Westmont of Culver City

Type of visit: Required - 1 Year

On 08/06/26, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annually required inspection visit to Westmont of Culver City. LPA was met by Dawn Smith, Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve 160 ambulatory residents aged 60 and over of which 160 may be non-ambulatory. The facility has an approved hospice waiver for 20 residents and approved for delayed egress. Currently the facility has (152) residents. The facility’s annual fees are current. The facility is a five-story structure located in a commercial neighborhood. The facility consists of (137) resident bedrooms. The 2nd through the 5th floor are assisted living units and independent living units consisting of studio, 1 bedroom and 2 bedroom units. All units have a refrigerator, stove, microwave, and personal washer and dryers located in the bathrooms. The 1st floor is comprised of Compass Rose Memory Care units. At 10:30am, LPA and staff toured the facility. There are no bodies of water or firearm/ammunition on the premises. LPA toured the following rooms: 154, 157, 164, 202, 221, 304, 314, 323, 402, 407, 430, 506, 508, 509, and 513. Beds and bedding were in good condition, adequate lighting provided, and adequate storage for resident personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. The shower was free of mold/mildew, there was adequate lighting, and sufficient toiletries were accessible to residents. The water temperature was within title 22 regulations in all bathrooms (range between 105-120f degrees). A comfortable temperature is maintained in the facility. Report Continued On LIC809-C LPA observed the facility to be clean, sanitary, and appropriately furnished at the time of visit. Storage areas for cleaning agents, toxins, and sharps were inaccessible to residents in the Compass Rose Memory Care units. The kitchens were inspected and there is enough perishable and non-perishable food available for the residents. All food items were stored properly. The water temperature measured 118.9F degrees in the kitchen. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked with manuals in both medication rooms. The fire extinguishers were charged and last inspected on 06/09/2026. The smoke and carbon monoxide detectors were operable. The last fire/emergency drill was conducted on 07/01/2026. The last evacuation drill was conducted on 04/07/2026. The facility’s administrator’s certificate (7005885740) is pending renewal, application was received on 07/10/2026. The facility’s liability insurance was valid from 09/15/2025 through 09/15/2026. LPA conducted a review of (10) resident records, (10) staff records, and reviewed the facility disaster plan. LPA observed that residents had the required medical documents and other pertinent documents in their resident folders. Staff records were complete with required documents and training. The facility disaster plan was last updated on 07/24/2026 and in compliance with Title 22 regulations at the time of visit. LPA reviewed (4) resident medication administration records, and medication, and did not observe any discrepancies at the time of visit. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA advised the facility to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues. No deficiencies were cited during this inspection visit. An exit interview was held, and a copy of this Facility Evaluation Report was provided to Dawn Smith, Administrator.the state’s words, verbatim · CDSS document, Aug 6, 2026

Allegation investigated: Facility gave stranger access to resident mailboxes.

On 07/28/2026 at 10:15am, the department conducted an initial complaint visit to the facility and was greeted by Dawn Smith, Executive Director. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegation mentioned above. The investigation consisted of the following: The department investigated the allegation mentioned in this complaint and conducted interviews with staff (S1-S4) and residents (R1-R10). The department received the following documents: Personnel Report (Dated: 07/24/2026), Resident Roster, Resident Council Policy (Revision Date: 03/31/2012), Westmont Resident Council Meeting Minutes (Dated: 06/09/2026), Town Hall Minutes (Dated: 06/16/2026), and a Letter from Concerned Residents were received from the facility. The investigation revealed the following: Allegation- Facility gave stranger access to resident mailboxes. Report Continued On LIC9099-C Unsubstantiated The details of the complaint allege that the facility allowed a stranger to access to residents’ mailboxes. It was reported that an anonymous letter was placed in the residents’ mailbox outlining how some of the residents are being unjustly rude to staff. The letter goes on to suggest that if there are any concerns, residents should not shout or be rude to staff but write down their concerns and place them in the suggestion box and from there their concerns will be addressed. On 7/28/2026, from 10:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) about the allegation. 4 of 4 staff denied the allegation that the Facility gave stranger access to resident mailboxes. All staff (S1-S4) stated that they did not give a stranger access to the residents’ mailboxes. Staff stated that the only people that have access and authority to open the mailboxes are the residents who have a key that will only open their mailbox. The concierge staff has the authority to open the mailboxes because they are the ones who receive the incoming mail from the postal mail carriers as well as giving them the outgoing mail. From there according to executive director (S1), who also has authority to open the mailboxes, the concierge staff then sorts and processes the mail and distributes it to the residents’ mailboxes. S1 stated that they gave the authority to the concierge staff to distribute the letter and place it in all the residents’ mailboxes because it concerned the facility and the residents living in the facility. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that they had no objection to receiving the letter and that they have not had any issues with anyone accessing their mailbox without their permission. While R1 stated that they wanted clarification that it was not against the law to get such an anonymous letter in their mailbox. The department reviewed the letter from Concerned Residents and observed that the letter stated that there was an increase in incidents, especially in the dining room, where residents shout at or even threaten staff members about issues with the food. The letter goes on to say that the issues the residents are upset about do not originate with the servers, therefore there is no need to be rude or offensive to someone who is doing their job to the best of their ability. Lastly, the letter asks that if the residents have an issue, they should put their concerns in a comment card and have their issues addressed by management. The department did not observe any personal rights violation by the facility by placing a letter from other residents, who wanted to remain anonymous, in the residents’ mailboxes because the letter addressed issues that concerned the residents as well as the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Facility gave stranger access to resident mailboxes. 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 investigation. An exit interview was conducted with Dawn Smith, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 11-AS-20260720083442

Allegation investigated: Facility is not conducting fire drills. Staff are neglecting residents in care.

On 07/24/26 at 9:20 am Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director Dawn Smith as the purpose of today’s visit was explained. The investigation consisted of the following: On 06/25/26 LPA Villegas obtained copies of the staff and resident rosters, fire drill logs for May 2026-June 2026, device activity report for 06/10/26-06/23/26, Inspection and testing certification certificate dated: 02/04/26, and Inspection and testing certification certificate dated: 05/16/25. On 06/24/26 LPA also obtained copies of the following documents for Residents #1-2 (R1-R2) Emergency ID form, Pre-appraisal, Admission agreements, Physicians reports, Needs and service plans, and August health notes for the month of June 2026. On 06/25/26 from Unsubstantiated 10am-12 pm LPA conducted interviews with Staff #1- 9 (S1-S9), and on 06/26/26 and 07/24/26 LPA conducted interviews with R1-R10. On 07/24/26 LPA conducted a tour of (5) resident bedrooms and conducted a review of the facilities fire drill logs for May 2026-June 2026. The investigation revealed the following: Allegation: Facility is not conducting fire drills. It is alleged that the facility is only testing the fire alarms and give no direction to residents on what to do in the case of fire. On 06/25/26 from 10am -12 pm LPA conducted interviews with S1-S9 regarding the allegation above. 8 of the 9 staff interviewed denied the allegation above and reported that drills are conducted regularly. Per 7 of the 8 staff interviewed, residents have participated in the drills although residents do have the right to refuse participation. Additionally, 8 of the 9 staff interviewed reported that residents are aware of the evacuation procedures. On 06/25/26 and 07/24/26 LPA conducted interviews with R1-R10 regarding the allegation above, 10 of 10 residents interviewed denied the allegation above and reported that drills are conducted often. 9 of the 10 residents interviewed reported they are aware of the of emergency evacuation procedures. 1 of the 10 residents interviewed reported that they have been told their family member to stay in their bedroom and a facility staff will assist in an emergency. On 07/24/26 LPA conducted a review of the facilities fire drill logs for May 2026 - June 2026. Fire drills conducted on 05/31/26 and 06/08/26 were performed with staff only, both drills lasted 20 minutes each, and staff were also trained on how to reset fire alarm panel. Allegation: Staff are neglecting residents in care. It is alleged that facility staff are not checking in on residents and instead residents are required to use pull cord, so staff know they are okay. On 06/25/26 from 10am - 12 pm LPA conducted interviews with S1-S9 regarding the allegation above. 8 of the 9 staff interviewed denied the allegation above and the facility does have a check in procedure that residents follow every morning. Procedure, If a resident does not use the check in procedure and they are not observed in the dining room the concierge will call the resident, if the resident does not answer then a caregiver will go to the residents bedroom to check in there is okay. 1 of the 9 staff reported having no knowledge of the allegation above. 10 of 10 staff interviewed reported rounds are being conducted according the the residents care needs. On 06/25/26 and 07/24/26 LPA conducted interviews with R1-R10 regarding the allegation above. 10 of 10 residents denied the allegation above and reported that they do not feel neglected by staff. 7 of 10 residents reported that staff are conducting rounds throughout the day, 2 of 10 residents reported they are unaware if staff are conducting rounds throughout the day, 1 of 10 residents reported that staff do not conducted rounds at all. Additionally, 4 of 10 residents interviewed confirmed that residents are required to use pull cord located in their bathrooms by 9 am in order for staff to know they are awake and are okay. On 07/24/26 LPA obtained a copy of the acknowledgement/ check in procedure that was distributed to resident 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, Jul 24, 2026 · control 11-AS-20260624102759

Allegation investigated: Facility fire alarm system is in disrepair. Staff leave residents unsupervised during emergency evacuations.

On 07/24/2026 at 8:30am, the Department conducted an subsequent complaint visit at the facility listed above to deliver the investigation findings. Licensing Program Analyst (LPA) Zina Brown met with Dawn Smith (Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 06/17/2026, the Department conducted interviews with A1, Staff (S1 - S8) and Residents (R1 - R9) between the hours of 9:15am - 2:35pm . The Department requested and obtained the following documentation such as staff roster (dated 06/17/2026), resident roster (received 06/17/2026) , Event History (June 2025 - June 2026), Annual Fire Alarm Inspection Confirmation Email (dated 04/23/2026), Inspection and Testing Certificate (dated 05/16/2025 & 02/04/2026), Inspection Summary (dated 05/15/2026), Fire Emergency Procedures, Pyrocomm Systems Inc Monitoring Account Contact Information (Dated 08/07/2024), Direct Supply Tels Logbook Documentation (Dated 03/29/2026, 05/31/2026), On Site In Service Sign In Sheet (dated 06/08/2026 - Fire Alarm Protocol, dated 04/07/2026 Evacuation Drill, 06/15/2026 Emergency Preparedness). Unsubstantiated The investigation revealed the following Allegation: Facility fire alarm system is in disrepair It was alleged that repeated false alarm activations occurred throughout the facility directing residents to exit the building by using stairwells including up to five (5) flights despite the reporting party stating this was not the correct emergency procedure and placed residents at risk. On 06/09/2026, between the hours of 11:50am -12:00pm, the Department interviewed A1 in regards to the allegation. A1 denied the allegation and stated the last documented fire alarm testing occurred on September 9, 2025. A1 explained the system entered a scheduled test beginning at 10:20am, the fire panel was placed “On Test” at 11:01am - 7:00pm, and maintenance checked smoke detectors and electrical loops during that time. A1 stated the alarms recorded that day were part of scheduled testing, not emergencies, and the facility’s automated system announces alarm events over the intercom with lights and sound. On 06/09/2026, between the hours of 9:15am - 9:22am, the Department interviewed 8 staff in regards to the allegation. 4 out of 8 staff confirmed the allegation and stated they were aware of false alarms occurring at the facility or had personally responded to false alarm activations. 2 out of 8 staff denied the allegation stated they had not experienced repeated false alarms or had not personally responded to an alarm activation. 2 out of 8 staff did not confirm nor deny the allegation and stated they had heard residents mention false alarms but had not personally responded to an alarm activation. On 06/09/2026, between the hours of 10:15am - 11:18am, the Department interviewed 9 residents in regards to the allegation. 8 out of 9 residents confirmed the allegation and stated the alarm activates frequently, is loud, occurs during both day and night, and staff do not consistently notify residents when the alarm event has ended. 1 out of 9 residents was aware of the allegation and stated knowing of the alarm activations but did not provide details regarding frequency or staff response. On 07/16/2026, between the hours of 2:00pm - 3:00pm the Department conducted a records review and observed the following: the facility’s fire alarm system logs dated September 9, 2025. At 10:20:53 AM, the fire alarm panel recorded a system trouble diagnostic during a scheduled testing window. Automated notifications were generated to facility contacts between 10:21am - 10:50am, including several live confirmations. At 11:01:47 AM, the fire panel was placed “On Test” through 7:00 PM, and additional diagnostic activity occurred between 11:36am - 11:41am, followed by device loop verification between 3:56pm - 3:58pm. The records reviewed showed the trouble signals documented on September 9, 2025 were generated during scheduled diagnostic testing performed by maintenance personnel. The Department did not observe documentation indicating that the fire alarm system was in disrepair. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough 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 UNSUBSTANTIATED Allegation: Staff leave residents unsupervised during emergency evacuations. It was alleged that residents were not informed when alarm events ended, and that at least three alarm activations occurred at night when no staff were present at the front desk. It was further alleged that alarms sounded simultaneously in resident rooms, hallways, and the Memory Care unit. On 06/09/2026, between the hours of 11:50am -12:00pm, the Department interviewed A1 in regards to the allegation. A1 denied the allegation and stated the facility uses a shelter-in-place protocol, evacuation only occurs for a confirmed fire, and staff supervise residents including overnight med-techs and caregivers. The administrator stated she was not aware of any alarm activation where residents were left unsupervised and stated the fire department leads evacuation during a true fire. On 06/09/2026, between the hours of 9:15am - 9:22am, the Department interviewed 8 staff in regards to the allegation. 7 out of 8 staff denied the allegation and stated residents are only instructed to use stairwells when evacuation is ordered and that staff remain available during alarm events. 1 out of 8 staff did not confirm nor deny the allegation and stated they had not worked night shifts during an alarm activation. On 06/09/2026, between the hours of 10:15am - 11:18am, the Department interviewed 9 residents in regards to the allegation. 7 out of 9 residents confirmed the allegation and stated staff provided inconsistent instructions, some residents received no direction, and during nighttime alarms no staff were visible in hallways or at the front desk. 2 out of 9 residents did not confirm nor deny the allegation and stated they were aware of alarm activations but did not provide details regarding staff supervision. On 07/16/2026, between the hours of 2:00pm - 3:00pm the Department conducted a records review and observed the following: reviewed available incident reports, staff logs, and facility documentation and did not observe any entries indicating that residents were left unsupervised during emergency evacuations or fire alarm events. No records were found documenting resident evacuation, lack of staff presence, or staff failing to supervise residents during an alarm. Based on information gathered through interviews and record reviews, there is not enough 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 UNSUBSTANTIATED Exit interview conducted with Dawn Smith (Executive Director) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 11-AS-20260609153600

Allegation investigated: Staff do not ensure the facility is free of bed bugs Resident sustained bug bites due to staff neglect

On 07/24/2026, at 8:30am, Licensing Program Analyst (LPA) Zina Brown arrived at the facility to conduct a subsequent visit to deliver the complaint investigation findings. At 8:45 AM, LPA met with Dawn Smith (Executive Director) and explained the purpose of the visit. The investigation consisted of the following: On 07/20/2026, the Department conducted interviews with Administrator (A1), Staff (S1–S9), and Residents (R1–R10) between the hours of 9:00am – 3:34pm, and on 07/24/2026 between the hours of 9:20am – 9:59 am, interviews were conducted with (S10) and (R11). The Department requested and obtained the following documents: Staff Roster (dated 07/10/2026), Resident Roster (received 07/20/2026), Housekeeping Schedule (received 07/20/2026), 17 Orkin Service Reports (from August 2025 and February 2026 – July 2026), Floor Plan, and resident records for three residents (R1, R2, R3), including LIC 601 Identification & Emergency Information, LIC 602 Physician’s Report, LIC 603 Pre-Appraisal, LIC 604 Admission Agreement, and LIC 625 Appraisal/Needs and Services Plan. Unsubstantiated The investigation revealed the following: Allegation: Staff do not ensure the facility is free of bed bugs It was alleged that a resident reported ongoing bites, a worker reportedly located a bed bug in a resident’s bed, the room was sprayed, and the resident is concerned about whether the facility is maintaining a bed bug free environment. On 07/20/2026, between the hours of 1:22pm – 1:33pm, the Department interviewed the Administrator (A1) regarding the allegation. A1 confirmed the allegation and stated bed bugs were reported in R1's, R3's, and R2's room. A1 stated that Orkin found one live bed bug and one dead bed bug in R2's room. On 07/20/2026 & 07/24/2026, between the hours of 9:00am – 3:32pm, the Department interviewed 11 staff regarding the allegation. 1 out of 11 staff confirmed the allegation and stated Orkin found a bed bug in R2's room. 10 out of 11 staff denied the allegation and stated they had never witnessed any bed bugs in any resident room and only heard about bed bug concerns through general facility communication. On 07/20/2026, between the hours of 12:31pm – 3:34pm, and on 07/24/2026, between the hours of 9:20am – 9:32am, the Department interviewed 11 residents regarding the allegation. 1 out of 11 residents confirmed the allegation, with R1 stating the first sign of bed bugs in their room occurred in June 2026. 9 out of 11 residents denied the allegation and stated they had never seen bed bugs in their rooms nor anywhere else in the facility. 1 out of 11 residents did not confirm nor deny the allegation and stated seeing bed bugs in their room back in August 2025. On 07/24/2026, between the hours of 9:15am – 10:07am, the Department conducted a tour of five resident rooms and observed the following: A1 conducted a bed inspection by removing all bed linens from the rooms of R1, R2, R3, R11, and R12 . No live or dead bed bugs were observed. On 07/24/2026, between the hours of 1:30pm – 2:30pm, the Department conducted a records review and observed the following: An Orkin inspection (dated 06/01/2026) (PC Standard – Every Two Weeks documented inspection of the interior and exterior building, kitchen area, front patio, dumpster room, break room, restrooms, garage/exterior rodent bait stations, and one resident unit for bed bug follow up. Live activity was found, with ten bed bugs located throughout the sheets of the primary bedroom. An Orkin Service Report (dated 06/19/2026) documented a canine inspection of three units and the third floor hallway, with no bed bug activity found. An LIC 624 Unusual Incident/Injury Report (dated 07/14/2026) documented that pest control inspected a resident’s apartment and noted one bed bug in the frame of the bed. A protectant cover was to be placed on the box spring, and Orkin was scheduled to perform treatment on 07/14/2026. An Orkin Service Report (dated 07/14/2026) documented a thorough inspection of the interior of R2’s and R12’s rooms, with live activity found; one adult bed bug was located underneath the mechanical bedframe (top left corner). A residual spray was applied to all walls of both rooms, and in R2’s room the mechanical bedframe, cover sheets, and bedframe were also treated. On 07/22/2026, Orkin also conducted a canine inspection between the hours of 5:00am– 5:30am in all common areas, including each floor sitting room, staff break room, library, living room, dining room, bistro, laundry room, housekeeping cart, activity room, fitness room, theater room, card room, and billiards room and no live or dead activity was discovered. Overall, records show that Orkin conducted ongoing pest control services, including PC Standard Every Two Weeks on 02/10/2026, 02/21/2026, 03/10/2026, 03/24/2026, 04/07/2026, 04/21/2026, 05/05/2026, 06/01/2026, and 06/30/2026, and Bed Bug Odd Job treatments on 05/22/2026, 05/29/2026, 06/16/2026, 06/19/2026, and 07/14/2026. These records demonstrate consistent pest control activity throughout the facility. Based on information gathered through interviews and record reviews, there is not enough 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 UNSUBSTANTIATED. Based on information gathered through interviews and record reviews, there is not enough 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 UNSUBSTANTIATED. Exit interview conducted with Dawn Smith (Executive Director) and a copy of this report was provided. Allegation: Resident sustained bug bites due to staff neglect It was alleged that a resident reported experiencing bites over a period of time and believes the bites occurred because staff did not adequately address the bed bug issue. On 07/20/2026, between the hours of 1:22pm – 1:33pm, the Department interviewed the Administrator (A1) regarding the allegation. A1 confirmed the allegation and stated R1 and R2 experienced bites. On 07/20/2026 & 07/24/2026, between the hours of 9:00am – 3:32pm, the Department interviewed 10 staff regarding the allegation. 4 out of 10 staff confirmed the allegation and stated they observed bites and/or red marks on R2, which R2 also reported. 4 out of 10 staff denied the allegation and stated they had not observed any bug bites on residents. 2 out of 10 staff did not confirm nor deny the allegation and acknowledged that residents reported itchiness, which staff could not attribute to bed bugs. On 07/20/2026, between the hours of 12:31pm – 3:34pm, and on 07/24/2026, between the hours of 9:20am – 9:32am, the Department interviewed 11 residents regarding the allegation. 2 out of 11 residents confirmed the allegation and stated R1 had bites on their chest and arms, while R2 had one bite on their arm. 8 out of 11 residents denied the allegation and stated they had never experienced any bites nor skin concerns related to bed bugs. 1 out of 11 residents did not confirm nor deny the allegation and stated they did not know whether they had been bitten nor was aware of any marks. On 07/24/2026, between the hours of 12:00pm– 1:30pm, the Department conducted a records review and observed the following: An LIC 624 Unusual Incident/Injury Report (dated 07/14/2026) documented that on 07/08/2026, a resident was noted to have small red spots on the right side of their neck, right side of their chest, and the back of their upper arm. The resident reported the areas were itchy and believed the spots may have been mosquito bites from sitting on the patio. The resident’s family was notified, and staff monitored the areas while investigating the possible cause of the skin lesions. On 07/20/2026, the Department observed a photo visible skin lesions on R1’s arm and back. Also as of 07/24/2026, the department did not observe any new reports of residents sustaining any bed bug bites.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 11-AS-20260716124054

Type of visit: Case Management - Deficiencies

On 06/17/2026 at 2:00pm, the Department conducted an unannounced case management deficiencies at the facility listed above. Licensing Program Analyst (LPA) Zina Brown met with Dawn Smith (Executive Director) and explained the purpose of the visit. During the complaint investigation for 11-AS-20260609153600, the Department observed 3 employees: Staff 3 (S3), Staff 5 (S5) and Staff 7 (S7) were not associated to the facility at the time of unannounced complaint investigation. As a result, civil penalties are being assessed and a deficiency is being cited under California Code of Regulation Title 22, Division 6, Chapter 8 are being cited on the LIC 809-D. Exit interview conducted with Dawn Smith (Executive Director) and a copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Jun 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jun 18, 2026

Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2)Obtain a California clearance or a criminal record exemption as required by the Department Based on observation and interview, S3 Pricilla Tejeda, S5 Mallory Hutcherson, and S7 Jovana Mendez were not associated to the facility as the time of unannounced complaint investigation which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: The facility shall associate S3 Pricilla Tejeda, S5 Mallory Hutcherson, and S7 Jovana Mendez in Guardian and submit proof of update via email at zina.brown@dss.ca.gov by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sparkle Day conducted this Case Management regarding an incident dated 2/10/26. Licensee Reported that R#1 missed several medications due to the facility ran out of the medications. It was reported that Resident #1 (R#1) missed eight (8) different medications from 4 to 8 days. During today's visit Licensing Program Analyst spoke with Dawn Smith, Executive Director and Rosetta Hines, Resident Service Director who were consistent in their statements that R#1 was managing their own medication according to physician report dated 5/15/2024. LPA reviewed the file of R#1 and observed an physician report indicating R#1 was able to manage and administer their own medication without assistance. The facility did have a list of the medications of R#1 upon admission but had no way of knowing if medications were missed. Due to this incident the facility has sent R#1 to the hospital for re assessment and R#1 is now on the medication management plan with the facility where ALL medications are now handled and administered by a Medication Tech at the facility. Licensing Day found that the incident report was not complete with ALL necessary information required. LPA Advised Executive Director of the Reporting Requirements per Title 22 No deficiency was cited today Exit interview conducted with Executive Director, Dawn Smiththe state’s words, verbatim · CDSS document, Feb 25, 2026

Type of visit: Case Management - Incident

On 11/10/2025 at 9:15am, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced Case Management- Incident visit to the facility listed above. LPA met with Marielena Cardenas, Business Office Director, and the purpose of today’s visit was explained. LPA was granted entry into the facility. On 11/05/2025, the Regional Office received an Unusual Incident/Injury Report stating that on 11/04/2025 Staff (S1) was observed by facility Staff (S2) shoving Resident (R1) into their wheelchair by pushing their left shoulder downward. Once Resident R1 was in their wheelchair, S1 proceeded to remove their soiled gloves and throw the soiled gloves and soiled wipes at Resident R1. During today’s visit, LPA received a Resident Roster, Staff Roster, Incident Report, SOC341, Resident Notes, In-Service Logs, interviewed Staff S2-S7, interviewed Witnesses W1-W2, and interviewed Resident R1. During interviews with Staff S2-S7 were asked if they observed S1 being physically aggressive with residents, five (5) out of six (6) stated no, they have not observed S1 be physically aggressive with residents. During an interview with Resident R1 was asked if they feel safe here at the facility, R1 stated yes. During Record Review, LPA observed Staff S1 was sent home and removed from the schedule following the incident. Additionally, Culver City Police Department were called out to investigate and provided case # 25-5668. LPA received and reviewed In-Service training logs (dated 11/08/2025) regarding Mandated Reporters, and Safety while providing ADLs. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted with Marielena Cardenas, Business Office Director, and a copy of this report was conducted.the state’s words, verbatim · CDSS document, Nov 10, 2025

Type of visit: Case Management - Incident

On October 27, 2025, at approximately 12:00 pm, Licensing Program Analyst- LPA Alfonso Iniguez conducted an unannounced Case Management/Incident visit at the facility. LPA Iniguez met with Marielena Cardenas, Business Office Director, and explained the purpose of the visit. On August 21, 2025, the Regional Office received a Report of Suspected Dependent Adult/Elder Abuse or SOC 341 stating that a former facility staff (S#2) had observed another facility staff (S#1) strike a resident’s (R#1) hand. After the incident was reported, the facility conducted an internal investigation, which revealed that (S#1) did not struck (R#1). On 10/27/25, LPA Iniguez spoke with (S#1), (S#1) stated that they did not strike (R#1) on their hand. Also, (S#1) said that they have never physically abused another resident in care. On 10/27/2025, LPA Iniguez spoke with (R#1), (R#1) stated that they have never been struck by (S#1) or any other facility staff. On the other hand, (R#1) noted that the facility workers here are “friendly and nice, and they are concerned about”. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Marielena Cardenas / Business Office Director.the state’s words, verbatim · CDSS document, Oct 27, 2025

Type of visit: Case Management - Deficiencies

On October 27, 2025, at approximately 2:30 pm, Licensing Program Analyst- LPA Alfonso Iniguez conducted an unannounced Case Management/Incident visit at the facility. LPA Iniguez met with Marielena Cardenas /Business Office Director and explained the purpose of the visit. On October 9, 2025, the Regional Office received an Unusual Incident Report (UIR) describing an incident that happened on 9/30/25. Based on Title 22 regulations, a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. LPA Iniguez observed that more than seven days had passed after the (UIR) was faxed to the Regional Office. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -Facility failed to report an incident within the time stipulated by Title 22. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Marielena Cardenas / Business Office Director.the state’s words, verbatim · CDSS document, Oct 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(1)(A-D) · Plan of correction due date: Nov 3, 2025

87211 Reporting Requirements (1) 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 requirement was not met as evidence by: Based on observation and record review, the licensee failed to ensure the incident report faxed on 10/9/25 was not sent within 7 days of the incident on 9/30/25. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 27, 2025

Plan of correction: Licensee will adhere to Title 22 at all times. As a Plan of Correction, the facility will conduct an in-service training session for all directors on the importance of promptly submitting incidents. A copy of the training will be forwarded to LPA Iniguez via email before the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Marielena Cardenas , Business Office Director and the purpose of the visit was discussed. The facility is licensed to serve 160 ambulatory residents age 60 and over of which 160 may be non ambulatory. The facility has an approved hospice waiver for 20 residents. There is also an approved delayed egress. Currently the facility serves 60 Assisted Living residents and 66 residents are in Independent living. Currently there is (1) residents receiving hospice services and (11) residents are receiving home health services. The facility does not handle any of the residents’ money. LPA Day reviewed 10 resident records, 10 resident medication records and 8 staff files. LPA found All records to be in order and complete according to Title 22. This is a 5 floor building consisting of: (137) resident bedrooms. The 2nd to 5th floor is Assisted Living Units and Independent living Units consisting of studio, 1 bedroom and 2 bedroom units. All units have personal washer and dryers located in the bathrooms. The 1st floor is Compass Rose Memory Care Units. LPA and Maintenance Director, Mario Carrillo toured the facility from the 1st floor to the 5th floor. and outside grounds. LPA toured the following rooms #512, #510, #522, #416, #411, #415, #313, #217, #228, #210 and The Memory Care unit. All bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 112 degrees - 116 degrees. . Common areas were clean and clear of hazards; doorways were free of obstructions. There are game rooms on the 3rd and 4th floor. There is a doggy area on the 2nd floor and medication room. The 1st floor consists of entrance, Concierge desk, Dining room, Lobby, Meeting area, outside Courtyard and grill, Kitchen, Mail room, Activity room, Wellness room, Theater, Public restrooms for men and women, Bistro and staff offices. All mandated inspection posters were displayed throughout the facility. Facility Annual Fess are current. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. Last Fire drill inspection was June 2025. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. Residents wear pendants and Wander guard watches for emergencies while in apartments. There are also pull stations in every room. During todays visit LPA did not observe any deficiencies. Exit interview conducted with Business Office Director, Marielena Cardenas and copy of this report was provided at time of visit.the state’s words, verbatim · CDSS document, Jul 24, 2025

Type of visit: Case Management - Other

On 03/13/25 Community Care Licensing division (CCLD) Staff, conducted a case management -other visit at the above facility. CCLD Staff met with Executive Director, Dawn Smith and Memory Care Director, Larianna Logan(S1) and explained the purpose of the visit was to gather information surrounding the fall of Resident #1(R1) The Regional office received a Unusual Incident Report from the facility who reported the fall. It was reported the fall occurred on 02/09/25 in the common area of the Memory Care Unit's activity area. Interview with (S1) indicated that staff (S2) and (S3) informed (S1) that (R1) had fallen on the floor of the activity area and complained of hip pain. (S2)and (S3) indicated that they were attempting to assist (R1) due to (R1) walking around in the common area carrying /dragging a blanket, in an effort to prevent an accident from occurring. (R1) became agitated which prompted (S2 and (S3) to give (R1) space and time to calm down. (R1) subsequently tripped on the blanket and fell to the floor. (R1) was taken to St. John's Providence Hospital, where surgery was performed on the hip. (R1) is currently in rehabilitation at Berkeley West, Santa Monica. (S1) indicated she has phoned family and left messages to check on resident but has not received any return calls as of today. LPA unable to interview (S2) and (S3) due to work schedule is 10 PM - 6 AM. Record review indicated (R1) on the Morse Fall Scale (MFS) indicates score of 25 - Level 2- Implement standard fall prevention interventions. No medications taken. Elopement Risk Evaluation indicates (R1) , yes - for wandering and Yes- for wandering around looking for a spouse or family member. An exit interview was conducted and a copy of this report was provided to the Executive Director, Dawn Smith.the state’s words, verbatim · CDSS document, Mar 13, 2025

Type of visit: Prelicensing

On 7/19/24 Licensing Program Analysts (LPA’s) Deborah Lee, Yolanda Rosser and Alfonso Iniguez conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized administrator: Tracy Flaherty. The licensee has applied for a license to serve (160) elderly residents age range 60 and over. The fire clearance is approved for (160) non-ambulatory only. Approved hospice waiver for (20). A tour of the entire facility was conducted: 1st, 2nd, 3rd, 4th, and 5th floors, kitchen, common areas, outside of facility, medication rooms, records room, bathrooms, activity room, fitness center, and cinema room. The following was observed during this visit: MEDICATIONS There are locked storage areas for Resident medications. PHYSICAL PLANT Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Areas of potential hazard are well-lit. Smoke alarms operate properly. Carbon monoxide detectors operate properly. Report continues LIC 809C. BEDROOMS There is a space for client’s own furniture that will accommodate a bed, a chair, a nightstand, a lamp, reading lights and a chest of drawers. BATHROOMS There is at least (137) toilet and washbasin per six (6) clients, family, and personnel. There is at least (137) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is between 105F°. and 120F°. Bathrooms are located inside clients’ bedrooms. There are nightlights in the hallways outside non-private bathrooms. SUPPLIES There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths. FOOD SERVICE Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A seven (7) day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. Report continues LIC 809C. RECORDS There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility. ADMINISTRATION The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. DELAY EGGRESS and SECURE PERIMETER Delay egresses are located on the 1st floor memory care entry. MISCELLANEOUS There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for commercial laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. Copy of liability insurance was email to LPA during this visit. Report continues LIC 809C. During this pre-licensing inspection, LPAs did not find corrections were needed. LPA Iniguez conducted the Component III Orientation with the administrator and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAU Analyst. Exit interview conducted with Tracey Flaherty/Administratorthe state’s words, verbatim · CDSS document, Jul 19, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 160 Census (if any clients in care): none COMP II Participants: Tracy Flaherty/Dawn Smith Interview Method: Telephone interview On July 3, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staffing requirements, training, general provisions 3. Pre Licensing Inspection readinessthe state’s words, verbatim · CDSS document, Jul 3, 2024