The Variel of Woodland Hills

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Angela Barutyan and Quoc Huynh conducted an unannounced Case Management - Incident visit at 10:10AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 06/24/2026. LPAs met with Executive Director (ED) Allison Marty and explained the reason for the visit. During today’s visit, LPAs conducted a physical plant tour and a medication review. On 07/02/2026, the Department received an incident report stating that on 06/24/2026 around 10:00PM, Resident #1 (R1) was administered an incorrect increased dosage of Buprenorphine. The error was identified during the facility nurse’s narcotic count when it was discovered that the resident had received 16 mg of Buprenorphine, which is beyond their prescribed regimen of 4 mg. Upon notification of the error, R1 was immediately assessed by the two (2) nurses on duty and was alert and stable. ED Marty, who was in the community, also responded to check on R1 and notified R1 of the error. ED also advised R1 that their responsible party and primary care physician (PCP) would be contacted. Per PCP’s recommendation, paramedics evaluated the resident. R1 was awake, alert, verbally responsive, ambulating independently, and no adverse effects noted. ED also observed R1 stable. Following the paramedic’s evaluation, R1 declined transport to the hospital. Frequent nursing assessments were conducted throughout the night for R1. Staff were provided with med-pass retraining and ongoing trainings. Based on the information obtained during today’s visit, it is determined that no deficiency is warranted at this time due to no immediate health and safety risk to R1 and the facility’s proactive response to rectifying the error. An additional report may follow if warranted. Exit interview conducted. A copy of the report provided.the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Angela Barutyan and Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 10:10AM. LPAs met Associate Executive Director (AED) Jessica Saks and Executive Director (ED) Allison Marty. Entrance interview conducted. Beginning at 12:03PM, the LPAs, along with ED Marty and AED Saks, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: FACILITY LAYOUT: The facility has three (3) buildings, which are named Building A, Building B, and Building C. The facility has three hundred thirty-six (336) units. Building B has a Memory Care Unit on the seventh (7th) floor and there are three (3) delayed egress doors on the seventh floor. LPAs tested one (1) delayed egress door and staff responded promptly. Buildings A and C are primarily for independent living, while Building B is for assisted living, mezzanine living, and memory care. KITCHEN: At 12:14PM, 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 in Building A on the second floor and is delivered to the separate dining rooms. Emergency water supply is stored in locked storage rooms on every floor. Report Continued on LIC 809-C. BEDROOMS: The LPAs toured a total of thirty-one (31) resident rooms. LPAs observed four (4) resident rooms in the Memory Care (MC) Unit. Rooms in the memory care unit are single occupancy and have no appliances. Lighting in the rooms appeared adequate. The rooms are equipped 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 rooms in Building A, Building B, and Building C (excluding the 7th floor Memory Care Unit) are equipped with a refrigerator, microwave, and sink, and in-unit washer and dryer. The rooms in Building A, Building B and Building C are majority single occupancy, with the availability of double occupancy in some rooms. The LPAs toured twenty-seven (27) additional resident rooms randomly selected on different floors of each building. All rooms were observed to be in compliance. BATHROOMS: LPA observed the bathrooms to be equipped with grab bars near the toilet and shower/tub, and slip-resistant surfaces and mats were observed in the shower/tub. LPAs tested hot water temperatures in resident bathrooms and were measured to be between 110.7-114.8 degrees Fahrenheit, which is within the required range. At 12:52PM, LPAs pulled the signal cord in resident restroom and staff arrived promptly in response at 12:58PM. AMENITIES: Building A has the following amenities and common areas: offices spaces, conference rooms, mail room and the bistro are located on the first floor. One (1) theater is located on the first floor and a second theater is located on the second floor. The main kitchen and dining area are located on the second floor. The second-floor amenities include: art room, the tavern with locked cabinets, the marketplace, the activity/simulator room, wine cellar, outdoor terrace, and assisted living gym. The third floor has a covered outdoor area with outdoor furniture for resident use and a wellness center. Building B has the following amenities and common areas: pet washroom, salon, activities/conservatory room and a community garden. Throughout Building B there are community rooms and covered outdoor areas for resident use located on the third floor. Building C has the following amenities and common areas: a fitness center with gym equipment, a yoga room, a juice bar, a physical therapy room, a massage room, a laundry room and a salon. There is an in-ground pool which is kept locked on the first floor of Building C. Report Continued on LIC 809-C. COMMON AREAS: The signal system can be activated in the resident bedrooms and restrooms by a pull cord. Residents also have pendants they can wear to signal staff. All systems go directly to a computer at the front desk and to hand-held devices. Designated staff carry a handheld device, which displays the location of the alarm that has been pulled. Staff also utilize walkie-talkies to communicate accordingly. There are cameras observed in exterior perimeter, in various community hallways, and throughout the MC unit. The community’s smoke detectors and carbon monoxide detectors are hard wired. The fire extinguishers are located on every floor in each building and were observed to be fully charged and serviced on 04/23/2026. 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 of Building A, near the mail room and the common hallway. LPAs observed the Ombudsman Poster and DSS Complaint Poster throughout the community. OUTDOOR AREAS: LPA toured the outdoor perimeter and observed self-latching gates. All exits were observed to be clear and free of hazards. MEDICATION REVIEW: Medications are locked and centrally stored in the wellness center office and the memory care director office. Medications for five (5) residents were reviewed and all are labeled and maintained in compliance with label instructions, and state and federal law. RECORD REVIEW: Beginning at 03:45PM, ten (10) resident and ten (10) staff records were reviewed 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 and staff files reviewed were complete and were observed to be in compliance. During today’s visit, LPAs obtained a copy of the facility’s liability insurance and disaster plan. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: The LPAs 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 plan is updated annually as required. Emergency disaster drills are conducted at least quarterly as is required, with the last drill conducted on 06/13/2026. The community’s smoke detectors and carbon monoxide detectors are hard wired and were last tested on 11/06/2025 by Hiller Fire and approved by the Los Angeles Fire Department. No citations issued. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2026

Allegation investigated: Resident sustained an injury due to staff neglect Staff did not provide proper first aid treatment to resident after a fall Staff did not answer resident's call button in a timely manner

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegations listed above at 01:35PM. LPA met with staff, Executive Director (ED) Allison Marty, and Associate Executive Director (AED) Jessica Saks. Entrance interview conducted. During today's visit, LPA conducted a brief physical plant tour and reviewed and obtained copies of pertinent documents. During the initial visit on 12/02/2025, LPA conducted interviews with two (2) staff and one (1) resident, reviewed and obtained copies of pertinent documents relevant to the investigation, conducted a brief physical plant tour, and discussed allegations with ED and AED. REPORT CONTINUED ON LIC9099-C. Unsubstantiated It was alleged that Resident #1 (R1) sustained a fall due to staff neglect after pressing their call button and attempting to self-transfer when staff did not arrive to provide assistance. LPA interviewed R1, R1’s responsible party, and staff. Interviews revealed that R1 attempted to self-transfer without first pressing their call button for staff assistance. R1 stated that they did not use the call button because response times are often lengthy. However, R1 also reported that staff check on them multiple times throughout the day and evening and that call button response times are generally no longer than 15 minutes. Interviews with staff, R1, and R1’s responsible party confirmed that R1 is a fall risk and is frequently monitored by staff. LPA reviewed R1’s care plan, signed and dated 10/21/2025, which states that R1 “requires supervision and cueing for transfers for safety” and “requires status checks every two hours due to recent hospitalization, illness, history of falls, medication change, etc.” The care plan further directs staff to perform a “SAFETY CHECK: Every 2 hrs. Please do not ring the bell. DO NOT CHECK ON [R1] AFTER 11PM.” Regarding fall prevention, the service plan documents the goal that R1 “will be encouraged to call for assistance when needed.” Interventions include maintaining a clutter-free environment, ensuring support and assistive devices are available and in good repair, keeping the bed in a low position at night when possible, placing personal items and the call device within reach, and providing non-glare soft lighting at night, among other measures. LPA also reviewed call button response records for R1 and observed that calls were typically answered in under four (4) minutes. Records from 11/01/2025 through 12/02/2025 show an average response time of five (5) minutes for 203 pendant alarms and bathroom e-calls. R1 fell during the overnight hours on 11/25/2025 and pressed their call button for assistance at 02:47AM after the fall. Staff arrived in R1’s room to provide assistance five (5) minutes later at 02:52AM. R1’s service plan directs staff to discontinue safety checks after 11:00PM at R1’s request. Therefore, based on interview and record review, the Department does not have sufficient evidence to corroborate the allegations. Although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that a violation occurred, therefore, the allegations “Resident sustained an injury due to staff neglect” and “Staff did not answer resident's call button in a timely manner” are deemed UNSUBSTANTIATED at this time. Report Continued on LIC9099-C. It was further alleged that R1 fell on 11/25/2025 and sustained gashes on their back and experienced severe pain but staff did not provide first aid to R1. Interviews with R1, R1’s responsible party, and staff revealed that R1 pressed their call button after their fall and staff attempted to assist R1 afterwards. Staff gave verbal checks to see if R1 hit their head or was experiencing pain. Interviews confirmed that staff attempted to perform a skin and body check but R1 declined and requested to go back to sleep. Staff stated there were no apparent observations such as grimacing, high blood pressure, or pain that could signal R1 needed additional first aid. Staff further stated that for residents in memory care, paramedics are automatically called for unwitnessed falls because those residents cannot verbalize or remember the fall. However, record review confirms that R1 does not have cognitive impairment or behavioral expression. R1 stated that they did not sustain injuries on their back from their fall on 11/25/2025 besides a rug burn which facility staff cleaned and applied ointment on. Staff stated that the nurse checked R1 on the morning of 11/25/2025 after the fall and saw redness on the upper left back but no open wounds or skin tears. Staff cleaned the abrasion and provided basic first aid. LPA reviewed photographs of R1’s back and observed redness and no open wounds. Staff stated that the full body check was done within the same day five (5) hours after the fall because R1 denied the initial body check but then accepted later after waking up. Furthermore, R1’s care plan signed and dated 10/21/2025 documents that R1 does not have fragile skin and “Resident does not need skin checks.” R1 stated that they want staff “to try more even though [R1] decline[s]." Staff stated that they cannot force R1 as it is their personal right to decline. Based on interview and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff did not provide proper first aid treatment to resident after a fall” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 29-AS-20251125090348

Allegation investigated: Staff are not providing resident with food in a timely manner Staff are not providing laundry service in a timely manner

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation at 12:25PM. LPA met with staff and Executive Director (ED) Allison Marty and Associate Executive Director Jessica Saks. Entrance interview conducted. During today’s visit, LPA conducted a brief physical plant tour between 01:12PM-02:10PM and conducted interviews with five (5) residents and two (2) visitors between 01:17PM-02:05PM. During the initial visit on 11/12/2025, LPA conducted interviews with five (5) staff, reviewed and obtained copies of pertinent documents relevant to the investigation, and discussed allegations with ED. Throughout the investigation, LPA interviewed residents and responsible parties telephonically and during other unrelated visits. It was alleged that Resident #1 (R1) is not being provided with food service in a timely manner. CONTINUED ON LIC9099-C. Unsubstantiated LPA interviewed R1 on 12/02/2025 who stated that they receive their room service/food orders on time. R1 stated that they sometimes cannot eat the food when staff leave the food in bags in the kitchen; sometimes staff serve the meals and other times, staff leave the food in the kitchen because R1 requests to eat later. However, R1 had no concerns about not receiving meals in a timely manner. During today’s visit, LPA interviewed five (5) residents and two (2) visitors and all interviews confirmed no concerns of food service not provided in a timely manner. Residents stated they receive their room service timely and staff will help serve the food if needed. Staff interviewed were knowledgeable in food service; no concerns were noted. LPA reviewed logs for meal service and observed daily orders for R1 fulfilled from times ranging between 07:52AM-08:24PM in the month of November 2025. 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 are not providing resident with food in a timely manner” is deemed UNSUBSTANTIATED at this time. It was further alleged that R1 is not being provided with laundry service in a timely manner. LPA interviewed R1 who stated that the caregivers and housekeeping will assist with laundry but sometimes there are delays and staff will finish the laundry between shifts. There was also a concern that laundry gets washed but then left in the washer and staff will not put the wet laundry in the dryer. LPA interviewed staff who stated that there is a laundry schedule, but soiled items will be washed immediately regardless of the residents’ laundry schedule. Staff also stated it is possible that laundry will get completed during multiple shifts, however, laundry will be completed that day. Staff stated they had not observed any laundry piled up in R1’s or other residents’ rooms. Staff were knowledgeable in laundry service; no concerns were noted. During today’s visit, LPA interviewed residents and visitors and all interviews confirmed no concerns of laundry not provided in a timely manner. Residents stated that housekeeping and caregivers help with laundry service and there are no delays. LPA reviewed R1’s logs for laundry service and observed a weekly schedule for R1’s personal clothing as well as direction to “if resident has any accidents wash [their] clothes immediately.” 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 are not providing laundry service in a timely manner” 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, Feb 19, 2026 · control 29-AS-20251104154033

Allegation investigated: Staff damaged a resident's personal item.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above at 12:25PM. LPA met with staff, Executive Director (ED) Allison Marty, and Associate Executive Director Jessica Saks. Entrance interview conducted. During the subsequent visit on 10/30/2025 and initial visit on 09/03/2025, LPA conducted interviews with four (4) staff and one (1) resident, reviewed and obtained copies of pertinent documents relevant to the investigation, conducted a brief physical plant tour, and discussed allegations with ED. CONTINUED ON LIC9099-C. Substantiated It was alleged that staff damaged Resident #1 (R1)’s duvet cover after washing it. Interviews with staff, ED, R1, and R1’s responsible parties confirmed that the duvet cover faded in color after it was washed by a staff member. The color faded from bronze to gray. The facility was notified of the damage to the duvet cover on 08/28/2025 and on 09/05/2025, a $207.43 credit was issued by the facility to R1/responsible parties for a replacement duvet cover. Interviews also confirmed that R1 was not left without a blanket and that the facility ensured R1 had appropriate bedding. Based on interview and record review, the allegation “Staff damaged a resident's personal item” is deemed SUBSTANTIATED at this time. However, the LPA determined that there is no direct impact to the residents, presented no danger, and did not effect the overall operation of the facility. This is considered a technical violation and no citations are being issued at this time. Exit interview conducted. A copy of today's report was provided It was alleged that staff did not wake up or dress Resident #1 (R1) on time for their early morning medical appointment on 08/29/2025. LPA conducted interviews with staff and R1’s responsible parties which confirmed that staff were informed in the evening of 08/28/2025 of R1’s appointment, however, proper protocol was not followed. One caregiver was notified in passing in the hallway instead of informing the Resident Care Coordinator or Wellness Office in advance. While the caregiver wrote the appointment details on the office whiteboard, morning shift caregivers were unaware of the appointment. R1’s care plan dated 07/24/2025 documents that R1 “requires Daily STAND BY assist with dressing” twice a day and R1’s assessment signed and dated 04/06/2025 documents that R1 “requires standby assistance with dressing and undressing or assistance with seasonal clothes selection.” Record review reveals that R1 is not on a care or service plan to receive full assistance with waking up or dressing. Interviews with staff and R1 confirmed that R1 prefers to wake up later in the day to afternoon, which is why the morning shift staff had not attempted to dress R1 in the early morning of 08/29/2025. It was not until staff on shift were notified of R1’s medical appointment an hour before the scheduled time, that they were able to assist R1 with waking up and dressing for the appointment. Record review confirms that R1 attended their appointment on 08/29/2025. Facility management held a meeting with R1’s responsible parties and discussed the most appropriate ways to communicate appointments or care-related requests to ensure that all team members get the necessary information needed to act on the requests. 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 ensure that resident attended a medical appointment” is deemed UNSUBSTANTIATED at this time. It was further alleged that staff did not ensure R1 received their prescribed nasal spray medication for seventeen (17) days. Staff interviews confirmed that R1 went to a doctor’s appointment for a cough/runny nose on 08/01/2025. The facility received a signed order from a physician on 08/01/2025 for Atrovent 0.06% nasal spray which the facility faxed to Guardian Pharmacy to get filled. The pharmacy stated that it was not a valid order as the refills section and date of birth were blank, and subsequently the pharmacy attempted to contact the prescribing physician. The facility followed up on 08/03/2025, 08/06/2025, and 08/07/2025 and the pharmacy stated the medication was being processed and would soon be delivered. However, the medication was not sent out because the order had expired and R1’s insurance was not allowing for a refill. The medication was received on 08/10/2025 after facility followed up again on 08/09/2025 and 08/10/2025 and the pharmacy was able to contact R1’s insurance to cancel the medication fulfillment at a different pharmacy. Report Continued on LIC9099-C. R1 did not receive the nasal spray for a total of nine (9) days from 08/01/2025-08/10/2025. However, the facility made multiple attempts to receive the medication. 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 ensure resident received prescribed medication” is deemed UNSUBSTANTIATED at this time. Lastly, it was alleged that on 08/28/2025, R1 had a confirmed outing to a hair salon with the facility’s transportation but was then left in the heat for 2 and a half hours with no ride back and the facility not answering R1’s/responsible party’s calls. LPA reviewed the employee timecards for 08/28/2025 and observed that both drivers were clocked out of their shifts by 04:33PM. Staff interviews confirmed that the drivers are either scheduled from 8AM-04:30PM or 07:30AM-4PM. LPA interviewed staff who stated that R1 notified them of their appointment shortly before their hair appointment at 2PM on 08/28/2025. R1 and responsible parties were informed that the facility can accommodate the ride to the salon, however, the drivers will be done with their shifts by 04:30PM and that they will not be able to drive R1 back to the facility if the appointment finishes after that time. Around 04:53PM the facility received a call from R1’s responsible party stating that R1 has been waiting in the heat and no one has picked R1 up. The facility ordered a Lyft to R1’s location at 04:56PM with a note to the driver that R1 “is at the hair salon.” The facility attempted to call R1 and R1’s responsible party to inform R1 that the Lyft driver had arrived, but was unable to get a response. The Lyft driver waited at the location until 05:10PM and cancelled the ride due to “rider no-show.” At 05:51PM, the facility ordered another Lyft with the same note to driver, however, the driver cancelled the ride at 06:02PM for “rider no-show.” After the second cancellation, Administrator Lourdes Bustamante drove to R1’s location and picked R1 up. R1 was back at the facility around 06:10PM, approximately 1 hour and 15 minutes from the first Lyft order at 04:56PM. LPA reviewed call logs of the facility’s drivers, R1, and concierge. There were no missed calls observed on 08/28/2025 to either driver. R1’s call logs had no record of calls made to the facility on 08/28/2025, however, there were six (6) missed calls from the facility to R1 between 05:53PM-05:59PM on 08/28/2025. The facility received a call from R1’s responsible party around 04:53PM and the Lyft order was subsequently placed. LPA did not observe missed calls to the concierge. Report Continued on LIC9099-C. The facility ordered multiple Lyft rides and made multiple attempts to contact R1 to arrange the transportation. Regulation states that, “in providing transportation the licensee shall do so directly or make arrangements for this service.” 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 pick resident up from an appointment in a timely manner” 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, Feb 19, 2026 · control 29-AS-20250829112317

Allegation investigated: Staff did not ensure that resident's medical equipment is operable.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegation listed above at 11:28AM. LPA met with staff and Director of Nursing (DN) Jessica Saks upon arrival and Executive Director (ED) Allison Marty who arrived shortly thereafter. Entrance interview conducted. During today’s visit, LPA interviewed two (2) staff and reviewed and obtained copies of pertinent documents. During the initial visit on 09/03/2025, LPA conducted interviews with four (4) staff and one (1) resident, reviewed and obtained copies of pertinent documents relevant to the investigation, conducted a brief physical plant tour, and discussed allegations with ED. Report Continued on LIC9099-C. Unsubstantiated It was alleged that staff did not replace the tennis balls/gliders on Resident #1 (R1)’s walker, making the walker inoperable. Interviews with R1, R1’s responsible party, and staff confirmed that the walker was not provided by the facility. R1’s responsible party purchased the gliders and had them attached to R1’s walker for easier use. Interviews stated that the gliders fell off the walker and were missing for a few days until R1’s responsible party repurchased and installed the gliders. LPA interviewed R1 who confirmed that their walker is operable and is able to be used with some difficulty when the tennis balls are missing. R1 stated that one of the tennis balls got lost in the facility car and R1’s walker was without the ball for a few days, however, R1 was still able to use their walker. LPA observed R1’s walker on 09/03/2025 and observed the walker to be operable. Staff interviews revealed that they had not observed R1’s walker to be inoperable. LPA reviewed records and observed that the facility purchased the glider replacement on 09/05/2025 and issued credit to R1’s responsible party for the glider accessory on 09/05/2025. 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 ensure that resident's medical equipment is operable.” 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, Oct 30, 2025 · control 29-AS-20250829112317

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.

Allegation investigated: Due to lack of supervision, resident injured another resident while in care

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegation listed above at 11:28AM. LPA met with staff and Director of Nursing (DN) Jessica Saks upon arrival and Executive Director (ED) Allison Marty who arrived shortly thereafter. Entrance interview conducted. During today’s visit, LPA interviewed two (2) staff and reviewed and obtained copies of pertinent documents. During the initial visit on 08/27/2025, LPA conducted interviews with four (4) staff and three (3) residents, reviewed and obtained copies of pertinent documents relevant to the investigation, conducted a brief physical plant tour, and discussed the allegation with Administrator Lourdes Bustamante. Report Continued on LIC9099-C. Unsubstantiated It was alleged that due to lack of supervision, Resident #1 (R1) threw an object, possibly a telephone, at Resident #2 (R2) causing R2 to sustain a C1 fracture. Staff and resident interviews revealed that R1 did throw an object at R2 resulting in injury. The Woodland Hills North Regional Office received an incident report and SOC 341 from the facility on 08/22/2025 stating that on 08/21/2025, R1 threw a hard object at the back of R2’s head in the dining room and R2 reported pain in the area. R2 was assessed and admitted to the hospital. Record review and interview revealed that R2 had a previous C1 fracture and it is unknown if the incident caused a new fracture or aggravated the pre-existing fracture. LPA interviewed R1, R2, and R1’s responsible party and no evidence of malicious intent was noted. R1 and R2 stated there is no lack of care and supervision being provided. Following the incident on 08/21/2025, R1 was seen by their physician and received new medication orders. Interviews with staff and R1’s responsible party noted that the medication change has been effective in addressing R1’s behavior. Interviews stated that R1 did not have a history of aggressive behaviors, and no similar incidents have occurred as of today’s visit. Interviews confirmed that two (2) kitchen staff members were nearby during the incident and R2 received medical attention immediately upon notifying staff. LPA reviewed records and observed that R1’s assessment signed and dated on 03/23/2025 document that R1 does not need supervision to perform activities of daily living (ADL), behavior management, or escorting and that R1 is oriented. R1’s physician’s report signed and dated on 07/07/2025 document that R1 exhibits confusion and is disoriented inconsistently and does not have aggressive or inappropriate behaviors. R2’s assessment signed and dated on 02/06/2025 documents that R2 needs some ADL and transfer assistance but does not need escorting and is oriented. R1 and R2’s care plans do not include 24/7 supervision or supervision in common areas. As R1 and R2 do not require supervision in common areas and the facility made a quick and effective response in addressing R1’s behavior, there is not sufficient evidence to support a lack of supervision. 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 “Due to lack of supervision, resident injured another resident while in care” 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, Oct 30, 2025 · control 29-AS-20250825121624

Allegation investigated: Staff did not clean a resident's room. Staff are not following a resident's care plan. Staff are not changing resident's clothing.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegations listed above at 11:48AM. Upon arrival, LPA met with staff and Executive Director (ED) Allison Marty. Entrance interview conducted. During today's visit, LPA conducted interviews with four (4) staff and one (1) resident between 11:55AM-03:10PM, reviewed and obtained copies of pertinent documents relevant to the investigation between 01:00PM-03:30PM, conducted a brief physical plant tour between 02:52PM-03:15PM, and discussed allegations with ED at 03:30PM. REPORT CONTINUED ON LIC9099-C. Unsubstantiated It was alleged that staff do not clean Resident #1 (R1)’s room as trash is left behind causing ants in the room. LPA reviewed records and observed that the facility was notified on 08/08/2025 by R1’s responsible party that there were ants in R1’s room. Ecolab was contacted and performed a pest control service same day on 08/08/2025. The invoice documents “no ant trails present but ant scouts [were] present” and that the “area was serviced for ants” and “no additional ant activity found after service.” Staff and resident interviews confirmed that trash is taken out daily and housekeeping is done once a week. LPA observed R1’s room to be clean and free of ants and trash. Based on interviews, observation, 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 clean a resident's room.” is deemed UNSUBSTANTIATED at this time. It was further alleged that staff do not change R1’s clothing as R1 needs dressing assistance and that staff do not check on R1 often enough. LPA reviewed R1’s care plan dated 07/24/2025 which documents that R1 “requires Daily STAND BY assist with dressing” twice a day and “safety checks frequently every 2 hours.” R1’s assessment signed and dated 04/06/2025 documents that R1 “requires standby assistance with dressing and undressing or assistance with seasonal clothes selection.” Record review reveals that R1 is not on a care or service plan to receive full assistance with dressing and that R1 receives frequent checks. Staff and resident interviews confirmed that R1 receives stand by dressing assistance twice a day to monitor R1 and prevent possible injury/falls and that R1 receives frequent checks by staff. The complainant alleged that staff do not assist or encourage R1 to change clothes however, record review and interview did not support the allegation. LPA reviewed logs of R1’s refusals for stand by dressing and interviews confirmed that R1 dresses themselves and is capable to choose their own clothing. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the above allegations “Staff are not following a resident's care plan.” and “Staff are not changing resident's clothing.” are 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, Sep 3, 2025 · control 29-AS-20250829112317

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 - Annual Continuation

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a second Case Management - Annual Continuation visit at 10:47AM continuing the inspection that began on 06/13/2025 and was continued on 08/05/2025. LPA met with Director of Nursing (DN) Jessica Saks and Executive Director (ED) Allison Marty. Entrance interview conducted. Beginning at 12:07PM, the LPA, along with ED Marty, DN Saks, Director of Plant Operations (DPO) Miguel Castenada, and Los Angeles County Public Health Environmental Health Specialist Edgar Antonyan toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: FACILITY LAYOUT: The facility has three (3) buildings, which are named Building A, Building B, and Building C. The facility has three hundred thirty-six (336) units. Building B has a Memory Care Unit on the seventh (7th) floor and there are three (3) delayed egress doors on the seventh floor. At 03:37PM, LPA tested one (1) delayed egress door and staff responded promptly. Buildings A and C are primarily for independent living, while Building B is for assisted living, mezzanine living, and memory care. KITCHEN: At 12:28PM, the LPA 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 in Building A on the second floor and is delivered to the separate dining rooms. Emergency water supply is stored in locked storage rooms on every floor. Report Continued on LIC 809-C. BEDROOMS: The LPA toured a total of thirty-seven (37) resident rooms. LPA observed four (4) resident rooms in the Memory Care (MC) Unit. Rooms in the memory care unit are single occupancy and have no appliances. Lighting in the rooms appeared adequate. The rooms are equipped 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 rooms in Building A, Building B, and Building C (excluding the 7th floor Memory Care Unit) are equipped with a refrigerator, microwave, and sink, and in-unit washer and dryer. The rooms in Building A, Building B and Building C are majority single occupancy, with the availability of double occupancy in some rooms. The LPA toured thirty-three (33) additional resident rooms, with eleven (11) in each of the three (3) buildings. All rooms were observed to be in compliance. BATHROOMS: LPA observed the bathrooms to be equipped with grab bars near the toilet and shower/tub, and slip-resistant surfaces and mats were observed in the shower/tub. LPA tested hot water temperatures in resident bathrooms and were measured to be between 109.2 and 116.6 degrees Fahrenheit, which is within the required range. At 12:42PM, LPA pulled the signal cord in resident restroom and staff arrived promptly in response at 12:43PM. AMENITIES/COMMON AREAS: Building A has the following amenities and common areas: offices spaces, conference rooms, mail room and the bistro are located on the first floor. One (1) theater is located on the first floor and a second theater is located on the second floor. The main kitchen and dining area are located on the second floor. The second-floor amenities include: art room, the tavern with locked cabinets, the marketplace, the activity/simulator room, wine cellar, outdoor terrace, and assisted living gym. The third floor has a covered outdoor area with outdoor furniture for resident use and a wellness center. Building B has the following amenities and common areas: pet washroom, salon, activities/conservatory room and a community garden. Throughout Building B there are community rooms and covered outdoor areas for resident use located on the third floor. Building C has the following amenities and common areas: a fitness center with gym equipment, a yoga room, a juice bar, a physical therapy room, a massage room, a laundry room and a salon. There is an in-ground pool which is kept locked on the first floor of Building C. Report Continued on LIC 809-C. COMMON AREAS: The signal system can be activated in the resident bedrooms and restrooms by a pull cord. Residents also have pendants they can wear to signal staff. All systems go directly to a computer at the front desk and to hand-held devices. Designated staff carry a handheld device, which displays the location of the alarm that has been pulled. Staff also utilize walkie-talkies to communicate accordingly. There are cameras observed in exterior perimeter, in various community hallways, and throughout the MC unit. The community’s smoke detectors and carbon monoxide detectors are hard wired. The fire extinguishers are located on every floor in each building and were observed to be fully charged and serviced on 04/22/2025. 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 of Building A, near the mail room and the common hallway. The LPA observed the Ombudsman Poster and DSS Complaint Poster throughout the community. OUTDOOR AREAS: LPA toured the outdoor perimeter and observed self-latching gates. All exits were observed to be clear and free of hazards. INTERVIEWS: During today's visit, LPA interviewed five (5) residents and six (6) staff. No citations issued. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 19, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Angela Barutyan and Emily Peraldi arrived at the facility unannounced to conduct a Case Management - Annual Continuation visit at 12:45PM continuing the inspection that began on 06/13/2025. LPAs met with Executive Director (ED) Allison Marty and explained the purpose of the visit. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: Beginning at 12:55PM, the LPAs 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 plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 07/08/2025. The community’s smoke detectors and carbon monoxide detectors are hard wired and were last tested on 05/19/2025 by Hiller Fire and approved by the Los Angeles Fire Department. RECORD REVIEW: Beginning at 01:55PM, ten (10) resident and ten (10) staff records were reviewed 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. Four (4) out of seven (7) 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. Due to time constraints, the LPA will return at a later date to continue the inspection. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct the deficiency 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, Aug 5, 2025

Allegation investigated: Facility staff did not properly assist resident with self-administration of medications as prescribed. Reporting requirements are not being met.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:00 a.m., the LPA met with staff and explained the reason for the visit. At 9:10 a.m., the Executive Director (ED), Allison Marty met with the LPA. At 9:14 a.m., the LPA conducted an interview with the ED. At 9:49 a.m., the LPA requested and obtained copies of pertinent documents. Starting at 10:00 a.m., the LPA reviewed Resident #1 (R1’s) records. At 11:26 a.m., the LPA, along with the Wellness Director conducted a brief physical plant tour. Between 12:22 p.m. and 1:38 p.m., the LPA conducted a review of medication and medication documentation with the Wellness Director for eleven (11) residents. Between 9:37 a.m. and 1:43 p.m., the LPA conducted interviews with three (3) staff and three (3) residents. Continued on LIC 9099-C. Substantiated Regarding the allegation: 1.) Facility staff did not properly assist resident with self-administration of medications as prescribed. On 06/10/2025, the Department received a complaint alleging staff not properly assisting Resident #1’s (R1’s) with the self-administration of R1’s liquid Escitalopram medication as prescribed. During today’s visit, the LPA reviewed R1’s records including but not limited to progress notes, Medication Administration Record (MAR), and resident appraisal. Per R1’s prescription order, on 04/22/2025, R1 was prescribed Escitalopram 5mg/ 5mL oral solution (Lexapro) to be taken 10 mL (10 mg) by mouth daily. Interview with the Wellness Director, Jessica Saks revealed that on 05/10/2025, she conducted an audit on R1’s medication. Upon the audit, it was revealed that Staff #1 (S1) did not properly assist R1 as S1 prepared and gave R1 5mL of Escitalopram oral solution instead of the 10 mL as prescribed. Jessica S. explained that S1 admitted to the medication error and has since been removed as a medication technician. Jessica S. stated that an exact date of the medication error was not given but believes that the error occurred between 04/24/2025 and 04/26/2025. Jessica S. stated that they self-reported the medication error to Community Care Licensing on 05/15/2025. Jessica S. explained that an in-service medication training was held on 05/10/2025 with staff regarding medication procedures and protocols. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff did not properly assist resident with self-administration of medications as prescribed” is deemed Substantiated at this time. Regarding the allegation: 2.) Reporting requirements are not being met. It was alleged that the facility staff failed to report all of Resident #1’s (R1’s) medication refusals to R1’s responsible person. Interview with the Wellness Director, Jessica Saks revealed that facility staff do and are supposed to communicate with families or responsible persons and doctors when a resident refuses medications or care. Per record review, and interview R1 refused Escitalopram 5mg/ 5mL oral solution on 05/07/2025 and facility staff did not report the refusal to R1’s responsible person. The LPA reminded the ED and Jessica S. that facility staff should be reporting any incident which threatens the welfare, safety or health of a resident such as refusal of medication. The LPA also reminded Jessica S. and the ED that facility staff should be documenting their efforts and form of communication with families, responsible persons and doctors. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation, “Reporting requirements are not being met” is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 29-AS-20250610122305

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 14, 2025

87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review & interviews, the licensee did not comply with the section cited above, staff did not properly assist R1’s medications per physician’s order which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2025

Plan of correction: Within 24 hours, the ED will provide the LPA with proof of medication training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 20, 2025

87211 Reporting Requirements(a) ... (1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events... (D) Any incident which threatens the welfare, safety or health of any resident…This requirement is not met as evidenced by: Based on interviews & records review, the licensee did not comply with the section cited above as the Licensee did not report to R1’s responsible person of R1’s medication refusal which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2025

Plan of correction: Wellness Director stated they will submit a statement of understanding confirming that they understand the importance of reporting any incidents, including medication refusal to residents’ responsible persons. Additionally, Wellness Director stated that an in-service training regarding reporting requirements will be conducted and proof will be sent to the LPA.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced required annual visit to this facility. At 9:00 a.m., the LPA met with staff and explained the reason for the visit. At 9:10 a.m., the Executive Director (ED), Allison Marty met with the LPA. At 11:26 a.m., the LPA, along with the Wellness Director, Jessica Saks conducted a brief physical plant tour. Between 12:22 p.m. and 1:38 p.m., the LPA conducted a review of medication and medication documentation with the Wellness Director for eleven (11) residents and observed that medications were properly documented and assisted with as prescribed. Medications are locked and centrally stored in the wellness center offices and the memory care director office. Due to time constraints the LPA will return to complete the annual at a later date. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 13, 2025

Allegation investigated: Resident eloped without supervision while in care.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above at 10:25AM. LPA met with Administrator/Director of Hospitality Lourdes Bustamante and Executive Director (ED) Allison Marty and explained the reason for the visit. During today's visit, LPA interviewed three (3) staff between 10:32AM-12:36PM, reviewed and obtained copies of pertinent documents between 11:56AM-12:15PM, conducted a brief physical plant tour with Director of Nursing (DON) Jessica Saks at 12:17PM, interviewed two (2) responsible parties/visitors of residents between 12:23PM-01:49PM, and discussed the allegation with ED at 04:07PM. Report Continued on LIC9099-C. Unsubstantiated It was alleged that Resident #1 (R1) who resides in the memory care (MC) unit on the seventh floor of Building B eloped two (2) times. On 04/24/2025, R1 and Resident #2 (R2) went to the second-floor dining room unsupervised and on 05/01/2025, R1 took the elevator outside of the MC unit to the first-floor lobby and walked outside of Building B towards Building C. In both incidents, R1 did not leave facility grounds, was found by staff immediately, and was unharmed, but R1 was unsupervised in the elevator both times that R1 left the MC floor. Staff confirmed that MC can only be entered and exited with a key fob. MC residents do not get their own key fobs, their responsible parties do upon request. MC has two (2) exits, one (1) to the Assisted Living (AL) lobby and one (1) to the parking garage. LPA observed MC with three (3) delayed egress doors and at 12:20PM, LPA confirmed that the MC exit doors to the elevators automatically lock immediately upon closing. Staff stated that the elevators on the seventh floor outside of MC can only go to the first floor without a key fob and not to floors 2-6 which include the main dining room and AL units. LPA interviewed two (2) responsible parties and three (3) staff who stated that R1 and R2 have left the MC floor on multiple occasions but have not left the facility. R1’s physician’s report signed and dated 04/29/2025 documents R1 with a dementia diagnosis and unable to leave the facility unassisted. However, R1 did not leave the facility. At this time, the California Code of Regulations, Title 22 Section 87101(e)(3) Definitions states that “’elopement’ occurs when a resident who is at risk of harm due to their cognitive condition leaves the facility unsupervised, or while in the licensee's care, leaves another safe location unsupervised.” As R1 and R2 did not leave the facility unsupervised and were not missing for an extended period of time, the incidents do not fall under the definition of “elopement” at this time. However, on a separate case management report, the facility was cited for lack of care and supervision (see LIC 809). Based on interviews, observation, 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 a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Resident eloped without supervision while in care” 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, May 21, 2025 · control 29-AS-20250515120119

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20250515120119). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation. During the visit on 05/21/2025, LPA interviewed three (3) staff between 10:32AM-12:36PM, conducted a brief physical plant tour with Director of Nursing (DON) Jessica Saks at 12:17PM, and interviewed two (2) responsible parties/visitors of residents between 12:23PM-01:49PM. The two (2) responsible parties and three (3) staff interviewed confirmed that Resident #1 (R1) and Resident #2 (R2) have left the memory care (MC) unit on the seventh floor of Building B on multiple occasions. On 04/24/2025, R1 and R2 went to the second-floor dining room unsupervised and on 05/01/2025, R1 took the elevator outside of the MC unit to the first-floor lobby and walked outside of Building B towards Building C. In both incidents, R1 did not leave facility grounds, was found by staff immediately, and was unharmed, but R1 was unsupervised in the elevator both times that R1 left the MC floor. Staff interviews confirmed that R1 and R2 left the MC unit on the seventh floor unsupervised in the elevator. Staff also confirmed that MC can only be entered and exited with a key fob and that the elevators on the seventh floor outside of MC can only go to the first floor without a key fob and not to floors 2-6 which include the main dining room and AL units. MC residents do not get their own key fobs, their responsible parties do upon request. However, the MC exit doors to the elevator are not supervised at all times and are not delayed egress. Report Continued on LIC809-C. The MC unit is equipped with three (3) delayed egress doors to the exterior, but not to the elevators. When someone enters the MC unit, MC residents could potentially exit the MC unit and take the elevator down if visitors leave the door open. At 12:20PM, LPA observed the doors to the MC elevators to automatically close and lock immediately. Staff and responsible parties stated that R1 and R2 were potentially let out by other visitors in the past. LPA spoke with the Executive Director (ED) Allison Marty who stated that R1 and R2 should not have been able to take the elevator unsupervised and that the facility plans to implement key fob pads to access the elevator from the MC floor. At 12:19PM, LPA observed the elevators in Building B equipped with functioning key fob pads inside that require scanning before going up or down to another floor. LPA observed that the elevator can be called from the outside on the MC floor and go down to the first floor without a key fob, meaning that MC residents can access the first floor if they get past the locked MC door when someone else enters. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. ED was informed that failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 21, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 4, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and observation, the Licensee did not comply with the section cited above as R1 and R2 left the memory care floor unsupervised with the elevator which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: Facility management contacted maintenance during the visit and put a service request to install key fob pads outside of the memory care elevators or to restrict the key fob pads inside the elevators to prevent memory care residents taking the elevator down. ED will submit proof to CCLD by 06/04/2025.

Allegation investigated: Staff does not ensure resident's door is in good repair.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above 10:03 AM. Upon arrival, LPA met with staff and Administrator/Director of Hospitality Lourdes Bustamante. Administrator called Executive Director (ED) Allison Marty at 10:29AM and reason for the visit was explained Entrance interview conducted. During today's visit, LPA reviewed and obtained copies of pertinent documents relevant to the investigation between 10:15AM-01:15PM, interviewed seven (7) staff members between 10:10AM-03:55PM, interviewed five (5) residents between 11:46AM-01:06PM, conducted a brief physical plant tour between 12:02PM-01:15PM, discussed allegations with Administrator at 01:17PM, and conducted a medication review for three (3) residents between 03:54PM-04:20PM. Report Continued on LIC 9099-C. Substantiated It was alleged that some residential rooms have the top door closer of their entry door off. LPA interviewed Administrator and ED who stated that all resident apartments in assisted living (AL) and independent living (IL) have the same doors. ED stated that some residents have asked to loosen the door closer hinges or take them off because the door is heavy, but they are not allowed to since they are fire doors and need to automatically close. One (1) out of seven (7) staff confirmed that the maintenance team will sometimes loosen the door closer or disconnect them per resident request if their door is too heavy or they require ambulatory assistance devices, such as walkers or wheelchairs. Between 01:02PM-01:11PM, LPA observed three (3) doors in the IL building A on the third, fourth, and sixth floors. Two (2) out of three (3) doors observed did not have a functional door closer; one door closer was observed to not fully close the door at 01:06PM and the other door closer was observed disconnected at 01:11PM, resulting in the door staying open. Maintenance staff was immediately notified to repair the door closers, and staff will get trained to deny the request about removing or loosening door closers as they are required for fire safety. The two (2) door closers were repaired during LPA’s visit. Administrator stated that staff will audit all resident doors and repair any door closers as needed. Based on observation and interviews, the allegation “Staff does not ensure resident's door is in good repair” is deemed SUBSTANTIATED at this time. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. Appeal rights and a copy of the report was provided. It was alleged that a resident’s medications were found in their wheelchair multiple times. There was also a concern about residents getting their medications administered. LPA conducted a medication review between 03:54PM-04:20PM for three (3) residents of which one (1) is independent living (IL) and one (1) is assisted living (AL). Medications are centrally stored and locked in the wellness 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 are properly documented on the centrally stored medications and destruction record. Medications are prepared for each shift and are not prepared for more than 24 hours in advance. No errors observed during the medication review. Staff interviewed were knowledgeable in medication administration, storage, and documentation and knew procedures for medication destruction and administration errors. No concerns were noted. Interviews conducted did not have supporting evidence of the allegation. Based on record review, interviews, and medication 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 a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff does not ensure resident's medication is being administered” is deemed UNSUBSTANTIATED at this time. It further was alleged that Resident #1 (R1) leaves the facility unassisted but is not capable of doing so. LPA reviewed R1’s assessment completed by the facility on 09/12/2023 which documents R1 as “does not require assistance with escorting.” However, R1’s physician’s report dated 09/15/2023 documents R1 with a dementia diagnosis, confused/disoriented mental condition, and unable to leave the facility unassisted. R1’s newer assessment completed by the facility on 04/15/2024 documents that R1 “requires escorting and/or physical assistance to attend meals and daily events.” LPA interviewed ED, Administrator, and R1’s responsible party who all confirmed that R1 has a private companion six (6) days a week and does not leave the facility unassisted. R1’s responsible party did not express concerns about R1’s amount of supervision or risk of wandering. Based on record review and interviews, 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 a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff does not provide adequate supervision resulting in resident wandering away from facility” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C. Lastly, it was alleged that residents in independent living (IL) do not get three (3) meals a day provided to them. LPA reviewed three (3) admission agreements for IL, assisted living (AL), and memory care (MC). The IL admission agreement states that “Independent Living residents will receive a monthly Flexible Spending Account that can be used toward a limited meal plan that includes snacks and our daily menu that is priced a la carte.” Food service is paid via a point system. IL residents are allotted 800 points per month where one (1) point is equivalent to $1. IL residents can choose to spend their 800 points however they wish, including for their visitors. The 800 points covers about two (2) meals a day as breakfast is typically $9 and a full lunch/dinner is $13. More points can be used depending on the entrée, for example, a filet mignon entrée will be more than the typical 13-point dinner, and on drinks like smoothies or coffee. Admission agreements do not specify the amount of points residents have in their monthly allowance, however, receipts provided for meals state the resident’s total allowance, usage, and remaining balance of points for that month. Residents can also request itemized monthly bills. IL residents were notified of their $800 meal allowance through a weekly update delivered to resident apartments on 07/21/2024 stating “DINING UPDATE: This is a friendly reminder that the dining credit for all IL residents will change to $800 starting the August rotation. This dining credit allowance meets the contractual requirement for two (2) four course meals for each IL resident.” AL residents get an allowance of 1050 points per month, which is about three (3) meals a day. LPA reviewed Appendix M of the AL admission agreement which states that “three meals a day in the dining areas or delivered by room services” are “included in the monthly rent” for “assisted living services.” AL residents were notified of the point system via a letter stating “Starting October 1st [2024], you will receive a monthly dining dollar credit of $1050.00. This credit can be used to purchase any of our dining options…” LPA also reviewed Appendix M of the MC admission agreement which states “three meals a day and snacks” are “included in the monthly rent” for “memory care services.” Five (5) out of five (5) residents interviewed expressed no concerns of food services and felt that the amount of food provided is adequate and taste/quality are no concern. LPA observed residents dining in the Warner’s dining hall at 12:17PM and observed adequate food service. Based on record review, interviews, 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 a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff does not provide adequate food service” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 26, 2025 · control 29-AS-20250319090503

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 9, 2025

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being... This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above as 2 out of 3 resident apartment doors did not have functioning door closers which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Administrator notified the maintenance team during the visit and the 2 door closers were repaired. Administrator agreed to audit all resident apartment doors for functioning door closers and will submit a signed statement of all doors in good repair to CCL by 04/09/2025.

Allegation investigated: Staff are not providing residents with comfortable accomodations

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation with the purpose of delivering findings for the allegation listed above at 10:07AM. Upon arrival, LPA met with staff, Executive Director (ED) Allison Marty, and Director of Nursing (DN) Jessica Saks. Entrance interview conducted. During the initial visit on 11/26/2024, LPA conducted a brief physical plant tour, conducted interviews with DN Jessica Saks, two (2) staff members, and seven (7) residents, reviewed and obtained copies of pertinent documents relevant to the investigation, and discussed allegation with DN Saks. It was alleged that there are heavy noises coming from the unit above Resident #1’s (R1) and Resident #2’s (R2) shared unit at various times during the day. Reporting party stated that management was notified but failed to respond appropriately or effectively address the issue. Report Continued on LIC 9099-C. Unsubstantiated Interviews with R1, R2, and DN confirmed that a plumber was contracted to inspect the pipes as the possible cause of the noise. LPA reviewed an invoice for the plumbing service call dated 10/10/2024 which documents that the bathroom faucets, showers, toilets, and kitchen faucet and drains were inspected, no leaks or issues were observed. The hot and cold water and toilet flushing were also tested. The invoice states, “found no issues throughout the unit and found all fixtures working properly” and “could not recreate any abnormal sounds throughout units.” DN, R1, and R2 further confirmed that the management offered to service a structural engineer to investigate the integrity of the unit but the offer was denied. The facility serviced an HVAC inspection on 12/03/2024 and the invoice reviewed states, “it was determined that unit works to manufacturer specs at present time.” As no cause of the noise could be found, management held multiple meetings with R1 and R2 and offered a different unit, which was denied. LPA interviewed five (5) residents of which three (3) were on the same floor as R1 and R2’s shared unit, one (1) was on the floor above, and one (1) was in the building adjacent. No residents interviewed supported the allegation. LPA interviewed three (3) staff and no information supporting the allegation was observed. Furthermore, the unit above R1 and R2’s was vacant for a period of about three weeks, meaning that no residents were in the above unit to cause the noise that was allegedly coming from that unit. ED Marty stated that residents in both units are being monitored and that the facility will continue to offer plans of action, such as servicing a structural engineer or offering to relocate the residents to another unit, to address the issue. The allegation is that staff are not providing residents with comfortable accommodations, however, LPA observed multiple attempts made by the facility to remedy the alleged noise concerns. Information obtained through interview and record review did not include evidence sufficient 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 allegation is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 3, 2025 · control 29-AS-20241122123219

Allegation investigated: Staff are not ensuring infection control practices are being followed Staff did not notify appropriate agencies of outbreak

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above 10:06AM. Upon arrival, LPA met with staff, Executive Director (ED) Allison Marty, and Director of Nursing (DN) Jessica Saks. Entrance interview conducted. During today’s visit, LPA conducted a brief physical plant tour, conducted interviews with three (3) staff members and three (3) residents, and reviewed and obtained copies of pertinent documents relevant to the investigation. It was alleged that the facility had a norovirus outbreak and did not ensure infection control practices are being followed. The facility has a current infection control plan that is reviewed and updated. Interviews confirmed that the dining room and other common areas such as the fitness center and bistro were closed to prevent, contain, and mitigate the spread of the virus. Continued on LIC 9099-C. Unsubstantiated Other infection control measures were taken such as increasing housekeeping/janitorial services and sanitization, using personal protective equipment (PPE) such as masks and gloves, closing all eating venues, meal delivery to each residential unit in disposable containers and utensils, self-isolating symptomatic residents until 48 hours after symptoms resolve, and providing in-service trainings to staff on hand hygiene, disinfecting, and proper PPE use. Interviews with staff and residents confirmed the measures used by the facility. LPA reviewed email communications and announcements documenting that families and residents were notified on 01/25/2025 of the closure of the dining venues in efforts to “prevent the spread of the stomach virus currently affecting residents” and that meals will be delivered to resident apartments. Information obtained through interview and record review did not include evidence sufficient 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 allegation “Staff are not ensuring infection control practices are being followed” is deemed UNSUBSTANTIATED at this time. It was further alleged that staff did not notify appropriate agencies of outbreak. Community Care Licensing (CCL) received multiple incident reports within 24 hours of symptom onset. Reports were received on 01/24/2025 for fifteen (15) residents exhibiting symptoms of diarrhea, fever, and vomiting; seven (7) beginning on 01/22/2025 and eight (8) beginning on 01/23/2025. Regulation states that outbreaks shall be reported within 24 hours, and it is noted that the reports were received at 12:01AM on 01/24/2025. CCL received reports on 01/25/2025 for three (3) residents with onset of 01/25/2025 and six (6) residents with onset of 01/24/2025. LPA reviewed records documenting that Los Angeles County Department of Public Health (LACDPH) was notified by facility staff on 01/23/2025. Facility staff followed LACDPH’s infection control guidelines. Line lists were updated when new staff/residents developed symptoms. Six (6) stool samples were collected from residents and were confirmed to be norovirus on 01/29/2025. No new cases were reported by 01/31/2025. Information obtained through interview and record review did not include evidence sufficient 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 allegation “Staff did not notify appropriate agencies of outbreak” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 3, 2025 · control 29-AS-20250127093828

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted a subsequent unannounced case management - incident visit at 01:45PM. Upon arrival, LPA met with staff and Executive Director (ED) Allison Marty. Reason for the visit was explained. On 10/31/2024, the Department received an incident report stating that on 10/30/2024, the facility was made aware of fraudulent activity from a staff member toward Resident #1 (R1). The SOC 341 reports that two (2) personal checks were made out from R1’s account to Staff #1 (S1) for “service pay” in the amounts of $3000 and $5000. S1 has since been terminated. The facility cross-reported to Adult Protective Services, the Long-Term Care Ombudsman, and Law Enforcement. During the initial visit on 11/26/2024, LPA conducted a brief physical plant tour, conducted interviews with Director of Nursing (DN) Jessica Saks at 02:35PM, two (2) staff members, and eight (8) residents between 03:20PM - 04:30PM, and reviewed and obtained copies of pertinent documents relevant to the investigation. Record review documented that S1 was suspended immediately on 10/30/2024 and terminated 10/31/2024. S1 did not have prior disciplinary actions. The facility staff pulled a report to see which residents S1 was in contact with and interviewed those residents to see if they could be at risk. Facility staff also contacted several families from the list who were briefly informed about the incident and were encouraged to monitor financial accounts for suspicious activity. Facility staff stated that no other parties stated they had suspicious activity on their financial accounts. Report Continued LIC 809-C... Facility management physically went to the police station to file a report but were told to submit one online. Management was unable to file an online report because the incident did not fit reporting requirements since R1’s bank stopped the crime from “completing.” Management reported the incident to the Department and cross-reported to appropriate agencies. Adult protective services (APS) conducted a visit shortly thereafter. No monies were taken from R1’s account(s) as R1’s bank prevented the checks from processing. LPA interviewed R1 who stated that the facility did everything they could to help and acted quickly. Based on interviews and record review, the facility responded quickly and effectively, made reasonable efforts to safeguard resident property, and took appropriate measures to safeguard resident’s cash resources. No citations issued. Copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 3, 2025

Allegation investigated: . Staff did not evacuate resident during a fire 2. Staff not properly trained for fire evacuation.

Licensing Program Analyst(LPA), Christine Yee conducted a subsequent unannounced complaint visit to conduct additional investigation and to deliver the findings of the above allegations. LPA Yee met with Jessica Saks, Director of Nursing and the reason for the visit was provided. An initial visit was conducted on 8/10/23 and facility documents were requested beginning at 12:05pm, facility records were reviewed at 1:24pm, interviews were conducted with Jessica Saks at 1:00pm and Jim Biggs at 2:31pm. Due to time constraints, residents could not be interviewed. Per information obtained on today's visit, further investigation is needed to make a finding for the above allegations. Exit interview was conducted. On today's visit, LPA Yee obtained additional facility documents throughout the visit, conducted an interview with Jessica Saks at 12:21pm and interviewed Residents #1 at 1:28pm. Unsubstantiated Per information received from interviews and review of facility records regarding Allegation #1 - Staff did not evacuate resident during a fire, on 8/8/23 the facility had a small kitchen fire sparked off by the vendor hired by the facility to extend the gas line in the kitchen for an additional fryer. The vendor did not turn off the gas before working on the gas line extension and the fire was sparked by the nearby stoves. The kitchen fire activated the sprinkler and Ansul system and the fire was immediately put out before the fire department arrived. Per information provided, the intercom system was also activated and residents were told to stay in their rooms until they are given different instructions. This information is also noted on the Resident Guide given to all the residents as part of their welcome package when they move in. Per review of the Resident Guide, the guide provides residents with information about the Community, Safety and Emergencies and Health Services. Under the Safety and Emergencies Section, Residents are advised to stay in place unless they are told differently. No resident evacuation protocol was activated on 8/8/23. Per interview conducted with Resident #1, they confirm that they were instructed to stay in place but they came down to enquire about evacuation plans for Resident #2 who uses a walker. Per Resident #1, they were aware that Resident #2 was never in danger and no staff told them that they did not know what to do. Per Resident #1, they did run into a staff who looked confused and this staff informed them that the front desk had a list of non-ambulatory residents and that the fire department would assist them with evacuation. When they enquired with the front desk about the availability of the list of non-ambulatory residents they were told that there was no list. Per Resident #1, the front desk staff may have been new or confused. Per interview with Jessica Saks, the front desk does have a list. It is kept in a folder at the front desk. A copy of the list was provided on today's visit. Per tour of 2 of the 7 stairwells conducted at 2:14pm on today's visit, evacuation chairs were observed at the top of the stairwells. Based on the information obtained during the investigation, there is insufficient evidence to support the allegation that staff did not evacuate resident during a fire, therefore the allegation is unsubstantiated. Per the investigation into Allegation #2 - Staff not properly trained for fire evacuation, the investigation revealed that the facility has 8 floors and is considered a high rise. The building was constructed with fire rated walls and doors that are fire rated for 90 minutes. The Fire Marshal shows up unannounced monthly to conduct fire drills for all three shifts and evacuation drills are conducted annually. Per review of the fire drill logs for 2023 and 2024, employees from every shift receive training alternately every 3 months. A different case scenario is simulated and the staff are trained on the responses and notifications to the appropriate agencies. Staff are also trained on the use of fire extinguishers. Based on the review of facility training records, there is insufficient evidence to support the allegation that the staff are not properly trained for fire evacuations, therefore the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 29-AS-20230809144351

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 02:10PM. Upon arrival, LPA met with staff and Director of Nursing (DN) Jessica Saks. Reason for the visit was explained. On 10/31/2024, the Department received an incident report stating that on 10/30/2024, the facility was made aware of fraudulent activity from a staff member toward Resident #1 (R1). The SOC 341 reports that two (2) personal checks were made out from R1’s account to Staff #1 (S1) for “service pay” in the amounts of $3000 and $5000. S1 has since been terminated. The facility cross-reported to Adult Protective Services, the Long-Term Care Ombudsman, and Law Enforcement. During today’s visit, LPA conducted a brief physical plant tour, conducted interviews with DN Saks at 02:35PM, two (2) staff members, and eight (8) residents between 03:20PM - 04:30PM, and reviewed and obtained copies of pertinent documents relevant to the investigation. Prior to issuing final licensing report, it has been determined that further investigation is needed at this time. Exit Interview Conducted and Report was Issued.the state’s words, verbatim · CDSS document, Nov 26, 2024

Allegation investigated: Resident records are falsified

On 10/21/2024 at 02:50PM, Licensing Program Analyst (LPA) Angela Barutyan conducted a subsequent complaint investigation visit to deliver final findings for the above allegation. During this visit, LPA met with Administrator Joyce Aquino and Director of Hospitality Lourdes Bustamante and explained the reason for the visit. On 4/9/2024 from 9:50am to 12:44pm, LPA Yee conducted an initial visit to start the investigation. LPA collected relevant documents and conducted interviews with the administrator at 10:11am, and with residents from 11:59am to 12:30pm. On the allegation: Resident records are falsified. It is alleged that the facility referred potential residents to a physician who provided them with false medical reports of their injuries/conditions that enabled the facility to secure insurance to pay for the cost of living at the facility. The allegation states the facility announced a new charge for residents to file documents required for the insured to receive benefits. Several residents allegedly complained that the facility should not charge the fee as they were not actually receiving the medical services that apparently, they are required to receive. Report Continued on LIC9099-C. Unsubstantiated On 04/09/2024, LPA conducted a complaint investigation visit to the facility above. During this visit, LPA requested and received relevant documentation pertinent to the complaint allegation for record review. LPA additionally interviewed both staff of the facility and residents in care at the facility during the complaint investigation visit. LPA received documents from the facility including an insurance claimant care needs assessment form to be completed by a licensed clinician to process a resident’s long-term care claim, insurance continued monthly residence form required as part of a monthly claim submission, an insurance company facility form regarding a claim for charges covered by the facility, insurance company facility verification form, insurance monthly verification form to be completed each month after services have been rendered, and insurance confinement form providing benefits on behalf of a resident based on residency in the facility. Each insurance form received by LPA from the facility is between 1-2 pages in length and all forms require dates and signatures from facility staff and/or a professionally licensed clinician. Each insurance form has multiple sections and/or questionnaires required to be completed that include resident information, facility information, provider information, and licensing information. Staff of the facility stated during their interviews with LPA that, beginning 05/01/2024 residents will be charged $150 when they submit forms or paperwork to the facility office to complete insurance paperwork so they can receive services from their long-term care insurance. According to Staff, the facility medical director sees approximately 12-15 residents, while most residents are seen by their own primary care physician (PCP). The census at the time of the initial complaint investigation visit by LPA was 350 residents in the facility. Staff stated to LPA that it takes about 3-4 hours a month to complete paperwork for each resident. Paperwork is usually completed by the residents' own PCP. A long-term care medical technician from the insurance company is first sent to do an assessment of the resident for eligibility and the assessment is then sent to an insurance adjuster for consideration. The services must be re-certified every 6 months to 1 year. The residents receive a monthly invoice for these services. Per Staff, the residents can complete their own insurance paperwork. The facility office completes only, if necessary, sections of the insurance forms such as: Can the resident remain in the same apartment for the entire month, were they hospitalized in the last month 1st - 30th, description of current apartment - Memory Care, Skilled Nursing, Assisted Living, and is any of the amount covered by Medicare or private pay. Report Continued on LIC9099-C. The residents are charged the $150 only if their insurance paperwork needs to be completed. The facility also provides the insurance company with a plan of care, copy of the Medication and Administration Record (MAR) log, and copy of the facility license. The $150 is charged only if a resident needs a portion of their insurance paperwork completed, and not just for sending out the insurance invoice. The $150 charged by the facility for the completion of medical insurance paperwork has nothing to do with receiving required medical services. Facility staff stated to LPA that insurance claims are requested by the resident or their representative/responsible party if the resident needs care and is living in assisted living setting. The process is started when a registered nurse (RN) provided by the insurance company is sent out to assess the resident. A letter is then sent to the resident and/or their representative/responsible party. According to all staff interviewed by LPA, the insurance company itself does not speak with the facility. The RN provided by the insurance company will make recommendations to the facility such as the provision of a shower chair or obtaining a better walker. The facility and insurance RN will discuss what additional services or equipment is needed for the resident. The medical evaluation for the resident is completed by the insurance RN. Long-term services for Activities of Daily Living (ADL) such as bathing, clothing, toileting, feeding, and hygiene are reimbursable for the resident, but if they do not follow the service process, then there is no reimbursement. LPA interviewed multiple residents at the facility who stated that they are assisted and transported to their PCP with their medical services scheduled by their representatives. Other residents interviewed by LPA indicated that they have not been charged for insurance paperwork. Residents stated to LPA that they receive a bill from the facility with charges that are warranted. They are not aware of the facility providing false insurance documents to receive medical services. Residents interviewed by LPA stated that they receive appropriate medical services from their physician. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Exit interview conducted. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Oct 21, 2024 · control 29-AS-20240402165306

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Angela Barutyan and Trevor Byrne Barutyan arrived at the facility unannounced to conduct a Case Management - Annual Continuation visit at 9:10AM continuing the inspection that began on 07/11/2024. LPAs met with Director of Nursing Jessica Saks and Director of Compliance Angel Ascencio and explained the purpose of the visit. RECORD REVIEW: LPAs began record review at 09:40AM. LPAs reviewed 10 (ten) staff files for documents including, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and appropriate trainings. Personnel files reviewed were complete and were observed to be in compliance. MEDICATION REVIEW: Medication review began at 11:03AM. Medications are locked and centrally stored in the wellness center office and the memory care director office. Medications for 5 (five) residents were reviewed and all are labeled and maintained in compliance with label instructions, and state and federal law. INTERVIEWS: During today’s visit, LPAs interviewed 5 (five) staff between 10:39AM-10:54AM. At 11:00AM, LPAs conducted a brief physical plant tour to ensure there are no health and safety hazards. No deficiencies cited at this time. Exit interview conducted. A copy of the report of provided.the state’s words, verbatim · CDSS document, Aug 6, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Angela Barutyan, Kelly Dulek, and Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 9:17AM. LPAs met with Administrator Joyce Aquino. Entrance interview conducted. Beginning at 10:25AM, the LPAs, along with Administrator Aquino, Director of Compliance (DC) Angel Ascencio, Director of Nursing (DN) Jessica Saks, and Maintenance Technician (MT) Mark Lagasca toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: FACILITY LAYOUT: The facility has 3 (three) buildings, which are named Building A, Building ,B and Building C. The facility has 336 (three hundred thirty-six) units. Building B has a Memory Care Unit on the 7th (seventh) floor and there are 3 (three) delayed egress doors on 7th (seventh) floor. At 1:27PM, LPAs tested 1 (one) delayed egress door and staff responded promptly. Buildings A and C are primarily for independent living, while Building B is for assisted living, mezzanine living, and memory care. The LPAs toured 5 (five) resident rooms in the Memory Care Unit. Rooms in the memory care unit are single occupancy and have no appliances. Lighting in the rooms appeared adequate. The rooms are equipped 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 rooms in Building A, Building B, and Building C (excluding the 7th floor Memory Care Unit) are equipped with a refrigerator, microwave, and sink, and in-unit washer and dryer. The rooms in Building A, Building B and Building C are majority single occupancy, with the availability of double occupancy in some rooms. The LPAs toured 25 (twenty-five) additional resident rooms, with 9 (nine) in Building C, 7 (seven) in Building A, and 9 (nine) in Building B which were observed in compliance. Report Continued on LIC 809-C BATHROOMS: LPAs observed the bathrooms for assisted living residents to be equipped with grab bars near the toilet and shower/tub, and non-skid surfaces and mats were observed in the shower/tub. LPAs tested water temperatures in resident bathrooms and were measured to be between 107.6 and 119.3 degrees Fahrenheit, which is within the required range. AMENITIES/COMMON AREAS: Building A has the following amenities and common areas: offices spaces, conference rooms, mail room and the bistro are located on the first floor. 1 (one) theater is located on the first floor and a 2nd (second) theater is located on the second floor. The main kitchen and dining area are located on the second floor. The second-floor amenities include: art room, the tavern with locked cabinets, the marketplace, the activity/simulator room, wine cellar, outdoor terrace, and Wellness center. The third floor has a covered outdoor area with outdoor furniture for resident use. Building B has the following amenities and common areas: pet washroom, salon, activities/conservatory room and a community garden. Throughout Building B there are community rooms and a covered outdoor area for resident use located on the third floor. Building C has the following amenities and common areas: a wellness center with gym equipment, a yoga room, a juice bar, a physical therapy room, a massage room, a laundry room and a salon. There is an in-ground pool which is kept locked on the first floor of Building C. COMMON AREAS: The signal system can be activated in the resident bedrooms and restrooms by a pull cord. Residents also have pendants they can wear to signal staff. All systems go directly to a computer at the front desk and to hand-held devices. Designated staff carry a handheld device, which displays the location of the alarm that has been pulled. At 11:12AM and 12:12PM, LPAs pulled signal cords in resident restrooms and both times, staff arrived promptly in response. Staff also utilize walkie-talkies to communicate with staff accordingly. There are cameras observed in exterior perimeter. The community’s smoke detectors and carbon monoxide detectors are hard wired. The fire extinguishers are located on every floor in each building and were observed to be fully charged and serviced on 04/09/2024. 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 of Building A, near the mail room and the common hallway. The LPAs observed the Ombudsman Poster and DSS Complaint Poster throughout the community. Report Continued on LIC 809-C KITCHEN: 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 in Building A on the second floor and is delivered to the separate dining rooms. Emergency water supply is stored in locked storage rooms on every floor. OUTDOOR AREAS: LPAs toured outdoor perimeter and observed self-latching gates. All exits were observed to be clear and free of hazards. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs 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 plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 05/11/2024.\ RECORD REVIEW: 10 (ten) resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All records reviewed were observed to be in compliance. Staff files will be reviewed during annual continuation. MEDICATION REVIEW: Will be reviewed during annual continuation. INTERVIEWS: During today's visit, LPAs interviewed 5 (five) residents. Staff interviews will be conducted during annual continuation. During today's visit, LPAs obtained a copy of the facility's liability insurance. Due to time constraints, the LPA will return at a later date to continue the inspection. No citations issued. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 11, 2024

Allegation investigated: Facility does not ensure that there is an adequate quantity of food to provide to residents in care.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent visit to deliver the findings for the allegation listed above. LPA Urena met with Administrator and explained the reason for the visit. On 05/03/2024, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the allegation listed above. LPA Urena met with Administrator Joyce Aquino and explained the reason for the visit. The LPA interviewed the Administrator at 12:30 p.m. and observed the dining room lunch time from approximately 12:45 to 1:30 p.m. The LPA interviewed residents, Culinary Director, and the Executive Chef. LPA Urena requested and reviewed records pertinent to the complaint. Facility does not ensure that there is an adequate quantity of food to provide to residents in care. On the allegation that the facility does not ensure that there is an adequate quantity of food to provide to residents in care, it is the concern of the reporting party that there are days when certain food items run out. To investigate the allegation the LPA conducted observations and resident and staff interviews. Unsubstantiated LPA Urena observed the dining areas during lunch time; lunch is served between 11:30 a.m. to 2:00 p.m. The facility has two dining areas located on the second floor and a Bistro located on the first floor. On specific days the facility provides a ‘themed’ Buffet by the Bistro area. The buffet is in addition to the two dining areas on the second floor. The dining areas provide ‘made to order meals’, which can be ordered from the daily menu and can take anywhere from 30 to 40 minutes to be prepared. The Daily Special menu meals are pre-prepared and are available for residents to be served right away. The LPA observed an abundance of meals being served to residents sitting in the dining room areas. The LPA interviewed 14 residents during the lunch period. The LPA asked if the kitchen ever runs out of certain food items? Two (2) out of 14 residents stated that on a couple of occasions, certain food items have run out; however, the residents stated that there are always several alternatives. When the LPA asked for examples, the residents stated that if the kitchen is out of one type of bread, there are other breads offered to them. Furthermore, all 14 residents added that the quantity of food served has never been a problem. They can eat all they want, there are no restrictions, and they can take food to their room; after they ate their meal in the dining room. The residents went on to rate the facility’s salads as ‘wonderful’, and meals as satisfying and plentiful. The residents commented on the Peruvian food buffet provided during the week and added that food was very good. The LPA interviewed the administrator about the quantity of food prepared by the kitchen, and the administrator stated the following, “Sometimes, some popular foods such as steak, and filet mignon, may run out, but it is usually due to residents eating their meals in the dining room and then taking additional food to their room. Residents are never restricted to one meal, and they can eat as much as they want. The kitchen also ensures to have alternate meals available to fulfill the food group, chicken, fish, pork, etc. The LPA interviewed the Culinary Regional Director (CRD) and the Executive Chef (EC) about the quantity of food prepared each day for the three different meals served. Both stated that they use the census to ensure that there are sufficient meals for all residents, plus they use a survey system to learn about the trends of the meals the residents favor. The CRD stated that they hold monthly ‘Culinary’ meetings with the residents’ council to discuss menu choices and to make recommendations to the chef. The CRD provided to the LPA the meeting agenda for the month of April 2024. Based on observation, and information gathered through interviews and documents, the allegation that the Facility does not ensure that there is an adequate quantity of food to provide to residents in care, is deemed Unsubstantiated at this time. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 4, 2024 · control 29-AS-20240501115626

Allegation investigated: Facility Administrator is not certified Staff is not TB tested

Licensing Program Analyst (LPA) Valeria Conway conducted an initial 10-day complaint visit to investigate the above allegations. Upon arrival, LPA met with Administrator/Director of Resident Care, Jocelyn "Joyce" Aquino at 9:02 a.m. The reason for today's visit was explained. Entrance interview conducted. During today’s visit, at 1:15 p.m., LPA conducted a tour of the physical plant. At 10:08 a.m., LPA requested to review facility files for a random sample of staff. Additionally, at 10:45 a.m., LPA obtained and reviewed copies of pertinent documentation relevant to the investigation. Between 11:20 a.m. and 1:54 p.m., LPA conducted interviews with facility ED, Administrator, and a random sample of facility staff and residents. Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099 It was alleged that the facility did not have a certified Administrator. A review of the facility Organizational Chart reflected the Administrator/Director of Resident Care reports to the facility Executive Director (ED). The primary role of the ED is the day-to-day operations of the facility which includes budgeting and all matters related to finances. The facility Administrator/Director of Resident Care handles all matters related to resident care and staffing. Per interviews, staff will bring forth any concerns to the Administrator prior to going to the ED. However, staff and residents are able to discuss any concerns with either party. Moreover, interviews reflected that the ED is assigned by corporate to sign any communication letters to the residents and family. The current Administrator of the facility Joyce Aquino holds a valid Administrator Certificate along with the required training and experience to fulfill this role. Based on information gathered, the Department does not have sufficient evidence to determine that the facility does not have a certified Administrator; therefore, the above allegation is deemed UNSUBSTANTIATED at this time. It was alleged that facility staff does not have a Tuberculosis (TB) clearance. During today’s visit, LPA reviewed a random sample of staff records and observed all fourteen (14) staff to have the appropriate TB clearances. LPA was informed that the files for the ED and the Sales/Marketing Director are stored offsite and the administrator was unable to access the online copy. However, at approximately 3:08, administrator provided LPA with proof of TB clearances for the ED and Sales/Marketing Director. Moreover, Administrator stated that during the hiring phase all employees are sent to WellnessMart an off-site clinic where TB Testing, finger printing and a physical will be conducted prior to starting employment. Based on the information gathered, the Department does not have sufficient evidence to determine that staff does not have the appropriate TB clearance; therefore, the above allegation is deemed UNSUBSTANTIATED at this time. No citations issued. A copy of this report was provided. Continued from LIC 9099 It was also alleged that staff do not have fingerprint clearances and are not associated to the facility. Information gathered during the course of the investigation reflected that Staff #1 (S1), and Staff #2 (S2) are all fingerprint cleared but not associated to the facility. Moreover, a review of the Guardian System reflected that Staff #3 (S3) has been employed at the facility since 09/01/2021 however, was associated at today, 03/08/2024 at 11:35 a.m. Based on the information gathered, the Department has sufficient evidence to determine that facility staff are not associated to the facility. Therefore, the above allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D) Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 8, 2024 · control 29-AS-20240305121059

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 9, 2024

Criminal Record Clearance. (e) All individuals subject to a criminal record review ... shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance...This requirement is not met as evidenced by: Based on record review, and interviews, licensee did not comply with the above section by not ensuring 3 out of 3 (S1, S2 and S3) had fingerprint association transferred to the facility prior working, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 8, 2024

Plan of correction: Administrator agreed to make sure all staff are associated to the facility and submit proof by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced Case Management Deficiency visit in conjunction with an initial 10-day complaint visit (CC #29-AS-20240305121059). LPA met with Joyce Aquino. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. During today’s visit, LPA requested to review files for Staff #1 (S1) and Staff #2 (S2). LPA was informed by the Administrator that the files for those individuals were kept offsite and online however, administrator was not able to access the files online. LPA explained that all files should be accessible to Licensing to audit/review during normal business hours. LPA further explained that it is acceptable for the files to be stored in a central location however, whenever Licensing requests to review those files, it should be readily available and accessible. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D) Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(g)(1) · Plan of correction due date: Mar 15, 2024

All personnel records shall be maintained at the facility and shall be available…licensing agency for review. (1) The licensee shall be permitted to retain such records in a central …location provided that they are readily available to the licensing… This requirement is not met as evidenced by: Based on interviews, licensee did not comply with the above section by not having 2 out of 14 files (S1, S2) readily available for CCL to review, which is a potential risk to residents in care.the state’s words, verbatim · CDSS document, Mar 8, 2024

Plan of correction: Administrator agreed to submit a letter of understing that files shall be available to Licensing by POC due date.

Allegation investigated: Facility dishwasher is in disrepair

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced initial 10-day complaint visit to investigate the allegation listed above. Upon arrival LPA met with Administrator Joyce Aquino and explained the reason for the visit. Entrance interview conducted. During today’s visit, at 10:00 a.m. LPA conducted a tour of the physical plant. Between 10:15 a.m. and 3:12 p.m., LPA conducted interviews with facility administrator, and a random sample of facility staff and residents. Additionally, at 11:45 a.m., LPA obtained and reviewed copies of pertinent documentation relevant to the investigation. Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099 It was alleged that facility dishwasher is in disrepair and there are piles of unwashed dishes and utensils in the kitchen. It was further reported that residents are served meals in dirty dishes and are given dirty utensils. During today’s visit, LPA observed residents having meal services in the dinning area. All serving ware and utensils appeared to be clean and sanitary at the time. Additionally, LPA also observed a surplus of additional dishes stores in cabinets for emergency use. During the physical plant tour, LPA observed the dishwasher to be functioning properly. Moreover, LPA observed staff pre rinsing the dishes prior to loading them in the dishwasher to avoid any issues. A review of Work Order records reflected that on 09/20/2023, the dishwasher was not in working order; however, maintenance was immediately contacted, and the dishwasher was repaired the same day. Interviews conducted with staff and residents did not reflect any concerns regarding dirty dishes or utensils. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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, therefore the above allegation “facility dishwasher is in disrepair” is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided. Continued from LIC-9099 It was also alleged that facility staff are not following general food service requirements. Per the RP, staff touch food after touching their clothing, the ice cream freezer is dirty, and staff serve old ice cream to residents. Interviews conducted did not reflect any concerns regarding unsanitary food handling practices by staff. LPA observed some kitchen staff with gloves practicing good hand hygiene. However, during today’s visit, LPA observed multiple open/uncovered tubs of ice cream in the freezer. Interviews reflected that the tubs are covered at the end of the day/shift but not after each use. Moreover, LPA toured the kitchen again at 2:45 p.m., and observed that all the ice cream tubs were moved from one freezer to other. Per information gathered, staff stated that the freezer was not unplugged therefore, the ice cream tubs needed to be moved to a different freezer. Staff agreed to properly cover and label all ice cream tubs. Based on the information gathered, the department has sufficient evidence to determine that “staff are not following general food service requirements”. Therefore, the above allegation is SUBSTANTAITED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D) Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 4, 2024 · control 29-AS-20240229140541

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(23) · Plan of correction due date: Mar 11, 2024

General Food Service Requirements. (b) The following food service requirements shall apply: All readily perishable foods or beverages capable of... which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: Based on observation and interviews, licensee did not comply with the section above by not covering and labeling the multiple ice cream tubs in the freezer, which is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Administrator agrees to provide trainig regarding General food service requierement by POC due date.

Allegation investigated: Staff failed to act appropiately to incident with resident Failure to comply with reporting requirements

Licensing Program Analysts (LPAs) Valeria Conway and Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:55 a.m., the LPAs met with staff and explained the reason for the visit. At 10:00 a.m., the LPAs met with the Director of Nursing, Jessica Saks. At 10:30 a.m., the LPAs conducted an interview with the Director of Nursing. At 10:42 a.m., the LPAs along with the Director of Nursing, conducted a physical plant tour. Between 11:07 a.m. and 2:15 p.m., the LPAs conducted interviews with seven (7) residents and four (4) staff. At 12:10 p.m., the LPAs spoke with the Administrator, Joyce Aquino. At 12:13 p.m., the LPAs reviewed records and requested copies of pertinent documents. At 12:25 p.m., LPA Conway conducted a telephonic interview with resident’s family member. Continue on LIC 9099C Unsubstantiated Regarding the allegations:1- Staff failed to act appropriately to incident with resident. 2- Failure to comply with reporting requirements. On 2/20/2024, the Department received a complaint alleging that Resident #1 (R1) slapped Resident #2 (R2) in front of staff in the memory care unit and that staff did not intervene. The complaint is also alleging that facility staff did not report the incident. The complainant alleged that R1 and R2 are husband and wife but was not sure if both R1 and R2 are residents of the facility. The complainant alleged that the incident occurred in December 2023, but the complainant did not provide any additional information. During the physical plant tour, the LPAs observed cameras in the Memory care unit however cameras facing common areas were installed beginning of February 2024. The LPAs were not able to obtain camera footage of the memory care unit common areas for the month of December 2023. During the time of the visit, the LPAs conducted an interview with the Director of Nursing, Jessica Saks. The Director of Nursing stated that R1 has not shown aggressive behavior in the past. The Director of Nursing stated that R1 and R2 get along well. The Director of Nursing explained that if facility staff witness an altercation or an incident, they report it to their supervisor and they also document it in their end of shift notes. Interview conducted with R1’s and R2’s family member revealed R1 and R2 have no history of being aggressive towards one another. R1’s and R2’s family member explained that R1 and R2 tend to speak loudly since both have hearing issues. R1 and R2’s family member did not voice concerns regarding facility staff or regarding the care of R1 and R2. Interview with R2 revealed that R2 feels safe around R1 and did not bring up any concerns regarding R1. Also, during the time of the visit, interviews with staff members denied the allegation and stated that R1 is not aggressive and that they have not witnessed R1 hit R2. Interviews with staff members revealed that if residents are arguing or have issues with one and other, that staff intervene and call other staff for additional assistance. Staff interviews also revealed that staff report any incidents to their supervisors and at the end of their shift they document any incidents or changes within their residents. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 29-AS-20240220162640

Allegation investigated: Staff do not ensure hot water is available to residents

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival LPA met with Administrator Joyce Aquino and explained the reason for the visit. At approx. 2:30pm, LPA conducted physical plant, interviewed residents, staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. It was alleged that staff do not ensure hot water is available to residents as it was reported that last Friday 12/29/2023, the facility was without hot water due to facility neglect. Interviews conducted with nine (9) residents revealed that all nine (9) residents did not express any immediate or potential concerns of staff not ensuring residents have hot water available. Continued on 9099-C Unsubstantiated Continued from 9099 All nine (9) residents also stated they were informed on the morning of 12/28/2023, that water will be shut off from 7:00 p.m. to 9:00 a.m. the next morning to install a pressure release valve (PRV). During the shut off residents were provided with drinking water and gallon sized water bottles to be poured into the toilet tank. Additional staff were scheduled to work. Group notifications were sent out via the facility's K4 system to advise all residents, family members and responsible representatives of the water shutoff notice. Based on the information gathered during the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that “Staff do not ensure hot water is available to residents” has been deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Jan 2, 2024 · control 29-AS-20231229150057

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident and suspected abuse report. LPA met with Administrator Joyce Aquino. LPA explained the reason for today's visit. Entrance interview conducted. Previously, on 12/19/2023, on duty LPA Emily Peraldi received a telephone call from the Administrator indicating an alleged incident had been reported to the facility Management involving Staff #1 (S1) inappropriately waking up Resident #1 (R1). Administrator indicated a suspected abuse report would be sent to the Woodland Hills Regional Office the following day. LPA Dulek then reviewed the document, which indicates that on 12/16/2023, S1 told Staff #2 (S2) to wake up R1 by pinching R1's nipples. Administrator indicated the facility is conducting an internal investigation and S1 is suspended during the investigation. Administrator sent photos to LPA Peraldi of R1's chest area, which did show bi-lateral bruising. During today's visit, LPA interviewed Administrator and Director of Compliance at 09:55AM, toured the facility with Director of Compliance at 10:06AM, LPA gathered and reviewed copies of pertinent documents and interviewed staff between 10:38AM and 11:45AM. Record review revealed that R1 resides in the facility's Memory Care unit and requires assistance with most ADLs, including grooming, hygiene, transfers and escorts. Interviews revealed that R1 is tired frequently, most often after meals, R1's family prefers they not rest sometimes, and that R1 can be difficult to arouse when in a deeper sleep. Interviews and written staff statements obtained during the facility's internal investigation did indicate staff have been told by S1 that S1 has awoken R1 by pinching R1's nipples and had instructed other staff to do the same when they are having difficulty waking up R1. Multiple staff reported being aware of this statement made by S1. Photographs of R1's chest area showed bruising on both sides of R1's chest, near their nipples, which appears consistent with pinching. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D). Exit interview conducted. Copy of report and appeal rights were reviewed and issued during today's visit.the state’s words, verbatim · CDSS document, Dec 27, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jan 3, 2024

87468.1 Personal Rights of Residents in All Facilities (a)(3)To be free from punishment, humiliation, intimidation, abuse, or other actions...interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on interview, review of witness statements and bruising observed on R1, S1 reportedly pinched R1's nipples to awaken R1, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 27, 2023

Plan of correction: Administrator indicated that S1 is not currently working, pending results of the investigation. Remaining staff were trained on 12/20/2023 on Resident Personal Rights and putting residents to sleep in their beds. Administrator will follow up with CCL by POC due date related to the employment status of S1.

Allegation investigated: Facility is in disrepair (water)

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegation and initially met with Joyce Aquino, Administrator. Today's visit was conducted primarily with Cassandra Moan, Director of Memory Care. The reason for today's visit was explained. On today's visit, LPA Yee conducted interviews with Cassandra Moan at 10:26am, Ray Rosales at 12:29pm, Jessica Saks at 1:06pm. LPA Yee also obtained copies of facility documents. Per information received from interviews conducted today, there was a water main that burst and water was observed flooding the street on 10/11/23. Facility staff were able to turn off the water. Los Angeles Department of Water and Power(LADWP) were contacted by staff and they were on site to assess the Unsubstantiated situation and they determined that the busted water main was on facility property and not their responsibility. Ray Rosales, Director of Engineering contacted a private contractor to conduct repairs the same day and the repairs were not anticipated to be completed until the morning of 10/12/23. The facility ordered drinking water and gallon sized bottles of water for use in the toilet. Arrangements were made to have food catered, additional staff were scheduled to work and residents given options to relocate to a nearby hotel. Group notifications were sent out via the facility's K4 system to advise all residents, family members and responsible representatives of the busted water main and the actions being taken to ensure that the residents are provided with water on 10/11/23. Flyers were also posted on residents' doors. The water main was repaired by noon on 10/12/23. When the water was turned back on, the pressure from the water main caused the pipes on the fourth floor, by room #421 of Building A, to leak. The water also went down to the third floor. The hallway walls on the fourth floor sustained water damage. The water had to be turned off again for repairs. The repairs were completed on 10/13/23 and water was restored to Building B and Building C. Residents located around the impacted area were also relocated to vacant rooms in building B and building C. Restoration of water supply to Building A was delayed by the availability of parts needed for the repair. As of this visit, the residents relocated are scheduled to return to their original rooms today. All residents continued to be provided with updates of the repairs. Residents also continued to be provided with care, food, water for drinking, toileting and shower while repairs were being conducted. The pipes were fixed and water supply was completely restored on 10/14/23. Per the above allegation that the facility is in disrepair(water), LPA Yee was not able to conclusively determine that the water main burst as a result of facility neglect or inaction. It is unknown as to what caused the water main to burst and the resulting effects of the burst cannot be anticipated. The facility did the necessary repairs in a timely manner, provided the required resident care and resources to ensure the residents well being and therefore, the above allegation is unsubstantiated. Exit interview was conducted.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 29-AS-20231016141337

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management visit to this location. At 8:45 a.m., the LPA met with the staff and explained the reason for the visit. At 9:04 a.m., the LPA met with the Director of Nursing Jessica Saks and Executive Director Jim Biggs. The reason for today's inspection is to follow up on a self-reported incident from 10/11/2023, the facility reported that the main water line had burst, and that the facility water was shut off. Between 9:07 a.m. and 9:24 a.m., the LPA and the Director of Nursing Jessica Saks, toured the facility. The LPA observed the following: gallons of water throughout the facility and resident rooms and catered food. The facility has sufficient amount of bottled water for resident and staff use. No immediate health and safety concerns were observed during today's inspection. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 12, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident visit to the facility. The LPA was greeted by Administrator Joyce Aquino and informed them of the reason for the visit. The purpose of today's visit is to address a self reported Unusual Incident/Injury Report (LIC 624) reported to CCL on 09/17/2023. The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred on 9/17/2023 regarding Resident #1 (R1) and two staff (S1, S2). It was documented that at approximately at 1:15 a.m on 9/17/2023, S1 was observed by S2 removing R1's sweater in a rough manner, pulling/gripping R1's arms trying to lay R1 on their bed. It was further reported that when a Wellness Nurse went to check on R1, R1 stated "Are you going to hit me too?" A Wellness Nurse completed a skin assessment of R1's body and noted redness on her arm. During todays visit, the LPA conducted four (4) staff interviews, three were conducted via telephone call, obtained pertinent records and interviewed the administrator throughout the visit. Staff interviews revealed that R1 was heard screaming by three staff (S2, S3, S4), which was stated to be unusual behavior for this resident and cause staff to be concern and run to check on R1. S1 was observed by S2, forcefully gripping R1 to remove their sweater, and forcefully sitting R1. Staff interviews further revealed that R1 was observed crying after the incident by S5, and staff ensure to not leave R1 alone with S1 for the remainder of the night. Documents obtained revealed that R1 had been assesses by AM wellness nurse with redness/bruises on their left arm, however Administrator stated they were unsure if they were new or old as R1 had a fall on 9/14/23. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D). Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Sep 28, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 28, 2023

87468.1Personal Rights of Residents in All Facilities (a)(3)To be free from punishment, humiliation, intimidation, abuse, or other actions...interfering with daily living functions such as eating, sleeping, or elimination.This requirement is not met as evidence by: Based on Records obtained. The licensee did not comply with the above cited section as S1 was observed forcefully gripping and forcefully sitting R1 which poses an immidiate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Plan of correction has been met as S1 is no longer working at the facility.