La Marea Senior Living.

(Continued from LIC9099, Page 1) Interviews with outside sources confirmed that there was an investigation performed by California Department of Pubic Heath (CDPH) into the reporting parties allegations. Outside Source 1 (OS1) stated that the hospice provider Resident 1 (R1) was receiving treatment with was investigated by the CDPH and allegations with identical claims were found to be unsubstantiated based on the evidence of the investigations. Additionally, OS1 stated there was another investigation performed by a nurse investigator who included a review of the facility and found the claims were unsubstantiated as well. Outside Source 2 (OS2) told the LPA that "without evidence of significant overdose or allergic reaction, it would be difficult to establish a causal link between Guaifenesin (Mucinex) dosage and death in a 99-year-old resident." Records Review revealed that the death certificate of R1 listed the cause of death as Organ Failure, with Cardiac Disease as a contributing factor. The circumstances noted do not indicate an unnatural or questionable death. This corroborates outside source interviews. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. On 04/02/2026 it was alleged that "Staff did not ensure medications were dispensed as prescribed" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside sources, and records review. Regarding the allegation, "Staff did not ensure medications were dispensed as prescribed," it was alleged that facility staff did not follow the prescribed directions of administering decongestant Mucinex to R1. Interviews with facility staff revealed that R1 was not taking the medication outside of the recommended dosage or outside of the attending physician's orders. (Continued on LIC9099C, Page 3) 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 Interviews with outside sources confirmed that there was an investigation performed by CDPH into the reporting parties allegations. OS1 stated that the hospice provider R1 was receiving treatment with was investigated by the CDPH and allegations with identical claims were found to be unsubstantiated based on the evidence of the investigation. Additionally, OS1 stated there was another investigation performed by a nurse investigator who included a review of the facility and found the claims were unsubstantiated as well. According to Outside Source 2 (OS2), "Guaifenesin (Mucinex) at recommended doses is not known to cause organ failure or cardiac death. The FDA-approved labeling for Mucinex (guaifenesin alone) does not list cardiac disease as a contraindication, nor does it warn about organ failure or cardiac complications when used at recommended doses." Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive DIrector Mariano Perez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Executive Director (ED) Janet Miller. The facility's license shows a maximum capacity of one hundred twenty-five (125) non-ambulatory residents, fifteen (15) of whom may be bedridden. Hospice waiver for fifteen (15) and the facility is approved for delayed egress on the first floor. During today’s inspection there were one hundred and seventeen(117) residents in care. During today’s visit, LPA with ED toured the interior and exterior of the facility, and inspected a sample of rooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per ED, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. No deficiencies were cited during the inspection. An exit interview was conducted with ED Miller to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

(continued from LIC9099, Page 1) Staff interviews revealed that Staff 1 (S1) and Staff 2 (S2) were alerted to the alleged incident on 12/12/25. S2 attested that a caregiver was assisting R1 when they told the caregiver they were sexually assaulted by someone at the facility back in June 2025. S1 notified police of the incident, and an investigation was opened. S2 spoke with family of R1 to notify them that the facility took the accusation seriously and made accommodations to make R1 feel safe at the facility while the investigation took place. Staff 3 (S3), whom sees R1 on a regular basis, stated in an interview that they were not aware of anyone hurting R1 and that R1 rarely leaves their room. Resident interviews revealed that R1 was unable to consistently describe the incident that took place. R1 stated that they believed a facility staff member was responsible for the alleged abuse. Additionally, R1 stated to the investigator they enjoy staying in their room, which corroborated staff interviews. Records review revealed that in a physician’s report dated on 8/31/2025, R1 is currently diagnosed with Major Neurocognitive Disorder. Outside Source interviews revealed that Outside Source 1 (OS1) was with R1 the entire day during the June 2025 event at the facility. OS1 confirmed that no one could have abused R1 during that time and that no such incident occurred. OS1 continued to state to the investigator that R1’s diagnosis had contributed to the alleged event and stated they had no concerns with the facility or that R1 was at risk for being sexually abused by facility staff. Based on interviews, Investigator observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with ED Johnathan Thomas, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced case management visit to provide the facility with an amended deficiency page from the visit conducted on 10/20/2025. LPA was welcomed by and discussed the purpose of the visit with Johnathan Thomas. No deficiencies were cited during today's visit. An exit interview was conducted with Johnathan Thomas to whom a copy of this report was provided. Their signature below confirms receipt of this document.

S2 added that staff would periodically refill the glass (that was kept beside the bed) throughout the day and encourage R1 to drink water. S3 shared that staff would sit with R1 during meals to assist R1 to eat and drink. S4 added that when S4 worked the night shift, S4 would always see R1 in the dining room for dinner. R1 would eat the majority of the food and R1 would drink coffee and water with R1s meal. S4 said R1 would ask for a snack and staff would give R1 half of a sandwich or something else R1 would request. R1 often had a snack with a glass of water during the evening before staff brought R1 back to the room for bed. The nurse practitioner (N1) of R1 was also interviewed and it was shared that staff would encourage R1 to eat and drink fluids and assist R1 when needed. N1 said R1 was having difficulty feeding himself/herself and drinking due to R1s weakening condition. Staff would sit with R1 during meals to assist R1 and ensure R1 ate and drank fluids. N1 said the last time N1 visited R1 before R1 went to the hospital. Although R1 was sleepy and appeared weak, all R1s vital signs were normal, and did not see any signs of dehydration. Based on interviews, observations and records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided.

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Continuation Required Annual Inspection that was originally initiated on 4/11/2025. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Executive Director Johnathan Thomas. The facility's license shows a maximum capacity of one hundred twenty-five (125) non-ambulatory residents, fifteen (15) of whom may be bedridden. Hospice waiver for fifteen (15) and the facility is approved for delayed egress on the first floor. During today’s inspection there were one hundred (100) residents in care. During today’s visit, LPA with Executive Director Thomas toured the interior and exterior of the facility, and inspected a sample of rooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Thomas, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Thomas to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Review of R1’s medical assessment records dated January 17, 2025, revealed that R1 had a diagnosis of dementia with behavioral disturbances, was confused/disorientated, and did exhibit inappropriate, sundowning, and aggressive behaviors. Also, according to R1’s medical assessment they required assistance with All Activities of Daily Living (ADLs) except for feeding themself and were non-ambulatory with a wheelchair. Due to R1’s baseline memory loss they were unable to be used as a reliable historian to aid in this investigation. Interviews and records reviewed did not reveal that S1 handled R1 in a rough manner nor did it reveal that any other staff member had handled R1 in a rough manner. Internal and external interviews did not reveal that S1 had yelled at or spoken inappropriately to R1. Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that staff did not handle residents with dignity and staff yelled at residents . Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Thomas, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted by, identified themselves to and discussed the purpose of the visit with Business Office Director Reika Marron & Memory Care Director Daisy Rodriguez. The facility's license shows a maximum capacity of one hundred twenty five (125) non-ambulatory residents, fifteen (15) of whom may be bedridden. During today’s inspection there were one hundred three (103) residents in care. During today's visit, LPA reviewed facility records and took a brief tour of the facility. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. No deficiencies were cited on today's date. An exit interview was conducted with Business Office Director Reika Marron, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Case Management visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Johnathan Thomas. Today's visit was in response to a self reported incident that occurred on 12/12/2024 regarding a medication error for Resident #1 (R1). [See LIC811 Confidential Names List.] During today’s visit LPA conducted a brief facility tour, reviewed facility records, and interviewed relevant staff. No deficiencies were cited during today’s visit. An exit interview was conducted with Executive Director Johnathan Thomas, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

However, staff interviews revealed that staff provide regular assistance with toileting. Interviews also revealed that resident’s sheets are changed immediately if they become soiled, otherwise sheets are changed by housekeeping staff weekly. 5:5 staff interviewed stated that they have not assisted R1 with putting gel in their hair. Resident interviews revealed that staff are meeting their hygiene needs, including changing soiled clothing and sheets when needed or at a minimum, once a week when housekeeping cleans the resident’s rooms. Residents interviewed expressed no concern with the level of hygiene care provided by the facility staff. Based on staff and resident interviews, this allegation is unsubstantiated. It is also alleged that the facility is malodorous. It was reported that the facility had feces and urine on the carpets in the public areas and that resident's rooms smelled of feces and urine. LPA conducted a tour of the facility on four separate occasions and did not observe any fecal matter or urine in the public areas. LPA also conducted a tour of 8 different resident rooms and found the rooms to be clean and sanitary. At no time during the LPA’s visits, did they encounter malodors. Interviews with staff and residents corroborated the cleanliness of the common areas and resident rooms. Based on interviews with staff, residents and LPA observations, this allegation is unsubstantiated. It was alleged that staff do not assist residents to dining hall. Interviews with staff and residents revealed that when residents make a request to go to the dining hall, staff provide assistance. Resident interviews revealed that staff arrive timely and provide stand assist or will push them in their wheelchair. Additionally, on 07/02/2024, 10/23/2024, and 01/22/2024, during unannounced facility visits, LPA observed staff assisting residents to the dining hall. Based on staff and resident interviews, along with LPA’s own observations, this allegation is unsubstantiated. It was also alleged that untrained staff were providing care and supervision. A records review from a random sampling of 8 staff members revealed that all staff have received adequate training through Relias. In addition, staff also receive additional hands-on training for a minimum of 1 week shadowing an experienced caregiver before being released to work independently. Interviews with staff also revealed that each staff member receives an additional 20 hours of training annually. Interviews with staff and residents confirmed they were able to meet resident’s needs. Based on records review, staff interviews, this allegation is unsubstantiated. (Continued on LIC9099C) 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 Lastly, it was alleged that staff are being rough with residents in care. It was reported that staff do not know how to properly remove a resident's shirt while providing assistance with dressing. Interviews with residents revealed that staff were gentle in the assistance being provided. Staff interviews revealed that training had been provided on how to change resident clothing. Outside source interviews confirmed the staff training. Based on records review, staff resident and outside source interviews, this allegation is unsubstantiated. This agency has investigated the complaint allegations, staff do not ensure that resident’s hygiene needs are being met, facility is malodorous, staff do not assist resident to dining hall, untrained staff providing care and supervision and staff handle residents in a rough manner. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted, and the report was along with licensee appeal rights (LIC 9058 03/22) reviewed with Resident Service Director Sonia Molina.

Resident interviews informed that the dining staff provides adequate food service to residents. Residents' interviews did not corroborate the allegation. Residents confirmed that the food acquired from the facility kitchen was of good quality and was made to their liking. Resident interviews did not raise any concerns about the ability of the kitchen staff. A review of facility records indicated that facility staff had adequate training. This training involved working on the floor with a more experienced serving staff and engaging in online training for food safety. The records review also showed adequate staffing for the dining area. LPA observations revealed that all food in the walk-in cooler was of good quality. LPA also observed that food items had expiration dates clearly posted on items in the refrigerator and the dry food area of the kitchen. LPA observed many items in the refrigerator, including blueberries, apples, oranges, cooked penne pasta, romaine lettuce, strawberries, iceberg lettuce, eggs, ranch dressing, and cheese. LPA observed daily menus on each dining room table indicating what food items were available for that day. LPA also observed residents' food items at the dining tables. Every plate that was observed looked to be of good quality. This agency has investigated the complaint alleging Staff do not provide adequate food service for residents. The department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the above allegation is found to be UNSUBSTANTIADED. An exit interview was conducted, and report was reviewed with the licensee/facility representative.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Gregory Case. Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 02/09/2024). The LIC624 described a medication incident involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1.] During today’s visit, LPA performed a brief facility tour and welfare check on R1, finding that they were alert, safe, and feeling well. LPA interviewed R1, outside sources, and relevant staff. LPA also collected copies of and reviewed patient care and medical records. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Case, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Licensing Program Analysts (LPA) Nacole Patterson and Ryan Fulton conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and discussed the purpose of the visit to Executive Director Gregory Case. The facility's license shows a maximum capacity of one hundred twenty five (125) non-ambulatory residents, 15 of whom may be bedridden. During today’s inspection there were 86 residents in care. LPAs and Executive Director Gregory Case toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order.  Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Gregory Case, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed staff and clients, and reviewed facility records.  The files reviewed by LPAs contained required documents.  Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Gregory Case to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Continued from LIC9099 Based on outside source records review, the allegation "License number was not included in an advertisement, as required" is unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. The allegation has therefore been dismissed. An exit interview was conducted with Executive Director Launa Moore, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided