Valley Vista Senior Living

Allegation investigated: Staff do not assist resident with medical care

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegation. Upon arrival at approx.10:15 a.m. LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Maya Mnoyan, Executive Director (ED) and the reason for the visit was explained. Entrance interview conducted. On 06/08/2026 the department received a complaint regarding the following allegation: Staff do not assist resident with medical care. On 06/17/2026 LPA Mosley conducted the initial 10-day visit. During the visit LPA and staff toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. Throughout the visit LPA conducted a file and record review for Resident #1 (R1), conducted an interview with R1, WD and a telephonic interview with the ED and obtained copies of pertinent documents relevant to the investigation. On 06/26/26 at 4:46 p.m. LPA conducted a telephonic interview R1’s Clinical Advisor (CA). On 06/24/26, 07/03/26 and 07/09/26 corresponded via email with the ED. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (PAGE 2) Report continued from LIC 9099... During today's visit starting at 10:40 a.m. LPA and ED briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. Starting at 11:03 a.m. and through the visit LPA conducted ten (10) random resident interviews, three (3) staff interviews and obtained copies of pertinent documents relevant to the investigation. On the allegation, Staff do not assist resident with medical care, it is the concern of the Reporting Party (RP) that R1 is unable to make their doctors appointments due to staff not assisting R1 with locating their transportation. To investigate this complaint, LPA conducted in person interviews, telephonic interviews, corresponded via email, file and record review, and obtained copies of pertinent documentation relevant to the investigation. Interview with R1 revealed that transportation to their medical appointments is arranged through their doctor’s office, and the facility does not handle any medical appointments, coordination, or arrangements. R1 reported that on three occasions they waited for a driver but did not see one. They contacted the driver directly, and the driver informed them they were on Van Nuys. R1 stated they instructed the driver that pickup should occur at the Vannowen entrance. R1 reported speaking with the driver twice, and each time the driver indicated they were on Van Nuys. On one occasion, R1 walked to Van Nuys, but the street was under construction. R1 stated they have not requested staff assistance and prefer to sit in the lobby and wait. They reported discussing transportation concerns with their doctor’s office, as the physician’s office arranges all transportation. R1 stated the facility’s Executive Director informed them that the facility could provide certain types of support; however, when asked about assistance with seeing a physician, R1 declined because they prefer to continue care with their primary care provider. Additionally, R1 stated they do not plan to ask the facility for assistance, as transportation is available through their doctor’s office and drivers simply need to locate the correct entrance. R1 reported that on one occasion facility staff attempted to assist but were unable to locate the driver. R1 further stated that sometimes drivers park too far away, and they are unwilling to walk that distance. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC 9099-C PAGE 2... Interview and email correspondence with the ED revealed that R1 receives little to no assistance from the facility and is considered “independent.” The ED further stated that they believe staff ensure all residents’ medical needs and concerns, including R1’s, are addressed appropriately. Staff interviews revealed that R1 is generally independent and rarely requires any assistance from staff. Interview with R1’s clinical advisor revealed that R1 had missed several medical appointments and reported that drivers were not following the instructions regarding the correct pickup location. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff do not assist resident with medical care is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 29-AS-20260608090830

Allegation investigated: . Staff do not ensure residents personal property is kept safely secured resulting in personal items going missing. 2. Staff rearranged furniture in residents room without authorization as a form of mental abuse. 3. Staff does not ensure provided furnishings in resident rooms are in good repair. 4. Staff do not respond to residents call light in a timely manner. 5. Staff do not assist resident with getting dressed due to neglect

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegations and met with Maya Mnoyan, Executive Director. The reason for today's visit was provided. On today's visit, LPA Yee conducted interviews with Maya Mnoyan, Executive Director at 11:06am, 12:16pm and 2:31pm, Staff #1 at 3:52pm and an attempted telephone interview with Resident #1 at 10:57am but was informed that they were at a medical appointment. A face to face interview was conducted with Resident #1 at 1:05pm. Per information received from interviews conducted with Resident #1, they vehemently denied that they filed the complaint and they did not make any of the above allegations. Per Resident #1, they dispute the allegations made, unless a copy of the recording of their voice can be provided as proof to establish that they had called to file the allegations on the complaint. They can dress themself, bath themself, take their own Unsubstantiated Page 2. medications and take care of them self. They do not need help. If she needs help, she calls the staff. Per Resident #1, they are highly intelligent and wouldn't make things up. They don't lie. Per Resident #1, the problem they have is with the microwave and refrigerator. Per Resident #1, both items belong to the facility. Per Resident #1, the microwave is not broken and the refrigerator just does not work properly. The microwave works but it trips the circuit and they have to re-set the circuit breaker and the refrigerator will freeze the food. Per Resident #1, they had a salad in the refrigerator and it froze. They thawed out the salad and ate it. Resident #1 also adamantly denied that the furniture in the room was rearranged or that the furniture is in disrepair. The only thing that was altered in the room was an armchair that was given to them to use by the previous Wellness Director. The chair came from room #513. Per Resident #1, they had the armchair removed because the chair had a very strong odor, like urine. In regards to the missing clothing and personal items, Resident #1 states that they are blessed to have plenty of clothes. Their clothing was never inventoried. Per Resident #1, if someone took their clothes and personal items, they hope that they enjoy it. Per Resident #1, this is the place for them. They like it here as they can come and go as they please. Per interviews conducted with Executive Director and staff, they are not aware of any missing clothing or personal items or the removal of any adapters. Resident #1, who is legally blind has a history of claiming thing are missing and when they go to the room, the missing items are there. Items are just not in the exact location that it was last placed. Resident #1 did not provide LPA Yee with a list of missing items when asked.. Per Staff, there was one incident where one of Resident #1's shirt was accidentally left stuck in the washer and it ended up with the next resident's laundry and resident claimed it was missing. Staff remembered the resident who had their laundry done next, located the shirt and returned it to the resident. Interviews with staff also reveal that Resident #1's furniture was not rearranged as alleged. There are no issues with the furniture as confirmed by Resident #1. Per interview regarding the microwave, staff state that the microwave belongs to the resident and the refrigerator belongs to the facility. Resident #1 was told by maintenance to solve the problem by purchasing another microwave. The facility owned refrigerator is in the process of being replaced. Per information provided, 15 refrigerators were ordered and was scheduled to be delivered on Page 3. 6/27/26 but was not delivered. The facility will follow-up on the status of the delivery and notify LPA Yee when it is delivered and provide a copy of the shipping receipt. Based on the information received during today's visit, there is insufficient evidence to support all the above allegations, therefore the all of the allegations are determined to be unsubstantiated at this time. 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. Exit interview was conducted with Melanie Ramirez, Director of Memory Care, since Maya Mnoyan had to leave at 3:40pm.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 29-AS-20260623110601

Allegation investigated: Staff did not ensure resident's care was increased following resident's surgery

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegations listed above at 11:40AM. LPA met with staff and Executive Director (ED) Maya Mnoyan. Reason for the visit was explained. During today’s visit, LPA conducted a physical plant tour and obtained copies of pertinent documents. During the subsequent complaint visit on 04/28/2026, LPAs Barutyan and Q. Huynh interviewed five (5) staff and four (4) residents, conducted a physical plant tour, and obtained copies of pertinent documents. During the initial complaint visit on 12/03/2025, LPA Barutyan conducted interviews with three (3) staff members and two (2) residents, reviewed and obtained copies of pertinent documents relevant to the investigation, conducted a brief physical plant tour, and discussed allegations with former ED Aaron Mayes. It was alleged that Resident #1 (R1)’s increased care needs were not being met following their scheduled surgery on 11/19/2025. Report Continued on LIC 9099-C. Substantiated Prior to the surgery, R1 required minimal assistance with activities of daily living (ADLs), primarily with showering. However, following the surgery, R1 required significantly increased assistance with ADLs due to decreased mobility and drowsiness associated with newly prescribed medications. On 11/11/2025, R1’s responsible parties and former Executive Director (ED) Aaron Mayes held a care plan meeting to discuss R1’s anticipated increased care needs following the surgery. During the meeting, a temporary care plan was developed to address these changes. Interviews confirmed that notice of R1’s increased care needs was posted in the medication room for staff reference; however, no formal staff meeting or written notification was conducted to ensure staff were informed of the changes. During the initial visit on 12/03/2025, ED Mayes and staff confirmed that several staff members had not seen the notice posted in the medication room regarding R1’s change in care needs. Staff further stated that the required two-hour checks intended to begin following the surgery were not consistently implemented until staff became aware of the updated care instructions. LPA was unable to obtain R1’s service plan that was in effect prior to the surgery due to management and organizational changes at the facility. However, LPA obtained a service plan dated 12/03/2025. The service plan documented R1 as a Level 3 out of 5 care and indicated that R1 required assistance with toileting and incontinence care throughout the day and night (moderate assistance), no assistance with transferring, verbal reminders and cueing for mobility (minimal assistance), hands-on assistance with bathing (moderate assistance), support with dressing and selecting appropriate clothing (moderate assistance), and no assistance with grooming. Staff, R1, and R1’s responsible parties stated that prior to the surgery, R1 was able to independently perform all ADLs except showering. Following the surgery, R1 required frequent monitoring and assistance with all ADLs. Staff and ED Mayes acknowledged there had been a “miscommunication” regarding R1’s increased care needs. On 12/01/2025, ED Mayes conducted a mandatory meeting and in-service training for all medication technicians and caregivers on all shifts regarding staff responsibilities to ensure residents’ care needs were properly addressed. LPA also observed logs documenting that R1 received two-hour checks throughout the night on 12/01/2025 and 12/02/2025. The facility was unable to provide earlier logs due to the management change that occurred on 12/01/2025. Based on interview and record review, the allegation “Staff did not ensure resident's care was increased following resident's surgery” is deemed SUBSTANTIATED at this time. ED Mnoyan was unable to remain for the remainder of the visit and designated Admissions Coordinator Stephanie Sarabia to sign the report. Report was reviewed telephonically with the ED. The following deficiency was observed (See LIC 9099-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 provided. It was alleged that Resident #1 (R1)’s clothes, briefs, and bedding were not changed in a timely manner. LPA interviewed R1, who stated that there had been occasions when their briefs were not changed promptly; however, R1 reported that they independently change their own clothing and that staff are responsible for changing the bedding. R1 was unable to recall specific details regarding any instance in which they remained in soiled briefs for an extended period of time. R1 stated that wet bedding is typically changed the same day and that bed linens are routinely changed weekly. R1 expressed no concerns regarding clothing changes and stated that they do not require assistance with dressing. LPA obtained R1’s service plan dated 12/03/2025, which documented R1 as a Level 3 out of 5 care and indicated that R1 receives assistance with toileting and incontinence care throughout the day and night (moderate assistance), support with dressing and selecting appropriate clothing (moderate assistance), and no assistance with grooming. Five (5) out of seven (7) staff interviewed stated that R1 frequently refuses care and services, particularly during the night and morning shifts, because R1 prefers to sleep in. R1 also confirmed that they do not like staff attempting to provide care or brief changes during the night or early morning hours. LPA reviewed logs from November and December 2025 documenting services provided to R1. The logs indicated that R1 did not receive a brief change during the AM shift for nine (9) out of twenty-five (25) days where R1 was at the facility from November-December 2025 due to being “unavailable.” ED Mayes stated that this is either due to R1 being asleep or R1 requesting staff to follow up at a later time. Staff interviews and statements from R1 confirmed that staff attempted to provide care during the morning hours, but R1 often preferred to continue sleeping. LPA also observed documentation reflecting that R1 received two (2) brief changes during the night (NOC) shift, which R1 confirmed. R1 stated that upon waking, they notify staff using their pendant when assistance or a brief change is needed. ED Mayes stated that although it may appear that R1 did not receive timely brief changes, the delays occurred because R1 was asleep and declined care at those times. Staff interviewed stated that multiple attempts to provide care were made and that responsible parties were notified regarding R1’s refusals. LPA interviewed five (5) additional residents, all of whom reported no concerns regarding incontinence care, bedding changes, or housekeeping services. Residents stated that linens are changed weekly or sooner if soiled and expressed satisfaction with housekeeping services. During a follow-up interview conducted on 04/28/2026, R1 confirmed that there was “never” a time when wet bedding was not changed. R1 also stated that they independently change their clothing daily. R1 further stated that staff did check on them, although response times occasionally “took a while.” Report Continued on LIC9099-C. LPA also observed R1 and their room on 12/03/2025 and 04/28/2026 and observed R1 to be appropriately dressed and R1’s bedding to be dry. No immediate health and safety concerns were noted. Based on interviews, record review, and observation, 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 “Staff did not ensure resident's clothes were changed” and “Staff did not change resident diapers/linens timely” are deemed UNSUBSTANTIATED at this time. It was further alleged that the facility did not provide R1 or their responsible parties with notice of required orders needed to provide care to R1. Staff interviewed stated that following R1’s toe amputation surgery on 11/19/2025, the surgical site was required to remain dry during showers. Staff reported that they protected R1’s foot by covering it with a plastic bag during showers in accordance with physician orders. LPA reviewed progress notes documenting that facility staff attempted to contact R1’s physician on 11/25/2025 to obtain clarification and an order regarding wrapping R1’s foot to allow showering. LPA also reviewed a physician’s order signed and dated 11/26/2025 stating that R1 was “allowed to have showers as long as [their] foot is dry. [R1] can use a plastic bag to cover [their] foot as [they] shower with tape as to prevent the dressings from getting wet.” Staff and R1 stated that R1 requested that a glove be placed over the surgical site instead of a plastic bag for extra security and waterproofing; however, the facility did not have a physician’s order authorizing the use of a glove. Staff stated that the post-surgical order specifically authorized the use of a plastic bag to cover the surgical site, and facility staff believed an additional physician’s order was required before using an alternative covering as the glove might be restrictive. Staff further stated that the facility notified R1 and R1’s responsible parties regarding the need for an updated physician’s order and attempted to contact R1’s physician to obtain clarification and authorization for the requested glove. In the meantime, staff continued covering R1’s foot with a plastic bag during showers in accordance with the existing physician’s order. R1 stated they had no concerns regarding shower assistance following the surgery and confirmed that showers continued to be provided. LPA reviewed R1’s service logs for November and December 2025, which documented that R1 received showers during the PM shift. The logs indicated that R1’s scheduled shower days were Monday, Thursday, and Saturday evenings. Report Continued on LIC9099-C. Documentation further showed that R1 refused five (5) out of eleven (11) scheduled showers offered during the review period. R1 stated that showers were offered consistently and expressed no concerns regarding the shower services provided by staff. LPA also reviewed a physician’s order from R1’s supportive wound care provider, signed and dated 12/04/2025, stating: “Please keep bandage on both feet completely dry! When showering either put bag on or leave feet out.” 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 resident with necessary information to meet care needs” is deemed UNSUBSTANTIATED at this time. ED Mnoyan was unable to remain for the remainder of the visit and designated Admissions Coordinator Stephanie Sarabia to sign the report. Report was reviewed telephonically with the ED. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 7, 2026 · control 29-AS-20251124120507

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: May 14, 2026

(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...with those activities of daily living such as dressing, eating, bathing... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited as Resident #1 (R1)'s agreed upon increased need for assistance with activities of daily living following their surgery was not provided which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: ED Mayes conducted a mandatory meeting and in-service training for all medication technicians and caregivers on 12/01/2025 regarding staff responsibilities to ensure residents’ care needs were properly addressed. ED Mnoyan stated that an in-service training will be conducted to review proper notification of care plan changes for residents. ED will submit proof to CCLD by the due date.

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-20251124120507). The purpose of the visit is to issue a citation for a deficiency observed during the initial and subsequent complaint investigations. During the subsequent complaint visit on 04/28/2026, LPAs Barutyan and Q. Huynh interviewed five (5) staff and four (4) residents and during the initial complaint visit on 12/03/2025, LPA Barutyan conducted interviews with three (3) staff members and two (2) residents. Interviews conducted with Resident #1 (R1) and former Executive Director (ED) Aaron Mayes on 12/03/2025 revealed that R1 has a history of refusing certain services, particularly nighttime incontinence care and brief changes. R1 and ED Mayes stated that despite R1’s refusals, staff would still complete the care. ED Mayes stated that because R1 has a Power of Attorney (POA), the POA could request that services be completed regardless of whether R1 accepted or refused the care. During interviews conducted with R1 on 12/03/2025 and again on 04/28/2026, R1 stated that staff did not respect their refusals regarding nighttime incontinence care.LPA discussed residents’ personal rights with ED Mayes, including a resident’s right to refuse services regardless of the involvement of a POA. LPA advised that a resident’s refusal of care must be honored unless otherwise legally authorized. ED Mayes stated that he understood the requirement, and an in-service training was subsequently conducted with night shift (NOC) staff regarding residents’ rights and refusals of care. 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.Current ED Maya Mnoyan was unable to remain for the remainder of the visit and designated Admissions Coordinator Stephanie Sarabia to sign the report. Report was reviewed telephonically with the ED. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(28) · Plan of correction due date: May 14, 2026

(a) In addition to the rights listed in Section 87468.1.... residents...shall have all of the following personal rights: (28) To request, refuse, or discontinue a service. This requirement is not met as evidenced by: Based on interview, the licensee did not comply as Resident #1 (R1)'s refusal requests were not being followed on multiple occasions which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: ED Mnoyan stated that an in-service for personal rights will be conducted with all staff and will provide proof to CCLD by the due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Quoc Huynh and Angela Barutyan arrived unannounced at 9:58AM for a required one-year visit. The LPAs met with Executive Director (ED) Maya Mnoyan and explained the reason for the visit. Entrance interview conducted. RECORDS: Resident records were reviewed at 11:23AM. The LPAs reviewed ten (10) files for, but not limited to: admissions agreements, medical assessment, appraisals, and consent forms. Resident records were observed to be incomplete as appraisals, consent forms, and personal rights did not have signatures. The LPAs reviewed ten (10) personnel records for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and appropriate trainings. One (1) caregiver was observed to have a first aid/CPR training that expired in 10/2025 and stated they were not aware it had expired. INFECTION CONTROL/EMERGENCY DISASTER: The LPAs reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPAs noted that the facility is in compliance with regulation with both plans reviewed annually. The facility conducts emergency disaster drills as required, with the last drill documented on 04/25/2026. Fire alarm system is tested annually with the last inspection on 03/10/2026 by KO Fire Inc. At 2:43PM, the LPAs and ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Report Continued on LIC 809-C KITCHEN: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries which occurs every Thursday. There was a sufficient supply of perishable and non-perishable food. The LPA observed the walk-in refrigerator and freezer; food appeared to be of good quality and labeled with expiration dates. Kitchen sinks had signage of tap water delivering above 125 degrees F. Emergency food and water were observed. RESIDENT ROOMS: The LPA observed ten (10) randomly selected rooms and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. Water temperature was tested throughout the units and measured between 115.7 degrees F and 121.4 degrees F. The LPAs advised the ED to lower the hot water temperature. COMMON AREAS: The facility had five (5) total floors with common areas that consisted of resident units, a movie theater, gym, patios/courtyards, lounges and activity space, library, laundry rooms, beauty shop, and common restrooms. The LPAs observed common areas to be clean, clear of obstructions/hazards, and furniture was in good condition with patios/courtyards providing shade for residents. Required postings were observed by the elevators on the first floor. There were no bodies of water observed during today’s visit. There were fire extinguishers throughout the facility, which were serviced on 02/02/2026. MEDICATION: The LPAs reviewed medications for five (5) residents. Medications are maintained inaccessible to residents in the medication room on the second and third floors. Resident medications reviewed were not maintained on the centrally stored medication and destruction records (CSMDR). As needed (PRN) medications were logged incorrectly and were not included on the CSMDR. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (Refer to LIC 809-D). Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, Apr 28, 2026

The state marks this report as 11 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced case management visit due to the deficiency noted during a visit to the facility today. LPA Yee met with Maya Mnoyan, Executive Director. The reason for today's visit was provided. Per information received on previous visits and based on the written job description provided by Maya Mnoyan, Executive Director for basis of their appeal to dismiss the initial citation issued on 3/9/26, Antonio Aguilar is the facility's Marketing Director. His duties are performed entirely outside of the facility. He is not an in-house staff member and does not work work inside the community. His responsibilities are strictly related to external marketing and lead development. In this role, he visits hospitals, nursing homes and other referral sources to identify potential residents who may benefit the community. The information is then turned over to internal staff for handling of tours, admission, coordination and full intake if the prospective resident is deemed a good fit. The job description states that his role is limited to the outside marketing activities and he does not interact with the residents of the community. However, per information received on today's visit, Antonio Aguilar, is paid directly by the facility for his role as the Marketing Director. He attends stand up meetings at the facility at least twice a week and participates in the tours of the facility together with Stephanie Sarabia, Community Relations Director and the prospective residents and their families. This does not fit the job description provided to the Department for review during the appeal process of the initial citation. Per information received from staff, he was present at the facility on continued on LIC809-C Page 2. 4/20/26 and was not present during today's visit. As of today's visit, Antonio Aguilar still does not have a criminal record clearance, requested a criminal record clearance transfer or have evidence that a criminal record exemption has been obtained to allow him to be present at the facility. Department records show his status as "pending". Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Civil penalties of $100 was assessed for his confirmed presence at the facility on 4/20/26. Exit interview was conducted, Appeals Rights were discussed and a copy was provided.the state’s words, verbatim · CDSS document, Apr 21, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Apr 22, 2026

Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department or..This requirement was not met as evidenced by: Antonio Aguilar(Hired 3/2/26) does not have evidence of a criminal record clearance and is present and working at the facility.the state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: Licensee will ensure that all staff, volunteers and any persons who are required to have a criminal record clearance prior to being present at the facility. Licensee will submit a plan of action to the Department as to how they will come into compliance prior to having any staff present at the facility or associate Antonio Aguilar via Guardian if he has obtained a criminal record clearance or a criminal record exemption and submit evidence that the deficiency has been corrected by 4/22/26.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced case management visit due to the deficiencies observed during a visit conducted to the facility today. LPA Yee met with Maya Mnoyan, Executive Director and the reason for the visit was provided. The following was observed on today's visit and verified with Department staff via telephone during the visit Per Department records, the status of the criminal record clearance indicates that it is "pending" for all three staff. Staff, Antonio Aguilar, hired on 3/2/26, does not have evidence of a criminal record clearance. Staff, Erica Arredondo Vasquez, hired on 2/9/26, does not have evidence of a criminal record clearance. Staff, Maria Ramirez Torres, hired on 2/20/26 does not have evidence of a criminal record clearance. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Immediate Civil Penalties of $1,500.00 was assessed. Exit interview was conducted with Kimberly Griffin, Wellness Director, Appeals Rights discussed and a copy was provided.the state’s words, verbatim · CDSS document, Mar 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 10, 2026

Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department or..This requirement was not met as evidenced by: Antonio Aguilar(Hired 3/2/26), Erica Arredondo Vasquez(2/9/26) and Maria Ramirez Torres(2/20/26) do not have evidence of a criminal record clearance and are working at the facility.the state’s words, verbatim · CDSS document, Mar 9, 2026

Plan of correction: Licensee will ensure that all staff, volunteers and any persons who are required to have a criminal record clearance prior to being present at the facility. Licensee will submit a plan of action to the Department as to how they will come into compliance prior to having the 3 staff present at the facility or associate the 3 staff via Guardian if they have obtained criminal record clearances by 3/10/26 and submit evidence that the association was completed by 3/10/26.

Allegation investigated: Resident's personal rights are being violated

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegation and met with May Mnoyan, Designated Executive Director. The reason for today's visit was provided. On today's visit, LPA Yee conducted an interview with Maya Mnyoan at 11:00a.m., Staff #1 at 11:33am, Staff #2 at 12:48pm, Staff #3 at 1:04pm, Staff #4 at 1:21pm and attempts to interview Resident #1 via telephone throughout the visit were unsuccessful. Resident #1's files were reviewed and copies were obtained. Per investigation into the above allegation that the resident's personal rights are being violated, information obtained from interviews conducted, it is alleged that Resident #1 is being harassed by someone via WIFI continued on LIC9099-C Unsubstantiated Page 2. and that Resident #1 is being watched by someone through a camera located inside the light fixture mounted above the bathroom sink while they are taking a shower. They are also being monitored through the cameras located in the hallway and the common areas of the facility. The perpetrator has also infiltrated WIFI and is also able to block and intercept calls to resident's phone, emails and control the electricity in the room. Air is also being piped into the bathroom to freeze resident during showers. Per information received from staff, Resident #1 has also gone to the police station in an attempt to file a complaint with the local police department and they didn't do anything. Per tour of Resident #1's room at 12:14 p.m., all electrical outlets, microwave, cellphone, light fixtures, electrical gadgets, the signal system and all electrical devices were observed covered with aluminium foil. There were no cameras observed in the resident's room or anything that looked out of place. Per interviews conducted with staff this has been going on with the resident since last year. Per interviews conducted with the Executive Director, Staff #1 and Staff #3, they were told by Resident #1 that the perpetrator is the former Maintenance Director. It is alleged that the former Maintenance Director was previously harassing Resident #1 when they worked here and is continuing to harass the resident even though they no longer work here. Per Staff #3, Resident #1 also indicated that they had an enemy in Beverly Hills and that it was they who were harassing them. Per file review, Resident #1 is diagnosed with mild cognitive impairment and hyperlipidemia. The physician also noted in the comment section of the resident's Physician's Report that the "patient with some evidence of paranoid ideation...Will need to be assessed by psychiatry in facility." Per information received on today's visit, the facility has not had any issues with their WIFI. There is no evidence that Resident #1 is being harassed, targeted by WIFI or is being watched by anyone. Based on today's visit, there is insufficient evidence to support the allegation that Resident's personal rights are being violated, therefore the allegation is unsubstantiated at this time. 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. Exit interview was conducted with Edelyn Lu, Receptionist and a copy was given.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 29-AS-20260113165252

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced Case Management visit to investigate the incident that occurred on 10/12/25 and reported to the Department on 10/17/25, regarding Resident #1. LPA Yee met with Aaron Mays, Designated Executive Director. The reason for today's visit was explained. Per information provided on the LIC624, Special Incident Report, Staff #2 observed Staff #1 push Resident #1. No other details were provided regarding the incident on the report. Upon further inquiry into the incident, the following was revealed. On 10/12/25, around 4am, Staff #1, who works the night shift was doing laundry and had left the laundry cart with Resident #2's clothes by their door and had stepped away. Resident #1, who has dementia was wandering around, grabbed a pair of Resident #2's pants from the cart. Staff #1 noticed and attempted to get the pants away from Resident #1. Resident #1 got mad and threw the pants on the floor and began stepping on it. Staff #1 and Staff #2 attempted to get the resident off the pants. Staff #1 got irritated and pushed the resident, causing the resident to fall on the floor and landing on their back. Staff #1 and Staff #2, both assisted Resident #1 to get up. Resident #1 walked with a limp. Per Staff #2, when they were changing Resident #1, a big bruise was observed on the resident's arm and bottom. This incident was reported to Staff #3 when Staff #2 returned to work later that evening. Staff #4 was not advised of the 10/12/25 incident until 10/14/25. Staff #1 who was off on 10/13/25, was suspended via telephone on 10/14/25 by Staff #4 and the designated Executive Director was also notified that morning. An internal investigation was attempted and Staff #1 was given the opportunity to come into the office continued on LIC9099-C Page 2. to provide a written statement of the incident that occurred on 10/12/25 and Staff #1 refused. Staff #1's employment was terminated on 10/17/25. On today's visit, LPA Yee interviewed Staff #4 at 11:49pm, Designated Executive Director at 12:14pm and reviewed and obtained documents from Staff #1, Staff #2 and Staff #3's files, documents from Resident #1's file. A copy of the facility's investigation was obtained. A copy of the video clip of the incident was also obtained during the visit. Per information obtained on today's visit, additional interviews and further investigation is needed to determine if the facility would be culpable for the action of the staff and if any further action is needed. LPA Yee will return to deliver her findings of her investigation once the investigation into the incident has been completed. Exit interview was conducted with Joanna Hernandez, Memory Card Director.the state’s words, verbatim · CDSS document, Nov 4, 2025

Allegation investigated: . Facility did not provide resident with a bed/dresser 2. Facility did not provide resident with hygiene products

Licensing Program Analyst (LPA) Christine Yee conducted another subsequent unannounced complaint visit to continue the investigation for the above allegations and to deliver the findings of the investigation. LPA met with Elizabeth Whittington, Executive Director. The reason for today's visit was provided. On the initial visit conducted on 5/22/24, LPA Yee conducted an interview with Maria Calderon at 11:41am, Jarred Massey-Baker, Memory Care Director at 12:07pm, Staff #1 at 1:23pm, Staff #2 at 1:50pm, telephone interview with Witness #1 at 2:04pm and the Administrator at 2:56pm. Resident #1's file was reviewed at 2:28pm and copies requested. Based on the information received during the initial visit, further investigation was needed to make a finding for the above allegations. Exit interview was conducted. A subsequent unannounced complaint visit was conducted on 6/19/25 to continue the investigation of the above allegations and LPA met with Elizabeth Whittington, Executive Director. On the subsequent visit Substantiated Page 2 LPA Yee reviewed and collected additional documents related to the investigation throughout the visit and conducted additional interviews with the Executive Director at 1:31pm, attempted to conduct telephone interviews with Staff #3 and Staff #4. Staff #3 returned LPA Yee's call at 3:51pm and began the telephone interview and the call was disconnected at 4:03pm. When LPA Yee called back at 4:04pm, she was informed by Staff #3 that the phone interview was being conducted on personal time and to conduct the interview during working hours. Staff #4 was contacted at 4:07pm and LPA Yee left a voice mail message to return the call. No return call was received when the subsequent visit was concluded. Hygiene products and toilet paper were observed in a large closet located on the second floor at 5:45pm. Additional hygiene products are also stored in a smaller closet on the third floor and toilet paper is located in the housekeeping closets on each floor. Based on the information received on today's visit and the need to conduct interviews with Staff #3 and Staff #4, it was determined that further investigation is needed before a determination could be made for the above allegations. An exit interview was conducted and a copy of this report was provided. On today’s visit LPA Yee conducted an interview with Staff #5 at 10:49am, Staff #6 at 11:34am and another telephone interview with Witness #1 at 11:23am to obtain additional information regarding facility furniture and hygiene products. Per the investigation conducted, the following was revealed regarding allegation #1-facility did not provide resident with a bed/dresser, the staff are confused about who provides the furniture for the residents’ use. Staff all indicated that the residents bring in their own furniture. Per interview conducted with Maria Calderon, Wellness Director at the time of Resident #1’s admission, she stated that the family of the resident provides the furniture for the residents’ use. Per interview conducted with Witness #1, they were told to purchase a bed and a dresser by Elizabeth Whittington, Sales Manager *****who was making the arrangements for Resident #1’s move in on 9/22/23. Per Witness #1, Elizabeth Whittington, told them that the facility does not provide a bed, a dresser, a phone and hygiene products. She provided the family with a link to Apria, where the facility buys their health supplies. Per Witness #1, they didn’t know that the furniture had to be delivered first before Resident #1 could move in. Per Witness #1, Resident #1 was taken back to the Emergency Room until the furniture could be delivered. Resident #1 did not move in until 9/29/23. Also, per review of the signed Admission Agreement - #5 j) “Furnishing” under “Accommodations and Basic Page 3 Services” the facility states that “If the resident is unable to provide Resident’s own furniture or if the resident chooses not to provide it, the Community will ensure that the resident is provided with the basic furniture.” This did not happen. The facility did not provide Resident #1 with a bed and dresser as stated in the Admission Agreement and delayed the resident’s move-in date to 9/29/23. Per the initial interview conducted with Executive Director on 5/22/24, LPA Yee was specifically told that they had beds and lamps that the family can rent or loan. In the subsequent interview conducted on 6/19/25, the Executive Director denies that she told the family that they had to buy a bed and a dresser. Based on the interviews conducted with staff, there is confusion as to who provides the required Title 22 furniture. Staff all indicated that the resident's families provide the required furniture. Per the information received during the investigation, there is sufficient evidence to support the allegation that the facility did not provide resident with a bed and a dresser, therefore the allegation is deemed substantiated at this time. The investigation into allegation #2 - Facility did not provide resident with hygiene products, revealed that the facility does not provide hygiene products to the residents on an ongoing basis. Per interviews conducted with staff, Residents’ families are required to bring in hygiene products such as body soap, shampoo, lotions, toothbrushes and toothpaste for the residents’ use. When the hygiene products run low, the manager contacts the family to replenish the hygiene products. Per staff, the facility will provide temporary hygiene products for residents’ use if they have extras or until the family is able to bring the hygiene products. Per review of the Admission Agreement under #2 “Fees” letter e) Personal Supplies: The Community assumes that the resident will provide their own supplies for personal care and hygiene. The Admission Agreement does not make provisions to ensure that residents who are unable or choose not to provide their own hygiene products, with hygiene items of general use such as soap and toilet paper. Based on the information obtained during the investigation, there is sufficient evidence to support the allegation that the facility does not provide residents with hygiene products, therefore the allegation is deemed substantiated at this time. Deficiencies are cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted, Appeals Rights were discussed and a copy was provided. Page 2A LPA Yee reviewed and collected additional documents related to the investigation throughout the visit and conducted additional interviews with the Executive Director at 1:31pm, attempted to conduct telephone interviews with Staff #3 and Staff #4. Staff #3 returned LPA Yee's call at 3:51pm and began the telephone interview and the call was disconnected at 4:03pm. When LPA Yee called back at 4:04pm, she was informed by Staff #3 that the phone interview was being conducted on personal time and to conduct the interview during working hours. Staff #4 was contacted at 4:07pm and LPA Yee left a voice mail message to return the call. No return call was received when the subsequent visit was concluded. Hygiene products and toilet paper were observed in a large closet located on the second floor at 5:45pm. Additional hygiene products are also stored in a smaller closet on the third floor and toilet paper is located in the housekeeping closets on each floor. Based on the information received on today's visit and the need to conduct interviews with Staff #3 and Staff #4, it was determined that further investigation is needed before a determination could be made for the above allegations. An exit interview was conducted and a copy of this report was provided. On today’s visit LPA Yee conducted an interview with Staff #5 at 10:49am, Staff #6 at 11:34am and another telephone interview with Witness #1 at 11:23am to obtain additional information regarding facility furniture and hygiene products. The investigation regarding Allegation #3 – staff stole the resident’s necklace, interviews and file review, reveal that Resident #1 and the facility did not complete an LIC621 “Client/Resident Personal Property and Valuables.” Per interviews conducted, no one observed Resident #1 with a gold chain and a gold cross. There is also no documentation that Resident #1 owned a gold chain with a gold cross and that it was brought into the facility. Staff who were interviewed stated that they observed Resident #1 with a rope chain that was tarnished with a cross that had rhinestones. Resident #1 was wearing it when they moved from the facility. Another Staff stated that they saw the resident wearing a thick chunky silver chain that was tarnished and does not remember if it had a cross or any pendant. Resident #1 also wore a bracelet. Resident #1 would take off the necklace and then put it back on. Per Staff interviewed, the jewelry were not of any value that someone would want to steal it or mind if it got lost. Per Staff #4, they had a great rapport Page 3A with the family and spoke daily and yet the family never mentioned anything about the missing chain. Per the Memory Care Director, they looked for the necklace when the family brought up the missing necklace and was not able to locate the necklace matching the During the investigation, LPA was not able to locate anyone who observed Resident #1 wearing a gold chain with a gold cross or anyone to establish the existence of the gold necklace. Unless new information surfaces, there is insufficient evidence at this time to support the allegation that the staff stole the residents necklace, therefore, the allegation is unsubstantiated at this time. Per LPA Yee's investigation in regards to Allegation #4 - staff stole residents perfume, the investigation revealed that staff observed that Resident #1 had many perfumes and loved perfumes. The mini bottles of perfumes were stored in a glass vanity drawer. The resident would take all the perfumes out of the drawer just to decide which perfume was going to be used and then put them all back. If the resident had anything of value, the perfumes would be it. Per interview with staff, the number of perfumes owned by Resident #1 varied. One staff indicated that the resident owned 7-8 mini bottles of perfume, one staff indicated that the resident had 2-3 medium bottles of perfume and another just indicated the resident had many but never saw anyone using them. Per staff, the perfumes were packed up when resident #1 relocated to another home on 1/15/24. Staff are surprised that the family are now bringing up all these missing items months later. Per staff, they don't know what happened to the perfumes. The family never said anything when Resident #1 lived here. Based on the investigation, LPA Yee was not able find sufficient evidence to support the allegation that staff stole the residents perfumes, therefore the allegation is unsubstantiated at this time. The investigation into Allegation #5 - Staff did not clean residents room, the resident's family alleges that they dropped a plant on the floor and the dirt fell out. Staff left the dirt on the floor for weeks and staff did not clean it up. Per interview conducted with Staff #1, who is assigned to the Memory Care Unit, Resident #1 had a tiny plant on the window. Resident #1 loved to throw the plant. They would pick up the dirt and put it back in the pot. Resident #1 threw the plant because resident would get anxious when family member left. Per Staff #1, Resident #1's room is cleaned every Wednesday and the common areas are cleaned everyday. There is no dirt left on the floor. Staff #1 works from Tuesday - Saturday and if the floor is dirty, staff will tell her. On the days Staff #1 is off and there is an emergency another staff will clean up. The floor is never left dirty. Other staff interviewed also confirm that the floor is never left dirty for days. Managers do room checks and staff will hear about it. Per the investigation, there is insufficient evidence to support the allegation that Page 4A staff did not clean the resident's room, therefore the allegation is deemed unsubstantiated at this time. Per information received during the investigation for Allegation #6 - Due to lack of supervision, resident had multiple falls resulting in injury, the investigation revealed that Resident #1, who is diagnosed with dementia and is placed in the Memory Care located on third floor. The third floor is fire cleared for delayed egress. She uses a walker to assist in ambulating. Per review of the staff schedule, the staff in Memory Care consists of a Medication Technician and 2 caregivers for the morning and evening shift and a Medication Technician and a caregiver in Memory Care and one in Assisted Living on the NOC shift. Per information, provided, Resident #1 is able to move around freely in their room and in the the common areas. Per interviews with staff, Resident #1 is very aggressive with their walker and is told to slow down or to be careful in the use of the walker. The staff do not restrict Resident #1's movement and do not follow the resident around and falls are expected since the facility does not provide one on one supervision to catch the resident each time they fall. Per review of hospital discharge documents obtained, Resident #1 has had 3 un-witnessed falls and one witnessed fall in the dining room. The resident had their first fall on 10/16/23 in the dining room. Resident did not sustain any injury and was not sent to the hospital at the request of family. The second fall was sustained on 12/10/23 and 911 was called and the resident was transported to the hospital to be assessed. CT scans were done on the head and cervical spine. There were no signs of fracture. Resident sustained a scalp hematoma that was treated and was discharged. The third fall was sustained on 12/17/23. A CT scan was done on the facial bones and no fracture was observed. A fourth fall was sustained on 1/1/24. CT scans were done on the cervical spine and brain, chest x-rays and right elbow x-rays were done. CT scans and x-rays were ordered and came back okay related to the fall. Resident had a frontal scalp swelling. The resident was placed on 24 hour monitoring upon return. Per the investigation, the falls are not due to lack of supervision, the resident has the right to move around and do activities without interference from staff. Staff are present to ensure the resident's safety and to obtain medical attention when the resident falls. Based on the investigation, there is insufficient evidence to support the allegation that due to lack of supervision, resident had multiple falls, resulting in injury, therefore the allegation is unsubstantiated at this time. Per investigation into Allegation #7 - Staff did not wash residents hair properly, the investigation revealed that Resident #1's hair is washed when they are showered. The resident is showered 2 times a week. Per information received from interviews, when the resident first moved in, they would not let the caregivers give them a shower, wash and comb their hair. The resident's hair would be matted because they were taking care of their own hair. Per the caregivers interviewed, once Resident #1 finally got comfortable with them, they would allow them to wash the resident's hair and add conditioner to take out the tangles. They would comb Resident #1's hair and put it in a pony tail everyday. Resident #1's hair was never in a dreadlock as alleged by family. Resident #1 is a very clean person and would bring a comb or brush to find Staff #3 or Staff #4 to comb their hair. Per Staff #3 and Staff #4, they also have African American hair and they know how to care for Resident #1's hair. They also put lotion on Resident #1 after a shower or if they observed their skin to be dry. Per staff, Resident #1 always smelled of lotion. Per interview with family, the facility has an outside hair contractor who refused to do hair grooming for Resident #1 because they were unfamiliar with African American hair. Based on the investigation, there is insufficient evidence to support the allegation that the staff did not wash residents hair properly, therefore the allegation is unsubstantiated at this time. Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8 Exit interview was conducted, Appeals Rights were discussed and a copy was given.the state’s words, verbatim · CDSS document, Jun 30, 2025 · control 29-AS-20240516080757

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(A-B) · Plan of correction due date: Jul 7, 2025

Personal Accommodations and Services:The following provisions shall apply-Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. A bed for each resident, except that married couples may be provided with one appropriate sized bed. B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. A bed and a dresser was not provided for Resident #1's usethe state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: The Licensee will ensure that a resident is provided with a bed, chair, lamp, night stand and a closet if they are unable or choose not to provide them. Licensee will review Title 22 Section 87307 - Personal Accommodations and Services and submit a written statement that the section was read, understood and will be adhered to at all times by 7/7/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Jul 7, 2025

Personal Accommodations and Services:The following provisions shall apply-Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident....if the resident is unable or chooses not to provide them, the licensee shall assure provision of D) Hygiene items of general use such as soap and toilet paper.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: The licensee will review and update the Admission Agreement to include provisions of personal hygiene supplies if the resident is unable to or chooses not to provide personal hygiene supplies and how the facility will make available hygiene items available for the residents' residents. use. Licensee will also educate the staff so that they are aware that hygiene products wll be provided by the facility if the resident chooses not to provide them. Provide a copy of the revised Admission Agreement related to Personal Hygiene by 7/7/25

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection visit using the CARE Inspection Tool and initially met with Kimberly Griffin, Wellness Director and Joanna Hernandez, Generations Director. Elizabeth Whittington, Executive Director arrived shortly after to conduct the visit. The reason for today's visit was explained. The facility is a 5 storey building. The first floor houses the administrative offices, a front lobby with chairs, coffee tables and a fire place, a industrial kitchen, the communal dining room, a private dining room, a fitness room, a movie theater and 4 common bathrooms. Located in the front is an enclosed sitting area that is furnished with tables, chairs and umbrellas for shade. A water fountain was also observed. Located in the back is another enclosed area furnished with 3 tables and 12 chairs. The second floor consists of 25 single units, 8 double units and a large sitting area, the third floor, approved for Memory Care has 23 single units and 8 double units and a large sitting area, the fourth and fifth floors has 26 single units, 8 double units with a sitting area. Located beneath the building is the garage for resident and staff use. The facility is fire cleared for 95 AMBULATORY, 39 NON-AMBULATORY and 30 BEDRIDDEN residents. The following domains were reviewed on today's visit: Infection Control, Operational Requirements and Planned Activities. Also reviewed on today's visit were 2 resident files and 1 Staff file. Per review of the 3 domains noted above, no deficiencies were cited. Any deficiencies observed on today's visit will be addressed on the return visit. Exit interview was conducted with Elizabeth Whittington and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 22, 2025

Allegation investigated: Staff are not ensuring that residents are administered their medication(s) as prescribed.

Licensing Program Analyst (LPA) Christine Yee conducted a subsequent complaint visit to conduct additional investigation and to deliver the findings for the above allegation. LPA Yee met with Elizabeth Whittington, Executive Director and the reason for today's visit was explained. On 3/27/24 Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 12:55 p.m., the LPA met with staff and explained the reason for the visit. At 1:10 p.m., the Executive Director (ED) Elizabeth Whittington met with the LPA Peraldi. At 1:12 p.m., LPA Peraldi conducted an interview with the ED. At 1:15 p.m., LPA requested copies of pertinent documents. At 1:42 p.m., the LPA, along with the Wellness Director conducted a brief physical plant tour. LPA Peraldi determined that further investigation is required prior to issuing a finding. Exit interview conducted with Wellness Director. A copy of the report was issued. Unsubstantiated Page 2 A subsequent complaint visit was conducted on 1/28/25 by LPA Christine Yee to conduct further investigation for the above allegation. LPA Yee met with Elizabeth Whittington, Executive Director. LPA Yee provided the reason for the visit. During the subsequent visit, LPA Yee interviewed Elizabeth Whittington, Executive Director at 1:11pm, Staff #1 at 2:44pm, Staff #2 at 4:37pm, Resident #1 at 3:27pm and obtained additional facility files. Based on information obtained on the subsequent visit, it was determined that additional interviews are needed to make a finding for the above allegation. Exit interview was conducted and a copy of this report was provided. On today's visit, LPA Yee reviewed and obtained copies of the Medication Administration Record for Resident #1 and Resident #2 beginning at 11:12am and clarified information obtained from resident and staff interviews with the Executive Director. Prior to conducting today's visit, LPA Yee also conducted a telephone interview with Staff #3 at 8:42am. Per interviews conducted regarding the allegation that staff are not ensuring that residents are administered their medication(s) as prescribed and Staff # 3, was specifically named as the alleged perpetrator. Due to Staff #3 being related to the their supervisor, nothing is being done to address the issues with medications. Staff #3 works the night shift from 10pm- 6:30am. Per information provided, Staff #3 works as a caregiver and provides coverage as a medication technician on the days that the regular medication technician is off. Per interviews conducted, majority of the medications are dispensed during the first and second shift. The night medication technician does not really dispense medications. They will dispense PRN medications when the resident request them at night. Per information provided, the facility has only 2 residents who requests their PRN medication at night. Resident #1 does not like taking their PRN Hydrocodone 10/325mg tablet for pain in the day time as it makes them sleepy and is known to requests their hydrocodone regularly at 11pm, unless they are asleep. Resident #1 has also asked for their medication as early as 10:30pm. Sometimes Resident #1 forgets that they took their Hydrocodone and staff has to remind them that they took it already. Staff now leaves the empty pill cup on the night stand as a reminder to the resident. Resident #2 will sometimes ask for their PRN medication occasionally and has been currently in the hospital. Per interview with Resident #1,they have not been refused their medications or had any medication issues. Per interview conducted with Staff #1, who the complainant alleges has information to confirm the above allegation, vehemently denies having any knowledge of medication issues. Staff #1 states that they provide care to the residents and only relay a message tot he Medication Tech when the residents requests their medications. Page 3 Beyond that they do not touch medications, they do not hang around the medication room to have observed anything and have no knowledge of any medication issues. They don't know why someone would say that they have any information related to the above allegation. Per interviews conducted, everyone stated that there are no medication issues and if there was, it would have been reported to the Wellness Director and she would have relayed it to the Executor Director. Per interview with the Executive Director, she has not received any complaints from the residents or made aware of any issues regarding medications. Based on the investigation conducted, there is insufficient evidence to support the allegation that Staff are not ensuring that residents are administered their medication(s) as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated at this time. No deficiencies were cited on today's visit. Exit interview was conducted.the state’s words, verbatim · CDSS document, Jan 30, 2025 · control 29-AS-20240319173705

Allegation investigated: . Due to lack of staff, resident calls are not answered timely

Licensing Program Analyst(LPA), Christine Yee, conducted a subsequent unannounced complaint visit to conduct additional investigation for the above allegation and met with Elizabeth Whittington, Executive Director. The reason for today's visit was explained. On 10/23/23 Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegations and met with Elizabeth Whittington, Community Relations Director. Marissa Drinkhouse-Quintana, Administrator was not present in the facility. The reason for the visit was explained. During the initial visit, LPA Yee reviewed and requested copies of facility documents, conducted face to face interviews with Staff #1 and Staff #2 at 11:50am, Resident #1 at 3:09pm, Resident #2 at 3:43pm and a telephone interview with Staff #3 at 1:42pm. Due to staff not having access to requested records and time Substantiated constraints, it was determined that additional investigation was needed to make a finding for the above allegation. Exit interview was conducted with Elizabeth Whittington and a copy of this report was provided. On today's visit, LPA Yee conducted an interview with the Executive Director at 12:01pm, Resident #3 at 1:09pm, Resident #4 at 1:49pm and Resident #5 at 1:57pm. Facility documents were obtained at 1:53pm. Per information obtained through interviews regarding allegation #1 - Due to lack of staff, resident calls are not answered timely, Residents interviewed when the complaint was initially received and on today's visit stated that they do not have any issues getting assistance but know of other residents who are kept waiting for long periods of time from the time they press their pendant to the time staff responds. Per interviews conducted when the complaint was initially filed on 10/18/23, the facility was having staffing issues during the night shift from 10pm - 6am. Staff were not calling in or reporting to work and one staff resigned. Staff scheduled to work from the employment agency were also not reporting to work. The Executive Director at the time that the complaint was files was also not on site often to oversee the operations of the facility and was aware that someone had called off on 10/17/23 and there was no backup coverage. The night shift in Assisted Living normally consists of a Medication Tech and a caregiver and 2 caregivers in Memory Care. As a result of the staff no call, no show on 10/17/23, the Medication Technician had to pitch in as a caregiver on the assisted living side of the facility, on top of their usual responsibilities. There was a total of 3 staff that night including the Medication Technician. Medication Tech did not request assistance from the 2 Memory Care staff as they had their own caseload. Attempts were made to reach the nurse for assistance and she could not be reached by telephone. Per review of the call for service logs, residents calls were not responded to in a timely on the night of 10/17/23 - 10/18/23. The longest response time was 47 minutes to room 406. Per review of the current call for service log from 11/16/24-11/30/24, the longest response time was 44 minutes to room 520 on 11/21/24. Based on the information obtained from interviews and review of facility records, there is sufficient evidence to support the allegation that due to lack of staff on 10/17/23, resident calls are not answered timely, therefore the allegation is substantiated at this time. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted, Appeals Rights discussed and a copy was given. constraints, it was determined that additional investigation was needed to make a finding for the above allegation. Exit interview was conducted with Elizabeth Whittington and a copy of this report was provided. On today's visit, LPA Yee conducted an interview with the Executive Director at 12:01pm, Resident #3 at 1:09pm, Resident #4 at 1:49pm and Resident #5 at 1:57pm. Facility documents were obtained at 1:53pm. Per interviews conducted regarding Allegation #2 -Facility is not providing a safe environment for the residents, information revealed that two homeless individuals, a male and a female, were observed by a resident wandering around in the common area on the fourth floor of the facility at around 3:30am on 9/25/23. Resident notified staff. The facility is enclosed on all four sides and secured by fences and gates. Visitors enter the facility through the front lobby and are required to check in and out. The front desk is manned 24 hours a day. It is unknown how the 2 individuals entered the premises. It is hypothesized that they either climbed over the fence or that a staff left the gate ajar for re--entry instead of using their keys. The 2 individuals were walked out by staff once they were discovered. Per information received, this was the only incident where the homeless were on the premises. Based on the information received, there is insufficient evidence to support the allegation that the facility is not providing a safe environment for the residents, therefore the allegation is unsubstantiated. Exit interview was conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 9, 2024 · control 29-AS-20231018081720

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 16, 2024

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above per interviews conducted, it revealed there are times when only one caregiver is on duty in the Assisted Living side of the operation with 46 residents. This poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2024

Plan of correction: The Licensee will review the needs of all the residents to ensure that the current staffing meets the needs of the residents and submit a written plan that will be implemented when staff call out to ensure that there is always staff coverage at all times by 12/16/24

Allegation investigated: . Facility staff failed to treat resident with dignity and respect 2. Illegal eviction 3. Facility staff failed to assist with the self-administration of a resident’s medication as prescribed

Licensing Program Analyst(LPA) Christine Yee conducted a subsequent unannounced complaint visit to conduct additional investigation and to deliver the findings for the above allegations and met with Elizabeth Whittington, Executive Director. The reason for today's visit was explainted. An initial unannounced complaint visit was conducted by LPA Yee on 3/2/23. During that visit, LPA Yee reviewed and obtained copies of facility records relevant to the complaint and conducted interviews with Stephanie Walters, Executive Director at 11:09am and 12:53pm, Staff #1 at 1:00pm, Staff #2 at 1:27pm, Staff #3 at 1:58pm and Resident #1 at 11:50am. Based on the information obtained during the intial visit, further investigation was needed to make a finding for the above allegations .Exit interview was conducted and a copy of the report was provided. Continued on LIC9099-C Unsubstantiated Page 2 On today's visit, LPA Yee interviewed Elizabeth Whittington, current Executive Director at 10:41am, attempted to conduct a telephone interview with Co-complainant and reviewed facility file at 12:14pm. Per interviews conducted regarding Allegation #1 - Facility staff failed to treat resident with dignity and respect, the complainant alleges that Stephanie Walters, former Executive Director and Staff #2 are mean and on an unknown date, Staff #2 called Resident #1 an "idiot." Per Co-complaint, they also witnessed that incident where Staff #2 called Resident #1 an "idiot and "stupid." Per the Co-complainant, they reported it to the former Executive Director and was terminated because Staff #2 is friends with the Executive Director. Per review of personnel files, the employment termination was related to the Performance Evaluation conducted in December 2022. Per interview conducted with Resident #1, Staff #2 is nice and they never mentioned that Staff #2 called them an idiot or stupid. Per interview conducted with Staff #2, they deny calling any resident any names. The former Executive Director also denies knowing of any incident where the staff called Resident #1 names. Per information provided, Resident #1 is aggressive, uses bad words and calls the women the "B" word and makes sexual innuendoes. They would ignore or stay away from Resident #1 when they are in a rage. Attempts were made to interview the Co-complaint via telephone on today's visit and LPA Yee was told that they have not worked for the facility for over a year and they don't remember anything. Based on the information received through the interviews conducted, there is insufficient evidence to support the allegation that facility staff failed to treat resident with dignity and respect. It may or may not have happened but there is no preponderance of evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED at this time. An interview was conducted with Resident #1 regarding Allegation #2 - illegal eviction, the resident indicated that the facility is trying to evict them. Per the interview conducted with Resident #1, they were told to leave the facility. Per interview with Stephanie Walters and Staff #2, they have not served Resident #1 or the resident's POA any eviction notices. However, they are working with Resident #1's family to find other placement since the resident wants to live closer to West Los Angeles and does not like it here. Per information received from interviews conducted, there is insufficient evidence to support the allegation that Resident #1 is being illegally evicted. Therefore the allegation is UNSUBSTANTIATED at this time. Continued on LIC9099-C Page 3 Per interviews conducted regarding Allegation #3 - Facility staff failed to assist with the self-administration of a resident’s medication as prescribed, the facility would have difficulty with Resident #1 taking their medication. Resident #1 would refuse to take the medication and than half hour later would take the medications. Per Staff interviewed, Resident #1 did not like being woken up for medication. The facility also had problems obtaining the resident's medications and refills. The pharmacy would call the doctor and they did not respond to requests for medications promptly and they were also having insurance issues. The pharmacy would not take Resident #1's insurance and the POA would not change the resident's insurance. Insurance also would not authorize the medications immediately. Based on the interviews conducted there is insufficient evidence to support the allegation that facility staff failed to assist with the self-administration of a resident's medication as prescribed. Therefore, the allegation is UNSUBSTANTIATED at this time. No deficiencies were cited on today's visit Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 25, 2024 · control 29-AS-20230228105824

Type of visit: Case Management - Incident

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit to follow up on the incident where a memory care resident was able to leave the facility without staff's knowledge. LPA Yee met with Elizabeth Whittington, Executive Director. The reason for today's visit was provided. On today's visit, interviews were conducted with the Administrator at 1:05pm, a telephone interview with a family member at 3:54pm, an attempted interview with Resident #1 at 2:49pm and tour of the Memory Care Unit at 2:40pm. Staff schedules and documents were also obtained from Resident #1's file from 1:05pm through 3:35pm. Based on the information obtained on today's visit, it has been determined that further information is needed to make a determination if the facility took all necessary safety measures to ensure that Resident #1 was not able to leave the Memory Care Unit without Staff's knowledge. Exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 6, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Emily Peraldi and Sandra Urena arrived at the facility unannounced to conduct a required annual visit. At 10:05 a.m., the LPAs were greeted and screened by staff. At 10:15 a.m., the LPAs met with the Executive Director (ED), Elizabeth Whittington and explained the reason for the visit. At 10:36 a.m., the LPAs and the Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The facility is a five-story building. Resident rooms are located throughout four floors, all floors are assisted living except for floor three (3) which is designated for memory care. Common spaces on the first floor include the reception area/lobby, a theater, salon, dining room, and fitness room. The remaining floors each have their common spaces for activities, and all have appropriate furniture. All activity rooms and common spaces appeared clean and in good repair. Activity schedules are posted throughout the facility. There were no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which were charged and last serviced 01/05/2024. Fire alarm/sprinkler system test was documented and tested 08/2023. Kitchen: Dining is located on the first floor and was observed to be clean and sanitary. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was posted, and the facility offers daily specials and a standard selection at every meal. Snacks and beverages are available for residents. Resident Units: The LPAs and Executive Director toured seven (7) randomly selected resident rooms throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Continued on LIC 809C. Restrooms: The LPAs and Executive Director observed restrooms in seven (7) resident units and common area restrooms. All restrooms were fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces in the bathing unit. Water temperature was tested throughout the visit, and water measured between 105.1 – 116.6 degrees Fahrenheit. Outside areas: There are multiple outdoor patios equipped with furniture for resident use. There were no bodies of water noted. Parking is available for residents and visitors. Files: Between 11:40 a.m. and 2:25 p.m., the LPAs conducted a file review for six (6) residents and six (6) staff. Six (6) resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. Six (6) personnel records were reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and training documentation showing required training completed. Personnel files were in order. Starting at 2:30 p.m., the LPAs conducted a review of medication records, policy and procedures with the Executive Director. Audit for seven (7) residents revealed that facility staff did not accurately record medications, and/or missing start dates. The Executive Director stated that facility staff will receive medication training. Documentation: The LPAs obtained a copy of the liability insurance, resident roster, and staff roster. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiency was cited (refer to LIC 809-D). The Executive Director was made aware that failure to correct the 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, Feb 26, 2024

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

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Emily Peraldi and Sandra Urena conducted an unannounced Case Management - Incident inspection. At 10:05 a.m., the LPAs were greeted and screened by staff. At 10:15 a.m., the LPAs met with the Executive Director (ED), Elizabeth Whittington and explained the reason for the visit. The reason for today's inspection is to follow up on one (1) self-reported Report of Suspected Dependent Adult/Elder Abuse (SOC 341) submitted on 02/14/2024 regarding Resident #1 (R1). During the time of the visit, the LPAs obtained copies of pertinent documents. At 10:36 a.m., the LPAs along with the Executive Director conducted a physical plant tour. No immediate health and safety concerns were observed during today's inspection. Further investigation is required at this time. An additional report may follow if warranted. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 26, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Sandra Urena and Emily Peraldi arrived at the facility unannounced to conduct a case management-deficiency as a result of the Licensee's failure to inform the Department about the court appointed Receivership. The LPAs met with the Executive Director Elizabeth Whittington and informed them of the reason for the visit. On 02/16/2024 the facility received a visit from Mr. Tom Seaman to inform the Executive Director that the facility was placed under Receivership, and that they were court appointed as the Receiver. However, the facility failed to inform the Department until the 21st of February 2024. Per California Health and Safety Code section 1569.686, you are hearby notified that a $100 civil penalty is being assessed per day. The total civil penalty for a continuous violation shall not exceed $2000. You will receive an invoice in the mail. Payment is due when billed. Payments must be made by a personal business or cashier's check or money order made payable to the "California Department Of Social Services". Please write the facility number and invoice number on your check and include copy of your invoice with the payment. You will find the invoice number on your invoice. DO NOT SEND CASH. The licensee was notified that a civil penalty is being assessed for failure to comply with this section and/or failure to report specified events, in writing, within 2 business days to the Department, the state long term ombudsman, all residents, and their representatives. Deficiency cited under Health and Safety code 1569.686. Pursuant to Health and Safety Code, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted/ Citations issued/ Civil Penalty assessed/ Appeal Rights discussed/ A copy of report was issued.the state’s words, verbatim · CDSS document, Feb 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.686(a)(4) · Plan of correction due date: Mar 1, 2024

1569.686 A licensee shall notify the department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their legal representatives, in writing, within two business days...(1) A notice of default...This requirement is not met as evidenced by: Based on interview, licensee failed to ensure The Department, LTCO, residents and their responsible parties were notified of the default received by licensee on 02/16/204, which caused an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 26, 2024

Plan of correction: Licensee stated they will inform the LTCO, residents, and their responsible parties of the notice of default by 03/01/2024. Civil penalty is assessed for violation of this section [Health and Safety code 1569.686(c)]

Allegation investigated: . Staff are neglecting residents in care 2. Residents' hygiene needs are not being met. 4. Staff leave residents unattended in soiled diaper for extended periods of time 5. Residents sustained diaper rashes while in care 6. Staff are failing to meet residents’ needs

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced complaint visit to conduct further investigation for the above allegations and met wth Elizabeth Whittington, Executive Director. The reason for today's visit was explained. On 2/8/22, LPAs Salia Walker and Ashley Smith conducted an initial unannounced complaint viisit to investigate the 8 allegations submitted on the complaint. The LPAs met with Executive Director Becca Black and Business Office Manager Angela Webb and explained the reason for the visit. During today’s visit, the LPAs conducted a physical plant tour with the Executive Director at 11:10 a.m., to ensure there are no health and safety hazards. From 12:10 p.m. until 1:48 p.m., the LPAs conducted interviews with six (6) facility staff. Based on LPA Walker and LPA Smith's investigation, It was determined at the time of the initial visit that allegation #3 - the facility is unkempt, allegation #7 - Staff failed to provide residents with clean linens Unsubstantiated and allegation #8 - Staff do not practice social distancing that the allegations were unsubstantiated. Interviews were also conducted with the 6 staff regarding the other five allegations during the initial visit and it was determined that further investigation was needed to make a finding. On today's visit, LPA Yee conducted an interview with Elizabeth Whittington, Executive Director at 12:10pm, Maria Calderon, Wellness Director at 1:30pm, Staff #1 at 1:59pm and Resident #1 at 2:34pm. The four facility bathrooms located on the first floor and each of the bathrooms located on the second floor through the fifth floor were toured beginning from 2:31pm through 3:05pm and all were observed to be clean. One of the bathrooms located on the first floor by the elevators was observed being cleaned during today's visit. Per information obtained from interviews at the time of the initial visit on 2/8/22 and today regarding allegation #1 - Staff are neglecting residents in care, staff state that they do not neglect the residents. Residents are monitored by staff. Staff are on hand to provide assistance to the residents getting to the bathroom, changed, cleaned and transferring. If the residents do not feel well, they ensure that the resident get's the care that they need. If something is observed, it is reported to management and the appropriate care or action is taken. Staff do not neglect to address any health concerns observed such as rashes on a resident. Based on the information obtained, there is insufficient evidence to support the claim that the staff neglected the residents in care.. This allegation is deemed Unsubstantiated at this time. Regarding Allegation #2 - Residents' hygiene needs are not being met, interviews reveal that residents who need assistance with bathing are placed on a bathing schedule. Some resident's request daily showers and some are bathed two times a week or the family requests more showers. If residents refuse to take a bath it is documented and the residents are encouraged during the evening shift if they refused to bath in the morning. Residents are also offered a bath the following day. Per Staff, they just come back at a later time and offer the shower again. The reasons that the residents refuse to bath are due to being tired, it being too cold or not feeling well. Currently Resident #3 is refusing to shower and the family is involved in encouraging Resident #3 to shower due to the resident being combative with staff. Based on the information obtained, there is insufficient evidence to support the claim that the residents' hygiene care are not being met. This allegation is deemed Unsubstantiated at this time. Regarding Allegation #4 - Staff leave residents unattended in soiled diaper for extended periods of time. Per interviews conducted with staff, residents are checked and changed every 2 hours. Residents are not left in a dirty diaper. Per interviews conducted during the initial complaint, a regular staff did observe residents left in wet diapers on the night shift covered by staff hired through an employment agency. The regular staff would change them in the morning. Residents are also able to ask staff to change them. Based on the information obtained, there is insufficient evidence to support the claim that staff leave residents unattended in soiled diaper for extended periods of time. This allegation is deemed Unsubstantiated at this time. Regarding Allegation #5 - Residents sustained diaper rashes while in care, staff interviewed state that their residents do not have diaper rash. They are checked every 2 hours and the residents do not develop diaper rashes. There are a couple of residents who have a rash or redness but it is not diaper rash, some residents like to stay in bed or sit all day. Per interview with the Executive Director, they currently have a new resident who sits all day due to fear of falling. As a result of sitting all day, the resident has redness in the bottom area. Based on the information obtained, there is insufficient evidence to support the claim that the residents sustained diaper rashes while in care. This allegation is deemed unsubstantiated at this time. Regarding Allegation #6 - Staff are failing to meet residents’ needs, staff state that they take good care of the residents. Staff state that they are meeting the needs of the residents. Residents are monitored by staff for any changes in their condition. Prescribed medications or creams are given or applied to ensure that the resident's health condition is healing or appropriate medical attention is obtained. Just recently, Resident #2 who was admitted with an ongoing leg condition was observed with swollen and weepy legs by staff. Resident #2 also complaint that there was burning pain in the legs. Staff ensured that the resident was sent to the hospital for treatment despite objections from a family member. Based on the information obtained, there is insufficient evidence to support the claim that the staff are failing to meet residents needs. This allegation is deemed unsubstantiated at this time. No citation were issued on today's visit. Exit interview was conducted with Maria Calderon and a copy of the report was providedthe state’s words, verbatim · CDSS document, Feb 13, 2024 · control 29-AS-20220204075140

Type of visit: Case Management - Incident

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to three incidents reported to the Department involving 2 alleged staff abuse incidents and a resident on resident altercation. LPA Yee met with Elizabeth Whittington, Executive Director. The reason for the visit was explained. On today's visit LPA Yee reviewed and obtained copies of files for Resident #1 - Resident #4, facility files throughout the visit, interviews were conducted with the Executive Director at 12:00pm, Staff #1 at 1:25pm, Jarred Massey-Baker, Director of Memory Care at 2:06pm Witness #1 at 11:17am, Resident #1 at 12:18am. The first incident of alleged resident abuse was reported to the Department on 1/17/24. Per the incident report, Resident #1 contacted a family member via telephone and informed them that the people here are hitting me. Per face to face interview with the family member, Resident #1 calls about 20 times a day. They informed facility staff about what Resident #1 told them. The family member states that the staff treats Resident #1 well and does not believe that the staff are hitting resident. The family member also heard Resident #1's spouse in the background loudly asking Resident #1 "what are you saying, no one is hitting you." Resident #1 and spouse are inseparable. Per interview with Resident #1, the staff hit them on their butt to wake them up. Resident #1 states that they don't like that. When Resident #1 was asked by the family member if it was a hit or was it a tap and the resident indicated that it was a tap but does not like being woken up that way. Per the family member, they will discuss with the Executive Director to get staff to tap Resident #1 on the shoulder instead. The second incident reported to the Department on 1/18/24 involved Resident #2 and Resident #3. Resident #2 slapped Resident #3 in the face. Per interview with the Executive Director and Director of Memory Care, this was a one time incident and has not happened again. Resident #2 and Resident #3 are residents in the Memory Care Unit and they were sitting in the living room when staff heard a slapping sound. Upon inspection by staff, redness was observed on left side of Resident #3's face. Family of both residents were notified. Family of Resident #2 were shocked as the resident does not have a known prior history of hitting. Resident #2 physician's was also notified. The facility plan to ensure that Resident #3 is not hit again, is to keep both residents separated and monitor them closely. The third incident was reported to the Department on 1/31/24 and involves Resident #4 and Staff #2. The incident reported to the Department was that Staff #1 and Staff #2(caregivers) were assisting Resident #4 get dressed and ready for the day around 6:35am. Resident #4 began to show signs of being agitated and raised both hands with closed fists. Conflicting verbal and written statements are being provided by Staff #1 and Staff #2 as to what occurred next. Per Staff #1, Staff #2 slapped Resident #4's hand and told resident "don't do that." Per Staff #2, Resident #4 was being aggressive and they raised their hand to protect themselves from being hit by Resident #4. This incident was reported to the Director of Memory Care by Staff #1. An immediate decision was made to place Staff #2 on suspension while the incident was being reviewed. Staff #2 was sent home on the day of the incident. The resident's family and physician were notified of the incident. An SOC341 Report of Suspected Dependent Adult/Elder Abuse was filed with Adult Protective Services and a LIC624 Special Incident Report was submitted to the Department. Training was provided on reporting requirements on 1/30/24 and Memory Care Residents: Redirecting & Communication was conducted on 1/18/24. On 2/6/24, a conference call was made to Staff #2 to terminate employment with the facility and the final check was picked up by Staff #2 on 2/7/24. Per investigation of all three reported incidents the facility took immediate and appropriate action to address each of the incidents. No citations were issued on today's visit. Exit interview was conducted.the state’s words, verbatim · CDSS document, Feb 7, 2024