The Ridge at Westlake Village

Allegation investigated: Staff did not provide a refund

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 10:15 AM. LPA met with facility Executive Director (ED) Kailey Vanderwall. Entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a brief physical plant tour, reviewed one (1) resident file, collected copies of pertinent documentation, and conducted interviews with the ED, one (1) Marketing Coordinator (MC), and the Business Office Director (BOD) between approximately 10:20 AM and 02:45 PM. Continued on LIC-9099C Substantiated The allegation of “Staff did not provide a refund.” Alleges that the facility did not provide a refund of the pre-admission/Community fee to a prospective resident after the resident rescinded their contract and did not take possession of the room in the facility. LPA reviewed the Residence and Services Agreement (RSA) for Resident #1 (R1). LPA observed the RSA to be signed by R1 on 04/28/2026. The RSA stated that financial responsibility for the unit began on 04/30/2026. LPA observed pages five (5) and six (6) to contain a section which outlined the fees that are charged which included but were not limited to the community fee and monthly fee. LPA observed that R1 was charged a community fee of $7,500 prior to admission into the facility. LPA reviewed an email dated 05/19/2026 from R1’s responsible party sent on behalf of R1 to the acting Executive Director at the time Caroline Frangieh which stated that they were providing a 30-day notice to vacate the unit. LPA reviewed R1’s RSA and observed a section which stated “At the time that You sign this Agreement, You will have paid to The Ridge a Community Fee of $7,500.00 dollars. $500 of the Community Fee is to cover the cost of performing the pre-admission assessment, and the remainder of the fee is used to maintain the common areas and furnishings of the community…This Community Fee is partially refundable, on a prorated basis, for three (3) months following the date You sign this Agreement….If You leave The Ridge during the first (1st) month, You will receive a refund of 80% of the Community Fee (minus the $500 for the assessment).” LPA interviewed BOD who confirmed that either the acting Executive Director or the BOD would be the staff member responsible for issuing a refund. BOD confirmed that no refund for the community fee had been paid to R1 due to an ongoing dispute regarding payment of the monthly fee. Based on the information obtained during record review and interviews there is sufficient evidence to support the allegation of “Staff did not provide a refund.” Therefore, the allegation is deemed Substantiated at this time. The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Jun 25, 2026 · control 29-AS-20260616105222

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5)(E)2.a. · Plan of correction due date: Jul 9, 2026

87507 Admission Agreements (g)...(5)...(E)...2... a. A refund of...80 percent of the preadmission fee...shall be provided if...the resident leaves the facility... during the first month of residency. This requirement is not met as evidenced by: Based on interviews and record review the Licensee did not comply with the section cited above as a 30-day notice to vacate was provided on 05/19/2026 and no preadmission (Community) fee had been refunded to R1 which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jun 25, 2026

Plan of correction: ED agreed to work with BOD to issue the appropriate refund to R1 and settle any outstanding fees for R1. ED agreed to provide proof of POC to CCLD no later than POC due date.

Type of visit: Office

Licensing Program Manager (LPM) Kristin Heffernan and Licensing Program Analysts (LPAs) Angela Barutyan and Emily Peraldi met with Executive Director (ED) Brian Larios, Vice President of Operations (VPO) Andrew Moret, and Southern California Director of Health Services (DHS) Ruby Ramirez for this facility to hold an informal conference at the Woodland Hills North Adult and Senior Care Regional Office. This informal conference was held to discuss compliance history and communication issues between the facility and the Department that occurred during an annual inspection on 01/15/2026. On 01/15/2026, LPAs Barutyan and Peraldi conducted an annual inspection and issues regarding the facility’s lack of elevator access to the fourth-level rooftop and water damage in the basement level were not reported to the LPAs. The Woodland Hills North Adult and Senior Care Regional Office received a call on 01/16/2026 regarding the elevator and basement flooding concerns. On 01/21/2026, LPA Peraldi conducted a Case Management – Deficiencies visit and the facility was cited for reporting requirements and issued civil penalties due to a repeat violation. The ED discussed the facility’s proactive measures to address the issues and were advised by the Department to obtain a building inspection to confirm there are no immediate health and safety hazards or concerns. LPM reviewed reporting requirements and discussed the regulation with the ED and representatives present for today’s visit. VPO Moret expressed understanding of the transparency issues between the facility and the Department. ED Larios stated that the Department shall be notified of concerns relating to the facility’s building and operation moving forward and explained that there is a reporting system in place to ensure reports are sent in a timely manner. ED stated that the elevator has been repaired and residents have access to the fourth-level rooftop. ED and VPO stated that the basement level is still not accessible to residents as the water issue is ongoing, but the facility has had a city inspection confirming that the water leakage is ground water and has no traces of sewage. Report Continued on LIC809-C. The carpets in the theater have been removed to mitigate risk of mold. The facility has implemented a valet service to ensure residents have parking. The standing water in the basement has been removed as the facility hired Servpro for water extraction and have cut into the cement to install pumps that are pumping out the water. ED and VPO explained that they are exploring long-term solutions as the goal is to reopen the theater to the residents. In the meantime, residents are able to watch movies in the living area and fitness area, and activities are still in place. The ED will submit a copy of the inspection report once the facility’s building inspection by a licensed building inspector is completed, and continue to communicate with the Department for any updates. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Apr 8, 2026

Allegation investigated: Staff did not treat resident with respect. Staff does not respond to call button in a timely manner. Staff unable to provide assistance in a timely manner. Staff does not provide safe environment for resident.

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegations. Upon arrival at approx. 09:45 a.m. LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met Brian Larios, Executive Director (ED) and the reason for the visit was explained. Entrance interview conducted. On 11/05/2025, the Department received a complaint regarding the following allegations, Staff did not treat resident with respect, Staff does not respond to call button in a timely manner, Staff unable to provide assistance in a timely manner and Staff does not provide safe environment for resident. On 11/13/25 LPA Angela Barutyan conducted the initial 10-day complaint visit, conducted a physical plant tour, interviewed three (3) staff, three (3) residents, and obtained copies of pertinent documents relevant to the investigation. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (PAGE 2) Report continued from LIC 9099... During today's visit LPA Mosley and ED toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. During the physical plant tour, LPA observed that the basement elevator remained closed off due to repairs previously cited during the 01/21/2026 visit. The ED informed the LPA that CCLD has been notified regarding the repair timeline. Starting at 10:30 a.m. LPA conducted six (6) in person staff interviews, starting at 11:31 a.m. conducted nine (9) in person resident interviews, conducted a record / file review and obtained copies of pertinent documents relevant to the investigation. On the allegation, Staff did not treat resident with respect, it is the concern of the Reporting Party (RP) that staff spoke to Resident #1 (R1) in a disrespectful manner noting if they wanted their medications, they would have to get them themselves. To investigate this complaint, LPA’s conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. Record review and interviews confirmed that R1 is not on a medication management program and that R1 manages their own medications. Staff do not administer or centrally store R1’s medications. R1’s physician’s report signed and dated 02/13/2025 documents that R1 is “able to administer own prescription/PRN medications” and is “able to store own medications.” R1’s assessment signed and dated 03/07/2025 documents that R1 “self-manages medications and self-manages orders/refills.” Resident interviews revealed that they feel respected by the staff. They have no concerns with the quality of care the staff provide. They have not felt disrespected by any of the staff. They have not experienced dissatisfaction with medication distribution. Staff interviews revealed that residents are always treated with dignity and respect. They acknowledge every resident by name. If they hear that a resident has had a rough day, they check in to make sure the resident is doing well. They maintain clear boundaries and communicate appropriately, discussing resident concerns. Residents’ preferences—such as food choices, activities, interests, and likes—are consistently acknowledged and honored. Additionally, staff speak to residents with respect, upholding high standards with how they communicate. Staff have not witnessed or spoken to residents in a disrespectful manner. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not treat resident with respect” is deemed UNSUBSTANTIATED at this time. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC 9099-C page 2... On the allegations, Staff does not respond to call button in a timely manner and Staff unable to provide assistance in a timely manner, it is the concern of the Reporting Party (RP) that residents may be waiting up to 30 minutes to an hour for their call buttons to be addressed and for assistance to be provided. To investigate this complaint, LPA’s conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. Records / file review of the facilities Pal Care system which tracks resident calls and staff response time revealed that in the time frame of the complaint, October and November of 2025. In October a total of 5,268 calls were made and in November a total of 5,421 calls were made. All calls were cleared and no calls were left uncleared. In October the average response time was 3.7 minutes and in November the average response time was 3.8 minutes. Resident interviews indicated that staff typically respond to call buttons within 5 to 15 minutes. On rare occasions, response times may extend to 30 minutes, depending on staffing levels. Residents stated that staff always respond when a call is made and assist promptly upon arrival. No delays in response time were reported, and no concerns were noted regarding staff responsiveness or call button procedures. Staff interviews revealed that the facility strives to respond to and clear all calls within 15 minutes, with an ideal goal of under 10 minutes. All calls are addressed promptly and consistently answered. Residents’ safety is the highest priority, and responding to call buttons is treated as an urgent matter. When staff are unable to respond immediately due to assisting other residents, they ensure communication with both team members and the residents to keep them informed. Additionally, staff provide assistance and tailor care to meet each resident’s individual needs. They make sure resident requests are addressed within the time frames specified by the residents, and all requests are fulfilled. Staff respond promptly and appropriately to specific residents’ needs. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violations did or did not occur, therefore the allegations of “Staff does not respond to call button in a timely manner and Staff unable to provide assistance in a timely manner” are deemed UNSUBSTANTIATED at this time. Report continued on LIC 9099-C PAGE 4... (PAGE 4) Report continued from LIC 9099-C page 3... On the allegation, Staff does not provide safe environment for resident, it is the concern of the Reporting Party (RP) that during a fire drill staff did not check on R1. To investigate this complaint, LPA’s conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. File and record review revealed that the emergency disaster plan was reviewed on 01/15/2026. Staff interviews revealed that the facility conducts emergency drills regularly to ensure preparedness. Residents are typically not required to participate in drills unless they choose to, but they are always informed when drills occur. Staff noted that the community maintains a safe environment and demonstrates strong emergency readiness. Care staff follow a detailed emergency guide and adhere to a structured plan. During drills or actual emergencies, staff promptly assemble, check each room, and provide assistance as needed. A binder with signage is utilized to indicate which rooms have been cleared and which require attention. After each drill, staff verify the well-being of all residents. Furthermore, the Emergency Disaster Plan is reviewed monthly to ensure it remains current and effective. Resident interviews indicated that they feel safe within the community and currently have no concerns regarding their safety. The facility conducts drills frequently, and residents may choose to participate, though participation is never mandatory. During these drills, staff consistently check on residents to ensure their well-being. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violations did or did not occur, therefore the allegation of “ Staff does not provide safe environment for resident” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 29-AS-20251105164527

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced case management - Deficiencies visit at 1:30 p.m. Upon arrival, LPA met with staff and Executive Director (ED) Brian Larios. Entrance interview conducted. During today’s visit, starting at 2:08 p.m., the LPA along with the ED conducted a physical plant tour. The LPA also requested copies of pertinent documents during the time of the visit. During the physical plant tour, the LPA inspected the garage/ basement areas. The LPA observed several portable dehumidifiers and two (2) large negative air machines throughout the basement elevator lobby and theater area. The ED explained that during the heavy rain in December 2025, the garage/ basement area leaked. The ED explained that due to the leaks, certain parts of the garage/ basement areas are inaccessible to residents such as the theater. For the time being, the residents are watching movies on the second floor. The ED explained that they are working with the restoration company, Servpro to address moisture migration and drying of the area. The ED explained that the construction team of the building conducted a visit yesterday, January 20th to address and locate the leak. The LPA observed the main elevator which does not have current access to the fourth floor. The ED explained that the fourth-floor elevator doors are inflated due to the heat, however the fourth floor can still be accessible through the stairs. The ED stated that the elevator doors are estimated to be fixed by the beginning of February, as they are waiting for parts. Continued on LIC 809-C. The LPA had a conversation with the ED regarding reporting major maintenance issues or construction occurring in the building. The LPA emphasized the importance of reporting and documenting any building issues as it could affect the residents’ safety and well-being. The LPA also reviewed the following regulation with the ED, 87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times… The LPA explained that any issues such as a leak hinders the facility from being safe and in good repair. The LPA also reviewed the following regulation: 87305(b) Alterations to Existing Building or New Facilities (b)The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. The LPA requested the ED to acquire a local building inspection to ensure that there are no potential safety concerns/ hazards such as mold. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited for reporting requirements (refer to LIC 809-D). Civil Penalty issued for the amount of $250. The ED was informed that failure to correct deficiency may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 21, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 30, 2026

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as the ED did not report to the Department major maintenance issues including the garage/ basement leak which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: The ED stated that he will submit a statement of understanding for the above regulation. Civil Penalty issued for the amount of $250 for repeat violation.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Angela Barutyan and Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 09:35AM. LPAs were greeted by staff and Executive Director (ED) Brian Larios. At 10:11AM, the LPAs, along with the ED and Maintenance Technician John Dasilva toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: FACILITY LAYOUT: The facility is one building with four (4) floors of which three (3) floors contain resident rooms. The fourth level is a rooftop area and there is a basement floor containing a theater. The facility has one hundred thirty-one (131) units. The first floor contains the Memory Care Unit and has four (4) delayed egress doors. There are twenty-six (26) resident rooms in the Memory Care Unit and five (5) rooms are shared. BEDROOMS: The LPAs toured a total of ten (10) resident rooms. LPAs observed four (4) resident rooms in the Memory Care (MC) Unit. Rooms in the memory care unit have no appliances. LPAs observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. The assisted living rooms on the first, second, and third floors are equipped with a refrigerator, microwave, and sink. The assisted living rooms range from studio apartments to two (2) bedroom units. Washer and dryer units are available throughout the floors for resident use, and the commercial laundry area for staff use is in the basement. All rooms were observed to be in compliance. Report Continued on LIC 809-C. RESTROOMS: Restrooms were clean, sanitary, and in operating condition with grab bars and slip-resistant surfaces. Between 10:15AM-11:25AM, hot water temperatures were tested on all floors in assisted living and memory care resident restrooms and were between 95.7-122.4 degrees F, which is not within the required range of 105-120 degrees F. Seven (7) out of ten (10) resident restrooms checked had hot water temperature that was out of compliance. Maintenance technician stated that the water temperatures will be adjusted to be in compliance. KITCHEN: At 10:53AM, the LPAs observed the kitchen to have a sufficient supply of perishable and non-perishable food at the time of the visit. Appliances in the kitchen were clean and appeared functional. Snacks and beverages are available for residents in the Bistro. Food is prepared in the main kitchen, which is located on the second floor. COMMON AREAS: The facility has the following amenities and common areas: office spaces, conference rooms, beauty salon, the bistro, lobby, rooftop access, memory care activity room, dining room, courtyard, and servery kitchen located on the first floor; one (1) theater located on the basement floor; the main kitchen and dining area, activity room, and fitness center located on the second floor; and lounge located on the third floor. Regarding the signal system, the system is activated in the resident bedrooms and restrooms. All systems go directly to a computer at the front desk and to hand-held devices and pagers. Designated staff carry a handheld device, which displays the location of the alarm that has been pulled. Staff also utilize walkie-talkies to communicate with staff accordingly. LPAs observed residents wearing pendants. There are cameras observed in exterior perimeter and entrance. The fire extinguishers are located on every floor in each building and were observed to be fully charged and last serviced on 07/24/2025. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the hallways. The emergency telephone numbers are posted in the entryway. Other required postings are posted on the first floor. LPAs observed the Ombudsman Poster and DSS Complaint Poster throughout the community. Report Continued on LIC-809C. MEDICATION REVIEW: At 12:52PM, LPA Peraldi, along with Health and Services Director (HSD) Ian Gadea reviewed medications for six (6) residents. Medications are centrally stored and locked in the medication offices. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record (CSMDR) as they were missing start dates. At 01:36PM, LPA observed Resident #1 (R1)’s Diltiazem HCL 120mg tablets had a recorded start date of 11/28/2025 on the medication bubble pack. The medication is thirty (30) tablets with an administration of once a day at bedtime. HSD stated that there was an error in recording the start date as it should have been 12/28/2025, however the CSMDR had no recorded start date. At 02:08PM, LPA observed Resident #2 (R2)’s Vitamin B-12 1000mcg tablets with a recorded start date of 12/22/2025 on the medication bubble pack. The medication is thirty (30) tablets with an administration of once a day in the morning. There were four (4) tablets left, but according to the start date of 12/22/2025, there should be five (5) tablets left. HSD was unable to account for the missing tablet. The CSMDR had no recorded start date for R2’s Vitamin B-12 medication. RECORD REVIEW: Beginning at 01:00PM, LPA Barutyan reviewed five (5) resident and five (5) staff records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, personal rights, and first aid/CPR training. All resident files reviewed were complete and were observed to be in compliance. Two (2) out of two (2) care staff files were missing valid first aid certification by qualified agencies. During today’s visit, LPAs obtained a copy of the facility’s liability insurance. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: Beginning at 02:40PM, LPA Barutyan reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 12/10/2025. The community’s smoke detectors and carbon monoxide detectors are hard-wired and were last tested on 12/09/2025 by Cal Building Systems. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted. Appeal rights and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 15, 2026

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Resident’s incontinence care is not being met

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation at 12PM. Upon arrival, LPA met with staff and Executive Director (ED) Brian Larios. Entrance interview conducted. During the initial visit on 10/15/2025, LPA interviewed three (3) staff and three (3) residents, reviewed and obtained copies of pertinent documents relevant to the investigation, conducted a brief physical plant tour between, and discussed allegation with ED. Report Continued on LIC 9099-C. Unsubstantiated It was alleged that Resident #1 (R1) was left in soiled clothes and diapers on multiple occasions for an unknown amount of time. On 10/15/2025, LPA interviewed facility care staff and R1 who confirmed that R1 refuses incontinence and other care services. R1 did not have concerns relating to incontinence care. LPA reviewed care logs and shift notes and observed multiple documented refusals by R1 of services such as showers, toileting, and dressing. LPA interviewed two (2) residents who receive incontinence care and no concerns were noted. Residents stated they have not been left in soiled clothes or diapers. R1’s assessment signed and dated 08/18/2025 documents R1 as “occasionally incontinent…and occasionally requires staff assistance” for toileting. R1’s individualized service plan signed and dated 08/18/2025 documents R1’s toileting instructions to “encourage resident to allow staff to assist with personal hygiene.” Staff stated they attempt to encourage R1 and try multiple times to provide care when it is refused. Facility staff and management stated they have voiced concerns about R1’s refusal of services and that care plan meetings have been held with R1’s responsible party. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Resident’s incontinence care is not being met” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 29-AS-20251007135807

Allegation investigated: Staff did not administer medication as prescribed. Facility does not have a back up generator.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegations listed above at 12PM. Upon arrival, LPA met with staff and Executive Director (ED) Brian Larios. Entrance interview conducted. During today's visit, LPA interviewed three (3) staff and three (3) residents between 12:07PM-01:55PM, reviewed and obtained copies of pertinent documents relevant to the investigation between 12:30PM-02:30PM, conducted a brief physical plant tour between 01:33PM-02:25PM, and discussed allegations with ED at 02:15PM. Continued on LIC9099-C. Unsubstantiated It was alleged that staff did not deliver Resident #1 (R1)’s medication. Record review and interviews confirmed that R1 is not on a medication management program and that R1 manages their own medications. Staff do not administer or centrally store R1’s medications. R1’s physician’s report signed and dated 02/13/2025 documents that R1 is “able to administer own prescription/PRN medications” and is “able to store own medications.” R1’s assessment signed and dated 03/07/2025 documents that R1 “self-manages medications and self-manages orders/refills.” Interviews revealed that staff attempted to deliver R1’s medication refill to their door past 5PM which is R1’s do not disturb hours. Staff made multiple attempts and were able to deliver the medication at 10PM. ED held a meeting with R1 and R1’s responsible party to discuss medication delivery and came to the consensus that medications will be held at the front desk until R1 can pick up or the medications can be delivered to R1’s door directly by R1’s pharmacy. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not administer medication as prescribed” is deemed UNSUBSTANTIATED at this time. It was further alleged that the facility does not have a backup generator and that R1 did not have access to power during a power outage even though they require oxygen 24/7. Staff and resident interviews confirmed that there is a generator and that residents had access to power when there was an outage. Staff and residents also confirmed that frequent checks were made to residents on oxygen during the outage to ensure that oxygen machines and tanks were functional. At 02:21PM, LPA observed the facility’s backup generator outside of the facility with a valid permit to operate. The generator appeared functional and had a fuel level of 90%. LPA reviewed the facility’s emergency disaster plan which documents that there is a permanently installed generator on the southwest side of the community, and it can be used for all three (3) elevators, common area lighting, main kitchen freezer, and main kitchen cooler. Based on interviews, record review, and observation, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Facility does not have a back up generator” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 29-AS-20251105164527

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 12:50PM. Upon arrival, LPA met with staff and Executive Director (ED) Brian Larios. Entrance interview conducted. During today’s visit, LPA conducted a brief physical plant tour, conducted interviews with ED and Health and Services Director Ian Gadea, and reviewed and obtained copies of pertinent documents relevant to the investigation. On 10/27/2025, the Department received an incident report stating that on 10/20/2025 around 01:30PM, a staff member heard Resident #1 (R1) call for help from their apartment and staff observed R1 laying on the floor. R1 was transported to the hospital, and it was determined that R1 had fractured both femurs and their left arm. During today’s visit, LPA conducted a file review and observed that R1’s physician’s report signed and dated 08/18/2025 documents R1 with osteopenia and osteoarthritis, affecting bone mass and density. R1’s care plan signed and dated 09/03/2025 documents that R1 “requires one-person physical assistance with transfers.” However, R1 attempted to self-transfer and tripped on their wheelchair. LPA reviewed pendant response times and observed that on 10/20/2025, R1 pressed their pendant at 01:31PM and it was cleared by staff at 01:34PM. 9-1-1 was called by staff at 01:34PM. LPA observed R1's room and did not observe any tripping hazards or immediate health and safety concerns. Report Continued on LIC809-C. Furthermore, on 10/27/2025, the Department also received multiple incident reports for incidents that occurred on the following dates: 09/25/2025, 09/27/2025, 09/29/2025, 10/01/2025, and 10/11/2025. Regulation states that incident reports shall be submitted within seven (7) days of occurrence. LPA discussed reporting requirements with the ED. ED stated that a plan has been put in place to ensure that the timeline for incident reporting will be in compliance. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited for reporting requirements (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties. An additional report may follow if warranted. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 11, 2025

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence... This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as six (6) incident reports were submitted after seven days of occurrence. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: ED stated that a plan has been put in place to ensure that incident reports get submitted in compliance. ED stated they will conduct training on reporting requirements and submit the written plan to CCLD by the due date.

Allegation investigated: Resident sustained multiple skin tears due to staff neglect

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation at 10:40AM. Upon arrival, LPA met with staff and Executive Director (ED) Brian Larios. Entrance interview conducted. During today’s visit, LPA Barutyan interviewed two (2) staff and one (1) resident between 10:43AM-11:10AM and reviewed and obtained copies of pertinent documents. During the initial visit on 07/17/2025, LPA interviewed four (4) staff and four (4) residents between 11:08AM-01:40PM, reviewed and obtained copies of pertinent documents relevant to the investigation, conducted a brief physical plant tour between 01:10PM-01:30PM, and discussed allegation with ED at 01:40PM. Report Continued on LIC 9099-C. Unsubstantiated It was alleged that on 07/06/2025 around 11PM, Resident #1 (R1) fell out of bed and was found by staff on 07/07/2025 at 5AM despite having staff requirements to check on residents every 2 hours. R1 then sustained multiple skin tears due to trying to get up from the floor and injuring arms. LPA interviewed ED, the Health and Services Director (HSD), and two (2) care staff and all interviews revealed that R1 was not placed on frequent monitoring or status checks that require R1 to be checked every 2 hours. Staff stated that the amount of checks depends on the resident’s condition and their care needs and that there is no standard requirement for all residents to get checked every 2 hours. LPA reviewed R1’s records and observed that R1’s physician’s report signed and dated on 05/27/2025 documented R1 as nonambulatory and unable to transfer to and from bed. R1’s assessment and care plan that was updated on 07/06/2025 and signed by R1’s responsible party documented R1 as a “moderate” fall risk and “requires status checks daily for safety or recent change of condition” as well as “requires standby assistance and cueing for transfers.” The Department received an incident report on 07/15/2025 stating that on 07/07/2025, R1 had been found on the floor by staff at 06:30AM with a large skin tear on their right arm after an unknown amount of time on the floor and emergency services were called immediately after R1 was found. LPA reviewed R1’s updated assessment from 07/21/2025 and signed by R1’s responsible party on 07/23/2025 which documents R1 as a “high fall risk” with “status checks each shift for safety or recent change of condition.” LPA interviewed R1’s responsible party and no concerns supporting the allegation were mentioned. Interviews supported that R1 presses their pendant often which results in R1 getting checked multiple times a day, even though the care plan from 07/06/2025 only required one (1) daily check. LPA reviewed call log history and response times for R1’s pendant and observed that on 07/06/2025, R1 pressed their pendant 23 times with the last two calls at 09:05PM (response time of 12.10 minutes) and 09:50PM (response time of 11.60 minutes). The day before R1’s fall on 07/05/2025, R1 pushed their pendant 29 times. The longest response time observed for R1 was on 06/17/2025 with a response time of 62.80 minutes, however, most response times were under 15 minutes. ED and HSD also stated that any response time for any resident that is over 15 minutes gets flagged and in-service trainings for pendant response times get provided to all staff. Resident interviews conducted did not reveal concerns about the care provided or staff responsiveness. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Resident sustained multiple skin tears due to staff neglect” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 29-AS-20250716090644

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced Case Management - Incident visit at 11:21AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 04/12/2025. Upon arrival, LPA met with Executive Director (ED) Brian Larios and staff. Entrance interview conducted. During today's visit, LPA interviewed ED and Health and Services Director (HSD) Ian Gadea, conducted a brief physical plant tour, and observed the medication office in the memory care unit. On 04/21/2025, the Department received an incident report stating that on 04/12/2025 at 08:15AM, Resident #1 (R1)’s Carbamide Peroxide 6.5% ear drop medication was incorrectly administered in R1’s eye by Staff #1 (S1). Three (3) of five (5) drops were administered and the error was observed immediately as R1 reported pain in their left eye. R1 reported burning sensation, redness, and blurry vision. Eye wash rinse was utilized without any relief of symptoms. Facility staff called 9-1-1 and R1 was transported to the emergency room where R1 was prescribed antibiotics. R1’s family was notified of the incident same day. The facility responded quickly and effectively to relieve R1’s symptoms. As of 04/12/2025, S1 is no longer handling medications. HSD and ED stated that there are no current plans of S1 returning to handle medications. HSD stated that additional training will be held, and staff will be reminded to read all medication labels and instructions prior to administering. Continued on LIC 809-C. At 11:33AM, LPA observed the facility’s procedures for administering and documenting medications, and observed residents’ Medication Administration Records (MAR) and Centrally Stored Medication and Destruction Records (CSMDR). Medication carts are kept locked. All medications are documented and logged with current administration instructions, RX number, date filled/started, prescribing physician, quantity, and expiration dates. The facility utilizes a digital MAR system and retains physical copies of CSMDRs. No concerns were noted. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 22, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(4) · Plan of correction due date: Apr 29, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws... This requirement is not met as evidenced by: Based on medication review and interview, the licensee did not comply with the section cited above as Resident #1 (R1)'s ear drop medication was not administered by Staff #1 (S1) as prescribed, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: S1 is no longer handling medications. HSD stated that staff will be reminded to read all prescription labels and administer medications one at a time. POC is cleared.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Angela Barutyan arrived for a pre-licensing visit at 10:00AM. The LPA met with Executive Director (ED) Brian Larios and Vice President of Program Development Rina Younan and explained the reason for the visit. This is a new facility. An dementia program was included in the plan of operation. Component III was conducted in conjunction with this pre-licensing visit. An approved fire clearance was granted on 01/07/2025 clearing for a total capacity of one hundred sixty-two (162) residents of which one hundred fifty-eight (158) are for nonambulatory residents and four (4) are for residents who are bedridden. All four (4) bedridden rooms are on the ground level only. Facility has requested a hospice waiver for fifteen (15) residents. Facility Layout: The facility is one building with four (4) floors of which three (3) floors contain resident rooms and one (1) floor is the basement. The facility has one hundred thirty-one (131) units. The first floor contains the Memory Care Unit and has three (3) delayed egress doors. There are twenty-six (26) resident rooms in the Memory Care Unit and five (5) rooms are shared. Memory Care resident rooms have no appliances. Lighting in the rooms appeared adequate. The model rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. The assisted living rooms on the first, second, and third floors are equipped with a refrigerator, microwave, and sink. The assisted living rooms range from studio apartments to two (2) bedroom units. Washer and dryer units are available throughout the floors for resident use, and the commercial laundry area for staff use is in the basement. Continued on LIC 809-C. The facility has the following amenities and common areas: office spaces, conference rooms, beauty salon, the bistro, lobby, rooftop access, memory care activity room, dining room, courtyard, and servery kitchen located on the first floor; one (1) theater located on the basement floor; the main kitchen and dining area, activity room, and fitness center located on the second floor; and lounge located on the third floor. Common Spaces: Regarding the signal system, the system is activated in the resident bedrooms and restrooms. All systems go directly to a computer at the front desk and to hand-held devices and pagers. Designated staff carry a handheld device, which displays the location of the alarm that has been pulled. Staff also utilize walkie-talkies to communicate with staff accordingly. All residents will also be offered pendants. There are cameras observed in exterior perimeter and entrance. The community’s smoke detectors and carbon monoxide detectors are hard wired and were installed within the past 12 months. The fire extinguishers are located on every floor in each building and were observed to be fully charged and serviced. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the hallways. The emergency telephone numbers are posted in the entryway. Other required postings are posted on the first floor. LPA observed the Ombudsman Poster and DSS Complaint Poster throughout the community. Kitchen: The community had a sufficient supply of perishable and nonperishable food at the time of the visit. Appliances in the kitchen were clean and appeared functional. Snacks and beverages are available for residents in the Bistro. Food is prepared in the main kitchen located on the second floor and is delivered to the separate dining rooms. Bathrooms: Bathrooms were equipped with grab bars near the toilet and shower/tub, and slip-resistant surfaces were observed in the shower/tub. During today's visit, water temperature was tested on all floors and ranged between 107.1 to 113.5 degrees Fahrenheit, which is within the required range per regulation of 105 to 120 degrees Fahrenheit. Report Continued on LIC-809C. Files: Resident records will be stored in a locked cabinet in the Business Director’s Office and in the medication room. Staff records will also be stored in a locked cabinet in the Business Director’s Office. Medications: There is a medication room in the Memory Care unit on the first floor and an assisted living medication room on the second floor. An additional medication room was observed on the first floor in the assisted living section and will be used when census grows. There are complete first-aid kits and a surplus of medical supplies. There are additional first aid kits throughout the community. There are medication carts with double locking system for narcotics. Grounds: Community has two (2) vehicles for transportation needs – a twenty-one (21) passenger bus and a six (6) passenger SUV. There are approximately sixty-four (64) parking spots available for residents and staff. Infection Control: There is hand sanitizer available throughout the community. The community has an adequate supply of Personal Protection Equipment (PPE) and the community is able to obtain additional supplies as needed. If needed, the community has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Physical plant is in compliance with Title 22 regulations at this time. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate and accept residents until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued via email.the state’s words, verbatim · CDSS document, Jan 28, 2025

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 162 Census (if any clients in care): 0 COMP II Participants: Sue McPherson & Brian Larios Interview Method: Virtual interview (Teams) On 1/13/2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jan 13, 2025