The Watermark at Westwood Village

Type of visit: Required - 1 Year

On 3/17/2026, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Jose Vazquez/Director of Facility Operations. LPA explained the purpose of today’s visit. The facility is licensed to serve (237) elderly adults ages 60 and above, of which (237) can be non-ambulatory and (25) bedridden on the 3rd floor. Approved for delayed egress. The facility has an approved hospice waiver for (25). Currently the facility has (136) residents. The facility features approximately (188) living units and around (225) bathrooms, spread across (14) stories with underground parking. The building is beige and predominantly made of glass. On the first floor, there is a full catering kitchen, a dining area, a lobby, conference room space, restrooms, a reception area, and (3) elevators. Additionally, a sitting area with an enclosed fireplace and a large outdoor patio with a fireplace and seating are also available. The 2nd floor includes a salon, a fitness center, storage space, and administrative office space. The 3rd floor is dedicated to residential accommodations for individuals requiring memory care support, with 18 apartments, a dining space that includes a patio, and some office space. Floors 4th to 7th are designated for assisted living residences, while floors eight to fourteen house units for independent living. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. LPA Iniguez and the maintenance director toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected residents bedrooms and bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113.5°F to 115.2°F, and the room temperature ranged from 76°F to 78°F. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there were sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 3/3/26. A review of (5) residents' service files and (5) staff personnel files was conducted. LPA reviewed (5) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See D page for details. Civil Penalty Assessed. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Jose Vazquez/Director of Facility Operations.the state’s words, verbatim · CDSS document, Mar 17, 2026

Allegation investigated: Staff are not providing adequate food service to residents. Staff left resident unattended for an extended period of time.

On 11/21/2025 at approximately 9:00 AM, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Stephanie Walters/ Senior Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Executive Director Interview (A#1), Facility Staff Interviews (S#1-S#9) and Resident Interviews (R#1-R#9). LPA gathered the following documents: Client Roster dated: 11/4/25, Staff Roster dated:11/4/25, copies of menus various dates and a health and safety check at the facility kitchen Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff are not providing adequate food service to residents. The details of the complaint alleged that food service to residents was delayed due to late distribution of menus On November 21, 2025, at approximately 12:00 PM, during a review of records, Licensing Program Analyst (LPA) Iniguez observed that the facility had copies of the menus available for the period from October 19 to November 8, 2025. These menus were distributed to all residents in care one week prior to their effective dates. Additionally, LPA Iniguez noted the presence of an alternate menu that is consistently available to residents at any time of day. This alternate menu is posted at the food bar in the facility's dining area. On November 6, 2025, during an interview, the Executive Director (A#1) stated that the facility follows a consistent process to ensure residents are informed about upcoming meals. When a new menu is developed, it is printed and posted in the dining area for visibility, and it is also distributed directly to all residents at least one week before the start of the menu cycle. This practice allows residents sufficient time to review meal options and communicate any dietary requests or preferences. Additionally, (A#1) confirmed that an alternate menu is always available to residents 24 hours a day. This alternative menu, which provides flexibility in meal choices outside of the standard range, is posted at the food bar in the dining area. When asked about any reported issues or delays in food service on November 4, 2025, (A#1) confirmed that there were no delays or concerns reported. The menu for that date had been posted and distributed in advance, and meal service was carried out as scheduled. On November 21, 2025, at approximately 10:00 am, interviews were conducted with residents (R#1 to R#9). (9) out of (9) reported that there were no delays in food service in the dining room during the week of November 4, 2025, and that they had not experienced any recent delays in receiving their meals. Additionally, (9) out of (9) residents confirmed that they receive the food menu each week, in accordance with the facility’s procedures for menu distribution. Evaluation Report continues LIC 9099-C On November 6, 2025, at approximately 11:00 AM, interviews were conducted with facility staff (S#1–S#9), (9) out of (9) reported that meals were served on time on November 4, 2025, and that menus had been distributed to residents one week in advance, in line with the facility's standard procedures. Furthermore, (9) out of (9) staff explained that if a staff member is unable to fulfill a resident's food order due to an unexpected situation, another staff member is quickly assigned to assist the resident, ensuring that service continues without delay. Allegation: Staff left resident unattended for an extended period of time The details of the complaint alleged that a resident was left unattended in the dining room for approximately one hour. On November 6, 2025, during an interview, Executive Director (A#1), LPA Iniguez inquired about the facility's supervision protocols for residents in common areas, particularly in the dining room. (A#1) confirmed that when residents are present in the dining room, staff members take note of their presence. Additionally, (A#1) mentioned that multiple staff members are present during mealtimes to ensure appropriate supervision and support. When asked if there had been any incidents or documentation regarding a resident being left unattended for an extended period, (A#1) stated that no such incidents have occurred and that residents are consistently monitored while in common areas. On November 21, 2025, at around 10:00 AM, interviews were conducted with residents (R#1 to R#9), (9) out of (9) reported that they had never seen another resident left alone in the dining area for an extended period. Additionally, (9) out of (9) residents expressed that they felt safe while in the dining room, and there are always staff members present. Evaluation Report continues LIC 9099-C On November 6, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1–S#9), (9) out of (9) confirmed that the dining staff are responsible for monitoring residents while they are in the dining area. They stated that it is an ongoing expectation to provide visual supervision of residents during mealtimes to ensure their safety and well-being. Furthermore, when asked if any staff had witnessed a resident being left alone in the dining room for an extended period, (9) out of (9) facility staff replied that they had never observed such an incident. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Stephanie Walters/ Senior Executive Director.the state’s words, verbatim · CDSS document, Nov 21, 2025 · control 11-AS-20251105144029

Allegation investigated: Staff financially abused resident

On 10/15/2025 at approximately 9:00 am, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met with Stephanie Walters / Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrators Interview (A#1), Residents Interview (R#1 and R#2), Witnesses Interviews (W#1 and W#2) and Facility Staff (S#1-S#5). LPA obtained and reviewed the following documents: Resident Roster dated: 10/15/25, Staff Roster or LIC 500 dated: 10/15/25. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff financially abused resident The details of the complaint alleged that (R#1 and R#2)’s caregiver (C#1) financially abusing them. On October 15, 2025, at approximately 1:00 PM, during the records review, LPA Iniguez reviewed the Staff Roster or LIC 500 dated: 10/15/25, LPA Iniguez observed that (C#1) is not listed on it. On October 13, 2025, at approximately 11:00 AM, Licensing Program Analyst (LPA) Alfonso Iniguez contacted Witness 1 (W#1) via telephone. LPA Iniguez introduced himself and explained that the purpose of the call was to gather additional information regarding an allegation of financial abuse involving Caregiver 1 (C#1) and Residents 1 and 2 (R#1 and R#2). On October 14, 2025, (W#1) confirmed that (C#1) is an outside caregiver who was privately contracted by the family of (R#1 and R#2) and clarified that (C#1) is not employed by the facility. On October 15, 2025, at approximately 10:30 AM, during an interview with (A#1), she stated that Caregiver 1 (C#1) is not a facility employee. (A#1) further explained that the facility had only recently become aware of the situation involving (C#1), allegedly financially abusing (R#1 and R#2) and during a conversation with (R#1 and R#2), (A#1) learned that the residents reported experiencing financial issues, including unexpected charges on food delivery applications, which they believed were made by (C#1). On October 15, 2025, at approximately 1:00 PM, LPA Iniguez spoke with (R#1). They reported that they had hired (C#1) as a private caregiver and companion, clarifying that (C#1) was not an employee of the facility. Additionally, (R#1) mentioned that (C#1) used to run errands, purchase items online, and order food through phone apps. However, they decided to terminate (C#1)'s services after noticing discrepancies in their credit card statements. Evaluation Report continues LIC 9099-C On October 15, 2025, at approximately 11:30 AM, during an interview with Witness 2 (W#2), they stated that that Caregiver 1 (C#1) was hired by Residents 1 and 2 (R#1 and R#2) in February of this year. Additionally, (W#2) confirmed that (C#1) is not an employee of the facility. On October 15, 2025, at approximately 12:00 PM, during an interview with the facility staff (S#1-S#5), (5) out of (5) stated that (C#1) was a private caregiver/companion hired by (R#1 and R#2) who used to run errands for them. Also, (5) out of (5) facility staff stated that (C#1) was not a facility employee. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Stephanie Walters/Executive Administrator.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 11-AS-20251010120127

Allegation investigated: Staff did not take proper steps to mitigate the spread of a communicable disease.

On 8/27/2025 at approximately 11:45 AM, LPA Alfonso Iniguez conducted a subsequent unannounced complaint visit. LPA Iniguez met Tommy Farid Taheri/Assistant Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Executive Director’s Interview (A#1), Residents Interviews (R#1-R#9) and Staff Interview (S#1-S#10). LPA obtained and reviewed the following documents: Resident Roster dated: 8/27/25, Staff Roster dated: 8/27/25, copy of facility’s Infection Control Plan dated: 7/15/25, Copies of Unusual Incident Report or LIC 624 dated: 8/15/25, 8/17/25, 8/19/25, 8/20/25 and 8/21/25, copy of email sent to the County Department of Public Health dated: 8/20/25. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff did not take proper steps to mitigate the spread of a communicable disease. The details of the complaint alleged that facility management are telling facility staff to come to work while they are sick. On August 27, 2025, at approximately 1:00 P.M., during the records review, LPA Iniguez observed the facility’s Infection Control Plan dated 7/15/25. LPA observed that the plan follows the following guidelines: Infection Control Lead, Infection Control Training, Standard Precautions, Hand Hygiene, Personal Protective Equipment, Cleaning and Disinfection, Respiratory Etiquette, Injections, Sharps, when a Resident has a Communicable Disease, and Emergency Infection Control Plan. Additionally, LPA Iniguez observed the copies of the Unusual Incident Reports or LIC 624 dated August 15, 25 17, 19, and 20, 25, and the Incident Reports were sent to CCLD via fax, along with a copy of the email sent to the County Department of Public Health dated August 20, 25. On August 27, 2025, at around 3:00 PM, during a health and safety check of the facility, LPA Iniguez observed hand sanitizing stations in the common areas and noticed signs in the elevators asking individuals to wear masks. On August 27, 2025, at approximately 12:00 PM, during an Interview with the Assistant Executive Director (A#1), he stated that the steps the facility take to mitigate the spread of Covid-19, or other infectious disease are the following: we immediately put up a letter to inform the residents regarding the active cases in the facility, we sanitized high traffic areas, we asked the residents if they present symptoms to self-isolate and of course if they agreed to do it. We also informed the Department of Public Health and CCLD regarding the active cases. Evaluation Report continues LIC 9099-C Additionally, (A#1) stated that facility staff do not come to work if they are diagnosed with COVID-19 or other infectious diseases, and he has never told a facility staff member to come to work when they are sick; on the contrary, he tells them to stay home. On August 27, 2025, at approximately 1:00 PM, during an interview with residents (R#1-R#9), (8) out of (9) stated that the facility has a protocol in place regarding COVID-19 or other infectious diseases. In addition, (9) out of (9) residents in care stated that they have not seen any facility staff coming to work sick. On August 27, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#10), (10) out of (10) stated that the facility has a protocol in place regarding COVID-19 or other infectious diseases. In addition, (10) out of (10) facility staff stated that they have not been asked by management to come to work while they are sick. During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Tommy Farid Taheri/Assistant Executive Director.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 11-AS-20250820132156

Allegation investigated: Staff does not ensure residents’ personal belongings are safely secured. Staff does not ensure facility is in good repair.

On August 03, 2025, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Sahar Masarati, the Executive Director of Enrichment, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above. The investigation included interviews, a collection of records, and a tour of the facility. Interviews were conducted with Resident #1 through Resident #10 (R1-R10), Staff #1 through Staff #7 (S1-S7), and Witness #1 (W1). The Department reviewed several documents, including the Personnel Report LIC 500 (dated 09/01/23 and 07/09/25), the Resident Roster (dated 01/22/25), Register of Facility Residents LIC 9020 (dated 06/13/25), and Resident #1 (R1)'s service records, as well as other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff does not ensure residents’ personal belongings are safely secured. It is claimed that the facility staff does not secure residents' personal belongings properly. The facility staff does not ensure that the personal belongings of Resident #1 (R1) are securely stored. It was reported that (R1’s) clothing frequently goes missing from (R1's) room but is sometimes returned. Management is aware of the issue regarding the missing items, yet no action has been taken to address it. No additional details regarding this matter have been provided. On July 10, 2025, between 11:18 AM and 03:59 PM, the Department interviewed the residents identified as Resident #1 through Resident #10 (R1-R10). Nine (9) out of the ten (10) residents were not able to validate this claim. Out of the ten (10) individuals interviewed, nine (9) expressed the belief that it is mainly the responsibility of residents to take proactive measures in securing their personal property. This statement emphasizes the importance of each person taking responsibility and staying alert to protect their belongings from theft and other risks. An interview with Resident #1 (R1) shed light on the situation that has persisted within (R1's) room for the past three years. (R1) disclosed that various personal items, particularly fabric textiles and arts and crafts materials, have gone missing over time. (R1) noted the concerns have been communicated to previous Executive Directors, yet no investigations or corrective actions have ever been initiated. (R1) is not able to pinpoint the exact timing of the last incident involving missing items or is unable to describe the items in detail. (R1) explained that the textiles stored in (R1's) closet can only be accessed through a bedroom door that is supposed to be securely locked. Neither staff members nor anyone outside of (R1's) spouse or roommate has a key to this door, making the situation even more perplexing. (R1) mentioned that some missing items sometimes come back unexpectedly. This adds a sense of mystery to the situation. This pattern has left (R1) feeling unsettled about the health and safety of residents in care. During the interview, (R1) talked more about the complaint from August 31, 2023, which included similar allegations. (R1) does not remember any recent activities related to this investigation. (Evaluation Report continues LIC 9099-C) Resident #11 (R11) identified as (R1’s) spouse and roommate declined to take part in an interview. On January 23, 2025, and July 10, 2025, between 11:08 AM and 4:12 PM, the Department conducted interviews with staff members identified as Staff #1 through Staff #7 (S1-S7). Seven (7) out of the seven (7) staff members stated that they could not corroborate the claim regarding missing property from Resident #1 (R1). They unanimously reported that they were not aware of any valuables missing from (R1). Additionally, all staff indicated they were only aware of one incident involving a resident and missing items, which had been reported, investigated, and resolved by Community Care Licensing (CCL). (S7) was not aware that (R1) had installed a security lock on (R1's) bedroom door. (S7) asserted that only housekeepers and maintenance staff possess keys to residents' units. Each time staff access these units, the action is carefully registered and logged. On July 15, 2025, between 09:40 AM and 10:0 AM, the Department interviewed the witness identified as family member of (R1), Witness #1 (W1). (W1) was unable to verify this claim. (W1) clearly explained the situation. In the past, (R1) and spouse owned a home near the facility, where (R1) experienced security issues. (W1) mentioned that (R1's) unresolved experiences are believed to be the main reason behind (R1’s) ongoing trust concerns. As a result, (R1) has struggled with persistent senses of anxiety and distrust over the years, which can be incredibly challenging to manage. A review of Resident #1 (R1's) Physician's Report LIC 602A (dated 11/07/24) revealed that (R1) is diagnosed with anxiety, with no mental condition. However, a review of Physicians Prescribed Medications (dated 06/30/21) exhibited that (8) out of the (14) medications have side effects linked to the cognitive impacts, confusion, difficulty concentrating, dizziness, anxiety, or blurred vision (ref: National Institute of Health (NIH). A review of (R1's) Theft and Loss Policy (dated 06/30/21) does not include a list of any valuable inventory. Further review of (CCL) Complaint # 11-AS-20230831163759 (dated 08/31/23) verified the same allegation was investigated and determined unsubstantiated. The Department inspected Resident #1's (R1’s) room and found the space to be well-used, with evidence of creative projects and mementos. Although some disorganization was present, it serves to identify the significance of some personal items that may be displaced. Based on the information gathered, there is not enough evidence to corroborate the allegation mentioned above. (Evaluation Reports continues LIC 9099-C) Allegation #2: Staff does not ensure facility is in good repair. The complaint details an allegation that the facility staff does not ensure the facility is in good repair. Specifically, it has been reported that two out of the three elevators are out of order, a situation that has persisted since November 2024. Additionally, reports indicate that more residents are to be admitted due to the Pacific Palisades fires, raising concerns about safety with only one functioning elevator. No further details regarding this issue were provided. On January 23, 2025, and July 10, 2025, between 11:08 AM and 04:12 PM, the Department interviewed the staff identified as Staff #1 through Staff #7 (S1-S7). Six (6) out of the seven (7) staff members were unable to validate this claim pertaining to non-operable elevators. Six (6) out of the seven (7) staff members confirmed that the facility has two functional elevators. During the interview with (S1), it was mentioned that one of the elevator's cabling wires has begun to tear, so it is currently under repair. Both (S1 and S7) reported that there has never been more than one elevator out of order at the same time. Whenever an elevator malfunctions, it is immediately noted for repair on the same day the issue occurs. (S1) mentioned that elevator repairs are managed by a third-party vendor and not carried out by the maintenance crew in-house. Consequently, delays often occur while waiting for parts to be ordered. (S1 and S7) have a verified contract agreement with TKE Elevator Corporation, and the Maintenance Log and Repair Log tracks the maintenance performed. On July 10, 2025, between 11:18 AM and 03:59 PM, the Department interviewed the residents identified as Resident #1 through Resident #10 (R1-R10). Nine (9) out of the ten (10) residents were not able to support this claim. Four (4) out of ten (10) residents acknowledged that the facility had non-operational elevators. However, nine (9) out of ten (10) respondents stated that at least two functioning elevators were always available, ensuring that it has never been an inconvenience. They acknowledge that, like most equipment used daily, elevators require preventive maintenance to ensure safety. A review of the facility's Maintenance and Repair Logs, covering the period from (November 14, 2024, to July 20, 2025), revealed a comprehensive record of elevator incidents, including specific dates and times of each occurrence, alongside the actual commencement and completion dates of the corresponding repairs. (Evaluation Report continues LIC 9099-C) This review confirmed that at no point was more than one elevator undergoing maintenance simultaneously, ensuring minimal disruption to service. Moreover, it was noted that repairs are consistently carried out on the same day as each incident, underlining the facility's commitment to prompt response and effective management of elevator operations. Further examination of the contract with TK Elevator Corporation, (dated 12/18/24), confirmed the existence of a proactive service agreement for ongoing support and maintenance of the facility's elevators. The inspections conducted on (07/10/24, and 08/03/25), confirmed that all elevators were in working condition. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. An exit interview was conducted with the Director of Enrichment, Sahar Masarati, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Aug 3, 2025 · control 11-AS-20250116144249

Type of visit: Case Management - Incident

On July 9, 2025, at approximately 1:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced Case Management visit at the facility. LPA met Farid Tommy Taheri/Assistant Executive Director and explained the purpose of the visit. On 5/28/25 the Regional Office received an Unusual Incident Report stating that several items were missing from (R#1 and R#2)’s room. The missing items include: - A check for $2,900 - Six unauthorized charges on a credit card - Two missing credit cards belonging to (R#2) - $300 in cash - A wedding band. On 7/9/2025, LPA Iniguez conducted the following interviews: Residents and witness interview (R#1, R#2 and W#1). In addition, LPA Iniguez gathered documentation pertaining to this investigation. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Farid Tommy Taheri/Assistant Executive Director.the state’s words, verbatim · CDSS document, Jul 9, 2025

Allegation investigated: Questionable death. Facility staff did not meet resident's oxygen needs.

This report supersedes the previous reports LIC9099 and LIC9099-C, created on May 15, 2025. The findings regarding the complaint remain unchanged. On June 05, 2025, LPA Richard conducted a subsequent visit and met with Senior Executive Director Stephanie Koffman and explained the purpose of this visit. On 5/15/25, at approximately 8:30 AM, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Stephanie Koffman-Senior Executive Director and explained the purpose of this visit. Investigation consisted of the following: The department obtained and reviewed copies of the staff and resident rosters, Resident (R1)’s physician’s report, Centrally Stored Medication and Destruction Record, and Admission Agreement. The department obtained and reviewed the concluded summary of the Los Angeles Fire Department report #1077, the 911 recording from the Los Angeles County Fire Department, and the Los Angeles Police Department report for the January 31, 2024, incident involving R1. The department obtained and reviewed the Los Angeles County coroner's report and death certificate for R1. The department conducted interviews with residents (R2-R3), staff (S1-S4), and Administrator/Litit Mnatsakanyan (A1), and R1’s private caregiver (W1). Unsubstantiated Investigation revealed the following Allegation #1: Questionable death The complaint alleges that R1 passed away due to the facility staff's failure to provide lifesaving oxygen. The department interviewed with A1, who stated that R1 required assistance with medication management and oxygen device maintenance. A1 stated R1 was independent in all other areas of daily living. The department interviewed with S2. S2 stated at 9:30 am, on January 31, 2024, S2 administered R1’s medication and ensured R1’s oxygen cannula was properly placed. At 11:30 AM, staff (S2) returned to R1’s room, inspected R1’s oxygen equipment, and utilized R1's pulse oximeter to measure R1’s oxygen saturation levels and oxygen levels were at 93-95%. S2 observed that R1's oxygen cannula was not properly positioned, and S2 repositioned R1’s nasal cannula. R1 was sleeping when S2 repositioned R1’s nasal cannula. R1 woke while receiving assistance from S2 and asked S2 to leave, so that R1 could go back to sleep. S2 stated during the 11:30 am visit with R1, S2 did not observe any signs of a respiratory deficiency, nor did R1 report having difficulties breathing. At approximately 12:30 pm, S2 conducted a status check on R1. S2 found R1 was lying in bed and napping. During this status check, W1 was present and asked S2 to return at 1:30 pm, as R1 would be awake. W1 reported no issues to S2 during this status check. At approximately 1:30 pm, S2 returned to R1's room and found R1 still sleeping. W1 informed S2 that R1 requested not to be disturbed. At approximately 3:00 pm, W1 approached S2 to report that R1 was experiencing shortness of breath. S2 called 911 while returning to R1’s room. S2 observed that R1 was “gurgling”. S2 checked R1’s airway and was instructed by 911 to begin CPR. At approximately 3:15 pm, EMS arrived and continued care. At 3:57 PM, R1 was pronounced deceased. The cause of death was determined to be cardiac arrest due to hypoxia, severe gastroparesis, and diabetes mellitus type II. Evaluation Report Continues LIC9099-C Based on the evidence gathered, interviews, and records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. As a result, the allegation is Unsubstantiated. Allegation #2: Facility staff did not meet the resident’s oxygen needs. It is alleged that the facility staff failed to meet the Resident's (R1) oxygen needs and this resulted in R1’s oxygen saturation level to drop below sixty (60). On April 10,2024, the department interviewed S2, who stated that on January 31, 2024, at 9:30 AM, S2 checked on Resident R1 to administer medications and ensure R1's oxygen cannula was properly placed. At approximately 11:30 am, S2 returned to R1’s room and checked R1’s oxygen levels, which were between 93% and 95%. S2 observed that R1's oxygen cannula was not positioned correctly and S2 provided assistance by repositioning R1’s oxygen cannula. S2 stated there were no signs of respiratory distress, and R1 did not report any difficulties in breathing. At approximately 12:30 pm, S2 conducted a status check on R1 and found R1 lying in bed and napping. W1 was present during the check and reported no issues to S2. At approximately 1:30 pm, S2 returned to R1's room and saw that R1 was still sleeping. W1 informed S2 that R1 had requested not to be disturbed. At approximately 3:00 PM, W1 approached S2 to report that R1's mouth was open and that R1 was gasping for air. S2 called 911, and the operator instructed S2 begin CPR. According to departmental records, Emergency Medical Services (EMS) arrived at 3:15 PM, and CPR continued during their arrival. EMS administered (3) doses of epinephrine; however, R1 did not respond to treatment and was pronounced deceased at 3:57 PM. Evaluation Report Continues LIC9099-C On February 27, 2024, the department interviewed four staff members, S1, S2, S3, and S4, all of whom denied the allegation. The department also interviewed two residents, R2 and R3, who both expressed that they enjoy living there and feel well cared for by the staff. Based on the evidence gathered, interviews, and records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. As a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of the report was provided to the Senior Executive Director Stephanie Koffman.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 11-AS-20240209102246

Allegation investigated: Licensee did not comply with facility theft and loss program requirements. Staff did not safeguard resident's personal belongings.

On 5/15/24, at approximately 8:30 AM, Licensing Program Analyst-PA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Stephanie Koffman-Senior Executive Director and explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Senior Executive Director Interview (A#1), Residents 1 Interview (R#1) and Witness 1 interview (W#1). LPA obtained and reviewed the following documents: Resident Roster dated:5/6/25, Staff Roster dated:3/22/25, Copy of the Health and Safety Code 1569.153 regulation, copy of Los Angeles Police Department Victim’s Supplemental Property Loss Report filled by (R#1) and dated on:8/26/24, Copy Excel spreadsheet of facility Initial Employee Trainings dated:9/20/2024, copy of 2024 facility staff trainings, copy of (R#1)’s of 1st Admissions Agreement dated:6/30/23, copy of (R#1)’s 2nd Admissions Agreement dated: 7/24/24, copy of (R#1)’s Client/Resident Personal Property and Valuables or LIC 621 dated: 7/5/24 and 7/25/24, and copy of (R#1)’s Physicians Report for Residential Care Facilities for the Elderly(RCFE) or LIC 602A dated:7/9/23. Evaluation Report continues LIC 9099-C Substantiated Investigation Revealed the Following: Allegation: Licensee did not comply with facility theft and loss program requirements. The details of the complaint alleged that licensee did not comply with the theft and loss program requirements of the Health and Safety Code 1569.153. On May 2, 2025, at approximately 8:30 AM, the Licensing Program Analyst (LPA), Iniguez, observed a copy of (R#1) 's Admissions Agreement dated:6/30/23; the admission package did not include the Client/Resident Personal Property and Valuables or LIC 621 on it. Also, LPA Iniguez reviewed (R#1) 's second Admissions Agreement dated: 7/24/24, there was a Client/Resident Personal Property and Valuables or LIC 621 with two different dates: 7/5/24-signed by (R#1), and 7/25/24-signed by facility staff. The form has (R#1) 's name and social security number written, but no personal items were listed. Moreover, LPA Iniguez observed (R#1)’s Physicians Report for residential Care Facilities for the Elderly (RCFE) or LIC 602A dated:7/9/23, LPA Iniguez noticed that it is marked that (R#1) is not confused and disoriented, can follow instructions, and can communicate their needs. In addition, LPA Iniguez reviewed the Excel spreadsheet for the facility's Initial Employee Training, dated September 20, 2024, during a records review, LPA Iniguez noted that the spreadsheet did not include any information regarding the theft and loss program for new employees, which should be addressed within the first 90 days of employment, based on the Health and Safety Code 1569.153(b) regulation. In addition, LPA Iniguez reported that five staff members were hired in 2024, as indicated in the Personnel Report or LIC 500 dated September 1, 2024. Additionally, during a review of the facility's Course Completion History for 2024, LPA Iniguez noted that none of the five employees received training on the orientation to the policies and procedures of the theft and loss program, as required by Health and Safety Code 1569.153(b) regulation. Evaluation Report continues LIC 9099-C On 9/18/24, at approximately 12:00 PM, during an interview with (R#1), they stated that when they moved in, they felt that they were not aware of what they were signing and felt pressure to sign documents they did not understand. Also, (R#1) stated that the facility failed to provide a copy of their signed LIC 621 twice. Allegation:Staff did not safeguard resident's personal belongings. The details of the complaint alleged that facility staff did not safeguard (R#1)’s personal belongings. On September 18, 2024, during an initial complaint investigation at approximately 9:00 AM, LPA Iniguez conducted a health and safety check of the facility and (R#1) 's room, accompanied by (R#1). LPA Iniguez asked (R#1) about the missing items from their room. (R#1) mentioned that they noticed some jewelry was missing on the evening of the incident. They also discovered that five designer bags were gone a few days later. (R#1) explained that the jewelry was kept in a locked drawer, while the designer bags were in another piece of furniture in their bedroom, next to their bed. LPA observed where (R#1) stored their handbags and noted that only the dust bags bearing the designer's name were left behind. Photos were taken as evidence. Additionally, (R#1) showed LPA where their jewelry was stored. LPA observed that the jewelry was kept in a small drawer next to the bathroom and noted that (R#1) had not locked that drawer. During the records review, LPA Iniguez observed that on 8/26/24, (R#1) filled out the Los Angeles Police Department Victim's Supplemental Property Loss Report, detailing stolen jewelry and its value. (R#1) claims that an unknown individual entered the facility that day and was escorted out by facility staff after 30 minutes being inside. Additionally, LPA reviewed the facility's video footage from the day of the incident. The video shows the intruder conversing with (R#1) in the elevator, during which the intruder asked (R#1) for their room number, to which (R#1) responded. LPA also viewed photographs of (R#1) 's jewelry that a friend had taken, identified as Witness #3 (W#3). (R#1) had requested (W#3) to document the jewelry with photographs. Evaluation Report continues LIC 9099-C On 9/18/24, at approximately 11:00 AM, during an interview with the executive director (A#1), she stated that the day that (R#1) reported the missing items, a police report was made. In addition, (A#1) stated that there are no cameras on the hallways, only in the lobby and elevator, there is no video footage of an intruder going inside (R#1) 's room, and the resident's door locks use regular keys. Moreover, (A#1) stated that she observed (R#1) came down to the bistro, they would always have a purse and some jewels on her. On 9/18/24, at approximately 12:00 PM, during an interview with (R#1), they stated that they always locked their door every time they go out. (R#1) mentioned that on the evening of the event, they noticed some jewelry was missing, and a few days later, they discovered five designer bags were missing. (R#1) explained that the jewelry was in a drawer with a lock, and the designer bags were in their bedroom next to her bathroom in a drawer. (R#1) stated that there were no signs of forceful entry on the door. (R#1) noted that a passkey can only open the door; the facility staff has this passkey. Additionally, (R#1) stated that they are living independently and can do their ADLs without staff assistance. (R#1) also stated that they can make their own medical and financial decisions. On 9/18/24, at approximately 1:00 PM, during an interview with facility staff (W#2), she stated she had been (R#1) 's housekeeper since they moved into the facility. (W#2) stated that she had seen (R#1) 's jewelry and handbags in (R#1) 's room. On 9/18/24, at approximately 2:00 PM, during an interview with (W#3), they stated that they took the pictures of (R#1) 's jewelry as requested by (R#1); also, (W#3) stated that they have seen (R#1) 's handbags and jewels. Evaluation Report continues LIC 9099-C During this investigation, LPA found sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Stephanie Koffman / Senior Executive Director. Investigation Revealed the Following: Allegation: Staff did not ensure a safe environment was provided for residents. The details of the complaint alleged that facility staff did not ensure a safe environment was provided for (R#1) and the other residents in care. On May 15, 2025, at approximately 1:00 PM, during a Health and Safety check at the facility, LPA Iniguez observed that a security guard was rounding the facility grounds. LPA Iniguez also observed the video cameras placed in the common areas and the secured gate by the parking entrance. In addition, LPA Iniguez observed the electronic sign-in system to register all visitors and vendors to the facility. On May 15, 2025, at approximately 9:30 AM, during an Interview with the Administrator (A#1), she stated that the facility offers a safe environment for all residents in care. In addition, (A#1) state that the facility has a security guard available 24/7 who patrols the building. Additionally, there is video monitoring, a gated garage equipped with video surveillance and a call box, as well as an electronic sign system. On May 15, 2025, at approximately 11:00 AM, during interviews with residents (R#1-R#12), (11) out of (12) stated that they think the facility offers a safe environment for them and everyone else. In addition, (11) out of (12) residents stated that they feel safe living here. On May 15, 2025, at approximately 10:00 AM, during interviews with facility staff (S#1-S#8), (8) out of (8) stated that they think the facility offers a safe environment for all residents in care. Evaluation Report continues LIC 9099-C Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Stephanie Koffman / Senior Executive Director.the state’s words, verbatim · CDSS document, May 15, 2025 · control 11-AS-20240910162855

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(2) · Plan of correction due date: Jul 15, 2025

87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153. This requirement was not met as evidence by: Based on a review of records and interviews, the facility failed to create and give the LIC 621 form to (R#1) upon admission on 2023 and second time they move on 2024, also, the facility failed to train facility staff regarding the orientation to the policies and procedures for all employees within 90 days of employment. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, May 15, 2025

Plan of correction: The licensee will adhere to Title 22 regulations at all times. The licensee shall reimburse (R#1) for or replace stolen or lost (R#1)'s property at its current value listed on the police report. Before the due date, a plan of correction (POC) will be submitted to the department.

Allegation investigated: Questionable death. Facility staff did not meet resident's oxygen needs.

On 5/15/24, at approximately 8:30 AM, Licensing Program Analyst-PA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Stephanie Koffman-Senior Executive Director and explained the purpose of this visit. Investigation consisted of the following: The department obtained and reviewed copies of the staff and resident rosters, Resident (R1)’s physician’s report, Centrally Stored Medication and Destruction Record, and Admission Agreement. The department obtained and reviewed the concluded summary of the Los Angeles Fire Department report #1077, the 911 recording from the Los Angeles County Fire Department, and the Los Angeles Police Department report for the January 31, 2024, incident involving R1. The department obtained and reviewed the Los Angeles County coroner's report and death certificate for R1. The department conducted interviews with residents (R2-R3), staff (S1-S4), and Administrator/Litit Mnatsakanyan (A1), and R1’s private caregiver (W1). Evaluation Report Continues LIC9099-C Unsubstantiated Investigation revealed the following Allegation #1: Questionable death The complaint alleges that R1 passed away due to the facility staff's failure to provide lifesaving oxygen. The department interviewed with A1, who stated that R1 required assistance with medication management and oxygen device maintenance. A1 stated R1 was independent in all other areas of daily living. The department interviewed with S2. S2 stated at 9:30 am, on January 31, 2024, S2 administered R1’s medication and ensured R1’s oxygen cannula was properly placed. At 11:30 AM, staff (S2) returned to R1’s room, inspected R1’s oxygen equipment, and utilized R1's pulse oximeter to measure R1’s oxygen saturation levels and oxygen levels were at 93-95%. S2 observed that R1's oxygen cannula was not properly positioned, and S2 repositioned R1’s nasal cannula. R1 was sleeping when S2 repositioned R1’s nasal cannula. R1 woke while receiving assistance from S2 and asked S2 to leave, so that R1 could go back to sleep. S2 stated during the 11:30 am visit with R1, S2 did not observe any signs of a respiratory deficiency, nor did R1 report having difficulties breathing. At approximately 12:30 pm, S2 conducted a status check on R1. S2 found R1 was lying in bed and napping. During this status check, W1 was present and asked S2 to return at 1:30 pm, as R1 would be awake. W1 reported no issues to S2 during this status check. At approximately 1:30 pm, S2 returned to R1's room and found R1 still sleeping. W1 informed S2 that R1 requested not to be disturbed. At approximately 3:00 pm, W1 approached S2 to report that R1 was experiencing shortness of breath. S2 called 911 while returning to R1’s room. S2 observed that R1 was “gurgling”. S2 checked R1’s airway and was instructed by 911 to begin CPR. At approximately 3:15 pm, EMS arrived and continued care. At 3:57 PM, R1 was pronounced deceased. The cause of death was determined to be cardiac arrest due to hypoxia, severe gastroparesis, and diabetes mellitus type II. Evaluation Report Continues LIC9099-C Based on the evidence gathered, interviews, and records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. As a result, the allegation is Unsubstantiated. Allegation #2: Facility staff did not meet the resident’s oxygen needs. It is alleged that the facility staff failed to meet the Resident's (R1) oxygen needs and this resulted in R1’s oxygen saturation level to drop below sixty (60). On April 10,2024, the department interviewed S2, who stated that on January 31, 2024, at 9:30 AM, S2 checked on Resident R1 to administer medications and ensure R1's oxygen cannula was properly placed. At approximately 11:30 am, S2 returned to R1’s room and checked R1’s oxygen levels, which were between 93% and 95%. S2 observed that R1's oxygen cannula was not positioned correctly and S2 provided assistance by repositioning R1’s oxygen cannula. S2 stated there were no signs of respiratory distress, and R1 did not report any difficulties in breathing. At approximately 12:30 pm, S2 conducted a status check on R1 and found R1 lying in bed and napping. W1 was present during the check and reported no issues to S2. At approximately 1:30 pm, S2 returned to R1's room and saw that R1 was still sleeping. W1 informed S2 that R1 had requested not to be disturbed. At approximately 3:00 PM, W1 approached S2 to report that R1's mouth was open and that R1 was gasping for air. S2 called 911, and the operator instructed S2 begin CPR. According to departmental records, Emergency Medical Services (EMS) arrived at 3:15 PM, and CPR continued during their arrival. EMS administered (3) doses of epinephrine; however, R1 did not respond to treatment and was pronounced deceased at 3:57 PM. Evaluation Report Continues LIC9099-C On February 27, 2024, the department interviewed four staff members, S1, S2, S3, and S4, all of whom denied the allegation. The department also interviewed two residents, R2 and R3, who both expressed that they enjoy living there and feel well cared for by the staff. Based on the evidence gathered, interviews, and records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. As a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of the report was provided to the administrator.the state’s words, verbatim · CDSS document, May 15, 2025 · control 11-AS-20240209102246

Type of visit: Case Management - Incident

On 5/15/25, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management visit at the facility. The LPA met with Farid Taheri, the Assistant Executive Director, and explained the purpose of the visit. On 5/14/25, the Regional office received a SOC 341 stating that (2) facility employees (S#1 and S#2) were observed by another facility employee (W#1) were “joking around” with a dementia resident (R#1), also (W#1) believes that they might have seen (S#1 and S#2) tapping towards (R#1) inner thigh and they saying “no stop it”. LPA collected phone numbers of (S#1 and S#2) and (W#1). Acording to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Farid Taheri/Assistant Executive Director.the state’s words, verbatim · CDSS document, May 15, 2025

Type of visit: Required - 1 Year

On 3/10/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Stephanie Koffman /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (237) elderly adults ages 60 and above, of which (237) can be non-ambulatory and (25) bedridden on the 3rd floor. Approved for delayed egress. The facility has an approved hospice waiver for (25). Currently the facility has (136) residents. The facility features approximately (188) living units and around (225) bathrooms, spread across (14) stories with underground parking. The building is beige and predominantly made of glass. On the first floor, there is a full catering kitchen, a dining area, a lobby, conference room space, restrooms, a reception area, and (3) elevators. Additionally, a sitting area with an enclosed fireplace and a large outdoor patio with a fireplace and seating are also available. The 2nd floor includes a salon, a fitness center, storage space, and administrative office space. The 3rd floor is dedicated to residential accommodations for individuals requiring memory care support, with 18 apartments, a dining space that includes a patio, and some office space. Floors 4th to 7th are designated for assisted living residences, while floors eight to fourteen house units for independent living. LPA Iniguez and the Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (7) bedrooms and (7) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113.5°F to 117.2°F, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 9/3/24. A review of (5) residents' service files and (10) staff personnel files. LPA reviewed (5) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -9 facility employees not associated on guardian. (Civil Penalty Rendered). -3 Facility employees with no TB Test/Health Screening on file. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Stephanie Koffman / Executive Director.the state’s words, verbatim · CDSS document, Mar 10, 2025

Allegation investigated: Staff transported clients while under the influence of marijuana.

On 12/30/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Stephanie Koffman / Senior Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#6) and Resident’s interviews (R#1-R#5). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, copies of November and December resident outing sign up list. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff transported clients while under the influence of marijuana. The details of the complaint alleged that facility driver transported residents while under the influence of marihuana. During the records review, LPA Iniguez observed the names of the residents who had driven by (S#1) in the past month and interviewed those residents. During an interview with the administrator (A#1), she stated that the facility has five facility staff who drive the residents in the facility cars (2). In addition, (A#1) stated that she has never received a complaint from residents or staff regarding (S#1) driving under the influence of marijuana. During interviews with residents (R#1-R#5), (4) out of (5) stated that they had never seen or smelled marijuana or cigarettes while riding with (S#1). During interviews with staff (S#1), they state that they have never been under the influence of marihuana while at work or driving the residents in care. During interviews with facility staff (S#2-S#6), (4) out of (5) stated that they had never seen or noticed (S#1) smoking or under the influence of marihuana while at work. On the other hand, (1) out of (5) staff stated that they have heard from another staff that (S#1) uses marihuana while at work. Evaluation Report continues LIC 9099-C During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Stephanie Koffman-Senior Executive Director.the state’s words, verbatim · CDSS document, Dec 30, 2024 · control 11-AS-20241227134058

Type of visit: Case Management - Other

On December 17,2024 Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management visit. The LPA met with Stephanie Koffman, Senior/Executive Director, and explained the purpose of the visit. While conducting another Case Management at the facility, LPA Iniguez requested more documentation regarding open investigation pertaining to complaint #11-AS-20240910162855. The Senior Executive Director provided copies of the documentation. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Stephanie Koffman / Senior Executive Director.the state’s words, verbatim · CDSS document, Dec 17, 2024

Type of visit: Case Management - Deficiencies

On November 7,2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management visit. LPA met with Stephanie Koffman / SeniorExecutive Director and the purpose of the visit was explained. During the review of records related to an ongoing investigation at the facility, the Department discovered that the surveillance cameras in the common areas were equipped with audio recording capabilities. This practice infringes upon the privacy rights of the residents. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See D page for more information. Technical Advisory Note given. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Stephanie Koffman / Senior Executive Director.the state’s words, verbatim · CDSS document, Nov 7, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Nov 18, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement was not met as evidenced by: Based on records reviews, the licensee failed to accommodate the privacy level of the residents in care by having audio in the video camera system in place by the facility, this poses a potential health and sefety risk for the residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: The Licensee will ensure that video surveillance cameras do not always have audio. Per the Plan of Correction, the Licensee will mute the audio on the video recording system. Executive Director will email LPA when the facility removes audio from video cameras.

Type of visit: Case Management - Other

On November 7, 2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management visit. The LPA met with Stephanie Koffman, Senior/Executive Director, and explained the purpose of the visit. While conducting another Case Management at the facility, LPA Iniguez requested more documentation regarding open investigation pertaining to complaint #11-AS-20240910162855. The Senior Executive Director provided copies of the documentation. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Stephanie Koffman / Senior Executive Director.the state’s words, verbatim · CDSS document, Nov 7, 2024

Allegation investigated: Residents pendents are disabled due to transition between new management company.

On 09/18/24 Licensing program analyst (LPA) Lizeth Villegas conducted a subsequent visit to deliver complaint findings. LPA met with Executive Director (ED) Stephanie Koffman as the purpose of the visit was explained. The investigation consisted of the following: On 04/25/24 (LPA) Wendy Gibbs conducted initial visit and conducted the following: a tour the facility, pendant test for bedrooms #502 and #608, interviews with staff (S1-S10), and interviews with residents (R1-R4). On 04/25/24 LPA Wendy Gibbs obtained the following documents: staff Roster, resident Roster, email to staff regarding room checks, room check log, death report, needs and service plan, admission evaluation, and physicians report. On 09/18/24 LPA Lizeth Villegas obtained a copy of the staff and resident rosters and conducted a tour, interviews with executive director (ED), and residents #5-10 (R5-R10). The investigation revealed the following: Substantiated Allegation: Residents pendents are disabled due to transition between new management company. It is being alleged that residents’ pendants and bedroom phones have not been working for 5 days due to change in management companies. On 04/25/24 LPA Wendy Gibbs conducted interviews with staff #1-10 (S1-S10) regarding the allegation above, 9 of 10 staff interviewed confirmed the allegation above and reported the phones and pendants were down for a couple of days. 1 of 10 staff interviewed reported being unaware of the residents’ phones and pendants being down. On 04/25/24 LPA Wendy Gibbs conducted interviews with residents #1-4 (R1-R4) regarding the allegation above, 2 of 4 residents interviewed confirmed pendants were down, 2 of 4 residents interviewed reported being unaware of the pendants being down as the pendants are not used regularly. On 09/18/24 LPA Villegas conducted interview with resident 5-10 (R5-R10) regarding the allegation above, 3 of 6 residents interviewed confirmed pendants were down, 3 of 6 residents interviewed denied the allegation above. On 09/18/24 LPA Villegas conducted interview with executive director (ED) regarding the allegation above, Per ED, ED has no knowledge of the allegation above as ED was employed after the change in management. On 09/18/24 LPA conducted tour of the facility and conducted a pendant test of 3 random pendants, pendant were observed to be operational with response time of 5-8 minutes. Based on LPAs observations, interviews, and record review(s) conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview conducted with Executive Director Stephanie Koffman, appeal rights explained, and a copy of this report was provided. Allegation: Residents missed meals due to phones not working due to transition between new management company It is being alleged that residents were unable to order their meals due to the phones being down. On 04/25/24 LPA Wendy Gibbs conducted interviews with staff #1-10 (S1-S10) regarding the allegation above, 6 of 10 staff interviewed reported being unaware of the allegation above, 2 of 10 staff interviewed denied the allegation above and reported meals were provided to all residents in care, 2 of 10 staff interviewed confirmed the allegation and stated there were residents who reported not receiving a meal. On 04/25/24 LPA Wendy Gibbs conducted interviews with residents #1-4 (R1-R4) regarding the allegation above, 4 of 4 residents interviewed denied the allegation above and reported receiving 3 meals a day. On 09/18/24 LPA Villegas conducted interview with resident 5-10 (R5-R10) regarding the allegation above, 6 of 6 residents interviewed denied the allegation above and reported receiving 3 meals a day. On 09/18/24 LPA Villegas conducted interview with executive director (ED) regarding the allegation above, per ED since ED took over there have been no issues with the facility phones and there have been no reports of any residents missing any meals. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director Stephanie Koffman, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 11-AS-20240419164424

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A-C) · Plan of correction due date: Sep 19, 2024

Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more... shall have a signal system which shall: operate from each resident's living unit. transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. Identify the specific resident living unit. Based on interviews and records review the facility transition from watermark retirement communities a to integral senior living the signal system was not operation with includes residents pendants, this poses a health and safetythe state’s words, verbatim · CDSS document, Sep 18, 2024

Plan of correction: Deficiency corrected at the time of visit, visit was done on 4/25/24.

Type of visit: Case Management - Other

On 8/30/24, Licensing Program Analysts (LPAs) Alfonso Iniguez and Yolanda Rosser conducted an unannounced Case Management visit at the community named above. The LPAs met with Stephanie Koffman, Senior Executive Director, and explained the reason for the visit in detail. On 8/28/2024, the El Segundo Regional Office received reports of a male dressed as a service worker entering community care facilities in the Westwood area. The Executive Director stated that the facility has many security filters, including the parking lot, main entrance, and elevator access. She stated that on the day of the occurrence, the individual just walked in using the main entrance door at approximately 11:30 AM and was escorted out at 12:08 PM. In addition, the Executive Director stated that the receptionist had just stepped out from the front desk to make a copy when the individual walked by and got into the community. The Executive Director emphasized the facility's commitment to staff training and safety. She stated that on the day of the event, there were sufficient staff at the facility. In addition, she highlighted the all-staff In service they conducted regarding these events, demonstrating their proactive approach to alerting everyone and keeping a close eye on security. The Executive Director stated that the residents who had their items stolen signed the form for Safeguard of Property and Valuables but did not list any personal items. During this visit LPAs conducted the following: -A health and safety check of the facility. -Copies of the staff roster and resident’s roster. -LPAs received copies of pictures of the intruder that went inside facility. -Copies of Staff in-service training -Copies of resident SPV form and theft and lost procedures admissions agreement. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPAs did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Stephanie Koffman/Senior Executive Directorthe state’s words, verbatim · CDSS document, Aug 30, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection. LPA met with Mariam Gezalian (Business Office Manager) and Lilit Mnatsakanvan ( Executive Director) and the purpose of the visit was discussed. Facility is licensed to serve 237 non ambulatory ages 60 and over of which 25 maybe bedridden on the 3rd floor and below is approved for bedridden. #rd floor only approved for delayed egress. A hospice waiver is approved for 25 residents. The facility does not handle any of the residents’ money: Facility has approx.188 living units, approx. 225 bathrooms, 14 stories with underground parking. The facility is beige in color and consist mostly of glass. On the first floor, the facility has a full catering kitchen, dining area, lobby, conference room space, restrooms, reception area, 3 elevators and a sitting area with an enclosed fireplace. There is also a large outdoor patio with a fireplace and seating. On the second floor, there is a salon and fitness center, storage space and administrative office space. The third floor consist of residential space for individuals that need support with memory care. There is a total of 18 apartments, a dining space with patio and some office space. Floors four to seven consist of residential space for assisted living. Floors eight to fourteen consist of units for independent living. All units come unfurnished. The units are spacious and will easily accommodate furnishings. There are no open bodies of water on the premises. All passageways, walkways, driveways, steps and patios are free from obstructions. Front, back and side areas are free of hazards. Building is equipped with a backup generator on-site. Facility has a full sprinkler No pool or jacuzzi onsite but pets will be allowed. LPA toured (5) Resident bedrooms and bathrooms, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 118 and 120F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational Fire drills are conducted and documented quarterly for each floor.. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. No Deficiencies were cited. A copy of the report was left Executive Director Lilit Mnthe state’s words, verbatim · CDSS document, Mar 27, 2024

Allegation investigated: Facility is not following Emergency Disaster Plan protocols.

On 01/17/2024 9:20 AM, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to investigate the following allegations. LPM and LPA met with Business Office Manager Mariam Gezalian and explained the purpose of the visit. Administrator Lilit Mnatsakanyan joined the inspection later. The investigation consisted of the following: During today’s investigation LPM, LPA, and staff conducted a tour of the facility which included the 14th floor, 3rd floor (Memory Care), 2nd Floor, and stairwells. LPM and LPA interviewed the Administrator and seven (7) staff members and interviewed 10 out of 101 residents. LPM and LPA reviewed the register of residents, Fire Safety Inc’s Fire Drill Reports conducted on 09/23/23, 10/30/23, 12/08/23, and 12/19/23, Personnel Report (LIC 500), and emergency disaster plan. Continue to LIC 9099-C. Unsubstantiated The investigation revealed the following: Regarding the allegation "Facility is not following Emergency Disaster Plan protocols," it is being alleged that the facility does not have a register of residents that indicates each resident’s location and ambulatory status readily available to first responders and that staff do not know what to do during emergency disaster drills. Record reviews indicate that the facility maintains an updated register of residents that indicates residents’ location and ambulatory status. During today’s visit, LPA requested the register of residents from the facility’s Administrator and Concierge, and it was provided on both occasions. Interviews with the Administrator and Director of Resident Care indicated that the register of residents will be provided to first responders. Record reviews indicate that fire safety and disaster trainings provided by outside vendor included instructions on how to evacuate residents during emergencies. LPA conducted record review of emergency disaster plan and observed that the facility has an evacuation procedure plan in place. Staff interviews indicated the following: Seven out of seven staff were able to explain their roles during emergencies. Resident interviews indicated the following: Six out of ten residents indicated that, although they feel that the drills were chaotic when conducted, they feel that they would receive help in an emergency. Four out of ten residents were not available. Regarding the allegation " Facility is not following Emergency Disaster Plan protocols," the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator Lilit Mnatsakanyan.the state’s words, verbatim · CDSS document, Jan 17, 2024 · control 11-AS-20240110121519

Allegation investigated: Facility did not follow Covid-19 protocols. Facility is in disrepair.

**This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 01/12/2023.** On 10/06/2023 Licensing Program Analyst (LPA) David España conducted a subsequent complaint investigation at the above facility to address the following allegations. LPA met with Lilit E. Mnatsakanyan, Administrator and explained the purpose of this visit was to deliver findings for this complaint. The investigation consisted of the following: On 12/05/2022 between 9:30am to 2:48pm, LPA conducted an initial 10-day visit and met with Resident Care Service Director, Kimberly Davis. LPA conducted a tour of the facility. On 12/05/2022 and 01/11/2023 between the hours of 10:12am - 3:00pm LPA completed interviews, requested, and reviewed copies of records. Documents were received at the time of visit. Substantiated The investigation revealed the following… regarding the allegation: Facility did not follow Covid-19 protocols. It’s being alleged “the facility had Covid-19 cases that were not reported to the proper agencies, the facility refused to test staff and residents, stop visitation and enforce masking for outside visitors.” LPA interviewed 7 out of 75 residents in total. 1 out of 7 residents confirm the allegation. During interviews with staff, LPA interviewed 7 out of 70 in total. 1 out of 7 confirm this allegation. During a record review on 12/02/2022, after receiving information of a possible Covid-19 outbreak, LPA Agard contacted the facility regarding the allegation. At that time, the acting Administrator confirmed there had been positive Covid-19 cases that were not reported to Community Care Licensing. On 12/02/2022, LPA Agard completed a Covid-19 intake for 3 Residents and 3 Associates. Regarding the allegation: Facility is in disrepair. It’s being alleged that the facility has incomplete wiring in some apartments, lifters in the patio that are loose, leaks in the building, and elevators not running on various occasions. 0 out of 7 residents were able to confirm the allegation. During interviews with staff, 5 out of 7 confirmed this allegation. S2 states, “not being aware of any leaks or wires being exposed. All the elevators are working. The patio is up for repair.” During a facility tour on 12/05/2022 and 01/11/2023, LPA observed the lifters in the center of the courtyard to be caving inward. This section is identified by tape and small safety cones. Based on the interviews with staff and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D. Licensing Program Analyst (LPA) David España conducted an exit interview and a hard copy was provided with appeal rights to Lilit E. Mnatsakanyan, Administrator. See LIC 9099-D on the next page Regarding the allegation: Facility does not have an emergency disaster plan. It’s being alleged the community may not have an emergency binder in place. Staff or residents may not know what the procedures are during an Emergency.” 2 out of 7 residents confirm the allegation. All residents unanimously agree that they are unaware if the facility has a physical hard copy of a disaster plan, but 5 residents confirmed being trained on what to do in the event of an emergency. During interviews with staff, 1 out of 7 confirmed this allegation. During a record review, LPA Agard reviewed and confirmed facility’s disaster plan. Regarding the allegation: Facility does not provide a safe environment for residents. It’s being alleged “the community has no security during the day and there have been various occasions homeless have entered the community putting the residents in danger.” 0 out of 7 residents confirmed the allegation. Residents denied feeling unsafe and reported there is a security guard outside at nighttime. During interviews with staff, 1 out of 7 confirmed this allegation. S2 states, there is concierge 24/7 and security from 7pm-7am. Regarding the allegation: Facility staff is not following safe food handling practices. It’s being alleged the kitchen prepares and distributes/serves meals without wearing gloves or hair nets.” 0 out of 7 residents confirm the allegation. Residents reported no safety concerns with the way their food is being handled. During interviews with staff, 1 out of 7 confirmed this allegation. During a visit on 12/05/2021 and 01/11/2023, LPA observed kitchen staff wearing gloves, a hairnet or chef’s hat. Regarding the allegation: Facility staff does not maintain accurate resident paperwork. It’s being alleged “residents are allowed to move in without their paperwork being complete.” 0 out of 7 residents confirm the allegation. All residents interviewed unanimously agreed not being aware of the specifics of this allegation and assume the facility has all the necessary paperwork for their file. During interviews with staff, 2 out of 7 confirm this allegation. During a visit on 12/05/2021 and 01/11/2023, LPA conducted a sample record review of resident files and found no records missing. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are unsubstantiated. Licensing Program Analyst (LPA) David España conducted an exit interview and a hard copy of the report was provided with appeal rights to Lilit E. Mnatsakanyan, Administrator.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 11-AS-20221201130811

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Oct 20, 2023

Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidence by: during an interview with the acting Administrator, it was revealed he did not report 6 positive covid-19 cases to licensing. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2023

Plan of correction: The administrator will create a plan to ensure future compliance to Tite 22 Regulation 87211(a)(2) Reporting Requirements. Proof of correction will be submitted to the department via email at David.espana@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 20, 2023

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 of residents, employees and visitors. This requirement was not met as evidence by: observation of the patio being in disrepair due to the ground lifters caving inward.the state’s words, verbatim · CDSS document, Oct 6, 2023

Plan of correction: The administrator will create a plan to ensure future compliance to Title 22 Regulation 87303(a) Maintenance and Operation. Proof of correction will be submitted to the department via email at David.espana@dss.ca.gov.