Brookdale Anaheim.

CONTINUED FROM FORM LIC9099 During the present visit, LPA requested and obtained the facility's census and staff schedule and conducted a tour of the physical plant and observed eleven units throughout the facility. Additional staff and resident interviews were conducted. Regarding the allegation that Staff are not providing adequate laundry services , the following has been concluded: LPA observed laundry day assignments are posted in clear view in each of the units visited. Residents interviewed reported no issues or concerns with the weekly laundry service provided. Linens are cleaned as needed in addition to the weekly scheduled service and were verified to be clean in each of the units visited. Residents observed in their bedrooms or in the facility's common living areas were all observed wearing clean clothing. Regarding the allegations that Staff are not assisting resident with cleaning and that There is an odor , the following has been concluded: A tour of the facility's three levels' common areas, hallways and eleven units failed to evidence any odors that could result from insufficient cleaning. Residents interviewed all confirmed that their units were vacuumed and cleaned once weekly by housekeeping staff on their regularly scheduled day. Staff interviewed confirmed the frequency of cleanings and added that additional soiled areas were typically addressed in a timely manner. Regarding the allegations that Staff make inappropriate comments to the residents and that Staff do not treat the residents with dignity , the following has been concluded: None of the interviews conducted with staff and residents evidenced any instance of staff members acting inappropriately or failing to treat the residents with dignity. All residents interviewed stated their appreciation for staff members and lack of concerns in how they are treated at the facility. Multiple residents interviewed have been admitted at the facility for multiple years and expressed overall satisfaction with the care received there. Based on the evidence gathered, the allegations listed above are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to a facility representative.

Per observations, LPA observed that some resident rooms were locked and unlocked and verified by residents that it was per personal preference. Resident interviews also verified that despite having locked doors, it did not result in services not being provided timely. LPA was unable to obtain copies of records relevant to the allegation due to LPA Rodriguez making multiple attempts to contact reporting party, to gather additional information, however calls were not returned, therefore, further information was not provided. It was alleged that resident is not being able to have adequate visitation. 8 out of 8 resident interviews did not corroborate with the allegation by verifying that visitation is allowed at the facility and reported no issues. 2 out of 2 staff interviews did not corroborate with the allegation. 1 staff interview revealed that the only instance where visitation was stopped, was during COVID times to ensure that the universal protocols were being adhered to, however residents were provided an option for video calls. LPA was unable to obtain copies of records relevant to the allegation due to LPA Rodriguez making multiple attempts to contact reporting party, to gather additional information, however calls were not returned, therefore, further information was not provided. It was alleged that resident is not being fed in a timely manner. 8 out of 8 resident interviews did not corroborate with the allegation by stating that they have to wait for their food “for a few minutes”. 2 out of 2 staff interviews did not corroborate with the allegation. During this visit, LPA observed staff serving breakfast and observed that meals were served to residents within a period of 5-14 minutes and observed that no residents were waiting for an extended period of time and verified that all residents received their meals. LPA was unable to obtain copies of records relevant to the allegation due to LPA Rodriguez making multiple attempts to contact reporting party, to gather additional information, however calls were not returned, therefore, further information was not provided. It was alleged that resident’s goods are being mishandled. 8 out of 8 resident interviews did not corroborate with the allegation by stating that there were no concerns regarding their goods/belongings being mishandled. 2 out of 2 staff interviews did not corroborate with the allegation by stating that residents are responsible for their own belongings. LPA was unable to obtain copies of records relevant to the allegation due to LPA Rodriguez making multiple attempts to contact reporting party, to gather additional information, however calls were not returned, therefore, further information was not provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 It was alleged that staff are handling resident in a rough manner when provided services. 8 out of 8 resident interviews did not corroborate with the allegation by stating that staff were “great” “kind” “welcoming” “knowledgeable” “professional” and “well-trained”. 8 out of 8 resident interviews also denied of experiencing or witnessing staff handle residents in a rough manner. 2 out of 2 staff interviews did not corroborate with the allegation. Per documentation review, staff complete trainings such as: resident personal rights, care and supervision, abuse trainings, and mandated reporting trainings – of which staff are unable to begin working on the floor with residents if not completed prior. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with ED Byington. A copy of this report was explained and provided.

During the tour of the facility, LPA observed kitchen staff engaging with residents, cooking meals from scratch, and observed that facility had an adequate supply of 2-day perishable and 7-day non-perishable food items. Per facility menu, facility offers breakfast (7:30AM-9:00AM), lunch (11:30AM-12:30PM), dinner and dessert (4:30PM-6:00PM), of which included fruits, vegetables, proteins, and carbs. It was also observed that tray service for meals to be served are provided to residents if and when needed. It was alleged that staff do not treat residents with respect. 7 out of 7 resident interviews did not corroborate with the allegation by stating that staff are “nice” “kind” and “a really good help”. Per record review, LPA observed that staff members complete training on care and supervision of residents, and resident rights. During the tour of the facility, LPA observed staff members on the floor, engaging with residents in discussions and activities. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation that occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with BOM Reyes. A copy of this report was provided and explained.

is unable to corroborate the allegations. Therefore the allegations are deemed to be UNSUBSTANTIATED, meaning although the allegations may have happened or is 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 report provided.

On July 17, 2025, Licensing Program Analyst Samer Haddadin conducted an unannounced annual inspection of the facility. Upon arrival, LPA Haddadin was greeted by Administrator Troy Byington, who granted entry and was advised of the purpose of the visit. Together, they toured both the interior and exterior of the three-story building, which houses a delayed-egress memory care unit, a commercial kitchen and large dining room, a medication room, multiple common areas and storage rooms, and two courtyards—one central and one dedicated to memory care—that offer shaded seating and ample space for resident activities. The facility contains 115 resident rooms, and the census at the time of inspection was 107 residents. During the visit, five residents were observed in their individual rooms, each of which was furnished with a bed, a chair, and clean linens, provided adequate storage, and was free of tripping hazards. Outdoor areas, including both courtyards, were well maintained: furnishings were in good repair, pathways were clear of hazards, and the grounds appeared safe and inviting. All safety equipment was current. The fire alarm system is maintained by a third-party contractor, with its most recent inspection completed on March 11, 2025. Fire Master serviced the extinguishers on June 2, 2025, and service tags indicate a prior inspection date of September 10, 2024. Hot water temperature was measured at 105.9°F, meeting regulatory requirements. The facility maintains sufficient food supplies, with at least a two-day cache of perishables and a seven-day cache of non-perishables. The kitchen was observed to be in good repair, and all major appliances were operational. Cleaning supplies were stored securely in the third-floor maintenance room, ensuring they remain inaccessible to residents. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 A review of resident files and corresponding medication logs revealed no discrepancies, and staff personnel records were complete, each containing the required documentation. Records further confirmed that the facility conducted its annual emergency drill on June 18, 2025. No deficiencies were noted during this inspection. An exit interview was conducted with Administrator Byington, and a copy of this report was provided at that time.

Regarding the allegation of unlawful eviction, it was reported that Resident #1 (R1) is being unlawfully evicted. Per review of the eviction notice, R1 is being evicted for a qualifying reason, and the notice included all elements required per Title 22 eviction procedures. R1 confirmed the rent was unpaid thus R1 is in breach of the Residency Agreement which states under I(1), Rule and Regulation Compliance, that resident “must pay all fees and charges” owed to the facility. Therefore, this agency has investigated the complaint and based on the interviews which was conducted and the records that were reviewed, the following allegation, Unlawful eviction, is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Executive Director Troy Byrington, and a copy of this report was provided at exit. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegation, Facility failed to safeguard resident’s personal items, it is alleged that cameras that belong to Resident #1 (R1) have gone missing. R1 confirmed losing 3 professional cameras, watches, black sunglasses, and many other valuable items. Based on LPA’s observations of R1’s room, the room was unorganized and full of clutter. During the walk through, LPA observed the three items listed on the LIC621 inventory such as a television, 4 watches, and sunglasses and other items. All personal property observed during the walk through was not inventoried upon admission as per the Theft and Loss Policy. Three out of three facility staff indicated that R1 moved in with a few personal belongings and had started to bring in more items that were hard to track and confirm the existence of such items. Additionally, five out of six residents denied experiencing theft. Therefore, based on the observations made, interviews which were conducted, and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation, Facility failed to safeguard resident’s personal items, is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Troy Byrington, and a copy of this report was provided at exit.

This unannounced case management deficiency visit is being conducted by Licensing Program Analyst (LPA) Sam Haddadin. Executive Director (ED) Troy Byington granted LPA Haddadin entry into the facility. On April 7, 2025, LPA Haddadin visited this facility to discuss the possibility of evicting a resident (R1) without providing a 30-day notice to Community Care Licensing for approval. It was determined at that time that the facility had not given a 30-day notice to R1; instead, R1 received a Pay or Quit letter, which does not constitute a legal eviction notice. According to regulations, the facility is required to submit a 30-day eviction notice to Community Care Licensing for approval before serving it to the resident. During today’s visit, and based on a review of records, LPA observed that an Unlawful Detainer had been issued by the facility through the Orange County Courts. Community Care Licensing never received a 30-day eviction notice from this facility for approval. Based on today’s visit, deficiencies were cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and information regarding appeal rights were discussed with and provided to the ED.

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced case management visit in regards of confirming a 30-day eviction notice. Upon arrival, LPA was greeted by Executive Director (ED), Troy Byington and was granted entry into the facility. LPA conducted a record review of the resident in question of the eviction and found that the resident’s file did not contain a 30-day eviction notice. LPA also interviewed the resident and confirmed that the resident was not given a 30-day notice. The facility is planning to move forward, at a later date, with the eviction. LPA advised ED to submit the 30-day eviction letter to Community Care Licensing for approval. An exit interview was conducted and a copy of this report was provided to ED.

It was alleged that facility staff entered the rooms of residents while they were getting dressed or disrobed. 5 out of 5 staff stated they did not enter any resident's room while they were getting dressed or disrobed. Staff all reported they knock on resident's rooms prior to entering. 6 out of 6 residents stated staff has not entered their rooms without permission and not while they were dressing. Regarding allegation staff do not ensure residents hygiene needs are met, 3 out of 5 residents stated they have not had any issues with staff assisting with showers and other hygiene needs or heard of any issues. The 2 other residents did not have direct knowledge as they do not need assistance with hygiene. 5 out of 5 staff deny they are not meeting resident's hygiene needs, Regarding the allegation staff do not ensure that resident is accorded dignity in their relationship with staff or other persons, 6 out of 6 residents stated they are treated with respect and dignity by all the staff at the facility. 6 out of 6 residents stated they no complaints about any of the staff. 5 out of 5 staff deny the allegation. Therefore based on records reviewed, interviews and observations the allegations staff do not give residents privacy to get dressed, staff do not ensure that residents hygiene needs are being met and staff do not ensure that residents are accorded dignity in their relations with staff or other persons are determined to be UNSUBSTANTIATED, meaning 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. An exit interview was conducted and a copy of the report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Therefore based on the preponderance of evidence through observations and interviews the allegation that Staff did not keep the facility clean and sanitary is determined to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. No deficiencies cited. An exit interview was conducted and a copy of this report was provided.

monthly service. Documentation stated no cockroach activity noted during treatment. LPA did not observe any cockroach activity during the visit. LPA observed three common restrooms during the visit, two located near the Administrator office and one in the Wellness office. All three restrooms are clean and sanitary with no health concerns noted. LPA did not observe any issues with the flooring or vents. Facility staff indicate restrooms are as they were in 2023 and no repairs have been done in that time frame. Based on interviews conducted and record review, LPA is unable to corroborate the allegations. Therefore the allegations are deemed to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of this report was left at the facility.

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. An exit interview was conducted and a copy of the report provided.

On October 2, 2024, at 12:30pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Visit to follow-up on a death report received from the facility. LPA Kim was greeted and granted entry by staff. LPA explained the purpose of the visit to Executive Director (ED) Troy Byington. During today’s visit, LPA conducted a health and safety check, and there were no imminent health/safety concerns observed. Facility maintained at a comfortable temperature for the residents in care. A two-day supply of perishable and seven-day supply of non-perishable food were observed to be sufficient at the time of inspection. LPA obtained LIC 500, LIC 9020, and R1’s records which includes the Physician’s Report, Admission’s Agreement, Emergency Information, Consent Forms, and Appraisal and Needs/Service Plan. LPA interviewed ED Troy Byington. No deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided to the Executive Director Troy Byington.

On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to follow up on documentation paperwork for a three day eviction notice issued on 9/23/2024. LPA met with Executive Director Troy Byington. LPA obtained the following requested documents for Resident 1 (R1): Residents Admission Agreement Resident's pre appraisal Most recent physician's report Caregiver progress notes/ Charting notes copy of medication list Copy of updated personal service plan copy of care plan LPA did not obtain any copies of pertinent incident reports, per Executive Director stated R1 did not have any on file. LPA did not obtain a copy of recent appraisal because one was not recently done but Facility provided copies of updated Care plan and Personal service plan. At today's visit LPA Tirre is issuing a citation for facility not providing documents when requested on 9/23/24. The following citation will be issued on D page. LPA conducted exit interview with Executive Director Byington. LPA provided copy of report along with 809 D-Page and LIC 811 confidential names list.

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 08/06/24 regarding Resident #1 (R1). LPA met with Administrator (AD) Troy Byington and discussed the purpose of the inspection. During the inspection, LPA and AD toured the facility and inspected R1’s room. LPA conducted health and safety checks on residents present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations, the electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA interviewed AD and staff and requested and reviewed copies of R1’s resident file. There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Troy Byington and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 9:00AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is composed of a single, three-story building with a delayed egress memory care unit on the first floor, a commercial kitchen and large dining room on the first floor, a medication room on the first floor, and resident rooms on all floors, along with multiple common areas, storage rooms, and a large central courtyard and a smaller courtyard dedicated to memory care with shaded seating for residents. There are a total of 115 resident rooms. Resident Bedrooms: the 12 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 12 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 degrees F and 120 degrees in the 12 resident bathrooms inspected. LPA also reviewed water temperature logs and inspected the thermostat on the outflow pipe from the large central water heater. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have been paid. At about 11:00AM, LPA reviewed 6 resident files and 6 staff files, interviewed 6 residents and 6 staff, and inspected medications for 6 residents. Facility does not handle resident money. There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

It was confirmed during the interviews with two out of the two staff that R1 stores the medications inside the pink lock box placed next to their recliner. R1 did not have a lock for the lockbox as the room is a for a single occupant. Four out of the five staff and one out of the one resident interviewed stated that they did not observe S1 stealing the medication. However, a witness staff indicated that S1 was observed to be on the second floor heading towards the direction of R1's room. S1 denied the allegation stating that they did not assist R1 in their bedroom on May 30th. LPA observed there were no surveillance cameras on the second floor. Therefore, based on the interviews which were conducted and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Staff stole the resident's medication is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Troy Byington, and a copy of this report including the LIC811s were provided at the end of the visit.

At the time the complaint was filed R1 did not respond to messages left by the LPA. R1 has since passed away. R1 was never interviewed. 5 out of 5 staff interviewed reported that they have never touched any resident inappropriately and had no knowledge of any staff touching R1 inappropriately. Based on the evidence gathered through a review of records and interviews the allegation, resident was touched inappropriate by staff is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, resident has fallen multiple times while in care , revealed the following. It was alleged that the resident fell multiple times while in care because the staff did not assist the resident. R1 was not interviewed at the time of the complaint because they did not respond to calls from the LPA investigating the complaint. R1 has since passed away and was never interviewed. 5 out of 5 staff interviewed stated that they had been informed that R1 was a fall risk and had been advised to use their walker and/or wheelchair but R1 did not always use them. 5 out of 5 staff interviewed reported that R1 was checked on regularly and informed to request assistance when transferring or needing any type of assistance. 5 out of 5 staff interviewed reported they had never seen R1 fall and were unaware of any recent falls by R1. R1’s responsible party reported that they knew R1 had multiple falls prior to moving into the facility but was unaware of any falls during 2021. 5 out of 5 staff interviewed reported that R1 has never reported any falls. The Administrator and Health Wellness Director reported that R1 has not suffered any falls recently. A review of special incident reports (SIRs) submitted to the Agency (Community Care Licensing) from the facility for the period of March 1, 2021, through June 30, 2021, showed that out of the 35 SIRs received there were no incidents with R1. Based on the evidence gathered through a review of records and interviews the allegation, resident has fallen multiple times while in care is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff are denying resident food revealed the following. 5 out of 5 staff interviewed reported that normally R1 went to the dining room on her own and did not request assistance when going to the dining room. 5 out of 5 staff interviewed reported that sometimes R1 requested that food be brought to her room, but they informed her that the facility only provided tray service free of charge during the Covid lockdown period in 2020. 2 out of 5 staff interviewed reported that on a few occasions they brought R1 meals to their room even though they were not on tray service. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 3 out of 5 staff interviewed reported asking R1 if they wanted anything to eat because they didn’t see R1 go to the dining room, but R1 declined. The Administrator and the Health and Wellness Director reported that they were unaware of any issues regarding R1 being denied food. R1’s responsible party reported on one occasion R1 had informed them that they had taken a nap and missed a meal, but they had told them the day after it took place. R1’s responsible party reported that other than that one instance R1 did not report to them that they were being denied food. R1 was not interviewed at the time of the complaint because they did not respond to calls from the LPA investigating the complaint. R1 has since passed away and was never interviewed. Based on the evidence gathered through interviews the allegation, staff are denying resident food, is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff are not checking on resident in a timely manner revealed the following. It was alleged that R1 would call the front desk of the facility, and no one would answer the phone and R1 would have to call 911 for assistance. R1 was not interviewed at the time of the complaint because they did not respond to calls from the LPA investigating the complaint. R1 has since passed away and was never interviewed. 5 out of 5 staff reported that when any resident calls for assistance using the facility call system they are assisted as quickly as possible. 5 out of 5 staff reported that they do not recall any instances when R1 had to wait more than 5 minutes for assistance when they used the facility call system. 2 out of 2 staff interviewed who answer the facility phone reported that the facility phone is always answered even at night and reported they are unaware of any instances when the phone is not answered. The Administrator and Health and Wellness Director reported that on a couple of occasions the fire department and police have showed up at the facility because R1 called them, but they left the facility and took no action because there was no need for their assistance. The Administrator reported that these incidents were not reported because none of the facility residents were in any danger, and no one was hurt in any way. Based on the evidence gathered through interviews the allegation is deemed unsubstantiated although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff are not checking on resident in a timely manner revealed the following. It was alleged that R1 would call the front desk of the facility, and no one would answer the phone and R1 would have to call 911 for assistance. 5 out of 5 staff reported that when any resident calls for assistance using the facility call system they are assisted as quickly as possible. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 5 out of 5 staff reported that they do not recall any instances when R1 had to wait more than 5 minutes for assistance when they used the facility call system. 2 out of 2 staff interviewed who answer the facility phone reported that the facility phone is always answered even at night and reported they are unaware of any instances when the phone is not answered. The Administrator and Health and Wellness Director reported that on a couple of occasions the fire department and police have showed up at the facility because R1 called them, but they left the facility and took no action because there was no need for their assistance. The Administrator reported that these incidents were not reported because none of the facility residents were in any danger, and no one was hurt in any way. Based on the information gathered the allegation, staff are not checking on resident in a timely manner, is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff are not providing a safe environment for resident, revealed the following. It was alleged that the facility does not have any doctors, dieticians, or nurses at the facility and that the Executive Director of the facility was going to cause harm to Resident 1 (R1). The Executive Director denied the claim and reported they would never harm or threaten any resident. The Executive Director reported that he was never contacted by the Police concerning this report. 3 out of 3 residents interviewed reported they have never been threatened or harmed by any staff members. 5 out of 5 staff interviewed reported they have never seen or heard any staff threaten or harm a resident. The facility is not required to have doctors, nurses, or dieticians at the facility as it is not a medical facility it is an assisted living facility. The facility does have a Licensed Vocational Nurse working at the facility. Based on the information provided the allegation, staff are not providing a safe environment for resident is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA met with the Health and Wellness Director Mink Medina and explained the reason for the visit. During the complaint investigation for complaint # 22-AS-20200915080631, LPA observed that the facility did not have the See Something, Say Something poster (PUB 475) posted in the main entrance way of the facility. LPA issued an advisory note, technical assistance for CCR (California Code of Regulation) 87468(c)(2)(A). LPA consulted with the Health and Wellness Director concerning CCR 87468(c)(2)(A) and reporting requirements. An exit interview was conducted and a copy of the report provided.

Based on the evidence gathered the allegation staff are not providing the care necessary to meet resident’s needs is deemed unsubstantiated, although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, resident was not accorded dignity in her relationships with staff, revealed the following. It was reported that staff spoke inappropriately to R1. No specific details were provided concerning this allegation. 4 out of 4 staff interviewed who assist R1 denied this report. R1 refused to be interviewed. There is no evidence to support the allegation, therefore the allegation, resident was not accorded dignity in her relationships with staff is deemed unsubstantiated, although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility did not provide resident's representative with proper notification of rate increases, revealed the following. R1’s level of assistance increased after their injury on 2/20/20 (see complaint #22-AS-20200227151034). The facility staff reported R1 needed additional assistance when using the restroom due to mobility issues and required a textured modified diet. Staff interviewed reported the changes were needed and reflected the proper level of care for R1. Facility staff reported that R1’s responsible party was called and never responded, and letters were sent to notify R1's responsible party of the increase. A review of records showed a copy of the letter sent to R1’s responsible party informing them of the rate increase. The records also showed the rate increase form and the mailing address used. Facility staff interviewed reported that R1’s responsible party never contacted the facility about the care plan or rate increase. R1’s responsible party reported they never received anything from the facility about the care plan or rate increase. Based on the information gathered the allegation, facility did not provide resident’s representative with proper notification of rate increases, is deemed unsubstantiated, although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of following up on a Report of Suspected Elder Abuse form (SOC341) submitted by the facility on July 31, 2023. LPA was greeted and granted entry by Executive Director (ED) Troy Byington after introducing himself and stating the purpose of the visit. LPA conducted an interview with ED regarding the circumstances of the reported incident. Anaheim Police Department came and interviewed residents R1 and R2 on July 31, 2023. The corresponding police report is referenced 23-11281. LPA accompanied with ED conducted a tour of the physical plant and visited R1 & R2 in their shared unit on the facility's second floor. Both residents appear well kempt and taken care of, with no apparent signs of distress observed. No other health and safety concerns noted at this time. LPA requested and obtained the facility's current census, employee roster (LIC500) as well as face sheets and most recent physician reports for residents R1 and R2. No deficiencies cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to facility representative.