Veterans Home of California - West Los Angeles

Type of visit: Case Management - Health Checks

On 04/02/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an announced Case Management - Health and Safety Check to the facility listed above. LPA met with DeVon Young, Administrator, and the purpose of the visit was explained. LPA was granted entry into the facility. On April 1, 2026, at 4:00 PM, the facility informed the Department that the facility had been placed on Fire Watch due to a faulty fire pump breaker. The facility clarified that the fire protection system remains operational and provided contact information for further questions. The department was provided with contact information for the representative from the Fire Department whom the facility reported to and has been speaking with. During today’s visit, LPA was informed that hourly checks are performed through the interior and exterior of the facility to ensure safety. The checks are performed by multiple staff members. All staff and residents have been notified of the situation and have been informed that if they see something please say something. Fire extinguishers were checked to ensure they are fully charged and accessible. The fire alarms were tested by the vendor on 04/02/2026. During the visit, LPA observed the Health and Safety Officer of the facility speaking with the security asking how the last fire watch round was and that the next round was coming up. The estimated time frame for repairing the faulty fire pump breaker is thirty (30) days. The Administrator stated they will inform the department if it is repaired sooner or if it is going to take additional time. Per the Administrator, fire watch and hourly checks will continue till the breaker is fixed. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the department did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted with DeVon Young, Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 2, 2026

Type of visit: Case Management - Other

On 9/18/2025, at approximately 12:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced Case Management visit at the facility. LPA Iniguez met with Devon Young / Administrator and explained the purpose of the visit. On September 13, 2025, the department received a Decision and Order (DO) against (S#1), stating that they are excluded from any care facility licensed by the department. On 9/15/25, LPA Iniguez emailed Devong Young(A#1), and he stated that nobody under the name of (S#1) worked before at the facility and they have received the (DO) via postal mail. In addition, LPA Iniguez reviewed the Personnel Report or LIC 500, he did not observe (S#1) listed on there. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Devon Young / Administrator.the state’s words, verbatim · CDSS document, Sep 18, 2025

Type of visit: Required - 1 Year

On 9/3/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Devon Young /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (84) elderly adults aged 60 and above, of which (84) can be bedridden. The facility has an approved hospice waiver for (8). Currently the facility has (65) residents. The RCFE facility consists of 2 floors, including 34 double rooms and 16 single rooms, a total of 50 bathrooms, a bathing room, barbershop, activity room, meditation room, dining room, 4 dens and a kitchen. LPA Iniguez and the Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (5) bedrooms and (5) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 114.5°F to 118.2°F, and the room temperature ranged from 73.2°F to 74.3°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 6/29/25. A review of (5) staff personnel and (5) residents service files was conducted; no discrepancies were found. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be emailed to LPA. Facility Annual Fess current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Devon Young / Administrator.the state’s words, verbatim · CDSS document, Sep 3, 2025

Type of visit: Case Management - Incident

On 6/5/2025, at approximately 11:30 AM, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced Case Management visit at the facility. LPA Iniguez met with Aithi Hong,/Standard and Compliance Manager, and explained the purpose of the visit. On May 19, 2025, the department received a Decision and Order (DO) against (S#1), stating that they are excluded from any care facility licensed by the department. On 5/27/25, LPA Iniguez emailed Aithi Hong/Standard and Compliance Manager(A#1), and she stated that nobody under the name of (S#1) worked before at the facility and they have not received the (DO) yet, LPA Iniguez attached a copy of the (DO) in the email. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Aithi Hong/Standard and Compliance Manager.the state’s words, verbatim · CDSS document, Jun 5, 2025

Allegation investigated: Staff are not preventing resident from being molested while in care.

On 5/23/2025 at approximately 8:30 AM, LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Marnell Banks/Resident Care Specialist. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA Iniguez conducted the following interviews: Resident Care Specialist (A#1), Standards and Compliance Manager (S#1) and Residents Interviews (R#1-R#7). LPA obtained and reviewed the following documents: Resident Roster dated: 5/23/25 and Personnel Report or LIC 500 dated:5/23/2025. Evaluation Report continues LIC 9099-C Unfounded Investigation Revealed the Following: Allegation: Staff are not preventing resident from being molested while in care. The details of the complaint alleged that (R#1)’s observed their roommate been observed by unknown individual. On May 23, 2025, at approximately 9:30 AM, during the records review, LPA Iniguez observed the Resident’s Roster dated 5/23/25. (R#1) is not listed in the roster. On May 23, 2025, at approximately 10:00 AM, during an interview with facility staff (A#1 and S#1), (2) out of (2) stated that (R#1) does not live here and never did. On May 23, 2025, at approximately 10:30 AM, LPA Iniguez was not able to interview (R#1) since they never resided at the facility. On May 23, 2025, at approximately 10:30 AM, during an interview with facility residents (R#2-R#7), (6) out of (7) stated that they had never seen or heard about (R#1) living at the facility. Unfounded: This agency has investigated the complaint alleging (Staff are not preventing resident from being molested while in care). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted, and a copy of the Complaint Report was given to Marnell Banks/Resident Care Specialist.the state’s words, verbatim · CDSS document, May 23, 2025 · control 11-AS-20250522115831

Allegation investigated: Staff did not follow sanitary practices for food storage units.

On February 4, 2025, Community Care Licensing Department staff Deborah Lee conducted an unannounced complaint visit to the address the allegation listed above. The department staff was greeted by the Standars and Compliance Manager Aithi Hong, who granted access to the facility and the purpose of the visit was discussed. This complaint alleges that Resident 1(R1) passed away on 1/23/25 at 9:30am and his body was placed in trailer generally used to store food in case of an emergency. R1’s body was allegedly picked up approximately 8:00pm from the loading dock where the trailers are located. The investigation consisted of the following: The department staff conducted a tour of facility both inside and out, made observation of food service and storage areas including the loading dock, reviewed resident rosters (dated 1/23/25 and 2/4/25), and interviews conducted with 3 staff (S1- S3) and the Standard and Compliance mnager (A1). Page 1 of 2 Unsubstantiated Allegation: Staff did not follow sanitary practices for food storage units The department staff conducted interviews with the Standards and Compliance Manager (A1) and Staff 1-Staff 3 (S1-S3). A1 reported that there has been no residents death in the month of January 2025. She also reported that when a resident passes away, the body is not moved until a mortuary or coroner arrives to remove the body and it is typically taken through the front door. A1 stated that "our policy is they come through the front door and they exit through the front door." Lastly, A1 stated that it is not possible for a body to be picked up from the loading dock or any place else. Of the 3 staff interviewed, 3 out of 3 staff state that when a person passes away the body is not moved and the process is as follows: the mortuary or corner is called, a family member is call, there is a small flag ceremony, the body is picked up and taken through the front doors. Lastly, 3 out of 3 staff and A1 stated that any resident who passed away has never been placed in an area where food is stored. The department staff observed food service and storage areas and found that all safety/infectious disease precautions were used such as wearing hair nets, masks, gloves and washing hands. All storage freezers where observed to be clean and sanitary. All items were appropriately stored. The department staff obtained and reviewed a copy of Residents' roster (dated 1/23/25 and 2/4/25) and did not observe any resident with initials matching R1's as indicated on the complaint. Based on the information provided, documentation reviewed, and interviews conducted, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited for the above allegations. Exit interview was conducted. A copy of this report was provided to Aithi Hong, Standards and Compliance Manager.the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 11-AS-20250131114522

Type of visit: Case Management - Other

On January 15, 2025, Licensing Program Analyst Alfonso Iniguez conducted an unannounced case management visit. The LPA met with Aithi Hong, the Assurance and Compliance Manager, to explain the purpose of the visit. The department issued a Decision and Order against (S#1), effective January 13, 2025. During the visit, LPA Iniguez confirmed that (S#1) was not working or associated with the facility. He spoke with Edward, the Human Resources Manager, who stated that they received the notice on January 14, 2025, and that (S#1) would be disassociated from Guardian as of January 15, 2025. Additionally, Aithi Hong provided LPA Iniguez with a copy of the current LIC 500 Personnel Report, which did not include (S#1). It is also important to note that (S#1) was officially terminated on December 17, 2023. During this visit LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Aithi Hong/Assurance & Compliance Manager.the state’s words, verbatim · CDSS document, Jan 15, 2025

Type of visit: Case Management - Other

On 09/19/24, Licensing Program Analyst LPA Alfonso Iniguez conducted a Case Management visit to clear plan of correction. De Von Young/Administrator greeted LPA, and LPA explained the purpose of the visit. On 8/17/24, LPA Iniguez conducted an unannounced, one-year-required visit at the location. During the annual inspection, LPA Iniguez was not able to observe residents' records since they were not available for inspection. LPA Iniguez inspected the following documents: -Residents Records: (R#1-R#5) -Staff Records: (S#1) LPA Iniguez was able to review missing records, the plans of correction has been cleared. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to DeVon Young / Administrator.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Required - 1 Year

On 8/17/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Stephanie Weaver /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (84) elderly adults ages 60 and above, of which (84) can be bedridden. The facility has an approved hospice waiver for (8). The RCFE facility consists of 2 floors, including 34 double rooms and 12 single rooms, a total of 50 bathrooms, a bathing room, barbershop, activity room, meditation room, dining room, 4 dens and a kitchen shaded area. LPA Iniguez and the Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (5) bedrooms and (5) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 114.5°F to 118.2°F, and the room temperature ranged from 73.2°F to 74.3°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 6/1/24. A review of (5) staff personnel files was conducted. LPA was not able to review (5) residents' service files and (5) Medication Administration Records (MARs), records were not available by facility staff. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -No CPR cards from care staff available for LPA to see during inspection. -No residents records readily available for LPA for review during inspection. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Stephanie Weaver / Administrator.the state’s words, verbatim · CDSS document, Aug 17, 2024

Allegation investigated: Facility staff did not notify residents' physician about changes in residents' condition while in care. Facility staff intimidated resident while in care.

On 03/28/24, at 10:00am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Teresa Starks, Deputy Administrator. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegations mentioned above. The investigation consisted of the following: LPA investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R11). Resident Roster, Staff Roster, Admission Agreement, Code of Conduct Violations, ID/Emergency Information, & Care Plan Report for R1 were obtained from the facility. The investigation revealed the following: Allegation #1- Facility staff did not notify residents' physician about changes in residents' condition while in care. Report continued on LIC9099-C Unsubstantiated The details of the complaint alleged that the facility administrator (S1) did not notify R1’s mental health provider about R1’s change in condition between 08/02/2023 and 12/01/2023. On 03/28/24, from 10:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R11) regarding the allegation. 4 of 4 staff denied the allegation that the Facility staff did not notify residents' physician about changes in residents' condition while in care. Staff (S1-S4) stated that they had no knowledge of changes in R1’s condition because R1 never came to the staff and let them know that R1 was having any issues. S2 stated If R1 had come to us and said R1 was in crisis we would have notified R1’s mental health provider, but R1 did not; R1 never had an acute episode in the facility to my knowledge. S2 stated further that R1 had clinical and mental health issues while R1 was staying here but they were not acute; and during this period, he did not report any to the staff. LPA interviewed residents R1-R11 about the allegation that Facility staff did not notify residents' physician about changes in residents' condition while in care. 10 of 11 residents denied the allegation and stated that whenever they have a change in their health and well-being, the staff does notify their physician about any changes in their condition. LPA observed in the Care Plan Report notes, dated 07/12/2023, that R1 declined to be evaluated for R1’s annual RCFE medical exam. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff did not notify residents' physician about changes in residents' condition while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 2- Facility staff intimidated resident while in care. The details of the complaint alleged that the administrator (S1) and security staff provoked and created false information against R1 which resulted in R1 having aggressive and suicidal thoughts. On 03/28/24, from 10:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R11) regarding the allegation. 4 of 4 staff denied the allegation that Facility staff intimidated resident while in care. All staff (S1-S4) stated that they have never intimidated or retaliated against R1 while R1 was a resident in care that caused R1 to be in distress. All staff stated further, that R1 was the one that would make staff and residents uncomfortable with R1’s combative and aggressive behavior. S2 stated that R1 was issued several codes of conduct violations for R1’s behavior towards staff and residents; and was involved in several interdisciplinary meetings to bring attention to R1’s behavior but it persisted and didn’t get any better. But at no time did anyone ever intimidate R1. LPA interviewed R1-R11 about the allegation that Facility staff intimidated resident while in care. 10 of 11 residents denied the allegation and stated that they have not had any problems with staff intimidating or making them feel uncomfortable in any way. Report continued on LIC9099-C Based on interviews, there is insufficient evidence to support the allegation that the Facility staff intimidated resident while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Teresa Starks, Deputy Administrator.the state’s words, verbatim · CDSS document, Mar 28, 2024 · control 11-AS-20240321143310

Allegation investigated: Facility illegally evicted a resident in care.

On 12/01/2023 at 08:00 am Licensing Program Analyst (LPA) David España conducted an initiated a 10-day complaint investigation follow-up visit for the allegation listed above. Upon arriving at the facility, LPA met with S#1 and S#2 who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections. The investigation consisted of the following: On 12/01/2023 at 08:00 am LPA España conducted a tour of facility plant with S#1. LPA reviewed resident records of Seven (7) out of Fifty-Nie (59) residents to ensure it was separate, complete, and current which are maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing. LPA España confirmed there are 59 residents. LPA España confirmed there are 34 staff members. Continued 9099-C Unsubstantiated LPA conducted an interviews with Five (5) out of Fifty-Nie (59) residents. LPA conducted an interviews with Five (5) out of Thirty-Four (34) staff. Four (4) out of Thirty-Four (34) residents expressed that they had no knowledge of a notice of eviction. Five (5) out of Thirty-Four (34) staff expressed no knowledge of illegally eviction. Four (4) out of Thirty-Four (34) residents expressed that they heard of one person moving out of the facility for unknown reason and had no knowledge of 30 day of eviction notice being given to said person. LPA conducted an interview with Five (5) out of Thirty-Four (34) staff who expressed that the facility following a code of conduct that all resident in care have signed when admitted to the facility. Per LPA interviews Five (5) out of Thirty-Four (34) staff expressed that at no time did any staff remove any resident in care. Five (5) out of Thirty-Four (34) staff expressed that at no time did any staff tell or suggest that resident must leave the facility. One (1) out of Thirty-Four (34) staff interviewed stated that there is an “Eviction process” that is specified in Admission Agreement and signed by the resident in Admission process Agreement section #19 Condition for Eviction. One (1) out of Thirty-Four (34) staff interviewed stated that the facility follows policies. One (1) out of Thirty-Four (34) staff interviewed stated there is an interdisciplinary plan of care (IDT) policy which is a SNF policy, not a RCFE policy. Per LPA record reviewed and interviews S#1 and S#2 the purpose of the Interdisciplinary Team is to develop and maintain an interdisciplinary plan of care that meets the individual of any changing needs of the Resident in the Skilled Nursing Facility. One (1) out of Thirty-Four (34) staff interviewed noted that the IDT (Interdisciplinary Team) meets about the following: A. New Admissions: within 14 days from the date of admission; B. Quarterly: within 90 days from the last assessment per MDS schedule; C. Significant Change: within 14 days from when the change was first identified (Reference: Resident; D. Post Fall: within 7 days from the date of any fall (Reference: Accident Prevention policy); and E. Physical Restraints: prior to utilization unless urgent or emergent situation etc. LPA further confirmed based on records reviewed that the facility follows processes which resident(s) have the right to refuse: to select among treatment options be instituted. Per LPA record reviewed the IDT when encouraged by Residents, ask for surrogates and representatives to participate in care planning, including encouraging them to visit the care planning conferences. Per LPA record reviewed Veteran Homes of California Administration which follow the Level of Care Criteria for Residential Care for the Elderly (RCFE) (i.e., 4639 v.1). Continued 9099-C Based on the record review and interviews, the facility followed Title 22, Division 6, Chapter 8, Article 04, Operating Requirements, 87224 Eviction Procedures. Therefore, there has been no violation of California Code of Regulations, Title 22, Division 6, and Chapter 8, and no deficiencies are being cited. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Teresa Starks, Administrator.the state’s words, verbatim · CDSS document, Dec 1, 2023 · control 11-AS-20231114150236