Brookdale Garden Grove.

Additionally, LPA Haddad, a resident’s responsible party and the outside agency representative reported no concerns and indicated that during their visits, they did not observe any uncomfortable temperatures within the facility. A review of records, including LPA Haddad’s complaint investigation report dated 04/22/2025, indicated that temperatures and thermostats in 12 resident rooms were inspected. The air conditioning and heating systems were observed to be functioning properly, and all rooms were maintained at comfortable temperatures as selected by the residents. Furthermore, during the investigation on 04/22/2025, it was reported that although the air conditioning system has been properly maintained, it began intermittently shutting off a few months prior, with increasing frequency over time. However, maintenance staff reported that the issue did not impact residents or result in uncomfortable temperatures, as the system was promptly restarted each time and was never off for more than one hour. It was also noted that the facility engaged third-party air conditioning technicians immediately upon identifying the issue and has been actively working to diagnose and resolve the problem. A review of the facility’s maintenance records confirmed ongoing efforts to address and repair the air conditioning system. Based on interviews and records reviewed during the investigation, LPA Lee was unable to corroborate the allegation. It was alleged that staff do not treat residents with respect. During the investigation, the Department conducted interviews with facility staff, residents in care, the assigned LPA Sean Haddad, a resident’s responsible party, facility staff and an outside agency representative. Five out of five residents interviewed reported no concerns regarding staff not treating them with respect. Additionally, residents stated that they feel safe living in the facility and that staff treat them well. One resident stated, “I love it here, staff have been wonderful and respectful.” Interviews with two facility staff who denied the allegations. Furthermore, LPA Haddad, a resident’s responsible party, and the outside agency representative all reported no concerns and indicated they have not observed facility staff mistreating residents and not respecting residents in care. Moreover, the outside agency representative reported witnessing Resident 1 (R1) on multiple occasions not treating other residents with respect during resident council meetings. Based on interviews and records reviewed during the investigation, LPA Lee was unable 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(s) did nor did not occur, therefore, the allegation is unsubstantiated. An Exit Interview was conducted with (FDA) Arrellano and a copy of this report was provided to the facility via email. A certified copy will be sent to the facility mailing address.

Regarding the allegation that resident sustained unexplained injury while in care: it was alleged that on May 11, 2021, R1 had a fall, was taken to the hospital with unknown injuries, stayed at a skilled nursing facility for three days, and then returned to the facility. It was also alleged that on July 27, 2021, blood was observed on the back of R1’s head, R1 was unable to recall what happened, and staff were unable to explain what happened. LPA interviewed the facility’s wellness director at the time who stated that R1 did have many falls, including one in May 2021 where R1’s head started bleeding, and R1 was sent to the hospital due to this fall. LPA attempted to interview R1, but R1 is no longer a resident of the facility. LPA interviewed four residents who reported no issues with the care they receive at the facility. LPA reviewed R1’s service plan dated August 12, 2021, which indicates R1 is on fall precautions. LPA reviewed R1’s facility progress notes which document that R1 had multiple falls, none of which resulted in fractures. Per R1’s facility progress notes, on May 10, 2021, R1 was found on the floor bleeding from their head and was taken to the hospital. R1’s facility progress notes do not contain an entry for the reported July 27, 2021, injury. LPA interviewed AD who stated that R1 did not have any fractures from these recent falls and, although R1 was sent to the hospital in relation to some falls, R1 was not hospitalized and was instead returned to the facility each time. LPA interviewed R1’s responsible party who stated that the facility took proper measures to address R1’s falls and that the most recent fall occurred around May 11, 2021, and resulted in a head laceration that was being treated by R1’s doctor. Although R1 had recent falls, the information obtained did not corroborate that R1 sustained any serious injuries or that the facility did not obtain timely medical care for R1. Regarding the allegation that resident’s room has bed bugs: it was alleged that R1’s room and mattress are infested with bed bugs and that on May 11, 2021, R1 was found on the floor by a caregiver due to bed bugs feeding on R1. LPA interviewed the administrator at the time who stated that the facility did have an issue with bed bugs which began in R1’s room and spread to nearby rooms, the facility immediately relocated R1 to another room with bed bug precautions, the facility then called a pest control company that treated the affected rooms for bed bugs, called in a second pest control company that treated the entire floor, and had a bed bug sniffing dog check for bed bugs. LPA interviewed the facility’s wellness director at the time who stated that there were bed bugs in R1’s room, but they were addressed. LPA attempted to interview R1, but R1 is no longer a resident of the facility. LPA interviewed four residents who reported no issues with bed bugs in their room, and two of the residents were aware that the facility had a bed bug issue that was addressed by the facility and one resident confirmed that a bed bug sniffing dog was used as reported by the administrator at the time. 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 LPA and the administrator at the time used an ultraviolet flashlight to inspect six rooms in the area affected by bed bugs, including R1’s original room, and observed no evidence of continued bed bug infestation. LPA reviewed pest control invoices corroborating that two pest control companies provided bed bug treatments, a bed bug sniffing dog was also used, and one of the pest control companies cleared the facility of bed bugs on August 6, 2021. LPA interviewed R1’s responsible party who was concerned that the bed bugs were discovered in R1’s room, but provided no information corroborating that the facility did not handle the bed bug situation properly. Although bed bugs were found in R1’s room, the information obtained showed that the facility addressed the situation properly. Regarding the allegation that resident’s room has pests: it was alleged that R1’s room and bed have ants. LPA interviewed the administrator at the time who denied there are issues with pests or other ants, stating that the facility’s pest control company monitors the entire building for pests regularly. LPA attempted to interview R1, but R1 is no longer a resident of the facility. LPA interviewed four residents who reported no issues with pests in their rooms. LPA and the administrator at the time used an ultraviolet flashlight to inspect six rooms in the area around R1’s room and observed no evidence of pests of any kind. LPA reviewed pest control invoices corroborating that two pest control companies provided pest control services to the facility. LPA interviewed R1’s responsible party who stated that the ants were addressed as soon as they reported it to the facility. Regarding the allegation that toiletries not provided to resident: it was alleged that on May 25, 2021, R1’s room had no toiletries. LPA interviewed the facility’s wellness director at the time who stated that R1 was moved to a new room due to bed bugs in their old room, nothing was transferred from their old room to their new room due to bed bug precautions, so facility staff gave R1 toiletries that they had on hand as R1’s toiletries were left in their old room. LPA attempted to interview R1, but R1 is no longer a resident of the facility. LPA interviewed four residents who reported no issues with toiletries, with one resident confirming that the facility provides toiletries to residents. LPA interviewed R1’s responsible party who stated that when R1 was relocated to a new room, their toiletries and other belongings were not relocated with them, but stated this did not have a significant impact on R1. Although R1’s toiletries were not relocated to R1’s new room due to bed bug precautions, the investigation did not reveal that R1 went a long period without access to toiletries or that the facility did not provide toiletries to R1 when they were requested. 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 that staff not maintaining residents’ hygiene: it was alleged that R1 went a week and a half without bathing. LPA interviewed the facility’s wellness director at the time who stated they were unaware of any issues with R1’s showers. LPA attempted to interview R1, but R1 is no longer a resident of the facility. LPA interviewed four residents who reported no issues with showers, with one resident confirming they get all the showers they need. LPA reviewed R1’s service plan dated August 12, 2021, which confirms R1 needed assistance with showers and they were scheduled for two showers a week. LPA reviewed the facility’s shower schedule which shows R1 was scheduled for two showers a week. LPA interviewed R1’s responsible party who stated that on one occasion they noticed that R1 had body odor and their hair was oily, they raised this concern to the facility, and R1’s showers were increased which addressed the problem. Per AD, the facility does not have shower logs from that period. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

This unannounced Case Management – Other inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering amended findings for Complaint Control Number 22-AS-20210726164318. LPA met with Staff #1 (S1) Patricia Jimenez and explained the reason for today’s inspection. During the inspection, LPA and S1 reviewed and discussed the previously delivered findings and the amended findings and LPA delivered the amended report to S1. An exit interview was conducted and copies of this report and the amended report were discussed with and provided to facility representative.

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of concluding the investigation into the self-reported incident report received in the Orange County Regional Office (OCRO) on November 7, 2025, regarding Resident #1 (R1). LPA met with Staff #1 (S1) Ted Dawit and explained the reason for today’s inspection. Administrator (AD) Brisseth Arrellano appeared via telephone. During today’s inspection, LPA inspected the facility and interviewed AD. Per the incident report received in the OCRO on November 7, 2025, on November 6, 2025, R1 reported $850 in cash missing from their room and believes a certain staff took it. LPA previously interviewed AD and R1, and reviewed R1’s property log, and the information obtained did not corroborate that the money was present in R1’s room as stated and the information obtained regarding the alleged theft was conflicting, but R1 claimed they had recently found evidence proving a certain staff took the money, and stated that they would share this evidence with the police in the near future. LPA interviewed AD who stated that the police reviewed this new evidence on November 25, 2025, were unable to determine whether the money was present in R1’s room as stated, determined that the money was lost and not stolen, and will not investigate the matter further. 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.

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 November 7, 2025, regarding Resident #1 (R1). LPA met with Administrator (AD) Brisseth Arrellano and explained the reason for today’s inspection. During today’s inspection, LPA inspected the facility, interviewed AD and residents, and requested and reviewed copies of the resident roster, staff roster, and R1’s property log. Per the incident report received in the OCRO on November 7, 2025, on November 6, 2025, R1 reported $850 in cash missing from their room and believes a certain staff took it. LPA interviewed AD who stated they investigated the situation, were unable to confirm that the money was ever present in R1’s room, questioned staff who denied taking the money, and searched the belongings of the accused staff and confirmed the money was not in the staff’s possession. Per AD, the facility reported the missing money to the police on November 6, 2025, but the police did not investigate. LPA reviewed R1’s property log which does not document the money. LPA interviewed R1 who stated the missing money was over $1,000, they believe they now have evidence proving a certain staff took the money, and they will share this evidence with the police in the near future. The information obtained did not corroborate that the money was present in R1’s room as stated and the information obtained regarding the alleged theft is conflicting. AD stated they will provide an update to LPA on December 8, 2025, regarding any new developments. 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.

LPA interviews with three out of five staff stated R1 has hoarding tendencies. Two out of five staff added R1 has had help to declutter R1's room. Physician's report for R1 stated diagnosis of compulsive hoarding. Regarding the allegation staff are going through residents personal belongings without consent, it was reported personal items have been moved in R1's room including hearing aids. LPA interview with R1 stated R1 had one of their two hearing aids missing for about 3 weeks. R1 stated they later found the second hearing aid on the floor next to the bed. R1 stated they did not witness a staff member move their hearing aids or other personal items. LPA interviews with two out of two additional residents stated they have not had any staff move their personal belongings without their consent. Based on Department interviews and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Exit interview was conducted and a copy of this report was left at the facility.

It was alleged that R1 has gastrointestinal issues causing odor, staff open R1’s door to air out their room into the hallway, and the odor goes into other resident’s rooms causing illness. LPA inspected the entire facility, including the memory care and assisted living sections, common areas, hallways, and 16 resident rooms, including the room of R1 and their neighbors, and noted no bad odors. LPA interviewed four neighboring residents and did not obtain information corroborating any issues relating to smell in the area around R1’s room. LPA interviewed AD who stated that R1 receives incontinence care, does not have any gastrointestinal issues and has regular bowel movements, receives incontinence care with the hallway door closed and the patio door open, and requests that the hallway door be opened after incontinence care is completed and the facility does not deny R1 this personal right. Per AD, there is nothing out of the ordinary about R1 or their incontinence care, the same type of care is provided throughout the facility with no issue, R1 has been out of the facility for almost a month and no complaints were received from other residents about the incontinence care provided to R1 while it was taking place at the facility, and the facility takes general steps to address odors from incontinence care including opening the patio doors, using sprays and diffusers, and running the central air conditioning system. AD stated that the facility was unaware of the alleged odor issue while R1 was in the facility, but if R1 had been at the facility, AD would have inspected their room and asked neighboring residents to gauge the impact of the smell and would have taken appropriate measures to try to mitigate the impact. LPA interviewed one staff who denied the allegation, claiming they never observed any out of the ordinary smells with R1 and that R1 had no gastrointestinal issues. LPA reviewed R1’s Medical Records which indicate that as of September 3, 2025, R1 was not noted to have any gastrointestinal concerns or diagnoses by their doctor. The investigation did not reveal any information corroborating that other residents contracted any gastrointestinal issues from R1. No information was obtained corroborating that there were out of the ordinary smells coming from R1’s room, that any residents were bothered by smells coming from R1’s room, or that the facility did not properly address odors relating to incontinence care. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

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 Arrellano, and a copy of this report was provided and explained.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to follow up on the deficiency issued during the Annual Inspection on August 28, 2025. Based on the review of the Type B deficiency, 87303(a), facility has complied with the terms of the Plan of Correction (POC) as per inspection of the apartment unit of Resident #1 (R1) with Maintenance Supervisor Francisco Sarabia. An exit interview was conducted with Business Office Manager Patty Jimenez, and a copy of this report including the Letter of Deficiency Citations Cleared were provided at the end of this visit.

It was alleged that the facility’s AC system is not being properly maintained resulting in poor performance, outages, and uncomfortable temperatures. LPA inspected the facility and observed no health and safety issues. LPA interviewed 11 residents and did not obtain information corroborating the allegation. LPA inspected the temperatures and thermostats in 12 residents rooms, observed the air conditioning and heating working properly, and observed that all rooms were at comfortable temperatures that the residents had chosen using their thermostats. LPA interviewed S1, the facility’s maintenance supervisor, who stated that the air conditioning system is properly maintained, but began shutting itself off a few months ago and the frequency at which it shuts itself off has increased over time. S1 denied that this issue has impacted residents or created uncomfortable temperatures within the facility, stating they always restart the system immediately, the system was never off for more than one hour, and there have not been many hot days in the last few months. Per S1, as soon as the problem began, S1 and third-party air conditioning technicians have been working to diagnose and fix the problem. LPA reviewed the facility’s maintenance records which corroborate that the facility has been diligently working to diagnose and fix the issue with the air conditioning system. Although the air conditioning system has been having problems recently, the investigation revealed that the facility has been diligently working to fix the problem and that residents have not been impacted with uncomfortable temperatures. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above 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 and a copy of this report was discussed with and provided to facility representative.

It was alleged that, due to lack of care and supervision, R1 had multiple falls at the facility that resulted in a head injury. LPA inspected the facility, conducted health and safety checks on R1 and other residents, and did not observe any health and safety issues. LPA reviewed R1’s Progress Notes which state that: on February 1, 2025, R1 had an unwitnessed fall, sustained a laceration to their head, was treated at a hospital, and returned to the facility the same day; on February 4, 2025, R1 had an unwitnessed fall, sustained a bruise to their head, was treated at a hospital, and returned to the facility the same day; and on February 5, 2025, R1 had an unwitnessed fall, did not sustain any injuries, and was seen by a nurse at the facility. LPA interviewed AD and one facility staff who reported that R1 moved in on December 9, 2023, was not a fall risk when they moved in, and had the facility’s basic fall prevention plan which includes encouraging residents to engage in the common area so they can be more closely monitored by staff and regular checks when they are in their rooms. LPA reviewed R1’s Physician’s Report dated November 29, 2023, which indicates R1 has Dementia, does not have any impairments relating to movement, is ambulatory, and can independently transfer to and from bed. Per R1’s Progress Notes, R1 had multiple falls in 2024. When interviewed, AD and facility staff stated that none of R1’s multiple falls in 2024 resulted in fractures or hospitalization, the facility reassessed R1 and noticed that R1’s balance issues were worsening, the facility held multiple care plan meetings with R1’s responsible party and updated R1’s care plan multiple times to address R1’s changing needs, and the facility conducted staff trainings on safe resident transfers, ergonomics, and gait belts. LPA reviewed R1’s Personal Service Plan dated January 1, 2024, R1’s Personal Service Plan dated August 30, 2024, and R1’s Personal Service Plan dated September 18, 2024, which corroborate that services were added to R1’s care plan as R1’s balance declined to ensure the facility was meeting R1’s needs with regards to their increasing fall risk. LPA also reviewed Staff Training Records that corroborated that the facility conducted additional staff training relating to falls. Per R1’s Progress Notes and interview with AD, R1’s falls in February 2025 did not result in hospitalization or fractures and R1’s laceration and bruise healed quickly with no issues. LPA reviewed R1’s Medical Records dated February 4, 2025, which indicate that R1 did not sustain any serious head injury from their fall on February 4, 2025. AD stated that in response to R1’s falls in February 2025, the facility took additional measures to address R1’s fall risk, including adding a fall mat, a wheelchair, and medication changes as facility staff had suspected one of R1’s medications was contributing to R1’s balance issues. Per AD and R1’s Progress Notes, R1 has not had a fall since February 5, 2025. LPA reviewed the facility’s staff schedule and did not note any staffing issues that may have contributed to R1’s falls. LPA interviewed R1’s responsible party who had no concerns about the care R1 was receiving at the facility. 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 LPA interviewed two care staff and did not obtain information corroborating the allegations. LPA interviewed 12 residents and did not obtain information corroborating the allegations. Based on the information obtained, while R1 has sustained falls at the facility, the falls did not result in serious injury or hospitalization and the facility has diligently updated R1’s care plan to address R1’s changing needs. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

CONTINUED FROM FORM LIC9099 During the present visit, LPA requested the facility census and toured the premises again. A total of six resident interviews were conducted during the visit. Regarding the allegation that Staff do not ensure the facility is free from mold , the following has been concluded: Based on two tours of the physical plant, a review of a total seven units during the initial inspection and seven units on the present visit as well as interviews with six residents, LPA was able to corroborate the occurrence of a water damage incident in the facility's boiler room in November 2024. Adequate containment measures were observed and the room was observed to be dry upon a second visit. Regarding leaks along sprinklers or air conditioners, no instances of leaks or indications of the potential presence of mold were evidenced. Interviews conducted additionally failed to provide sufficient evidence of suspicion of mold on the premises either. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.

On today's date, LPA Quiroz called Administrator (AD) Jeri Miles via telephone to discuss amended report for complaint control #22-AS-20240226102932 dated 6/21/2024 on page 2 of 2. LPA Quiroz discussed amended report with AD Jeri Miles. An exit interview was conducted with AD Miles via telephone, and it was explained that a copy of amended report for complaint control #22-AS-20240226102932 and today's report would be emailed to facility. An electronic email read receipt confirms receiving of the report. AD Miles agreed to print the amended report and today's case management report, sign and email copy including signatures to LPA Quiroz.

On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a subsequent visit to cite deficiency discovered during the investigation of Complaint Control #22-AS-20240226102932. LPA met with Jeri Miles, Administrator and Brisseth Rivera, Health and Wellness Director and discussed the purpose of the visit. During the course of the investigation, based on interviews and file review, the facility did not provide 30 day written notice to Resident 1 (R1) and their responsible party prior to moving R1 from Assisted Living to Memory Care unit. This poses a potential risk to residents in care. An exit interview was conducted with AD Jeri Miles, and a copy of this report LIC 809 D, Appeal Rights and LIC 811- Confidential Names list were provided at exit.

CONTINUED...During the course of the investigation, 4 of 4 interviewees indicated there were 2 staff working in Assisted living area and two staff working in the memory care unit during incident of R1s wandering behavior. Three of four interviewees indicated the need for additional staffing during the night shift. Regarding the allegation that “Staff did not adequately notify resident’s authorized representative of a change in resident's placement,” the investigation revealed the following: The Facility attempted to communicate with who the facility staff believed to be R1’s responsible party; however the facility contacted a Family member identified on the LIC 601-Identification and Emergency Form under Person(s) responsible for financial affairs, payment for care, legal guardian if any, but not the authorized representative. Regarding the allegation that “Staff inappropriately placed resident in a locked unit,” the investigation revealed the following: The facility did not provide the resident and responsible party with a 30 day notice, and did not communicate with Authorized representative prior to placing the resident in delayed egress memory care unit. Although, the facility was attempting to ensure R1s Health and Safety by placing R1 in delayed egress memory care unit, the facility attempted to substitute R1’s supervision needed to meet R1s need and provide necessary supervision. Therefore, based on evidence through records reviewed and interviews conducted the allegations “Staff did not provide adequate supervision, resulting in a resident wandering away from the facility,” “Staff did not adequately notify resident’s authorized representative of a change in resident's placement,” and “Staff inappropriately placed resident in a locked unit” are determined to be SUBSTANTIATED, meaning the complaint allegations are valid and that a violation has occurred. (SEE LIC 9099-D) The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with (AD) Jeri Miles and (HWD) Brisseth Rivera, and a copy of this report, Appeal rights, LIC 9099-D page, and LIC 811- Confidential names were 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 CONTINUED... responding paramedics and SCAN provider and by the SENIOR DOC provider on 2/10/2024 and reassessed by the SCAN provider on 2/11/2024 at 12:57am and 3/26/2024 at 1:57pm. Interview conducted with 1 of 1 witness reported that the assessment with SENIOR DOC on 2/10/2024 may have been inauthentic, multiple attempts were conducted to interview provider with SENIOR DOC, however, LPA Quiroz was unable to speak to SENIOR DOC provider. Interview with 1 of 1 witness reported that the assessment with SCAN on 2/11/2024 may have been inauthentic as the witness reported the SCAN provider was not on duty at the time of the reported assessment. I nterview with 1 of 1 witness reported that the assessment dated 3/26/2024 may have been inauthentic as R1 was not present at the facility on the date and time of the reported assessment. Therefore based on the preponderance of evidence gathered through interviews, documentation review and observations conducted by LPA Quiroz, the allegation that the " Staff did not conduct a timely reappraisal following a change in resident’s condition," was found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Jeri Miles and a copy of this report, LIC 811-Confidential names were provided at exit. ***THIS IS AN AMENDED REPORT***

correspondence to update requestor and with information that records needed to be gathered and records would be available by Tuesday (March 19, 2024) of the following week. Records obtained reflect that on March 19, 2024, records were sent over via email to the requestor. As of today, the records request has been fulfilled and the requestor has obtained copies. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations 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 Executive Director and a copy of this LIC9099 report was left at facility.

Licensing Program Analyst (LPA) arrived unannounced for a Case Management visit. LPA met with Executive Director Jeri Miles and explained the reason for the visit. During today's visit, LPA interviewed Resident #1 (R1) in connection to Complaint Control Number: 22-AS-20230919083629 and obtained records. An exit interview was conducted with Executive Director Jeri Miles, and copy of this report and LIC811 were provided at the end of the visit.

CONTINUED...During the course of the investigation, the investigation revealed the following: Resident 1(R1) was admitted to the facility on 9/30/2017. (R1s) Physician report dated 11/10/2020 indicates primary diagnose as Parkinson’s disease and secondary diagnose as Progressive Supranuclear Disease (PSP). PSP is a condition that causes symptoms similar to those of Parkinson's disease involving damage to many cells of the brain including the part of the brainstem where cells that control eye movement are located and the area of the brain that controls steadiness when you walk is also affected. On 12/8/2020 while conducting 10 day visit, interviewee indicated that (R1) was noted to be wheelchair dependent stating “Staff have reported observing (R1) trying to get out of their wheelchair and confused and disoriented.” Documentation review of physician report dated 11/10/2020 indicates (R1) to be wheel chair dependent and confused and disoriented. Three of five staff interviewed indicated not knowing or meeting (R1) due to recent employment with the facility. Ten of ten interviewees consisting of staff, residents and other witnesses indicated staff speak appropriately to residents in care as evidenced by treating residents with dignity and respect. The department has investigated the allegations listed above. Therefore based on the preponderance of evidence gathered through interviews conducted, documentation review and observations conducted by LPA Quiroz, the allegations that the “Resident was inappropriately pushed while in care,” “Residents sustained unexplained injuries while in care,” “Staff speak inappropriately towards a resident while in care” and “Residents sustains multiple falls while in care” were found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Business Office Manager Patricia Jimenez and a copy of this report, along with LIC 811- Confidential Names were provided at exit. .