Westmont of Riverside

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Yolanda Delgado is conducting an unannounced case management visit on this date to check on the health, safety, and welfare of clients in care. LPA learned one hundred sixty-six (166) clients reside at the facility and forty-three (43) clients reside in Memory Care. There are twenty-seven (27) staff on duty currently for the area. LPA conducted interviews, in addition, LPA toured the facility and found no immediate H&S concerns present during today’s visit. Based on the information obtained today, there are no deficiencies that were issued per Title 22, Division 6, Chapter 8 of the California Code of Regulations. This report was reviewed with Moses Rivas along with LIC811 and copy provided at the time of the exit interview.the state’s words, verbatim · CDSS document, Mar 4, 2026

Allegation investigated: Staff are mismanaging resident's medications

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegations. LPA met with Judith Pierfax Executive Director and explained the reason for the visit. The investigation consisted of the following: On 4/15/22 LPA Danielson conducted an initial investigation visit. On 9/26/25 LPA Flores interviewed 3 staff over the phone. On 9/29/25 LPA Flores conducted a visit and interviewed 4 additional staff, 11 residents, conducted a medication check for 11 residents, conducted a tour of 11 resident rooms with Moises Rivas Resident Service Coordinator and tested pendant call button/call cord in each room. On 10/1/25 LPA Flores delivered findings for above allegations. The investigation revealed the following: Regarding allegation: Staff are mismanaging resident's medications. It is alleged residents are not getting their medications as prescribed. (CONTINUED ON LIC 9099C) Substantiated Interviews with 6 out of 11 residents stated to receive assistance with medication by facility staff. 2 out of the 6 residents stated either the staff had run out of the resident’s medication or the facility staff did not provide medication timely. 4 out of 11 residents stated they manage their own medications. 1 out of 11 residents was unable to be interviewed due to cognitive skills. Interviews with staff revealed medication technicians past medication to residents daily based on the physician’s orders. Medication technicians check the medication system and provide the medication to the residents a check mark is noted on quickmar. Medication technicians are responsible for refilling medications for the residents and request refills between 7 to 14 days before running out. Per documents reviewed for resident #1and#2(R1-R2) the residents were able to manage their own medications at the time of the allegations and per medication sheets between March -April of 2022 R2 received their medication daily. Medication review conducted on 9/29/25 revealed residents were missing either routine, as needed, or both medications. Resident #3 (R3) was missing acetaminophen 325mg, and diclofenac sodium 1%. LPA also found a medication bottle with another resident’s name inside R3’s medication bag. Resident #4(R4) was missing Ibuprofen 800mg, and diclofenac sodium 1%. Resident #5(R5) was missing aspercreme lido max 4% patch, antacid-antigas liquid, milk of magnesium, and loperamide 2mg was observed with expiration date of 7/17/25. Resident #6(R6) was missing nano pen needle 32g-4mm, onetouch delica plus 30g, onetouch verio flex meter, onetouch verio test strip, semglee 100 unit/ml pen, alburetol HFA 90mcg inhaler, BD Veo ins .3ml, ondansetron ODT 4mg, onetouch verio mid cntrl soln, Resident #7(R7) was missing acetaminophen 500mg, banophen 25mg, diclofenac sodium 1%, furosemide 20mg, psyllium husk, zeasorb AF 2% powder. Resident #8(R8) had a bottle of ibuprofen 600mg which was not listed on medication list and was missing baclofen 10mg. Resident #9(R9) was missing balmex 11.3% crm. Resident #10(R10) was missing rivastigmine 13.3mg, and lorazepam 1mg. Resident #11(R11) was missing baclofen 10mg, and lidocain 4% patch. Resident #12(R12) was missing polyethylene glycol 3350 powder. Resident #13(R13) was missing senna 8.6mg and had a prescription order of mirtazapine 15mg which is not listed on the medication list. Based on medication reviewed there were missing medications and medication errors for residents. Therefore, this allegation is substantiated. 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 was conducted and a copy of this report, LIC 9099D, and appeal rights were provided. Interviews with residents revealed 9 out of 11 residents stated the facility staff respond to the pendant call. 6 out of the 9 residents stated time of responds varies from 15-30 minutes. 2 out of 11 residents were either unable to answer due to cognitive skills or have not used the pendant call button. Interviews with staff revealed staff respond to the pendant call as soon as they are available. Per the staff facility’s policy is to respond to residents calls within 10 minutes. On 9/29/25 LPA observed 11 random resident rooms and tested either the pendant call button that residents carried or the pull cord in the residents’ bathroom. Caregivers responded within 2-10 minutes. Facility’s policy does not provide a time frame in which staff should respond to calls. Documents reviewed for R2, pendant call log between April 3rd-15th, 2022. R2 used the pendant call twice, staff cleared the pendant calls as follow; the first one within 23 minutes and the second one within 17 minutes. 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: Resident's do not have access to a telephone. It is alleged residents are in a shared unit with no phone access. Interviews with residents revealed 10 out of 11 residents stated to have either a landline or a cellphone to make phone calls. 1 out of 11 residents was unable to answer due to cognitive skills. Interviews with staff revealed residents have a phone in their rooms. Per staff, residents are encourage to obtain a free government cellphone if necessary, and they can also ask the front desk person to assist them with making calls if necessary. On 9/29/25 LPA observed either a landline, a cellphone, or both in each resident’s room toured. 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 do not assist residents with required blood pressure checks. It is alleged facility staff are not regularly checking residents’ blood pressure. Interviews with residents revealed 1 resident stated that they required blood pressure checkups. However, the facility is not responsible for providing that care and a private nurse provides that care for them. The other residents stated they either don’t require the services or are aware that the facility does not provide medical services. Interviews with staff revealed the facility does not provide medical services. (CONTINUED ON LIC 9099C) Therefore, blood pressure check-ups are not a service they provide to the residents in care. Staff upon observation of a change in condition follow the facility’s protocol to notify medication technician for evaluation, or physician. 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 was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 18-AS-20220408102211

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(6) · Plan of correction due date: Oct 2, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs,… This requirement is not met as evidence by: Based on medication review conducted the licensee did not ensure medications were available for R3-R13 which poses an immediate risk to the residents health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: Executive Director will work with nurse and medication technicians to audit the medication and provide training to the medication technicians. Executive Director will provide a copy of training with date, topic, and signatures, and will provide updated medication list or pictures of medication obtained by POC due date 10/1/25.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry by Mary Valendez. LPA began inspection with introduction, visit purpose and provided the facility LPA identification and business card. Resident record review began- Twenty (20) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Employee records review began- Ten (10) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification expires 09/11/2027. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 108.2 degrees F. Laundry facilities located on each floor with automatic detergent dispensing and other chemicals secured and locked in the designated areas. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. (Continued on Page 2) (Continued from Page 1) Food Service- Food supply meets the of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 12/26/2024. Facility is conducting emergency disaster drills monthly, last done on 09/23/2025. Corporation is active and in good standing. Based on the information received during this visit today, zero (0) deficiency is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with Judith Pierfax and a copy provided at the time of the exit interview. *LPA was away from the facility from 12:00 PM-1:00 PMthe state’s words, verbatim · CDSS document, Sep 30, 2025

Allegation investigated: Facility does not have the ability to accommodate non ambulatory residents(s) with dementia in case of fire. Facility does not conduct emergency drills as required.

On 08/23/2025, at approximately 8:07 AM, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced complaint visit. LPA Richard met with Genesis Roman, Resident Services Director. LPA Richard explained the purpose of this visit. The investigation consisted of the following: On 08/23/2025, the Department reviewed and obtained electronic copies of the following pertinent documents: The following documents were reviewed: Staff schedule and roster (dated 08/23/2025), Resident roster (dated 08/23/2025), records of resident emergency preparedness fire drills (dated 09/30/2024), and staff training modules regarding fire drills (dated 01/27/2023, 02/23/2023, 04/02/2023, and 07/31/2025), as well as emergency disaster and earthquake drills (dated 09/26/2024). Additionally, a community map, LIC610e (dated 08/01/2025), and the Facility Plan of Operation were included. On 08/23/2025, at approximately 10:00 AM, the LPA and the Resident Services Director conducted a tour of the facility, both inside and outside. During this visit, the LPA interviewed eight residents (R1-R8) and five staff members (S1-S5). Unsubstantiated Allegation: #1: Facility does not have the ability to accommodate non-ambulatory residents with dementia in case of fire. The complaint alleges that there aren’t a lot of emergencies or fire exits for residents in care. From 11:00 AM to 1:00 PM, the License Program Analyst (LPA) interviewed the Resident Services Director (RSD), who denied the allegations. The RSD stated that the facility has multiple exit doors and sufficient staff to assist non-ambulatory residents. During the same period, the LPA also interviewed five staff members (S1-S5), all of whom denied the allegations. They mentioned that they have been trained to assist residents during a fire, particularly those with dementia. The staff further noted that both the dementia wings and assisted living wings have numerous emergency exits. And the facility has a number of staff working on any given day. Additionally, the LPA interviewed eight residents (R1-R8), all of whom denied the allegations and stated that they knew something about evacuating in case of a fire. Records of the facility’s Memory Care layout indicated that there are several fire exits throughout the building. During the facility tour on August 23, 2025, the LPA observed multiple fire exit doors, fire extinguishers, exit lights, and an Evacuation Plan poster with instructions posted in various locations. The LPA also noted that most fire exit doors open outward, facilitating safe exits from the building. Some doors open automatically when approached, eliminating the need for a push-button feature and allowing residents to navigate the facility safely. Report continued LIC9099-C Based on the information gathered, and the interviewed conducted, there is insufficient evidence to support the allegation. Although the allegations above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. Allegation: #2: Facility does not conduct emergency drills as required. The complaint alleges that the facility hasn’t been providing fire and safety drills, and that is creating a fire hazard for residents in care. On August 23, 2025, from approximately 11:00 AM to 1:00 PM, the LPA interviewed the Resident Services Director (RSD), who denied the allegations. The RSD stated that the facility conducts fire drills and fire safety training quarterly and provides in-service training for all staff. During the same time frame, the LPA also interviewed five staff members (S1-S5), all of whom denied the allegations and claimed they had been trained to conduct fire drills monthly. Additionally, they mentioned that they receive training in earthquake and disaster preparedness quarterly, and that the facility conducts annual fire drills for residents. The LPA interviewed eight residents (R1-R8) on the same day, all of whom denied the allegations. They stated they had attended some fire drills. The LPA reviewed records of the last in-service fire drills and disaster preparedness training, which were conducted on January 27, 2023, February 23, 2023, April 2, 2023, and July 31, 2025. The last Emergency Preparedness drill for residents took place on September 30, 2024. During a tour of the facility on August 23, 2025, the LPA observed multiple fire extinguishers mounted throughout the premises. Furthermore, on that day, the LPA noted that the facility experienced a power outage, and all staff were prepared to assist residents in their care. Based on the information gathered, and the interviewed conducted, there is insufficient evidence to support the allegation above. Although the allegations above may have happened or are 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 cited. An exit interview was conducted. A copy of this report was provided to the staff Giovanna Pazmino.the state’s words, verbatim · CDSS document, Aug 23, 2025 · control 18-AS-20230414125937

Allegation investigated: Resident has not received treatments that were ordered by her doctor.

On 11/23/2021, Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to conducted an investigation and met with Administrator Keith Kasin. On 07/12/25, LPA Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Memory Care Director Alicia Ballard and the purpose of the visit was explained. Investigation consisted of the following: On 11/23/21, LPA Delgado interviewed one staff and one resident, requested and obtained copies of pertinent documentation, and toured the facility. On 07/12/25, LPA received Register of Residents and Resident #1 (R1)’s record and interviewed seven staff (S1 – S7) and nine residents. NOTE: LPA was unable to interview Resident #1 due to R1 passing away in February 2022. Continue to LIC9099-C. Unsubstantiated Regarding the allegation, “Resident has not received treatments that were ordered by her doctor,” it is being alleged that Resident #1 (R1) is being neglected by staff because R1 did not receive R1’s medication infusion. Record Review of R1’s Admission Orders (dated 09/02/21) does not include the medication infusion. R1’s Hospice Care Plan (dated 01/21/22) does not include medication infusion. R1’s Medication Destruction Record (dated 02/24/22) does not include medication infusion. Interview with Witness #1 indicated that R1 received medication infusion through a Home Care agency. Witness #2 indicated that there were multiple orders, including in November and in December. Seven out of seven staff interviews (S1 – S7) indicated they have not received resident complaints about being neglected for not receiving home health services such as infusions. Four out of four residents (R2 - R3, R7 - R8) indicated they receive their home health and/or hospice services and have no complaints about services. R4 indicated that they were independent and manage their own medication. R10 indicated that R10 receives non-medical care services according to the agreement but manages own medication. Three out of three residents (R5 - R6, R9) indicated that they do not receive home health and/or hospice services but receive their medication as prescribed by the doctor. Regarding the allegation, “Resident has not received treatments that were ordered by her doctor” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to the Memory Care Director Alicia Ballard.the state’s words, verbatim · CDSS document, Jul 12, 2025 · control 18-AS-20211119094333

Allegation investigated: Licensee left resident in soiled diaper. Licensee did not safeguard resident's property.

On 6/29/2025 at 8:00 AM, LPA Antonine Richard conducted a subsequent unannounced complaint visit. LPA Richard met with Community Relation Director Cynthia Cisneros. LPA explained the purpose of this visit. The investigation included the following details: On June 28, 2025, LPA Richard reviewed and obtained copies of the resident roster, dated from June 1, 2025, to June 26, 2025, as well as the staff roster covering the same period. LPA reviewed and obtained specific documents for Resident #1 (R1), which included the admission agreement dated June 17, 2022, the emergency ID form, the physician's report dated September 16, 2022, and the needs of services plan dated November 2, 2022. Additionally, LPA reviewed staff training records on health and safety checks dated from January 31, 2021, to January 9, 2023, and hospice notes covering November 30, 2022, to December 4, 2022. The theft and loss policy is dated June 17, 2022. On June 28, 2025, between 10:30 AM and 12:00 PM, LPA interviewed the Memory Care Director (MCD) Alicia Ballard and six staff members (S1-S6). Between 1:30 PM and 3:00 PM, LPA conducted interviews with six residents (R2-R7). On June 29, 2025, LPA visited two residents rooms, and interviewed one resident #8.(R8) Unsubstantiated Allegation #1: The Licensee left the resident in a soiled diaper. The complaint alleges that the caregiver left a resident either "soaking wet or that the bedding smelled of urine". On June 28, 2025, between 10:30 AM and 12:00 PM, the Licensing Program Analyst (LPA) interviewed the Memory Care Director (MCD) Alicia Ballard, who denied the allegation. The MCD stated that all residents in memory care receive care checks every 2 to 4 times a day, or as needed, to ensure they are changed and that their continence issues are addressed. The MCD also noted that each resident has different care needs throughout the day. For example, Resident #1 (R1) is checked more frequently due to specific needs. The MCD emphasized that no residents are ever left in soiled diapers or with dried urine. During the same day, between 10:30 AM and 12:00 PM, the LPA interviewed six staff members (S1-S6). Of those, 4 out of 6 denied the allegations, stating that they continuously monitor the residents and promptly change them whenever they notice they are soiled, ensuring residents are placed in dry diapers. Later, on June 28, 2025, between 1:30 PM and 3:00 PM, the LPA interviewed six residents (R2-R7). Five out of 6 denied the allegations, confirming that they are changed before breakfast, after breakfast, before lunch, after lunch, as needed, and at bedtime. They also stated that they are never left in soiled diapers, nor does their bedding smell of urine. On June 29, 2025, the LPA interviewed with Resident #8 (R8), who denied the allegation. Evaluation Report continues LIC 9099-C Additionally, the LPA reviewed R1's Needs of Service Plan dated November 2, 2022, which indicated that R1 is being toileted six times a day and as needed. On 06/29/25, the LPA visited residents' rooms #101 and #107, where the residents appeared to be well cared for, healthy, clean, and showed no smell of urine. The LPA was unable to interview Resident #1 because R1 had passed away. No date was provided. Based on interviews, observations, and records reviewed, there is insufficient evidence to support the allegation: “Licensee left resident in soiled diaper.” 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; the allegation is Unsubstantiated. Allegation #2: Licensee did not safeguard resident's property. The complaint alleges that the Licensee failed to safeguard a resident's property, which resulted in damage to the hearing aid. On June 28, 2025, between 10:30 AM and 12:00 PM, the Licensing Program Analyst (LPA) interviewed the Memory Care Director (MCD), who denied the allegation. The MCD explained that all residents in Memory Care do not keep valuable items in their rooms; instead, their families retain them. The MCD also stated that for residents who use hearing aids, the nurse places them in the residents' ears each morning, removes them before bedtime, and stores them safely in the Med Tech cart until the next morning. Additionally, the MCD noted that the facility has a theft and loss policy in place for all residents. Evaluation Report continues LIC 9099-C During the same time, the LPA interviewed six staff members (S1-S6). Of those, four out of six denied the allegations, stating that residents had never complained to them about missing items from their rooms. On the same day, between 1:30 PM and 3:00 PM, the LPA interviewed six residents (R2-R7) regarding the allegation. All six residents denied the allegation, asserting that the facility keeps their belongings safe and that they have not lost any of their items; they mentioned that sometimes they might misplace things within their rooms. Additionally, on June 29, 2027, between 11:00 AM and 11:24 AM, the LPA interviewed one resident #8 (R8), who also denied the allegation. Furthermore, during a record review of the admission agreement on June 29, 2025, the LPA found that the inventory policy for resident #1 (R1) did not list any items. LPA was unable to interview resident #1 R1 due to the resident's passing. No date was given. Based on LPA's observations, interviews, and reviews, LPA did not find sufficient evidence to support the allegation that the Licensee did not safeguard the resident’s property. Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove that it is valid or did occur; therefore, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of the report was provided to Community Relation Director Cynthia Cisneros.the state’s words, verbatim · CDSS document, Jun 29, 2025 · control 18-AS-20221205092330

Allegation investigated: Facility is not maintained in good repair

On June 29, 2025, Department of Social Services staff conducted a subsequent complaint visit regarding the above allegation. The Department met with Cynthia Cisneros, Community Welness Director and explained the reason for the visit. The investigation consisted of the following: On 6/25/2025, the Department conducted a telephone interview with Executive Director Judith Pierfax (A1). On 6/27/2025 the Department reviewed electronic copies of the following pertinent documents: Staff schedule and roster (date 6/26/25), Resident roster (dated 6/26/25), Work History maintenance report (dated 6/27/25). On 6/28/25, the Department and Memory Care Director toured the facility inside and out. The Department conducted 5 staff interviews (S1-S5), Executive Director (A1), and 6 Residents (R2-R7). On 6/29/25, the Department conducted interview with 1 resident (R1) Page 1 of 3 Unsubstantiated The investigation revealed the following: Allegation: Facility is not maintained in good repair The complaint alleges that the automatic push button assessable door did not work to the Trash/Recycle Room, and the automatic push button assessable door outside the entrance/exit nearest resident’s apartment was broken and hasn’t been repaired. On 6/25/25 the Department interviewed the Executive Director (A1), who denied allegation and stated that she has only been working at the facility for a little over a month, but the automatic push button accessible doors are functioning properly at the present time and there has been no report of any of the automatic doors not properly functioning. On 6/28/25 during the facility tour the Department tested each automatic push button accessible door and found them to be working properly. On 6/28/25 between 10:00am and 12:00pm, the department interviewed 5 staff regarding the allegation. Of those interviewed, 5 out of 5 stated the automatic doors are properly working. 1 out of 5 stated that in the past, the doors had not been working but the maintenance person “fixes” the issue “right away. On 6/28/25 between 1:00pm and 3:00pm the Department interviewed 6 residents. Of the 6 residents 5 out of 6 stated that they had had no problems with the automatic doors in the facility and they had been working properly. 1 out of 6 stated that they have had issues with the doors not working in the past, but admitted that lately, they have been working properly. On 6/29/25 at 11:15am, the Department interviewed 1 resident (R1) who stated the automatic access door that hadn’t worked in the past is now a “regular door” with no automatic push button. However, R1 stated that R1 can use other access doors (that open automatically when approached) that requires no push button feature allowing R1 to navigate the facility safely. Page 2 of 3 On 6/27/25 the Department obtained and reviewed an electronic copy of the Work History maintenance report (dated 6/27/25). The document shows that the automatic push button accessible doors are maintained on a regular basis. Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegations above 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. There were no deficiencies cited during today's visit. Exit interview conducted, and copy of report provided to Community Care Director, Cynthia Cisneros. Page 3 of 3the state’s words, verbatim · CDSS document, Jun 29, 2025 · control 18-AS-20240202083337

Allegation investigated: Facility staff is insufficient to meet resident's needs Facility staff are not assisting resident with toileting needs in a timely manner Resident sustained multiple falls while in care

On June 28, 2025, Department of Social Services staff conducted a subsequent complaint visit regarding the above allegations. The Department met with Judith Pierfax and explained the reason for the visit. The investigation consisted of the following: On October 12, 2021, the Department conducted and unannounced initial complaint visit and obtained the following pertinent documents: R1’s Service Plan (dated: 7/6/21), staff roster (dated 9/5/21 and 10/10/21), R1’s eMAR (for Aug 2021), Unusual Incident Report (UIR) dated 9/18/21 and 9/1/21. It was determined at the time of the initial visit that the complaint required further investigation. On 6/25/2025, the Department conducted a telephone interview with Executive Director Judith Pierfax (A1). On 6/27/2025 the Department reviewed electronic copies of the following pertinent documents: Staff schedule and roster (date 6/26/25), Resident roster (dated 6/26/25), Facility’s Fall Policy (dated 3/1/2025), Emergency and call system monitoring policy (date 8/1/24), and Staff training on Resident Rights (dated 1/3/25). Page 1 of 5 Unsubstantiated On 6/25/2025, the Department conducted a telephone interview with Executive Director Judith Pierfax (A1). On 6/27/2025 the Department reviewed electronic copies of the following pertinent documents: Staff schedule and roster (date 6/26/25), Resident roster (dated 6/26/25), Facility’s Fall Policy (dated 3/1/2025), Emergency and call system monitoring policy (date 8/1/24), and Staff training on Resident Rights (dated 1/3/25). On 6/28/25, at 9:24am, the Department and Memory Care Director (S2) toured the facility inside and out. The Department conducted 5 staff interviews (S1-S5), Executive Director (A1), and 6 Residents (R2-R7). The investigation revealed the following: Allegation: Facility staff is insufficient to meet resident's needs The complaint alleges that “the facility is trying to save money, and they are short staffed.” On 6/25/25 at 12:26p via telephone, the Department interviewed the Executive Director (A1) who denied allegation and stated that she has only been working at the facility a little over a month, she is certain that the facility has sufficient staff to meet residents’ needs. On 6/28/25 between 10:00am and 12:30pm, the Department interviewed 5 staff (Staff #1-5) regarding the allegation; 4 out of 5 staff denied the allegation and reported that there is enough staff to meet the needs of the residents. On 6/28/25, between 1:30pm and 3:00pm, the Department interviewed 6 Residents (Residents #2-7). R1 no longer lives at the facility. Of the 6 Residents interviewed, 5 out of 6 denied the allegation. 5 out of 6 stated that their needs are taken care of and that they feel that there are enough staff to meet their needs. On 6/28/25, The Department observed sufficient staff present at time of visit. On 6/27/25, The Department obtained, reviewed, and evaluated staff schedules and resident roster (current and week of incident) and found that sufficient staffing is maintained at the facility to meet the residents’ needs. Based on the information gathered, there is insufficient evidence to support the stated allegation Although the allegations above 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. Page 2 of 5 Allegation: Facility staff are not assisting resident with toileting needs in a timely manner The complaint alleges that when R1 tells the staff that R1 “has to use the restroom,” the staff takes longer to respond. On 6/25/25 at 12:26p via telephone, the Department interviewed the Executive Director (A1) who denied the allegation and stated that staff are not supposed to take more than 10 minutes to respond to a resident who calls for assistance. A1 further stated the staff are aware of the policy of responding to residents in a timely manner when they call for assistance. On 6/28/25 between 10:00am and 12:30pm, the Department interviewed 5 staff (Staff #1-5) regarding the allegation; 5 out of 5 staff denied the allegation and reported whenever a resident calls for assistance they help. 5 out of 5 staff interviewed stated that they have never waited too long to assist residents when they call. 5 out of 5 staff stated that they are aware of the Emergency and call system monitoring policy. On 6/28/25 between 1:30pm and 3:30pm the Department interviewed 6 Residents (R2-R7) regarding the allegation. 5 out of 6 residents stated that staff assist them in a timely manner when they called for assistance. On 6/27/25 the Department obtained, reviewed, and evaluated the Emergency and call system monitoring policy (dated 8/1/24) which states in part that “It is expected that emergency calls are responded to timely,” and “upon move in the Executive Director or designee will provide all assisted living residents with training on the use of emergency call devises.” Page 3 of 5 Based on the information gathered, there is insufficient evidence to support the stated allegation Although the allegations above 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: Resident sustained multiple falls while in care The complaint alleges that R1 was admitted to hospital due to a fall on 9/1/2021 and R1 allegedly has had multiple falls within the year. Additionally, it is alleged that R1’s medication and chronic condition is making R1 “feel faint” resulting in falls. On 6/27/2025 at 12:26p, the Department interview A1 who stated that R1 no longer lives in the facility and the facility doesn’t have any records pertaining to R1’s case due to the time frame that the facility is required to keep records (records are kept for 3 years) and this complaint is from 2021. However, during the initial complaint visit on 10/12 /21, the Department obtained copies of R1’s Service Plan (dated: 7/6/21), R1’s eMAR (for Aug 2021), Unusual Incident Report (UIR) dated 9/18/21 and 9/1/21. The Department reviewed the documents listed above which showed that R1 has had a couple falls during that time and the facility took appropriate steps to ensure that R1 was seen by a medical professional and followed up with R1’s primary care physician . It is unknown what was put in place for R1 specifically, due to the lack of information. The Department obtained and reviewed a copy of the facility’s fall policy (Dated 3/1/25), which includes: Fall risk reduction, environmental safety, and lift assistance Page 4 of 5 Based on the information gathered, there is insufficient evidence to support the stated allegation Although the allegations above 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. There were no deficiencies cited during today's visit. Exit interview conducted, and copy of report provided to Executive Director Judith Pierfax. Page 5 of 5the state’s words, verbatim · CDSS document, Jun 28, 2025 · control 18-AS-20211008135633

Allegation investigated: Staff do not provide adequate food service to residents.

On 06/28/25, at 8:00 am, Licensing Program Analyst (LPA) Antonine Richard conducted an initial complaint visit regarding the allegation above. LPA met with Alicia Ballard, the Memory Care Director (MCD), and explained the purpose of today’s visit. LPA and MCD toured the facility inside and outside. The investigation consisted of the following: On June 28, 2025, LPA Richard reviewed and obtained copies of the resident roster (dated June 1, 2025, to June 26, 2025), the staff roster (dated June 1, 2025, to June 26, 2025), and facility menus (dated June 8, 2025, to July 5, 2025). Additionally, LPA requested and obtained copies of specific documents for Resident #1 (R1), including the admission agreement (dated January 31, 2022), the emergency ID form, the physician's report (dated January 26, 2022), and the needs of services plan (dated August 24, 2023). On June 28, 2025, LPA Richard conducted a tour of the kitchen and observed the lunch service from 11:15 AM to 11:30 AM. Between 10:30 AM and 12:00 PM on the same day, LPA interviewed six staff members (S1-S6). Later, between 1:30 PM and 3:00 PM, LPA interviewed six residents (R2-R7). Unsubstantiated Allegation: Staff do not provide adequate food service to residents. The complaint alleges that the residents have to wait two hours for their food, which is often served cold. On June 28, 2025, between 10:00 AM and 10:20 AM, the Licensing Program Analyst (LPA) interviewed the Memory Care Director (MCD), who denied the allegation, stating that food is served on hot plates. The MCD also mentioned that residents rarely complain to the kitchen staff about the food being cold or too hot. Additionally, the facility does not allow microwaves in any of the residents' rooms in the Memory Care unit, except in the dining area. Later on, June 28, between 10:30 AM and 12:00 PM, the LPA interviewed six staff members (S1-S6). Four out of the six staff members denied the allegation, asserting that they are aware food is served on hot plates. They also mentioned that if a resident requests reheating, the kitchen staff would accommodate this, although it happens rarely. Furthermore, on the same day, between 1:30 PM and 3:00 PM, the LPA interviewed six residents (R2-R7). All six residents denied the complaint, stating that the food served to them is always hot and does not need reheating. However, they confirmed that if they wanted to warm up their food, the staff would assist them. Between 1:00 PM, LPA Richard reviewed the facility's menu, dated from June 8, 2025, to July 5, 2025, which showed that there were various food options available. Evaluation Report Continues LIC9099-C On June 28, between 11:15 AM and 11:30 AM, LPA conducted a tour of the kitchen and dining room, where LPA observed that lunch had been served, was hot, and of good quality. Unfortunately, LPA could not interview Resident #1 because R1 was no longer residing in the facility. Based on LPA observations, interviews, and record reviews, LPA did not find sufficient evidence to support the allegation that the staff do not provide adequate food service to residents. Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove that it is valid or did occur; therefore, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted and a copy of the report was provided to Executive Director Judith Pierfax.the state’s words, verbatim · CDSS document, Jun 28, 2025 · control 18-AS-20230413163515

Allegation investigated: Staff inappropriately pulled on a resident while in care. Staff did not address a resident's change in medical condition.

On 6/22/2025 at approximately 8:30 AM, LPA Alfonso Iniguez conducted a subsequent unannounced complaint visit. LPA Iniguez met with Alicia Ballard/Memory Care Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Executive Director Interview (A#1), Witness Interview (W#1), Residents Interviews (R#1-R#5) and Staff Interview (S#1-S#3). LPA obtained and reviewed the following documents: Resident Roster dated: 6/21/25, Staff Roster dated: 6/17/25 and Copies of Staff Training Modules regarding Residents Personal Rights, First Aid, and CPR dated: 5/15/25. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff inappropriately pulled on a resident while in care. The details of the complaint alleged that facility staff inappropriately pulled (R#1)’s arm. On June 22, 2025, at approximately 9:00 a.m., LPA Iniguez conducted a records review and examined copies of staff training modules in Relias, dated May 15, 2025. It was noted that facility staff receives annual training on the “Essentials of Resident Rights.” Additionally, LPA Iniguez observed other trainings, including “Person-Centered Care in Assisted Living,” that are also taken annually. On June 21, 2025, at approximately 11:00 AM, during an Interview with the Executive Director (A#1), she stated that facility staff are trained on residents' rights, and they receive training every year. Also, (A#1) stated that to her knowledge, facility staff did not pull (R#1) arm or any other resident in care in an inappropriate way. On June 21, 2025, at approximately 8:30 AM, during a telephone conversation with (W#1), LPA Iniguez asked (W#1) whether they had ever witnessed (R#1) being mistreated by facility staff or being pulled by their arm. (W#1) responded that they had not witnessed any such behavior during their visits to the facility. On 6/21/25, at approximately 10:00 AM, Licensing Program Analyst-LPA Alfonso Iniguez was not able to spoke with (R#1) since they are no longer living at the facility. On June 21, 2025, at approximately 10:00 AM, during interviews with residents (R#2-R#5), (4) out of (4) stated that they think the facility staff is trained on resident’s rights and they have never been pulled inappropriately by them. Evaluation Report continues LIC 9099-C On June 21, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#3), (3) out of (3) stated that they are trained on resident’s rights, and they get trained every year. In addition, (3) out of (3) facility staff stated that they have never pulled (R#1)’s arm or any other resident in care inappropriately. Allegation: Staff did not address a resident's change in medical condition. The details of the complaint alleged that facility staff made fun of resident when they requested medical attention. On June 22, 2025, at approximately 9:00 a.m., LPA Iniguez conducted a records review and examined the copies of staff training modules in Relias. During the review, LPA Iniguez noted that facility staff had received training on "First Aid, Workplace Emergencies, and Natural Disasters: An Overview." Additionally, LPA Iniguez observed that CPR training was also listed. On June 21, 2025, at approximately 11:00 AM, during an Interview with the Executive Director (A#1), she stated that the facility staff are trained in first aid and CPR, (A#1) stated that they renew their training every two years. In addition, (A#1) stated that she has never observed facility staff making fun of residents in care when they request medical attention. On June 21, 2025, at approximately 8:30 AM, during a telephone conversation with (W#1), (W#1) mentioned that the staff was always excellent with (R#1) and the other residents and that they never saw any staff members making fun of (R#1) or any other resident in care. On 6/21/25, at approximately 10:00 AM, Licensing Program Analyst-LPA Alfonso Iniguez was not able to spoke with (R#1) since they are no longer living at the facility. Evaluation Report continues LIC 9099-C On June 21, 2025, at approximately 10:00 AM, during interviews with residents (R#2-R5), (4) out of (4) stated that they think the facility staff is trained regarding medical emergencies. Additionally, (4) out of (4) residents in care state that the facility staff have not made fun of them when they requested medical attention. On June 21, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#3), (3) out of (3) stated that they are trained in first aid and CPR in case of a medical emergency, and they renew their training every two years. Additionally, (3) out of (3) facility staff stated that they had never made fun of any resident in care when they requested medical attention. 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 Alicia Ballard/Memory Care Director.the state’s words, verbatim · CDSS document, Jun 22, 2025 · control 18-AS-20220318110117

Allegation investigated: Facility staff does not provide a safe environment for residents in care. Facility staff are not adequately trained.

On 6/22/2025 at approximately 8:30 AM, LPA Alfonso Iniguez conducted a subsequent unannounced complaint visit. LPA Iniguez met with Alicia Ballard/Memory Care Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Executive Director Interview (A#1), Residents Interviews (R#1-R#13) and Staff Interview (S#1-S#5). LPA obtained and reviewed the following documents: Resident Roster dated: 6/21/25, Staff Roster dated: 6/17/25, Copies of Staff Training Modules such as: Providing Medication Assistance-California, Medication Management Medications, Managing Medications in Assistant Living Facilities(ALFs): Helping with self-administration, Managing Medications in (ALFs), Antipsychotic and Beyond and Polypharmacy: Monitoring Medications dated: 5/15/25, and a Health and Safety Check of the facility. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Facility staff does not provide a safe environment for residents in care. The details of the complaint alleged that facility staff did not provide a safe environment for (R#1). On June 21, 2025, at approximately 4:00 p.m., LPA Iniguez performed a health and safety check at the facility. LPA Iniguez did not observe any immediate or potential dangers to the residents in care. On June 21, 2025, at approximately 10:00 AM, during an interview with the Executive Director (A#1), she stated that the facility staff are trained on residents' rights and work to provide a healthy and safe environment for (R#1) as well as all other residents in their care. On June 21 and 22, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R13), (12) out of (13) stated that they believe the facility staff is trained in residents' rights and they strive to keep a healthy and safe environment. Additionally, (12) out of (13) residents in care stated feeling safe in the facility. On June 21, 2025, at approximately 02:00 PM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that they are trained on resident’s rights, and they take the training every year. Additionally, (5) out of (5) facility staff members stated that they are providing a healthy and safe environment for all residents in their care. Evaluation Report continues LIC 9099-C Allegation: Facility staff are not adequately trained. The details of the complaint alleged that facility staff are not trained on how to handle resident’s medications. On June 22, 2025, at approximately 10:00 AM, during a records review, LPA Iniguez observed the facility MedTech’s training dated:5/15/25, such as Providing Medication Assistance-California, Medication Management Medications, Managing Medications in Assistant Living Facilities (ALFs): Helping with self-administration, Managing Medications in (ALFs), Antipsychotic and Beyond and Polypharmacy: Monitoring Medications. In addition, LPA Iniguez observed that these trainings are conducted annually as part of their mandatory training. On June 21, 2025, at approximately 10:00 AM, during an interview with the Executive Director (A#1), she stated that the facility's MedTechs undergo mandatory annual training as well as on-the-job training. Additionally, (A#1) mentioned that the MedTechs are trained to handle the medications of resident (R#1) and all other residents in the care facility. On June 21 and 22, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R13), (12) out of (13) stated that they think the facility staff responsible for managing medications are properly trained in handling their medications and those others. On June 21, 2025, at approximately 02:00 PM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that the facility staff that handles residents' medications are the Medtechs and they get trained every year as part of their mandatory training. 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 Alicia Ballard/Memory Care Director.the state’s words, verbatim · CDSS document, Jun 22, 2025 · control 18-AS-20221114094514

Allegation investigated: Facility required resident to pay for exterminator services. Staff handles residents roughly. Staff speak inappropriately to resident. Staff do not respond to residents call button timely.

On 10/14/2021, Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to initiate a complaint investigation into the allegations list above. LPA met with Executive Director (ED) Keith Kasin. On 06/21/2025, LPA Regina Cloyd conducted a subsequent and met with staff. On 06/22/2025, LPA Cloyd conducted a subsequent. LPA met with Memory Care Director Alicia Ballard and the purpose of the visit was explained. Investigation consisted of the following: On 10/14/2021, LPA toured the facility with Resident Services Director (RSD) Deserie Rodillo and interviewed one (1) staff and three (3) residents. LPA also obtained copies of pertinent documents and records. RSD was advised that at this time, the complaint requires further investigation which may include possible follow-up telephone calls, additional interviews, or visits before reaching investigation findings. On 06/17/2025, LPA received an electronic copy of the Personnel Record (06/17/2025) and Register of Residents (printed 06/17/25). On 06/18/25, LPA retrieved Departmental records (interview notes with Resident #2 – Resident #4 and with Staff #3 and Resident #1’s Face Sheet) electronically. CONTINUE TO LIC9099-C. Unsubstantiated On 06/21/2025, LPA received the following records: Orkin Agreement (dated 06/29/2021), Resident #1 Residency Agreement and 2021 – 2022 Resident Detail Ledger, Resident #2 (R2) Face Sheet, and 14 staff training records. LPA also interviewed two (2) Witnesses, Staff and Residents. NOTE: As of 06/21/25, Residents #1 – 4 no longer live at the facility and Staff #1 – 4 no longer work at the facility. R1 is deceased. On 06/22/2025, LPA called ten residents and was able to interview five (5) residents. NOTE: LPA unable to interview Staff #1 and Staff #2. Investigation revealed the following: Regarding the allegation, “Facility required resident to pay for exterminator services,” it is alleged that Staff #4 required Resident #1 (R1) had to pay $2,000 for exterminator services. Orkin Agreement revealed that the facility received pest and fly control services four times per month for one year. Executive Director (S5) was unable to provide invoice for services rendered for R1. R1’s Detailed Ledger did not reveal pest control charges from 09/2021 – 12/2021. R1’s Residency Agreement (Section H(2)) revealed resident agree to maintain their apartment in a clean, sanitary and orderly condition. Resident shall be responsible for any loss or damage that resident or their guests cause to their apartment or other property of the community, or to other residents and their property, unless due to ordinary wear and tear (page 17). Interview with Witness #1, R1’s son, indicated W1 does not recall paying for exterminator services but purchased R1 a new bed. Interview with S13 indicated that R1 did not pay for exterminator services but R1 mentioned having to purchase new furniture and a new bed. S13 indicated that the rooms below and above was also treated. S5, S9 indicated that the facility pays for bed bug treatments. S10 indicated there aren’t any bed bugs but ants are reported to maintenance. S6 – S8, S12 are unaware whether the facility or the resident pays for exterminator services. R5 indicated that R5 purchases own products. Interview with R7 – R12 indicated that they do not pay for exterminator services. Regarding the allegation, “Facility required resident to pay for exterminator services,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. CONTINUE TO LIC9099-C. Allegation: Staff handles residents roughly. Regarding the allegation, “Staff handles residents roughly,” it is alleged that Staff #1 (S1) yanked Resident #2 (R2) top off and R2’s head flew back. It also alleged that S1 was rough with Resident #3 (R3) while dressing. It is alleged that Staff #2 (S2) informed Staff #3 (S3) and Staff #4 (S4). Resident #2 - 4 indicated (source: departmental records) that staff does not handle them roughly. R3 indicated that staff was a little rough one time when taking R3’s shirt off. It tugged on R3’s ear. Six (6) out of six (6) resident (R6 – R10, R12) interviews denied that staff handles them roughly. Two (2) out of two (2) resident (R5 and R11) indicated that staff does not provide assistance with dressing and grooming. S3 (source: departmental records) denied the allegation. Six (6) out of eight (8) staff (S4-S10, S12) interviews denied that staff handles residents roughly. Training records revealed that fourteen (14) out of fourteen (14) staff had completed the Resident Rights training. Regarding the allegation, “Staff handles residents roughly,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation: Staff speak inappropriately to resident. Regarding the allegation, “Staff speak inappropriately to resident,” it is being alleged that Staff #1 (S1) called Resident #3 (R3) an inappropriate name. Resident #2 - 4 indicated (source: departmental records) that staff does not call them by inappropriate names. R5 – R12 indicated staff does not speak inappropriately to residents. S3 (source: departmental records) denied the allegation. Nine (9) out of nine (9) staff (S4 – 10, S12 – S13) interviews denied the allegation. Training records revealed that fourteen (14) out of fourteen (14) staff had completed the Resident Rights training. Regarding the allegation, “Staff speak inappropriately to resident,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. CONTINUE TO LIC9099-C. Allegation: Staff do not respond to residents call button timely. Regarding the allegation, “Staff do not respond to residents call button timely,” it is being alleged that Resident #4 (R4) fell, used the call button, and staff did not check on R4. Departmental records revealed that R4 indicated that R4 did not activate the call button and was on the floor for about 30 minutes. R4 indicated that staff always come right away when called. Resident #2 indicated that the response time depends on the shift (mornings, evenings, and overnight). Resident #3 indicated that it takes about 30 minutes for staff to respond to call button. Three (3) out of four (4) resident (R5, R7, R8, R9) interviews indicated staff respond to residents call button in a timely manner. R6 and R12 indicated they do not call for assistance. R11 indicated that R11 could not provide a definitive answer. Seven (7) out of seven (7) staff (S5, S7 – S8, S10 – S13) interviews denied the allegation. S6 and S9 indicated that memory care does not have call buttons. S6 indicated rounds are conducted every two hours and residents are in the common areas when they are awake. Regarding the allegation, “Staff do not respond to residents call button timely,” based on interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted and a copy of this report was provided to the Memory Care Director Alicia Ballard.the state’s words, verbatim · CDSS document, Jun 22, 2025 · control 18-AS-20211014112239

Allegation investigated: Facility neglected the care of a Resident

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude the complaint investigation regarding the allegation listed above. LPA was granted entry and met with Operational Specialist Sheryl McCaskill who was informed of the purpose for the visit. The investigation consisted of observations, interviews, and records review. Regarding the allegation “Facility neglected the care of a Resident”, it was reported on 10/09/2024 at approximately 11:15am, Resident One (R1) had an unwitnessed fall and was found on the floor in R1’s apartment soaked in urine. Staff One (S1) responded to the call button request for R1 and assisted R1 off the floor with help from Staff Two (S2) and two (2) additional relevant parties. R1 reported to relevant parties that R1 was on the floor since the night prior and was unaware of how R1 ended up on the floor. Interview conducted with Staff (S3) reported upon admission, R1 was assessed as a Level 1 care and did not need medication management or assistance with his activities of daily living (ADL). Interviews conducted with S1 revealed R1 does not require assistance or supervision with their activities of daily living (ADL). Unsubstantiated S1 reported they had conducted a safety check on the morning of 10/09/2024 and observed R1 in bed sleeping. Interview conducted with R1 reveled they were not sure how long they were on the floor after they slipped off their recliner in their apartment. R1 reported they were on the floor for approximately “30 to 45 minutes”. R1 reported they feel safe living at the facility. R1 stated “staff are always taking care of me, feeding me, and every time I call staff they come”. LPA conducted a record review of R1’s Service Plan dated 08/15/2024 has R1’s care level set at Level 1. Service Plan reveals R1 is independent and does not require assistance with "Dressing", "Grooming", "Oral Care", "Toileting", "Transfer", "Mobility", and "Medication Management". Record review of R1’s physician’s report dated 06/27/2024 reveals R1 is able to bathe self, able to groom self, able to feed self, able to care for toileting needs, able to manage and store own medication, and able to administer own medication. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided to Operational Specialist Sheryl McCaskill.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 18-AS-20241010091534

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Operations Specialist Sheryl McCaskill who was informed of the purpose of the visit. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. The outdoor area was observed to be free of hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies, detergents, and the sharp and dangerous objects were locked and inaccessible to the residents in the facility's janitorial and maintenance supply rooms. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector, carbon monoxide, and facility sprinkler system was operational and is maintained annually. LPA tested the hot water temperature in multiple resident bathrooms which met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA was informed the facility receives multiple food deliveries a week. LPA reviewed five staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training. Eight (8) resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. LPA observed a MedTech walking with a medication cart supplying the resident's with their morning medication. MedTech documented intake on the facility's electronic Medication Administration Record (eMAR). LPA reviewed resident medications for resident and found all medication listed on MARS and all required labeling was found to be in place. Facility has an updated emergency and disaster plan and Infection Control plan. LPA observed all facility exits were clear from obstructions. Facility contained multiple charged fire extinguishers located throughout the facility. Facility had performed a fire drill during August 2024 which met department requirements. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Operations Specialist Sheryl McCaskill.the state’s words, verbatim · CDSS document, Sep 10, 2024

Allegation investigated: Staff did not ensure resident was administered their medication as needed.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Executive Director (ED), Monya Henry, after the start of the visit. The LPA informed Henry of the purpose for the visit. A report was received by the Department alleging a temporarily contracted employee, Staff One (S1), of the facility denied medication administration to Resident One (R1) on 07/19/2024. The investigation included staff and resident interviews, a review of records, and collection of relevant documentation. One staff interview revealed R1 does not receive medication assistance from the facility. A letter from R1's medical provider revealed an order for R1 to begin self-administration of medications as of 04/01/2024. R1 was interviewed and confirmed the facility does not administer their medications. R1 reported their medications were delivered to the facility and S1 refused to retrieve the medications and bring them to the resident. R1's statement was conflicting; R1 later reported in the interview that S1 was already in possession of the medications and refused to provide them to the resident. R1 could not provide information on how they knew S1 was in possession of Unsubstantiated the medications. A facility director was interviewed and reported S1 is an employee of a staffing agency and was contracted to provide services on 07/19/2024. S1 could not be reached prior to the conclusion of the investigation. An interview was conducted with a facility employee who worked with S1 and revealed S1 did report they received the delivery, and they did not know if the resident was allowed to self-administer their medications. Per staff, S1 reported they later delivered the medications to S1, on the same day, once realizing the resident could self-administer. R1 reported they believed they did later receive their medications. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. This report was reviewed with ED Henry and a copy was provided.the state’s words, verbatim · CDSS document, Aug 8, 2024 · control 18-AS-20240801090923

Allegation investigated: Facility is increasing rent more than 10%.

On 6/5/2024, Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted a visit to the facility to deliver findings on the above allegation. LPA met with Monya Henry, Executive Director, and explained the purpose of the visit. During the course of the investigation, LPA conducted interviews with Executive Director, Monya Henry, Resident #1 (R1), and additional witness. On 5/14/2024 CCLD received a complaint alleging that the facility is increasing rent more than 10% for Resident #1 (R1). It was reported that the facility is increasing R1's rent after multiple increases in September 2023, February 2024, and another rent increase will be in July 2024. Information obtained from interviews indicated that additional witness acknowledged the rate increase letters were given 60 days in advance of the increase, but feel the rate increases are too high and too frequent. Unfounded LPA obtained copies of the rate increase letters that were given to R1’s family. The rate increase letters were dated 4/26/2024, 2/7/2023, and 8/9/2022. The letters included a general explanation of the reason for increase. LPA was provided a copy of the Admission Agreement signed and dated by R1. Witness was present at the signing of the Admission's Agreement. Review of the signed admissions agreement specifically state facility may increase the rate for monthly fees upon sixty days’ written notice. In the event of a rate increase, the Community will include with the notice the amount of the increase, reasons for the increase and a general description of the additional costs that the Community incurred that led to the increase. Based on the information obtained, the allegation of facility is increasing rent more than 10% has been investigated and found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted with Monya Henry, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 5, 2024 · control 18-AS-20240514092410

Allegation investigated: Staff member steals resident's money

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Henry and explained the elements of the complaint. Regarding the allegation that staff member steals resident's money: LPA Prieto interviewed staff #1, who confirmed that resident #1 (R1), in question, does reside in the assisted living portion of the facility, but has not been notified of monies being stolen from R1. Witness (W1) to R1's statement was not provided with an alleged perpetrator's name, date of event, location of thief or amount of money that was allegedly stolen. ****Continued on LIC 9099C**** Unsubstantiated LPA Prieto attempted to interview R1, in question, without success. S1 confirmed that R1 has left Westmont Village, to a medical facility not licensed by State Licensing and will not be returning. Based on the information obtained there is not enough evidence that staff member steals resident's money. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Henry and a copy was left with the facility.the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 18-AS-20200630082903

Allegation investigated: Facility is not maintained in good repair.

On 1/10/2024, Licensing Program Analyst (LPA) Chinwe Nwogene conducted an unannounced visit to investigate the above allegation. LPA met with Executive Director, Monya Henry who was informed of the purpose of the visit. At the time of visit, LPA interviewed staff, interviewed residents, and conducted an inspection of the facility. Regarding the allegation “Facility is not maintained in good repair” it was alleged that an elevator and double door in the assisted living section in the facility is in disrepair. Staff were interviewed who reported the double door was never in disrepair but the elevator broke in December 2023 and is in the process of being repaired. Staff stated facility has another elevator by the end of the building for residents to use. Residents were interviewed who reported the elevator has been in disrepair for over a month. Residents stated facility has another elevator, however the elevator is located at the end of the building and it’s hard for the residents to do the long walk to the elevator and it's hard for residents on wheelchair to wheel themselves to dinning. LPA conducted a facility inspection including the mentioned double door and elevator and observed the double door to be operating without issues. The elevator was observed to still be out of service. Based on LPA's observations, 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 22, Division & Chapter number 6) are being cited on the attached LIC9099D). An exit interview was conducted, and a copy of this report was reviewed with and provided along with appeal rights to Monya Henry. Substantiatedthe state’s words, verbatim · CDSS document, Jan 10, 2024 · control 18-AS-20240102154208

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a) · Plan of correction due date: Jan 19, 2024

Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met based as evidence by observation and interview. The licensee did not comply by having the elevator in disrepair for over a month which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Executive Director stated the elevator will be repaired and proof provided to LPA by the POC due date 1/19/2024.