Vista Del Mar Senior Living

Allegation investigated: Resident has sustained multiple unwitnessed falls. Staff do not respond timely when resident falls. Staff are not adequately caring for resident's wounds. Staff are not meeting resident's hygiene needs. Staff did not ensure the facility is kept sanitary and free from pests.

On August 20, 2026, California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Antonine Richard conducted a follow-up complaint visit. LPA Richard met with Suzette Johnson, Executive Director, and explained that the visit's purpose was to investigate the allegations and deliver findings. The investigation included a collection of records, and interviewed: The Department reviewed several documents, including the Facility Staff Roster (dated 03/18/26), Personnel Report LIC 500 (dated 03/18/26), and Resident #1 (R1)'s Identification and Emergency Information LIC 601 (dated 07/06/23), Physician's Report LIC 602A (dated 05/01/26), Service Plan (dated 02/21/26), Resident Assessment (dated02/21/26), Dowey Pet Control invoice (date) scheduled residents rooms treatments, and residents shower schedules, Bayview Hospice Notes. As well as other pertinent records associated with this complaint. On August 19, 2026, LPA interviewed the Administrator (A1), the Licensed Vocational Nurse (LVN), Medical Technician (MT1), and two staff (S1-S2), and ten residents (R2-R11). LPA was unable to interview R1 because R1 moved R1 out of the facility on June 15, 2026. Unsubstantiated Allegation #1: Resident has sustained multiple unwitnessed falls. The complaint alleged that resident R1 had experienced multiple un-witnessed falls and that facility staff was delayed in responding to R1's needs. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegations. A1 stated that when staff found R1 on the floor of R1's room, they called the Med Tech or Nurse to evaluate R1. However, R1 consistently refused assistance, insisting that they were fine and had no pain. A1 also explained that for any resident who experienced an un-witnessed fall, staff would always call the Med Tech or Nurse to assess if the resident was in pain; if there were any injuries, they would immediately call Medical Emergency Services (MES). The department also interviewed the Licensed Vocational Nurse (LVN), who denied the allegations, stating that when staff discovered an un-witnessed fall, they would call the Med Tech and Nurses to conduct evaluations. If any injuries were found, they would contact MES right away. On the same date, the department interviewed the Medical Technician (MT1), who also denied the allegations and confirmed that they follow procedures regarding un-witnessed falls by contacting the LVN for resident assessment. Additionally, the department spoke with two staff members (S1 and S2), who similarly denied the allegations and stated that for un-witnessed falls, they would call both the MT1 and LVN to assess the residents, regardless of whether the residents reported pain or injuries. The department reviewed the facility notes dated (02/20/26, 02/22/26), in which staff found R1 on the floor lying with the pillow. R1 had no injuries or pain and refused to go to the hospital. The facility staff notified R1's family. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated. Allegation #2: Staff do not respond timely when resident falls. The complaint alleged that the facility staff delayed their response to Resident 1's (R1) care. On August 19, 2026, the department interviewed the Administrator (A1), who denied this allegation. A1 stated that each resident has a call button around their neck or in their pocket that, when pressed, prompts a staff member to respond. The Administrator also mentioned that R1 knows how to ask for help and communicates very effectively. A1 also stated R1 had multiple un-witnessed falls without any injuries; R1 always refuses Medical Emergency Services (MES) and stated there was no pain and that they were feeling fine. On the same day, the department interviewed the Licensed Nursing Volunteer (LNV), who also denied that staff delayed their response to residents. According to LNV, residents pressed the call button for assistance, and a staff member responded within minutes. Additionally, the department spoke with the Medication Technician (MT1), who similarly denied the allegation, stating that when residents requested help, staff responded immediately. Two staff members (S1 and S2) were also interviewed and denied the claim. They confirmed that when a resident pressed the call button, a staff member responded right away. The department interviewed ten additional residents (R2-R11), all of whom reported no neglect while seeking help. On August 19, 2026, the department observed two residents pressing their call buttons, and staff arrived eight minutes later. The department also reviewed the hospital discharge papers for R1, dated from February 3, 2026, to March 4, 2026, which indicated that R1 had been hospitalized several times for various symptoms. Additionally, the department examined the physician's report for R1, which confirmed that R1 was capable of performing activities of daily living independently and managing self-medication. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated. Allegation #3: Staff are not adequately caring for resident's wounds. The complaint alleged that a family member is concerned about wounds on the resident's left heel that allegedly have not healed properly. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that the facility nurse had observed a wound on the resident R1's left heel. After the wound evaluation and treatment, the facility contacted Bayview Hospice, and R1 agreed. On April 04, 2026, R1 started Hospice care treatment with Bayview Hospice. A1 stated after enrolling in Bayview Hospice, R1 decided to discontinue hospice care services. On April 23, 2026, the facility, staff members, a representative from Bayview Hospice, and R1's family were present when R1 decided to discontinue hospice care. Staff explained to R1 the benefits of receiving hospice assistance for wound care. Because the facility is not a medical center, staff took the time to explain R1's wound situation to the resident, who is independent and does not have a Power of Attorney (POA). On August 19, 2026, the department interviewed the Licensed Vocational Nurse (LVN), who denied the allegations and stated that the facility could not provide wound care to residents. Instead, the facility would contact Hospice Care and home health services to assist residents with wounds. The LVN emphasized that R1 needed support from one of these services, as the facility is not a medical facility. The department also reviewed the Bayview Hospice notes from the same date, which indicate that services were started and then discontinued for resident R1. The department also viewed a picture of R1's left foot tapes, which shows that R1 had a wound on the left foot. Allegation #4: Staff are not meeting resident's hygiene needs. The complaint alleged that a family member had several concerns about safety, hygiene, and the care provided in the resident's assisted living. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that Resident 1 (R1) can perform activities of daily living (ADLs) independently. R1 has a scheduled shower three times a week. A1 also stated that all staff members must follow the resident's physician reports and the service plan to assist residents with their hygiene needs. If a resident can’t, the staff would assist with the (ADLs) activities. On August 19, 2026, the department interviewed the Licensed Vocational Nurse (LVN), who also denied the allegation and confirmed that the staff adheres to the resident's physician report, doctor’s orders, and service plan to meet the resident’s hygiene needs accurately. The department also interviewed the Medication Technician (MT1), who denied the allegation and stated that they follow the resident's service plan to meet hygiene needs. The department interviewed two staff members, referred to as S1 and S2, both of whom denied the allegations. They confirmed that they have access to residents' face sheets, service plans, and shower schedules for each resident. They clarified that residents in a specific program are entitled to three showers per week. For private-pay residents, the number of showers is determined by how many the residents choose to purchase. On August 19, 2026, the department reviewed the physician's report and the service plan needs for Resident 1 (R1), which indicated that R1 was capable of self-care. Additionally, the department reviewed the facility’s shower schedule, which included dates, times, and room numbers, along with residents' names for the personal shower schedule. The staff also stated that if a resident refuses to shower, they document the refusal. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated. Allegation #5: Staff did not ensure the facility is kept sanitary and free from pests. The complaint alleged that the complainant saw rodents and cockroaches in resident R1's bedroom. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that Dewey Pest Control visits the facility weekly. A1 also stated that the facility rotates residents' rooms weekly. If a resident complained that a room had pets, the company would service the rooms and follow up the following week. On August 19, 2026, the department interviewed two staff members (S1-S2), both of whom denied the allegation and stated that pest control visits the facility weekly; if there is a problem with a resident's room, they let them know. Additionally, the department interviewed ten residents (R2-R11); 9 of 10 residents denied seeing any pets in their rooms and stated that pest control visits the rooms sometimes. On August 19, 2026, the department visited eight rooms: 315, 316, 317, 318, 272, 219, 217, and 114. On August 19, 2026, the department reviewed the physician's report and the service plan needs for Resident 1 (R1), which indicated that R1 was capable of self-care. Additionally, the department reviewed the facility’s shower schedule, which included dates, times, and room numbers, along with residents' names for the personal shower schedule. The staff also stated that if a resident refuses to shower, they document the refusal. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated. Allegation #5: Staff did not ensure the facility is kept sanitary and free from pests. The complaint alleged that the complainant saw rodents and cockroaches in resident R1's bedroom. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that Dewey Pest Control visits the facility weekly. A1 also stated that the facility rotates residents' rooms weekly. If a resident complained that a room had pets, the company would service the rooms and follow up the following week. On August 19, 2026, the department interviewed two staff members (S1-S2), both of whom denied the allegation and stated that pest control visits the facility weekly; if there is a problem with a resident's room, they let them know. Additionally, the department interviewed ten residents (R2-R11); 9 of 10 residents denied seeing any pets in their rooms and stated that pest control visits the rooms sometimes. On August 19, 2026, the department visited eight rooms: 315, 316, 317, 318, 272, 219, 217, and 114. The department observed no pets or cockroaches during the room inspection. The department observed no pets or cockroaches during the room inspection. The department reviewed the Dewey pest control invoice dated 06/01/2026, 07/01/2026, and 08/01/2026 for monthly services rendered to the facility. Additionally, include the apartment services log for each resident's room, dated 01/01/2026 to 06/01/2026. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to Administrator Suzette Johnson.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 11-AS-20260316124852

Type of visit: Office

On July 17, 2026, a virtual office meeting was held as requested by Executive Director/Administrator Suzette Johnson. Attendees included Licensing Program Manager (LPM) Ulysses Coronel, Licensing Program Analyst (LPA) Socorro Leandro, Vice President of Operations James Bender, and Executive Director/Administrator Suzette Johnson. The following topics were discussed: · Patterns or recurring issues noticed among the complaints. · Facility’s ongoing efforts to build community partnerships. · Facility’s ongoing efforts to build relationships with residents. · Facility’s employment development plan. · Improvements being implemented by the facility regarding medications. · The Department’s offer of the Technical Support Program (TSP). This report was emailed to the Executive Director/Administrator Suzette Johnson.the state’s words, verbatim · CDSS document, Jul 17, 2026

Allegation investigated: Staff do not prevent residents from using illegal drugs on the facility premises while in care.

On July 08, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, a subsequent an unannounced complaint visit. Suzette Johnson, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, record reviews, and a tour of the facility. Investigation conducted by Investigator Dennis Seng of the CDSS Investigation Branch. Interviews with Staff member S#1 - S#7 (S1-S7), Resident #1 - #6 (R1- R6) and Witness #1 (W1). The Department reviewed several documents, including the Facility Resident Roster (dated 03/18/26), Personnel Report LIC 500 (dated 03/18/26), (R1’s and R2’s) Physicians Report LIC 602 A (dated 03/03/26 and 04/17/25), Appraisal/Needs & Service Plan LIC 625 (dated 10/12/23, 08/01/25 and 09/13/25) (Evaluation Report continues LIC 9099-C) Unsubstantiated Preplacement LIC 603 (dated 10/17/21 and 08/01/25) Physicians Orders Medication (dated 04/04/25 and 07/22/25) Residence and Care Agreement (dated 10/19/21). Additional review of Resident Warning Notice-Contraband Items (dated 03/14/26), Unusual Incident Report LIC 624 (dated 03/18/26), Photographs of Evidence (dated 03/14/26), and Long Beach Police Department Report DR 260111793 (dated 03/16/25). INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff do not prevent residents from using illegal drugs on the facility premises while in care. It is alleged that the facility staff fails to prevent residents from using illegal drugs on the premises. Reports indicate that staff discovered drug paraphernalia related to methamphetamine on March 14, 2026. Two residents, referred to as Resident #1 (R1) and Resident #2 (R2), are using illegal drugs on the premises while under care and are providing these substances to other residents. On April 3, 2026, May 19, 2026, June 10, 2026, and June 11, 2026, between 1:45 PM and 3:27 PM, the department conducted interviews with staff members identified as Staff #1 through Staff #7 (S1-S7). Seven (7) of the seven (7) staff members were unable to corroborate the claim that staff were accountable for neglect or a lack of supervision to prevent Residents #1 and #2 (R1 and R2), from using illegal drugs on the premises. On March 14, 2026, during a routine medication round, Staff #2 (S2) checked on (R1 and R2). (S2) observed a white powdery substance on the table, which (S2) believed to be illegal methamphetamine. (S2) reported that (R2) placed a box over the powder to conceal it. (S2) then left the room and informed Staff #3 (S3), who came to assist (S2). Together, (S2 and S3) attempted to confiscate the drugs but were unsuccessful. After the incident, (S2 and S3) notified Staff #1 (S1), who instructed Staff #4 (S4) to confiscate the described powdery substance found on (R2’s) nightstand. (S1) also ordered (S4) to conduct several unannounced inspections following the incident. (S4) then handed the drugs, along with a pipe, to Staff #5 (S5), who returned to (R1 and R2) to issue them a Resident Warning Notice on March 14, 2026, which they signed. (S5) reported that (R1 and R2) did not want to disclose who provided the drugs or where they were obtained. Staff #1 through Staff #7 (S1-S7) reported that they had never witnessed (R1 or R2) using drugs and that neither had a prior history of drug use. (Evaluation Report continues LIC 9099-C) On the same day, (S7) reported that law enforcement had been notified and had confiscated the methamphetamine. The responsible parties, (R1 and R2), along with their primary physician, were informed. Additionally, the California Department of Social Services Community Care Licensing, was notified of an Unusual Incident Report (LIC 624) on March 18, 2026. On April 3, 2026, and June 4, 2026, between 02:09 PM and 05:26 PM, the Department interviewed resident members identified as Resident #1 through Resident #6 (R1-R6). Six (6) of the six (6) resident members cannot support this claim. (R1 and R2) denied any use of illegal drugs on the facility premises. (R1) explained to have spoken to (R2) on March 14, 2026, and notice that a staff gave (R1) notice to sign. (R1) reported that (S2) found the drug on the round table on (R2’s) side of the room. Three (3) of the four (4) residents (R2-R6) stated that they did not witness (R1 or R2) under the influence of illegal drugs. However, (R6) mentioned that there was one occasion when (R2) had methamphetamine at the facility, specifically in the patio smoking area. (R6) suggested that the staff probably did not know about the drugs because, had they been aware, the drugs would have been taken away, and (R2) would have ended up being evicted. On April 3, 2026, and June 4, 2026, between 01:42 PM and 04:51 PM, the Department interviewed witness identified as Witness #1 (W1). Witness #1 (W1), who had firsthand knowledge of the incident, asserted that Resident #1 (R1) was not involved in the drug abuse and never used methamphetamine at the facility. (W1) believed that it was Resident #2 (R2) who procured the drugs and misused them in their room. Furthermore, (W1) expressed skepticism about the facility staff's awareness of any drug abuse; had they known, they surely would have acted by evicting (R2) or confiscating the drugs and reporting the incident appropriately. The Department reviewed the facility complaint history and incident reports; there was no previous indication that Resident #1 and Resident #2 (R1-R2) had engaged in drug abuse while receiving care at the facility. Further review of (R1’s and R2’s) Physicians Report LIC 602 A (dated 03/03/26 and 04/17/25), Appraisal/Needs & Service Plan LIC 625 (dated 10/12/23, 08/01/25 and 09/13/25) Preplacement LIC 603 (dated 10/17/21 and 08/01/25) Physicians Orders Medication (dated 04/04/25 and 07/22/25) Residence and Care Agreement (dated 10/19/21). Additional review of Resident Warning Notice-Contraband Items (dated 03/14/26), Unusual Incident Report LIC 624 (dated 03/18/26), and Long Beach Police Department Report DR 260111793 (dated 03/16/25). (Evaluation Report continues LIC 9099-C) Based on the gathered information, it appeared that the facility was unaware of any previous instances of drug abuse involving Resident #1 and Resident #2 and that they acted promptly by reporting and confiscating the drugs once staff found them. There is insufficient evidence to corroborate the allegation. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted with SUZETTE JOHNSON, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 11-AS-20260316164851

Allegation investigated: Rooms are malodorous Facility is not equipped with sufficient hygiene supplies

On 07/07/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced continuation complaint investigation visit regarding the allegations listed above. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 01/29/2026, a facility tour was conducted and Resident 1 (R1) to Resident 10 (R10) and Witness 1 (W1) to Witness 2 (W2) were interviewed. On 04/09/2026, a facility tour was conducted and Staff 1 (S1) to Staff 13 (S13) and Resident 11 (R11) to Resident 14 (R14) were interviewed. On 04/10/2026, nine resident Medication Administration Records (MARs) were reviewed along with their medications. On 05/05/2026, Witness 1 (W1) to Witness 9 (W9) were interviewed. On 05/06/2026, Witness 10 (W10) was interviewed. On 05/08/2026, Witness 11 (W11) to Witness 13 (W13) were interviewed. Records were gathered and reviewed. On 07/03/2026, documentation/records were reviewed. Substantiated The investigation revealed the following: Allegation: “Rooms are malodorous”, it is being alleged that residents’ rooms are malodorous. Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation, moreover, staff explained that housekeepers are continuously working to keep up with the needs of residents. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 6 out of 14 residents agreed with the allegation, moreover they indicated that the facility has incontinent and cigarette smells; 5 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 11 out of 13 witnesses denied the allegation, furthermore, witnesses stated that facility staff clean up after residents; 2 out of 13 witnesses agreed with the allegation. On 01/29/2026, resident rooms were toured and the following was observed: room 267 had strong incontinent smells and room 284 had strong odors. On 04/09/2026, resident rooms were toured and the following was observed: room 242 was malodorous; room 121 had strong incontinent smells; room 126 had strong cigarette odor; room 127 had strong incontinent odor; room 272 had strong incontinent smells; room 115 had strong incontinent smells, resident visitor stopped facility staff in the hallway and informed them that they have been attempting to reach staff and have not been assisted, additionally, resident visitor informed staff the room is “smelling so bad” requesting for the diapers in the trash bin to be removed and the bed sheets to be removed and replaced with clean bed sheets, resident visitor had on two disposable medical face masks, staff called for assistance. Records reviewed revealed the following: the facility has a laundry schedule and cleaning schedule for the Memory Care Unit and the Assisted Living Unit; on 04/27/2026, the facility implemented a plan to ensure that resident appliances (e.g. refrigerators) were to be maintained cleaned, resident rooms will be cleaned and “residents requiring additional support will be flagged for staff follow-up.” Substantiated: Based on observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Allegation: “Facility is not equipped with sufficient hygiene supplies,” it is being alleged that residents are not provided with sufficient hygiene/bathroom supplies such as paper towels, hand soap, and so on. Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation, staff explained that residents receive a clean hand towel but do not receive paper towels and there are no electric hand dryers in the resident bathrooms. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 2 out of 14 residents denied the allegation; 9 out of 14 residents agreed with the allegation, furthermore, they explained that the facility provides them with toilet paper and a hand towel, and at times they provide them with hand soap, moreover, residents explained that they purchase their own hand soap and hygiene supplies. Observations of resident rooms on 01/29/2026 and 04/09/2026 in the Memory Care Unit and Assisted Living Unit revealed the following: Resident bathrooms are provided with a hand towel even if there are two residents per room; residents are not provided with paper towels nor an electrical hand dryer. There were five bathrooms that did not have hand soap, and there were several bathrooms that did not have toilet paper and a hand towel. Substantiated: Based on observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. The investigation revealed the following: Allegation: “Unqualified staff are providing medication assistance to residents in care”, it is being alleged that untrained staff are providing medication assistance to residents in care which have resulted in medication errors. Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation, moreover, staff indicated that staff are trained in medication administration and staff are not aware of any medication errors. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation and 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. Records reviewed of Medication Administration Trainings from 01/2025 to 01/2026 revealed the following: Medical Technicians (MedTech’s) and Licensed Vocational Nurses (LVNs) received in-service trainings on Medication Destruction, Receiving Medication, Centrally Storing Medication, Expired Medications, Managing Orders, Communication Documentation, Refusal of Medication, Counting Narcotics, Medication Crushing, Discontinued Medication, MAR Documentation, and so on. Records reviewed revealed that in 2026 MedTech’s received a Certificate of Completion for successfully completing 8 hours of in service of Medication Administration Techniques & Medication Forms Documentation. Records reviewed revealed that LVNs have a current Vocational Nurse License. Unsubstantiated: 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. An exit interview was conducted, and a copy of this report was left with the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 11-AS-20260122103758

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(2) · Plan of correction due date: Aug 3, 2026

Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observations and interviews the licensee did not comply with the section cited above by not providing residents with comfortable accommodations by not having rooms free of malodors which included incontinent odors, cigarette smoke odors, etc. which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Executive Director has agreed to create a plan to ensure that residents are provided with comfortable accommodations by maintaining a facility that is clear of malodors. Plan should include the following: removal of used incontinent supplies from resident rooms, the number of times staff will go into residents rooms to remove items that are/can cause malodorous and smoking prevention inside the facility. The Executive Director will train staff on said plan. Email plan & trainings to Socorro.Leandro@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C)(D) · Plan of correction due date: Aug 3, 2026

Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. (D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Based on observations and interviews the licensee did not comply with the section cited above by providing residents with a common hand towel and not ensuring that residents had hand soap and toilet paper are available to them at all times which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Executive Director has agreed to create a plan to ensure that the use of common (hand) towels are prohibited in the facility. And residents have hand soap, toilet paper, and hand drying material (e.g. paper towels, hand dryer, individual hand towels) available to them at all times. Email plan & trainings to Socorro.Leandro@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 07/07/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of this visit is to deliver deficiencies observed during the course of the investigation regarding complaint control number 11-AS-20260122103758. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility. Deficiencies observed were as follows: Record review of the facility Plan of Operation revealed the following: · “Medication Refills…Medication refills will be obtained in a timely manner to ensure residents have all physician ordered medication available. 1. The designated staff member contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to running out of medication…When the medication is ordered it entered onto the Refill Roster…3. Medications are never allowed to run out.” · “Missed or Refused Medications…1. Missed/refused medications are documented in the resident’s medication record…” · “Blood Pressure and/or Pulse Reading to Determine the Need for a Medication…resident’s vital signs are taken to determine the need for admiration of medications: a)…A written record is made on the MAR. b) When the medication is given, the date, time, and initials of the person who took the vital signs and/or gave the medication are documented. · “Assisting with Administration: Oral Medications…5. Document administration of medication on them Medication Assistance/Administration Record.” On 04/10/2026, resident MARs were reviewed along with their medications in the Memory Care Unit and Assisted Living Unit and the following was revealed: · Resident 2 (R2) did not have their prescription or nonprescription PRN medication available to them which was “Hyoscyamine 0.125 mg tab”. MedTech was unable to locate PRN medication. · Resident 15’s (R15) March 2026 MAR shows the following: o “Furosemide 40 mg tablet – take 1 tablet by mouth daily for CHF Hold for SBP <110” § On 03/01/2026 medication was not provided to R15 and Blood Pressure (BP) was not documented. § On 03/05/2026 medication was provided to R15 and BP was not documented. § On 03/25/2026 medication was provided to R15 and BP was not documented. o “Digoxin 125 mcg tablet – take 1 tablet by mouth once daily at 12 PM for a-fib (Hold if apical pulse below 60)” § On 03/05/2026 medication was provided to R15 and pulse was not documented. § On 03/25/2026 medication was provided to R15 and pulse was not documented. § On 03/31/2026 medication was provided to R15 and pulse was not documented. o “Sacubitril-Valsartan 24-26 mg – take 1 tablet by mouth twice daily (hold if sbp below 110)” § On 03/01/2026 at 8:00 AM R15 medication was not provided to R15 and BP was not documented. § On 03/05/2026 and 03/25/2026 at 8:00 AM R15 medication was provided to R15 and BP was not documented. § On 03/05/2026, 03/06/2026, 03/07/2026, 03/13/2026, 03/14/2026, 03/29/2026, and 03/31/2026 at 5:00 PM R15 medication was provided to R15 and BP was not documented. ·Resident 16 (R16) April 2026 MAR shows the following: o “Vitamin D3 50,000 unit capsule – take capsule by mouth once weekly on Fridays” was not available to R16. MedTech was unable to locate the routine medication. Records reviewed revealed that a refill was not submitted and no notes were written. o “Alum-Mag Hydroxide-Simeth Susp” – PRN medication was not available for R16. MedTech was unable to locate PRN medication. Said medication has not been provided to the resident. o “Loperamide 2 mg capsule” - PRN medication was not available for R16. MedTech was unable to locate PRN medication. Said medication has not been provided to the resident. o “Milk of Magnesia Suspension” - PRN medication was not available for R16. MedTech was unable to locate PRN medication. Said medication has not been provided to the resident. · Resident 7 (R7) April 2026 MAR shows the following: o “Pantoprazole sod dr 40 mg tab – Take 1 tablet by mouth twice daily before meals for 14 days.” § There were 9 medication errors for this medication. § The medication bubble states that the medication was dispensed on “03/28/2026” with “no refills” and a “quantity of 28 tablets” (28 divided by 14 equals a total of 14 days of medication, the last day of the medication would have been 04/10/2026 if R7 started to take medication in the morning of 03/28/2026); the bubble pack has an “AM” sticker. There is no bubble pack with a “PM” sticker. The April 2026 MAR shows that R7 received medication at 8 AM and 5 PM from 04/01/2026 to 04/09/2026 and R7 refused 8 AM medication on 04/10/2026. The bubble pack has 12 tablets popped out and 16 tablets in the bubble pack (there should have been one more tablet left over if R7 started to take medication in the morning of 03/28/2026). According to interviews with staff in the Medication Room, they only provide this medication to R7 at 8 AM but not at 5 PM. Physicians Orders and Hospice records confirmed that this medication was prescribed to be taken twice a day for 14 days. · Resident 10 (R10) April 2026 MAR shows the following: o There are 14 medication errors. § 14 Medication bubble packs for “AM” are popped out for 04/09/2026. § April 2026 MAR for 04/09/2026 at 8 AM are left blank with no initials for 14 different medications. · Resident 13 (R13) April 2026 MAR shows the following: o 2 routine medications were not found in the Medication Room; MedTechs were unable to locate the medications. According to MAR the resident has been taking the medication as prescribed. The medications were “Spiriva Handihaler 18 mcg cap” and “Bacitracin 500 unit/gm ointment.” Physician’s Orders confirmed that said medications were prescribed. o 8 PRN medications were not found in the Medication Room; MedTechs were unable to locate the medications. Physician’s Orders confirmed that said medications were prescribed. Said medications have not been provided to the resident. Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, Jul 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Aug 3, 2026

Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by: Based on observations, interviews, and record review the licensee did not comply with the section cited above by not following the facility’s Plan of Operation and not providing medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Executive Director has agreed to review the facility’s Plan of Operation regarding medication and train MedTechs & LVNs. Confirmation of reviewed Plan of Operation regarding medication and trainings shall be emailed to Socorro.Leandro@dss.ca.gov

Allegation investigated: Staff do not provide adequate food service.

On 06/25/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. California Department of Social Services (CDSS) was met by staff one, Suzette Johnson (S1), and the purpose of the visit was explained. The investigation consisted of the following: On 06/25/26 CDSS requested and reviewed facility documents which included resident roster (dated 06/25/26), staff roster (dated: 06/25/26), a resident's care plan (R1) (dated: 06/14/26), R1's Medication Administration Record (MAR) (dated: 06/25/26), weekly menu (dated: 06/21/26 through 06/27/26) and CDSS toured the facility. Between 10:45AM and 3:15PM, LPA interviewed nine (9) residents and three (3) staff. The investigation revealed the following: Regarding the allegation “Staff do not provide adequate food service.”, it is being alleged that staff do not wake a resident for breakfast and lunch mealtimes. Interviews revealed that seven (7) residents and all three (3) staff have denied the allegation has taken place, while one (1) resident refused CDSS' interview. Report continues, please see LIC9099C. Unsubstantiated CDSS made the following observations: CDSS observed a "PM" meal in a to go box, which had been brought up to R1 on 06/24/26. The meal appeared to be dinner from the night before, which included a cup of soup, a roll, a slice of cantaloupe and Shepherd's pie. The meal had not been altered, meaning the meal had not been touched. CDSS record reviews consisted of R1's MAR, R1's service plan and weekly menu along with an alternative menu which is available each day. All of these files were reviewed and appeared to have no discrepancies. Based on interviews conducted, observation and record reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was conducted with Suzette Johnson, Executive Director, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jun 25, 2026 · control 11-AS-20260618154401

Type of visit: Office

On May 26, 2026, at 1:30 pm, an office meeting was held to discuss Complaint 11-AS-20240429113918. Present at the meeting were Eva Alvarez, Licensing Program Manager (LPM); Antonine Richard, Licensing Program Analyst (PLA); Suzette Johnson, Executive Director (ED), People Operations; Claudia Crowley; and James Bender, Vice President. During the meeting, LPM reviewed the details of the Complaint. On May 16, 2025, the Department substantiated an allegation that a resident sustained a fracture due to lack of care from staff. At this time, the Department is considering an enhanced civil penalty under Health and Safety Code Section 1569.49(f). The department is reviewing the complaint to determine whether to assess an enhanced civil penalty for Serious Bodily Injury pursuant to H&S 1569.49(f). The total civil penalty for Serious Bodily Injury is $10,000. An exit interview was conducted with Suzette Johnson, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 26, 2026

Allegation investigated: Staff speaks inappropriately to resident in care

On 05/20/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. California Department of Social Services (CDSS) was met by staff two, Sidonia Cordis - Resident Care Director (S2) and later by staff three, Suzette Johnson - Executive Director (S3), and the purpose of the visit was explained. The investigation consisted of the following: On 05/20/26 CDSS requested and reviewed facility documents and toured the facility. Between 8:00AM and 11:00AM, LPA interviewed ten (10) out of two-hundred and forty-three (243) residents (R1-R10) and six (6) out of one-hundred and twenty-two (122) staff (S1-S6). S1 was not available for CDSS interview, as S1 did not answer CDSS phone call. The investigation revealed the following: Regarding the allegation “Staff speaks inappropriately to resident in care”, it is being alleged that staff speak inappropriately to the residents during medication rounds. Report continues, please see LIC9099-C. Unsubstantiated Record reviews have indicated that S1 has fulfilled all staff requirements under personnel requirements and personnel records and is eligible to work at and are associated to the facility. Interviews revealed that nine (9) out of ten (10) residents and all six (6) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was conducted with Suzette Johnson - Executive Director, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 11-AS-20260512153126

Allegation investigated: Staff did not keep facility free of vermin.

THIS REPORT SUPERSEEDS THE REPORT DATED 04/09/2026 TO CHANGE COMPLAINT INVESTIGATION FINDING(S). On 04/09/26 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director as the purpose of today’s visit was explained. The investigation consisted of the following: On 04/01/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre placement appraisal dated: 02/20/25, Admission agreement dated: 02/18/25 , resident assessment dated: 03/05/25, Physicians report dated: 02/13/25, service plan dated: 06/17/25, updated service plan dated 03/26, shower schedule, facility notes dated: 03/2026, facilities laundry schedule, pest control service logs dated: On 01/2026-04/2026. On 04/01/26 from 10:00 am- 12pm LPA conducted Interviews with Residents #2-10 (R2-R10). On 04/01/26 LPA was unable to interview R1 as R1 was out of the Unsubstantiated facility at the time of visit. On 04/01/26 LPA conducted interviews with staff #1-3 (S1-S3) and conducted a tour of the facility. On 04/09/26 LPA conducted interviews with staff #4-6 (S4-S6). On 04/09/26 at 2pm LPA conducted interview with R1. The investigation revealed the following: Allegation: Staff did not keep facility free of vermin. It is alleged that the facility has a rat problem as rat feces have been observed at the facility. On 04/01/26 and 04/09/26 LPA conducted Interviews with R1-R10 regarding the allegation above. 8 of the 10 residents interviewed denied the allegation above, 2 of the 10 residents interviewed confirmed the allegation above. 10 of 10 residents interviewed confirmed that the facility is being treated by pest control. On 04/01/26 and 04/09/26 LPA conducted interviews with S1-S6. 4 of the 6 staff interviewed denied the allegation above, 2 of 6 staff interviewed confirmed the allegation above and reported seeing mice at the facility. 5 of the 6 staff confirmed that pest control services are coming out to service the facility. 1 of the 6 staff interviewed reported having no knowledge of pest control services at the facility. On 04/01/26 LPA observed pest control to be servicing the facility at the time of the visit. On 04/01/26 LPA conducted a review of pest control service report dated: 3/25/26. Per the report, 20 rooms were serviced, interior and exterior inspected and baited, no activity found, EZ snaps are inspected each time facility is serviced, sanitation conditions listed as Fair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 12, 2026 · control 11-AS-20260325122703

Type of visit: Case Management - Deficiencies

On 05/12/26, Licensing Program Analyst (LPA) Villegas conducted an unannounced case management visit in association with complaint visit 11-AS-20260325122703 conducted on 04/09/26. LPA met with Executive Director Suzette Johnson as the purpose of the visit was explained. On 04/09/26, while LPA Villegas walked down the facility hallway the following deficiency was observed: 87303(a) LPA observed live cockroach in facility hallway. Deficiency cited on 809D page. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 12, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 9, 2026

87303 Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This deficiency was not met as LPA observed a live cockroach in facility hallway which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Executive Director to submit plan to LPA by POC due date detailing what the facility is going to do regarding pest control throughout the facility. What measure will be added to cleaning procedures to ensure pests at the facility is under control to ensure residents’ health and safety. Deficiency was cleared on 04/27/26, prior to LPA Villegas superseding report.

Allegation investigated: Staff did not shower residents in care Staff did not wash residents’ clothing Staff do not practice proper hand hygiene when handling foods Staff did not provide housekeeping services to residents Staff did not maintain facility restrooms in a clean condition Intoxicated residents engage in loud and disruptive behaviors in the facility

On 05/08/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced continuation complaint investigation visit regarding the allegations listed above. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 1/29/2026, a facility tour was conducted and Resident 1 (R1) to Resident 10 (R10) and Witness 1 (W1) to Witness 2 (W2) were interviewed. On 04/09/2026, a facility tour was conducted and Staff 1 (S1) to Staff 13 (S13) and Resident 11 (R11) to Resident 14 (R14) were interviewed. On 4/10/2026, nine resident Medication Administration Records (MARs) were reviewed along with their medications. On 05/05/2026, Witness 1 (W1) to Witness 9 (W9) were interviewed. On 05/06/2026, Witness 10 (W10) was interviewed. On 05/08/2026, Witness 11 (W11) to Witness 13 (W13) were interviewed. Records were gathered and reviewed. Unsubstantiated The investigation revealed the following: Allegation: “Staff did not shower residents in care.” Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 11 out of 13 witnesses denied the allegation; 2 out of 13 witnesses agreed with the allegation. Records reviewed revealed the following: The facility has a shower schedule for the Memory Care Unit and the Assisted Living Unit. Observations revealed the following: residents in the Memory Care Unit and Assisted Living Unit appeared to be groomed on a routine basis. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not wash residents’ clothing.” Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. Records reviewed revealed the following: The facility has a laundry schedule for the Memory Care Unit and the Assisted Living Unit. Observations revealed the following: laundry rooms were toured in the Memory Care Unit and Assisted Living Unit, and staff were washing clothes and taking clean clothes to residents’ units. Resident rooms were toured in the Memory Care Unit and Assisted Living Unit and residents had clean clothes available to them. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff do not practice proper hand hygiene when handling foods.” Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. Records reviewed revealed the following: On 06/15/2025, staff were trained on hand washing for handling food. Observations revealed the following: staff appeared to be in good hand hygiene during mealtimes in the Memory Care Unit and Assisted Living Unit. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not provide housekeeping services to residents.” Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 11 out of 13 witnesses denied the allegation; 2 out of 13 witnesses agreed with the allegation. Records reviewed revealed the following: The Memory Care Unit has a cleaning/organizing schedule for residents’ rooms. The Assisted Living Unit has a Deep Cleaning Schedule. Observations revealed the following: Housekeepers were present in the facility providing housekeeping services to residents in care, for example, cleaning resident rooms and cleaning communal areas. Tours of the Memory Care Unit and Assisted Living Unit were conducted, and rooms appeared to be clean; Memory Care Unit Rooms were very well organized. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not maintain facility restrooms in a clean condition.” Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. The Memory Care Unit has a cleaning/organizing schedule for residents’ rooms. The Assisted Living Unit has a Deep Cleaning Schedule. Observations revealed the following: Housekeepers are present in the facility providing housekeeping services to residents in care, for example, cleaning resident bathrooms. Tours of the Memory Care Unit and Assisted Living Unit were conducted; resident bathrooms appeared to be clean and sanitary. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Intoxicated residents engage in loud and disruptive behaviors in the facility.” Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. Records reviewed revealed the following: there were no unusual incident reports indicating that residents were intoxicated engaging in loud and disruptive behaviors in the facility. Observations revealed the following: residents were not observed intoxicated engaging in loud and disruptive behaviors. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, May 8, 2026 · control 11-AS-20260122103758

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide adequate supervision, resulting in resident sustaining fractures

On 05/01/26 The Department conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director as the purpose of today’s visit was explained. The investigation consisted of the following: On 02/18/26 The Department obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre-appraisal dated: 01/04/24, Physicians report dated: 04/21/2025, needs and service plan dated: 04/12/25, communication notes for February 2026, and unusual incident report dated: 02/15/26. On 03/02/26 The Department conducted interviews with staff #1-3 (S1-S3), and interviews with residents #1-2 (R1-R2). On 03/02/26 The Department reviewed police report from the Long Beach Police Department. On 03/03/26 The Department reviewed medical records from Long Beach Memorial Hospital for (R1). On 03/12/2026 The Department conducted a review of medication compliance list for (R2). On 05/01/26 The Department conducted interviews with Residents #3-10 (R3-R10) regarding the allegation above. The investigation revealed the following: Unsubstantiated Allegation: Staff did not provide adequate supervision, resulting in a resident in care sustaining fractures. It is alleged that facility staff did not respond in a timely manner when a resident in care called for help. On 03/02/26 and 05/01/26 The Department conducted interviews with R1-R10 regarding the allegation above. During interview with R1, R1 confirmed being assaulted but could not provide detailed information regarding the above allegation, however, R1 believes it took 5 minutes for staff to respond and assist. Additionally, R1 states feeling safe to return to the facility for care. During interview with R2, R2 confirmed the assault however R2 did not provide any information regarding the allegation above. During interviews with R3-R10, 7 of the 8 residents interviewed denied the allegation above and reported that assistance from staff is provided when requested, 1 of the 8 residents interviewed reported being independent and assistance from staff is not required. Furthermore, 6 of the 8 residents interviewed on 05/01/26 indicated that staff response time is within minutes, 1 of the 8 residents reported staff response time can take up to an hour, 1 of the 8 residents interviewed reported being unaware as staff assistance is not required. On 03/02/26 The Department conducted interviews with S1-S3 regarding the allegation above. 3 of 3 staff interviewed denied the allegation above. Per 2 of the 3 staff interviewed, they were on shift the night of the incident and assisted as soon as they were notified of the situation. Per 3 of 3 staff interviewed, there was no history of violence between R1 and R2 nor individually with other residents in care. On 03/12/26 The Department conducted a review of medical records from Long Beach Memorial Hospital date: 2/15/2025 which indicated that R1 was admitted to Long Beach Memorial Hospital with a diagnosis of: Assault, Closed non displaced fracture of head of left radius sequela, and Closed fracture of multiple ribs of left side, initial encounter. On 03/12/2026 The Department conducted a review of medication compliance list for R2, per medication administration record R2 had been refusing to medications from 02/6/26- 02/13/26. Upon review it is unclear if the refusal of these medications during this period contributed the assault/battery that occurred between R1 and R2. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was not provided.the state’s words, verbatim · CDSS document, May 1, 2026 · control 11-AS-20260217132633

Allegation investigated: Staff gave resident the wrong medication.

On 05/01/26 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director as the purpose of today’s visit was explained. The investigation consisted of the following: On 04/09/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre placement appraisal dated: 07/20/21 Physicians report dated:12/09/25, Physicians orders, Medication Administration Record (MAR) for 03/2026- 04/2026, service plan dated: 09/12/25, and facility notes dated: 07/2023-03/2026. On 04/09/26 from 11:00 am- 12pm LPA conducted Interviews with Staff #1-4 (S1-S4), and on 04/09/26 from 1pm- 2:30pm LPA conducted interviews with residents # 1-10 (R1-R10). On 04/22/26 LPA Villegas conducted a review of documents obtained. On 04/22/26 The Department addressed similar complaint allegation which was found to be unsubstantiated. On 05/01/26 LPA Villegas conducted a medication administration records review. The investigation revealed the following: Unsubstantiated Allegation: Staff gave a resident the wrong medication. It is alleged that facility staff gave a resident in care medication for two days that were prescribed to a different resident in care. On 04/09/26 from 11:00 am- 12pm LPA conducted Interviews with S1-S4 regarding the allegation above. 4 of the 4 staff interviewed denied the above allegation. Per 4 of 4 of the staff interviewed, residents with the same or similar name staff are verifying birth dates prior to administering medications. Additionally, 2 of the 4 staff interviewed reported that the facilities electrical medication administration record (EMAR) has some of the resident’s pictures which are also used to confirm that the medication is being administered to the correct resident. On 04/09/26, 4 of the 4 staff interviewed reported that a supervisor is notified if a medication error occurs. On 04/09/26 from 1pm- 2:30pm LPA conducted interviews with R1-R10 regarding the allegation above. 7 of the 10 residents interviewed denied the allegation above. 1 of the 10 residents interviewed reported managing their own medications therefore they have no knowledge of the allegation above. 2 of the 9 residents interviewed confirmed the allegation above and report they made the staff aware of the error. On 04/22/26 LPA Villegas conducted a review of documents obtained, per preplacement appraisal dated: 07/20/21, Physicians report dated:12/09/25, and Service plan dated: 09/12/25 R1 requires assistance with medication and R1 cannot store nor administer their own medications. On 04/22/26 The Department addressed similar complaint allegation which was found to be unsubstantiated. 05/01/26 LPA Villegas conducted a medication review and observed all medications to be accounted for and documented on EMAR. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was not provided.the state’s words, verbatim · CDSS document, May 1, 2026 · control 11-AS-20260403114442

Allegation investigated: Lack of care and supervision.

On 04/22/2026, at approximately 1:00 PM, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent visit to deliver findings. LPA met with the Administrator Suzette Johnson. This report supersedes the previous report issued on 03/19/2026. The purpose of this report is to provide additional information; the findings have not changed and remain SUBSTANTIATED. The investigation consisted of the following: On 04/22/2026, The Department toured the memory care unit. Reviewed records including the personnel report, staff roster, February 2026 memory care staffing schedule, grouping sheet, incident reports, resident progress notes, and facility procedures. Conducted interviews with six staff (S1–S6) and seven family witnesses (W1–W7). On 04/22/2026, additional interviews with five residents (R1–R5) were conducted. The investigation revealed the following regarding the allegation: “Lack of care and supervision.” It is alleged that facility staff failed to provide adequate supervision, resulting in a resident sustaining an unwitnessed fall during the night with no staff awareness of when or how the fall occurred. Please see (LIC9099-C) for report continuation. Substantiated Interviews conducted revealed the following: Staff (S1) reported the incident was unwitnessed and discovered at approximately 6:00 AM during morning rounds. Staff (S2–S3) reported the resident was found with a bump on the head at approximately 5:30 AM. Staff (S1–S3) reported they were unable to determine when or where the fall occurred. Staff (S1) reported four staff were scheduled for the overnight shift; however, three staff were present due to staffing changes. Staff (S2–S3) confirmed three staff were assigned to the overnight shift. Staff (S6) reported that three staff provide care for approximately 35 memory care residents during the overnight shift. Witnesses (W1–W5) reported concerns regarding night supervision, staffing levels, and prior unwitnessed falls. Witnesses (W6–W7) reported no concerns. Of the residents interviewed, (2) out of (5) residents reported staff do not check on them during the night or do not recall staff presence. (3) out of (5) residents were unable to confirm whether staff conducted nighttime checks. (4) out of (5) residents reported prior falls or being on the floor, including (1) resident who reported a fall that was not reported to staff. (6) out of (6) residents were not able to provide interviews due to their medical conditions. Observations revealed the following: LPA toured the memory care unit and observed multiple hallways and resident rooms extending in different directions, not visible from a single central area. The unit houses approximately 35 residents, including residents requiring incontinence care. Staff reported grouping residents in a common area for visibility. At the time of the visit, approximately 4–5 staff were observed present with residents. Records review revealed the following: Review of the February 2026 staffing schedule confirmed that three staff, including registry staff, were assigned to the overnight shift on 02/13/2026–02/14/2026. Incident reports and progress notes confirmed that (R1) sustained an injury consistent with a fall that occurred overnight. Documentation did not identify the time or circumstances of the fall. Progress notes dated 02/14/2026 document that caregivers reported the injury in the morning and indicated limited information was available from the overnight shift regarding the incident. Review of incident reports and progress notes dated 02/06/2026, 02/10/2026, and 02/14/2026 document residents were found on the floor with injuries during morning hours, with no documentation identifying when or how the falls occurred. Resident records indicate that all 35 out of 35 memory care residents require incontinence care and supervision due to behaviors such as wandering/exit seeking behaviors. Based on the evidence gathered, including interviews, observations, and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87411(a), which requires sufficient staff to meet resident care and supervision needs. A citation is issued on the attached LIC 9099-D. An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 11-AS-20260218190506

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 26, 2026

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews, observations, and records review, the licensee failed to ensure sufficient staffing to meet the needs of 35 residents during overnight hours. Records review confirmed that three staff were assigned to provide care during the overnight shift. Incident reports and progress notes document a pattern of residents found with injuries during morning hours, with no documentation identifying when or how the incidents occurred. This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Licensee agreed to submit a plan of correction to LPA Jose Anguiano at Jose.Anguiano@dss.ca.gov by due date.

Allegation investigated: Staff did not assist resident with dressing

On 4/22/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Executive Director, Suzette Johnson and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 4/22/26 LPA Felisa Shirley reviewed copies of the following records: Staff and Resident Roster, Medical Assessment for Residential Care Facilities for the Elderly, Service Plan 4/21/26, Service Plan 4/8/26, and Resident Assessment 4/8/26. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-5 (S1 – S5), and Resident -1 – Resident – 10 (R1-R10). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not assist resident with dressing It is being reported that resident was not assisted with getting dressed. Resident was admitted to this facility 4/8/26. Per review of Admission Resident Assessment dated, 4/8/26, R1 was assessed as Independent, and self-care for level of assistance with dressing and grooming. LPA also observed the Service Plan for R1 dated 4/8/26 indicating resident as, Independent, self-care for both dressing and grooming. During interviews on 4/22/26, LPA Felisa Shirley spoke with a family member, W1. W1 stated she’d been contacted for a care plan meeting regarding R1. W1 stated that R1 was reassessed and R1 was reclassified as requiring complete, hands-on assistance with dressing and grooming. LPA Shirley reviewed new Service Plan for R1 dated 4/21/26. Service plan indicated that R1 requires full assistance with dressing in the morning and full assistance with undressing at bedtime. LPA interviewed staff 1 – staff 5 (S-1 – S-5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 10 out of 10 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not assist resident with dressing,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 11-AS-20260417082655

Allegation investigated: Facility staff are not dispensing medications as prescribed Facility staff are not keeping accurate resident records

On 04/22/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. California Department of Social Services (CDSS) was met by staff one, Suzette Johnson (S1), and the purpose of the visit was explained. S1 and CDSS toured the facility. The investigation consisted of the following: On 04/22/26 CDSS requested and reviewed facility documents, including medication administration records (MAR) of R2, R11-R13 and toured the facility. Between 09:30AM and 3:00PM, CDSS interviewed ten (10) residents (R1-R10) out of two-hundred forty-two (242) residents and nine (9) staff out of one-hundred twenty-one (121) staff (S1-S9). The investigation revealed the following: Regarding the allegation “Facility staff are not dispensing medications as prescribed”, it is being alleged that facility staff are not dispensing residents’ medication as prescribed. Report continues, please see LIC9099-C. Unsubstantiated Interviews revealed that eight (8) out of ten (10) residents (R1 through R4 and R6 through R9) and all nine (S1-S9) staff have denied the allegation has taken place. Record reviews have indicated that the MARs have been marked and there are no discrepancies observed. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Facility staff are not keeping accurate resident records", it is being alleged that MARs are being backdated in order to cover up any errors. Interviews revealed that all ten (10) residents (R1-R10) and six (6) out of nine (9) staff (S1, S2, and S6 through S9) have denied the allegation has taken place. Record reviews have indicated that the MARs have been properly marked, which include whether a medication has been denied by a resident or if the medication is out of stock at the pharmacy. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Staff one, Suzette Johnson - Executive Director (S1), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 11-AS-20260416144522

Allegation investigated: Staff did not keep facility free of vermin.

On 04/09/26 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director as the purpose of today’s visit was explained. The investigation consisted of the following: On 04/01/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre placement appraisal dated: 02/20/25, Admission agreement dated: 02/18/25 , resident assessment dated: 03/05/25, Physicians report dated: 02/13/25, service plan dated: 06/17/25, updated service plan dated 03/26, shower schedule, facility notes dated: 03/2026, facilities laundry schedule, pest control service logs dated: On 01/2026-04/2026. On 04/01/26 from 10:00 am- 12pm LPA conducted Interviews with Residents #2-10 (R2-R10). On 04/01/26 LPA was unable to interview R1 as R1 was out of the facility at the time of visit. On 04/01/26 LPA conducted interviews with staff #1-3 (S1-S3) and conducted a tour of the facility. On 04/09/26 LPA conducted interviews with staff #4-6 (S4-S6). On 04/09/26 at 2pm LPA conducted interview with R1. Substantiated The investigation revealed the following: Allegation: Staff did not keep facility free of vermin. It is alleged that the facility has a rat problem as rat feces have been observed at the facility. On 04/01/26 and 04/09/26 LPA conducted Interviews with R1-R10 regarding the allegation above. 8 of the 10 residents interviewed denied the allegation above, 2 of the 10 residents interviewed confirmed the allegation above. 10 of 10 residents interviewed confirmed that the facility is getting treated by pest control. On 04/01/26 and 04/09/26 LPA conducted interviews with S1-S6. 4 of the 6 staff interviewed denied the allegation above, 2 of 6 staff interviewed confirmed the allegation above and reported seeing mice at the facility. 5 of the 6 staff confirmed that pest control services is coming out to service the facility. 1 of the 6 staff interviewed reported having no knowledge of pest control servicing the facility. On 04/01/26 LPA observed pest control to be servicing the facility at the time of the visit. On 04/01/26 LPA conducted a review of pest control service report dated: 3/25/26. Per the report, 20 rooms were serviced, interior and exterior inspected and baited, no activity found, EZ snaps are inspected each time facility is serviced, sanitation conditions listed as Fair. On 04/09/26 while LPA walked down facility hallway LPA observed a live cockroach. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Division (6) and Chapter (8) are for RCFE Exit interview conducted, appeal rights explained, and a copy of this copy is provided. The investigation revealed the following: Allegation: Staff left resident in a soiled diaper for a long period of time. It is alleged that resident in care is left in a soiled diaper as staff are not using residents’ diapers located in residents dresser. On 04/01/26 and 04/09/26 LPA conducted Interviews with R1-R10 regarding the allegation above. 6 of the 10 residents interviewed denied the allegation above and reported they change themselves when soiled. 3 of the 10 residents interviewed denied the allegation above and reported they have not been left soiled as staff are assisting. 1 of the 10 residents interviewed confirmed the allegation above and reported being left soiled a few times by staff. Additionally, 7 of the 10 residents interviewed denied needing assistance with incontinence care, 3 of the 10 residents interviewed confirmed needing assistance with incontinence care. On 04/01/26 and 04/09/26 LPA conducted interviews with S1-S6 regarding the allegation above. 2 of the 6 staff interviewed reported being unaware of the allegation above, 2 of the 6 staff interviewed denied the allegation above, 2 of the 6 staff interviewed confirmed the allegation above and reported that residents have been found to be soiled upon arrival to the morning shift. On 04/01/26 LPA conducted a review of R1s’ preplacement appraisal dated: 02/20/25 which indicated R1 can toilet self. Per service plan dated: 06/17/25 R1 can toilet self. On 04/01/26 LPA observed an updated service plan dated March 2026 that R1’s responsible party has not signed. Allegation: Staff did not ensure that residents’ clothing was changed. It is alleged that resident in care is left in the same clothing. On 04/01/26 and 04/09/26 LPA conducted Interviews with R1-R10 regarding the allegation above. 10 of the 10 residents interviewed denied the allegation above and reported having clean clothes available after bathing. On 04/01/26 and 04/09/26 LPA conducted interviews with S1-S6 regarding the allegation above. 5 of the 6 staff denied the allegation above, and 1 of the 6 staff interviewed reported being unaware of the allegation above. On 04/01/26 LPA conducted a review of R1s’ preplacement appraisal dated: 02/20/25 which indicated R1 can bath/shower self without assistance, dressing- self, grooming- partially depends on others. Per service plan dated: 06/17/25 R1 can dress- self-care, grooming- verbal queuing and set up. Per shower schedule, R1 is scheduled 2x a week Tuesday and Friday mornings. Per facilities laundry schedule, R1's laundry day is scheduled for Wednesday mornings. On 04/01/26 LPA observed an updated service plan dated 03/26 that R1’s responsible party has not signed. Athough the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 11-AS-20260325122703

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 30, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This deficiency was not not met as as LPA observed a live coackroach in facility hallway which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Executive Director to submit plan to LPA by POC due date detailing what the facility is going to do regarding pest control throughout the facility. What measure will be added to cleaning precedures to ensure pest at the facility is under control to ensure residents health and safety.

Allegation investigated: Lack of care and supervision

On 03/19/2026, at approximately 11:00 AM, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent visit to deliver findings. LPA met with the Administrator Suzette Johnson. The investigation consisted of the following: LPA toured the memory care unit, conducted interviews with six staff (S1–S6) and seven family witnesses (W1–W7), and reviewed records including the personnel report, staff roster, February memory care staffing schedule, staff contact information, grouping sheet, incident reports, resident progress notes, physician discharge note, plan of operation, and registry staff schedule. The investigation revealed the following regarding the allegation: “Lack of care and supervision” It is being alleged that staff failed to provide adequate supervision, resulting in a resident with dementia sustaining an unwitnessed fall during the night with no staff awareness of when or how the fall occurred. Please see (LIC9099-C) for report continuation. Substantiated Observations revealed the following: The memory care unit has a spread layout and houses approximately 35 residents, including residents requiring incontinence care and identified as fall risks. Staff reported grouping residents in a common area for visibility. At the time of the visit, approximately 4–5 staff were present. Based on the layout and resident care needs, this level of staffing may limit the ability to provide continuous supervision, particularly during overnight hours. Interviews conducted revealed the following: Staff (S1–S5) reported the fall was unwitnessed and discovered during morning rounds, and staff were unable to determine when or where the fall occurred. Staff (S1) reported four staff were scheduled; however, only three staff were present on the night shift due to staffing changes. Staff (S2–S3) confirmed three staff were assigned to the nocturnal shift. Staff (S6) reported that three staff typically care for approximately 35 memory care residents during night shift and stated this may not be sufficient to meet resident care needs. Witnesses (W1–W5) reported concerns regarding night supervision, staffing levels, and prior unwitnessed falls. Witnesses (W6–W7) reported no concerns. Records review revealed the following: Review of the February 2026 staffing schedule confirmed that three staff, including registry staff, were assigned to the overnight shift on 02/13/2026–02/14/2026. Records confirmed the resident sustained an injury consistent with a fall that occurred overnight. Documentation did not identify the time or circumstances of the fall and did not demonstrate staff awareness at the time of the incident. Nursing notes indicate limited information was available from the overnight shift regarding the incident. Review of incident reports and resident records identified a pattern of unwitnessed falls in February 2026, including incidents on or about 02/06/2026, 02/10/2026, and 02/14/2026, where residents were found on the floor with injuries during morning hours. Documentation consistently indicated staff were unaware of when or how the falls occurred. While appropriate medical care was provided after discovery, records do not demonstrate effective overnight monitoring. Based on the evidence gathered, interviews conducted, observations, and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is issued on the attached (LIC-9099D). An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 11-AS-20260218190506

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 26, 2026

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews, observations, and records review, the licensee failed to ensure sufficient staffing to meet residents needs during overnight hours, resulting in an unwitnessed fall and a pattern of unwitnessed falls where staff were unaware of when or how incidents occurred, posing an potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Licensee agreed to submit a plan of correction to LPA Jose Anguiano at Jose.Anguiano@dss.ca.gov by due date.

Allegation investigated: Staff handled resident in an aggressive manner.

On February 23, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Suzette Johnson Executive Director greeted the LPA. LPA explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included a collection of records, interviews and tour of the facility. The Department collected service records for Resident #1 (R1), Physician's Report LIC 624 (dated 12/15/25), Face Sheet and Emergency Informaition (dated 12/29/25), Service Plan (dated 12/31/25), Medication Administration Record and Physicians Orders (dated 02/23/26), Unusual Incident Report LIC 624 (dated 02/20/26) and other documents pertinent or associated with this complaint. (Evaluation Report contnues LIC 9099-c) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff handled residents in an aggressive manner. The complaint alleges that staff at a facility handled Resident #1 (R1) aggressively. On February 14, 2026, both (R1) and Resident #2 (R2) attempted to use the restroom at the same time. According to reports, a staff member aggressively grabbed (R1), pulled (R1) out of the restroom, pinched (R1's) arm, and hit (R1's) head. Further investigations revealed no visible markings or bruises on (R1); however, the administrator stated that an internal investigation was conducted, resulting in the termination of the staff member involved. No further information has been provided regarding this situation. On February 23, 2026, between 10:20 AM and 02:10 PM, the Department interviewed residents members identified as Resident #1 through Resident #11 (R1-R11). Ten (10) out of eleven (11) residents could not validate this claim. (R2-R11) were under the care and supervision of Staff #1 (S1) on February 14, 2026. All residents praised the staff for their professionalism and courteous behavior. They confirmed that they had never experienced or witnessed any aggressive mistreatment of residents. (R2-R11) stated that if such inappropriate behavior were observed, it would be reported to management or Community Care Licensing (CCL). During the interview (R1) reported a mistreatment incident involving Staff #1 (S1), claiming that the (S1) roughly grabbed (R1) by the left arm and struck (R1) several times on the head. (R1) stated that (R2) was present during the incident but not in any way involved in the restroom issue. (R1) did not provide the staff’s name or a clear description and claimed to have called 9-1-1 for law enforcement, but they did not arrive. The statement from (R1) disputes the information reported to (CCL). (R1) mentioned that, despite being struck multiple times on the head, no medical attention was deemed necessary, and this was not reported to management. According to (R2), no such incident occurred. (R2) stated that any inappropriate behavior by staff will be reported immediately and clarified that no such incident has ever occurred on February 14, 2026. On February 23, 2026, between 09:30 AM and 12:00 PM, the Department interviewed staff members identified as Staff #2 through Staff #5 (S2-S5). Four (4) out of the four (4) staff members could not corroborate this claim involving (R1) and (S1). All staff members were verified to have acted appropriately, both verbally and physically, towards the residents. (Evaluation Report continues LIC 9099-C) (S3) and (S4), who were working on the day of the incident, did not witness any inappropriate behavior by staff members. However, they received inconsistent accounts of what transpired between (R1) and (S1). (S3) reported to have walked in during the incident involving (R1) and noted that (R1) appeared agitated while getting out of the shower. According to (S3), (S1) left the scene after supervising (R1) out of the shower, and there was no physical engagement with (R1). (S3-S4) examined (R1) and did not observe any injuries or bruises on (R1). Both (S3) and (S4) confirmed that (R2) was present in the room when this incident occurred. Both (S2 and S5) stated that an investigation was conducted. They clarified that S1 is not an employee of Vista Del Mar but rather of Great Comfort Home Care, which the facility uses for staffing. Additionally, (R1) provided inconsistent accounts of what occurred. (S5) further clarified that (S1) was not terminated, as was previously reported. On February 23, 2026, between 02:00 PM and 02:30 PM, the Department interview witness identified as Witness #1 (W1) by telephone. (W1) has information about the incident from (R1) but did not witness it. (W1) also noted that (R1) tends to distort statements unintentionally and may have confabulation issues. The Department made several attempts to contact Staff #1 (S1) for an interview, but the calls went unanswered and were not returned. During the investigation on February 23, 2026, the Department observed staff members interacting with residents and noted that their conduct was appropriate. The Department found that the facility upholds the rights of its residents. Posters detailing Resident Rights, Personal Rights, were displayed prominently throughout the facility. The Department inspected for bodily injuries on (R1) and found none. Furthermore, recent phone records show no log of (R1) making any 9-1-1 calls on February 14, 2026, confirming that there was no emergency. The Department reviewed Resident #1 (R1’s) Medical Assessment for Residential Care Facilities for the Elderly LIC 624A (dated 12/15/25), Face Sheet and Emergency Information (dated 12/29/25), Service Plan (dated 12/31/25), Preplacement Appraisal Information LIC603A (dated 12/30/25) and Unusual Incident Report LIC 624 (dated 02/2025) revealed that (R1’s) medical diagnosis contributes to (R1’s) line of thinking/belief system. Further review of Medication Administration and Physician’s Orders (dated 02/23/26) revealed (R1) is on 19 prescribed medications and (8) of the (19) contribute to risk of unusual bruising and mental status conditions of dizziness and confusion (ref: National Institute of Health). (Evaluation Report continues LIC 9099-C) Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information gathered from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with Suzette Johnson, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 11-AS-20260220150636

Allegation investigated: Staff mishandled a resident's medications.

On 02/09/26 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted a initial/subsequent complaint visit regarding the allegation(s) above. LPA met with Collene Rosatti as the purpose of today’s visit was explained. The investigation consisted of the following: On 02/09/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre-appraisal dated:06/08/25, Physicians report dated: 03/01/23, current physicians orders, service plan dated:04/26/25, and the Medication Administration Record (MAR) for December 2025- February 2026. On 02/09/26 from 10:00 am- 12pm LPA conducted Interviews with residents# 1-10 (R1-R10), and from 1pm- 2:15 pm LPA conducted interviews with staff #1-4 (S1-S4). On 02/09/26 LPA conducted a review of R1's file including medications review, and conducted an interview with witness #1 (W1). The investigation revealed the following: Unsubstantiated Allegation: Staff mishandled a resident's medications. It is being alleged that medications were left sitting alone on a cluttered counter rather than being safely administered by facility staff. On 02/09/26 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 8 of the 10 residents interviewed denied the allegation above and reported that staff watch them take their medications before exiting their bedroom. 1 of 10 residents interviewed reported handling their own medications and do not require staff to watch them take their medications. 1 of 10 residents interviewed confirmed the allegation above and reported they have found medications left in their bedroom, and reported that there have been times where staff will hand over the medication and walk away. On 02/09/26 from 1pm- 2:15 pm LPA conducted interviews with S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported they watch the residents take their medications before leaving the room. On 02/09/26 LPA conducted an interview with W1 regarding the allegation above, per W1 there have not been any concerns with the care and assistance R1 is receiving. On 02/09/26 LPA conducted a review of R1's file, per the pre-appraisal dated:06/08/25, Physicians report dated: 03/01/23, and Service plan dated: 04/26/25 R1 requires assistance with medication administration. On 02/09/26 LPA and S1 conducted a review of R1's medications and Medication Administration Record (MAR) for December 2025- February 2026, during the review it was determined all medications were administered. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 11-AS-20260201205407

Type of visit: Case Management - Deficiencies

On 02/09/26 Licensing Program Analyst (LPA) Villegas conducted an unannounced Case Management visit to the facility in connection with complaint #11-AS-20260201205407. LPA met with Collene Rosatti as the purpose of the visit was explained. The department determined that the facility is not in compliance with Title 22 Regulations in connection with the complaint and issued a citations for Resident Records 87506(a). Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. An exit interview was conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Feb 23, 2026

87506 Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidence by: based observation, records review, and interview LPA observed that MAR for R1 was not properly documented from 12/2025- 02/09/26. Medications were provided but MAR is missing several signatures which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: Licensee/Administrator to train all staff that assist with medication administration by 02/23/26, and provide LPA with a copy of all materials reviewed and the sign in sheet with signatures of all who participated. LPA to obtain copies by POC due date.

Allegation investigated: Questionable death. Staff did not seek medical attention for resident.

On 01/27/26 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit for the allegation(s) above. LPA met with Interim Executive Director Collene Rozatti (S1) as the purpose of the visit was explained. The investigation consisted of the following: On 01/20/26 LPA obtained copies of the resident and staff rosters, as well as the following for resident #1 (R1): Emergency ID form, Admission Agreement dated: 09/14/25, Pre -appraisal, Physician Report dated: 09/18/25, Individual Service Plan, Physicians orders, facility notes, and a list of all staff that worked from 01/01/26- 01/05/26, and Administration Records (MAR) for 11/01/25- 01/2026. LPA also obtained a copy of the physicians attestation form dated: 01/14/26. On 01/20/26 and 01/27/26 LPA conducted interviews with staff #1-6 (S1-S6), and on 01/27/26 from 11am-12:30pm LPA conducted interviews with resident #2-11 (R2-R11). On 01/27/26 LPA conducted a review of of R1's file. The investigation revealed the following: Unsubstantiated Allegation: Questionable death. It is being alleged that facility staff did not respond or take appropriate action when resident in care requested medical assistance, which resulted in residents death. On 01/20/26 and 01/27/26 LPA conducted interview with S1-S6 regarding the allegation above. 6 of the 6 staff interviewed denied the allegation above and reported staff do not refuse to call 911 when needed. Additionally, 6 of 6 staff reported that a nurse or med tech will conduct an assessment when a resident is feeling unwell. On 01/27/26 from 11am-12:30pm LPA conducted interviews with R2-R11 regarding the allegation above. 6 of the 10 residents interviewed denied the allegation above and reported that facility staff assist them when assistance is requested. 1 of 10 residents interviewed confirmed the allegation above and reported that staff does not provided assistance when needed. 3 of 10 residents interviewed reported they have not had the need to ask for assistance but state they believe the staff would provide assistance. On 01/27/26 LPA conducted a review of R1's file. LPA observed that the physicians report dated: 09/18/25 indicates that R1's primary diagnosis were: acute and chronic respiratory failure with hypoxia, COPD, diabetes mellitus type 2, hypertensive heart disease with heart failure,dysphagia, muscle weakness, morbid obesity due to excess calories, difficulty walking, incentive spirometry, CPAP, and oxygen via nasal canula. On 01/27/26 LPA conducted a review of physicians attestation form dated: 01/14/26. Per attestation form the immediate cause of death was a cardiac arrest. Allegation: Staff did not seek medical attention for resident. It is being alleged that facility policy prohibits caregivers from calling 911 directly. On 01/20/26 and 01/27/26 LPA conducted interview with S1-S6 regarding the allegation above. 6 of 6 staff denied the allegation above and reported that caregivers are allowed to call 911 in an emergency situation and to not wait until they find a med tech or nurse to call 911. Additionally, 4 of 6 staff interviewed reported that a meeting was held where caregivers were told that they are allowed to call 911 when needed. On 01/27/26 from 11am-12:30pm LPA conducted interviews with R2-R11 regarding the allegation above. 6 of 10 residents interviewed denied the allegation above and reported that staff have not refused to call 911 when needed. 4 of the 10 residents interviewed reported they have not needed 911 to be called but believe staff would call 911 if needed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 11-AS-20260115161934

Allegation investigated: Staff do not ensure the residents shower is properly working Staff do not ensure the facility is free of cockroaches Staff do not ensure the residents are assisted with meals

On 01/07/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Vista Del Mar Senior Living and was greeted by Administrator Colleen Rozatti (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S5, residents R1-R24. LPA Calderon obtained the following records: Housekeeping (dated 01/2026), work order for room 120 (dated 12/29/2025), deep cleaning schedule (dated 01/01/2026), Dewey Pest Control (dated 10/01/2025 to 12/26/2025) The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff do not ensure the residents shower is properly working. This complaint alleged that the facility did not provide a working shower for residents’ needs. LPA Calderon inspected room 120 and noted the shower head dripping but working. LPA Calderon inspected rooms 125, 132, 134 and room 206. All showers were working. Records review indicate the following: Work order (dated 12/26/2025) to fix shower head in room 120 was ordered. Interviews indicate the following: S2 indicates that resident in room 120 the shower head was dripping, and a new part was ordered. S2 states that the shower works. 5 out of 5 staff deny the allegation. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the residents shower is properly working” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff do not ensure the facility is free of cockroaches. This complaint alleged that the facility did not provide a free environment with no cockroaches. LPA Calderon inspected room 120 and found no cockroaches. LPA Calderon inspected rooms 125, 132, 134 and room 206. All rooms clear and did not find any cockroaches. LPA Calderon checked the dining room, kitchen and common areas and did not see any cockroaches. Records review indicate the following: Dewey Pest Control (dated 10/01/2025 to 12/26/2025), work orders show rooms were treated and common areas showed no sign of cockroaches. Deep cleaning order (dated 01/01/2026) showed room 120 was cleaned and no cockroaches were found. Interviews indicate the following: 5 out of 5 staff deny the allegation. S2 indicates that 20 rooms are treated per day to include room 120. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the facility is free of cockroaches” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff do not ensure the residents are assisted with meals. This complaint alleged that the facility did not provide meals for residents in care. LPA Calderon toured the facility and noted many residents taking their meals in the dining room. LPA Calderon noted a food cart for those residents that cannot take their meals in the dining room. Resident meals include a food tray and fork, spoon and the meal. Interviews indicate the following: S1 indicates that residents in room 120 takes meals in the room. Staff indicate that meal staff from the dining room provide the residents with meals and a fork. 5 out of 5 staff deny the allegation. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the residents are assisted with meals is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Colleen Rozatti (S1).the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 11-AS-20251229153904

Allegation investigated: Staff do not ensure the residents shower is properly working Staff do not ensure the facility is free of cockroaches Staff do not ensure the residents are assisted with meals

On 01/07/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Vista Del Mar Senior Living and was greeted by Administrator Colleen Rozatti (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S5, residents R1-R24. LPA Calderon obtained the following records: Housekeeping (dated 01/2026), work order for room 120 (dated 12/29/2025), deep cleaning schedule (dated 01/01/2026), Dewey Pest Control (dated 10/01/2025 to 12/26/2025) The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff do not ensure the residents shower is properly working. This complaint alleged that the facility did not provide a working shower for residents’ needs. LPA Calderon inspected room 120 and noted the shower head dripping but working. LPA Calderon inspected rooms 125, 132, 134 and room 206. All showers were working. Records review indicate the following: Work order (dated 12/26/2025) to fix shower head in room 120 was ordered. Interviews indicate the following: S2 indicates that resident in room 120 the shower head was dripping, and a new part was ordered. S2 states that the shower works. 5 out of 5 staff deny the allegation. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the residents shower is properly working” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff do not ensure the facility is free of cockroaches. This complaint alleged that the facility did not provide a free environment with no cockroaches. LPA Calderon inspected room 120 and found no cockroaches. LPA Calderon inspected rooms 125, 132, 134 and room 206. All rooms clear and did not find any cockroaches. LPA Calderon checked the dining room, kitchen and common areas and did not see any cockroaches. Records review indicate the following: Dewey Pest Control (dated 10/01/2025 to 12/26/2025), work orders show rooms were treated and common areas showed no sign of cockroaches. Deep cleaning order (dated 01/01/2026) showed room 120 was cleaned and no cockroaches were found. Interviews indicate the following: 5 out of 5 staff deny the allegation. S2 indicates that 20 rooms are treated per day to include room 120. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the facility is free of cockroaches” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff do not ensure the residents are assisted with meals. This complaint alleged that the facility did not provide meals for residents in care. LPA Calderon toured the facility and noted many residents taking their meals in the dining room. LPA Calderon noted a food cart for those residents that cannot take their meals in the dining room. Resident meals include a food tray and fork, spoon and the meal. Interviews indicate the following: S1 indicates that residents in room 120 takes meals in the room. Staff indicate that meal staff from the dining room provide the residents with meals and a fork. 5 out of 5 staff deny the allegation. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the residents are assisted with meals is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Colleen Rozatti (S1).the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 11-AS-20251229153904

Allegation investigated: Staff do not ensure that resident's medical needs are met. Staff do not ensure that resident's dietary needs are met.

On 12/29/25 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Colleen Rozatti as the purpose of today’s visit was explained. The investigation consisted of the following: On 12/22/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, Physicians report dated: 5/23/24, needs and service plan dated: 9/8/25, and facility notes dated: July 2025- December 2025. On 12/22/25 from 11:00 am- 1pm LPA conducted Interviews with Residents #2-10 (R2-R10). On12/22/25 and 12/29/25 LPA unable to interview R1, as R1 did not wish to be interviewed. On 12/22/25 and 12/29/25 LPA conducted interviews with S1-S6 and conducted a tour of facility. The investigation revealed the following: Allegation: Staff do not ensure that residents’ medical needs are met. It is being alleged that staff are not assisting a resident in care with getting ready for weekly schedule medical appointments, causing scheduled transportation services to cancel. Unsubstantiated On 12/22/25 from 11:00 am- 1pm LPA conducted Interviews with R2- R10 regarding the allegation above. 5 of 9 residents interviewed denied the allegation above and stated that staff assist as needed and staff provide reminders the day before the upcoming appointment. 4 of the 9 residents interviewed reported they do not need assistance with getting ready for appointments. Additionally, 5 of the 9 residents interviewed reported that the facility provides transportation to appointments, 4 of the 9 residents interviewed reported that they do not obtain transportation from the facility if the transportation calendar is fully booked. On 12/22/25 and twice on 12/29/25 LPA attempted to interview R1 but was unsuccessful. On 12/22/25 and 12/29/25 LPA conducted interviews with S1-S6 regarding the allegation above. 5 of 6 staff interviewed denied the allegation above and reported that the staff provide a reminder to residents about upcoming appointments, staff also assist residents get ready for the appointment prior to staff bringing resident down to the lobby to wait for transportation. 1 of 6 staff confirmed the allegation above and reported that there is a lack of communication regarding scheduled appointments, and states that due to lack of communication staff do not have enough notice to get residents ready in a timely manner. On 12/29/25 LPA conducted a review of facility notes dated: December 19th, 2025, LPA observed that an updated schedule for weekly appointments was provided to R1 as R1 arranges own transportation. On 12/29/25 LPA conducted a review of needs and service plan dated: 9/8/25. Per service plan, R1 needs ongoing assistance with care coordination with outside healthcare and home care providers. Additionally, service plan states care team supports R1 with receiving quality healthcare services by helping coordinate healthcare appointments. Allegation: Staff do not ensure that residents’ dietary needs are met. It is being alleged that staff have failed to provide resident in care with food prior to weekly scheduled appointments. On 12/22/25 from 11:00 am- 1pm LPA conducted Interviews with R2- R10 regarding the allegation above. 6 of the 9 residents interviewed denied the allegation above and reported having meals prior to leaving for a scheduled appointment. 2 of the 9 residents interviewed confirmed the allegation above and reported not having a meal prior to scheduled appointment. 1 of 9 residents interviewed stated that they sometimes have a meal as it depends on appointment time. On 12/22/25 and twice on 12/29/25 LPA attempted to interview R1 but was unsuccessful. On 12/22/25 and 12/29/25 LPA conducted interviews with S1-S6 regarding the allegation above. 6 of 6 staff interviewed denied the allegation above and reported that residents are provided with a meal before appointment, or are provided with a packed meal, or are saved a meal for when they return.On 12/29/25 LPA conducted a review of needs and service plan dated: 9/8/25. Per service plan, R1 requires a special diet. On 12/29/25 LPA conducted a tour of the kitchen facility, LPA observed all special diets, and dietary needs are printed and displayed on kitchen wall. The Kitchen staff also have a binder with all residents and their dietary needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 11-AS-20251218154121

Allegation investigated: Staff are not properly addressing scabies in the facility. Staff do not ensure residents hygiene needs are being met. Staff do not ensure that residents have clean bedding.

On 12/29/25 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Colleen Rozatti as the purpose of today’s visit was explained. The investigation consisted of the following: On 12/18/25 LPA Villegas obtained copies of the staff and resident roster, cleaning schedule, laundry schedule, shower schedule, list of residents that require assistance with ADL's. On 12/18/25 LPA obtained copies of the following for resident #1 (R1): physicians report dated: 5/10/25, physicians orders, after visit summary dated: 11/12/25, Kaiser Permanente dated: 08/16/25, and copies of communication between facility and family. On 12/18/25 from 10:00 am- 12pm LPA conducted Interviews with resident #1-10 (R1-R10), and from 1pm-1:45pm LPA conducted interviews with staff #1-5 (S1-S5). On 12/18/25 LPA conducted tour of memory care unit. The investigation revealed the following: Allegation: Staff are not properly addressing scabies in the facility. Unsubstantiated It is being alleged that residents in memory care may have scabies, and the facility is unable to control the spread of scabies. On 12/18/25 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 10 of 10 residents interviewed denied the allegation above, 2 residents reported having rashes that are being treated. On 12/18/25 from 1pm-1:45pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above. 1 of the 5 staff interviewed stated that there was a resident that was taken to urgent care for scratching, however it was determined that the scratching was due to an allergic reaction for a medication that has since been discontinued. On 12/24/25 LPA conducted a review of after visit summary dated: 11/12/25, it is indicated in the after visit summary that R1 was seen for generalized rash which was found to likely be an allergic reaction and was provided with a prescription. Allegation: Staff do not ensure residents’ hygiene needs are being met. It is being alleged that residents are not being bathed properly and are dressed in dirty clothes. On 12/18/25 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 7 of the 10 residents interviewed reported they do not require assistance with bathing needs, 3 of 10 residents reported obtaining bathing assistance from staff .10 of 10 residents interviewed denied the being dressed in dirty clothes. On 12/18/25 from 1pm-1:45pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above. On 12/24/25 LPA conducted a review of laundry schedule. Per laundry schedule, laundry is done daily, each resident gets their laundry done once a week unless the service plans indicate that a resident requires laundry service multiple times a week. Allegation: Staff do not ensure that residents have clean bedding. It is being alleged that residents' bedding isn't being changed. On 12/18/25 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 10 of 10 residents interviewed denied the allegation above. On 12/18/25 from 1pm-1:45pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above, and reported linen exchange is done weekly, unless a resident has an accident then linen exchange is done more than once a week. On 12/18/25 LPA conducted tour of the facility and observed laundry actively being done, LPA observed 5 bedrooms that were observed to have clean linen. On 12/24/25 LPA conducted a review of laundry schedule. Per laundry schedule, laundry is done daily, each resident gets their laundry done once a week unless the service plans indicate that a resident requires laundry service multiple times a week. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 11-AS-20251211153009

Allegation investigated: Staff dispose resident’s food.

On 12/22/25 at 10:55 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Colleen Rozatti as the purpose of today’s visit was explained. The investigation consisted of the following: On 12/22/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, Physicians report dated: 2/06/25, needs and service plan dated: 11/20/24, and physicians orders. On 12/29/25 LPA obtained a copy of R1's admission agreement. On 12/22/25 and 12/29/25 LPA conducted Interviews with Residents #1-10 (R1-R10). On 12/22/25 and 12/29/25 LPA conducted interviews with S1-S6 and conducted a tour of facility. The investigation revealed the following: Allegation: Staff dispose resident’s food. Unsubstantiated It is being alleged that staff threw away the lunch a resident in care left in residents’ refrigerator. On 12/22/25 and 12/29/25 LPA conducted Interviews with R1-R10 regarding the allegation above. 7 of the 10 residents interviewed denied the allegation above. 1 of the 10 residents interviewed reported that staff will throw away anything in the refrigerator that is no longer good, resident reports being okay with staff doing so. 1 of the 10 residents interviewed reported they do not have a refrigerator in their bedroom therefore does not have any information on the allegation above. 1 of 10 residents interviewed confirmed the allegation above, and reported that staff admitted to doing so per supervisor’s orders. On 12/22/25 and 12/29/25 LPA conducted interviews with S1-S6 regarding the allegation above. 4 of the 6 staff interviewed denied the allegation above. 2 of the 6 staff interviewed confirmed the allegation above and stated that food is only thrown away if it is rotten or molded. Per the 2 of 6 staff who confirmed the allegation above, the resident is informed of what was thrown and why. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 11-AS-20251222112624

Allegation investigated: Staff did not ensure facility was free from pests.

On 11/06/2025, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent complaint investigation regarding the above allegation to deliver findings and met with Interim Administrator Colleen Rozatti. On 11/05/2025, Licensing Program Analyst (LPA) Jose Anguiano conducted an initial complaint investigation. Investigation consisted of the following: LPA toured the facility inside and out, including resident rooms, common areas, kitchen, and storage areas. LPA interviewed eleven (11) residents (R1–R11) and eight (8) staff members (S1–S8). LPA also reviewed and collected the following records: Admissions Agreement, Personnel Report, Resident Roster, Housekeeping/Laundry Task Legend and Work Log, four (4) Dewey Pest Control Apartment Service Logs, three (3) Dewey Pest Control Invoices for the months of August, September, and November, four (4) Waxie Sanitary Supply Invoices for cleaning products, one (1) carpet cleaning invoice, and two (2) CR&R invoices for Monday through Saturday trash and recycling pickup. Please see LIC9099-C for report continuation. Substantiated Investigation revealed the following: Regarding the allegation, “Staff did not ensure the facility was free from pests,” it was alleged that staff did not ensure the facility was free from pests, specifically cockroaches. LPA interviewed eight (8) staff members and eleven (11) residents. Of those interviewed, one staff member and three residents confirmed ongoing issues with pests, specifically cockroaches. Residents reported sightings in their rooms and expressed concern about the facility’s ability to maintain a pest-free environment. Interviews with housekeeping staff confirmed that they alternate shifts and clean 2–3 times per day. However, despite these efforts, the presence of live and dead cockroaches observed during the visit indicates that current cleaning practices have not been effective in preventing pest activity. Records reviewed included pest control documentation from Dewey Pest Control, which showed that in October 2025, only 40 out of 165 resident rooms were fogged for cockroaches. Service logs dated 10/01, 10/15, 10/18, and 10/22 each documented fogging of only 10 rooms per visit. Sanitation conditions were marked as “Fair” in most rooms, with two rooms on 10/01 noted as “Poor.” Additionally, LPA reviewed the facility’s housekeeping and maintenance work logs. The logs confirmed that 165 resident rooms require cleaning, not including common areas. The housekeeping work log showed that two housekeeping staff (S3–S4) are assigned to clean the floor where Resident (R1) resides. During the tour, LPA observed and photographed three live cockroaches and four dead cockroaches inside Resident Room R1, confirming the presence of pests. Although the facility has a pest control contract and cleaning protocols in place, the limited scope of treatment, inconsistent cleaning practices, and direct observation of live pests support the allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is being issued on the attached (LIC-9099D). An exit interview, a copy of this report and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 11-AS-20251027112748

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(f) · Plan of correction due date: Nov 20, 2025

Maintenance and Operation…facility shall be clean…sanitary…at all times…for the safety…of residents...(f) All waste shall be located…and disposed of in a manner that will not…provide a breeding place or food source for insects or rodents. This requirement was not met as evidence by: Based on observations and record review, the licensee did not maintain a clean and sanitary environment. On 11/05/2025, LPA observed and photographed live and dead cockroaches in one resident room.This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: Administrator and staff will meet to develop a plan to address and eliminate the cockroach infestation. The facility agreed to submit proof of treatment and corrective actions to LPA Jose Anguiano atjose.anguiano@dss.ca.gov by due date.

Allegation investigated: Staff are not providing adequate care and supervision to resident in care. Facility staff failed to provide transportation to resident to and from medical appointment.

On 10/08/25 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Sidonia Cordis as the purpose of today’s visit was explained. The investigation consisted of the following: On 10/07/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Face sheet, Preplacement appraisal dated: 4/30/24, Service plan dated: 9/13/25, Physicians report dated: 5/24/24 , Physicians orders, facility notes and Transportation policy. On 10/07/25 and 10/08/25 LPA conducted interviews with Staff #1-5 (S1-S5), and on 10/08/25 from 1:45pm-2:15 pm LPA conducted interviews with residents #2-10 (R2-R10). On 10/07/25 and 10/08/25 LPA attempted to conduct interview with R1, however R1 refused interview. On 10/08/25 LPA conducted a review of R1's file. The investigation revealed the following: Allegation: Staff are not providing adequate care and supervision to resident in care. Unsubstantiated It is being alleged that residents in care are missing appointments due to staff not providing assist in a timely manner. On 10/07/25 and 10/08/25 LPA conducted interviews with S1-S5 regarding the allegation above. 5 of 5 residents interviewed denied the allegation above, per 5 of 5 staff residents have refused assistance and have refused to attend medical appointments. On 10/08/25 from 1:45 pm-2:15 pm LPA conducted interviews with R2-R10 regarding the allegation above. 9 of 9 residents interviewed denied the allegation above, 1 of 9 residents reported they have refused to attend scheduled medical appointment. On 10/07/25 and 10/08/25 LPA attempted to conduct interview with R1, however R1 refused interview. On 10/08/25 LPA conducted a review of R1's file. LPA conducted review of facility notes, LPA observed documentation indicating R1 has refused medical appointments on multiple occasions. Allegation: Facility staff failed to provide transportation to resident to and from medical appointment. It is being alleged that the facility is not providing residents in care with transportation to and from medical appointments. On 10/07/25 and 10/08/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 residents interviewed denied the allegation above. Per 5 of 5 staff, some residents have Access accounts, some residents are transported by families, and some obtain assistance by the facility. On 10/08/25 from 1:45 pm-2:15 pm LPA conducted interviews with R2-R10 regarding the allegation above. 9 of 9 residents interviewed denied the allegation above, 5 of 9 residents reported having their own means of transportation, 1 of 9 residents reported the facility assist with all medical appointments, 1 of 9 residents is now aware of how they get to medical appointments, 2 of 9 residents reported that a physician comes to the facility to see them. On 10/07/25 and 10/08/25 LPA attempted to conduct interview with R1, however R1 refused interview. On 10/08/25 LPA conducted a review of R1's file. LPA conducted review of facility notes, LPA observed documentation indicating R1 has cancelled transportation arrangements on multiple occasions. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 11-AS-20251001161907

Allegation investigated: Staff did not keep facility free of rodents.

On 09/26/25 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Interim Executive Director Sidonia Cordis, as the purpose of today’s visit was explained. The investigation consisted of the following: On 09/24/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for resident #1 (R1) face sheet, service plan dated: 04/14/25, Physicians report dated: 03/10/25, physicians orders, housekeeping schedule, deep cleaning schedule, Dewey pest control report dated: 9/18/25, and work order dated 09/17/25. On 09/24/25 from 9:30am-12:00 pm LPA conducted Interviews with residents 2-10 (R2-R10), and from 1:35pm- 2:32pm LPA conducted interviews with staff #1-6 (S1-S6). On 09/24/25 LPA conducted tour of the facility and conducted check of 6 bedrooms. On 09/26/25 LPA conducted an interview with R1. Unsubstantiated The investigation revealed the following: Allegation: Staff did not keep the facility free of rodents. It is alleged that a resident in care observed 6 rodents in the residents’ bedroom. On 09/24/25 from 9:30am-12:00 pm LPA conducted Interviews with R2-R10 regarding the allegation above. 6 of the 9 residents interviewed denied the allegation above. 3 of the 9 residents interviewed confirmed the allegation above and reported observing pest, per the 3 of 9 residents interviewed pest was reported to staff and staff services bedrooms. Additionally, 9 of 9 residents reported bedrooms being cleaned daily by staff, and 8 of 9 residents interviewed confirmed that the facility has a pest services come out to service. On 09/26/25 LPA conducted an interview with R1 regarding the allegation above, per R1 staff have addressed R1’s concerns and R1 has not observed any rodents in bedroom. On 09/24/25 from 1:35pm- 2:32pm LPA conducted interviews with S1-S6 regarding the allegation above, 6 of the 6 staff interviewed denied the allegation above. Per 6 of the 6 staff interviewed, the facility common areas, and bedrooms are cleaned daily. 6 of 6 staff also confirmed that the facility has a pest control contract, and that pest control comes out regularly to service the facility. 6 of the 6 staff interviewed also stated that if and when a resident reports observing pest, a work order will be created, maintenance staff will inspect, and pest control will come out to further service the reported area. On 09/24/25 LPA conducted a check of bedrooms: 119, 135, 137, 217, ML 21, and ML22, LPA observed bedrooms to be clean and pest free. On 09/26/25 LPA conducted a review of the work order dated 09/17/25, per work order resident’s bedroom was inspected for mice infestation and a hole behind residents’ refrigerator. On 09/26/25 LPA conducted a review of Dewey pest control service agreement, per agreement 10 bedrooms are treated weekly as well as common areas, and the building exterior. Per Dewey pest control service agreement dated 9/18/25 resident’s bedroom was inspected and there was no activity found. A review of the housekeeping schedule was conducted, and it reads that every housekeeper cleans 8 bedrooms per shift. Bedrooms are deep cleaned once a week. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided to Sidonia Cordis.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 11-AS-20250917144609

Type of visit: Required - 1 Year

On 09/24/25 Licensing Program Analyst's (LPA's) Villegas and Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA's met with Executive Director Suzette Johnson as the purpose of today’s visit was explained. The facility is licensed to serve 300 non-ambulatory elderly adults 60 and over of which 10 may be bedridden, there is an approved hospice waiver for 50 residents. The facility has a dementia wing w/ delayed egress. Annual fees are current, the facility has an active liability insurance with expiration date of 10/26/25. The facility is a 3-story structure located in a residential neighborhood and consists of the following: 278 bedrooms, 4 common bathrooms, multimedia rooms, commercial kitchen, activity room, large dining room, medication room, a large outside patio, laundry room, and administrative offices. There is an memory care unit is located on the 2nd floor of the facility which contains delayed egress doors that were observed to be operable, a common space, dinning/kitchen area, med room, administrative office, and laundry area. LPA’s conducted a records review of 6 staff records, 10 resident records, and 10 medication administration records, records were maintained accordingly with no discrepancies. LPAs observed medications were centrally stored and properly locked. The last fire and disaster drill was conducted on 09/15/25 by the fire safety services inc., fire extinguishers fully charged and observed throughout the facility, carbon monoxide detectors, smoke detectors and auditory signals are operational. Fire/Smoke door inspection conducted on 06/05/25 by DC Electronics, inc. Evacuation chair observed on on each floor at the stairwell. During facility tour 6 Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, showers were free of mold/mildew, and there are sufficient toiletries accessible to residents. Pull cords observed in every bathroom, Water temperatures were tested in the kitchen(s), and in 6 bedrooms. LPAs conducted tour of commercial kitchen, LPAs observed an adequate supply of perishable and non-perishable food. Toxins and knifes were observed to be inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 24, 2025

Allegation investigated: Staff do not ensure residents dietary care plan is being followed Staff do not ensure resident is provided with breakfast, lunch and dinner each day Staff does not ensure adequate care and supervision is provided to residents

*** The purpose of the visit is to add additional information not included in the report dated 04/28/2025 and 08/05/2025; findings remain the same. *** On 09/17/2025 at 1:30 p.m., the Department conducted a subsequent visit to gather information regarding the above allegations. The Department met with Executive Director Brittney Buchannan and explained the purpose of today's visit. LPA was granted entry to the facility. The investigation consisted of the following: On 04/28/2025, the Department requested, reviewed, and obtained copies of the Resident Roster (dated 04/28/2025), Personnel Report (dated 04/28/2025), Dietitian's Report (dated 03/28/2025), Weekly Menu (dated 02/16/2025–05/03/2025), Resident 1's Records (dated 04/28/2025), Resident 1's Progress Notes (dated 06/01/2024–04/28/2025), and Tray Service Request. Interviews were conducted with staff members #1–#5 (S1–S5) and residents #1–#10 (R1–R10). The facility kitchen was toured. At 11:30 a.m., the Department observed residents eating well-balanced and nutritious meals. An ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days was observed. See continued LIC9099-C, page 2. Unsubstantiated Continued LIC9099-C, page 2 Investigation revealed the following: Allegation: Staff do not ensure the residents' dietary care plan is being followed. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. Five out of five (5 out of 5) staff members and nine out of ten (9 out of 10) residents stated that staff ensure residents' dietary care plans are being followed. They confirmed that staff consistently adhere to physician-prescribed dietary menus and that residents are served well-balanced, nutritious meals according to the doctors' orders. 5 out of 5 staff members and 9 out of 10 residents also stated that the facility does have a dietitian. R1 reported that staff do not ensure the residents' dietary care plans are being followed. LPA requested R1's physicians' report and reviewed the resident's special diet documentation. 5 out of 5 staff members confirmed that R1 is on a diabetic diet, and R1's physician's report, dated 05/28/2024, also indicated that R1 is on a diabetic diet. LPA observed both the facility's regular menu as well as the diabetic alternative menu available for residents on a special diet. Staff stated that according to the residents' physicians' orders, they will accommodate special diets, including low sugar, carbohydrate, mechanical soft, and pureed options. S1-S5 and R2-R10 all denied the allegation. Allegation: Staff do not ensure the resident is provided with breakfast, lunch, and dinner each day. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. All five staff members (5 out of 5) and nine out of ten residents (9 out of 10) stated that staff ensure the residents are provided with breakfast, lunch, dinner, and snacks. Residents (9 out of 10) confirmed they receive three meals per day, and alternative food choices are offered. The facility provides a diverse range of food options, and if a resident requests a second serving, staff accommodate the request. Residents #2-#10 (R2-R10) stated they receive plenty of food to eat, and if they don't want to dine in the dining lounge, they can complete a tray service request. Staff will collect the request slip and deliver the meal to the resident's room. R1 stated that staff do not ensure residents are provided with breakfast, lunch, and dinner each day. LPA observed residents eating lunch and dinner and reviewed the food menus. LPA also observed an ample supply of perishable and non-perishable food items, as well as staff serving meals during breakfast and lunch. Additionally, LPA reviewed the resident's tray service form. S1-S5 and R2-R10 all denied the allegation. Staff members #1-#5 (S1–S5) and residents #2-#10 (R2–R10) all denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation: Staff do not ensure adequate care and supervision are provided to residents On 04/28/2025, between 10:00 a.m. and 11:30 a.m., the Department interviewed five (5) staff members identified as Staff #1 through #5 (S1-S5), regarding the allegation that staff do not ensure adequate care and supervision is provided to residents. The concern involved an incident in which a resident allegedly entered Resident #1's (R1) room without permission while R1 was sleeping. Staff #1, #3, #4, and #5 (4 out of 5) staff members stated they had no knowledge of any resident entering R1's room without permission while R1 was sleeping, and that this matter was never brought to their attention. S #2 stated that R1 reported another resident had entered their room; however, there were no witnesses to the incident, and a review of the facility’s surveillance cameras dated 04/20/2025 did not reveal any unauthorized entry. S2 also stated maintenance checked R1's door and confirmed it was in operable condition. All five staff members (5 out of 5) stated that adequate care and supervision are provided to all residents. 5 out of 5 staff members explained that care staff conduct wellness checks on residents every two hours. 5 out of 5 staff members stated that residents have pendants and call buttons to alert staff if they need assistance. 5 out of 5 staff members confirmed that no unauthorized individuals were observed entering residents’ rooms. 5 out of 5 staff members stated residents’ doors remain locked, and each resident has a personal key to their own room. S1-S5 reported that the facility currently has about 93 staff members employed and is fully staffed, and that residents are receiving appropriate care, supervision, and assistance with their daily needs. All five staff members interviewed (5 out of 5) confirmed the facility is sufficiently staffed and denied the allegation. On 04/28/2025, the Department observed R1's room and confirmed the doorknob was in operable condition; once locked, the door required a key to be unlocked. The surveillance footage dated April 20, 2025, did not show a resident entering Resident #1's room at night. See continued LIC9099-C page 4 Continued LIC9099-C page 4 On April 28, 2025, between 11:45 a.m. and 12:00 p.m., the Department reviewed the facility’s Personnel Report (LIC 500), which listed the following staff positions: Executive Director; Human Services Director; Vice President of Operations; Business Office Manager; Human Resources Director; Resident Care Director; ALW Coordinator; 4 Licensed Vocational Nurses (LVNs); 2 Community Liaisons; 2 Maintenance Staff; 4 Cooks; 5 Kitchen Staff; 4 Food Servers; 2 Dishwashers; 6 Dietary Aides; 9 Medication Technicians; 7 Memory Care Caregivers; 1 Memory Care Activity Director; 2 Activities Assistants; 25 Caregivers; 7 Housekeepers; 4 Receptionists; and 1 Driver a total number of employees listed: 93, confirmed the facility is adequately staffed. On April 20, 2025, there were 10 staff members on the night shift at 9:30 p.m. No incident reports were filed regarding the allegation. None of the caregivers reported witnessing anything, and nothing was documented or found in the residents' records. On April 28, 2025, between 12:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with ten residents #1-#10 (R1–R10) regarding the allegation of inadequate care and supervision. 9 out of 10 residents stated that the facility is adequately staffed and confirmed they are receiving the necessary care and supervision. 9 out of 10 also states that staff are consistently present every shift. 1 out of 10 residents expressed concern about staffing and did not feel care and supervision were adequate. Nine out of ten (9 out of 10) residents reported that they were happy living at the facility and had no problems or complaints. The majority of residents (9 out of 10) denied the allegation and stated that their daily needs were being met. Based on interviews, available evidence, observation, information received, and records reviewed, there was not enough sufficient evidence to support the allegations. 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. LPA Bunker provided Executive Director Brittney Buchannan with copies of the LIC9099 and LIC9099Cs Complaint Investigation Reports. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 17, 2025 · control 11-AS-20250421123647

Allegation investigated: Staff are threatening resident. Staff did not prevent resident from smoking in the room. Staff did not prevent a resident from threatening another resident.

On 09/11/25 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 09/10/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1- 2(R1-R2): face sheets, Pre-appraisals, Service plans, physicians reports, medication administration record (MAR) for August and September 2025, ALW info for R1, admission agreements and facility notes. On 09/10/25 and 09/11/25 LPA conducted Interviews with Residents #1-11 (R1-R11). On 09/10/25 and 09/11/25 LPA conducted interviews with staff #1-7 (S1-S7). On 09/11/25 LPA conducted interview with witness #1 (W1). The investigation revealed the following: Allegation: Staff are threatening residents. It is being alleged that staff are threatening residents in care. On 09/10/25 from 9:30 am- 12pm LPA conducted Interviews with R1-R11 regarding the allegation above. 11 of 11 residents denied the allegation. Unsubstantiated On 09/10/25 and 09/11/25 LPA conducted interviews with S1-S7 regarding the allegation above, 7 of the 7 staff interviewed denied the allegation above. On 09/11/25 LPA conducted interview with W1 regarding the allegation above, per W1 there are no safety concerns. Allegation: Staff did not prevent residents from smoking in their bedroom. It is being alleged that facility staff are allowing residents in care to smoke cigarettes in their bedroom and bedroom balcony. On 09/10/25 and 09/11/25 LPA conducted Interviews with R1-R11 regarding the allegation above. 10 of the 11 residents interviewed denied the allegation above. 1 of the 11 residents interviewed confirmed the allegation above and reported calling staff members for help, however, by the time the staff arrives to the bedroom the resident smoking is no longer in the bedroom and there is no evidence that smoking occurred. On 09/10/25 and 09/11/25 LPA conducted interviews with S1-S7 regarding the allegation above, 6 of the 7 staff interviewed denied the allegation above, however report that residents that have been caught smoking in a bedroom are redirected to the smoking patio and are reminded of the facility rules. 1 of the 7 staff interviewed did not have any information regarding the allegation above. On 09/11/25 LPA conducted interview with W1 regarding the allegation above, per W1 there are no safety concerns. On 09/11/25 LPA conducted review of facility notes dated 8/11/25 and 09/03/25, facility notes indicated that resident in care has made reports of peer smoking in the bedroom, however staff have not observed any proof that cigarette smoking has occurred. Allegation: Staff did not prevent a resident from threatening another resident. It is being alleged that facility staff are not calling the police when a resident is threatened by a peer. On 09/10/25 and 09/11/25 LPA conducted Interviews with R1-R11 regarding the allegation above. 9 of the 11 residents interviewed denied the allegation above and reported feeling safe at the facility. 1 of the 11 residents interviewed denied the allegation above, however stated that a peer has threatened resident but it was not reported to staff. 1 of the 11 residents interviewed confirmed the allegation above and stated that staff was able to assist but the police was not called. On 09/10/25 and 09/11/25 LPA conducted interviews with S1-S7 regarding the allegation above, 7 of the 7 staff interviewed denied the allegation above. On 09/11/25 LPA conducted interview with W1 regarding the allegation above, per W1 there are no safety concerns. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 11-AS-20250904103516

Allegation investigated: Staff are not properly addressing pest infestation in the facility.

On August 22, 2025, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Suzette Johnson, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, a collection of records, and a tour of the facility. Interviews were conducted with Resident #1 through Resident #9 (R1-R9), Staff #1 through Staff #6 (S1-S6). The Department reviewed several documents, including the Facility Resident Roster (dated 08/22/25), Personnel Report LIC 500 (dated 08/22/25), Dewey Pest Control Service Agreement (dated 12/20/24 & 06/17/25), Dewey Pest Control Control Sevice Log (dated 06/20/25 & 08/19/25) and (R1's) Physicians Report LIC 602A (dated 05/25/25) as well as other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff are not properly addressing pest infestation in the facility. The complaint states that the staff are not adequately addressing the pest infestation in the facility. It has been reported that Resident #1 (R1) is facing a vermin infestation in their room. Despite multiple attempts to contact the person responsible for resolving the issue, (R1) has been unable to obtain assistance. Additionally, (R1) must deal with exterminating various small and large bugs daily and have experienced pest bites. No further details regarding this matter have been provided. On August 22, 2025, between 09:05 AM and 11:09 AM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members expressed that they could not support this claim. (S1-S2) emphasizes its commitment to ensuring the safety and well-being of residents by implementing effective, environmentally friendly pest management measures. The facility has an active service agreement with a reputable pest control company that performs weekly pest control services. (S2) stated that these scheduled services treat ten rooms and common areas each week. (S1-S2) reported that (R1's) room was serviced, with treatments conducted on June 20, 2025, and August 19, 2025, along with adjacent rooms on the same floor. (S1-S6) noted that (R1) has not recently informed staff about any pest issues and prohibits them from entering (R1's) room for cleaning and care assistant services. Furthermore, all six staff members interviewed reported that (R1) has made it clear that they will not permit anyone to enter their room without their presence. They have stated that if this boundary is not respected, they will not hesitate to contact law enforcement or legal counsel to enforce their rights. This situation creates challenges for the facility in maintaining a safe and healthy environment for (R1). On August 22, 2025, between 10:45 AM and 12:08 PM, the Department interviewed resident members identified as Resident #1 through Resident #9 (R1-R9). Seven (7) out of the nine (9) residents could not validate this allegation. Residents from (R3-R9) have stated that they have no issues or concerns as they have not encountered any pest in their rooms or common areas. Additionally, they have observed pest control professionals actively performing treatments throughout the premises, ensuring a safe and pest-free environment for everyone. (R10), identified as( R1's) roommate, declined to be interviewed. (Evaluation Report continues LIC 9099-C) (R1-R2) expressed concerns regarding a pest issue in their rooms and mentioned that they have informed the staff, but no action has been taken yet. (R1) indicated that they have reported the issue to the care staff daily; however, (R1) was unable to recall the names of the staff members involved. Additionally, (R1) did not remember if the room had been treated on June 20, 2025, or August 19, 2025. (R1) verified that staff must not enter the room without the presence of (R1), nor should they provide any cleaning or care assistance services without (R1's) presence. This rule is crucial to maintain proper standards according to (R1's) preference. (R1) stated she has not seek any medical assistance for bites due to pest problems. The Department inspected the facility on August 22, 2025, focusing on the first floor, second floor, and common areas. Rooms inspected included #284, # 285, 286, 287, and #289. The rooms were found to be maintained and clean. The rooms are in order to prevent pest infestations, ensuring a comfortable environment for everyone. Housekeeping and maintenance staff were observed carrying out their responsibilities. (R1's) room was found to be disorganized, with clothes and tableware left soaked for an extended period. There was also standing water, which could attract and create a breeding ground for flies. Additionally, uncovered food packages and drinks left in glassware are likely to attract various types of flies. The Department did not observed any sign vermin or pest infestation. The Department did not observed what appear to be pest bites on (R1). The Department reviewed a Dewey Pest Control Service Agreement dated December 12, 2024, and another dated June 17, 2025, which provided evidence of an annual service contract. This contract indicated that ten service visits were performed each month, totaling 40 treatments per month. Additionally, an examination of the Dewey Pest Control Service Log, covering the period from June 20, 2025, to August 19, 2025, confirmed that service treatments were performed for (R1's) room. Telecommunications records from July 13, 2025, indicated that (R1) had prohibited staff from entering the room for cleaning assistance. Further review conducted on (R1's) Physician's Report LIC 624 A and the Service Plans dated May 25, 2025, and June 21, 2025. (Evaluation Report continues LIC 9099-C) Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with Suzette Johnson, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 11-AS-20250820152434

Allegation investigated: Facility staff did not provide adequate food service to resident in care.

On 08/21/25 Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Executive Director Suzette Johnson (S1) as the purpose of today’s visit was explained. The investigation consisted of the following: On 08/21/25 LPA Villegas obtained copies of the staff and resident roster, and requested the following documents for resident #1 (R1) admission agreement dated: 11/19/24, physicians report dated: 02/06/25 , preplacement appraisal dated: 11/19/24, needs and service plan dated:11/19/24. On 08/19/25 LPA conducted interview with Resident #1 (R1), and on 08/21/25 LPA conducted interview with staff #1-2 (S1-S2) regarding the allegation above. The investigation revealed the following: Allegation: Facility staff did not provide adequate food service to resident in care. Unsubstantiated It is being alleged that facility kitchen does not provide lunch to go when requested. On 08/19/25 LPA conducted interview with R1 regarding the allegation above, R1 reported the allegation is being addressed however R1 has been dealing with the allegation above for 3 months. on 08/21/25 LPA conducted interview with S1-S2 regarding the allegation above, 2 of 2 staff interviewed denied the allegation above, Per 2 of 2 staff interviewed residents have requested to go meals and the kitchen staff has completed the request. Additionally 2 of 2 staff interviewed reported that the requested packed meal are not always picked up by R1. 1 of 2 staff interviewed reported that the kitchen cooks big quantities of food to ensure that residents who are out during scheduled meal services can have food available upon their arrival. On 08/21/25 LPA reviewed the admission agreement page A-3 letter E titled meals, upon review of the admission agreement, LPA did not observe any documentation stating that the facility will provide packed meals for residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 11-AS-20250811140929

Allegation investigated: Resident fell due to staff neglect resulting in injury Staff did not seek medical attention for resident

On 08/14/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted a subsequent unannounced complaint investigation visit regarding the allegations listed above. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility Unsubstantiated Investigation consisted of the following: On 07/02/2025, interviews were conducted, and records were gathered. Interviews conducted consisted of 10 resident interviews [Resident 2 (R2) to Resident 11 (R11) were interviewed]. Resident 1’s (R1) records were gathered which consisted of Medication Administration Record (MAR) from 03/2025 to 04/2025; Unusual Incident Report dated 05/16/2025; Progress Notes from 03/2025 to 04/2025; Admission Agreement dated 04/07/2025; Emergency Information dated 07/02/2025; Resident Assessment dated 02/25/2025; Preplacement Appraisal Information dated 02/28/2025; Appraisal/Needs & Services Plan dated 03/05/2025; Consent Forms dated 03/09/2025; Personal Rights dated 03/09/2025; and other pertinent information. Facility records were gathered which consisted of Resident Roster; Personnel Report dated 04/2025; Personnel Report dated 07/02/2025; LVN-Medication Technician Job Role Description; Time-Sheets from 04/05/2025 to 04/06/2025; Fall Risk Mitigation and Prevention Policy; Inservice Training from 03/05/2024 to 03/19/2025; Plan of Operation; and other pertinent information. On 8/14/2025, interviews were conducted, and records were reviewed. Interviews conducted consisted of 9 staff interviews [Staff 1 (S1) to Staff 9 (S9) were interviewed] and 2 witness interviews [Witness 1 (W1) to Witness 2 (W2) were interviewed]. Allegation: “Resident fell due to staff neglect resulting in injury”, it is being alleged that R1 fell due to staff neglect which resulted in R1 sustaining an injury. Interviews conducted with R2 to R11 revealed the following: 10 out of 10 residents denied the allegation. Interviews conducted with S1 to S9 revealed the following: 9 out of 9 staff denied the allegation. Interviews conducted with W1 to W2 revealed the following: 2 out of 2 witnesses denied the allegation. Records reviewed of R1’s facility notes revealed the following: on 04/05/2025 at 11:15 PM R1 had an unwitnessed fall; R1 was seen by Caregivers and by a Licensing Vocational Nurse; R1 was unhurt. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. 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: “Staff did not seek medical attention for resident”, it is being alleged that staff did not seek medical attention for R1. Interviews conducted with R2 to R11 revealed the following: 9 out of 10 residents denied the allegation. 1 out of 10 residents agreed with the allegation. Interviews conducted with S1 to S9 revealed the following: 9 out of 9 staff denied the allegation. Interviews conducted with W1 to W2 revealed the following: 2 out of 2 witnesses denied the allegation. Records reviewed of R1’s unusual incident report dated 04/06/2025 revealed the following: on 04/06/2025 at 3:00 PM, resident had a low oxygen level and 911 was called. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. 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 provided. An exit interview was conducted, and a copy of this report was left with the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, Aug 14, 2025 · control 11-AS-20250625150231

Allegation investigated: Staff are not properly addressing pest infestation in the facility.

On 08/12/25 at 10:45 am Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director Suzette Johnson, as the purpose of today’s visit was explained. The investigation consisted of the following: On 08/12/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for resident #1 (R1) face sheet, service plan dated: 06/21/25, Physicians report dated: 05/25/25, medication administration record (MAR) for 08/2025, communication notes, housekeeping schedule, deep cleaning schedule, Dewey pest control agreement, Dewey service logs dated June 2025-August 2025. On 08/12/25 from 12pm-1:25pm LPA conducted Interviews residents #2-10 (R2-R10), and from 1:35pm- 2:32pm LPA conducted interviews with staff #1-5 (S1-S5). On 08/12/15 LPA unable to interview R1 as R1 refused interview. On 08/12/25 LPA conducted tour of the facility and conduct check of 5 bedrooms. Unsubstantiated The investigation revealed the following: Allegation: Staff are not properly addressing pest infestation in the facility. It is being alleged that a resident in care has bugs crawling on body and face throughout the night. On 08/12/25 from 12pm-1:25pm LPA conducted Interviews with R2-R10 regarding the allegation above, 3 of 9 residents interviewed reported observing pest in the bedrooms, and reported having their bedrooms treated after staff was made aware. 6 of 9 residents interviewed denied the allegation above and reported their bedrooms have been treated for pest as a precaution. On 08/12/15 LPA unable to interview R1 as R1 refused interview. On 08/12/25 from 1:35pm- 2:32pm LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above, and reported that R1 does not allow staff to come into R1's bedroom to provide cleaning services. Additionally 5 of 5 staff interviewed stated that R1 threatens to call law enforcement and a Lawyer if staff attempt to enter R1's bedroom. On 08/12/25 LPA conducted a review of Dewey pest control services logs, per service log R1's bedroom was services on 6/20/25. LPA conducted a review of Dewey pest control service agreement, per agreement 10 bedrooms are treated weekly as well as common areas, and the building exterior. On 08/12/25 LPA conducted a review of communication notes, LPA observed documented communication from staff reported that R1 does not allow entry into R1's bedroom. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 12, 2025 · control 11-AS-20250807142442

Allegation investigated: Licensee did not ensure bathroom was in good repair. Licensee did not ensure required notices were visibly posted in the facility. Staff did not allow resident to leave their room.

This report supersedes report dated 07/17/2025 to obtain additional information. On 08/06/2025 at 10:40 AM, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint findings. During today's visit, LPA met with Suzette Johnson and the explained the purpose of the visit. The investigation consisted of the folloing: On 07/17/2025, LPA interviewed Administrator (A1), Staff #1 - Staff #10 (S1 - S10) and Resident #2 - #9 (R2 – R9) ; Resident 1 (refused to be interviewed during the investigation). LPA requested copies of the staff roster (dated 07/17/2025), resident roster (received 07/17/2025), Face Sheet & Emergency (for R1 - received on 07/17/2025), LIC 602: Physician Report (for R1 - dated 05/29/2025), Admission Agreement (for R1 - dated 06/24/2025), LIC 603: Preplacement Appraisal Information (for R1 - dated 06/24/2025), Service Plan (for R1 - dated 06/24/2025) and Work Order for R1's room. Unsubstantiated The investigation revealed the following: Allegation 1: Licensee did not ensure bathroom was in good repair. It was alleged bathroom, is not working for days and they have not ask someone to come fix it. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated she is not aware of any recent issues with R1's bathroom and residents can report to the front desk where a work order is placed and maintenance will complete the order. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 2 of out of 10 staff confirmed the allegation. 7 out of 10 staff denied the allegation. 1 out of 10 staff were unsure of the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 8 out of 9 residents denied the allegation. 1 out of 9 residents unsure or unaware of the allegation. On 07/17/2025 at approximately 1:03pm and on 08/06/2025 between the hours of 11:09am - 11:29am LPA conducted a tour with S9 of the following rooms 118,135,208,211,237,247,283,285 and 306 & observed the following: the sink, shower and toilet are operable and in good repair. On 07/17/2025 at approximately 1:30pm, LPA conducted a records review of the work order (created on 06/25/2025) and did not observe any documentation to support the allegation. Based on interviews conducted, records review and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. Allegation 2: Licensee did not ensure required notices were visibly posted in the facility. It was alleged that the facility its just plain walls with no emergency information or telephone. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated the required posting are publicly visible in the common areas of the facility which is a standard protocol. Between 8:51am - 10:06am, LPA interviewed 10 staff regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 3 out of 9 residents confirmed the allegation. 4 out of 9 residents denied the allegation. 2 out of 9 residents were unsure or unaware of the allegation. On 07/17/2025 between the hours of 8:35am -8:40am, LPA conducted a tour of the facility with S8 and observed in the main lobby area posted on the wall are following: the facility license, the Emergency Disaster Plan for Residential Facilities, the Long Term Ombudsman contact information (also posted on the 2nd floor in the library area which was observed during the tour by LPA with S9 on 08/06/2025 between the hours of 11:09am - 11:28am), and the California Department of Social Services Community Care Licensing Division Centralized Complaint & Information Bureau contact information. Report continues on LIC 809-C On 08/06/2025, between the hours of 11:09am - 11:28am, LPA conducted a tour with S9 and observed a working telephones at the front desk, the first and the second floor of the facility which are easily accessible for all residents to use. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. Allegation 3: Staff did not allow resident to leave their room. It was alleged the facility won't let resident out of the room. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated residents are only restricted from common areas in the event that a resident is on isolation due to testing positive for COVID. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 9 out of 9 residents denied the allegation. Between the hours of 8:35am -8:40am, LPA conducted a tour of the facility and observe residents throughout the facility in common area. Upon records review, R1 is diagnosed with dementia as stated in R1's - LIC 602A Physician's Report for Residential Care Facilities for the Elderly (RCFE). On the LIC 602 under Section 14. Mental Condition it states (k). Able to Leave Facility Unassisted is check of NO. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. On 07/17/2025, LPA attempted to interview Resident #1 (R1) who declined to be interviewed about the three allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Suzette Johnson (Administrator) & copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 11-AS-20250714095011

Allegation investigated: Staff do not ensure residents dietary care plan is being followed Staff do not ensure resident is provided with breakfast, lunch and dinner each day Staff does not ensure adequate care and supervision is provided to residents

On 08/05/2025 at 3:00 p.m., The Department conducted an initial visit to gather information regarding the above allegations. The Department met with Executive Director Suzette Johnson and explained the purpose of today's visit. LPA was granted entry to the facility. Investigation consisted of the following: On 04/28/2025, the department requested, reviewed and obtained copies of Resident Roster (Dated 04/28/2025), Personnel Report (Dated 04/28/2025), Dietitian's Report (Dated 03/28/2025) Weekly Menu (Dated 02/16/2025 - 05/03/2025) Resident 1's Records (Dated 04/28/2025) Resident 1's Progress Note (Dated 06/01/2024 - 04/28/2025), and Tray Service Request. Interviews were conducted, with staff 1-5 (S1-S5) and residents 1-10 (R1-10). We toured the facility kitchen. At 11:30 a.m., the Department observed residents eating well-balanced and nutritious meals. We observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Investigation revealed the following: Allegation: Staff do not ensure residents' dietary care plan is being followed. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. Five out of five (5 out of 5) staff members and nine out of ten (9 out of 10) residents stated that staff ensure residents' dietary care plans are being followed. They confirmed that staff consistently adhere to physician-prescribed dietary menus and that residents are served well-balanced, nutritious meals according to the doctors' orders. 5 out of 5 staff members and 9 out of 10 residents also stated that the facility does have a dietitian. R1 reported that staff do not ensure the residents' dietary care plans are being followed. LPA requested R1's physicians' report and reviewed the resident's special diet documentation. 5 out of 5 staff members confirmed that R1 is on a diabetic diet, and R1's physician's report, dated 05/28/2024, also indicated that R1 is on a diabetic diet. LPA observed the facility's regular menu as well as the diabetic alternative menu available for residents on a special diet. Staff stated that according to the residents' physicians' orders, they will accommodate special diets, including low sugar, carbohydrate, mechanical soft, and pureed options. S1-S5 and R2-R10 all denied the allegation. Allegation: Staff do not ensure the resident is provided with breakfast, lunch, and dinner each day. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. Staff members (5 out of 5) and 9 out of 10 residents stated that staff ensure the residents are provided with breakfast, lunch, dinner, and snacks. Residents confirmed they receive three meals per day, and alternative food choices are offered. The facility provides a diverse range of food options, and if a resident requests a second serving, staff accommodates the request. R2-R10 stated they receive plenty of food to eat, and if they don't want to dine in the dining lounge, they can complete a tray service request. Staff will collect the request slip and deliver the meal to the resident's room. R1 stated that staff do not ensure residents are provided with breakfast, lunch, and dinner each day. LPA observed residents eating lunch and dinner and reviewed the food menus. LPA observed an ample supply of perishable and non-perishable food items. LPA observed staff serving meals during breakfast and lunch. LPA also reviewed the resident's tray service form. S1-S5 and R2-R10 all denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation: Staff do not ensure adequate care and supervision is provided to residents On 04/28/2025, between 10:00 a.m. and 11:30 a.m., the Department interviewed two staff members #1 and #5 (S1-S5), regarding the allegation. S2 stated that a resident reported another resident had entered their room; however, there were no witnesses to the incident, and a review of the facility’s surveillance cameras did not reveal any unauthorized entry. Maintenance checked the resident's door and confirmed it was in operable condition. S1 and S5 explained that care staff conduct Wellness checks on residents every two hours. All residents have pendants and call buttons to alert staff if they need assistance. Staff confirmed that no unauthorized individuals were observed entering residents’ rooms. S1 and S5 stated residents’ doors remain locked, and each resident has a personal key to their own room. S1-S5 states the facility currently has about 93 staff members employed and is fully staffed, and that residents are receiving appropriate care, supervision, and assistance with their daily needs. Both interviewed staff (5 out of 5) confirmed the facility is sufficiently staffed and denied the allegation. On April 28, 2025, between 11:45 a.m. and 12:00 p.m., the Department reviewed the facility’s Personnel Report (LIC 500), which listed the following staff positions: Executive Director; Human Services Director; Vice President of Operations; Business Office Manager; Human Resources Director; Resident Care Director; ALW Coordinator; 4 Licensed Vocational Nurses (LVNs); 2 Community Liaisons; 2 Maintenance Staff; 4 Cooks; 5 Kitchen Staff; 4 Food Servers; 2 Dishwashers; 6 Dietary Aides; 9 Medication Technicians; 7 Memory Care Caregivers; 1 Memory Care Activity Director; 2 Activities Assistants; 25 Caregivers; 7 Housekeepers; 4 Receptionists; and 1 Driver a total number of employees listed: 93, confirmed the facility is adequately staffed. On April 20, 2025, there were 10 staff members on the night shift at 9:30 p.m. No incident reports were filed regarding the allegation. None of the caregivers reported witnessing anything, and nothing was documented in the residents' records. See continued LIC9099-C page 4 Continued LIC9099-C page 4 On April 28, 2025, between 12:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with ten residents #1-#10 (R1–R10) regarding the allegation of inadequate care and supervision. 9 out of 10 residents stated that the facility is adequately staffed and confirmed they are receiving the necessary care and supervision. 9 out of 10 also stated that staff are consistently present every shift. 1 out of 10 residents expressed concern about staffing and did not feel care and supervision were adequate. 9 out of 10 residents reported that they were happy living at the facility and had no problems or complaints. The majority of residents (9 out of 10) denied the allegation and stated that their daily needs were being met. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. 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. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 11-AS-20250421123647

Allegation investigated: Licensee did not ensure bathroom was in good repair. Licensee did not ensure required notices were visibly posted in the facility. Staff did not allow resident to leave their room.

On 07/17/2025 at 8:27p, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint findings. During today's visit, LPA met with Suzette Johnson and the explained the purpose of the visit. The investigation consisted of the following: On 07/17/2025, LPA interviewed Administrator (A1), Staff #1 - Staff #10 (S1 - S10) and Resident #2-#9 (R2 – R9) ; Resident 1 (refused to be interviewed during the investigation). LPA requested copies of the staff roster (dated 07/17/2025), resident roster (recieved 07/17/2025), Face Sheet & Emergency (for R1 - received on 07/17/2025), LIC 602: Physician Report (for R1 - dated 05/29/2025), Admission Agreement (for R1 - dated 06/24/2025), LIC 603: Preplacement Appraisal Information (for R1 - dated 06/24/2025), Service Plan (for R1 - dated 06/24/2025) and Work Order for Room 285 (created 06/23/2025) Report continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation 1: Licensee did not ensure bathroom was in good repair. It was alleged bathroom, is not working for days and they have not ask someone to come fix it. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated she is not aware of any recent issues with R1's bathroom and residents can report to the front desk where a work order is placed and maintenance will complete the order. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 2 of out of 10 staff confirmed the allegation. 8 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 8 out of 10 residents denied the allegation. 1 out of 10 residents were unsure or unaware of the allegation. At approximately 1:03pm, LPA conducted a tour of room 285 where Resident 1 (R1) resides and observed the following: the sink, shower and toilet operable and in good repair. At approximately 1:30pm, LPA conducted a records review of the work order (created on 06/25/2025) and did not observe any documentation to support the allegation. Based on interviews conducted, records review. and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED Allegation 2: Licensee did not ensure required notices were visibly posted in the facility. It was alleged that the facility its just plain walls with no emergency information or telephone. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated the required posting are publicly visible in the common areas of the facility which is a standard protocol. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 3 out of 9 residents confirmed the allegation. 4 out of 9 residents were unsure or unaware of the allegation. 2 out of 9 residents denied the allegation. Between the hours of 8:35am -8:40am, LPA conducted a tour of the facility and observed in the main lobby area posted on the wall are following: the facility license, the Emergency Disaster Plan for Residential Facilities, the Long Term Ombudsman contact information, and the California Department of Social Services Community Care Licensing Division Centralized Complaint & Information Bureau contact information. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. Report continues on LIC 9099 Allegation 3: Staff did not allow resident to leave their room. It was alleged the facility won't let resident out of the room. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated residents are only restricted from common areas in the event that a resident is on isolation due to testing positive for COVID. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 10 out of 10 residents denied the allegation. Between the hours of 8:35am -8:40am, LPA conducted a tour of the facility and observe residents throughout the facility in common area. Upon records review, R1 is diagnosed with dementia as stated in R1's - LIC 602A Physician's Report for Residential Care Facilities for the Elderly (RCFE). On the LIC 602 under Section 14. Mental Condition it states (k). Able to Leave Facility Unassisted is check of NO. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. On 07/17/2025, LPA attempted to interview Resident #1 (R1) who declined to be interviewed about the three allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Suzette Johnson (Administrator) & copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 11-AS-20250714095011

Allegation investigated: Resident sustained an unexplained fracture. Staff did not seek medical attention to resident in a timely manner.

On 07/15/25 The Department conducted a subsequent to deliver complaint findings, LPA Villegas met with Executive Director Suzette Johnson as the purpose of today's visit was explained. The investigation consisted of the following: On 12/10/24 LPA Villegas obtained copies of resident #1 (R1) complete file, copies of the staff and resident rosters, copy of unusual incident report for 12/06/24, and copy of communication between staff regarding R1 from dates 12/01/24-12/09/24. On 01/22/25 The Department conducted interviews with staff #1-3 (S1-S3), and interviews with residents #2-4 (R2-R4). The Department was unable to conduct an interview with Resident #1 (R1) due to communication barrios. On 04/23/25 The Department obtained a copy of R1’s Kaiser Permanente Medical Records. On 05/05/25 The Department conducted a records review. The investigation revealed the following: Allegation: Resident sustained an unexplained fracture. Unsubstantiated It is being alleged that a resident sustained an acute minimally displaced LI fracture while in care. On 01/22/25 The Department conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. Per 1 of 3 staff interviewed, on 12/01/24 resident reported sliding off bed, resident was assessed, resident denied any pain or injury, resident refused to go to the hospital, and resident was placed on “watch alert.” On 01/22/25 The Department conducted interviews with R2-R4 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. The Department was unable to conduct an interview with Resident #1 (R1) due to communication barrios. The Department conducted a review of medical records for R1, medical records revealed that R1 has a history of Osteopenia, subsequent L1 fracture, and mild degeneration (grade 2) to both the right and left hip, which has a higher risk of subsequent fractures. The Department conducted a review of R1’s file, per preplacement assessment dated 08/17/23 R1 is independent in bed mobility and transfer. Allegation: Staff did not seek medical attention for resident in care in a timely manner. It is being alleged that resident did not have a medical evaluation done after fall. On 01/22/25 The Department conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. Per 1 of 3 staff interviewed, on 12/01/24 resident reported sliding off bed, resident was assessed, resident denied any pain or injury, resident refused to go to the hospital, and resident was placed on “watch alert.” On 01/22/25 The Department conducted interviews with R2-R4 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. The Department was unable to conduct an interview with Resident #1 (R1) due to communication barrios. The Department conducted a review of R1’s file, per preplacement assessment dated 08/17/23 R1 is independent in bed mobility and transfer. Per review of communication log dated 12/01/24-12/19/24 R1 was being checked on by staff, per communication log there were no complaints of pain or discomfort, and resident refused to go to the hospital. The Department confirmed that an unusual incident report was sent to CCLD regarding R1’s fall on 12/01/24. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 11-AS-20241209092305

Allegation investigated: Staff are not safeguarding resident's belongings.

On 07/15/25 Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with (S1) Executive Director Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 07/15/25 LPA Villegas obtained copies of the staff and resident roster, surety bond and requested the following documents for resident #1 (R1); emergency ID form, admission agreement dated: , physicians report dated: 12/24/24 preplacement appraisal dated:9/10/24, service plan dated:9/13/24, resident personal property and valuables dated 9/11/24, resident theft and loss record, P&I account log from October 2024-July 2025. On 07/15/25 from 10:15 am- 12:18 pm LPA conducted Interviews with Residents#00-10 (R0-R10), and between 1:00pm- 2pm LPA conducted interviews with staff # 1-00 (S1-00). On 07/15/25 LPA conducted a review of R1's file. The investigation revealed the following: Unsubstantiated Allegation: Staff are not safeguarding resident's belongings. It is being alleged that someone is stealing money from a resident in care. On 07/15/25 from 10:15 am- 12:18 pm LPA conducted Interviews with R1-R10 regarding the allegation above, 9 of 10 residents interviewed denied the allegation above and stated their money have not been stolen or misplaced at the facility. 1 of 10 residents interviewed confirmed the allegation above, per resident money has gone missing twice, however it was not reported to staff. On 07/15/25 from 1:00pm- 2pm LPA conducted interviews with S1-S6 regarding the allegation above, 6 of 6 staff denied the allegation above. 6 of 6 staff interviewed reported that if a resident reports having their property stolen, staff will document it on the communication log, and report it to management for investigation. On 07/15/25 at 2:30 pm LPA spoke to W1 regarding the allegation above, W1 has no concerns regarding the allegation above. On 07/15/25 LPA conducted a review of R1's file, per physicians report dated: 12/24/24, R1 cannot handle own cash resources, R1 has a financial power of attorney. On 07/15/25 LPA reviewed the Resident theft and loss record, LPA did not observe R1 to be listed as reporting any loss or theft. On 07/15/25 LPA reviewed P&I account log from October 2024-July 2025, per log R1 has been receiving funds weekly. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 11-AS-20250708103808

Allegation investigated: Staff did not keep the facility free of rodents

On 07/10/2025 Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent visit to deliver findings regarding the above allegation; this report supersedes the investigation report that was delivered on 07/02/2025. The purpose of this report is to provide additional information gathered during the investigation. LPA met with Suzette Johnson and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 07/01/2025 at approximately 1:50 PM, LPA Anguiano interviewed 10 staff members (S1–S10). Around 3:00 PM, LPA conducted inspections of ten resident rooms: 204, 259, 265, 253, 246, 211, 112, 135, and 138 (seven rooms on the second floor and three on the first floor), and interviewed 11 out of 251 residents (R2-R11). On 07/02/2025 at approximately 8:40 AM, LPA Anguiano conducted a physical plant inspection of the kitchen, and dining room and conducted record reviews. Unsubstantiated On 07/09/2025 around 9:00 AM, LPA interviewed Resident (R1). Investigation revealed the following: Interviews conducted revealed the following: 9 out of the 10 staff members did not agree with the allegation, S1 stated that the facility has pest control measures in place and is currently in preventative mode. S2 indicated that kitchen cleaning is performed regularly. 9 out of the 10 residents did not agree with the allegation. R1 indicated that mice have been seen however had been taken care of in a slow manner when it’s brought up to the staff. LPA observations revealed the following: No live rodents were observed at the time of the visits. Records review revealed the following: LPA Anguiano reviewed a Dewey Pest Control Service Agreement, which indicated proof of an annual service contract. This contract indicated that the services are performed monthly on Wednesday’s. Additionally, a review of the Dewey Pest Control Service Log, covering the period from March 1, 2025, and April 29, 2025, confirmed that treatment services are being performed monthly. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation “staff did not keep the facility free of rodents” 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. An exit interview was conducted, and a copy of the Complaint Report was given to Suzette Johnson.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 11-AS-20250625084748

Allegation investigated: Staff are not disposing of medications. Staff did not safeguard residents medications. Staff are not administering medications to residents. Staff are not following residents care plans Staff left residents in a soiled diaper for a long period of time. Staff are not bathing residents in care. Staff are not feeding residents in care. Staff are teasing residents in care.

On 07/03/2025 around 08:00AM Community Care Licensing Division (CCLD) staff initiated an investigation with Vista Del Mar Senior Living for the allegations listed above. Today’s complaint investigation was conducted face to face with Administrator Suzette Johnson S1. During today’s visit, LPA Calderon, and Administrator Suzette Johnson S1 toured the facility including all common areas and the medication room on the second floor. LPA Calderon requested copies of the following: A copy of the admission agreement, Physician Report for R1-R9, Medication Administration Record (MAR) for April, May, June 2025 for R1-R9, shower logs, toileting assistance logs (dated 05/04/2025 to 05/29/2025), service plans for R1-R9, weekly menu for April 27 to May 31, 2025. LPA Calderon interviewed residents R1-R12 and staff S1-S8. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. LPA Calderon toured the facility with S1. LPA Calderon did not notice any negative interactions with residents. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff are not disposing of medications. This complaint alleged that the facility staff did not dispose of resident medication. LPA Calderon toured the facility with S1. LPA Calderon walked into the medication room on the second floor and witnessed staff preparing medications to be given to residents in care. LPA Calderon noted that staff work with an electronic Medication Administration Record (MAR) for dispensing the residents’ medications. The medications were locked in drawers and moved to locked medication carts which are used to move the resident’s medication. LPA Calderon noted there is a disposable bin for expired medications. LPA Calderon was shown the cabinet that holds liquid medications such as eye drops which were stored and locked. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not disposing of medications.” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff did not safeguard resident’s medications. This complaint alleged that the facility staff did not safeguard resident’s medications. LPA Calderon toured the facility with S1. LPA Calderon walked into the medication room on the second floor and witnessed staff preparing medications to be given to residents in care. LPA Calderon noted that staff work with an electronic Medication Administration Record (MAR) for dispensing the residents’ medications. The medications were locked in drawers and moved to locked medication carts which are used to move the resident’s medication. LPA Calderon noted there is a disposable bin for expired medications. LPA Calderon was shown the cabinet that holds liquid medications such as eye drops which were stored and locked. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff did not safeguard resident’s medications.” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not administering medications to residents. This complaint alleged that the facility staff did not administer medication to residents. LPA Calderon toured the facility with S1. LPA Calderon walked into the medication room on the second floor and witnessed staff preparing medications to be given to residents in care. LPA Calderon noted that staff work with an electronic Medication Administration Record (MAR) for dispensing the residents’ medications. The medications were locked in drawers and moved to locked medication carts which are used to move the resident’s medication. LPA Calderon noted there is a disposable bin for expired medications. LPA Calderon was shown the cabinet that holds liquid medications such as eye drops which were stored and locked. Records review indicate the following: Reviewed the MAR for April, May and June 2025 for R1-R9. Medications given to residents with no errors. Reviewed Physician orders for R1-R9, noted staff ordered medications for resident in care. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not administering medications to residents.” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not following residents care plans. This complaint alleged that the facility staff did not follow the residents’ care plan. Records review indicate the following: Reviewed service plan for R1-R9, staff following service plan. Reviewed Physician report for R1-R9, staff following physician report for residents in care. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not following residents care plans” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff left residents in a soiled diaper for a long period of time. This complaint alleged that the facility staff did not dispose of soiled diapers for a long period of time. Records review indicate the following: Service plan for R1-R2 indicates full assistance with all aspects of bathroom activities and hygiene. Shower and Toileting logs indicate that bathing, grooming and toileting are provided to R1-R2 multiple times per day or per week. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff left residents in a soiled diaper for a long period of time.” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not bathing residents in care. This complaint alleged that the facility staff did not bathe residents. Records review indicate the following: Reviewed Service plan for R1-R9, assistance needed for showering noted by staff. Shower and Toileting logs indicate that bathing, grooming and toileting are provided to R1-R2 multiple times per day or per week. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not bathing residents in care.” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not feeding residents in care. This complaint alleged that the facility staff did not feed bedbound residents. Records review indicate the following: Reviewed Weekly Menu for residents in care, noted wide range of options to eat for residents. Breakfast, lunch and dinner are served. There is 1st seating and 2nd seating starting at 7am to 9am, lunch from 11 am to 1pm and dinner from 4pm to 6pm. Alternative menu is offered. Standard admission agreement indicates page A3-A4, section E meals: We will serve 3 nutritionally balanced meals and snacks daily to residents. Tray Service, we will provide a tray service to your apartment during an illness at no extra charge. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not feeding residents in care.” is found to be UNSUBSTANTIATED Regarding the Allegation: Staff are teasing residents in care. This complaint alleged that the facility staff did not treat residents with respect. Toured the facility and did not notice any negative interactions with residents in care. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are teasing residents in care.” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Suzette Johnson (S1).the state’s words, verbatim · CDSS document, Jul 3, 2025 · control 11-AS-20250626115305

Allegation investigated: Staff did not keep the facility free of rodents

On 07/02/2025 at 8:11 AM, Licensing Program Analyst (LPA) Jose Anguiano conducted an initial visit to gather information regarding the above allegation. LPA met with the Resident Care Director Sidonia Cordis, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 07/02/2025 at approximately 8:40 AM, LPA Anguiano conducted a physical plant inspection of the kitchen, and dining room. During the kitchen inspection, rodent droppings were observed on multiple areas, including: • On the floor beneath the prep tables • Behind the refrigerators • Underneath the water container storage area Please see LIC9099-C for additional documentation. Unsubstantiated No live rodents were observed at the time of the visit. Per interview with (S2), who has been employed at the facility for approximately one month, kitchen cleaning is performed regularly; however, no formal cleaning logs or documentation are maintained. Photographs of the observed droppings were taken by LPA. LPA Jose Anguiano also reviewed a Dewey Pest Control Service Agreement, which provided valid proof of an annual service contract. This contract indicated that the services are performed monthly on Wednesday’s. Additionally, a review of the Dewey Pest Control Service Log, covering the period from March 1, 2025, and April 29, 2025, confirmed that treatment services are being performed monthly. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of the Complaint Report was given to Suzette Johnson.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 11-AS-20250625084748

Allegation investigated: Resident sustained an unexplained injury while in care.

On 07/02/25 Licensing Program Analyst (LPA) Villegas conducted a subsequent visit to deliver complaint findings. LPA met with (S1) Executive Director Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 06/18/25 LPA Villegas obtained copies of the staff and resident roster, and the following documents for resident #1 (R1) face sheet, admission agreement dated:3/24/23, physicians report dated:04/24/2024 , physicians orders, resident preplacement appraisal dated: 3/23/23, needs and service plan dated: 09/08/2024, unusual incident reports dated: 05/19/25, 06/4/25, 06/16/25, fall risk Evaluation dated: 6/4/25, 6/9/25, 06/16/25, and an order from provider dated: 6/16/25 for R1 to be sent to ER. On 06/18/25 at 10:00 am-11:45am LPA conducted Interviews with residents # 2-10 (R2-R10), and between 1:00 pm-2:00pm LPA conducted interviews with staff #1-7 (S1-S7). On 06/18/25 LPA unable to interview R1 as R1 is out of the facility at the time of visit. On 06/26/25 LPA conducted a review of R1's file and obtained a copy of a Physicians order for PT/OT. On 06/27/25 LPA conducted telephone interviews with S8 and R1. Unsubstantiated The investigation revealed the following: Allegation: Resident sustained an unexplained injury while in care. It is being alleged that a resident in care had swelling and bruising around their right eye that was not there 2 days prior. On 06/18/25 at 10:00 am-11:45am LPA conducted Interviews with R2-R10, 9 of 9 residents interviewed denied the allegation above, and reported feeling safe living at the facility. On 06/18/25 and 6/27/25 LPA conducted interviews with S1-S8 regarding the allegation above, 8 of 8 staff interviewed denied the allegation above. Per 8 of 8 staff interviewed, families and Primary Care Physicians are notified of any falls or injuries a resident may experience while in care. On 06/26/25 LPA conducted a review of R1's file, LPA observed incident reports dated: 05/19/25, 06/04/25, and 06/16/25, per incident reports R1 experienced un-witnessed falls and declined medical attention. LPA confirmed incident reports dated: 05/19/25, 06/04/25, and 06/16/25 were sent and received by CCLD. During file review LPA observed documented fall risk assessments conducted on 06/04/25, 06/09/25, and 06/16/25, per fall risk assessments R1 was at high risk of falls. In addition, during file review LPA observed an order from provider dated 6/16/25 for residents to be sent to ER due to recent falls and refusal of medical attention. On 06/27/25 LPA conducted telephone interview with R1 regarding the allegation above, R1 denied the allegation above. Per R1, R1 is clumsy and has fallen quite a bit. R1 states that the facility has offered medical service after each fall, however R1 did not see it necessary as R1 is able to take care of self. R1 stated the staff at Vista Del Mar have been very kind since R1’s has been admitted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 11-AS-20250609110500

Type of visit: Case Management - Deficiencies

On 07/02/2025 at around 9:20 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced visit for complaint 11-AS-2025062515023. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility. On 07/02/2025, LPA Leandro observed the following deficiency in room 316 at around 2:23 PM: · R1’s bed had no fitted bed sheets. A deficiency is being cited based on LPAs observations. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, and plans or correction were developed. A copy of this report was left with the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, Jul 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3)(C) · Plan of correction due date: Jul 22, 2025

Personal Accommodations and Services (3) Equipment and supplies necessary for personal care...the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets...The quantity shall be sufficient to permit...prohibited. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by R1's bed not having fitted bed sheets which poses a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: The licensee has agreed to place fitted sheet R1's bed. The licensee has agreed to create a plan to stay in compliance with CCR 87307(3)(C). The licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Allegation investigated: Staff did not prevent resident from engaging in inappropriate behaviors. Staff are not providing a comfortable environment for resident.

On 07/1/25, at 09:00am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Suzette Johnson, Executive Director. LPA explained the purpose of this visit is to gather information about the complaint, gather facility files, interview staff/residents, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R10) from 10:00am-02:00pm. The department received the following: Resident Roster (No Date) Staff Roster (Dated: 07/01/2025), ID/Emergency Information (Dated: 01/13/2023, 08/03/2024) Admission Agreement (Dated:01/13/2023, 08/03/2024), Pre-Placement Appraisal (Dated: 08/06/2024, 01/13/2023), Physicians Report (Dated:08/01/2024, 04/23/2025), Appraisal/Needs and Service Plan (Dated: 09/08/2024, 04/14/2025), Vista Del Mar Senior Living Work Order (Dated: 06/28/2025) and Facility Notes (Dated: 07/01/2025) from the facility. Report Continued On Lic9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Staff did not prevent resident from engaging in inappropriate behaviors. The details of the complaint alleged that the resident (R1) has a roommate that is sundowning and is up during the night, and R1 has caught the roommate messing with their oxygen tank. It was reported that the resident feels unsafe with their current roommate and would like to change rooms. On 7/1/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not prevent resident from engaging in inappropriate behaviors. All staff (S1-S4) interviewed stated that they had no knowledge that R1s roommate had allegedly interfered with their oxygen tank. They stated that no one told them about this issue and now that they know they will address the issue and take appropriate action. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied any knowledge of ongoing issues with resident’s engaging in inappropriate behaviors. The majority of the resident’s stated that they either do not have a roommate or that they do not have any such issues with their current roommate and/or other resident’s. The Department reviewed the Vista Del Mar Senior Living Work Order (Dated: 06/28/2025) and Facility Notes (Dated: 07/01/2025) and observed that a work order was created on 06/28/2025 to move the resident (R1) to another room in the facility. The department also observed that management was made aware of the issue between the two roommates and started the process of taking appropriate actions to resolve the concern. S1 stated that R1 was given an option to switch sides within the room to help resolve the disagreement but R1 declined the offer and chose to stay on their side of the room. Subsequently, the facility decided to move R1 and created a work order to do so on 06/28/2025. R1 is scheduled to be transferred to a new room within a week or so. Once the room has been prepped, the team will assist R1 with their move to their new location in the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not prevent resident from engaging in inappropriate behaviors. 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. Report Continued On LIC9099-C Allegation #2- Staff are not providing a comfortable environment for resident. The details of the complaint alleged that the resident (R1) has a roommate that is causing the resident to live in an uncomfortable environment, but the facility has not moved or changed the resident to a new room. It was reported that the roommate and their family members turn off the air condition in the bedroom when it is hot, causing the resident (R1) to feel uncomfortable. On 7/1/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff are not providing a comfortable environment for resident. All staff (S1-S4) interviewed stated that when they learned of the issue with the roommates, they took appropriate action to resolve the issue. They stated that they had a discussion with both resident’s and concluded that they would relocate R1 to another room in the facility. Staff stated that they are in the process of making that happen and it should not take more than a week to find a room and prepare it for R1 to move in. They further state that R1 will be assisted with the move by a team within the facility. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that they were comfortable with the environment within the facility and were satisfied with the care and supervision provided by the staff. The majority of the resident’s stated that they are provided a comfortable environment to live in by the facility. The Department reviewed the Vista Del Mar Senior Living Work Order (Dated: 06/28/2025) and Facility Notes (Dated: 07/01/2025) and observed that a work order was created on 06/28/2025 to move the resident (R1) to another room in the facility. The department also observed that management was made aware of the issue between the two roommates and started the process of taking appropriate actions to resolve the concern. R1 is scheduled to be transferred to a new room within a week or so. Once the room has been prepped, the team will assist R1 with their move to their new location in the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not providing a comfortable environment for resident. 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. An exit interview was conducted with Suzette Johnson, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 11-AS-20250626084043

Allegation investigated: Staff did not ensure resident's catheter care was properly managed.

* This report supersedes the report dated 05/14/2025. It does not supersede the findings but is being used to clarify the findings. On 05/30/2025 Licensing Program Analyst (LPA) Troy Watson made a subsequent unannounced complaint visit to the above listed facility. LPA Watson was greeted by the Administrator Suzette Johnson and explained the purpose of this visit is to deliver findings for the allegation mentioned above. CONTINUED ON LIC9099-C Unsubstantiated The investigation consisted of the following: LPA Watson conducted interviews with residents and staff. LPA Watson requested and received the following: Staff and Resident Roster, SIR reports, Physician's report.A tour of the facility was conducted with the Administrator Suzette Johnson on 05/13/2025. The investigation revealed the following: Allegation: Staff did not ensure resident's catheter care was properly managed. It is being alleged that staff did not ensure that resident’s catheter was regularly emptied and cleaned. On 05/08/2025 the department conducted interviews with Residents #2 - Residents #11 (R2-R11). An attempt to interview Resident #1 (R1) was made but they were no longer at the facility and did not respond to several calls and messages left on their phone/voice mail. The department asked the residents if staff catheters were properly emptied, cleaned and managed? Of those interviewed, 10 out of 10 residents denied the above allegation. On 05/08/2025 the department interviewed Staff #1- Staff #11 (S1-S11). The department asked the staff if catheters were properly emptied, cleaned and managed? Of those interviewed, 11out of 11staff denied the above allegation. Based on interviews and observations there is insufficient evidence to support the allegation: Staff did not ensure resident’s catheter care was properly managed. 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. An exit interview was conducted with the Administrator Suzette Johnson and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 30, 2025 · control 11-AS-20250430092910

Allegation investigated: Facility staff did not dispense medications as prescribed.

On 05/16/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the facility to deliver findings. LPA was met by staff one, Suzette Johnson Exective Director (S1), and the purpose of the visit was explained. The investigation consisted of the following: On 11/22/24 LPA requested staff and resident roster, three (3) resident admissions agreement (R1, R6, R7) and toured the facility and interviewed ten (10) out of two-hundred and thirty-eight (238) residents (R1-R10) and five (5) out of one-hundred and five (105) staff (S1-S5). Resident seven (R7) was sleeping and denied LPA's interview. On 12/05/24 CCLD staff interviewed four (4) residents (R11-R14) and two (2) staff (S5 & S6). LPA requested further records, including home health service visit notes for a resident. The investigation revealed the following: Regarding the allegation, "Facility staff did not dispense medications as prescribed.". It has been alleged that a resident did not receive their weekly dosage of a medication, as ordered by resident's physician (Dr.), due to medication being misplaced by staff. Report continues, see LIC9099-C. Substantiated Record reviews of the medication administration record (MAR) reveal that a doctor's order had been placed for the medication in question (M1) on September 5th, 2024 (09/05/2024). Though M1 is to be provided once per week (1x/week), M1 had been marked as having been administered to a resident nineteen (19) times during the month of September (09/2024). The MAR, following M1, indicates that a resident's Dr.'s order had been followed between the dates of 10/25/2024 through 11/07/2024. M1 was provided to the resident on November the eighth, 2024 (11/08/2024) and November the fifteenth, 2024 (11/15/2024), again following a resident's Dr. order, yet no more administration marks had been placed on the MAR during the month of November (11/2024). Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D. One deficiency has been cited during today's visit, please see LIC9099-D. An exit interview was held with Suzette Johnson, Executive Director, and a copy of appeal rights, this deficiency and this report have been provided. The investigation revealed the following: Regarding the allegation, "Resident developed a pressure injury due to staff neglect". It has been alleged that a resident has not been rotated as often as needed. Although the facility does not keep a rotation log for the residents requiring this service, LPA interviews revealed that nine (9) out of fourteen (14) residents and all six (6) staff interviewed, out of one-hundred and five (105) staff, have not agreed with the allegation. Record reviews revealed that a resident did have a stage two (2) pressure injury, but on November nineteenth, 2024 (11/19/24) the same resident requested discharge from their home-health services provided by Excel Home Health in order to choose an alternate service(s) which are also related to a resident's health condition. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violation did occur. Therefore, the above allegation is found to be Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Suzette Johnson, Executive Director, and a copy of appeal rights and this report have been provided.the state’s words, verbatim · CDSS document, May 16, 2025 · control 11-AS-20241119135616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: May 23, 2025

87465 Incidental Medical...care (a) A plan for incidental medical...care shall be developed by each facility. The plan...provide for assistance in obtaining such care...: (6) When requested by...a record of dosages of medications shall be maintained by the facility. This requirement has not been met as evidenced by: R1's medication admission record (MAR) in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: LPA and licensee have agreed that med-tech staff will undergo training to reiterate how important medication (med) management, including focus on med storage, is for residents in care. Licensee has agreed that facility will send inservice conference information, including the time included & sign-in sheet, on or prior to the POC due date 05/23/2025, via email to LPA at mario.leon@dss.ca.gov

Allegation investigated: Resident sustained a fracture due to lack of care from staff.

On 05/16/2025, the department conducted a subsequent complaint visit in order to render investigation findings. The department met with Resident Care Director Sideonis Cordis and the purpose of the visit was explained. The investigation consisted pf the following: On 04/30/2024, the department obtained and reviewed the following: Needs and Service Plan (dated 03/19/2024), Pre-Placement Appraisal (dated 05/06/2023), Physicians Report (dated 03/15/2024), Incident report (dated 04/19/2024 and 04/20/2024), Physician’s Orders (dated 03/19/2024), Memorial Care Long Beach Medical Center medical records (dated 04/24/2024), and Providence St. Joseph Hospital medical records (dated 4/19/2024) for R1. The departmetnt interviewed four staff (S1-S3), including the Executive Director Janie Acosta. The department interviewed three residents (R1-R3). Report continued on LIC9099-C Substantiated Allegation #1: Resident (R1) sustained a fracture due to a lack of care from staff. It is alleged that Resident (R1) fell and sustained a vertebral fracture injury due to falling from R1’s wheelchair. This investigation revealed that R1 was admitted to Vista Del Mar Senior Living on 03/03/24. A record review of R1’s Physician Report (dated: 03/15/24) revealed that R1 is non-ambulatory and requires staff assistance to transfer to and from bed. On 4/22/25, staff found R1 sitting on the floor in R1’s room. Staff observed R1’s forehead was bleeding, and an abrasion under the left eye. Staff reported R1 experienced an unwitnessed fall and called 911. R1 was transported to Memorial Care Long Beach Medical Center, where an imaging test was performed. The department conducted a review of Memorial Care of Long Beach's medical records and found that the imaging test results detected R1 sustained a cervical spine fracture and soft tissue swelling. The department conducted a record review of the facility’s notes and found that R1 experienced unwitnessed falls from R1’s wheelchair in R1’s room on 03/25/24, 3/26/24, and 3/28/24. The department conducted a review of the facility notes and found that R1 did not prefer to sleep in a bed and would sleep in R1’s wheelchair. The department conducted interviews with S1-S4 and found that staff were aware that R1 would fall asleep in R1’s wheelchair, fall forward, and fall from the wheelchair. Report continued on LIC9099-C The department found no record of the facility implementing a fall risk management plan for R1. The department conducted interviews with three residents (R1-R3). 3 out of 3 expressed no issues with staff supporting their needs. During this investigation, the department found sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and a citation was issued (ref. LIC 9099D). An immediate civil penalty of $500 is warranted in accordance with the California Health and Safety Code. See LIC421IM. An exit interview was conducted. A copy of this report, along with the appeal rights were provided to the Executive Director Suzette Johnson. Allegation #2: Staff refused to accept the resident back at the facility following a hospital visit. It has been alleged that staff refused to accept a resident back at the facility following a hospital visit, despite the resident being cleared for return. On April 22, 2024, the resident was admitted to Memorial Care Long Beach Medical Center (MCLBMC) after experiencing an unwitnessed fall from a wheelchair. On April 30, 2024, between 10:00 AM and 12:00 PM, the department interviewed Staff Member 1 (S1), who denied the allegation. S1 stated that on April 23, 2024, R1 arrived in the office on a gurney without a cervical collar (C-collar), prompting S1 to send the resident back to the hospital. S1 indicated that she had spoken with the emergency room physician at MCLBMC regarding the resident's condition. The physician explained that the resident had two cervical spine fractures and required a C-collar and further treatment; however, the R1 refused care. S1 informed the physician that the resident needed to be placed in a skilled nursing facility before returning to the assisted living facility, as the facility could not provide the necessary level of care. The physician agreed with this plan and consented to find an alternative placement. S1 also noted that R1 was not cooperating with the hospital staff, resulting in the hospital discharging R1. Report continued on LIC9099-C On 04/30/2024, the department interviewed four staff members (S1-S4), 4 out of 4 denied the allegation and stated that R1 was not refused readmission to the facility, the facility wanted R1 to go to skilled nursing for more treatment, in then come back to the facility after treatment. On 05/16/2025, the department interviewed 5 Residents (R1-R5) 5 out of 5 denied the allegation. The department reviewed medical records from Memorial Care Long Beach Medical Center dated 04/22/24 to 04/24/24, indicated that R1 refused multiple attempts for an MRI and refused to wear a C-collar for R1's neck fractures, and demanded to be discharged from the hospital. On 04/23/24 at 11:07 am, the hospital called the facility and spoke to S1 and stated that R1 does not want any further care and does not want to wear a C-collar; therefore, R1 will be discharged back to the facility. Based on the records reviewed and interviews conducted, there is insufficient evidence to support the allegation that the staff refused to accept the resident back at the facility following a hospital visit. 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 citations were issued. An exit interview was conducted, and a copy of this report was provided to the Executive Director Suzette Johnson.the state’s words, verbatim · CDSS document, May 16, 2025 · control 11-AS-20240429113918

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 19, 2025

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. Based on interview and record reviews, the licensee failed to provide R1 with more assistance and supervision following discharge from the hospital on 04/19/24 due to being a high fall risk. R1 continued to experience multiple falls that resulted in a fracture of C5 and C6 vertebrae on 04/22/24, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: The Executive Director will provide a fall risk plan, and the facility will provide in- service training to all staff. The Executive Director will email LPA the POC. POC due date 05/19/25.

Allegation investigated: Facility staff did not dispense medications as prescribed.

On 05/16/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the facility to deliver findings. LPA was met by staff one, Suzette Johnson Exective Director (S1), and the purpose of the visit was explained. The investigation consisted of the following: On 11/22/24 LPA requested staff and resident roster, three (3) resident admissions agreement (R1, R6, R7) and toured the facility and interviewed ten (10) out of two-hundred and thirty-eight (238) residents (R1-R10) and five (5) out of one-hundred and five (105) staff (S1-S5). Resident seven (R7) was sleeping and denied LPA's interview. On 12/05/24 CCLD staff interviewed four (4) residents (R11-R14) and two (2) staff (S5 & S6). LPA requested further records, including home health service visit notes for a resident. The investigation revealed the following: Regarding the allegation, "Facility staff did not dispense medications as prescribed.". It has been alleged that a resident did not receive their weekly dosage of a medication, as ordered by resident's physician (Dr.), due to medication being misplaced by staff. Report continues, see LIC9099-C. Substantiated Record reviews of the medication administration record (MAR) reveal that a doctor's order had been placed for the medication in question (M1) on September 5th, 2024 (09/05/2024). Though M1 is to be provided once per week (1x/week), M1 had been marked as having been administered to a resident nineteen (19) times during the month of September (09/2024). The MAR, following M1, indicates that a resident's Dr.'s order had been followed between the dates of 10/25/2024 through 11/07/2024. M1 was provided to the resident on November the eighth, 2024 (11/08/2024) and November the fifteenth, 2024 (11/15/2024), again following a resident's Dr. order, yet no more administration marks had been placed on the MAR during the month of November (11/2024). Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D. One deficiency has been cited during today's visit, please see LIC9099-D. An exit interview was held with Suzette Johnson, Executive Director, and a copy of appeal rights, this deficiency and this report have been provided. The investigation revealed the following: Regarding the allegation, "Resident developed a pressure injury due to staff neglect". It has been alleged that a resident has not been rotated as often as needed. Although the facility does not keep a rotation log for the residents requiring this service, LPA interviews revealed that nine (9) out of fourteen (14) residents and all six (6) staff interviewed, out of one-hundred and five (105) staff, have not agreed with the allegation. Record reviews revealed that a resident did have a stage two (2) pressure injury, but on November nineteenth, 2024 (11/19/24) the same resident requested discharge from their home-health services provided by Excel Home Health in order to choose an alternate service(s) which are also related to a resident's health condition. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violation did occur. Therefore, the above allegation is found to be Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Suzette Johnson, Executive Director, and a copy of appeal rights and this report have been provided.the state’s words, verbatim · CDSS document, May 16, 2025 · control 11-AS-20241119135616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: May 23, 2025

87465 Incidental Medical...care (a) A plan for incidental medical...care shall be developed by each facility. The plan...provide for assistance in obtaining such care...: (6) When requested by...a record of dosages of medications shall be maintained by the facility. This requirement has not been met as evidenced by: R1's medication admission record (MAR) in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: LPA and licensee have agreed that med-tech staff will undergo training to reiterate how important medication (med) management, including focus on med storage, is for residents in care. Licensee has agreed that facility will send inservice conference information, including the time included & sign-in sheet, on or prior to the POC due date 05/23/2025, via email to LPA at mario.leon@dss.ca.gov

Allegation investigated: Staff did not ensure resident's catheter care was properly managed.

On 05/14/2025 Licensing Program Analyst (LPA) Troy Watson made an unannounced complaint visit to facility listed above to deliver findings and was greeted by the Administrator Suzette Johnson. LPA explained the purpose of the visit and was granted access to the facility grounds. The investigation consisted of the following: On 5/8/2025 LPA Watson conducted interviews with Residents #1- Residents #10 (R1-R10) and Staff #1- Staff #11 (S1-S11). LPA Watson requested and received the following: Staff and Resident Rosters, Special Incident Reports, Physician's reports. CONTINUED ON LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure resident's catheter care was properly managed. It is being alleged that staff did not ensure that resident’s catheter was regularly emptied and cleaned. On 05/08/2025 the department conducted interviews with Residents #1- Residents #10 (R1-R10). The department asked the residents if their catheters were properly emptied, cleaned and managed. Of those interviewed, 1 out of 10 residents had a catheter and stated he had no issues with staff’s management of his catheter while the out 9 of 10 residents did not have catheters but had not heard about anyone having issues with their catheters. On 05/08/2025 the department interviewed Staff #1- Staff #11 (S1-S11). The department asked staff if catheters were properly emptied, cleaned and managed. Of those interviewed, 11 out of 11staff denied the allegation. Based on interviews and observations there is insufficient evidence to support the allegation: “Staff did not ensure resident’s catheter care was properly managed”. 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. An exit interview was conducted with the Administrator Suzette Johnson and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 14, 2025 · control 11-AS-20250430092910

Allegation investigated: Staff does not provide comfortable water temperature for resident(s). Staff does not keep resident’s room free from pests.

On May 1, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced visit to gather information regarding the above allegations. LPA met with Executive Director Suzette Johnson, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1-#5 (S1 to S5), and resident members #1-#10 (R1 to R10). List of documents reviewed/obtained Resident Roster (dated 05/01/25), Personnel Report LIC 500 (dated 05/01/25), Dewey Pest Control Service Agreement (dated 12/12/24),Dewey Pest Control Service Log (dated 04/01/25 through 04/29/25), and other documents pertinent with this complaint. (Evaluation Report continues LIC 9099C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff does not provide comfortable water temperature for resident(s). The complaint details the staff allegedly failing to provide a comfortable water temperature for residents in care. Reports indicate that there is no hot water available. The common shower area fails to provide consistent hot water, and despite notifying a staff member about this issue, no actions have been taken to resolve it, and no further information has been provided. On May 1, 2025, between 9:30 AM and 10:30 AM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the (5) staff members could not validate this allegation. (S1-S2) acknowledged since April 22, 2023, there have been some issues with the water pressure due to one of the boilers that operates by gas not operating correctly. (S1) notified Community Care Licensing (CCL) by submitting an incident report on April 23, 2025. (S1) provided a subsequent report to (CCL) on April 26, 2025, written notification to Residents and Families of Vista Del Mar Senior Living of Hot Water Service Disruption for the first and second floors. In the notice that it described, the HVAC contractor and Southern California Gas have been working to identify and resolve problems with the facility’s boiler system. The notice offered temporary accommodations with vacant rooms and common area shower rooms for residents affected by this problem. (S2) stated that all rooms have access to hot water because there is still one operational boiler. This boiler effectively transfers heat to the water by passing it through a pipe within the heated gas chamber. Consequently, while the water may take slightly longer to heat up, it remains universally available in every room. Utilizing two separate boilers enables a quicker heat transfer process that residents recognize. Staff member #3 (S3) stated that (S3) does not recall discussing the hot water issues with residents. Additionally, (S3) indicated that no residents have reported any concerns related to this matter. On May 1, 2025, between 10:35 AM and 12:00 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of the ten (10) resident members could not corroborate this allegation. (R1-R10) have access to running hot water in their rooms. Five (5) out of the ten (10) residents acknowledged receipt of the written notification regarding alternative amenities. (Evaluation Report continues LIC 9099-C) On May 1, 2025, between 1:30 PM and 2:30 PM, the Department conducted inspections of rooms #105, #117, #235, #236, #237, #238, and #239, as well as the kitchen and public restrooms. During the inspection, heated water was available, with temperatures ranging from 105.1°F to 118.0°F, which complies with Title 22 Regulations. Additionally, the Department observed the HVAC technician servicing the boiler systems. The Department also reviewed written communication reports dated April 23, 2025, and April 26, 2025, which indicated that the facility is taking proactive measures to address the boiler system issue. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Allegation #2: Staff does not keep resident’s room free from pests. The staff allegedly neglected to ensure that the residents were free from pests. Three cockroaches were reportedly found in a resident's room. Although a staff member was notified about the issue, no action has been taken to address it, and no further details have been provided. On May 1, 2025, between 9:30 AM and 10:30 AM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the (5) staff members expressed no pest activity in the facility, including resident’s rooms. (S1-S2) emphasizes its commitment to ensuring the safety and well-being of residents by implementing effective, environmentally friendly pest management measures. Their proactive approach protects their residents and promotes a healthier living environment for everyone. The facility has an active Service Agreement with a reputable pest control company that performs weekly routine pest control services. (S2) stated that these scheduled services are done every Tuesday and will treat 10 rooms and common areas weekly. Staff member #3 (S3), referenced in this complaint, indicated that (S3) do not remember conversing with residents regarding pest control issues. On May 1, 2025, between 10:35 AM and 12:00 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of the ten (10) resident members could not validate this allegation. All residents from (R1-R10) have stated that they have not encountered any pests within their rooms or in the facility's common areas. Additionally, they have observed pest control professionals actively performing treatments throughout the premises, ensuring a safe and pest-free environment for everyone. (Evaluation Report continues LIC 9099-C) On May 1, 2025, between 1:30 PM and 2:30 PM, the Department conducted inspections of rooms #105, #117, #235, #236, #237, #238, and #239, as well as the kitchen, activity rooms, and dining room. Upon inspection, no signs of pest activity were present in the area. The Department also reviewed a Dewey Pest Control Service Agreement dated December 12, 2024, which provided valid proof of an annual service contract. This contract indicated that ten units of service were performed monthly, totaling 40 treatments per month. Additionally, a review of the Dewey Pest Control Service Log, covering the period from April 1, 2025, to April 29, 2025, confirmed that treatment services are being performed weekly. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview with Executive Director, Suzette Johnson and reports were provided.the state’s words, verbatim · CDSS document, May 1, 2025 · control 11-AS-20250428095622

Allegation investigated: Staff do not ensure residents dietary care plan is being followed Staff do not ensure resident is provided with breakfast, lunch and dinner each day Staff does not ensure adequate care and supervision is provided to residents

On 04/28/2025 at 9:26 a.m., The Department conducted an initial visit to gather information regarding the above allegations. The Department met with Executive Director Suzette Johnson and explained the purpose of today's visit. LPA was granted entry to the facility. Investigation consisted of the following: On 04/28/2025, the department requested, reviewed and obtained copies of Resident Roster (Dated 04/28/2025), Personnel Report (Dated 04/28/2025), Dietitian's Report (Dated 03/28/2025) Weekly Menu (Dated 02/16/2025 - 05/03/2025) Resident 1's Records (Dated 04/28/2025) Resident 1's Progress Note (Dated 06/01/2024 - 04/28/2025), and Tray Service Request. Interviews were conducted, with staff 1-2 (S1-S2) and residents 1-10 (R1-10). We toured the facility kitchen. At 11:30 a.m., the Department observed residents eating well-balanced and nutritious meals. We observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Investigation revealed the following: On 04/21/2025, it was alleged that a resident was unable to eat the food served due to the resident's dietary restrictions. It was reported that the facility maintains a record of residents’ special dietary needs; however, it does not consistently follow them. It was also reported that the facility does not have a dietitian. The facility does not provide substitutions that residents can eat on a regular basis. Although the facility uses meal menu slips for residents who are unable to make their way to the dining hall, staff have at times forgotten to pick up residents’ meal slips from their rooms, resulting in residents not receiving meals on multiple occasions. It was reported that on 04/20/2025 at 9:30 p.m., a male resident with dementia entered a resident’s room without permission while the resident was sleeping. The resident woke up, yelled at the male resident to leave, and pressed the pendant for assistance. The staff responded within three minutes and removed the male resident. Allegation: Staff do not ensure residents' dietary care plan is being followed. On 04/28/2025, the Department interviewed staff members 1-2 (S1-S2) and residents 1-10 (R1-R10) regarding the allegation. Staff members (2 out of 2) and 9 out of 10 residents stated staff does ensure residents' dietary care plans are being followed. They confirmed that staff consistently adhere to the physician-prescribed dietary menu, and residents are served well-balanced, nutritious meals according to the doctors' orders. S1-S2 and R2-R10 stated that the facility does have a dietitian. R1 stated that staff do not ensure residents' dietary care plan is being followed. S1-S2 and R2-R10 all denied the allegation. Allegation: Staff do not ensure the resident is provided with breakfast, lunch, and dinner each day. On 04/28/2025, the Department interviewed staff members 1-2 (S1-S2) and residents 1-10 (R1-R10) regarding the allegation. Staff members (2 out of 2 ) and 9 out of 10 residents stated staff does ensure the residents are provided with breakfast, lunch, dinner, and snacks. Residents confirmed they receive three meals per day, alternative food choices are offered. The facility provides a diverse range of food options, and if a resident requests a second serving, staff accommodates the request. R2-R10 stated they receive plenty of food to eat, and if they don't want to dine in the dining lounge, they can complete a tray service request. Staff will collect the request slip and deliver the meal to the resident's room. R1 stated that staff do not ensure residents are provided with breakfast, lunch, and dinner each day. S1-S2 and R2-R10 all denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation: Staff do not ensure adequate care and supervision is provided to residents On 04/28/2025, between 10:00 a.m. and 11:30 a.m., the Department interviewed two staff members #1 and #2 (S1-S2), regarding the allegation. S2 stated that a resident reported another resident had entered their room; however, there were no witnesses to the incident, and a review of the facility’s surveillance cameras did not reveal any unauthorized entry. Maintenance checked the resident's door and confirmed it was in operable condition. S1 and S2 explained that care staff conduct Wellness checks on residents every two hours. All residents have pendants and call buttons to alert staff if they need assistance. Staff confirmed that no unauthorized individuals were observed entering residents’ rooms. S1 and S2 stated residents’ doors remain locked, and each resident has a personal key to their own room. S1-S2 states the facility currently has about 93 staff members employed and is fully staffed, and that residents are receiving appropriate care, supervision, and assistance with their daily needs. Both interviewed staff (2 out of 2) confirmed the facility is sufficiently staffed and denied the allegation. On April 28, 2025, between 11:45 a.m. and 12:00 p.m., the Department reviewed the facility’s Personnel Report (LIC 500), which listed the following staff positions: Executive Director; Human Services Director; Vice President of Operations; Business Office Manager; Human Resources Director; Resident Care Director; ALW Coordinator; 4 Licensed Vocational Nurses (LVNs); 2 Community Liaisons; 2 Maintenance Staff; 4 Cooks; 5 Kitchen Staff; 4 Food Servers; 2 Dishwashers; 6 Dietary Aides; 9 Medication Technicians; 7 Memory Care Caregivers; 1 Memory Care Activity Director; 2 Activities Assistants; 25 Caregivers; 7 Housekeepers; 4 Receptionists; and 1 Driver a total number of employees listed: 93, confirmed the facility is adequately staffed. On April 28, 2025, between 12:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with ten residents #1-#10 (R1–R10) regarding the allegation of inadequate care and supervision. 9 out of 10 residents stated that the facility is adequately staffed and confirmed they are receiving the necessary care and supervision. 9 out of 10 also stated that staff are consistently present every shift. 1 out of 10 residents expressed concern about staffing and did not feel care and supervision were adequate. 9 out of 10 residents reported that they were happy living at the facility and had no problems or complaints. The majority of residents (9 out of 10) denied the allegation and stated that their daily needs were being met. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. 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. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Apr 28, 2025 · control 11-AS-20250421123647

Allegation investigated: Resident had unknown exposure to fentanyl while in care.

On 12/31/2024, at 9:25am, the department made an unannounced initial visit to the facility and was greeted by Suzette Johnson, Administrator (S1). The purpose for today’s visit was to obtain facility files pertaining to the above-mentioned allegation. The investigation consisted of the following: On 12/31/24 the department conducted an initial visit and met with Administrator, Suzette Johnson (S1). A subsequent visit was completed by the department on 04/4/2025. During the initial visit, the department conducted a tour of the facility’s physical plant and observed residents in care. The department obtained copies of the following documents: Resident Roster (No Date), Staff Roster (Dated: 12/31/2024), and In-Service Medication Training for Staff (Dated: 10/18/2023-11/05/2024) for the facility. Records for resident (R1): ID/Emergency Information (Dated: 12/31/24) Admission Agreement (Dated:09/06/2024), Appraisal & Needs Service Plan (Dated: 09/18/2024), Physicians Report (Dated: 07/24/2024), After Visit Summary (Dated: 12/24/2024), Unusual Incident/Injury Report (Dated: 12/20/24 & 12/31/2024)..... Page 1 of 3 LIC9099 Unsubstantiated Medication Administration Records (Dated: 10/01/2024-12/31/2024), and current Physician’s Orders (Dated: 12/31/2024) were also obtained from the facility. This complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigation Bureau Investigator, Olivia Spindola. As a part of the investigation, Investigator Spindola subpoenaed copies of College Medical Center medical records for resident (R1) which included: progress notes, physicians orders, psychological exam, lab results, and medication list. Additionally, the investigator conducted interviews with staff (S1-S4), witness (W1), and residents (R1-R3). The investigation revealed the following: Allegation-Resident had unknown exposure to fentanyl while in care. It is alleged that resident had exposure to an illegal drug while living at the facility. On 12/18/24 the resident was admitted to College Medical Center where they tested positive for the illegal drug Fentanyl. On 01/15/25, from 11:30am-1:00pm, the department interviewed staff (S1-S3); On 2/11/25, from 11:00am-3:30pm, the department interviewed residents (R1-R3) and staff (S4), and on 3/18/25, from 4:00pm-4:30pm, the department interviewed witness (W1) about the complaint allegation. 4 of 4 staff denied the allegation that the Resident had unknown exposure to fentanyl while in care. Staff denied knowing how the resident tested positive for the illegal drug. Staff also stated the resident resides in a locked area and cannot leave without supervision or assistance from staff. They further deny that the resident had access to illegal narcotics inside the facility or that anyone would provide the resident with Fentanyl. The department interviewed residents (R1-R3) about the allegation and 2 of 3 residents denied the allegation, while one resident was unable to participate in the investigation due to poor health. The residents that were interviewed stated that they have not witnessed any illegal drug use in the facility and was not aware of anyone providing illegal narcotics to residents. The department reviewed medical records from College Medical Center for R1 and observed that (R1) tested positive for Fentanyl on 12/18/2024, and 12/31/2024, when hospitalized at College Medical Center (CMC). The CMC records revealed that (R1) was hospitalized on an involuntary psychiatric hold for reported increased aggression and combativeness. Although the medical records indicated (R1) tested positive for Fentanyl during both hospitalizations, the department did not uncover any evidence or obtained any witness statements indicating that (R1) had access to Fentanyl or any other illegal narcotics, as (R1) resides in the Memory Care Unit of the facility, which is a locked area. The CMC records also indicated that (R1) takes several psychotropic medications to treat schizoaffective disorder, which included Olanzapine, Risperidone, Lorazepam, Quetiapine, and Trazadone. According to www.pubmed.ncbi.nlm.nih.gov, antibiotics, analgesics, and antidepressants medications such as Quetiapine and Risperdal are known to give false-positive for Fentanyl in laboratory testing. The nurse assistant (W1) stated that Quetiapine and Risperidone are drugs known to give false-positive for Fentanyl. Page 2 of 3 LIC9099-C Based on records reviewed and interviews conducted, there is insufficient evidence to support the allegation that the Resident had unknown exposure to fentanyl 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 citations were issued for this complaint. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Suzette Johnson, Administrator. Page 3 of 3 LIC9099-Cthe state’s words, verbatim · CDSS document, Apr 4, 2025 · control 11-AS-20241226135225

Allegation investigated: Facility memory care unit is not properly staffed.

On 02/20/25 Licensing program analyst (LPA) Villegas conducted an unannounced initial compaint visit regarding the allegation above. LPA met with Executive Director Suzette Johnson as the purpose of the meeting was explained. The investigation consisted of the following: On 02/20/25 LPA obtained copies of the following: resident and staff rosters, memory care staff time cards, and memory care schedules for the month of February 2025 and March 2025. On 02/20/25 LPA conducted a tour of the facility and there were no health and safety concerns. On 02/20/25 from 10am-11am LPA conducted interviews with staff #1-4 (S1-S4), and from 11:15 am to 12:45pm interviews were conducted with R1-R6. The investigation revealed the following: Allegation: Facility memory care unit is not properly staffed. It is being alleged that resident falls are a result of insufficient staffing in the Memory Care unit. Unsubstantiated On 02/20/25 from 10am-11am LPA conducted interviews with (S1-S4) regarding the allegation above, 4 of 4 staff interviewed denied the allegation above. Per 1 of 4 staff interviewed, the facility works with a registry/agency if there is a shift that needs to be covered. On 02/20/25 from 11:15 am to 12:45pm LPA conducted interviews with R1-R6, 4 of 6 residents denied the allegation above, 2 of 6 residents interviewed reported experiencing an un-witnessed falls in the past. 6 of 6 residents reported feeling safe when assisted by staff. On 02/20/25 LPA conducted a review of memory care staff time cards and schedules, LPA observed that there is a total of 42 memory care residents which are split into 4 groups daily. LPA observed memory care to have 6 staff for the morning, 4 staff in the evening shifts, and 2 staff for NOC shift. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interviewed conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 11-AS-20250212143057

Allegation investigated: Facility staff did not provide resident with a bedroom chair.

On 2/05/25, at 1:30pm, Community Care Licensing Division (CCLD) Staff conducted an initial complaint visit to the facility and was greeted by Suzette Johnson, Executive Director. CCLD explained the purpose of this visit is to gather information about the complaint, interview staff and residents, and deliver findings for the allegation mentioned above. The investigation consisted of the following: An initial complaint visit was completed by (CCLD) staff on 2/05/2025. The department investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R10). Resident Roster (Dated: No Date) and Staff Roster (Dated: 2/05/2025) were obtained from the facility. The investigation revealed the following: Allegation- Facility staff did not provide resident with a bedroom chair. Report Cpontinued On LIC9099-C Unsubstantiated The details of the complaint alleged that the facility does not provide the required personal accommodations to residents. It is alleged that residents are not provided a chair in their room per Title 22 regulations. On 02/05/25, from 1:00pm-3:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Facility staff did not provide resident with a bedroom chair. All staff (S1-S4) interviewed stated that the facility does provide the required items per Title 22 regulations. S1-S4 stated that when a resident moves in they are provided with a bed, nightstand, chair, lamp, and dresser. Staff also stated that sometimes a resident brings their own furniture, but the option is still available to them if they need it. S1 stated that one resident recently asked if they could provide them with a gamer chair in their room. S1 stated no because the facility does not offer that kind of chair but could provide the resident with a standard chair. S1 stated the resident was not happy and wanted the gamer chair. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Facility staff did not provide resident with a bedroom chair. The majority of the residents (9 of 10) stated that they did not have a problem with the facility. 4 of 9 residents stated that they brought their own furnishings with them when they moved in and 5 of 9 residents stated that the facility did provide them with a chair and the other furnishings for their bedroom. The department toured the facility and observed bedrooms # 109, 116, 118, 137, 138, 242, 245, 271A, 271B and 293; and all rooms had the required furnishings per Title 22 regulations. Based on interviews conducted, there is insufficient evidence to support the allegation that the Facility staff did not provide resident with a bedroom chair. 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 citations were issued on this complaint visit. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Suzette Johnson, Executive Director.the state’s words, verbatim · CDSS document, Feb 5, 2025 · control 11-AS-20250127155801

Allegation investigated: Staff do not ensure medication is stored in originally received container. Staff do not ensure the facility is free of insects. Staff mismanaged residents' medication. Staff are falsifying residents' medication administration record.

On 01/31/25 Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Executive director (ED) Suzette Johnson as the purpose of the visit was explained. The investigation consisted of the following: On 01/23/25 LPA requested copies of the following documents; staff and resident rosters, pest control reports for December 2024 and January 2025, and the following documents for residents #1-6 (R1-R6), emergency ID form, physicians reports, medication list, and Medication administration records (MAR) for January 2025. LPA requested copies of previous medication inservices held, ED to send copies via email by 01/24/25. On 01/23/25 between 10:20am- 11:43am LPA conducted interviews with R3-R10,LPA unable to interview R1-R2 as residents were out of the facility at the time of the visit. On 01/23/25 between 12 pm-12:25pm LPA conducted a medication review for R1-R6, and on 01/23/25 between 12:25pm- 1pm LPA conducted interview with Staff #1-2 (S1-S2). On 01/31/24 at 11:15am LPA conducted interviews with S3-S4, R1-R2, and ED. Unsubstantiated On 01/31/25 LPA obtained copies of progress notes where it is Documented that physicians have been contacted regarding medication refusals. The investigation revealed the following: Allegation: Staff do not ensure medication is stored in originally received container. It is being alleged that staff are preparing medications several days in advance. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff denied the allegation above. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 9 of 10 residents interviewed denied the allegation above and reported meds are prepared in front of them by med room staff, 1 of 10 residents interviewed reported resident is provided with meds already in a med cup. On 01/23/25 LPA conducted a tour of the medication room and observed medications to be in their originally bottle or bubble packs. Allegation: Staff do not ensure the facility is free of insects. It is being alleged that there are roaches in the medication room. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 3 of 5 staff interviewed reported pet have been observed in the past, it was reported, and the med room was treated by pest control. 2 of 5 staff interviewed denied the allegation above. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 6 of 10 residents interviewed denied the allegation above, 4 residents interviewed reported pest has been observed in the past however, it was reported to maintenance treatment has been provided. On 01/23/25 LPA conducted a tour of the medication room and did not observe any signs of pest, and med room was clean. On 01/31/25 LPA reviewed the pest control reports for December 2024 and January 2025, it is documented that the pest control company is coming out every week to treat rooms where pet have been reported as well as common areas. Allegation: Staff mismanaged residents' medication. It is being alleged that staff are being instructed to give a resident a medication that belongs to another resident because the resident was out of a particular medication. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. 4 of 5 staff interviewed reported there is an over flow of medications located in the med room to ensure a resident does not run out of medications. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 9 of 10 residents denied the allegation above and reported they have not run out of medications. 1 of 10 residents interviewed reported running out of medications from Kaiser due to a payment mis-communication with family. On 01/23/25 LPA observed there is an over flow of medications for residents stored in med room cabinet. Over flow was observed to be organized and labeled with residents name. LPA reviewed in-service held and attended by all medroom staff dated 09/25/24 and 10/16/24 for ordering and documenting medications. Allegation: Staff are falsifying residents' medication administration record (MAR). It is being alleged that med techs are entering meds as given even when they don't administer it. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. 4 of 5 staff interviewed reported MARs are documented in real time. On 01/23/25 LPA conducted a medication review for R1-R6, LPA did not observe any discrepancies on the MAR. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 31, 2025 · control 11-AS-20250114124633

Allegation investigated: Staff did not seek medical attention for resident in a timely manner . Staff did not keep resident's authorized person informed about incidents involving the resident.

On 12/19/24, at 11:57am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Suzette Johnson, Executive Director, and Andrea Perez, Marketing Director. LPA explained the purpose of the visit is to gather information about the complaint, gather facility files, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R10) from 12:00pm-02:00pm. The department received the following: Resident Roster (No Date) Staff Roster (Dated: 12/19/2024), ID/Emergency Information (No Date) Admission Agreement (Dated:12/29/2019), After Visit Summary (Dated: 12/14/2024), Service Plan (Dated: 01/16/2024) Resident Appraisal (Dated: 11/08/2024), Physicians Report (Dated: 03/14/2024), Unusual Incident/Injury Report (Dated: 12/19/24), Faxed Receipt of Incident Report (Dated: 12/19/2024), and Resident Incident Charting Notes (Dated: 12/14/2024) were obtained from the facility. Complaint Investigation Report Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1-Staff did not seek medical attention for resident in a timely manner. The details of the complaint alleged that the resident (R1) had a fall at the facility two days prior before (R1) was taken to the hospital for head trauma and dizziness; and no one sought medical attention for the resident. On 12/19/24, from 12:00pm-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not seek medical attention for resident in a timely manner. All staff (S1-S4) interviewed stated that the facility had no knowledge of a fall and that they informed the family member on 12/14/24 when it was discovered that R1 had dried blood on the left side of R1s face and shaved hair in spots on the left side of R1s head as well. Staff stated that they checked R1s room for evidence of a fall and did not notice anything out of the ordinary. Staff also stated that they checked R1s room, floors, pillows, bathroom, furniture, and clothing for blood stains and could not find any. S2 stated that they observed the dried blood on R1 and asked R1 if R1 was in pain, R1 said no. S2 then asked who shaved your head like that, did you or anyone else do that, R1 said R1 was not sure. S2 then stated that they alerted management and management called the family member the same day that it was noticed on 12/14/24, and the family came and took R1 to urgent care. Staff also stated that they had no reports that R1 had fallen and when asked if R1 had fallen, R1 said no. Staff (S3) stated that S3 saw R1 on 12/13/24 and R1 looked fine and had no issues. But that on 12/14/24 they noticed a problem. S1 stated that the resident had shavers in R1s room, S1 stated that they packed them up and gave them to R1s family member. The Department reviewed the Unusual Incident/Injury Report (Dated: 12/19/24) that was sent to the department noting that R1 was found with dry blood and part of the top of R1s left head shaved in spots. The department also reviewed the After Visit Summary (Dated: 12/14/2024) that noted R1 had dry blood on left forehead and was unclear of etiology. The report also stated that R1 had no acute intracranial abnormalities. R1 was evaluated and returned to the facility. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff did not seek medical attention for resident in a timely manner. The majority of the residents interviewed (9 of 10) stated that they have not had any problems with staff seeking medical attention when they need it. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not seek medical attention for resident in a timely manner. 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. Complaint Investigation Report Continued on LIC9099-C Allegation #2- Staff did not keep resident's authorized person informed about incidents involving the resident. The details of the complaint alleged that the staff did not inform the resident’s authorized person about the incident that occurred at the facility. On 12/19/24, from 12:00pm-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not keep resident's authorized person informed about incidents involving the resident. All staff (S1-S4) interviewed stated that the family member was notified on 12/14/24 when they noticed that the resident had dried blood and hair that was shaved in spots on the left side of R1s head. Staff (S4) stated that the family member was notified that day and that S4 sent the family member a picture of R1 that showed the dry blood and shaved hair. S4 also stated the family responded by coming to the facility on that same day and as a precaution took R1 to urgent care. All staff (S1-S4) corroborated that the family member was made aware of the incident with R1. The department reviewed the Resident Incident Charting Notes (Dated: 12/14/2024) that showed the incident was logged and the family was notified. The department also received an incident report (Dated: 12/19/24) that was sent to the Department of Social Services, Community Care Licensing Division, detailing the incident. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff did not keep resident's authorized person informed about incidents involving the resident. The majority of the residents (9 of 10) interviewed stated that the staff does inform their authorized person when they have incidents at the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not keep resident's authorized person informed about incidents involving the resident. 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. An exit interview was conducted with Suzette Johnson, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Dec 31, 2024 · control 11-AS-20241216102632

Allegation investigated: Staff do not assist resident with obtaining medical care. Staff do not allow resident to choose care provider. Staff did not safeguard resident's personal belongings.

On 12/26/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Suzette S. Johnson/ Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#9) and Resident’s interviews (R#1-R#14). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#4) Identification and Emergency Information, (R#1-R#4) Admissions agreements, (R#1-R#4) Physicians Report or LIC 602A, (R#1-R#4) Client/Resident Personal Property and Valuables or LIC 621, (R#1)’s Doctor’s letter dated 12/9/24. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Allegations: Staff do not assist resident with obtaining medical care. The details of the complaint alleged that facility staff is not assisting (R#1) with their medical appointments. During the records review, LPA Iniguez reviewed (R#1)’s medical file; LPA observed that (R#1) has Kaiser as their medical provider. A letter dated 12/9/24 from (R#1)’s doctor states that (R#1) requested to manage their own medications and medical care; the doctor wrote that they could manage their medications and medical care. During an Interview with the Administrator (A#1), she stated that in the case of (R#1), they call Kaiser to have them pick them up, but we can always provide transportation for them if they need it. During interviews with residents (R#1-R#14), (8) out of (14) stated that the family takes them to their medical appointments, (1) out of (14) stated that they go on their own, (5) out of (14) state that the used the facility transportation and (1) out of (14) stated that their doctor comes at the facility to see them. In addition, (13) out of (14) residents stated that they feel the facility will assist them if they require transportation to their medical appointments. During interviews with facility staff (S#1-S#9), (9) out (9) stated that the facility provides and assists the residents in care with transportation. Evaluation Report continues LIC 9099-C Allegation: Staff do not allow resident to choose care provider. The details of the complaint alleged that facility administrator is forcing (R#1) to choose in-house doctor. During the records review, LPA Iniguez examined (R#1)’s medical file and noted that (R#1) is enrolled with Kaiser as their medical provider. A letter dated December 9, 2024, from (R#1)’s doctor confirms that (R#1) requested to manage their own medications and medical care and has an active membership on file. During an interview with the administrator (A#1), she stated that she had never forced (R#1) or other residents in care to change their primary care physicians to choose our in-house doctor. During interviews with residents (R#1-R#14), (13) out of (14) stated that the administrator has never forced them to change their primary care physician for an in-house doctor. During interviews with facility staff (S#1-S#9), (9) out (9) stated that they had never heard that the administrator was forcing the residents in care to change their doctors for the facility doctor. Evaluation Report continues LIC 9099-C Allegation: Staff did not safeguard resident's personal belongings. The details of the complaint alleged that facility staff is not safeguarding (R#1)’s personal belongings. During the records review, LPA Iniguez reviewed (R#1)’s admission file. LPA observed that (R#1) declined to list their personal belongings on the Client/Resident Personal Property and Valuables or LIC 621 form, which is dated 3/14/2024 and signed by (R#1). In addition, LPA reviewed (R#2-R#4)’s admission files, and everyone has an LIC 621 form on file. During an Interview with the Administrator (A#1), she stated that the facility staff safeguard the personal belongings of (R#1) and the residents in care. The facility staff never takes anything from the resident’s room, including money. In addition, (A#1) stated that she had never heard about a resident sleeping in their wheelchair the whole night because their bed was broken. During interviews with residents (R#1-R#14), (13) out of (14) stated that they have an inventory list on file and that the facility staff is not taking their personal belongings, including money. In addition, (13) out of (14) residents stated that they had never heard of another resident sleeping in their wheelchair the whole night because their bed was broken. During interviews with staff (S#1-S#9), (9) out (9) stated that they do not take the personal belongings of (R#1) or other residents in care, including money. In addition, (9) out of (9) facility staff never heard about a resident sleeping in their wheelchair the whole night because their bed was broken. Evaluation Report continues LIC 9099-C During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Suzette S. Johnson / Executive Director.the state’s words, verbatim · CDSS document, Dec 26, 2024 · control 11-AS-20241219092922

Allegation investigated: Staff allowed resident in care to leave the facility without supervision.

On 12/20/24 at 8:36 am Licensing program analyst (LPA) Villegas conducted an unannounced initial complaint visit regarding the allegation above. LPA met with Executive Director (ED) Suzette Johnson as the purpose of the visit was explained. The investigation consisted of the following: On 12/20/24 LPA obtain copies of the following: staff and resident rosters, resident sign in/sign out sheets for December 2024, and visitors log for the month of December 2024. On 12/20/24 LPA also obtain the following for R1: Admission agreement dated 09/13/24, emergency ID form, service plan dated 09/13/24, preplacement appraisal dated 09/13/24, and Physicians report dated 09/13/24. On 12/20/24 between 10am- 11am LPA conducted interviews with ED, staff #1-4 (S1-S4), responsible party. On 12/20/24 between 11am-12:30pm LPA conducted interviews with residents #2-3 (R2-R3), and between 12:30pm-12:45pm LPA conducted interview with R1. The investigation revealed the following: Substantiated Allegation: Staff allowed resident in care to leave the facility without supervision. It is being alleged that R1 left the facility unassisted and was later found wandering the streets. On 12/20/24 between 10am- 11am LPA conducted an interview with Executive Director(ED) Suzette Johnson. Per ED Johnson, she was told that R1 informed staff that R1s partner would be coming by to pick R1 up, and R1 proceeded to make their way into the community. Per ED, the facility has procedures in place for when a resident is requesting to go out into the community. The reception desk will check August health to determine if a resident is able to go out without supervision, if a resident is not allowed, the resident is redirected. On 12/20/24 between 10am- 11am LPA conducted interviews with staff 1-staff 4 (S1-S4) reading the allegation. Of those interviewed, 4 of 4 staff denied the allegation and reported there is always a staff member at the front desk to ensure that residents who cannot leave the facility unassisted do not make their way out into the community. Per S1, residents who cannot leave the facility unassisted have an asterisk next to their name in the computer. On 12/20/24, between 11am-12:30pm, LPA conducted interviews with residents #2-3 (R2-R3). Of those interviewed, 2 of 2 residents denied the allegation and reported being unable to leave the facility unassisted. On 12/20/24 between 12:30pm-12:24pm LPA conducted interview with R1 regarding the allegation. R1 stated during the interview they walked right out the front door of the facility, unassisted by staff. On 12/20/24 LPA reviewed incident report sent to CCLD on 12/13/24. On 12/20/24 LPA conducted a records review for R1 and observed the physicians report, dated 09/13/24, which indicates resident has wandering behaviors and is unable to leave the facility unassisted. On 12/20/24 LPA reviewed Needs and Services plan, dated 09/13/24, which indicates that R1 had a wander guard device. On 12/20/24 LPA reviewed facility resident sign out sheet. Per the sheet, R1 was signed out by their responsible party on 12/11/24 at 10 am. On 12/20/24 LPA conducted interview with Witness 1 (W1), responsible party for R1. Per W1, they arrived to the facility around 1pm when it was determined R1 was out in the community and R1 was found at around 3pm. Based on LPAs observations, interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8)are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 20, 2024 · control 11-AS-20241212123022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 3, 2025

Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations... this requirement was not met as R1 who has a dementia diagnosis was able to leave the facility unassisted which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: Licensee and Executive Director will submit to the department a plan detailing what measures the facility is taking to ensure this dificiency does not reoccur moving forward. Licensee and Executive Director will ensure all residents are reassessed when a change in condition is observed.

Type of visit: Case Management - Deficiencies

12/10/24 LPA Villegas conducted case management deficiencies visit in order to issue a citation observed during complaint investigation, control number 11-AS-20241209092305. LPA met with Executive Director Suzette Johnson as the purpose of the visit was explained. The facility failed to report an incident that occurred on 11/30/24 where resident #1 (R1) sustained a fall at the facility. Based on observations LPA Villegas did observe documentation on nurse notes that R1 sustain a fall on 12/01/24. On 12/10/24 ED confirmed that incident occurred on 12/01/24 and confirmed an incident report was not submitted to CCLD within (7) days. The licensee is being cited with Title 22 Reporting Requirements 87211(a)(1)(B) Based on interviews, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8 by not reporting the incident to Community Care Licensing. Exit interview conducted with Executive Director Suzette Johnson, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Dec 13, 2024

Reporting Requirements.Each licensee shall furnish to the licensing agency such reports as the Department may require...a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...(B) Any serious injury ... occurring while the resident is under facility supervision. Based on records and interviews, the facility failed to submit a written report to ccld for R1's fall within (7) days. This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 10, 2024

Plan of correction: Licensee/Administrator shall read Title 22, Section 87211 “Reporting Requirements” and send a written statement to CCLD that they have read and understand this section and will report all resident's incidents in the future. Written statement must be submitted to LPA Villegas by 12/13/24.

Allegation investigated: Facility staff did not respond to resident's calls for assistance

On 12/05/24 The Department of Social Services, Community Care Licensing Division (CCLD) staff held a subsequent complaint visit at the above-mentioned facility. CCLD was met by staff one Suzette Johnson, exective director (S1). The investigation consisted of the following: On 12/05/24 CCLD staff further interviewed four (4) residents (R11-R14) and two (2) staff (S4-S5). CCLD staff requested further records, including home health services visit notes for a resident. On 11/22/24 CCLD staff requested staff and resident roster, three (3) resident admissions agreement (R1, R6, R7) and toured the facility and interviewed ten (10) out of two-hundred and thirty-eight (238) residents (R1-R10) and five (5) out of one-hundred and five (105) staff. Resident seven (R7) was sleeping and denied CCLD staff's interview. The investigation revealed the following: Regarding the allegation "Facility staff did not respond to resident's calls for assistance", it has been alleged that staff do not respond to the call button. Report continues, see LIC9099C. Substantiated On 11/22/24, at 10:13AM, CCLD staff initiated an "emergency call" via pull cord, located in the restroom. CCLD staff interviewed a resident, within their room, and observed there was no response for at least 22 minutes. CCLD continued facility tour at 10:35AM, without CCLD observing any caretaker response. On 12/05/2024 CCLD staff tested five (5) additional pull cords located in residents' restrooms, four (4) of which were in working order. CCLD also tested the pull cord in the theatre room on the second (2nd) floor. CCLD did not observe a caretaker response. During the testing of the working pull cords, CCLD observed an average response time of 5 minutes. Interviews revealed that five (5) out of fourteen (14) residents and one (1) out of six (6) staff have agreed with the allegation. Based on CCLD staff's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited. Please see the attached LIC-9099D. An exit interview was held with Suzette Johnson, Executive Director (S1), and a copy of the appeal rights, one (1) deficiency cited, and this report have been provided.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 11-AS-20241119135616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 19, 2024

87303 Maintenance and Operation (a) The facility shall be...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This has not been met as evidenced by: Based on CCLD's observations, the licensee has failed to ensure the facility has been maintained in good repair which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: The licensee and CCLD staff have agreed that the facility will have their maintenance team inspect each room to ensure that resident's emergency pull cord are in working condition. All updates will be forwarded to CCLD staff at Mario.Leon@DSS.CA.GOV

Allegation investigated: Facility staff did not respond to resident's calls for assistance

On 12/05/24 The Department of Social Services, Community Care Licensing Division (CCLD) staff held a subsequent complaint visit at the above-mentioned facility. CCLD was met by staff one Suzette Johnson, exective director (S1). The investigation consisted of the following: On 12/05/24 CCLD staff further interviewed four (4) residents (R11-R14) and two (2) staff (S4-S5). CCLD staff requested further records, including home health services visit notes for a resident. On 11/22/24 CCLD staff requested staff and resident roster, three (3) resident admissions agreement (R1, R6, R7) and toured the facility and interviewed ten (10) out of two-hundred and thirty-eight (238) residents (R1-R10) and five (5) out of one-hundred and five (105) staff. Resident seven (R7) was sleeping and denied CCLD staff's interview. The investigation revealed the following: Regarding the allegation "Facility staff did not respond to resident's calls for assistance", it has been alleged that staff do not respond to the call button. Report continues, see LIC9099C. Substantiated On 11/22/24, at 10:13AM, CCLD staff initiated an "emergency call" via pull cord, located in the restroom. CCLD staff interviewed a resident, within their room, and observed there was no response for at least 22 minutes. CCLD continued facility tour at 10:35AM, without CCLD observing any caretaker response. On 12/05/2024 CCLD staff tested five (5) additional pull cords located in residents' restrooms, four (4) of which were in working order. CCLD also tested the pull cord in the theatre room on the second (2nd) floor. CCLD did not observe a caretaker response. During the testing of the working pull cords, CCLD observed an average response time of 5 minutes. Interviews revealed that five (5) out of fourteen (14) residents and one (1) out of six (6) staff have agreed with the allegation. Based on CCLD staff's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited. Please see the attached LIC-9099D. An exit interview was held with Suzette Johnson, Executive Director (S1), and a copy of the appeal rights, one (1) deficiency cited, and this report have been provided.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 11-AS-20241119135616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 19, 2024

87303 Maintenance and Operation (a) The facility shall be...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This has not been met as evidenced by: Based on CCLD's observations, the licensee has failed to ensure the facility has been maintained in good repair which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: The licensee and CCLD staff have agreed that the facility will have their maintenance team inspect each room to ensure that resident's emergency pull cord are in working condition. All updates will be forwarded to CCLD staff at Mario.Leon@DSS.CA.GOV

Allegation investigated: Staff do not ensure facility is free from pests. Staff does not ensure that facility is adequately cleaned.

On 11/22/24, at 09:00am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Suzette Johnson, Executive Director. LPA explained the purpose of this visit is to gather information about the complaint, gather facility files, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R10). The department received the following: Resident Roster (No Date) Staff Roster (Dated: 11/22/2024), Pest Control Invoice (Dated: 07/31/2024, 08/31/2024, 09/30/2024, & 10/31/2024), and Deep Cleaning Schedule (Dated: 07/24/2022) were obtained from the facility. The investigation revealed the following: Allegation #1-Staff do not ensure facility is free from pests. Complaint Report continued on LIC9099-C Unsubstantiated The details of the complaint alleged that the facility has roaches throughout the building and in the Spa Room. On 11/22/24, from 9:30am-12:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff do not ensure facility is free from pests. All staff (S1-S4) interviewed stated that the facility has a pest control company (Terminix) that comes weekly and sprays, set traps, and tries to prevent any further infestations. During a record review, the department received and reviewed receipts from Terminix Pest Control company dated 07/31/2024, 08/31/2024, 09/30/2024, & 10/31/2024. The Department observed that Terminix has weekly visits to the facility to provide services for any current pests as well as ensure the facility remains pest free by doing preventative services. The department toured the kitchen, Spa Room, bathrooms, dining areas, activity rooms, and resident bedrooms and did not observe any roaches or other pests at the time of the visit. The department interviewed residents (R1-R10) about the allegation and 8 of 10 residents that were interviewed denied the allegation that Staff do not ensure facility is free from pests. The majority of the residents interviewed (8 of 10) stated that they have not seen any pests in the facility for quite a while. They further state that they believe the facility is doing what it can to keep it free from pests by having pest control come out weekly. Based on interviews, observation, and records reviewed, there is insufficient evidence to support the allegation that the Staff do not ensure facility is free from pests. 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- Staff does not ensure that facility is adequately cleaned. The details of the complaint alleged that the staff does not ensure that the facility is adequately cleaned. On 11/22/24, from 9:30am-12:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff does not ensure that facility is adequately cleaned. All staff (S1-S4) interviewed stated that the facility is cleaned daily by maintenance, the janitorial staff, house keepers, and caregivers. S1 stated that the Spa Room, kitchen, bathrooms, dining areas, common rooms, and bedrooms are cleaned daily. Additionally, S1 stated that a deep cleaning of those areas is done weekly. The department toured those areas and observed them to be clean, sanitary, and in compliance with Title 22 regulations. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff does not ensure that facility is adequately cleaned. The majority of the residents (9 of 10) interviewed stated that the staff does ensure the facility is cleaned and sanitary. Based on interviews, observations, and records reviewed, there is insufficient evidence to support the allegation that the Staff does not ensure that facility is adequately cleaned. 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. An exit interview was conducted with Suzette Johnson, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 11-AS-20241120082650

Allegation investigated: Staff do not ensure the facility is free from pests. Staff do not ensure the facility is clean and sanitary. Staff do not ensure resident has hot water.

On 11/22/24 Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit to deliver findings. LPA met with Executive Director Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 11/20/24 between 9:30am-11:30am LPA conducted interviews with residents #1-7 (R1-R7), and between 11:30am-12:15pm LPA conducted interviews with staff #1-4 (S1-S4). On 11/20/24 LPA conducted a tour of the inside and outside of the facility and conducted water temperature checks in (4) bedrooms. On 11/20/24 LPA obtained copies of the following documents: staff and resident rosters, Terminex invoices for the months of September and October 2024, deep cleaning schedule, housekeeping schedule for the months of August-November 2024, and the water temperature log for the months of January 2024 -November 2024. On 11/20/24 LPA obtain copies of documents pertinent to the complaint for R1. On 11/22/24 LPA conducted interviews between 9am-11:30am with staff #5 (S5), and residents #8-10 (R8-R10). Unsubstantiated The investigation revealed the following: Allegation: Staff do not ensure the facility is free from pests It is being alleged that there is a mice, rats, and roach problem at the facility. On 11/20/24 between 11:30 am-12:15pm LPA conducted interviews with S1-S4, 4 of 4 staff interviewed denied the allegation above and reported bedrooms are sprayed by Terminex pest control when pest are reported by residents. 4 of 4 staff also reported rooms are being monitored for pest when cleaning is being conducted. On 11/20/24 between 9:30 am-11:30am LPA conducted interviews with residents R1-R7, 3 of 7 residents interviewed denied the allegation above, 1 of 7 residents refused interview, 3 of 7 residents interviewed confirmed the allegation and reported traps are placed and the bedroom gets sprayed when reported. On 11/22/24 at 9am LPA conducted interview with (S5),1 of 5 staff interviewed denied the allegation above and reported pest control visits the facility regularly to spray. On 11/22/24 between 9:15am- 11:30am LPA conducted interviews with R8-R10 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. On 11/20/24 while touring the inside and outside of the facility, LPA did not observed any pest activity. On 11/22/24 LPA conducted a a review of Terminex service reports and observed that the facility is being treated weekly. Allegation: Staff do not ensure the facility is clean and sanitary. It is being alleged that the facility is dirty and that the staff don't clean the rooms nor the bathrooms well. On 11/20/24 between 11:30 am-12:15pm LPA conducted interviews with S1-S4, 4 of 4 staff interviewed denied the allegation above and reported bedrooms along with the rest of the facility are cleaned daily and bedrooms are deep cleaned 1 time per week. Per 4 of 4 staff, some bedrooms require cleaning 2-3 times a week. On 11/20/24 between 9:30 am-11:30am LPA conducted interviews with residents R1-R7, 5 of 7 residents interviewed denied the allegation above, 1 of 7 residents refused interview, and 1 of 7 residents interviewed confirmed the allegation above, and stated the bedroom is cleaned once a week. On 11/22/24 at 9am LPA conducted interview with (S5),1 of 5 staff interviewed denied the allegation above and reported bedrooms and all common areas are cleaned daily and bedrooms are deep cleaned 1 time per week. On 11/22/24 between 9:15am- 11:30am LPA conducted interviews with R8-R10 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. On 11/21/24 while conducting tour of the facility LPA observed both floors being cleaned by the staff; trash was being removed and housekeepers were moping the floors. On 11/22/24 LPA reviewed the housekeeping schedule and observed that rooms are cleaned daily and deep cleaned once a week. Allegation: Staff do not ensure resident has hot water It is being alleged that R1's bathroom sink has no hot water and get's lukewarm at best. On 11/20/24 between 11:30am-12:15pm LPA conducted interviews with S1-S4, 4 of 4 staff interviewed denied the allegation above. 1 of 4 staff interviewed stated residents have asked for the water temperature to be higher however it was explained that the facility has to be incompliance with water temperatures and hotter water temperatures may be harmful to other residents. On 11/20/24 between 9:30am-11:30am LPA conducted interviews with residents R1-R7, 5 of 7 residents denied the allegation above, 1 of 7 residents refused the interview, 1 of 7 residents confirmed the allegation and reported the water temperature was turned down, the water temperature is too low and not to the residents liking. On 11/20/24 LPA checked the water temperatures of 4 random rooms and the following was observed: room # 135 water temp 111.7 F, room # 137 water temp 113.6F, room # 293 water temp is 114.2 and room 227 water temp is 116.2. On 11/22/24 at 9am LPA conducted interview with S5, 1 of 5 staff interviewed denied the allegation above. On 11/22/24 between 9:15am- 11:30am LPA conducted interviews with R8-R10 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. On 11/22/24 LPA conducted review of the water temperature log for the months of January 2024 -November 2024, LPA observed that water temperatures are checked regularly to ensure compliance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director Suzette Johnson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 11-AS-20241115123831

Allegation investigated: Staff is serving food that is not of good quality. Foods are not properly labeled.

On 10/24/24 at 9:00am, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit regarding the allegation above. LPA met with Executive Director (ED) Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 10/17/24 LPA Villegas conducted an initial complaint visit regarding the allegation above. On 10/17/24 LPA obtained copies of the following: Staff and resident rosters, menus for September- October 2024, alternative menu, and sanitation inspection of kitchen dated 09/21/24, documentation of food temperatures for September-October 2024 as well as copies of pertinent documents for resident #1 (R1). On 10/17/24 from 9:30am-10 am LPA conducted interview with R1, and between 10:00am- 11:30 am LPA conducted interviews with ED and staff #1-5 (S1-S5). LPA toured facility kitchen and observed dining room during lunch seating(s). On 10/24/2024 Between 9:30am- 11:45am LPA conducted interviews with residents #2-10 (R2-R10), and once again observed dining room during lunch seating(s). Unsubstantiated The investigation revealed the following: Allegation: Staff is serving food that is not of good quality. It is alleged that facility is not serving food of good quality. On 10/17/24 between 10:00am- 11:30 am LPA conducted interview with ED regarding the allegation above, ED denied the allegation above and reported there are monthly meetings held to hear the needs of the residents. On 10/17/24 between 10:00am- 11:30am LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above and reported residents have not complained of the food quality. On 10/17/2024 LPA toured the inside of the facility, during the tour LPA observed the kitchen, dining area and the facility’s food supply. LPA observed residents eating in the dining area and LPA did not observe food not of good quality being served. On 10/17/24 from 9:30am-10 am LPA conducted interview with R1, and on 10/24/2024 between 9:30am- 11:45am LPA conducted interviews with R2-R10. 8 of 10 residents interviewed denied the allegation above and reported having no concerns regrading the quality of food being served, 2 of 10 resident interviewed stated the food can be better. On 10/24/24 LPA observed residents having lunch in the dining area and did not observe food not of good quality being served. Allegation: Foods are not properly labeled It is being alleged that drinks served are not labeled sugar or sugar free. On 10/17/24 between 10:00am- 11:30 am LPA conducted interview with ED regarding the allegation above, ED denied the allegation above and reported kitchen manager oversees the labeling in the kitchen. On 10/17/24 between 10:00am- 11:30am LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. On 10/17/24 LPA conducted a tour of the facility kitchen as well as observed lunch seatings, LPA observed sugar free items to be separated and labeled in the pantry. LPA also observed the juice which was placed in a beverage pitcher to be labeled as regular/sugar and or sugar free. On 10/17/24 from 9:30am-10 am LPA conducted interview with R1, and on 10/24/2024 between 9:30am- 11:45am LPA conducted interviews with R2-R10. 5 of 10 residents interviewed denied the allegation above, 2 of 10 residents interviewed were unsure of labeling, 2 of 10 residents interviewed reported drinks are sometimes labeled, and 1 of 10 residents interviewed confirmed the allegation and reported juices are not labeled when served. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director Suzette Johnson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 11-AS-20241008133500

Allegation investigated: Staff do not answer resident's calls for assistance Staff do not ensure facility is free from pests Staff do not maintain facility in good repair.

On 10/23/24, Licensing Program Analysts (LPA), Wendy Gibbs and Perry Scott, conducted an unannounced complaint visit. During the visit the Department met with Executive Director, Suzette Johnson, and the purpose of today’s visit was explained. During today’s visit the Department conducted a facility inspection, interviewed Staff S1-S8, interviewed Residents R1-R11, and received documents pertinent to the investigation. The following documents were received and reviewed Resident Roster, Staff Roster, pest control receipts from Terminix, and Work Orders. The investigation revealed the following: Unsubstantiated Allegation: Staff do not answer resident’s calls for assistance. The complaint allegation alleges that the facility staff do not always answer calls for help or assistance. During the facility inspection, the Department tested resident call buttons in rooms 111, 205, 242, and 316. The Department timed how long it took for a caregiver to answer the call for assistance and the following times were recorded 6 minutes, 5 minutes, 6 minutes, and 8 minutes. During interviews with Staff S1 – S8, were asked how long it takes to respond to a resident’s call for assistance, eight (8) out of eight (8) stated they respond to residents calls for assistance in less than 10 minutes. During interviews with Residents R1-R11, were asked how long it takes staff to respond to their calls for assistance, seven (7) out of eleven (11) stated the staff come right away when called. Additionally, Residents R1-R11 were asked if there was a time they called for assistance and staff did not respond or come, four (4) out of eleven (11) stated there has been a time when they called for assistance and staff did not come to assist. Additionally, Residents R1, R3, R4, and R6, were asked what time of day the incident occurred, four (4) out of four (4) stated it happened during the evening and nights. Allegation: Staff do not ensure facility is free from pests. The complaint allegation alleges roaches were observed in the dining room and residents’ bed has bed bugs. During the facility inspection, the Department did not observe insects or any traces of insects. The facility and rooms inspected were observed clean and sanitary. During Record review, the Department received and reviewed receipts from Terminix pest control company dated 07/03/24 through 09/25/24. The Department observed Terminix has come out weekly to provide services. During interviews with Staff S1-S8, were asked if they have recently observed any insects or pests inside the facility, six (6) out of eight (8) stated they have not seen any insects inside the facility. Two (2) out of eight (8) stated they see cockroaches off and on but not since June. Additionally, Staff were asked if there is a pest control company that comes and provides services, eight (8) out of eight (8) stated Terminix comes out on a weekly basis to provide services. During interviews with Residents R1- R11, were asked if they have recently observed any insects or pests inside the facility, five (5) out of eleven (11) stated they have observed cockroaches inside the facility. Additionally, they stated if they see them inside the facility is on it and takes care of it quickly. Additionally, Residents R1-R11, were asked if there is a company that comes out to treat for the cockroaches, eleven (11) out of eleven (11), stated there is a company that comes out regularly. Allegation: Staff do not maintain facility in good repair. The complaint allegation alleges that their air conditioning and refrigerator in their room is not working properly. During the facility inspection, the Department observed the facility to be in good repair. The Department checked residents air conditioning and refrigerator in rooms visited and observed them to be working. During record review, the Department received and reviewed work orders from 09/14/24 through 10/23/24. During interviews with Staff S1 – S8, were asked what the process and procedure is if a resident reports something not working in their room is, eight (8) out of eight (8) stated once an issue is reported a work order is created, maintenance goes right away to check on the issue and they decide what is needed for a repair and once parts are ordered and received the issue is fixed. If the issue can be fixed right away, they fix it then. During interviews with Residents R1- R11, were asked if there was anything in the facility or in their room that is not working properly, ten (10) out of eleven (eleven) stated everything in their room is working properly and if something needs fixed, they come right away to fix it. During an interview with R1, they stated their refrigerator keeps freezing up and needs defrosted then sometimes takes a while to get cold. During the facility inspection, the Department observed R1’s refrigerator was working properly. During the course of the investigation, LPA was unable to find evidence to support the allegations. Although the allegations 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 with Executive Director, Suzette Johnson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 23, 2024 · control 11-AS-20241015140936

Allegation investigated: Staff neglect resulted in the death of residents Staff did not prevent a resident from causing self harm

This report serves as an amendment to the 9/12/2024 report . The complaint findings reflected on the report dated 9/12/2024 remain the same and does not change. On todays date 11/26/24 LPA Day amended the 9/12/2024 report to soley include Administrators interview. On 9/12/2024 ThLicensing Program Analyst (LPA) Sparkle Day conducted a susbsequent visit to the facility regarding the above allegations. The investigation consisted of the following: LPA reviewed Death Reports of all Deaths in the facility from 3/2024 to 6/2024. R#1 passed away 3/15/2024 R#2 passed away 3/15/2024 R#3 passed away 3/15/2024 R#4 passed away 3/25/24 R#5 passed away 5/27/24 and R#6 passed away 5/29/24. LPA interviewed Staff #1 - Staff #2. LPA contacted (3) hospice Agencies: W#1 - Allied Hospice, W#2 Devine Hospice, W#3 Apprea Hospice and W#4, Conservator of R#6 Regarding Allegation: Staff Neglect resulted in the death of residents It was alledeged that staff neglect resulted in deaths of residents; During this visit LPA Day received the names of 6 residents who passed away from 3/2024 to 6/2024. Resident #1 (R#1) - Resident #5 (R#5) were all on Hospice during this time . During this visit LPA contacted the hospice agencgies and confirmed that the deaths of R#1 - R#5 was due to end stage illnesses. LPA contacted conservator for R#6 and confirmed that the cause of death was Unsubstantiated due to an end stage illness. All Hospice agencies contacted and conservator where unaware of any staff neglect. Based upon this information gathered LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Regarding Allegation : Staff did not prevent a resident from causing self harm It was alleged that facility staff did not prevent a resident from causing self harm by cutting her wrist. During this visit LPA reviewed incident report of this incident dated 5/30/2024. LPA interviewed Staff #1 and Staff #2 which are both Med room staff who observed R#7 on day of incident. Incident report and staff interviews were consistent with incident: R#7 brought scissors to the Medroom and asked the staff to keep her scissors for her. Staff #1 asked R#7 why did she want them to hold the scissors for her and R#7 stated It would be safer for her. Staff took the scissors. Staff insist that R#7 did not seem distressed and acted normal. Later R#7 sustained a self cut to her wrist. LPA Day interviewed Administrator Suzette Johnson who explained the facility procedures of when a resident presumes to be distress or unusual behavior, that resident is put on a hourly watch. After R#7 brought the scissors to the Medroom S#1 alerted Administrator and was put on an alert. However R#7 cut herself within minutes of leaving the Medroom. LPA reviewed Physician report and Needs and Service Plan of R#7 which did not indicate any history of suicidal tendencies nor a history of cutting herself. During this visit LPA was unable to interview R#7 due to she has moved and whereabouts are unknown. Based on the information gathered and the interviews conducted LPA Day finds that the Staff had no knowledge of R#7 intent to harm herself , therefore could not prevent it. There is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED An Exit interview was conducted with Suzette Johnson Administrator and Sidonia Cordis, Resident Care Director and a copy of this report was providedthe state’s words, verbatim · CDSS document, Sep 12, 2024 · control 11-AS-20240604125752

Type of visit: Required - 1 Year

On 09/11/24, Licensing Program Analyst's (LPA's) Villegas and Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA's met with Executive Director Suzette Johnson as the purpose of today’s visit was explained. The facility is licensed to serve 300 non-ambulatory elderly adults 60 and over of which 10 may be bedridden, there is an approved hospice waiver for 50 residents. The facility has a dementia wing w/ delayed egress. Executive Director was provided with upcoming fees info and pin, fees due on 10/11/24. The facility has an active liability insurance with expiration date of 10/26/24. The facility is a 3-story structure located in a residential neighborhood and consists of the following: 278 bedrooms, 4 common bathrooms, multimedia rooms, commercial kitchen, activity room, large dining room, medication room, a large outside patio, laundry room, and administrative offices. LPA’s conducted a records review of 8 staff records, 10 resident records, and 10 medication administration records, records were maintained accordingly with no discrepancies. LPAs observed medications were centrally stored and properly locked. The last fire and disaster drill was conducted on 06/19/24, fire extinguishers fully charged and observed throughout the facility, carbon monoxide detectors, smoke detectors and auditory signals are operational. Landline and internet service was observed. During facility tour 10 Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, showers were free of mold/mildew, and there are sufficient toiletries accessible to residents. Water temperature properly measured between 105-120 F., there was a comfortable temperature maintained throughout the facility. LPAs conducted tour of commercial kitchen, LPAs observed an adequate supply of perishable and non-perishable food. Toxins and knifes were observed to be inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards. Exit interview conducted with Executive Director Suzette Johnson, and copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2024

Allegation investigated: Staff does not ensure resident is allowed to leave the facility at anytime with visitors.

On 09/04/24 at 1:30 pm, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint to render findings. LPA met with Executive Director (ED) Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 08/16/24 LPA obtained copies of staff and resident rosters, visitors/visitation policy, resident sign in and sign out sheet or July 2024 and August 2024, and the following documents for R1: Emergency ID form, Admission agreement date 12/10/21, physicians report, physicians orders, needs and service plan, pre-appraisal, copy of POA document(s), and copy of documentation reporting POA's request regarding visitations. On 08/16/24 between 12pm- 1:15pm LPA conducted interviews with ED, staff #1-4 (S1-S4), and conducted a tour of the facility, there were no health and safety concerns observed. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with residents #1-10 R1-R10. Substantiated The investigation revealed the following: Allegation: Staff does not ensure resident is allowed to leave the facility at any time with visitors. It is being alleged facility staff is not allowing R1 to leave the facility with visitors. On 08/16/24 between 12pm- 1:15pm LPA interviewed with ED regarding the allegation above, ED denied the allegation above and reported the facility is following POAs request regarding visitations outside the facility. ED continued to report that R1 has restrictions set in place by POA and that visitor(s) are aware of the restrictions. On 08/16/24 between 12pm- 1:15pm LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported that residents are allowed to go out of the facility with visitors unless there are restrictions in place per POA. On 08/16/24 LPA conducted interview with responsible party for R1, responsible party informed LPA that R1 has restrictions for visitations outside of the facility due to financial abuse concerns. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R1 regarding the allegation above, R1 reported it is not allowed for R1 to go out into the community with visitor although R1 would like too. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R2-R10 regarding the allegation above, 6 of 9 residents interviewed denied the allegation above and reported bring able to leave the facility with visitors, 2 of 9 residents interviewed reported not being able to leave the facility unaccompanied, 1 of 9 residents interviewed reported choosing to stay in the facility. On 09/04/24 LPA conducted review of the California all-purpose certificate of acknowledgment dated April 29, 2021 part 1 which is titled: Appointing an agent to make health care decisions, which reads “In this document I appoint an agent. That agent will make health care decisions for me in the future, if and when I no longer have the mental capacity to make my own health care decisions.” On 09/04/24 LPA reviewed provider information notice PIN 21-48-ASC page 3 title “Residents’ Right to Visitors, Telephone Calls, and Personal Mail” which details what POA agents are limited to the powers granted in the POA document. On 09/04/24 LPA conducted a review of title 22’s personal rights. Based on records reviewed and interviews conducted facility staff violated R1 personal rights by allowing a POA that only has the authority to make health care on behalf of R1 to make decisions on R1 personal rights. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter 8 are being cited on the attached LIC 9099D. exit interview conducted with Executive Director Suzette Johnson, appeal rights explained, and a copy of this report was provided. Allegation: Staff did not ensure resident was allowed to have visitors It is being alleged that facility staff do not allow residents to have visitors. On 08/16/24 between 12pm- 1:15pm LPA interviewed with ED regarding the allegation above, ED denied the allegation above and reported that visitors are always welcomed during visitation hours. On 08/16/24 between 12pm- 1:15pm LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported visitors are allowed daily. On 08/16/24 LPA conducted interview with responsible party for R1, responsible party stated that there are no visitor restrictions for visits conducted inside the facility. On 08/22/24 LPA between 9:30am-11:45am conducted interviews with R1 regarding the allegation above, denied the allegation above and reported having visitors. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R2-R10 regarding the allegation above, 7 of 9 residents interviewed denied the allegation above, 2 of 9 residents interviewed reported not having any visitors that come by the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. exit interview conducted with Executive Director Suzette Johnson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 11-AS-20240808083344

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Sep 20, 2024

Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night... Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The facility staff is following the instructions of a POA over healthcare regarding R1 right to leave the facility with visitors on outings. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Administrator will submit a plan on how the facility will ensure R1 Personal Rights are not violated. Facility will reach out to the ombudsman and or law enforcement if and elder abuse is suspected.

Allegation investigated: Staff do not ensure the facility is free from pests. Staff do not ensure resident’s room is adequately cleaned.

On 08/22/24 at 9:00 am, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Executive Director (ED) Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 08/16/24 LPA obtained copies of staff and resident rosters, house keeping schedule for August 2024, deep cleaning schedule and a copy of termix invoices for July 2024.On 08/16/24 LPA obtained copies of the following documents for R1: Emergency ID form, Admission agreement date 12/10/21, physicians report, physicians orders, needs and service plan, pre-appraisal, copy of POA document(s). On 08/16/24 LPA conducted interviews with ED, staff #1-4 (S1-S4), and conducted a tour of the facility, there were no health and safety concerns observed. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R1-R10, on 08/22/24 between 12pm-1:25pm LPA conducted interviews with S5-S6. On 08/22/24 LPA obtained copies of document(s) detailing what rooms have been treated for the month of June 2024-August 2024, terminix invoice for Unsubstantiated June 2024-July 2024, Terminix inspection report, and documentation detailing the dates and times R1's bedroom is cleaned. The investigation revealed the following: Allegation: Staff are not ensuring that facility is free of pests. It is being alleged that roaches have been observed underneath R1’s bed. On 08/16/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that Vista Del Mar Senior Living has increased their contract with Terminix commercial who will now come out once a week to spray the facility and bedrooms that require treatment. On 08/16/24 LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported that the facility is cleaned daily, bedrooms are cleaned daily and bedrooms are deep cleaned once a week. 4 of 4 staff interviewed also reported Terminix sprays the facility weekly. On 08/16/24 LPA interviewed W1 via phone who confirmed Vista Del Mar Senior Living have increased their services to once a week from twice a month. On 08/22/24 LPA conducted interviews with S5-S6, 2 of 2 staff interviewed denied the allegation above and reported bedrooms are being cleaned daily and that Terminix is coming out weekly to spray the facility and bedrooms that require treatment. On 08/22/24 LPA interviewed R1-R10 regarding the allegation above, 6 of 10 residents interviewed denied the allegation above, 4 of 10 residents interviewed reported observing and reporting pest in the past and reported that staff provided treatment. On 08/22/24 LPA toured R1's bedroom and did not observe any health or safety concerns nor pest. Allegation: Staff are not ensuring resident's room is cleaned It is being alleged staff are not cleaning R1’s bedroom floor properly. On 08/16/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above and reported that R1’s bedroom is cleaned daily and deep cleaned once a week per cleaning schedule. On 08/16/24 LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff denied the allegation above and stated that resident bedrooms are cleaned every day which consist of trash being removed, beds are made, and floors are cleaned. On 08/22/24 LPA conducted interviews with S5-S6, 2 of 2 staff interviewed denied the allegation above and reported that rooms are being cleaned daily and deep cleaned once a week. On 08/22/24 LPA interviewed R1-R10 regarding the allegation above, 9 of 10 residents reported bedrooms are cleaned daily, 1 of 10 residents reported bedroom is cleaned twice a day. On 08/22/24 LPA toured R1's bedroom and did not observe any health or safety concerns, documentation detailing when the bedroom was cleaned was observed on the bedroom door. On 08/22/24 LPA reviewed admission agreement page 3 letter C which states facility will provide daily, light housekeeping services (bed making, trash removal, and general tidying) and deep clean weekly. If you, fail to do so, you understand that the facility may provide additional housekeeping services to your bedroom, and residents shall agree to pay for such services, as facility deem necessary. Facility will provide additional housekeeping services beyond the standard daily and weekly services for an additional fee, as described Appendix A. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director Suzette Johnson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 22, 2024 · control 11-AS-20240813145825

Allegation investigated: Staff did not administer medication to resident.

** This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 07/25/2024.** On 07/25/2024 at 8:00 am Licensing Program Analyst (LPA), David España conducted a complaint Subsequent Visit to facility to gather information for the above allegation(s). There are currently 12 residents in memory care with Covid-19. LPA was granted access and allowed to enter the facility to conduct the inspection. LPA España was met by Suzette Johnson, Administrator and the purpose of today’s visit was explained. Investigation consisted of the following: On 07/24/2024 as part of the LPA España investigation, LPA requested and received copies the following documents for resident #1-#5 (R1-R5) and staff #1-#5 (S1-S5): staff roster, resident rosters and LPA requested to review the Medication Administration Records (MARs) to check when medications were given to residents, who gave them, and what doses were administered. COMPLAINT INVESTIGATION REPORT 9099C CONTINUED Unsubstantiated Investigation revealed the following: On July 25, 2024, LPA España conducted interviews regarding an allegation of staff did not administer medication to resident. The Executive Director (ED) denied the allegation, stating that staff administers medication correctly and communicates with the Licensed Vocational Nurse (LVN) to prevent errors. LPA España Interviews with Staff #1-#5 (S1-S5) also revealed unanimous denial of the allegation, with staff reporting that routine cycle medications are automatically delivered. LPA España conducted a medication review confirmed sufficient medication availability for residents. LPA España interviewed resident #1-#5 (R1-R5), of those 4 out of 5 denied the allegation, reporting timely receipt of medication; 1 resident refused to participate in the interview. Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Staff did not administer medication to resident. 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(s) is Unsubstantiated. No deficiencies were cited during this visit. Exit interview conducted. A copy of the report was given to Suzette Johnson, Executive Director. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank.the state’s words, verbatim · CDSS document, Jul 25, 2024 · control 11-AS-20240717094224

Allegation investigated: Staff did not prevent a resident from attacking another resident.

On 07/19/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced visit at this facility. LPA was greeted by the Executive Director Suzette Jonhson. LPA explained the purpose of this visit was to deliver findings for the allegation mentioned above. The investigation consisted of the following: A copy of the facility's roster for residents and staff, service records for resident #1 (R1's) Physician Report LIC 602A (dated: 06/07/24), College Medical Center Psychiatric Evaluation (dated: 04/21/24 and 05/24/24), Physical Examination/Progress Notes (dated: 05/25/24),Unusual Incident Report LIC 624 (dated: 07/15/24), Physician’s Orders Medications List (dated: 06/16/24), and (R2's) Preplacement Appraisal Information LIC 603A (dated: 04/24/24). Interviews with resident #1-#10 (R1-R11), Executive Director #1 (ED1) and staff #1-#4 (S1-S4). A tour of the faciltiy was conducted. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not prevent a resident from attacking another resident. The details of the complaint alleged resident #1 (R1) was attacked and the facility staff failed to prevent the physical assault. The complainant reported (R1) was physically assaulted by a another resident and sustained abrasions and lacerations on the front of the leg. The complainant did not provide further details on this matter. Investigation revealed resident #1 (R1) came from Ocean Ridge Post Acute a skilled nursing facility. According to resident #1 (R1’s) Identification and Emergency Information LIC 601 (dated: 06/07/24) was admitted to Vista Del Mar on 06/07/24. (R1’s) Physicians Report LIC 603A (dated: 06/07/24) is non-ambulatory and requires assistance services with medication, transferring, bathing, dressing, and grooming. On 07/18/24, between 09:30 am – 02:00 pm, the Department interviewed (5) out of (5) Executive Director #1(ED1) and staff #1-#4 (S1-S4) claimed this allegation was false. (A1 and S1-S2) claimed there was no physical assault that took place between resident #1 (R1) and resident #2 (R2). (S1-S2) reported that (R1) had an unwitnessed fall on 07/07/24 at 07:00 pm, (R1) sustained a minor skin tear on the leg and was assisted by a facility licensed vocational nurse/med-tech. (S1-S2) stated the skin tear was minor and did not require hospitalization. On 07/08/24 at 10:00 am, when being assisted by the care staff experienced combative behavior and delusional hallucinations and needed further medical evaluation according to the facility medical physician and was sent to College Medical Center on a (5150). (S3-S4) primary caregivers to (R1), explained that (R1) has displayed combative behavior when assisted with daily activity services. (S3-S4) stated (R1) had an intense fear of being touched and would respond by acting in inappropriate physical behavior with staff. (S2) reported when (R1) was admitted to Vista Del Mar from Ocean Ridge, (R1) already had multiple skin problems. (R1) is taking Eliquis, a blood thinner that can cause bruising and skin tears. According to (S2), both (R1) and (R2) require medical devices or mobility support as they are non-ambulatory. (R2) was diagnosed with Paralysis, which is a loss of muscle function in part of the body that would limit (R2's) ability to move, causing no physical assault on (R1). (S2) indicated that the facility's physician modified one of (R1's) prescribed medications to help improve (R1's) disorderly behavior on 06/21/24. (Evaluation Report continues LIC 9099-C) On 07/18/24, between 10:20 am 11:45 am, the Department interviewed (10) out of (10) residents (R2-R10) #2-#10 who denied having experienced physical assault while in care at this facility. (R2-R10) claimed not to have witnessed any physical altercations or assaults between residents. (R2-R10) praised the facility staff and mentioned they were responsive to their care and supervision. (R2) declared that (R2) had never engaged in physical contact with (R1). On 07/18/24, between 12:30 pm – 12:55 pm, the Department interviewed (1) out of (1) witnesses #1 (R1’s) family representative who verified that (R1) has a history of physical aggression on facility aids. (W1) confirmed that due to agitation or anxiety (R1) has a history of disruptive behaviors in individuals who assisted (R1) with daily activities. (W1) reported the facility notified (W1) of the unwitnessed fall with the minor skin tear on the leg along with the disorderly conduct and was sent for further evaluation at College Medical Center. On 05/16/24, between 10:00 am – 10:15 am, the Department interviewed resident #1 (R1). (R1) who is currently at College Medical Center and is being treated on (5250) was interviewed by telephone. (R1) was not able to carry a full conversation and was unable to provide statements. As a result of the Department reviewing (R1’s) Physician Report LIC 602A (dated: 06/07/24), College Medical Center Psychiatric Evaluation (dated: 04/21/24 and 05/24/24), Physical Examination/Progress Notes (dated: 05/25/24), and Unusual Incident Report LIC 624 (dated: 07/15/24) verified (R1’s) has been evaluated with some form of mental disorder. A review of (R1’s) Physician’s Orders Medications List (dated: 06/16/24), revealed (R1) is on (22) routine medications. Thirteen (13) out of twenty-two (22) prescribed medications have side effects that can cause unusual skin irritation, peeling, or bruising per the National Institute of Health (ref: NIH). (R2’s) Preplacement Appraisal Information LIC 603A (dated: 04/24/24) confirmed (R2’s) health condition and ambulatory status verified the statement stated by (S2). Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned in this complaint. 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. An exit interview is conducted with Suzette Johnson, and a copy of the report is provided.the state’s words, verbatim · CDSS document, Jul 19, 2024 · control 11-AS-20240712155653

Allegation investigated: Staff are not ensuring that facility is free of pests. Facility staff failed to meet residents needs. Staff are not safeguarding resident’s personal items. Staff made inappropriate comments to resident. Staff are not meeting resident’s laundry needs. Staff are not ensuring resident's room is cleaned.

On 06/13/24 Licensing program analyst (LPA) Villegas conducted a subsequential complaint visit to render findings regarding the allegation(s) above. LPA met with Executive Director (ED) Janie Acosta, as the purpose of the visit was explained. The investigation consisted of the following: On 06/05/24 LPA Villegas obtained a copy of the following documents: staff and resident rosters, laundry and room cleaning schedule, invoice for Terminix services for the months of April 2024 and May 2024, and conducted a tour of facility. On 06/05/24 LPA Villegas obtained the following for residents #1 (R1): facesheet (move in date: 04/25/2024), physicians report (signed 04/16/24), pre-appraisal (dated 04/25/24), needs and service plan (dated 05/07/24), admission agreement (signed: 04/25/2024) and MAR for April 2024-June 2024. On 06/05/24 LPA Villegas obtained the following for residents #2 (R2): facesheet (move in date: 07/19/22), physicians report (signed 11/16/23), pre-appraisal (signed 07/16/22), needs and service plan (signed on 08/14/23), admission agreement (signed 07/14/22), MAR for month of May 2024, physician’s orders for May 2024-June 2024. Unsubstantiated On 06/05/24 LPA Villegas conducted interviews between 9:30am- 12:30pm, with ED, and staff # 1-5 (S1-S5), LPA conducted interviews between 12:30pm-2:30pm with R#1-10 (R1-R10). The investigation revealed the following: Allegation: Staff are not ensuring that facility is free of pests. It is being alleged that R1 has been complaining about roaches. On 06/05/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that Vista Del Mar Senior Living has increased their contract with Terminix commercial who will now come out 3 times a month to spray the entire facility. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 4 of 5 staff interviewed denied the allegation above and reported that the facility is cleaned daily, and bedrooms are cleaned daily but are deep cleaned once a week. 1 of 5 staff interviewed reporting having no knowledge of the Terminix contract. On 06/05/24 LPA interviewed W1 via phone who confirmed facility is on the recommended treatment plan from Terminix pest control. W1 also reported Vista Del Mar Senior Living have increased their services to 3 times a month. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 5 of 10 residents interviewed reported that their rooms are cleaned daily and have not observed any pest in their bedrooms, 2 of 10 residents interviewed reported observing pest in their restroom and having the restroom sprayed right after, 2 or 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. Allegation: Facility staff failed to meet residents needs It is being alleged that facility staff are storing personal belongings under R1’s bed, and R1 is unable to obtain belongings when needed. On 06/05/24 LPA toured R1’s bedroom and did not observe any belongings to be stored underneath the bed. On 06/05/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that personal belongings are stored in different areas of the bedroom, depending on the resident’s preference. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and reported all residents have dresser, nightstand, and a shared closet where residents belonging can be stored and are accessible. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 7 of 10 residents interviewed denied the allegation above and reported their belongings are accessible as belongings are stored in their dresser(s), and closet. 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. On 06/05/24 LPA reviewed service plan and service plan does not specify a need for items to be stored in a particular area of the bedroom. Allegation: Staff are not safeguarding resident’s personal items It is being alleged that S2 took R1’s wheelchair and gave R1 a wheelchair that was not R1’s. On 06/05/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that wheelchairs are not provided by Vista Del Mar Senior Living as wheelchairs are provided by resident’s insurance. ED also stated that all wheelchairs are labeled with the name of the resident it belongs too. On 06/05/24 LPA interviewed S2 regarding the allegation above, S2 denied the allegation above. S2 stated that upon R1’s arrival to the facility R1 was in a wheelchair that was too low which did not allow R1 to move around the facility comfortably, S1 states she provided R1 with a lender wheelchair that was higher while R1 was able to obtain a new wheelchair. S2 continued to report that after R1 received R1’s new wheelchair S2 asked for the lender wheelchair back; however, R1 was under the impression S2 was attempting to take away the new wheelchair from R1. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 5 of 10 residents interviewed denied the allegation above and reported that their wheelchair or walker have not been misplaced, 2 of 10 residents reported not using a wheelchair or walker, and 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. On 06/05/24 while conducting interviews LPA observed wheelchairs to be labeled with resident names. Allegation: Staff made inappropriate comments to resident It is being alleged that facility staff made inappropriate comments to R1. On 06/05/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that Ed has not been informed of any staff member speaking inappropriately to any resident in care. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 7 of 10 residents interviewed denied the allegation above and reported that staff treat them with respect, 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. Allegation: Staff are not meeting resident’s laundry needs It is being alleged staff are not meeting R1’s laundry needs. On 06/05/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above and reported that R1’s personal laundry is washed once a week and linen is washed 1 once a week. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and stated that not all residents are provided with laundry services, however, residents who have laundry services included in their admission agreement are provided with laundry services once a week. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 3 of 10 residents interviewed denied the allegation above and reported that staff provide laundry services weekly, 4 of 10 residents interviewed reported ding laundry themselves, 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. On 06/05/24 LPA reviewed R1’s admission agreement that states that R1’s laundry services are waived monthly as part of the assisted living waiver program. On 06/11/24 LPA reviewed laundry schedule for June 2024 that shows R1 will have laundry done on Saturday’s. On 6/11/24 LPA reviewed admission agreement page 3 letter B that states facility will launder towels and linens once a week, if a resident would like towels and linens to be laundered more frequently, facility will do so for an extra charge, as set forth in Appendix A. Allegation: Staff are not ensuring resident's room is cleaned It is being alleged staff are not cleaning R1’s bedroom. On 06/05/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above and reported that R1’s bedroom is cleaned daily and deep cleaned once a week per cleaning schedule. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and stated that resident bedrooms are cleaned every day. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 7 of 10 residents interviewed denied the allegation above and reported that bedrooms are cleaned daily and deep cleaned once a week, 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. On 06/11/24 LPA reviewed admission agreement page 3 letter C which states facility will provide daily, light housekeeping services (bed making, trash removal, and general tidying) and deep clean weekly. If you, fail to do so, you understand that the facility may provide additional housekeeping services to your bedroom, and residents shall agree to pay for such services, as facility deem necessary. Facility will provide additional housekeeping services beyond the standard daily and weekly services for an additional fee, as described Appendix A. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 11-AS-20240529134240

Allegation investigated: Staff did ensure universal precautions were taken.

On 06/13/24 Licensing program analyst (LPA) Villegas conducted a subsequential complaint visit to render findings regarding the allegation(s) above. LPA met with Executive Director Janie Acosta, as the purpose of the visit was explained. The investigation consisted of the following: On 06/05/24 LPA Villegas obtained a copy of the following documents: staff and resident rosters, kitchen menu for April 2024-June 2024, in-services for March 2024, April 2024 and May 2024, and serve safe food handling certifications for all kitchen staff. LPA Villegas conducted a tour of facility kitchen and dining room to observe cleaning procedures. LPA Villegas obtained the following for residents #1-3 (R1-R3); facesheet, physicians report, pre-appraisal, needs and service plan, admission agreement and MAR for the last two months. LPA also conducted interviews between 9:30am- 12:30pm, with ED, and staff # 1-6 (S1-S6), LPA Villegas conducted interviews between 12:30pm-2:30pm with R#2-10 (R2-R10). On 06/13/24 at 10:10 am LPA Villegas interviewed Resident #1 (R1). The investigation revealed the following: Allegation: Staff did ensure universal precautions were taken Unsubstantiated It is being alleged that R1 became ill due to the food served at Vista Del Mar Senior Living. On 06/05/24 LPA Villegas interviewed ED regarding the allegation above, ED denied the allegation above and stated all kitchen staff is trained on and are implementing all universal precautions. ED continued to report that the food service director provides initial training as well as enrolls new staff in reliase training for ServSafe certification. On 06/05/24 LPA Villegas obtained copies and verified that all kitchen staff have active ServSafe and food handler certification. On 06/05/24 between 9:30am- 12:30pm, LPA Villegas interviewed S1-S6 regarding the above allegation, 4 of 6 staff denied the allegation above and reported that all meals are fresh, there are no leftovers, temperatures are conducted daily, and that food quality checks are conducted daily. 2 of 6 staff reported not having any knowledge of the kitchen protocols. On 06/05/24 LPA Villegas toured facility kitchen with S1, LPA observed kitchen staff wash off dishes and utensils prior to placing them into the dish washer that provides sanitation. LPA Villegas observed all food stored in pantry to be dated and observed the refrigerator and freezer to have appropriate temperatures. LPA Villegas toured dinning room following lunch service and observed staff sanitizing all tables and chairs. On 06/05/24 between 12:30pm-2:30pm LPA Villegas interviewed R1-R10 regarding the allegation above, 2 of 10 residents interviewed refused to be interviewed, 7 of 10 residents interviewed denied the allegation above. The 7 of 10 residents interviewed stated they have not been sick due to the food provided at Vista Del Mar Senior Living. On 06/13/24 at 10:10 am LPA Villegas interviewed R1 regrading the allegation above, per R1 R1 went to the E.R. twice in May 2024 and was provided with Anti- Nausea, anti-diarrhea, and cepacol medication, and reports R1 has requested a no Mayonnaise diet moving forward. Based on observation, interviews, and records reviewed there is not enough evidence to support the allegation above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 11-AS-20240530104557

Allegation investigated: Staff did not seek medical attention for resident. Facilty staff failed to meet residents needs.

On 06/13/24 Licensing program analyst (LPA) Villegas conducted a subsequential complaint visit to render findings regarding the allegation(s) above. LPA met with Executive Director Janie Acosta, as the purpose of the visit was explained. The investigation consisted of the following: On 06/05/24 LPA Villegas obtained a copy of the following documents: staff and resident rosters, a list of all residents that require blood pressure checks (date: June 1st, 2024-June 5th, 2024), a list of residents that require blood glucose checks (updated 05/31/24). LPA obtained the following for resident #1 (R1) face-sheet (move in date: 03/14/24), physicians report (signed 03/12/24), pre-appraisal (signed 03/12/24), needs and service plan (signed on 03/20/24), admission agreement (signed 03/14/24), and MAR for months of April 2024-May 2024. LPA Villegas obtained the following resident #2 (R2) face-sheet (move in date: 07/19/22), physicians report (signed 11/16/23), pre-appraisal (signed 07/16/22), needs and service plan (signed on 08/14/23), admission agreement (signed 07/14/22), MAR for month of May 2024, and physician’s orders for May 2024-June 2024. On 06/05/24 LPA Villegas also conducted interviews between 9:30am- 12:30pm, with ED, Unsubstantiated and staff # 1-5 (S1-S5), LPA conducted a medication review for Residents #1-2 (R1-R2), LPA Villegas conducted interviews between 12:30pm-2:30pm with R#1-10 (R1-R10). The investigation revealed the following: Allegation: Staff did not seek medical attention for resident. The details of the complaint allegation alleged that facility staff failed to obtain R1’s medication prescribed by Kaiser psychiatrist. On 06/05/24 LPA Villegas interviewed ED regarding the allegation above, ED denied the allegation above and stated that med room staff were unable to administer R1’s medication as R1 is obtaining medication from Kaiser pharmacy and Kaiser pharmacy had not delivered the medication when requested by R1. On 06/05/24 between 9:30am- 12:30pm, LPA Villegas interviewed S1-S5 regarding the above allegation, 5 of 5 staff denied the allegation above and stated that when an outside pharmacy is used medication refills are ordered 7 days prior to the medication running out. On 06/05/24 between 12:30pm-2:30pm LPA Villegas interviewed R1-R10 regarding the allegation above, 8 of 10 residents denied the allegation above and reported receiving medication daily and have not run out of meds. 2 of 10 residents did not wish to be interviewed. On 06/05/24 LPA Villegas conducted (2) medication reviews and did not observe any discrepancies. Allegation: Facility staff failed to meet resident’s needs. It is being alleged that the facilities med room staff failed to monitor R1’s blood pressure. On 06/05/24 LPA Villegas interviewed ED regarding the allegation above, ED denied the allegation above and stated that R1 does not have a doctor’s order for blood pressure checks. On 06/05/24 between 9:30am- 12:30pm, LPA Villegas interviewed S1-S5 regarding the above allegation, 5 of 5 staff denied the allegation above and stated that R1 does not have an order for blood pressure checks, however med room staff have been conducting blood pressure checks when it is requested by R1. On 06/05/24 between 12:30pm-2:30pm LPA Villegas interviewed R1-R10 regarding the allegation above, 5 of 10 residents interviewed denied the allegation above and reported med room staff conducted blood pressure checks daily, 3 of 10 residents interviewed reported not requiring blood pressure checks, 2 of 10 residents did not wish to be interviewed. On 06/05/24 LPA reviewed R1’s MAR for the months of April 2024 and May 2024 and did not observe a doctor’s orders for blood pressure checks. Based on interviews and records reviewed there is not enough evidence to support the allegation above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 11-AS-20240530110920

Allegation investigated: Staff did not provide resident an admission agreement. Staff did not pick resident up after a medical appointment. Staff prohibit resident form eating in their room.

On 06/13/2024, Licensing Program Analyst (LPA) Antonine Richard conducted an initial 10-day visit regarding the complaint allegations above. LPA met with Resident Care Director Sidonis Cordis in the purpose of today’s visit was explained. later was joined by Executive Director Janie Acosta. The investigation consisted of the following: On 06/13/2024, LPA interviewed the Resident Care Director, staff #1-5 (S1-S5), Resident #1-5 (R1-R5). LPA obtained copies of the following: staff and resident roster, as well as the following documents for R1, R2, R3, R4 and R5, face sheet, admission agreement, pre-placement appraisal, physicians report, needs and service plan. Unsubstantiated Allegation 1- Staff did not provide resident an Admission Agreement. It is being alleged that staff did not provide resident with an admission agreement since R1 moved to the facility on 05/31/24. On 06/13/24 LPA interviewed (ED) regarding the above allegation, ED denied the above allegation stating that the facility provides its clients with a copy of their admission agreement. If the client would like to have a copy of their admission agreement, they would only come to the office, and ask the staff, to make them a copy, from their client file. Sometimes client may ask for other items on their file, as they may need some for banking, social security, and medical. The staff in the office are available to assist the clients with whatever paperwork they need. LPA obtained a copy of the admission agreement for R1 upon reviewing the admission agreement, LPA discovered that the resident R1 signed the admission agreement on 05/31/24. LPA interview 5 residents (R1-R5) 4 out of 5 stated that the facility did let them sign the admission agreement and they told them if they need a copy they could come and get it in the office. LPA interviewed R1, client R1 stated that R1 don’t have any knowledge ever signing the form, but the admission agreement for resident R1 had the resident signature on it. Based on the records review and interviews there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is found to be unsubstantiated. Allegation 2 - Staff did not pick up resident up after a medical appointment. It is being alleged that staff did not pick up resident after a medical appointment. Interviews were conducted with staff 1-2 (S1-S2), and residents 1-5 (R1-R5). LPA asked all residents, “Do you receive help with transportation when you need it?”, 4 out of 5 residents stated, “Yes”, Administrator does assist in transportation needs. LPA noted that Resident Care Director RCD stated that the facility offers to take residents to the appointments if requested and if they have issues with their schedule pick up. LPA interviewed five residents 4 out of 5 residents stated that they must schedule their medical appointment pick-up and drop-off in advance. The RCD noted that the insurance had already set up an arrangement for dialysis patients before they even move in. On 06/13/2024, during the review of the admission agreement in the section on transportation, stated that, “the facility would provide transportation to the nearest appropriate health facilities for medical and dental appointments, local destinations, banking, shopping, religious activities, and social services agencies.” There was no mention of transportation for dialysis patients. On 06/04/2024, ED stated that the facility staff helped some residents get to their medical appointment since their transportation's were running late, understanding that the residents, regular transportation BS and Access would bring them back to the facility if it were after 5:00 PM. Based on records review, interviews there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is found to be unsubstantiated. Allegation 3 - Staff prohibit resident from eating in their room. It is alleged that staff prohibit resident from eating in their room resulting of resident missing several meals. During the interviews with five residents (R1-R5) 5 out of 5 stated that they never had any problem eating inside their room unless the rooms are being repair or the caregiver is mopping the floor. Resident also stated that the facility allows them to come down and get their food and go back to their room and eat it. LPA interviews five staff (S1-S5) 5 out of 5 all stated that some residents want to eat outside or in their room to watch TV, this is their choice they have rights we have to obey them. During the facility tour, LPA observed the residents eating breakfast inside their rooms. LPA asked Executive Director ED about staff prohibit residents from eating breakfast inside their rooms. ED stated that we cannot control what the resident brings inside their room let alone their breakfast, lunch, and dinner. She also stated we encourage the resident to come to the dining room to eat with other residents is to help them interact with one an another. Based on the interviews and observation LPA could not to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is found to be unsubstantiated. No deficiencies cited. exit interview conducted a copy of the report was provide to Executive Director Janie Acostathe state’s words, verbatim · CDSS document, Jun 13, 2024 · control 11-AS-20240606114646

Allegation investigated: Staff did not allow resident to use a doctor of their choice Staff did not provide resident medication as prescribed Staff do not treat resident with dignity or respect Staff do not respond in a timely manner to resident's call for assistance

Licensing Program Analyst (LPA) Sparkle Day conducted an “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1,Administrator and the purpose of the visit was discussed. The investigation consisted of the following: LPA Day obtained copies of the facility's roster for residents and staff. LPA reviewed (R#1) file, including Physicians Report , Admission Agreement , Appraisal/Needs and Service Plan, MARs from March 2024 to May 2024 and Face sheet . LPA interviewed the following: Staff# 1-S6 and Resident #1-6. The investigation revealed the following: Allegation: STAFF DID NOT ALLOW RESIDENT TO USE A DOCTOR OF THEIR CHOICE It is alleged that facility staff did not allow resident to choose her own doctor. Unsubstantiated On 6/5/24 at around 10:00am LPA interviewed S1 - S6 regarding the allegation. 6 out of 6 staff deny the allegations and stated when resident #1 came to the facility an in- house doctor was assigned to the resident, however Resident #1(R1) changed her doctor to a doctor of her choice which is a Kaiser physician On 6/5/24 at around 11:30 am LPA interviewed R1-R6. 5 of 6 residents informed LPA that they can choose the doctor that they like . On 6/5/24 at around 12:40pm . LPA interviewed R#1 who informed LPA that she changed her doctor when first came to Vista Del Mar. She changed from a In House doctor of the facility to a Kaiser physician. R#1 still has that Kaiser physician. LPA observed file, medication and appointments from Kaiser for R#1. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Regarding Allegation - STAFF DID NOT PROVIDE RESIDENT MEDICATION AS PRESCRIBED It is alleged that facility staff do not dispense medications correct dosage as prescribed. On 6/5/24 at around 11:30am LPA interviewed the S1 - S5 regarding the allegation. 5 out of 5 staff deny the allegation Staff state the medication is given as listed on the Mars. LPA interviewed R1 who informed LPA of the following: The medication Clorazepam should be given 2 times a day. The medication Sulfurate should be given 5 times daily and the medication Miralax should be given morning and night. On 6/5/2024 during this visit LPA reviewed the Mars of Resident #1 (R1) from March 2024 , when R#1 was admitted (March 2024) to present June 2024 LPA found that the medication dosage is the same and has not changed since the admission of R#1. LPA interviewed R2-R6 all residents deny the allegation and states that their medication is given to them timely and as prescribed.. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Regarding the Allegation - STAFF DO NOT TREAT RESIDENT WITH DIGNITY OR RESPECT It is alleged that staff do not treat resident with dignity or respect due to the staff do not allow residents to make jokes or use sarcasm . On 6/5/24 at around 1:15 pm LPA interviewed R#1 - R#7 . 6 of 7 residents were consistent in their statements that the facility staff treat them with dignity and respect without question. R#1 informed LPA that due to she said some curse words and staff seemed offended because staff put their hands to their mouth like they had never heard cures words she was not treated with dignity or respect. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Regarding the Allegation: STAFF DO NOT RESPOND IN A TIMELY MANNER TO RESIDENTS CALL FOR ASSISTANCE It is alleged that on 6/3/24 residents push their call button and staff did not come. On 6/5/2024 LPA interviewed Staff #4-5 who were on duty 6/3/24. 2 of 2 staff denied the allegation. LPA reviewed the call list of 6/3/24 and 6/4/24 and observed that All buttons pushed between 6/3/24 and 6/4/2024 were answered timely. LPA observed that the call that took the longest time was 12 mins. A button was pushed at 6:09am and the call is reported as complete at 6:21am, meaning they answered and took care of the problem in that time. On 6/5/2024 LPA interviewed 6 residents. 5 of 6 residents were consistent in their statements that the staff respond timely to their calls. Staff state their goal is 10 mins. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Exit interview conducted . A copy of this report was left with the Administrator Janie Acostathe state’s words, verbatim · CDSS document, Jun 5, 2024 · control 11-AS-20240604111353

Allegation investigated: Questionable death. Resident fell while in care. Resident was left on floor for an extended period of time. Staff did not seek medical attention to resident. Staff mishandled resident's medications. Staff do not answer facility phone.

On 5/24/24, Licensing Program Analyst LPA Alfonso Iniguez conducted a subsequent complaint visit to deliver findings for the complaint assigned to LPA Calderon on 7/29/22. LPA Iniguez met with Janie Acosta/Executive Director and explained the purpose of the visit. During this investigation, LPA Calderon interviewed Resident (R1-R14), Administrator (A1), staff (S1-S5). These interviews were conducted on 05/05/2023 and 07/20/2023. On 07/20/2023 LPA Calderon obtained and reviewed the following: Needs and Service Plan (dated 06/08/2022), Pre-Placement Appraisal (dated 05/15/2022), Physicians Report (dated 03/29/2022), complaint form (dated 07/26/2022), Incident report (dated 07/16/2022 and 07/25/2022), Regal Specialty Pharmacy (dated 05/04/2022), Monterey wellness center (dated 05/11/2022) for R1. On 10/25/2022, Community Care Licensing Investigation Branch (IB) confirmed participation in this investigation and Investigator Ryan Philippe was assigned to this case. Investigator Philippe provided an IB report after concluding IB’s investigation which revealed the following: Evaluation Report continues LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation 1: Questionable death. This complaint alleged that (R1) death was questionable. On 10/25/2022, LPA Calderon reviewed the department's Investigation Branch (IB) Investigator Ryan Philippe's report. The investigator's report stated that interviews were conducted with witnesses and staff members. On 07/26/2022 at approximately 10:00 hours, In-Home support services (IHSS) staff stated that R1 was alive in the morning. That following afternoon, at approximately 12:45 hours, IHSS staff entered (R1)'s room and discovered (R1) sitting on the toilet with their pants down, "sitting sideways," (IHHS) staff managed to get (R1) upright. (IHSS) staff screamed for help, and facility staff responded immediately. Staff members began life preventative measures (CPR) and called 911. When 911 arrived, they took over the life-preventative measures for (R1). In the (R1)’s personal folder were orders of "Do Not Resuscitate" (DNR) dated 03/01/2022 signed by (R1) and R1's conservator as a witness." 911 stopped, and (R1) was pronounced dead at the scene. Long Beach Police Department (PD) DR#: 220036549 Officer J. Clark's #11410 observed R1's body and found no "bruising, injury, or other signs of foul play." (R1) had died of natural causes, according to (R1)'s conservator. Evaluation Report continues LIC 9099-C Allegation 2: Resident fell while in care. The complaint alleged that (R1) fell while in care. On 10/25/2022, LPA Calderon reviewed the department's Investigation Branch (IB) Investigator Ryan Philippe's report. The investigator's report stated that (R1), a resident in the assisted living of Vista Del Mar Senior Living, had an unwitnessed fall in (R1)'s room. Night shift staff asked (R1) how they got on the floor, and (R1) replied: "I fell on my buttock trying to get my dessert on the vanity." Staff assessed (R1) and found no visible signs of injuries. The internal incident report noted, "Please keep monitoring." Since (R1) was a resident in assisted living and did not need assistance with ADLs or mobility. LPA Calderon interview with Administrator: (A1). (A1) stated that residents fall due to age and health and that (R1) has fallen in the past. In addition, (A1) stated that facility staff helped (R1) and provided medical aid when they needed. LPA Calderon interviewed staff (S1-S5), (5) out of (5) stated that (R1) lives in the assisted living section of the facility and does fall due to age and health issues. LPA Calderon interviewed residents (R2-R14), (6) out of (13) stated that they have never fallen. Also, (4) out of (13) stated that they had fallen in the past, and facility staff were always quick to aid. LPA Calderon could not interview (R1), they had passed away. LPA Calderon reviewed the incident report (dated 07/25/2022), which stated that facility staff promptly found (R1) on the floor in their room. (R1), who had lost balance, was not injured, and got off the floor alone. Evaluation Report continues LIC 9099-C Allegation 3: Resident was left on the floor for an extended period. This complaint alleged that staff left (R1) on the floor for an extended period. LPA Calderon interviewed Administrator: (A1). A1 stated that facility staff did not leave any resident on the ground for an extended period unless there was a medical need not to move the resident. Also, (A1) stated that (R1) did fall to the floor in their room and was found by staff within 10 minutes of the fall. In addition, (A1) stated that facility staff checked on all residents per shift, and no resident in care had been left on the floor for an extended period. LPA Calderon interviewed facility staff (S1-S5), (5) out of (5) stated that (R1) was checked regularly and was found on the floor on 7/25/2022. In addition, (5) out of (5) facility staff stated that 5 to 10 minutes went by until a staff found (R1) on the floor. Also, (5) out of (5) facility staff stated that no resident has been left on the floor for more than 5 minutes. LPA Calderon interviewed residents (R2-R6, R10, and R13), (13) out of (14) stated that they had fallen in the past, and on average, it takes 5 to 10 minutes for staff to help unless residents get off the floor on their own. LPA Calderon could not interview (R1), they had passed away. LPA Calderon reviewed the incident report (dated 07/25/2022). The report states that facility staff found (R1) on the floor in their room. (R1) lost balance and was not injured. (R1) got off the floor by themselves. In addition, LPA Calderon reviewed the preplacement appraisal (dated 05/15/2022); (R1) had health issues, was non-ambulatory, and needed assistance getting in and out of bed. Moreover, LPA Calderon reviewed (R1)’s needs and services plan (date 06/08/2022). (R1) had health issues and ambulated with a walker. Evaluation Report continues LIC 9099-C Allegation 4: Staff did not seek medical attention from residents. This complaint alleged that staff did not seek medical attention for (R1). LPA Calderon conducted an interview with Administrator (A1). (A1) stated that all facility staff had the authorization to call 911 if needed. Also, (A1) stated that facility staff are trained to call the RN or LVN for residents' medical needs and, if needed, to call 911. LPA Calderon interviewed facility staff (S1-S5), (5) out of (5) stated that staff had called 911 in the past when a resident was not responding to urgent care provided. Also, (5) out of (5) facility staff stated that the facility offers additional training on calling 911, RN, or LVN. In addition, (5) out of (5) facility staff stated that (R1) was provided with the best care possible. LPA Calderon interviewed residents (R2-R14), and (13) out of (14) stated that the facility staff provides medical care to any resident who needs it. Also, (13) out of (13) residents stated that facility staff has called 911 for residents and facility staff acts quickly on residents' medical needs. LPA Calderon could not interview (R1), they had passed away. Evaluation Report continues LIC 9099-C Allegation 5: Staff mishandled residents’ medications. This complaint alleged that staff mishandled (R1) medications. LPA Calderon interviewed with Administrator (A1). (A1) stated that no medication errors had happened, but if they happen, corrections are addressed with additional staff training if a mistake is made. In addition, (A1) stated that the facility has new electronic Medication Administration Records (MARs). With these latest (MARs), facility staff could avoid making more mistakes on (R1) or other resident's medications. In addition, (A1) stated that all facility staff handling medications are provided with the necessary training. LPA Calderon interviewed facility staff (S1-S5), (5) out of (5) stated that no medication errors were made, and in case they happened, facility staff addressed them and corrected the issue. In addition, (5) out of (5) facility staff stated that if an error is made, the error is reported to the RN or LVN, and the resident’s family is also informed. Also, (5) out of (5) facility staff stated that training is provided to all who handle residents’ medications. Moreover, (5) out of (5) facility staff stated that no errors were found regarding (R1) medications. Furthermore, (5) out of (5) facility staff stated that the new (MARs) are being used, and it is hard for any error to happen. LPA Calderon interviewed residents (R2-R14). (13) out of (14) stated that no medication errors have occurred with their medications. Also, (13) out of (13) residents stated that if a medication error is made, facility staff corrects the error. LPA Calderon could not interview (R1), they had passed away. LPA Calderon reviewed the Monterey Healthcare medication summary report (dated 05/11/2022) and observed (7) medications ordered by phone for (R1). Also, LPA Calderon reviewed the authorization from Regal Specialty Pharmacy (dated 05/04/2022) given to (R1)’s family to order their medications. LPA Calderon did not find discrepancies in (R1)’s medications. Evaluation Report continues LIC 9099-C Allegation 6: Staff do not answer facility phones. This complaint alleged that staff do not answer the facility call button when (R1) pushes the button. LPA Calderon interviewed with Administrator: (A1). (A1) stated that, on average, facility staff answers the call button within 10 to 15 minutes. In addition, (A1) stated that facility staff are trained to answer the call if they are near the resident’s room and push the call button. Also, (A1) stated that if a resident pushes the call button, the closest staff member will answer the call within 10 to 15 minutes. LPA Calderon interviewed facility staff (S1-S5), (5) out of (5) stated that when a resident pushes the call button, it takes, on average, 10 to 15 minutes for them to respond to the call.LPA Calderon interviewed residents (R2-R14), (13) out of (14) stated that when they push the call button, it takes 10 to 15 minutes for facility staff to answer the call. Also, (13) out of (13) residents stated that facility staff promptly answer the call button. In addition, (13) out of (13) residents stated that they have no problems with the services provided by facility staff. LPA Calderon could not interview (R1), they had passed away. During this investigation, LPA did not find sufficient evidence to support the above allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Janie Acosta /Executive Director..the state’s words, verbatim · CDSS document, May 24, 2024 · control 11-AS-20220729081919

Type of visit: Case Management - Other

On 5/ 24/ 2024, Licensing Program Analyst-LPA Alfonso Iniguez conducted a Case Management visit during a subsequent complaint visit. LPA Iniguez meet with Janie Acosta/Executive Director and explained the purpose of the visit. LPA Iniguez cleared Plan of Correction (POC) from complaint 11-AS-20220718085319. Executive Director sent proof of correction to LPA before POC due date. A copy of Letter of Deficiency Citations Cleared was given to Janie Acosta/Executive Director. 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 Janie Acosta/Executive Director.the state’s words, verbatim · CDSS document, May 24, 2024

Allegation investigated: Resident sustained multiple pressure injuries while in care

This is an amendment of the report dated 05/22/2024. On 5/22/24, the Community Care Licensing Department (CCLD) conducted a subsequent unannounced complaint visit to deliver the complaint investigation findings. Upon arrival, CCLD staff was greeted by the administrator Janie Acosta, and the purpose of his visit was explained. CCLD staff and administrator conducted a health and safety check of facility. The investigation consisted of the following. On 07/19/2022 CCLD initiated a complaint investigation and toured the facility including all common areas, kitchen, dining room. Copies of the following records were requested: Staff and Resident Roster, SIR reports for current complaint, physician report, needs and service plan, home health care plan Kindred Paramount Hospital medical records, College Medical Center of Long Beach medical records, doctors’ orders for R1. On 07/21/2022, the Department interviewed staff and residents. On 05/22/2022 the Department conducted a subsequent complaint investigation and delivered the initial complaint investigation findings. On 06/02/2024 the Department conducted a review of the complaint investigation. Unsubstantiated The investigation revealed the following. Regarding the allegation “Resident sustained multiple pressure injuries while in care.” It is being alleged that resident R1 developed stage 3 and/or stage 4 Pressure Injuries while in care. The Department reviewed R1’s records, home health records and hospital records,and records indicate that R1 did not develop a stage 3 or 4 pressure injuries while in care and during R1’s hospitalization on 06/29/2022. Home Health Records indicate that R1 was being provided wound care for an unrelated injury between 04/22/2022 and 06/27/2022. Hospital Medical Records indicates that during R1’s hospitalization on 06/29/2022 the hospital wound care nurse assessed that R1 had a wound indicative of a stage 2 pressure injury, there was no documented evidence that R1 had a stage 3 or 4 pressure injury prior to R1’s admission at College Medical Center. Hospital Medical records also indicates that R1 was discharged from College Medical Center and admitted to Kindred Paramount Hospital on 07/14/2024. On 07/15/2024 Kindred Paramount Hospital staff diagnosed R1 with multiple unstageable injuries on R1’s back. Interviews revealed the following: R1’s unrelated wounds were healed and R1 was cleared by home health before R1 was sent to College Medical Center. 7 out of 7 staff indicate that R1 did not have a pressure injury prior to being admitted to the hospital. Staff denied the allegation and reiterated that they would have seen R1’s lower back area several times per day. Staff indicated that a home health nurse was treating wounds on the front of R1 upper thigh and R1 skin area. S3 performed diaper changes on R1, and this involved repositioning R1, cleaning and drying R1. S3 did not see any skin breakdown for R1. Based on interviews and record reviews, the preponderance of evidence standard has not been met. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation “Resident sustained multiple pressure injuries while in care”, is found to be UNSUBSTANTIATED. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 22, 2024 · control 11-AS-20220718085319

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: May 23, 2024

87615(a)(1)Persons who require health services for or have a health condition including, but not limited to...Stage 3 and 4 pressure injuries.This requirement is not met as evidenced by: Based on records review and interviews conducted the facility retained resident 1 despite being informed by the home health agency that the resident had pressure injury. This poses a health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: Licensee/Administrator will ensure to comply and review Title 22 Regulations, Section 87615 (a)(1) Prohibited Health Condition and create a plan of correction (POC) to ensure to stay in constant communication with medical professionals and if the resident’s medical condition elevates, meaning they require a higher level of care, Licensee/Administrator will ensure the resident is relocated to a skilled- nursing facility(SNF) or hospital and the relocation will take place immediately. Licensee/Administrator agreed to submit a verification of completion to CCLD/ El Segundo ASC office no later than 5/23/24.

Allegation investigated: Staff did not ensure prescribed medical equipment was provided to resident in care.

On 5/15/24 at 1:15 pm, Licensing Program Analyst (LPA) Sparkle Day conducted the initial Complaint visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1,(Resident care Director) who assisted with the visit. Todays investigation consisted of the following: LPA Day obtained copies of the facility's roster for residents and staff. LPA reviewed (R#1)- (R#10) files, including Physicians Report , Admission Agreement , Appraisal/Needs and Service Plan, MARs and Face sheet . LPA interviewed the following: Staff #1-S#4 and witness #1(W-1.). LPA attempted to interview Resident #1 (R1) but R1 refused to be interviewed. The investigation revealed the following: Allegation: STAFF DID NOT ENSURE PRESCRIBED MEDICAL EQUIPMENT WAS PROVIDED TO RESIDENT IN CARE Unsubstantiated It is alleged that facility staff has orders to get resident #1 a medical bed, but has not done so. On 5/15/24 at around 1:45pm LPA interviewed (S1-(S3) regarding the allegation, 3 of 3 staff interviewed denied the allegation and stated resident #1 did not come to the facility with an order for a hospital bed. On 5/15/24 LPA interviewed witness #1 (W1), 1 of 1 witnesses interviewed denied the allegation that there was no hospital bed prescription for a resident #1. On 5/15/24, LPA conducted a file review of Resident #1 filed and did not observed any prescription for a hospital bed dated priori to R1 admission to the facility. On 5/15/24, LPA was unable to interview R1 since R1 refused to be interviewed. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED An exit interview was conducted and a copy of this report was left with the Executive Directorthe state’s words, verbatim · CDSS document, May 15, 2024 · control 11-AS-20240508145728

Allegation investigated: Staff did not assist resident with obtaining prescribed medication Staff did not administer resident's medication as prescribed

On 5/15/24 at 10:24 am, Licensing Program Analyst (LPA) Sparkle Day conducted the initial10 day Complaint visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1,(Resident care Director), S#2(Health Services Director) and S#3(Executive Director) who assisted with the visit. Todays investigation consisted of the following: LPA Day obtained copies of the facility's roster for residents and staff. LPA reviewed (R#1) - (R#10) files, including Physicians Report , Admission Agreement , Appraisal/Needs and Service Plan, MARs and Face sheet . LPA interviewed the following: R1- R8, Staff 1-S7 and witness #1(W-1). The investigation revealed the following: Allegation: STAFF DID NOT ASSIST RESIDENT WITH OBTAINING PRESCRIBED MEDICATION t is alleged that facility staff did not order a medication for resident and facility staff refused to pick up the medication. Unsubstantiated On 5/15/24 at around 10:40am LPA interviewed the Executive Director and Health Services Director regarding the allegation, Executive Director and Health Services Director denied the allegations and stated when resident #1 came to the facility an in- house doctor was assigned to the resident so that so that the previous medication that was being given to resident 1 could continue. Health Services Director explained due to medication being considered a controlled substance it could not follow resident #1 from last placement. The exact date is not known but shortly after Resident #1 switched health care to Kaiser without the knowledge of any of Vista Del Mar staff until they were requesting the medication. Staff were told that resident 1 was not a patient of theirs and would not be refilling the medication. Staff were not able to get medication from their pharmacy. Staff 3 (Health Director ) then called Kaiser for medication and was told, due to medication being a control substance the resident would have to be seen before medication refilled. On 5/15/24 between 11:45am - 1:00pm LPA interviewed 9 of 10 residents who were consistent in their statements that the facility staff has assisted with obtaining their medications regularly without failure. On 5/15/23, LPA interviewed Staff 1-S7 regarding the allegation. 7 of 7 staff interviewed denied the allegation. LPA conducted a file review and information obtained wad consistent with Facility staff interviews. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Regarding Allegation - STAFF DID NOT ADMINISTER RESIDENT'S MEDICATION AS PRESCRIBED It is alleged that facility staff do not dispense medication on a timely basis. This medication is supposed to be dispensed one hour before meals and it’s dispensed during or after meals. On 5/15/24 at around 11:30am LPA interviewed the Med Tech Supervisor(S4) regarding the allegation ,S4 denied the allegation and stated resident 1 has a medication that is to be given an hour before dinner, however although staff is there to give it on time, there are times when the medication is refused by resident 1 and the Mars is the receipt of the days refused. On 5/15/24 around 11:45 am LPA interviewed 6 of 6 staff regarding the allegation. 6 of 6 staff denied the allegation. On 5/15/24 during this visit LPA Day observed The MARs of Resident 1 were resident #1 refused timely medication seven (7) times. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED An exit interview was conducted a copy of this report was left with the Executive Director.the state’s words, verbatim · CDSS document, May 15, 2024 · control 11-AS-20240507095441

Allegation investigated: Facility is in disrepair. Staff did not administer resident's medication as prescribed. Staff do not treat residents with respect. Staff do not assist residents in a timely manner. Staff cannot communicate effectively with residents due to language barrier.

On 04/11/2024 Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to Vista Del Mar Senior Living to deliver the investigation findings for the allegations listed above. LPA Calderon met with Administrator Janie Acosta (A1) and the purpose of the visit was explained. During this investigation, LPA Calderon interviewed Residents (R1-R10), Administrator (A1), staff (S1-S6). These interviews were conducted on 04/10/2024. On 04/10/2024 LPA Calderon obtained copies of the following: Staff training from Regal Specialty Pharmacy (date 01/19/2023), Email from DBA Glass Land (date 03/14/2024) for door replacement, Invoice from DBA Glass Land (date 04/10/2024) for door replacement, Relias training for staff (date 02/25/2023), In-service training (date 03/06/2024 and 03/13/2024) for entering resident rooms and answering call buttons. LPA Calderon toured the facility grounds with A1 and entered rooms 263, 292, 304, 306, 315 and 316. The investigation revealed the following: Unsubstantiated Allegation 1: Facility is in disrepair. This complaint alleged that facility front door is damaged. LPA Calderon conducted an interview with A1. A1 states that a resident struck the front door to the facility with a wheelchair damaging the front door. A1 states that there was no safety issues and staff boarded up the door for safety issues. A1 states that staff and guests to use the front door damaged and A1 ordered a new door and glass. A1 states that the front door was damaged for 3 weeks and repaired on 04/10/2024. LPA Calderon conducted an interview with staff (S1-S6). 6 out of 6 staff state that the front door was damaged by a resident wheelchair and was not a safety issue for residents. 6 out of 6 staff state that the front door was damaged for 3 weeks and repaired on 04/10/2024. LPA Calderon conducted an interview with residents (R1-R10). 9 out of 10 residents state that the front door has been damaged for 3 weeks and was not a safety issue. 9 out of 10 residents state that staff maintain the facility and the facility is not in disrepair. On 04/10/2024 LPA Calderon reviewed email from DBA Glass Land (date 03/14/2024). Emailed noted that staff was given a quote for $10,000 dollars to replace the front door. LPA Calderon reviewed quote from DBA Glass Land (date 04/10/2024) for glass replacement. LPA Calderon and A1 toured the facility. LPA Calderon noted that staff and vendor were working on the facility front door. LPA Calderon toured the facility common area, and the facility was not in disrepair. LPA Calderon inspected room 263, 292, 304,306, 315 and 316 and there were no issues with the residents’ rooms. Allegation 2: Staff did not administer residents’ medication as prescribed. This complaint alleged that staff did not advise resident about medications taken. LPA Calderon conducted an interview with A1. A1 states that staff are trained to advise residents regarding the medications given. A1 states that staff must advise residents regarding medications given. LPA Calderon conducted an interview with staff (S1-S6). S3 and S5 (Med tecks) state that they always advise resident the name of the medications they are giving to the residents. S3 and S5 state that staff are given training on how to give medications to residents in care, LPA Calderon conducted an interview with residents (R1-R10). 9 out of 10 residents state that the Med-tecks always advise them of the medications they are taking. 9 out of 10 residents state that they know the name of the medications they are taking and what the pills look like prior to taking the medications. Reviewed training from Relias Company and Regal specialty pharmacy regarding medication management medication review. Allegation 3: Staff do not treat residents with respect. This complaint alleged that staff do not knock on resident room door prior to entering. LPA Calderon conducted an interview with A1. A1 states that all staff are given training on how to enter a resident’s room. A1 states that staff are trained to knock 4 times and to advise the resident why they are coming inside the room. A1 states that R1 shares the room with another resident and may have been confused as to why the staff entered the room. LPA Calderon conducted an interview with staff (S1-S6). 6 out of 6 staff state that they always knock on resident’s front door prior to entering and 6 out of 6 staff state that staff always advise residents why they are entering the room. LPA Calderon conducted an interview with residents (R1-R10). 9 out of 10 resident states that staff always knock on the front door prior to entering and 9 out of 10 residents state that staff always treat them with respect. LPA Calderon reviewed In-Service training (date 3/6/2024 and 03/13/2024). Training provided to all staff on being respectful and the proper way to enter a resident room. LPA Calderon toured the facility with Administrator and staff. Staff knocked on front doors to 263, 292, 304, 306, 315 and 316. Staff knocked and advised why they were entering the resident room. Allegation 4: Staff do not assist residents in a timely manner. This complaint alleged that staff do not answer call button when pressed by residents. LPA Calderon conducted an interview with A1. A1 states that staff are given training on what to do if a resident pushes the call button for help. A1 states that staff do answer call buttons every day and on average it takes 5 to 10 minutes to answer the call. LPA Calderon conducted an interview with staff (S1-S6). 6 out of 6 staff state that they are given training on what to do if a resident pushes the call button for help. 6 out of 6 staff state that normally it takes staff 5 to 10 minutes to answer a resident call button for help. LPA Calderon conducted an interview with residents (R1-R10). 9 out of 10 resident states that when they push the call button for help it takes staff 5 to 10 minutes to respond to their call for help. LPA Calderon reviewed In-service training (date 03/06/2024 and 03/13/2024) regarding how to respond to a resident call for help. LPA Calderon toured the facility with A1. LPA Calderon entered rooms 263, 292, 304, 306, 315 and 316. LPA Calderon pushed the room call button and average response from staff was 2 to 6 minutes. Allegation 5: Staff cannot communicate effectively with residents due to language barrier. This complaint alleged that staff do not speak to resident in English. LPA Calderon conducted an interview with A1. A1 states that all A1 staff first language is not English. A1 states that all A1 staff can communicate in English and if not can find a staff member that can communicate with the residents. A1 states that if a staff member can not find a way to communicate with residents, they may not have a job. A1 states that it is normal for staff to speak to each other in a language other than English. LPA Calderon conducted an interview with staff (S1-S6). 6 out of 6 staff state they have no issues communicating in English and 6 out of 6 staff state that they have no issues speaking to residents in care. LPA Calderon noted 1 out of 6 staff that LPA Calderon spoke to the staff member in Spanish, but the staff did understand English and spoke some English. LPA Calderon conducted an interview with residents (R1-R10). 8 out of 10 resident state to have no communications issues with staff and can speak to staff in English. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “Facility is in disrepair”. “Staff did not administer resident's medication as prescribed”. “Staff do not treat residents with respect”. “Staff do not assist residents in a timely manner”. “Staff cannot communicate effectively with residents due to language barrier” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Janie Acosta (A1).the state’s words, verbatim · CDSS document, Apr 11, 2024 · control 11-AS-20240404170613

Allegation investigated: Staff neglected resident resulting in dehydration.

On 04/09/24, at 09:30am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Janie Acosta, Executive Director. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegation mentioned above. The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R10). Resident Roster, Staff Roster, ID/Emergency Information, Physicians Report, Unusual Incident Report, & Needs and Service Plan for R1 were obtained from the facility. The investigation revealed the following: Allegation #1- Staff neglected resident resulting in dehydration. Report continued on LIC9099-C Unsubstantiated The details of the complaint alleged that the facility was not monitoring R1’s fluid intake causing R1 to be dehydrated. On 04/09/24, from 10:00am-01:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 was in the hospital, however LPA did interview R1’s family member. 5 of 5 staff denied the allegation that the Staff neglected resident resulting in dehydration. All staff (S1-S5) stated that they did not neglect R1 in any way. They stated that R1 would get fluids with each of R1’s three meals and that R1 had about six cases of water in R1’s room, that was not restricted in any way. S1-S5 stated that R1 was an independent resident and could eat and drink by R1’s self. They further stated that R1 would get monitored throughout the day and that R1 seemed to be doing okay, until one day R1 seemed to have confusion and was lethargic; 911 was called on 03/25/24 and R1 was admitted to the hospital. S3 stated that R1 was very independent and did not want to be bothered but whenever S3 would take R1’s food and drink, R1 would eat and drink and did not seem to have any issues. R1’s family member stated that R1 was dehydrated and was malnourished when R1 entered the hospital and was not sure if staff were monitoring R1’s food and water intake. LPA took a tour of R1’s room and observed that the resident had six cases of water and several bags of empty water bottles in R1’s room. LPA interviewed residents R1-R10 about the allegation that Staff neglected resident resulting in dehydration. 9 of 10 residents that were interviewed denied the allegation and stated that the staff gives them enough food and fluids throughout the day and that they are happy with their care and supervision provided by the staff. Based on interviews, there is insufficient evidence to support the allegation that the Staff neglected resident resulting in dehydration. 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. An exit interview was conducted with Janie Acosta, Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 11-AS-20240403154839

Allegation investigated: Resident sustained multiple injuries while in care. Facility staff are not properly trained Facility vehicle is not in good repair

“This is an amendment of the Investigation Report (LIC9099) dated 04/04/2024, the purpose of this amendment is to provide additional information that this report supersedes the LIC9099 dated 05/03/2024.” On 04/04/2024 Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to Vista Del Mar Senior Living to deliver the investigation findings for the allegations listed above. LPA Calderon met with Administrator Janie Acosta (A1) and the purpose of the visit was explained. During this investigation, LPA Calderon interviewed Residents (R2-R12), Administrator (A1), staff (S1-S5). These interviews were conducted on 12/13/2021 and 03/30/2023. On 12/13/2021 LPA Calderon obtained copies of the following: Needs and Service Plan (dated 09/03/2021), Pre-Placement Appraisal (03/18/2018), Physicians Report (02/02/2018), hospital records (dated 03/22/2021), Incident report (dated 03/21/2021) for R1. LPA obtained vehicle maintenance record (dated 10/14/2021), driver D1 driving records (dated 03/02/2021). Unsubstantiated The investigation revealed the following: Allegation 1: Resident sustained multiple injuries while in care. On 12/7/2023, the allegation “Resident sustained multiple injuries while in care” was assigned to Investigator Peter Zertuche with the Department of Social Services Investigation Branch. Investigator Zertuche provided an investigation report to the El Segundo Regional office on 01/25/2022. Investigator Zertuche’s report conclusion states, on 3/23/2021, R1 fell off R1’s wheelchair while being transported to R1 doctors' appointment. Interviews corroborated that R1 seatbelt was not properly secured during transport, which resulted in a fall when facility driver S5 “slammed” on the brakes at a yellow light. R1 attended the scheduled doctor appointment after the fall and a full examination was conducted. According to medical records, no serious injuries were found. A minor abrasion on the left knee was reported only. A follow-up doctor appointment for x-rays was scheduled for R1 on 3/25/2021, and no injuries were found on any part of R1’s body according to x-ray images reported in R1’s medical records. Investigator Zertuche conducted an interview with R1 who confirmed falling out of R1’s wheelchair during transit on 3/23/2021; however, R1 reported feeling “ok” and did not report that injuries were sustained as a result of the fall. Investigator Zertuche conducted an interview with S5, who confirmed not properly securing R1’s seatbelt and R1 fell out of R1’s wheelchair when S5 had to brake at a light on 3/23/2021. S5 observed R1 for injuries after R1’s fall and found R1 had a knee scrape and no other visible injuries. Based on interviews conducted, observations, and records reviewed, Investigator Zertuche was unable to find sufficient evidence to support “Resident sustained multiple injuries while in care”. Allegation 2: Facility staff are not properly trained This complaint alleged that staff are not trained in how to transport residents in the facility van. LPA Calderon conducted an interview with A1. A1 states that A1 facility drivers have been trained on how to properly transport residents in the facility van. A1 states that S3 is the facilities primary driver and when S3 is out, S5 is a back-up drive. LPA Calderon conducted an interview with S5, who states that S5 was provided training on how to properly transport residents in the facility van by management and the facility primary driver S3. S3 states S3 receives transportation safety training by an outside vendor. S3 then provides training to S5 the back-up driver. On 12/13/2021, LPA Calderon reviewed driving records and confirmed that S5 has a clean driving record and has been with the facility for over 10 years and no personnel issues on record. LPA Calderon conducted an interview with R2 -R13 for complaint. 12 out of 13 residents state that residents have been transported by facility staff in the company van and that all residents were secured with a seatbelt. Based on interviews conducted, observations, and records reviewed, LPA Calderon was unable to find sufficient evidence to support “Facility staff are not properly trained”. Allegation 3: Facility vehicle is not in good repair. This complaint alleged that the facility vehicle is not maintained by mechanic. LPA Calderon conducted an interview with A1 who states that all facilities vehicles are given maintenance by third party vendors and the breaks are checked to make sure they are in good working order and all other vehicle services are done monthly to make sure the facility vehicles are in good working order. LPA Calderon conducted an interview with S3 and S5. S3 and S5 state that the facility van has been serviced and had new brakes and tires prior to the accident. S3 and S5 state that the facility van was in working order and the incident did not happen due to vehicle failure. On 12/13/2021 LPA Calderon reviewed Jiffy Lube (10/14/2021) records for facility van and noted that the facility van has been serviced and was in good repair prior to the incident. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegations: "Resident sustained multiple injuries while in care", "facility staff are not properly trained", and "faculty vehicle is not in good repair'' did or did not occur, are unsubstantiated. An exit interview was conducted with Administrator Janie Acosta (A1), and a hard copy providedthe state’s words, verbatim · CDSS document, Apr 4, 2024 · control 11-AS-20211207093606

Allegation investigated: Resident sustained a pressure injury while in care Staff left resident in soiled diaper for extended period of time Facility has roaches

On 05/04/2023 Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA Calderon met with Administrator Janie Acosta with Vista Del Mar Senior Living and the purpose of the visit was explained. During this investigation, LPA Calderon interviewed Administrator (A1), residents (R1-R20), staff (S1-S7). These interviews were conducted on 01/25/2023. On 08/31/2021 LPA Calderon obtained copies of Staff and Resident rosters, Medication Administration Records (MAR) (08/17/2021), Needs and Service plan (01/20/2021), Physician Report (02/09/2021) for R1 and pest control invoices (June to August 2021) for facility. On 8/31/21, Community Care Licensing Investigation Branch (IB) confirmed participation in this investigation and Investigator Peter Zertuche was assigned to this case. On 10/07/2021 Investigator Zertuche provided an IB report after concluding IB’s investigation. The investigation revealed the following: Substantiated Allegation #1: Resident sustained a pressure injury while in care. This complaint alleges that R1 sustained a pressure injury while in care: the investigation revealed that Resident #1 formed a Stage III pressure injury on its coccyx beginning 08/23/21; and it quickly progressed to Stage IV by 09/02/21. Resident #1 had been receiving hospice care since 03/03/21 for an unrelated issue. Facility staff were instructed to reposition Resident #1 every two (2) hours due to the resident’s status of Bedridden. The wound worsened over the next week – while the resident continued to reside in the facility – with no new hospice care plan or wound training. The facility was directed to reposition Resident #1 every two (2) hours; but according to Witness #1 (Hospice Care Nurse), the reposition chart was not being followed; and, it had missing initials in spaces where the resident was supposed to be turned and its pressure injury was listed as Stage IV by 09/02/21. Resident #1’s health was in decline and the facility continued to retain Resident #1 with a prohibited health condition until its passing on 09/03/21. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained a pressure injury while in care is found to be SUBSTANTIATED. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” Allegation #2: Facility has roaches. This complaint alleges that the facility has roaches. LPA Calderon conducted an interview with A1. A1 expresses that residents have advised that there are roaches in certain rooms. A1 expresses that staff sprays certain rooms, and that pest control is called, and pest control company sprays the building and rooms for roaches and other bugs. LPA Calderon conducted an interview with S2-S7. S5, S6 and S7 have seen roaches in the building but expressed that pest control comes monthly and sprays for roaches. LPA Calderon conducted an interview with R1-R20. R2, R7 and R10 have seen roaches in their room. Residents called staff and pest control came out and sprayed their rooms. R1 and R13 have seen roaches in the dining room while eating food. Pest control came out and when the dining room was closed sprayed the dining room area. R4 states that R4 noted seeing roaches in the patio area. On 01/25/2023 LPA Calderon reviewed pest control paperwork that stated that pest control company sprayed roaches in the facility. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained a pressure injury while in care is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D). Allegation 3: Staff left resident in soiled diaper for extended period. This complaint alleges R1 diaper was not changed timely. LPA Calderon conducted an interview with A1. A1 expressed that R1’s incontinence care occurred 3 times per shift. A1 was unable to provide an incontinence care log to support dates and times incontinent care has been provided to R1. LPA found R1 was diagnosed with a stage 3 pressure ulcer on the coccyx on 8/23/21. R1 was receiving hospice care for the pressure ulcer and pre-existing health condition; however, the facility failed to update the hospice care plan to reflect incontinence needs. LPA Calderon was unable to obtain documented incontinence care instructions and staff training for R1’s incontinence care. Based on interviews conducted and lack of records provided to support R1’s incontinence needs were met according to Hospice orders, LPA Calderon found sufficient evidence to support the above-mentioned allegation and finds this allegation “Substantiated”. Based on interviews, observations and supporting documents facility staff failed to ensure a physicians order/hospice care plan were in place to address R1 pressure injury by an appropriate skilled medical professional The preponderance of evidence standard has been met; therefore, the allegation of “resident sustained a pressure injury while in care” and “facility has roaches”, “Staff left resident in soiled diaper for extended period”, is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8) the following deficiency has been observed and citations issued (ref LIC9099D) A face-to-face meeting was conducted with Administrator Janie Acosta, and a hard copy was provided. Allegation #1: Staff did not administer the correct medication dosage to residents. This complaint alleges the facility failed to increase R1 medication dosage per a physician’s order. LPA Calderon conducted an interview with Janie Acosta (A1). A1 stated R1’s medications were administered per doctors’ orders. LPA Calderon obtained and reviewed R1’s Medication Administration Record (MAR) and found 7 out of 8 medications were not administered on 08/25/21 and 08/26/21. LPA Calderon was unable to find or obtain a record of a doctor’s order indicating a change in any of the medication dosages. LPA obtained and reviewed a PRN Authorization Letter dated 2/9/21 and signed by the Hospice Medical Director. The PRN Authorization Letter states Hydrocodone Bitartrate and Loperamide can be taken added to R1’s PRN’s. These medications were found in the PRN section on R1’s MAR. LPA Calderon conducted an interview with 3 Staff members who handle Resident medications. LPA Calderon conducted interviews with 6 staff members. LPA found 6 out of 6 staff members did not report medication dosage issues. LPA Calderon conducted an interview with 20 Residents. LPA Calderon found 3 out of 20 Residents stated having experienced issues with medication administered; however, corrections were made, and issues resolved by the facility. LPA Calderon found 17 out of 20 Residents have not experienced issues with medication administered. Based on records obtained and interviews conducted, LPA Calderon was unable to find sufficient evidence to support the above-mentioned allegation and finds this allegation “Unsubstantiated”. Allegation #2: Staff leave food in residents’ room for extended period. This complaint alleges that staff leave food trays in R1’s room and this is contributing to a roach problem. LPA Calderon conducted an interview with A1 who expressed that R1 receives tray service for all meals as R1 is bedridden. A1 stated staff will retrieve the food tray 3 times per day from R1’s room. A1 stated that roaches have been present in the facility and pest control is employed for this reason. LPA Calderon conducted an interview with Staff S2-S7 and found 3 out of 6 staff expressed that some residents prefer to eat in their rooms and food trays are retrieved from the Resident rooms timely. S5-S7 expressed that S5-S7 follows up with dining staff to make sure food trays are picked up timely. LPA Calderon conducted interviews with Residents R2-R20 for complaint and found 19 out of 20 residents either received tray service and expressed tray pick-up occurred timely or eat meals in the facility dining room; therefore, they were unable to speak to the timeliness of tray retrieval by staff. , LPA Calderon was unable to find sufficient evidence to support the above-mentioned allegation and finds this allegation “Unsubstantiated”. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations “staff did not administer the correct medication dosage to resident” “staff leave food in residents’ room for extended period” did or did not occur, therefore the allegations is UNSUBSTANTIATED. A face-to-face meeting was conducted with Administrator Janie Acosta A1, and a hard copy was provided.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 11-AS-20210831121113

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Mar 22, 2024

Prohibited Health Conditions (a) Persons who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure sores (dermal ulcers). This requirement is not met as evidenced by: Facility retained Resident #1 with a Stage IV pressure injury on its coccyx (a prohibited health condition) until the resident passed away on 09/03/21. This requirement was not met as evidenced by Based on records reviewed and interviews conducted the licensee failed to care for resident with stage 3 and 4 pressure sores. This poses a Safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Licensee/Administrator agreed to comply and review Title 22 Regulation, Section 87466 ‘Prohibited Health Condition’ and create a plan of correction (POC) to ensure to stay in constant communication with the medical professional; and, if the resident's medical condition elevates - meaning they require a higher level of /21care, Licensee/Administrator will ensure the resident is relocated to a skilled-nursing facility (SNF) or hospital; and, the relocation will take place immeLicensee/Administrator agreed to comply and review Title 22 Regulation, Section 87466 ‘Prohibited Health Condition’ and create a plan of correction (POC) to ensure to stay in constant communication with the medical professional; and, if the resident's medical condition elevates - meaning they require a higher level of /21care, Licensee/Administrator will ensure the resident is relocated to a skilled-nursing facility (SNF) or hospital; and, the relocation will take place immediately. Licensee/Administrator agreed to submit a verification of completion to CCLD/El Segundo ASC Office no later than 03/22/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 29, 2024

87303(a) Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair always… Based on records reviewed and interviews conducted, the licensee failed to control roaches inside the facility for residents in care. This poses a Safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: The administrator will provide pest control reports for a 3-month period and log pest control reports to LPA Calderon by the due date of 03/29/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87612(a)(7) · Plan of correction due date: Mar 29, 2024

87612(a)(7) Restricted Health Conditions (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (7) Incontinence of bowel and/or bladder as specified in Section 87625. This requirement was not met as evidenced by Based on records reviewed and interviews conducted the licensee failed to provide an incontinence care log to support dates and times incontinent care has been provided to R1. LPA found R1 was diagnosed with a stage 3 pressure ulcer on the coccyx on 8/23/21. This poses a Safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: The administrator will provide training to staff on how to document the incontinence log notes for residents in care by the due date of 03/29/2024.

Allegation investigated: Staff did not prevent a resident from assaulting another resident.

On 03/19/24 at 9:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegations above. LPA met with Executive Director (ED) Janie Acosta as the purpose of today’s visit was explained. The investigation consisted of the following: On 03/19/24 LPA interviewed ED, staff #1-5 (S1-S5), Resident #1-10 (R1-R10), and witness 1 (W1). LPA obtained copies of the following; staff and resident roster, as well as the following documents for R1 and R2; facesheet, admission agreement, preplacement appraisal, physicians report, needs and service plan, physicians orders and staff notes. The investigation revealed the following: Allegation- Staff did not prevent resident from physically assaulting another resident in care. It is being alleged that resident was assaulted by roommate while in care. On 03/19/24 LPA interviewed (ED) regarding the above allegation, ED denied the above allegation stating that the facility is assessing Unsubstantiated residents, following up with psychiatrist, conduct room change, and continued monitoring of resident’s behaviors to ensure this type of situation does not occur. ED also reported this was the first incident involving R1 and R2 as there has been no history of aggression for neither resident while in care. On 03/19/24 LPA interviewed R1-R10, 8 of the 10 residents interviewed denied the allegation above and reported feeling safe and believe staff would assist if they were being assaulted. On 03/19/24 LPA interviewed R1 regarding the above allegation, R1 reported being pushed by R2 after a verbal confrontation over a remote control. On 03/19/24 LPA interviewed R2 regrading the above allegation, R2 denied the allegation above and reported R2 did not physically touch R1. R2 continued to report that both R2 and R1 were pulling on a remote control and when R2 let the remote control go R1 lost R1s balance and stumbled but R1 did not fall or obtain injury. On 03/19/24 LPA interviewed S1-S5 regarding the above allegation, 4 of 5 staff interviewed denied the above allegation. 4 of 5 staff reported residents are separated, residents are talked to, and residents are assessed and are offered activities. 1 of 5 staff interviewed reported witnessing the incident and was able to intervene, per staff residents were pulling the remote control back and forth from each other when staff asked R2 to stop, let the remote go, and let staff handle the situation. As R2 let the remote go it is being reported that R1 lost R1s balance and took a step back but did not fall nor obtained injury. On 03/19/24 LPA spoke to W1 regarding the allegation above, per W1 W1 was made aware of the incident and after receiving the information of incident W1 does not have any safety concerns regarding R1. On 03/19/24 LPA conducted a review of R1 and R2s file and did not observe any prior incidents involving R1 and R2. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Executive director (ED) Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 11-AS-20240313095158

Allegation investigated: Staff is not preventing the spread of scabies Staff are not preventing resident from engaging in inappropriate behaviors

On 3/13/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted a subsequent unannounced complaint visit to the address listed above. LPA arrived at and spoke to Executive Director Janie Acosta and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 11/28/22 Pamela Bunker conducted an unnanounced visit and interviewed then Executive Director Reggie Jones. Due to insufficient information available at that time, a needs further investigation was done. On 2/29/24 LPA Felisa Shirley reviewed both Staff and Resident files and toured the facility. LPA requested and received copies of the following: ID and Emergency Information, Preplacement Appraisal Information, Admission Agreement, Appraisal/Needs and Services Plan, Physician’s Report, Incident reports, Assessments, and Response to Public Health notice. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Staff is not preventing the spread of scabies On 3/13/24 LPA Shirley reviewed resident’s files and incident reports. LPA observed 2 incident reports that were sent to CCLD for scabies. The first report indicated there to be one incident that occurred 6/9/22, reported 6/14/22. Assessment of all the residents in Memory care unit proved signs of possible scabies on a few other residents. The Physician was notified, the community was locked down and quarantined. All residents were treated for possible scabies. Family, POA and Public health were all notified. LPA observed the second report that indicated a scabies outbreak in Memory Care unit that occurred 3/28/23. Four residents were diagnosed and treated for scabies. Measures were put into place to help mitigate the spread and keep it contained. Families and public health were notified. LPA reviewed response from public health in which guidance on Outbreak Management was provided along with an attached Scabies Toolkit. On 2/29/24 LPA Shirley interviewed Staff 1 – Staff 10 (S1-S10). LPA asked, did residents in the Memory Care unit have scabies? Of those interviewed, 5 out of 10 answered yes. LPA asked residents, did you know about an outbreak of scabies. Of those interviewed, 10 out of 10 was not aware of an outbreak. Based on information gathered, the department did not find sufficient evidence to support allegation "Staff is not preventing the spread of scabies.” This facility was not negligent, residents were tested and public health was contacted as is protocol. 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: Staff are not preventing residents from engaging in inappropriate behaviors It was reported that a resident from the assisted living side of the facility digs in the trash and the dog disposal and takes things out the trash and touches things within the facility. On 3/13/24 LPA Shirley reviewed resident’s file, which included yearly Appraisal/Needs and services plans and assessments. Upon review of documents, LPA observed that R1 has had this behavior their whole life and that their behavior has been documented on several needs and services plans and also provided what precautions that the staff were taking. Resident was moved from the assisted living side and placed in the Memory Care Unit of this facility. Con'd on 9099-C On 2/29/24 LPA Shirley interviewed Staff 1 – Staff 10 (S1-S10). LPA asked, did a resident from the assisted living side dig in the trash every day which also contained a dog disposal in the trash can? Of those interviewed, 8 out of 10 answered yes. LPA asked residents, have you ever seen a resident that use to dig in the trash everyday? Of those interviewed, only 2 out of 10 remembered the incident and answered yes. Based on information gathered and interviews conducted, the department did not find sufficient evidence to support the allegation, staff are not preventing residents from engaging in inappropriate behaviors. 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. An exit interview was conducted and a copy of the LIC 9099 was provided to Executive Director Janie Acosta.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 11-AS-20221118101001

Allegation investigated: Facility staff are not dispensing medications as prescribed for resident. Facility staff are not providing meals for resident.

On 03/01/24 at 9:00 am, Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegations above. LPA met with Executive Director (ED) Janie Acosta as the purpose of today’s visit was explained. The investigation consisted of the following: On 03/01/24 LPA obtained copies of staff and resident rosters, facility infection control plan, menu dated 10/30-12/03, a copy of assisted living isolation rooms, and the following documents for Resident #1 (R1); identification and emergency info. form, admission agreement, physicians report, needs and service paln, diet clarification request, and after visit summary. On 03/01/24 LPA interviewed Residents #1-09(R1-R09), Executive Director, staff #1- 7(S1-S7), and obtained copies of MAR for R10-R11. The investigation revealed the following: Allegation- Facility staff are not dispensing medications as prescribed for resident. Unsubstantiated It is being alleged that facility staff failed to dispense medication to residents while on quarantine for covid. On 03/01/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above. Per ED, med techs administered medications in the room the residents were quarantined in while wearing full PPE. On 03/01/24 LPA interviewed S1-S7 regarding the allegation above, 7 of 7 staff interviewed denied the allegation above reporting med techs would administer medications in the quarantine room while wearing PPE. S1-S7 reported quarantine residents were checked on every two hours, however, residents were asked to use their call button when they needed any assistance. On 03/01/24 LPA interviewed R1-R9 regarding the allegation above, 8 of the 9 residents interviewed denied the allegation above stating medication was administered daily. 1 of the 9 residents interviewed reported never having covid. On 03/01/24 LPA conducted review of MAR for R10-R11 and did not observe any discrepancies. Allegation: Facility staff are not providing meals for resident. It is being alleged that the facility failed to provide residents with dinner while on quarantine for covid. On 03/01/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above. Per ED, when a resident test positive for covid the resident is placed on the kitchens meal tray lists and kitchen staff will deliver the meal to residents door and caregivers will then provide the meal directly to the residents on quarantine. On 03/01/24 LPA interviewed S1-S7 regarding the allegation above, 7 of 7 staff interviewed denied the allegation above reporting that kitchen staff will bring residents tray to room door and the caregivers in full PPE will provide the tray directly to the residents. If a covid positive resident requires assistance with feeding, caregiver will assist in full PPE and discard PPE once feeding is completed. On 03/01/24 LPA interviewed R1-R9 regarding the allegation above, 8 of the 9 residents interviewed denied the allegation above stating 3 meals a day were provided in their quarentine bedrooms. 1 of the 9 residents interviewed reported never having covid or was placed in quarantine, however reports receiving 3 meals everyday. On 03/01/24 LPA reviewed facility menu and observed a variety of meals listed, LPA also observed lunch pass and observed residents being accommodated with different food options upon request. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Executive Director Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 1, 2024 · control 11-AS-20221123130647

Allegation investigated: Facility staff fails to change resident's diaper. Facility staff fails to re-position bedridden resident. Facility staff fails to provide resident with basic services.

On 02/01/24 at 09:00am, Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Resident care director (CD) Sidona Cordis as the purpose of today’s visit was explained. The investigation consisted of the following: On 02/01/24 LPA interviewed CD, staff #1-9 (S1-S9), residents #1-10 (R1-R10), and obtained the following copies of the staff and resident roster, and a document listing residents that require toileting assistance and residents who are on hospice. LPA obtained the following for R1 and R2; Face sheet, Emergency I.D., admission agreement, physicians report, physicians order, needs and service plan, preplacement appraisal. A copy of R1's repositioning log was provided as well as a copy of the daily room service log. The investigation revealed the following: Allegation: Facility staff fails to change resident's diaper. Unsubstantiated It is being alleged facility staff fails to change resident's diaper. On 02/01/24 LPA interviewed CD regarding the above allegation, CD denied the allegation stating residents are checked on and changed every 2 hours. CD added a change can occur before the 2 hour mark if a resident has an accident. On 02/01/24 LPA interviewed S1-S9 regarding the above allegation, 9 of 9 staff interviewed denied the allegation above reporting that residents are changed every 2 hours or as needed depending on the residents needs. Per 9 of 9 staff there is a changing log for hospice residents. On 02/01/24 LPA interviewed R1-R10 regarding the above allegation, 7 of 10 residents interviewed denied the allegation above, 2 of the 10 residents interviewed reported they do not use diapers, and 1 of 10 residents interviewed did not provide an answer. On 02/01/24 LPA reviewed incontinent/changing log for R1 and did not observe any discrepancies. Allegation- Facility staff fails to re-position bedridden resident. It is being alleged that staff fails to re-position bedridden residents. On 02/01/24 LPA interviewed CD regarding the above allegation, CD denied the allegation stating bedridden residents are checked on and repositioned every 2 hours after they are changed. On 02/01/24 LPA interviewed S1-S9 regarding the above allegation, 9 of 9 staff interviewed denied the allegation above reporting that residents are repositioned every 2 hours and it is documented on a form located in the residents room. 9 of 9 staff continued to report that caregivers reposition residents and can obtain assistance from LVN when needed. On 02/01/24 LPA interviewed R1-R10 regarding the above allegation, 10 of 10 residents interviewed denied the allegation above reporting that staff are checking on resident often and their needs are being met. On 02/01/24 LPA reviewed repositioning log for R1 and did not observe any discrepancies. Allegation: Facility staff fails to provide resident with basic services. It is being alleged facility staff fails to provide resident with basic services when residents are asking for water. On 02/01/24 LPA interviewed CD regarding the above allegation, CD denied the allegation reporting that staff are constantly in residents room making sure residents have what they need. CD continued to report there is a list of bedridden residents which caregivers use to ensure residents have what they need. On 02/01/24 LPA interviewed S1-S9 regarding the above allegation, 9 of 9 staff interviewed denied the allegation above reporting that residents will use their pendants to request food/water and the caregivers will provide the items. On 02/01/24 LPA interviewed R1-R10 regarding the above allegation, 10 of 10 residents interviewed denied the allegation above reporting that staff are providing food/water when needed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted with Executive Director Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 11-AS-20240122170207

Allegation investigated: Staff did not prevent resident from physically assaulting another resident in care.

On 02/01/24 at 9:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Resident care director Sidona Cordis as the purpose of today’s visit was explained. The investigation consisted of the following: On 11/30/23 LPA interviewed Executive Director (ED), staff #1, and interviewed residents # 3-11 (R3-R11). LPA obtained copies of the following for R1 and R2, face sheet, emergency Identification form, service plan, physicians report, physicians orders and preplacement appraisal information. On 12/14/23 LPA interviewed resident #1 (R1), and staff #2-6 (S2-S6). The investigation revealed the following: Allegation- Staff did not prevent resident from physically assaulting another resident in care. Unsubstantiated It is being alleged that staff did not prevent resident from physically assaulting another resident in care. On 11/30/23 LPA interviewed (ED) regarding the above allegation, ED denied the above allegation stating that the facility is assessing residents, following up with psychiatrist and continued monitoring of resident’s behaviors to ensure this type of situation does not occur. ED also reported this was the first incident involving R1 and R2. On 11/30/23 LPA interviewed R3-R11 regarding the above allegation, 8 of 9 residents interviewed denied the above allegation reporting feeling safe at the facility. 1 of 9 residents interviewed reporting having a physical fight with roommate, however reports feeling safe at the facility as resident had a room change. On 12/14/23 LPA interviewed S2-S6 regarding the above allegation, 5 of 5 staff interviewed denied the above allegation. 5 of 5 staff reported residents are separated, residents are talked too, residents are assessed and are offered activities. On 12/14/23 LPA interviewed R1 regarding the above allegation, R1 denied the above allegation stating R1 could not remember the incident in question. LPA was unable to interview R2 as R2 is no longer a resident at this facility and there is no contact info on new location. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Resident care director Sidona Cordis and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 11-AS-20231127174916

Allegation investigated: Staff did not prevent a resident from hitting another resident in care. Staff did not prevent facility from becoming malodorous. Staff did not keep facility free of insects. Staff did not check resident's blood sugar.

On 01/02/24 at 9:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegations above. LPA met with Executive Director (ED) Janie Acosta as the purpose of today’s visit was explained. The investigation consisted of the following: On 01/02/24 LPA interviewed Executive Director (ED),Resident #1-10 (R1-R10), and staff #1-5 (S1-S5). On 01/02/24 LPA obtained copies of the following; Staff and resident rosters, housekeeping and janitotial schedule for December 2023 and January 2024, copy of invoice from Terminix dated 12/04/23, 12/18/23, a copy of terminix's last service visit dated 12/26/23, and a copy of vital signs log. On 01/02/24 LPA obtained copies of the following for R#1; face sheet, emergency I.D. form, physician’s report, medication list, needs and service plan, and admission agreement. The investigation revealed the following: Allegation- Staff did not prevent a resident from hitting another resident in care. Unsubstantiated It is alleged that staff did not prevent a resident from hitting another resident in care. On 01/02/24 LPA Villegas interviewed (ED) regarding the above allegation, ED denied the allegation above reporting that there were no recent reports made of a resident hitting another resident. Per ED, staff will de-escalate by separating residents, talking to residents and investigate what caused the incident. On 01/02/24 LPA Interviewed S1-S5 about the above allegation, 5 of 5 staff interviewed denied the allegation above stating they had no knowledge of a recent resident on resident incident. On 01/02/24 LPA Interviewed R1-R10 about the above allegation, 9 or 10 residents interviewed denied the allegation above and reported feeling safe at the facility. 1 of 10 residents interviewed admitted hitting a peer in the head, resident reported the incident occurred in their shared bedroom while no staff was present. Resident continued to report staff was later made aware of the incident and staff provided a room change, per resident this was the first time this has occurred. Allegation- Staff did not prevent facility from becoming malodorous. It is alleged that staff did not prevent facility from becoming malodorous. On 01/02/24 LPA Villegas interviewed (ED) regarding the above allegation, ED denied the allegation above reporting that common areas are cleaned 3 times a day. On 01/02/24 LPA Interviewed S1-S5 about the above allegation, 2 of 5 staff interviewed denied the allegation above, 3 of 5 staff interviewed stated the facility may become malodorous at times due to residents having accidents in common areas, however housekeeping is really good about cleaning right away. On 01/02/24 LPA Interviewed R1-R10 about the above allegation, 10 of 10 residents interviewed denied the allegation above. Allegation-Staff did not keep facility free of insects. It is alleged that staff did not keep facility free of insects. On 01/02/24 LPA Villegas interviewed (ED) regarding the above allegation, ED denied the allegation above. Per ED the facility has an ongoing pest control as a preventative measure for the facilities size. On 01/02/24 LPA Interviewed S1-S5 about the above allegation, 2 of 5 staff interviewed reported residents have reported insects. Per 2 of 5 staff interviewed, an inspection of the location will be done and it will be treated by terminix right away. 3 of 5 staff interviewed denied the above allegation, reporting no resident has reported any insects. On 01/02/24 LPA Interviewed R1-R10 about the above allegation, 4 of 10 reported seeing insects in the facility and reporting it, 6 of 10 residents interviewed denied the allegation above. On 01/02/24 LPA conducted tour of the facility and did not observe any insects. Allegation: Staff did not check resident's blood sugar. It is alleged that Staff did not check resident's blood sugar. On 01/02/24 LPA Villegas interviewed (ED) regarding the above allegation, ED denied the allegation above. Per ED, blood sugars are checked according to the Doctors orders, and can be checked from 2 times a day to 4 times a day. On 01/02/24 LPA interviewed S1-S5 regarding the above allegation, 2 of 5 staff interviewed do not assist with medication administration, 3 of the 5 staff interviewed denied the above allegation. Per 3 of 5 staff interviewed, blood sugars are checked and documented daily according to Doctors orders. On 01/02/24 LPA interviewed R1-R10 regarding the above allegation, 9 of 10 residents interviewed were unable to provide information in regards to allegation above, 1 of 10 residents interviewed reported conducting own sugar checks as assistance from staff is not needed. On 01/02/24 LPA reviewed resident vital signs log and did not observe any discrepancies or missed blood sugar checks. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted with Executive Director Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 2, 2024 · control 11-AS-20231226133527

Allegation investigated: Resident burned another resident with a cigarette.

On 12/14/23 at 9:00am, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit to render investigation finding. LPA met with Executive director (ED) Janie Acosta and the purpose of today’s visit was explained. The investigation consisted of the following: On 11/30 /23 LPA interviewed Executive Director (ED), staff #1-8 (S1-S8), witness #1 (W1), and interviewed residents # 2-11 (R2-R11). LPA obtained copies of the following for R1 and R3, face sheet, emergency Identification form, service plan, physicians report, physicians orders and preplacement appraisal information. The investigation revealed the following: Allegation- Resident burned another resident with a cigarette. It is alleged Resident #1 had cigarette burns on the skin that were caused by another resident at the facility. On 11/30/23 LPA interviewed ED regarding the above allegation, ED denied the allegation above Unsubstantiated stating that no resident has disclosed being burned with a cigarette. Per ED, smoking is only allowed in the smoking patio which is located at the back of the facility building, ED continued to state that residents wear a pendant in case they need help and that staff conduct rounds to ensure safety. Per ED, staff will intervene, de-escalate, talk to residents involved, report to family, Primary Care Practitioner, and document if any such incident had occurred. 11/30/23, LPA interviewed S1—S8, 8 out of 8 staff interviewed denied the above allegation. 8 of 8 staff interviewed stated they did not have any knowledge of any resident being burned with a cigarette. On 11/30/23 LPA interviewed R2-R11 regarding the above allegations, 9 out of 11 residents interviewed denied the allegation. On 11/30/23 LPA interviewed W1 about the allegation above, W1 reported there were no burn marks observed during the body check conducted upon resident #1 admission to the new facility R1 is currently residing. On 11/30/23, LPA made an attempt to interview R1 via telephone due to R1 not currently residing at the facility. During the interview R1 was unable to answer LPA Villegas question due to communication barriers. As a part of the investigation LPA received photos of R1 with what appears to possibly be a burn mark. LPA was not able to verify when and where R1 sustained the burn marks as R1 is currently in a Skilled Nursing Facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Executive director (ED) Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 14, 2023 · control 11-AS-20231120195648

Allegation investigated: Staff are not properly addressing scabies at facility.

On 11/17/23 at 9 am Licensing program analyst (LPA) Lizeth Villegas conducted an initial vist rageding the allegation above. LPA met with Resident Care Director Sidonia Cordis (D1) as the purpose of today’s visit was explained. During today's visit LPA obtained copies of the following: Staff and client rosters, and the facilities Prevention and contol of scabies in California healthcare settings. On 11/17/23 LPA interviewed Resident Care Director(D1), Staff # 1- 11(S1-S11), residents # 1- 10(R1-R10), and conducted a records review of to confirm facility has a scabies prevention and control plan. The investigation revealed the following: Allegation: Staff are not properly addressing scabies at facility. Unsubstantiated It is being alleged that staff are not properly addressing scabies at facility. On 11/17/23 LPA Villegas interviewed D1, who denied the allegation above. Per D1, there were 2 residents a few weeks ago but treatment has been completed and the public health department was notified. On 11/17/23 LPA Villegas interviewed R1-R10 regarding the allegation above, 10 of 10 residents interviewed denied the allegation above. On 11/17/23 LPA Villegas interviewed S1-S11 regarding the allegation above, 10 of the 11 staff interviewed denied the allegation above, 1 of the 11 staff interviewed corroborated the allegation and indicated that the facility failed to properly address scabies case. On 11/14/23 LPA reached out to Long Beach Department of Public Health and confirmed facility reported scabies and followed the recommended treatment plan. Although the allegation may have happened or is valid there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. Exit interview conducted with Resident Care Director Sidonia Cordis, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 17, 2023 · control 11-AS-20231114134358

Type of visit: Case Management - Deficiencies

On 11/17/23 LPA conducted a case management visit to issue citation observed during complaint investigation (Complaint control # 11-AS-20231114134358) as facility failed to report scabies case to community care licensing. Exit interview conducted with Resident Care Director Sidonia Cordis, appeals rights explained and a copy of this report was provided. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 809D.the state’s words, verbatim · CDSS document, Nov 17, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 24, 2023

87211 Reporting requirement Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any, and....the state’s words, verbatim · CDSS document, Nov 17, 2023

Plan of correction: Director to submit a plan to ensure Vista Del Mar Senior Living is in compliance with 87211 (a)(1) and submit plan outlining the steps that will be taken to ensure compliance of section cited. Director will also submit incident report for scabies cases by POC due date.

Type of visit: Required - 1 Year

On 10/13/23, Licensing Program Analyst's (LPA's) Villegas and Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA's met with Executive Director Janie Acosta as the purpose of today’s visit was explained. The facility is licensed to serve The facility is licensed to serve 300 elderly adults 60 and over non-ambulatory of which 10 may be bedridden, may retain 30 hospice residents and has a dementia Wing w/ delayed egress. Current census is 241. The facility is a 3-story structure located in a residential neighborhood and consists of the following: 278 bedrooms and 4 common bathrooms, multimedia rooms, commercial kitchen, large dining room, media room and a large common patio. LPA’s conducted a records review of 10 staff records, 10 resident records, and 10 medication Administration Records. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire and disaster drill was conducted on 09/08/23, fire extinguishers fully charged and observed throughout the facility, carbon monoxide detectors, smoke detectors and auditory signals are operational. Landline and internet service was observed. Liability insurance is current and active. Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards. During today’s visit the following discrepancy was cited on 809 D page. Exit interview conducted with Executive Director Janie Acosta, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 13, 2023

Allegation investigated: Facility staff failed to properly address pests control problem. Staff serve food of poor quality. Facility staff did not ensure eating utensils and dishes are sanitary and in good repair.

On 10/11/23 at 9 am Licensing program analyst (LPA) Lizeth Villegas conducted an initial complaint investigation visit regarding the above allegation(s). LPA met with Resident Care Director Sidonia Cordis (D1) as the purpose of today’s visit was explained. During today's visit LPA obtained copies of staff and resident rosters, Pest control invoices, menus for September and October, Dietician records, Food handlers’ certificates, In service for food handling, in services for sanitation and housekeeping schedule. LPA toured the kitchen, dining room area, and 5 resident bedrooms. On 10/11/23 LPA interviewed Resident Care Director(D1), Staff # 1-9 (S1-S9), residents # 1-1 (R1-R10) and witness #1 (w1) via phone interview. LPA was later joined by Director Janie Acosta. The investigation revealed the following: Allegation: Facility staff failed to properly address pests control problem. On 10/11/23 LPA interviewed S6 regarding the above allegation, per S6 facility has a contract with Terminix commercial who comes out 2 times a month to spray dining room, kitchen area, memory care Unsubstantiated kitchen, common areas, all offices, 10 bedrooms per visit and a flush is done quarterly in areas where food is prepped. LPA interviewed R1-R10, 5 out of 10 residents interviewed denied the allegation above, 5 out of 10 residents interviewed reported seeing roaches in their restroom. LPA interviewed S1-S10 who denied the allegation above. 10 out of 10 staff reported the facility and bedrooms are cleaned daily and bedrooms are deep cleaned once a week. On 10/11/23 LPA interviewed W1 via phone who confirmed facility is on the recommended treatment plan from Terminix pest control. LPA reviewed Terminix invoices and confirmed Terminix visits the facility 2 times a month. Allegation: Staff serve food of poor quality. On 10/11/23 LPA interviewed S2 regarding the above allegation, S2 reports that the facility has many vendors who are known for top quality food and the facility provides alternative meal options and accommodates special diets. S2 stated food supplies are checked for expiration dates and freshness upon delivery. S2 reported that food menu is reviewed by dietician once a month, kitchen is aware of modified diets, meetings are conducted sometimes once a month with residents and that there is a food board in the kitchen that helps kitchen staff identify what meal is for each resident. LPA interviewed R1-R10, 10 out of 10 residents interviewed denied the allegation above. LPA interviewed S1-S10 who denied the allegation above. LPA reviewed the facility menu and confirmed menu is checked monthly by dietician. While at the facility LPA observed food being served and did not observe any immediate concerns. LPA reviewed food handler certificates, menus and dietician records and did not observe any immediate concerns. Allegation: Facility is utilizing dishes that are hazardous to residents. On 10/11/23 LPA interviewed S2 regarding the above allegation, S2 reports that if any plate or utensils become broken, they are thrown out right away to ensure safety. Per S2 no resident has sustained injury due to plates or utensils. LPA interviewed S1 and S3-10 who denied the allegation above. LPA interviewed R1-R10, 9 out of 10 residents interviewed denied the allegation above, 1 out 10 residents reported that the serving plates are dirty. LPA toured the kitchen and dining room and did not observe any hazards utensils or immediate concerns. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Janie Acosta and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 11-AS-20231002152933