Downey Retirement Center.

Licensing Program Analyst (LPA) Tena Herrera arrived unannounced to conduct the required annual inspection, LPA and met with Administrator Brandie Mendibles and Assistant Administrator Jason Perez, and the purpose for today’s visit was explained. The facility is licensed to serve 252 Non-Ambulatory Residents ages 60 and over (of which 5 may be bedridden in rooms #136,#102,#103, #104 and #112, there are currently 0 bedridden residents). The facility has an approved Hospice Waiver on file for thirty (30) residents and currently have 8 residents using Hospice Services. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility maintains the required Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and additional information for Bedridden Residents. Facility maintains the required liability insurance and Surety Bond that has an expiration date on 7/1/27. Physical Plant & Environment Safety: LPA toured facility, a total of 13 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom that were tested an operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees. There are two shaded patio/garden areas for residents one within the memory care wing and the other in the assisted living area. (continued on LIC809-C) 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 Staffing & Personnel Records-Training : There appears to be sufficient staffing at all times in the facility. Staff have criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. Administrator Brandie Mendibles certificate expires on 7/12/27. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted on each floor/section: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities. During tour LPA observed residents in memory care and assisted living engaging in activities. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. There are 2 medication rooms one for assisted living and the other for memory care and first floor of assisted living, both medication rooms were toured and a total of 10 Residents medications were reviewed with no issues. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 6/19/25. Residents with Special Health Needs: Facility admits residents with dementia, hospice and bedridden, staff files reviewed today all have required training documented, the delay egress within the memory care wing was tested and was observed to be operable, LPA reviewed 2 Resident files that are on hospice care and all required documentation was within the files. During tour LPA observed the required sinage outside of rooms that have residents that use oxygen. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays visit. Exit interview held and a copy of the report was provided to Administrator Brandie Mendibles.

The investigation revealed the following: Allegation: Unlawful eviction. It is alleged that R1 was unlawfully evicted following an incident in late January 2026, where R1 was hospitalized and fentanyl was found in their system. LPA interviewed 4 staff and each denied the allegation and stated that an eviction notice has not been issued to resident, the room is still vacant and being safeguarded, and they are waiting for R1 to complete their rehabilitation and from there they will know if R1 will be returning or being admitted to another assisted living facility. LPA interviewed 2 Witnesses W2 stated that R1 is part of the Assisted Living Waiver (ALW) and with the most recent hospitalization they are in jeopardy of losing their waiver, the facility has been working with R1 and in trying to provide the best care. W1 is case manager for R1 and stated that they believe its in the best interest of R1 to be relocated and have had that conversation with R1 also, since there seems to be drug use it would be safest for R1 to have a change of environment. LPA interviewed 11 residents and 10 residents denied the allegation and stated they have never been evicted or been threatened with eviction. Allegation: Staff did not safeguard resident's personal belongings. It is alleged that upon R1 being admitted to a new location only a few of R1’s belongings were sent to the new placement. LPA interviewed 4 staff and each denied the allegation and stated that R1’s belongings are still in their room and the room is being held until post rehab and the skilled nursing home advises if R1 is ready to return or will be transferred to another facility. S1 and S2 stated that R1 has not been issued with an eviction notice. S2 stated that since R1 will be out for quite some time they have placed a hoteling lock on R1’s door to ensure the room is not accessible. LPA toured facility and observed the hoteling lock on the door, entered R1’s room and observed room to be fully furnished, and filled with personal belongings including, clothing, food, a power wheelchair, art supplies and numerous other items. S1 and S2 stated that they have taken items to R1 per their request to the skilled nursing facility on 2-3 different occasions. LPA interviewed 2 Witnesses, and both denied the allegation and stated that the facility has been taking items to R1 during hospitalization and do not believe that R1’s belongings are not being cared for. LPA interviewed 11 residents and 10 residents denied the allegation and stated they haven’t had any of their belonging go missing or stolen and they are able to lock their rooms to safeguard their belongings. Based on the investigation conducted, interviews with staff/residents and R1's file, there was insufficient evidence to support the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview was held, and a copy of this report was provided.

Licensing Program Analyst (LPA) Tena Herrera conducted a Case Management Visit-Deficiencies stemming from Annual Inspection dated 8/28/25, LPA met with Administrator Brandie Mendibles and Assistant Administrator Jason Perez, the purpose for todays visit was explained. Per additional information gathered on Appeal that the department received on 9/15/2025 for a deficiency cited during Annual Inspection and LPA’s observations, the Department determined the following citations were to be issued based on the Annual visit dated 8/28/25 and are listed in detail on the following page. The following citations will be issued during todays visit: Section 87465(h)(3) - Facility failed to have a separate container with the required information on the label for residents #3 and #5. Section 87465(a)(4) - Facility failed to obtain a D/C order and centrally store Resident #1’s PRN medications Section 87465(h)(6)(A-E) - Facility failed to list Resident #3’s routine medication on the eMAR Exit interview was conducted. A copy of this report, deficiencies and appeals rights were provided.

Allegation: Staff did not safeguard resident's personal belongings. The investigation revealed the following: The complaint alleged that the facility failed to safeguard R1’s personal belongings such as a watch, refrigerator and microwave. An investigation was conducted to determine whether the facility complied with applicable safeguarding requirements. During staff interviews, multiple staff members reported that if a resident raises concerns regarding missing personal belongings staff are required to immediately notify supervisory or administrative personnel. Staff consistently stated that reports of missing items are investigated by administration and that items are often located after searching the resident’s room. Staff reported that items rarely go missing at the facility and that surveillance cameras are available and reviewed when concerns arise. Staff reported that R1’s room was cleaned following a roach infestation, during which spoiled food and infested items were discarded. Staff denied discarding any valuables. Staff reported that R1 has a history of hoarding food in his room, which previously resulted in pest infestations. Staff further reported that facility issued refrigerator and microwave were removed from residents room due to infestation concerns. During the resident interview, R1 reported that a refrigerator, microwave and watches were missing from his room following cleaning related to pest control. R1 stated that caregivers and housekeeping staff have access to his room and expressed dissatisfaction with a specific staff member. During the investigation, LPA reviewed R1’s admission agreement. The admission agreement does not indicate that the facility provides a refrigerator or microwave to residents. Per staff one (S1) states that residents are permitted to purchase and maintain their own appliances in their rooms. LPA reviewed R1’s Personal Property and Valuables Inventory. The inventory did not list a watch and was initialed by the resident dated June 1,2023. R1 further disclosed that he did not report missing watch to facility staff. Based on the investigation conducted, including interviews with staff and residents and review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was held, and a copy of this report was provided.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 4 interviews (S1 – S4), Resident#1-10 (R1-R10), Interview of Orkin Pest Control Technician (W1), Orkin Pest Control Services Reports dated 01/2025 through 05/2025, Caregiver Response To Residents Care Log for the month of 06/2025, In-Service Training Logs for 01/2024 through 12/2024, In-Service Training Sign-in Sheet for 05/28/2025, Direct Care Orientation Training Checklist for staff#4 (S4), Dementia Care Staff Training for staff#3 (S3), and physical plant tour. The investigation revealed the following: regarding the allegation “Staff did not ensure the facility was free of pests.” It is alleged the facility has pests throughout the facility. Ten (10) out of the ten (10) residents interviewed corroborated this allegation. During record review, LPA Ramirez reviewed Orkin Service Report dated 05/28/2025, revealed Orkin pest technician documented “ Duster six units under refrigerator that I found massive German roaches and set up new monitors, and I suggested to (S2) to add a one more scope of service of month to get the issue under control (202, 210, 211, 223, 234, and 124).” Interview of S2 revealed the facility maintains monthly pest control services and on 05/28/2025, pest control technician did recommend to S2 that adding an additional service of pest controls services would help control the ongoing insect issues. S2 revealed to LPA Ramirez that the facility did not need an additional pest control services and that the staff would be placing more insect traps and would try to address the insect issues themselves. Interview with Administrator Mendibles, revealed the facility addresses the ongoing insect issues by treating the affected rooms themselves along with monthly pest control service. Orkin Service Report dated 01/31/2025, revealed pest control technician treated resident rooms #226, 227, 251, 233, 121, and 112. Orkin Service Report dated 02/28/2025, revealed pest control technician treated interior resident rooms# 234 and 235. Orkin Service Report dated 03/27/2025, revealed pest control technician treated resident rooms# 115, 206, 211, 226, 233, 238, and 251. During facility tour on 06/17/2025, LPA Ramirez observed live roaches in disposable roach glue traps in resident room#111. The facility has been receiving regular pest control services, and in addition, they have taken proactive steps to address the issue by applying pesticides themselves. However, despite these efforts, the presence of insects persists, suggesting that the current approach may not be working and the Orkin report dated 05/28/2025, reflects some of the same resident rooms that were treated in the past 5 months are still experiencing insects. Based on interviews, records reviewed and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . SEE 9099-C 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 “Unqualified staff providing care to residents.” It is alleged that staff are not properly trained or certified to be caregivers. Four (4) out of the four (4) staff interviewed denied this allegation. Ten (10) out the ten (10) residents interviewed denied this allegation. During record review, LPA Ramirez observed In-Service Training logs for several caregivers dated 01/2024 through 12/2024, and these logs did not reflect required annual training hours and topics on dementia, postural supports, restricted health conditions, and hospice care, as required by Title 22, Division 6, Health and Safety Code, Chapter 03.2 Residential Care Facilities for the Elderly, Article 06. Other Provisions- Staff Training 1569.625(b)(1)(2)(3)- (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.(3) The department shall establish, in consultation with provider organizations, the subject matter required for the training required by this section. LPA Ramirez observed the following documented topics : Shift Report-Elderly Needs dated 01/11/2024, Burnout dated 01/25/2024, Kitchen Safety dated 02/01/2024, Emergency Shut off dated 02/29/2024, Resident Right-Proper entry into resident rooms dated 03/13/2024, Mobility, Falls, and Dementia dated 06/27/2024, Postural Supports/ Dementia dated 10/24/2024, and change in condition dated 11/14/2024. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . Two (2) deficiencies were cited as result of this complaint investigation. Exit interview was conducted and a copy of this report was provided via email. A copy of this report, 9099-D and appeals rights was 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 The investigation revealed the following: regarding the allegation “Staff are not responding to residents call button in a timely manner.” It is alleged that staff are not responding to residents call button in a timely manner. Ten (10) out of the ten (10) residents interviewed denied this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. LPA Ramirez tested call button in random rooms during facility tour and staff responded in a timely manner. Review of Caregiver Response To Residents Care Log for the month of 05/2025 and 06/2025, did not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Staff are not providing adequate food service to residents. It is alleged staff are not providing adequate food service to residents and making residents ill. Ten (10) out of the ten (10) residents interviewed denied this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. LPA Ramirez toured facility kitchen and observed all refrigerators and freezers to be operational. LPA Ramirez did not observe spoiled or rancid food items on serving plates or in pantry. LPA Ramirez observed staff wearing gloves while handling food. During record review, LPA Ramirez did not observe incident reports that indicated residents became ill due to food provided by 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, therefore the allegation is UNSUBSTANTIATED . No deficiencies were cited for these allegations. Exit interview was conducted. A copy of this report was provided via email.

The investigation revealed the following: Allegation: Staff smoking marijuana while oxygen tanks are in use. It is alleged that kitchen staff are smoking marijuana in the smoking area and in the presence of residents with oxygen tanks. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that they do not smoke and have never seen or heard of other staff members smoking marijuana nor cigarettes. LPA interviewed 13 residents and 12 out of 13 residents denied the above allegation and stated they have never seen staff smoke cigarettes let alone marijuana. During tour LPA did not observe any odors of cigarette smell or marijuana smell. Allegation: Staff make inappropriate comments in the presence of residents. It is alleged that stated S2 allows staff members to speak inappropriately with each other in the presence of residents. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated they have never witnessed or heard of this type of inappropriate behavior. LPA interviewed S2 and S2 stated they do not recollect the reported allegation and stated if they would have observed something like this they would report it. LPA interviewed 13 residents and 13 out of 13 residents denied the above allegation and stated they have never witnessed or heard staff speaking inappropriately in their presence. Allegation: Staff denies resident’s milk. It is alleged that staff will check residents refrigerator for milk and if residents have milk they will not be provided with more. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation, interviews with S1 and S2 revealed that housekeeping does inspect residents refrigerators during cleaning rounds to ensure that residents do not have any spoiled food/drinks and if removed they notify the resident and residents are able to request for replacement milk/food that has been thrown out. Interview with S3 and S4 revealed that residents often times ask for extra milk and are never denied it, they are provided milk in styrofoam cups with lids for them to take to their rooms. LPA interviewed 13 residents and 13 out of 13 residents denied the above allegation and stated they are never denied any food or drinks at facility. Interview with R12 and R4 revealed that the facility had ran out of milk at one time in July but it was replenished by the next meal. (Continued on the LIC9099-C page) 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 Allegation: Staff denies residents food. It is alleged that residents ask staff members for an orange and are denied. LPA toured kitchen, inspected the walk-in refrigerator and observed a crate full of oranges, other crates with other fruit such as honeydew, watermelon, and pineapple. There were prepared fruit bowls ready for the residents with their requested fruit, cut and ready to serve. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that there is always fresh fruit available for the residents and if more is desired they just have to ask and kitchen staff will prepare it for them. LPA interviewed 13 residents and 13 out of 13 residents denied the above allegation and stated that staff have never denied them any food or fruit, stated that there is a fruit bar during lunch, and if they request fruit on the alternative menu it is provided to them. Based on statements and interviews conducted with staff and residents, tour of facility and inspection of food supply, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report was emailed.

The investigation revealed the following: Allegation: Facility staff failed assist a resident in a timely manner. It is alleged that on October 18, 2023 at 12am, R1 fell out of their wheelchair several times and staff did not respond when called. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation, staff stated that during this time R1’s room was located on the 1 st floor of the Assisted Living area of facility and this is where residents who require more assistance and monitoring are places as it is closer to the med-tech, LVN and management personnel. Staff stated R1 was noted as a fall risk resident and was checked on every 30-45 minutes, as opposed to every 1-2 hours that other residents are checked on. Additionally, staff stated that when a resident suffers a fall immediate action is taken, caregiver calls for nurse to assess while staying with resident, nurse will assess resident to ensure it is safe to staff to assist with lifting resident, and proper care is provided from there. LPA interviewed 13 residents and 12 out of 13 residents denied the above allegation and stated that staff arrive promptly when they need assistance. 6 of the 13 resident stated they have suffered a fall at the facility and staff assisted them right away and were taken to the hospital for evaluation and treatment. Based on statements and interviews conducted with staff, tour of facility, and resident record review, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview held, and a copy of this report was 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 The investigation revealed the following: Allegation: Resident suffered a fall due to staff neglect/lack of care and supervision. It is alleged that while R1 was being assisted with a shower staff walked away resulting in R1 sustaining a fall with injuries that have caused R1 to be bedridden. This incident was investigated by LPA Herrera on 5/31/24 after facility self-reported and submitted a Special Incident Report (SIR) that explained staff that was assisting R1 with a shower, left R1 unattended while assisting with the shower, R1 then experienced an unwitnessed fall and suffered injuries during the time they were left unattended, which resulted in R1 being sent to the hospital and receiving staples on a laceration on their head. Staff has since then been terminated from employment at facility and Administrator retrained all staff in assisting Residents with Activities of Daily Living (ADL's) and re-retrained staff on proper procedures to take when a backup caregiver assistance is needed. There was a citation previously issued for this incident under regulation number 87468.2(a)(4). The plan of correction was submitted to LPA by the due date and has since been cleared. No citation will be issued on todays visit since this was previously addressed, however, since this incident did occur the above allegation is Substantiated. Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Exit interview held, and a copy of this report and appeal rights were provided.

The investigation revealed the following: Allegation: Facility water is not regulated at the required temperature It is alleged that the water within the kitchen is not within the required reading and measured at 70 degrees F. LPA toured facility and measured water temperature within Kitchen (residents do not have access to kitchen) and water temperature measured at 120.7 degrees F, per requirement there is to be a sign posted where water temperature exceeded the required range of 105-120 degrees F and facility had required sign posted that reads, Warning, Water Temperature Exceeds 120 degrees F. LPA toured facility both first and second floors including memory care, there was a total of 5 private resident restrooms where water temperature was tested and each were within the required range. (unsubstantiated) Based on statements and interviews conducted with staff, tour and water temperature that was tested throughout facility, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided.

The investigation revealed the following: Allegation: Staff are not addressing smoking on the premises It is alleged that there is an ongoing issue with smoking on the premises (in non-designated smoking areas) and staff has not tried to enforce the smoking rules. LPA toured facility along side Assistant Administrator Jason Perez, both 1 st and 2 nd floors were toured including a tour of 5 resident rooms. LPA did not observe and odors of smoke during tour nor were there signs of smoking in restricted areas. Upon arrival, and prior to leaving facility LPA observed both the front and rear entrance and did not see any residents smoking in the non-designated areas or near the entrance/exit doors. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation, some stated they have seen residents begin to smoke in the restricted area in front of the facility but they do remind the residents of the smoking policy and where they are able to smoke, in which residents will comply and move to the appropriate smoking area. LPA interviewed 13 residents and 13 out of 13 residents denied the above allegation stating that facility staff are enforcing the smoking rules and designated areas. Some residents stated that staff were not doing much in the past on enforcing the smoking areas to the residents but within the last two months they have seen a change and confirmed they have observed staff enforcing the rules. 6 of the 13 residents interviewed are smokers and each confirmed they are aware of the smoking areas, try their best to follow the staffs directive on approved smoking areas and have witnessed staff redirect residents when they are smoking in restricted areas. Based on statements and interviews conducted with staff/residents, and LPA's observations, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided.

The investigation revealed the following: Allegation: Staff did not dispense medication as prescribed. It is alleged that R1 is often not provided her medications on time, sometimes waiting for hours. The RPs stated that R1 is supposed to receive their medications at 5 PM, but staff frequently do not provide them until 8 - 9 PM. LPA reviewed R1’s medication and the Medication Administration Record (MAR), records indicated that resident often times refuses medication which then pushes out the time that resident is scheduled to take the medication. Due to resident frequently visiting with family there are some missing information on the MAR since family administer the medication while resident is away. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation, stating that medication is administered on time and as prescribed by physician. LPA interviewed S2 and S3 who work directly with medication and it was revealed that R1’s Power of Attorney (POA) has specific instructions to not wake resident up for medications, changes or showers. LPA spoke with family and this was confirmed , however, the instruction to not wake resident for medication was denied. Interviews with S2 and S3 also revealed due to R1 sometimes refusing medications in the morning, this does interfere with the time that medication is given and pushes out the next dose later, residents do have a right to refuse medication and it was confirmed that although after refusing there are attempts to encourage residents to take their medication, however, there are times that the encouragement is not successful and notes are documented in the residents file (which LPA observed during file review). LPA interviewed 15 residents and 13 out of 15 residents denied the above allegation, stating that they are given their medication as prescribed by physician. Additionally, LPA reviewed a total of 8 residents medication with no issues observed. Allegation: Staff did not provide residents with medical attention in a timely manner. It is alleged that R1 had pink eye which is believed to be contracted by R2 and neither resident received medical attention from staff. During medication review LPA observed both R1 and R2 to have medication treating the eyes on both residents. Interview with POA revealed that staff are not able to make medical appointments or contact pharmacy for R1, therefore, POA was the person who assisted R1 with visiting a physician for medication and assessment of eye, POA stated that they were told at the first signs of R1’s eye being glossy and a visit with physician was made right away. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation. (continued on LIC9099-C) 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 (continued) Allegation: Staff did not provide residents with medical attention in a timely manner. Interviews with S2 and S3 revealed that family was contacted once the first signs of R1’s eye being glossy and family arranged a visit with physician as staff are not allowed to make appointments or call on behalf of the resident for medication, both staff confirmed the only time they are able to assist with medical needs for R1 is in the case of emergency which was also confirmed by POA during conversation with LPA. During file review LPA observed notes in R1’s file that detailed what staff observed the watery eye, when, and that family was informed immediately. LPA interviewed 15 residents and 14 out of 15 residents denied the above allegation, stating that they are provided with medical attention in a timely manner. Allegation: Staff are not providing activities for residents in care. It is alleged that residents have not been offered any activities and are confined to the dining room or TV area throughout the day. LPA toured dining room (which is also used as the activity room) and observed a sufficient amount of supplies for activities. LPA reviewed activity calendar and there appeared to be sufficient activities scheduled throughout the day. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation stating that activities are provided to residents throughout the day. Interview with S4 revealed that activities are provided and encouraged for residents to participate in, often times residents in the memory care area are assisted to the assisted living area to be included in those activities, S4 also stated that when residents in the memory care area want to go for a walk and if weather permits, staff will take residents for a walk (LPA observed residents from memory care being assisted with staff for a walk during initial visit). Allegation: Facility is in disrepair. It is alleged that the thermostat in the memory care area is broken or non-functional, that the exits within the memory care side have delayed egress that are non-operable and that the patio screen door within R1’s room does not close. LPA toured memory care area along side of S1 and thermostats throughout the area appeared to be operable, LPA entered 4 residents rooms (including R1’s room) and each thermostat was operable and tested by S1 during visit. R1’s patio doors were inspected and both the glass door and screen open and closed properly with no issues. LPA also tested each exit within the memory care area (including door that leaves to patio) and all exits were observed to have the delayed egress in operating condition with alarms that sounded. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation stating that housekeeping regularly checks the thermostats in residents rooms and there haven’t been any reports of any not working, staff also stated that there has not been a time where the delayed egress was non-operable and those are tested regularly as well. During initial visit LPA observed a resident trying to leave through one of the side exits and the delayed egress sounded and staff were able to redirect resident with no issues. (continued on LIC9099-C) 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 Allegation: Staff did not ensure that facility was kept clean. It is alleged that facility floors within memory care are sticky due to incidents involving residents, and staff have not properly cleaned the spills. LPA toured memory care area and floors to appeared to be clean and not sticky. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation, stating that if there is ever a spill the area is monitored and cleaned immediately by housekeeping or maintenance. LPA interviewed 15 residents and 15 out of 15 residents denied the above allegation, stating that the facility is cleaned regularly and floors are not sticky. Allegation: Facility is malodorous. It is alleged that there is a smell of urine throughout the memory care are of the facility. LPA toured memory care area and did not observe any smell of urine, floors were also observed and there was no indication of spill or urine on floors. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation stating that the facility is kept clean and free from odors. LPA interviewed 15 residents and 14 out of 15 residents denied the above allegation. Based on statements and interviews conducted with staff/residents, review of resident medication, and tour of memory care of facility, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this amended report was provided to Brandie Mendibles.

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Claudia Tejeda (Caregiver Supervisor), sortly after Administrator Brandie Mendibles and Assistant Administrator Jason Perez arrived and assisted with the visit, the purpose for today’s visit was explained. The facility is licensed to serve 252 Non-Ambulatory Residents ages 60 and over (of which 5 may be bedridden in rooms #136,#102,#103, #104 and #112). The facility has an approved Hospice Waiver on file for thirty (30) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training. Facility maintains the required liability insurance and Surety Bond. Physical Plant & Environment Safety: LPA toured facility, a total of 10 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom that were tested an operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees. There are two shaded patio/garden areas for residents one within the memory care wing and the other in the assisted living area. (continued on LIC809-C) 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 Staffing : There appears to be sufficient staffing at all times in the facility. Personnel Records-Training : Staff have criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. Administrator Brandie Mendibles certificate expires on 7/12/25. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted on each floor/section: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. There are 2 medication rooms one for assisted living and the other for memory care, both medication rooms were toured. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 6/24/24. Residents with Special Health Needs: Facility admits residents with dementia and staff files reviewed today all have required training documented. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays visit. Exit interview held and a copy of the report will be emailed to Administrator Brandie Mendibles.

Allegation: Staff did not provide a comfortable and safe environment for residents It is alleged that S7 witnessed a verbal altercation where R2 made a verbal threat to R1 and staff did nothing to mediate the citation. LPA interviewed S7 and although they did not recall the situation, they did state that residents do sometimes get into verbal altercations with one another and action is taken when this is observed or brought to their attention; staff will separate the residents, speak to each one individually and remind them that everyone is to be treated with respect and feel safe, staff will also remind residents of their contract and let them know that if such behavior continues it may result in eviction (all other 6 staff also confirmed these steps are taken when there is an altercation between residents). LPA interviewed 9 residents and 8 out of 9 residents stated that when staff notices or are informed of an argument/altercation between 2 residents, immediate action is taken and staff separate residents and speak to those involved in altercation separately and in private. Allegation: Facility is malodorous It is alleged that there is the smell of weed and cigarettes all throughout the facility , there are multiple residents that smoke in their rooms causing this smell travel throughout the facility and staff are not addressing the issue/concerns of residents. LPA toured facility both outside and inside, the 1 st and 2 nd floors were toured along with the facility patio (non smoking area), and common areas, LPA did not observe any odors of weed or cigarettes during tour, various rooms were also inspected and there were no odors in any of the rooms that LPA entered. LPA observed lobby area which is near the entrance where residents where residents were observed smoking and upon entering on both initial and subsequent visits the smell of smoke was not present inside lobby area of facility. During interview with S1, staff stated that although sometimes you can smell a faint smell of cigarette smoke from time to time, it is difficult to identify where the smell is coming from , and most smokers carry that smell with them on their clothing, skin and hair . S1 further stated that if the smell is observed an investigation is conducted and staff remind residents of the smoking policy. Allegation: Staff don’t assist residents in a timely manner It is alleged that whenever the residents call the staff for assistance via the landline provided in each room , the phone will either ring up to 10-13 times , the staff don’t answer it or when staff do answer, they just hang up on the residents. During tour LPA tested multiple phone lines and each time the line was answered within 2-3 rings. LPA interviewed 7 staff and 7 out of 7 staff denied the above allegation, multiple staff stated that they are trained to assist with answering the phones and are told to lend a helping hand with the phones if the front desk staff is occupied or on another call. (Continued on LIC9099-C) 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 Allegation: Staff don’t assist residents in a timely manner (continued) Some staff stated that on different occasions residents will knock the phone off the receiver causing the phone to tie up the line, therefore, the phone will not ring until that phone is hung up properly, staff are able to see a blinking light on switchboard and a caregiver is summoned to check on resident and clear line. LPA interviewed 9 residents and 7 out of 9 residents stated that when they call the phone is answered by the 3 rd ring or within 10-15 seconds. 8 out of 9 residents stated that they have never observed front staff not answering phones when they are ringing. Allegation: Staff did not treat residents with dignity and respect It is alleged that staff do not treat residents with dignity and respect. LPA interviewed 7 staff and 7 out of 7 staff denied the above allegation and stated that although residents may give verbal (sometimes physical) attacks to staff, they do not react and instead to a face change (where the caregiver is switched) and try to calm resident down, but have never witnessed staff mistreat or fail to treat any resident with dignity and respect. LPA interviewed 9 residents and 8 out of 9 residents denied the above allegations and stated that although they may see residents mistreat the staff they have never seen or heard of a staff mistreat a resident and themselves have not been mistreated in anyway by staff. Allegation: Staff did not ensure that facility was kept clean It is alleged that staff do not ensure facility is free of cigarette butts, the smoking areas and entrance of the facility and garden/grass area have cigarette butts thrown everywhere. During initial visit on 6/18/24 LPA toured facility, non-smoking patio (garden) area, front entrance and front designated smoking area along with smoking area in the rear of the facility were observed to be clean and fee of any cigarette buds. LPA also inspected entrance front designated smoking area along with smoking area in the rear of the facility during subsequent visit on 6/20/24 and there was no evidence of smoke butts being thrown everywhere. LPA interviewed 7 staff and 7 out of 7 staff denied the above allegation and stated that house keepers are continuously making rounds and ensuring that the facility is well kept, clean and free of any trash/cigarette butts. LPA interviewed 9 residents and 8 out of 9 residents denied the above allegation and stated that there is always someone picking up throughout the facility and have never seen the garden area, patios, entrance or smoking areas to have cigarette butts thrown everywhere. Based on statements and interviews conducted with staff and residents, review of client files and admission agreement/house rules, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations)did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided to Assistant Administrator Jason Perez.

The investigation revealed the following: Allegation: Staff did not prevent resident from having access to illegal drugs. It is alleged that R2 smokes marijuana in the facility and consumes methamphetamines. This allegation was investigated by Investigations Branch (IB) investigator Canto which revealed the following: The staff members and residents that Cano interviewed stated some residents are known to smoke marijuana outside the facility but have not seen anyone use methamphetamines. R2 admitted to consuming methamphetamines (meth) while residing in the facility, and stated they obtained and consumed the meth off grounds and was never facilitated by the Downey Retirement Center (DRC) employees. Canto found no evidence to corroborate the allegation that facility staff members allowed the consumption/use of illegal substances at the facility. Allegation: Staff did not prevent residents from smoking inside the facility. It is alleged that R2 smokes marijuana inside R10’s bedroom. LPA’s toured facility both upstairs and downstairs, with some of the residents rooms doors open, and did not observe any odors of smoke. LPA’s reviewed Admission Agreement under “House Rules/General Facility Policies” there was a section that covered smoking policies and designated areas for smoking: “#2. Smoking in the facility, including balconies and courtyards, is strictly forbidden due to the health and safety risks to other residents and to facility staff”. Per S1 if a resident fails to comply with any of the house rules, that resident is spoken to and given a copy of the house rules, they must sign house rules and that copy is placed in resident file as a warning, if the behavior persists and they continue to break the rules continuously the resident is reassessed and sometimes transferred to a higher level of care if they are no longer fit for facility. Based on interviews with staff 5 out of 5 staff stated that they do not allow residents to smoke inside the facility, and that although they have never caught a resident smoking inside the facility when there is a heavy smoke smell present in their room or in an area that residents are, staff ask if they have smoked in the area and remind residents that if they are caught smoking inside the facility they risk being evicted. Based on interviews 2 out of 10 residents stated that they have never seen or heard of residents smoking inside the facility, that there are designated areas in the front and back of building for smoking, and that staff have told them where the designated areas are . S10 stated that they do not smoke and have never seen another resident smoking inside the facility. (Continued on 9099-C) 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 Allegation: Staff did not prevent resident from making inappropriate comments towards other residents. It is alleged that R12 has offered to give residents a “blow job” for stuff (money/cigarettes). Based on interviews with staff 5 out of 5 staff stated that they were aware of R12’s comments and behaviors. S1 stated that R12 had been spoken to on many occasions and staff had been working on redirecting R12 to discontinue inappropriate comments to other residents, S1 further stated that R12 is no longer a resident at the facility and has since been transferred to a different facility for a higher level of care. LPA’s reviewed incident report dated 10/10/2023 that revealed R12 was sent to hospital for re-evaluation and was transferred out on 10/16/2023 to a facility for higher level of care. Based on interviews with residents 8 out of 10 residents stated that they have never seen/heard R12 make these inappropriate comments, however, R12 is no longer residing here and have not had these comments made to them by any other resident. Allegations: Staff did not prevent resident from engaging in inappropriate sexual behaviors (and) Staff did not prevent resident from engaging in inappropriate behaviors. It is alleged that R12 was masturbating in front of the facility. LPAs interviewed staff and 4 out of 5 staff stated that they have never seen or heard of this type of behavior or of the reported allegation. LPA’s asked if there are any cameras that may have covered this alleged area and S1 stated that the facility does not have any video surveillance. LPA’s interviewed 10 residents and 9 out of 10 residents stated that they have never heard about the reported allegations and have never seen/heard of a resident engaging in inappropriate sexual behaviors or inappropriate behaviors. Allegation: Staff did not prevent resident from hitting another resident. It is alleged that R1 and R9 got into a physical altercation where R1 got hit on the calf and stomach by R9. LPA’s reviewed SOC341 dated 8/21/23, the following parties were notified of the incident: Community Care Licensing, Law Enforcement, Local Ombudsman and Responsible Parties. Based on interview with R1, resident stated that staff were not around during time of incident of 8/20/23 and incident happened fast that once staff arrived the incident had de-escalated and there were no further occurrences after that, and resident did file a police report that day. Based on interviews with residents 8 out of 10 residents stated that they have not been in any physical or verbal altercations and feel staff would try their best to prevent any altercations between residents. Based on interviews with staff 5 out of 5 staff stated that there are typically never any physical altercations between residents, in the case that there are, staff will address the situation, separate the residents, speak to each one individually and monitor to ensure no further altercations arise. (Continued on 9099-C) 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 Allegation: Facility is malodorous. It is alleged that it smells like feces upstairs for a long time. LPA’s toured facility both upstairs and down stairs and did not observe any feces odors at any point during tour. LPA’s interviewed 5 staff and 5 out of 5 staff stated that they have not observed any feces smell throughout the facility, however, the odor may happen in rooms with residents with incontinence issues or in passing from a resident who refuses to bathe. Staff stated that with multiple attempts of redirection they are able to have a resident agree to bathe so they no longer have that odor. Based on interviews with residents 7 out of 10 residents stated that they do not observe any odors of feces in the facility, 3 out of the 10 residents stated that although there had been moments where the odor was present it has gotten better and have not currently observed any feces odor. Based on statements and interviews conducted with staff and residents, review of client files and admission agreement/house rules, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations)did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided to Administrator Brandie Mendibles.

The investigation revealed the following: In regards to allegation: " Staff not providing medical attention to resident’s pressure sore." It is alleged that R1 has pressure sores and is given the run around by staff on who can assist with applying anti bacterial ointment. It is also alleged that R1 used to receive wound care but it stopped. Interviews conducted with 5 of 5 staff members denied this allegation. Staff members interviewed indicated that they assist all residents and do their checks and rounds including diaper changes to residents 3x per shift, or every 2-3 hours. Staff indicated that they were given instructions on R1's care and cleaning procedures which they follow. Staff interviewed indicated that they never refused a resident's request to put ointment or cream on them, but sometimes there are certain creams/ointments that caregivers cannot apply, only nurses can. Staff indicated that nurses are responsible to verify the correct dose, assess and monitor the stages of the residents wound. Interview with R1 indicated that R1 understands that caregivers and nurses have different functions and denied stating that R1 was given the run around by staff. R1 stated that he is able to move around and just requires some assistance or supervision. R1 also stated that the staff help him. R1 stated that N1 gave him recommendations on proper and faster healing techniques. Interview with N1 revealed that R1's pressure sore was superficial and R1 was provided wound care. N1 stated that R1's pressure sore has been healed since, hence wound care ended. Interviews conducted with 10 of 10 residents denied the allegation and never experience given a run around by staff. Interviewed residents also stated that the staff assist them when they ask. Additionally, residents indicated that the facility staff are helpful and nice to them. LPA reviewed documents and records that showed Home Health Nurse and facility staff provided medical attention to R1 and that the facility staff and Home Health nurse communicated regularly with regards to R1's pressure sores. Based on statements and interviews conducted with clients and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held and a copy of this report was provided to Brandie Mendibles, Facility Administrator.

the Nurse indicated that the resident's husband don't care for African Americans and said the husband said things like they were going to make sure he gets his license taken away. They also made allegations to imply that they don't like the Health and Wellness Director for reasons of the same nature. The resident also claims that they Nurse and Wellness Director are both related. The Administrator and Wellness director said the Nurse is not related to them in any way. She said the resident have made it known that they dont like black people and they say things in Spanish like those people, you people, that black person. LPA Wesley saw the video and didn't see the Nurse falling asleep, he was walking around the office, attentive and when I asked to see the video again, because I didn't see the resident sleeping, R1 said that's okay never mind and her husband was on the phone speaking loud and said you know what, "you People," LPA Wesley asked, what are you saying "you people" who are you referring to, his wife began apologizing. I explained if you don't let me see the video how can i justify what you are saying? LPA interviewed 6 out of 7 residents who stated that they haven't had any problems with Staff did not seek timely medical attention for a residents in a timely manner and the Nurse gets them medical attention in a timely matter. Regarding allegation Staff was sleeping while providing care and supervision. LPA observed the video from the residents husband and did not see the Nurse falling asleep, when the LPA wanted to see the video again for clarification they husband and wife refused. The R1 indicated that the Nurse goes to sleep in his car, and the Administrator and Wellness Director said the Nurse can do whatever they choose to on their lunch break they work the PM shift. LPA interviewed 6 out of 7 residents who said they never saw staff including the nurse fall asleep, or go to sleep on duty. Regarding allegation: Staff yelled at a resident while in care, and Staff behavior poses as a risk to a resident R1 indicated the night they came back from the hospital they refused to be seen by the Nurse to take her vitals and get her situated in her room, and they sent Med Tech #1 in to take her vitals. R1 said the Wellness Director came to her room and was yelling as to why she didn't want the Nurse to take her vitals and R1 told her that its not good for her heart for the Wellness Director to be yelling at her. The Wellness Director said that she questioned R1 as to"How was it possible for the Nurse to fall asleep?" then R1 asked for her to leave the room. LPA interviewed 6 out of 7 who said that staff doesn't yell at them which includes the Wellness director and they do not pose a risk to the residents in care. LPA asked R1 for the dates she went to the hospital because the records show the last hospitalization was on 07/13/23 and 07/15/23 and the date on the video is 07/21/20.R1 said her husband had the paper work Continued on LIC 9099C page2 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 husband had the paper work and its at her house. she will get the exact dates a refile. LPA Wesley tried to assist but without the evidence that she is referring to there's nothing I could do. Based on LPAs observation and interviews, the preponderance of evidence standard has not been met, therefore the above allegations are found to be Unsubstantiated. A copy of this report was given to the Administrator .

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Brandie Mendibles. There are currently one hundred twenty nine (129) elderly residents 60 years and older residing in the facility, of which t en (10) residents are receiving hospice care. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has COVID-19 signage posted throughout the facility including notification at the front door of exposure to Covid-19 if an individual visits the facility. According to the Administrator, ten (10) residents had been tested covid positive between 8/23/23 – 8/25/23 but have now been cleared. LA Dept. of Public Health had visited and assessed the facility last week and there were no additional recommendations given. Although there are currently zero (0) covid positive cases, the facility continues to conduct covid testing 2x a week until cleared by LA Dept. of Health. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Hospice Waiver for 30 is approved. A fire clearance is in place. Fire Drill was last conducted on 08/07/2023 at 2:55pm. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 07/01/2024. Surety bond (Worldwide Insurance Specialists) of $50,000.00 is current. Physical Plant/Environment Safety: The facility is a two story building which consist of: First floor: Lobby, 4 dining areas, forty four (44) resident bedrooms (including Memory Care) with an attached bathroom, family room, reception area, administrator office, 4 common restrooms, 2 medication rooms, kitchen, storage rooms, cooler, electrical room, employee lounge, game room, conference room and outdoor seating area. Second floor: Seventy six (76) resident bedrooms with an attached bathroom, beauty shop, records room, storage room, staff break room and foyers. The facility is licensed to serve age range 60 and over. 252 non-ambulatory, of which 5 may be bedridden. Bedridden rooms #136, #102, #103, #104 and #112. Hospice waiver for 30. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in eight (8) random rooms (Rooms #101, #103, #132, #129, #217, #224, #232 and #264) in the first & second floors. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. *****CONTINUED ON LIC809-C***** 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 Staffing: A total of seventy eight (78) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records/Staff Training: LPA reviewed five (5) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expiring on 07/12/2025. Resident Records/Incident Reports: Resident files are maintained at the facility. A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, Individual Service Plans, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records. RCFE complaint poster and Personal rights were observed posted outside the reception desk. The Incident report binder was reviewed. Resident Rights-Information: Resident personal rights are posted. Per Administrator, facility provides internet services to all residents and have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. LPA observed an activity calendar posted by the dining room and in the elevators. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities. Weekly activities had been developed. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Sanitation practices and kitchen cleanliness was observed. Kitchen staff workers were observed to be wearing masks and disposable gloves while working. Incident Medical and Dental: Five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Currently, ten (10) residents receive hospice care and zero (0) bedridden resident. There is an adequate number of direct care staff to support residents needs. Half bed rails for mobility assistance were observed in some resident beds. Functional Capability and Pre Placement Appraisals are on file. One (1) resident has prohibited health condition and is under Hospice care. "Oxygen In Use" signs were posted on the resident doors who are using oxygen. No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided to Brandie Mendibles, Administrator.