Rose.the state’s words, verbatim · CDSS document, Oct 6, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A-D)(b) · Plan of correction due date: Oct 20, 2023

87211 Reporting Requirements (a) licensee shall furnish to the licensing agency such reports as the Department... (1) A written report shall be submitted to the licensing agency... within seven days...(A) Death of any resident from any cause regardless of where the death occurred... This requirement is not met as evidence by: Based on interview, Licensee failed to report incident involving R1. This violation possesses a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2023

Plan of correction: Licensee will adhere to the regulations and will ensure any unusual incidents or change in condition or death will be reported to CCLD. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 10/20/23

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(d)(1)(A-D) · Plan of correction due date: Oct 20, 2023

Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons... This requirement is not met as evidence by: Based on interview, Licensee failed to resubmit eviction notice corrections for department approval and proceeded with (R1's) eviction. This violation possesses a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2023

Plan of correction: Licensee will adhere to the regulations and will ensure to review Title 22 87224. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 the regulations was reviewed to El Segundo Regional office by 10/20/23.