William J. Pete Knight Veterans Home-Lancaster

Type of visit: Required - 1 Year

On 1/28/2026 at approximately 9:50 a.m., Licensing Program Analysts (LPAs) Evelin Rios and Lorena Casillas conducted an Annual Required visit. Upon entry LPAs signed in by a security guard at reception. LPAs met with Assistant Administrator Wendi Doyon and explained the reason for the visit. LPAs later met with the Administrator, Edina Lemus. The Inspection Tools was used to complete this visit. LPAs requested a copy of the following: resident roster, personnel report, last fire inspection, menu and activities calendar. At approximately 10:46 a.m., LPA Rios initiated a physical plant tour and the following was observed: By the main entrance and throughout the facility LPA observed appropriate postings such as, resident's rights, Rights of Resident Council, the facility's activity calendar, menu and emergency evacuation routes. Kitchen: The kitchen has an industrial setting and observed to be clean and in proper order. Appliances and fixtures were observed to be functional. Sufficient amount of perishable and non-perishable food was in stock and properly stored. Kitchen is inaccessible to residents. Dishwashing liquids and other cleaning agents are separate from food preparation areas. LPA discussed food delivery, meal planning and overall food monitoring with the Food Manager, A. Sebert. According to the Food Manager the facility hosts a monthly meeting open for residents to discuss future menus. LPA also observed the 72 hour supply of food in the facility and was informed by the Food Manager that another eight (08) day supply of emergency non perishable supply of food is kept in storage by the facility. (Continue to LIC809) (Continued from LIC809) Common Areas: These include the activity room, lounge, snack rooms, laundry rooms and dining areas. The furniture is in good repair. Hallways and passageways are free of obstruction. Surrounding Grounds: Entry/exits and hallways were free of obstruction. There is a courtyard accessible to residents with appropriate outdoor furniture. The outdoor area was free of hazards. There are no bodies of water. Bedrooms: LPA toured five (05) resident bedrooms of which two (02) were private use and three (03) were shared. LPA observed rooms were clean appropriately furnished and had sufficient storage and lighting. Bathrooms: LPA toured five (05) resident bathrooms and found that all bathrooms were clean and equipped with the required grab bars, non-slip flooring, and an adequate supply of toilet paper and hand soap. Medications: At 11:42 a.m., LPA Rios, with the assistance of Licensed Vocational Nurse (LVN) J. Ulmer, conducted a review of medications and medication records at one (1) of the two (2) nursing stations. All centrally stored medications were observed to be securely locked in medication cabinets and properly labeled. Medications requiring refrigeration were stored appropriately in the designated medication refrigerator. With assistance from the LVN, LPA reviewed both the physical medications and the electronic medication records. LPA Casillas reviewed facility's Emergency Disaster Plan (LIC610E), Emergency Operation Plan, Fire and Safety Inspection (STD850) for the modular unit, Fire Drills, Liability Certification and Bond and specialty insurance. LPA Casillas reviewed the annual inspection report conducted by the County of Los Angeles Fire Department. The CA Department of Forestry and Fire Protection conducted an annual inspection on 02/19/2025. Report states that there were no deficiencies noted and that required corrective action previously mentioned have been corrected. LPAs also examined the facility’s infection control plan, fire drill records last conducted on 12/23/25, and after-action reports for both the "Shake Out" drill and the reception of West Los Angeles RCFE residents affected by the Palisades Fire. Facility provided LPAs with a fire system smoke detector inspection conducted by Champions Fire System Inc certifying no defects for devises. It appears all fire extinguishers were last serviced on 01/12/2026. (Continued to LIC809-C) Page 2 of 2 (Continued form LIC8090C) From approximately 1:30 p.m. to 4:32 p.m., LPAs, with the assistance of Supervising Psychiatric Social Worker, S. Misra and Registered Nurse (RN) M. Altamirano, reviewed ten (10) resident records to verify completeness and compliance with licensing standards. Additionally, with the support of C. Ezparza, LPAs reviewed six (6) staff records to ensure adherence to licensing requirements and confirmation of current training. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during today’s visit. Exit interview conducted. Copy of this report issued. (Page 3 of 3)the state’s words, verbatim · CDSS document, Jan 28, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Evelin Rios conducted a Case Management - Incident visit. LPA met with the Administrator, Edina Lemus and Assistant Administrator, Wendi Doyon. LPA informed them of the purpose of the visit. On 11/17/25, the Department received a self-reported Unusual Incident Report (UIR) indicating that on 11/14/25, the California Highway Patrol (CHP) visited the facility to investigate an allegation involving Staff #1 (S1). The allegation reported that S1 engaged in neglect, yelling, and intimidation towards Resident #1 (R1), and failed to provide basic services to Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4). Additionally, S1 was alleged to have intimidated Resident #5 (R5). During today’s visit, LPA interviewed staff and residents, and reviewed a copy of the letter provided to CHP as well as the UIR. According to the Administrator, on 11/21/25, CHP conducted resident interviews and informed the Administrator that the investigation would be closed. LPA interviewed five (5) out of five (5) residents named in the report, as well as a randomly selected Resident #6 (R6). All six residents denied experiencing any form of mistreatment from staff and stated they were satisfied with the care provided. R2 stated they prefer to do their own laundry and do not require staff assistance for most basic needs. S1 denied the allegations. LPA’s review of records confirmed that once the facility was informed of the allegation by CHP, they notified Community Care Licensing and the Long-Term Care Ombudsman as required. Based on the information reviewed, no further action will be taken at this time. LPA did not identify any witnesses to the alleged incidents, and interviews conducted did not corroborate the allegations. No health or safety hazards were observed during the visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 2, 2025

Allegation investigated: Staff are not following a physician's orders.

On 09/05/25, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival, LPA was greeted by staff and asked to sign in. LPA then met with the Administrator Edina Lemus. LPA explained the purpose of the visit. Allegation: Staff are not following a physician's orders. Regarding the allegation, it was reported that staff did not administer Resident (R1)'s PRN (as-needed) medication at the time it was requested, and that R1's oxygen tank was removed by staff. To investigate the allegation LPA Rios conducted an initail visit on 08/25/2025. During the visit, at approximately 10:39 a.m., LPA requested documentation including, but not limited to, the resident roster, personnel report, R1's physician’s report, centrally stored medication records, and Inter-disciplinary Team (IDT) meeting notes. At approximately 10:56 a.m., LPA Rios conducted an interview with the Supervising Registered Nurse, Takira Florence. From approximately 12:30 p.m. to 2:00 p.m., LPA completed a physical plant tour of the facility and interviewed five (05) residents. At 3:19 p.m., LPA interviewed an additional staff member. (Continue to LIC9099-C) Unsubstantiated (Continued from LIC9099) During today's subsequent visit, at approximately 1:33 p.m., LPA interviewed Dr. Mariam Schwartz, a licensed Physician and Surgeon. Although Dr. Schwartz is not R1’s primary physician, she indicated she is part of the IDT that ensures alignment in care for R1. LPA also briefly met with Supervising Registered Nurse and staff member to clarify information provided during the previous interview conducted on 08/25/2025. LPA’s interview with R1 on 08/25/2025 revealed that the resident affirmed the allegation. According to R1, there were two separate occasions that staff held R1's medication while it was being centrally stored by the facility citing a written order to delay administration following prior opioid use. R1 was only able to provide a date for one of the two incidents. R1 did not believe their was such an order. Additionally, R1 affirmed her oxygen tank was removed from her room, with the facility citing R1 did not have a prescription order for the use of oxygen. According to R1 they have a letter from their doctor confirming the use and need of the oxygen. LPA obtained a copy of the letter. LPA confirmed with R1 that they were reassessed and now have control of all their PRN medication. Interview with four (04) out five (05) residents on 08/25/2025 corroborate not having issues regarding their medication. An interview with the staff member on 08/25/2025 confirmed that on one occasion, PRN medication was delayed because R1 had recently taken a dose of opioid PRN medication for pain. The staff member recalled the incident may have happened in August 2025. Both the staff member and Dr. Schwartz indicated—though not verbatim—that delaying medication in such circumstances is a safety precaution intended to monitor the resident’s response. According to Dr. Schwartz and the Supervising Registered Nurse, the medication in question is in pill form and requires time to dissolve and take effect. Page 2 of 3 Continued to LIC9099-C LPA’s review of R1’s centrally stored medication records, medication administration record (MAR) for June and July 2025, and medication profile for August 2025 revealed that the medication order was updated in July to include instructions to hold PRN opioid medication for four hours if a prior dose of opiod medication had been administered. This instruction was not present in the June documentation. According to R1's physician's report their medication became centrally stored on 06/10/2025. LPA's review of R1's letter confirmed R1's use of oxygen. However it was not a prescription and no current prescription or letter has been provide stating the medical reason for the use of oxygen. LPA's review of Inter-disciplinary Team (IDT) meeting notes, Dr.Schwartz interview and clinical notes corroborate that R1's physicians state there is no indication for the use of oxygen. R1's physicians will also not provide a prescription. Interview with Administrator and Supervising Registered Nurse on 08/25/2025 confirmed the oxygen supplement was removed from R1's room and placed in facility storage for R1. Based on record reviews indicating no documented medical need for oxygen, confirmation of medication hold orders, and corroborating staff interviews, this allegation is deemed unsubstantiated at this time. No health or safety concerns were observed at the time of the visit. An exit interview was conducted, and a copy of the report was provided. Page 3 of 3the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 31-AS-20250819093514

Allegation investigated: Residents are not allowed privacy.

On 08/13/2025, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility for an unannounced subsequent complaint visit. Upon arrival, LPA was greeted by security and asked to sign in. LPA then met with Assistant Administrator Wendi Doyon and Administrator Edina Lemus. The purpose of the visit was explained, and an entrance interview was conducted. LPA Rios conducted a physical plant tour of the facility and did not observe any immediate health or safety concerns. Allegation:Residents are not allowed privacy. Regarding the allegation, it was reported that residents are not accorded privacy during sensitive conversations with Veterans Service Officer (VSO). LPA’s review of the CalVet website found that VSOs work directly with individual veterans and their families to ensure veterans receive benefits they earned through their service. (Cont. to LIC9099-C) Substantiated (Cont. from LIC9099) To investigate this allegation, LPA Rios interviewed the Administrator on 07/09/2025. The Administrator explained that the VSO had previously been teleworking and conducting resident meetings by telephone, which allowed residents the opportunity to discuss topics in private. However, the VSO has since transitioned to working from a cubicle and would schedule appointments in a small conference room when meeting with residents. During today's visit the Assistant Administrator informed LPA the VSO was no longer working for the facility and provided LPA a tour of the cubicles the VSO would have used when working at the facility. LPA Rios also interviewed four (04) residents or approximately 10 percent of the facility’s population and one (01) staff member. Resident #1 (R1) and Resident #2 (R2) both reported that they did not have privacy during their appointments with the VSO. They stated not verbatim, that meetings were held in a cubicle within arm’s length of another person and that they were not offered the option of a private room. Resident #3 (R3) had not personally met with the VSO but reported hearing complaints from other residents expressing discomfort with the lack of privacy during cubicle meetings. Resident #4 (R4) did not recall meeting with the VSO. R3 added that although they personally did not mind the lack of privacy, they understood why others might be concerned. They did not consider the information discussed to be sensitive but acknowledged that privacy expectations vary among individuals. LPA’s review of the facility’s HIPAA privacy policy found that while staff are required to receive appropriate training, training alone does not replace the need for physical safeguards to protect resident privacy. Based on the information obtained through resident interviews and LPA’s own observations, the allegation that residents are not allowed privacy during VSO appointments is deemed Substantiated at this time. Deficiency cited (refer to LIC9099-D). Exit interview conducted. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 31-AS-20241211135010

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 29, 2025

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on LPA's observation and interviews, the licensee did not comply with the section cited above by not providing privacy and conducting VSO appointments in a cubicle by other staff, which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 13, 2025

Plan of correction: The Administrator agreed to conduct an action plan that will be implemented to allow for private meetings in a closed conference room. Plan will be emailed to LPA by the POC due date.

Allegation investigated: Staff is not following food service sanitation practices. Facility did not follow food safety guidelines when preparing food.

On 07/09/25, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival, LPA was greeted by security and asked to sign in. LPA then met with Assistant Administrator, Wendi Doyon and later with Administrator Edina Lemus. LPA explained the purpose of the visit. Allegation: Staff is not following food service sanitation practices. Regarding the allegation it was reported that staff used personal cellphones while serving meals and and did not use gloves while preparing food. To investigate the allegation LPA Rios conducted an initial complaint visit on 06/06/25. On 06/06/25 LPA Rios interviewed seven (07) out of thirty-six (36) residents or over 10% of the population. LPA Rios interviewed the administrator and six (06) staff. LPA also obtained and reviewed copies of the facility’s Hand Washing and Food and Nutrition Service Policies, along with documentation of in-service training sessions conducted on 12/02/24, 02/13/25, and 04/24/25. Job applications for food service staff were also examined to verify qualifications and experience. (Continue to LIC9099-C) Unsubstantiated (Continued from LIC9099) An additional staff interview was conducted on 09/09/25 at approximately 1:00 p.m. LPA's interview with seven (07) out of (07) residents 06/06/25 deny the allegation. Residents corroborate not witnessing staff on their cellphones while serving meals. LPA's interview with five (5) out of (07) staff denied seeing coworkers use cellphones while serving meals or failing to follow sanitation protocols. One (1) staff member noted that new employees occasionally need reminders to wear gloves, but confirmed that these issues were addressed before any incidents occurred. Another staff member acknowledged a past concern involving cellphone use but stated it had been resolved and had not occurred recently. Two (2) staff members reported having witnessed other staff use cellphones without washing their hands or changing gloves during meal service. One (1) of these staff also recalled seeing staff #1(S1) prepare food without gloves. However, the second staff did not corroborate that specific observation. LPA’s review of facility policy confirmed clear guidance on hand washing procedures, and documentation confirmed that staff had participated in multiple training sessions involving hand hygiene. Staff job applications reviewed by LPA revealed staff have appropriate qualifications to perform assigned food service duties. While some staff reported isolated concerns, the majority of resident and staff interviews did not corroborate the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Facility did no follow food safety guidelines when preparing food. Regarding the allegation it was reported that food felt under cooked. To investigate the allegation, LPA Rios conducted an initial complaint visit on 06/06/25. On 06/06/25 LPA Rios interviewed seven (07) out of thirty-six (36) residents or over 10% of the population. LPA Rios interviewed the administrator and six (06) staff. LPA also obtained and reviewed copies of the facility’s menu, residents that ate meals prepared by the facility, nurse's daily notes for 05/03/25, food temperature log, along with staff individual food safety training. LPA Rios also observed the kitchen and dining area on 06/06/25 during lunch time. LPA's interview with four (04) out of (07) residents interviewed on 06/06/25, stated they were satisfied with the quality and temperature of the food served and denied the allegation. LPA's interview with three (03) out of seven (07) residents reported that their meals felt colder than preferred, believing the food may have been undercooked. However, the residents did not reference the same meal or confirm a consistent issue. One (1) of the three noted that such concerns were in the past and that the food served more recently has improved. Six (06) out of (07) staff denied the kitchen staff do not follow food safety guidelines. (Page 2 of 3) (Continued from (LIC9099-C) five (5) acknowledged that one resident prefers food to be extremely hot and may return meals that do not meet that personal preference—even when temperatures are within regulatory range. Staff consistently stated that food is temperature checked after cooking and again while placed on the steam table prior to serving. LPA observed staff conduct temperature checks during lunch service, and all measurements were found to be within the appropriate range. Although some residents expressed personal preferences regarding food temperature, the investigation did not reveal consistent or corroborated evidence of undercooking or failure to follow food safety protocols. Based on LPA's observations and facility records, the allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. Copy of report provided. (Page 3 of 3)the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 31-AS-20250529104617

Allegation investigated: Staff do not ensure that resident needs are met. Staff photographed residents without the resident's consent

On 07/09/25, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility for an unannounced subsequent complaint visit. Upon arrival, LPA was greeted by security and asked to sign in. LPA then met with Administrator Edina Lemus and Assistant Administrator Wendi Doyon and explained the purpose of the visit. An entrance interview was conducted. To investigate the allegations LPA Rios conducted an initial complaint visit on 12/16/24 in conjunction with an Annual Required visit. On 12/16/24 from 10:30 a.m. to 12:00 p.m., LPA conducted a physical plant tour of the facility with Agnieszka Sibbitt, the Supervisory Registered Nurse. At approximately 4:07 p.m., LPA obtained a copy of the facility's policies. LPA interviewed administrator at 4:33 p.m. On 04/14/25 LPA Rios conducted an annual continuation visit, during that visit LPA toured two (02) bedrooms and interviewed two (02) residents. On 05/28/2025 LPA Rios interviewed seven (07) residents, the assistant administrator and five (05) staff. (Continue to LIC9099-C) Unsubstantiated (Continued from LIC9099) Allegation: Staff do not ensure that resident needs are met. Regarding the allegation, it was reported that staff are neglecting residents’ needs due to personal socializing during work hours. LPA’s interview with seven (07) out of nine (09) residents, denied staff’s socialization interferes with providing them or other residents with assistance. One (01) out of the seven (07) residents that provided information regarding the allegation stated staff will have small talk and socialize but are professional. Two (02) out of the nine (09) residents interviewed declined to comment or expressed that the issue was not of concern to them. Based on interviews, LPA was unable to corroborate the allegation. LPA did not find consistent evidence to suggest that staff socializing negatively impacts the care of residents. Therefore, this allegation is deemed Unsubstantiated at this time. Allegation: Staff photographed residents without the resident's consent. Regarding the allegation, it was reported staff are compromising residents' privacy and dignity by taking selfies in the dining room with residents in the background. To investigate the allegation LPA Rios conducted interviews with the facility administrator and staff #1 (S1), reviewed photo in question, and interviewed residents. The administrator and S1 confirmed that, on 12/11/24, during breakfast service in the dining area, staff members were observed engaging in personal activities unrelated to resident care—specifically, taking a selfie with a personal cell phone while residents were present in the background. S1 stated the photo was taken in a casual dining space—not during direct care—and believed the residents were not identifiable or the focus of the image. LPA’s review of the photo corroborated this, noting that residents in the background were not clearly identifiable. LPA’s Interviews with two (2) of nine (9) residents conducted on 04/14/25 and 05/28/25, revealed that they have witnessed staff using cell phones, though they could not determine whether usage was for personal or work related matters. One (1) of those two (02) residents recalled seeing a staff member take pictures but did not raise any concerns regarding the incident; this was confirmed to be unrelated to the event described in the allegation. LPA’s review of CalVet’s policy revealed that personal cell phone use is only allowed on breaks and away from residents, visitors, and other staff. While the use of personal cell phones during duty hours may conflict with internal facility policy, the specific allegation regarding photographing residents without consent is Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 31-AS-20241211135010

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 07/09/25, in conjunction to complaint control number 31-AS-20241211135010, Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced case management deficiency visit. LPA met with the Administrator Edina Lemus and explained the reason for the visit. During the investigation LPA confirmed that facility staff used a personal cell phone to take a "selfie" in the residents’ dining area in the proximity of residents and other staff. Though no residents were identifiable in the image, and consent was not determined to be required, the use of cellphones violated the facility’s internal policy prohibiting personal cell phone use during work hours and within resident areas. Interview with Staff #1 (S1) and the administrator corroborated that S1 used a personal cell phone during duty hours to take a selfie with other staff. The administrator stated they have addressed the issue with S1 and a new letter of expectations will include the policy. Technical Violation issued (refer to LIC9102). Appeal rights provided. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 9, 2025

Allegation investigated: Staff requests gifts from residents. Staff interferes with Resident Council meetings.

On 06/06/25, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above for an subsequent complaint visit to deliver findings on the above allegations. LPA was greeted by security and asked to sign in. LPA met with the Administrator, Edina Lemus and Assistant Administrator, Wendi Doyon. LPA explained the purpose of the visit. Entrance interview conducted. LPA requested a copy of the resident roster and personnel report. To investigate the allegations LPA Rios conducted an initial complaint visit on 12/16/24 in conjunction with an Annual Required visit. On 12/16/24 from 10:30 a.m. to 12:00 p.m., LPA conducted a physical plant tour of the facility with Agnieszka Sibbitt, the Supervisory Registered Nurse. At approximately 4:07 p.m., LPA obtained a copy of the facility's policies. LPA interviewed administrator at 4:33 p.m. On 04/14/25 LPA Rios conducted an annual continuation visit, during that visit LPA toured two (02) bedrooms and interviewed two (02) residents. On 05/28/2025 LPA Rios interviewed seven (07) residents, the assistant administrator and five (05) staff. (Continue to LIC9099-C) Unsubstantiated (Continued from LIC9099) Allegation: Staff requests gifts from residents. Regarding the allegation, it was reported that, staff will make requests from residents for certain baked goods or sweets as well as accept gifts from residents. During an interview conducted by LPA on 12/16/24, the administrator denied this allegation. Additionally, interviews with nine (09) residents on 04/14/25 and 05/28/25 corroborated that they had not been asked by staff for any gifts. Two (02) residents stated that the facility discourages residents from gifting staff, citing an strict facility policy. LPA's interview with resident #3 (R3) revealed that they enjoy purchasing candy on Valentine’s Day and distributing it to everyone. R3 expressed disagreement with the policy, stating that they wish to show appreciation to staff. LPA was unable to find corroborating evidence to support the allegation. Based on the interviews, the allegation is deemed Unsubstantiated at this time. Allegation: Staff interferes with Resident Council meetings. Regarding the allegation it was reported that staff regularly attend the Resident Council meetings without invite which causes residents to not feel free to discuss matters. An interview conducted by LPA with the assistant administrator on 05/28/2025 revealed that, at least in their case, they were invited by a Resident Council member and have not been informed that their presence is a concern. Additionally, an interview with one (01) staff member who attends the meetings indicated that they were invited and provide assistance through note-taking. LPA confirmed with the Resident Council member that they did invite staff to attend meetings and has not rescinded the invitation. Of the nine (09) residents interviewed on 04/14/2025 and 05/28/2025, six (06) stated that they participate in Resident Council meetings. Among them, one (01) resident expressed concerns about staff presence and participation in meeting discussions. However, this resident also believes that staff were invited and that the issue has not been formally addressed among residents or staff. Further interviews with five (05) out of the seven (07) residents who attend meetings revealed that they have no concerns or issues regarding staff participation or presence. Based on these interviews, the allegation is deemed Unsubstantiated at this time. No deficiencies issued. Exit interview. Report signed and delivered.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 31-AS-20241211135010

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Resident rooms are unsanitary. Resident visitors are not allowed to visit privately. Staff is opening residents mail.

On 05/28/25, Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above for an subsequent complaint visit. LPA was greeted by security and asked to sign in. LPA met with the Assistant Administrator, Wendi Doyon and Executive Secretary I, Nanci Alvarado. LPA explained the purpose of the visit. Entrance interview conducted. LPA requested a copy of the resident roster and personnel report. To investigate the allegations LPA Rios conducted an initial complaint visit on 12/16/24 in conjunction with an Annual Required visit. On 12/16/24 from 10:30 a.m. to 12:00 p.m., LPA conducted a physical plant tour of the facility with Agnieszka Sibbitt, the Supervisory Registered Nurse. At approximately 4:07 p.m., LPA obtained a copy of the facility's policies. LPA interviewed administrator at 4:33 p.m. On 04/14/25 LPA Rios conducted an an annual continuation visit, during that visit LPA toured two (02) bedrooms and interviewed two (02) residents. On today's visit LPA Rios interviewed seven (07) residents, the assistant administrator and five (05) staff. (Continue to LIC9099-C) Unsubstantiated Allegation: Resident rooms are unsanitary. In regards to the allegation is was reported that two (2) rooms are unsanitary. On 04/14/25 during an annual continuation visit LPA toured the two (02) rooms reported in the allegation. LPA observed both rooms where the residents bed is to be cluttered with residents' personal belongings such as unopened drinks and food on the floor and on furniture surfaces. Both rooms bathrooms were observed clean and clear of clutter. LPA's interview with resident #1 (R1) and resident #2 (R2), confirmed that housekeeping regularly visits their room to clean. Interview with R1 revealed they direct staff to clean around their belongings without moving them. Interview with R2 revealed they decline cleaning services and admitted to the LPA that they may become hostile with staff when they enter the room to clean. Interview with seven (07) residents on 05/28/2025 state that housekeeping is regularly cleaning their rooms and have no concerns regarding the cleanliness of their bedrooms. On 12/16/24, LPA toured three (03) shared rooms and on 05/28/2025 toured two (02) shared rooms. LPA observed the rooms to be clean and sanitary. Interview with one (01) housekeeping staff on 05/28/25 revealed they clean rooms every day and has experienced reluctance specifically from R2 but per management direction they are working on engaging with the resident in order to be able to clean the room more often. Interview with the administrator on 12/16/24, the Administrator is aware of the resident’s refusal and continues to engage in ongoing discussions regarding their preferences. Although the bedrooms mentioned in the allegation were observed with items cluttering surfaces, the residents residing in the rooms informed LPA they refused cleaning services. Based on interviews the allegation is deemed Unsubstantiated at this time. Allegation: Resident visitors are not allowed to visit privately. In regards to the allegation it was reported that management has been having the residents’ visitors escorted for the entire visit. LPA's interview with the administrator on 12/16/24 informed LPA visitors are allowed in resident's bedrooms and outside if they wish to meet residents in private. Interview with five (05) out of the nine (09) total residents interviewed on 04/14/25 and 05/28/25 that stated they have visitors in the facility did not corroborate the allegation. Interview with Residents' revealed no issues or concerns regarding meeting visitors in private such as in their room. Interview with five (05) staff on 05/28/2025 denied the allegation. LPA was unable to find corroborating evidence to the allegation. Based on interviews the allegation is deemed Unsubstantiated at this time. (Page 2 of 3 Continue to LIC9099-C) Allegation: Staff is opening residents mail. In regards to the allegation is was reported that resident's mail is being opened before the resident is informed. LPA's interview with two (02) out of nine (09) residents interviewed on 12/16/24 and 05/28/25 revealed they had issues regarding their mail. Interview with Resident #3 (R3) revealed a few years ago they had retrieved a letter from their mail box and it appeared to have been slightly open from one corner. However, R3 was not sure if it was an issue with the mail person or the staff in the facility. Interview with Resident #4 (R4) revealed they had new medication mailed to them and it was held at the medication room. According to R4 the nurse was going to open the package in front of them. Interview with the administrator on 12/14/25 revealed the mail is left with the security guard and they place the mail into residents' mailboxes and the only time they would hold a delivery is when there may be medication in the package. Staff are directed to open the package in front of the resident in order to document medication and centrally store medication if needed. Interview with one (01) Licensed Vocational Nurse corroborated the procedure for handling medication delivers going into further detail if new medication arrives they will call the resident's doctor to confirm the medication or receive a prescription for it to place on file. Interview with the other seven (07) seven residents did not corroborate the allegation stating they have no issues or concern regarding their mail. Based on interviews the allegation is deemed Unsubstantiated at this time. No deficiencies issued. Exit interview. Report signed and delivered. (Page 3 of 3 Continued from LIC9099-C)the state’s words, verbatim · CDSS document, May 28, 2025 · control 31-AS-20241211135010

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

Type of visit: Case Management - Annual Continuation

On 04/14/25, at approximately 9:30 a.m., LPA Evelin Rios conducted an unannounced annual continuation case management visit. Upon arrival, LPA signed in at reception as requested by the security guard. LPA was then greeted by Supervisor Psychiatric Social Worker Seema Misra, who escorted LPA to the Administrator's office. There, LPA met with Administrator Edina Lemus and explained the purpose of the visit. During the initial annual visit on 12/16/24, the facility had completed the required corrective actions noted in its fire and life safety inspection from 06/10/24. As part of today’s assessment, LPA reviewed the facility’s fire and life safety re-inspection report dated 02/19/25. The inspection confirmed the facility had passed. Additionally, LPA reviewed the annual inspection report conducted by the County of Los Angeles Fire Department, which showed no deficiencies. LPA also examined the facility’s infection control plan, fire drill records, and after-action reports for both the "Shake Out" drill and the reception of West Los Angeles RCFE residents affected by the Palisades Fire. From approximately 11:06 a.m. to 12:00 p.m., LPA, assisted by Staff Services Manager I, Annette Barrera, and Nurse Instructor Takira Florence, reviewed seven (07) staff records to ensure compliance with licensing requirements and up-to-date training. From 1:00 p.m. to 3:30 p.m., LPA reviewed six (06) resident records for completeness and adherence to licensing standards. No issues were observed during the review. During the initial annual visit on 12/16/24, LPA toured three (03) shared rooms. On today’s visit, LPA toured two (02) additional shared rooms. All rooms were appropriately furnished and had sufficient lighting. (Continue to LIC809-C) During today's visit, two (02) residents confirmed that housekeeping regularly cleans their rooms. One (01) resident, however, stated they decline cleaning services. The Administrator is aware of the resident’s refusal and continues to engage in ongoing discussions regarding their preferences. During the initial annual visit on 12/16/24, LPA toured three (03) resident bathrooms. On today’s visit, two (02) additional bathrooms were inspected. All bathrooms were found to be clean and equipped with the required grab bars, non-slip flooring, and an adequate supply of toilet paper and hand soap. Medications are centrally stored in two designated locations. All medications were observed to be securely locked in medication cabinets, properly labeled, and stored according to regulations. Medications requiring refrigeration were appropriately stored in a designated refrigerator. With assistance from Barbara Fahey, LPA reviewed both the medication and electronic medication records, as well as observed the medication assistance process. No issues were noted. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Apr 14, 2025

Type of visit: Required - 1 Year

On 12/16/2024 at approximately 10:30 a.m. Licensing Program Analyst (LPA) Evelin Rios, conducted an Annual Required visit and inspection of the facility. Upon entry LPA was asked to sign in by a security guard at reception. Facility utilizes one main entrance for visitors and has different entry and exits for residents and staff through out the facility. LPA met with Administrator Edina Lemus, and explained the reason for the visit. LPA requested a copy of the resident roster, personnel report, and facility's policy other than what was submitted during the application process. LPA along with the administrator and later with Agnieszka Sibbitt, the Supervisory Registered Nurse conducted a physical plant tour at approximately 10:50 a.m., and the following was observed: By the main entrance and through out the facility LPA observed appropriate postings such as, resident's rights, Rights of Resident Council, the facility's activity calendar and menu. Kitchen: The kitchen has an industrial setting and observed to be clean and in proper order. Appliances and fixtures were observed to be functional. Sufficient amount of perishable and non-perishable food were in stock and properly stored. Kitchen is inaccessible to residents. Dishwashing liquids and other cleaning agents are separated from food preparation area. LPA discussed food delivery, meal planning and overall food monitoring with the Food Manager on today's visit. The CA Department of Forestry and Fire Protection conduct an annual inspection on 06/10/2024. LPA requires more time to review CAL FIRE's report. Report states deficiencies were noted and require corrective action. Facility provided to LPA, a fire system smoke detector inspection conducted by Champions Fire System Inc certifying no defects for devises. It appears all fire extinguishers were last serviced on December 15, 2023. Common Areas: These includes the activity room, gym, lounge, snack rooms, and dining area. (Continue to LIC809) The furniture is in good repair. Hallways and passageways are free of obstruction. Surrounding Grounds: Entry/exits and hallways were free of obstruction. There is a court yard accessible to residents with appropriate outdoor furniture. The outdoor area was free of hazards. There are no bodies of water. LPA reviewed facility's Emergency Disaster Plan (LIC610E), Emergency Operation Plan, Fire and Safety Inspection (STD850) for the modular unit, Fire Drills, Liability Certification and Bond and speciality insurance. At approximately 2:10 p.m. LPA and the administrator discussed the PolicyTech and whether the administrator before had submitted the information to CCL. Administrator could not definitely say if one was provided but confirmed any updates or changes to PolicyTech have not been submitted to CCL. Due to time restraints, LPA was unable to complete the annual visit at this time. LPA did not review any staff files, resident records, or medication documentation at the time of this visit. A follow-up visit will be conducted at a later date to complete the annual inspection. Deficiency Cited and cleared on todays visit (refer to LIC809-D). Exit interview conducted. Appeal Rights Provided. Copy of report signed and provided.the state’s words, verbatim · CDSS document, Dec 16, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Evelin Rios, Michael Cava and Raymond Comer conducted an Annual Required visit and inspection of the facility. LPAs met with Administrator Edina Lemus, and explained the reason for the visit. Facility is fire cleared for fifty (50) non-ambulatory residents, and ten (10) bedridden for a total capacity of sixty (60) residents. Facility has a Hospice waiver for ten (10) residents. LPA's observed required postings through out the facility. The facility's smoke alarms are hard wired and facility conducts quarterly inspections. The Department of Forestry and Fire Protection and Champions Fire System Inc, conduct annual inspections. The fire extinguishers throughout the facility hallways, all extinguishers were last serviced on December 15, 2023. At approximately 11:30 a.m., with the assistance of the administrator and Chief of Plant Operations, Mordacious Mortem a tour of the physical plant was conducted and the following was observed. Bedrooms: Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Bathrooms: Resident bathrooms were properly supplied and had functional fixtures. Hot water temperature in random resident bathrooms were checked and measured a range of 105.°F to 120°F and within the required range. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility; properly stored. Residents do not have access to the kitchen; dangerous items are properly stored and inaccessible to residents. The facility menu appears to meet the daily dietary needs of the residents. There were no pesticides or poisons observed near any food areas. Common Areas: Common areas, including two (2) activity rooms, (2) libraries, one (1) dining room, and sittings areas through out the facility appeared clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The facility sectioned off areas that have active construction for resident safety. Resident Files: LPA conducted a file review of five percent of the current census. LPAs reviewed resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: The medications were centrally stores in two locations. Medications were locked in medication cabinets, properly labeled and stored. Medication requiring refrigeration was observed in a locked refrigerator. Medication documentation was observed complete. Facility keeps electronic medication records. There are First Aid Kits through out the facility hallways. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Feb 27, 2024