Sunrise Assisted Living of Hermosa Beach.

Investigation Revealed the Following: Allegation: Staff administered the incorrect medication to a resident in care. The details of the complaint alleged that facility staff gave the wrong medication to (R#1) On May 5, 2026, at approximately 10:00 a.m., during the records review, the Department observed a copy of the Unusual Incident Report (LIC 624) dated April 25, 2026. The report states that on April 24, 2026, (S#1) approached (R#1) in the first-floor reading room and asked if they were (R#2). According to the report, (R#1) confirmed the identification. The report further indicates that shortly thereafter, upon returning to the medication cart on the second floor, (S#1) realized that medications intended for (R#2) had been administered to (R#1). In addition, the Department reviewed a copy of (R#1)’s Medical Assessment for Residential Care Facilities for the Elderly (LIC 602A), dated March 9, 2026, which indicates that (R#1) is not able to self-administer their medications due to cognitive impairment. On May 5, 2026, at approximately 10:30 a.m., the Department interviewed the facility administrator (A#1). (A#1) stated that (S#1) is a part ‑ time care manager who had not been working at the facility since late February 2026. (A#1) reported that new residents, including (R#1), were admitted during that period, and (S#1) was not familiar with (R#1). According to (A#1), on April 25, 2026, (S#1) went to administer medications to (R#1) but did not find them in their room. (S#1) observed (R#1) in the reading room and asked if they were (R#10). (A#1) stated that (R#1) responded “yes,” and (S#1) proceeded to administer (R#10)’s medications to (R#1). (A#1) reported that after returning upstairs to document in the Medication Administration Records (MARs), (S#1) saw (R#1) and realized the wrong medications had been administered. (A#1) stated that following the incident, (S#1) notified the wellness director, the resident care director, and the hospice agency providing services to (R#1). (A#1) further reported that the facility notified (R#1)’s physician, responsible representatives, and the licensing department. Evaluation Report continues LIC 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 On May 5, 2026, the Department could not interview staff (S#1) because they were not on duty at the facility. The Department attempted to contact (S#1) via telephone; however, (S#1) did not answer the call. On May 5, 2026, at approximately 11:30 a.m., the Department interviewed facility staff (S#2). (S#2) stated that on April 25, 2026, (S#1) asked them how (R#1) ambulates. (S#2) reported that when they asked why, (S#1) stated, “I think I gave the wrong medication to (R#1).” (S#2) stated that after receiving this information, staff immediately monitored (R#1) throughout the day and notified (R#1)’s responsible representatives, physician, and hospice agency. During this investigation, The Department found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Judith Uy Villaruz/Executive Administrator. 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 Investigation Revealed the Following: Allegation: Staff are not completing medication logs. The details of the complaint alleged that facility staff are not completing medication logs. On May 5, 2026, at approximately 10:00 a.m., during the records review, the Department observed copies of the Medication Administration Records (MARs) for residents (R#1) through (R#4) dated February, March, and April 2026. The Department noted that there were no discrepancies in the residents’ medication intake records for those months. On May 5, 2026, at approximately 10:30 a.m., the Department interviewed the facility administrator (A#1). When asked to describe the facility’s process for ensuring that medication administration logs are completed at the time medications are provided to residents, (A#1) stated that it is the facility’s practice for Med Techs to document the medication administration immediately after providing medications to residents. In addition, when asked what systems or oversight practices the facility uses to verify that staff are documenting all administered, refused, or held medications on the Medication Administration Records (MARs), (A#1) stated that the resident care director conducts quality-assurance reviews of completed MARs. Moreover, when asked how the facility addresses missing or incomplete entries on a medication log and ensures corrective action is taken, (A#1) stated that the issue is brought back to the staff member who administered the medications to determine why the entry was not completed. On May 5, 2026, at approximately 10:30 AM, during interviews with residents in care (R#2-R#9), (8) out of (8) stated that staff stay with them when assisting with their medications. Residents also stated that they have observed staff writing information down or using a chart after providing medications. In addition, (8) out of (8) residents reported that they have not experienced a time when they did not receive the medication they were expecting or received later than usual. Evaluation Report continues LIC 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 On May 5, 2026, at approximately 11:30 AM, during interviews with facility staff (S#1-S#2), (2) out of (2) stated that their usual process after assisting a resident with medication. Staff stated that they ensure the resident takes the medication, provide sufficient water, ensure the resident is not choking, and confirm that no medication is left unattended. Staff reported that once the medication is administered and the resident’s identity has been verified, they document the administration on the Medication Administration Records (MARs). In addition, when asked how they document medications that are refused, delayed, or unavailable, staff stated that if a medication is refused, they offer it up to three times and explain the benefits of the medication while also informing the residents of their right to refuse. Staff reported that refusals are documented on the MARs and that the residents’ physicians and responsible representatives are notified. Moreover, when asked how the facility ensures that all medication entries are completed for the shift, (2) out of (2) staff stated that documentation is completed in the electronic system, which indicates when a medication has been administered. Staff also reported that the service care coordinator conducts regular quality-assurance reviews of the MARs. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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. An exit interview was conducted, and a copy of the Complaint Report was given to Judith Uy Villaruz/Executive Administrator.

Regarding the allegation, “facility does not have hot water,” it is being alleged that showers were not provided to residents from 12/20/2025 – 12/25/2025. Record review of Broadway National Estimate (08/15/2025) revealed staff was to arrive onsite AFTER normal business hours. Project will take approximately (7-9) nights to complete. In order to complete the work safely and efficiently, a temporary shutdown of the water supply will be required. To prevent disruption to daily operations, all work will be scheduled to take place after hours. Record review of email correspondence (12/25/2025 12:59 PM) revealed the facility restored its hot water. Interview with Witness #1 indicated the project was expected to be completed in a week-long job, staff worked day and night, and hot water was to be intermitted. Interview with Staff #1 – 2 indicated the work was to be completed in one day. Staff #1 indicated there was a leak in the old tank and the work to replace it was expected to take a day. However, complications arose, and a second contractor was hired to finish the work. As a result, hot water was provided from kettles so residents could receive/take hot sponge baths. Plus some residents went to their family’s home to shower. Interview with Staff #8 indicated hot water from kettles was offered to some residents but not all. Some residents said they would wait. Eight out of eight staff interviews (S1 – S8) indicated that the facility was without hot water for four to five days due to the replacement of a hot water tank. Five out of eight residents (R1 – R8) interviews, including spouses, indicated they were unable to shower, was not presented with alternatives or did not receive shower assistance/sponge bath according to schedule. Regarding the allegation, “facility does not have hot water,” based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, plans of correction developed, and a copy of this report with the appeal rights was provided to Executive Director Judith Uy-Villaruz.

Investigation consisted of the following: On 07/09/2025, interviews were conducted, a tour of the Reminiscence Neighborhood was conducted, records were gathered. Interviews conducted consisted of 7 resident interviews [Resident 2 (R2) to Resident 8 (R8) were interviewed] and 6 staff interviews [Staff 1 (S1) to Staff 6 (S6) were interviewed]. Facility records were gathered which consisted of Resident Roster dated 07/01/2025; Personnel Report; Abuse, Neglect & Exploitation – Prevention, Reporting and Investigation Facility Policy, Unusual Incident/Injury Report dated 06/11/2025; Staff Certificates of Completion for Abuse & Neglect Prevention; and Reminiscence Neighborhood Residents Emergency Contact Information. On 07/10/2025, Witness 1 (W1) was interviewed. On 08/28/2025, Witness 2 (W2) was interviewed. On 11/20/2025, interviews were conducted, and records were reviewed. Interviews conducted consisted of 1 staff [Staff 2 (S2) was interviewed] and 7 witness interviews [Witness 3 (W3) to Witness 9 (W9) were interviewed]. Records reviewed consisted of pertinent Resident 1’s (R1) records. The investigation revealed the following: Allegation: “Staff did not seek medical attention for resident in care”, it is being alleged that staff did not seek emergency medical attention for R1 on 06/08/2025 which included calling 9-1-1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Interviews conducted revealed the following: Interviews conducted with R2 to R8 revealed the following: 7 out of 7 residents denied the allegation, moreover, residents indicated that if they required medical attention staff would assist them. Interviews conducted with W1 and W3 to W9 revealed the following: 7 out of 8 witnesses denied the allegation and 1 out of 8 witnesses agreed with the allegation. Moreover, 1 out of 8 witnesses indicated that when they observed R1 on 06/08/2025 it seemed as if R1 had been physically assaulted, R1 had bruises on their eyes and face, they observed blood in R1’s room, they were informed by facility staff that R1 had a broken tooth, they took R1 to urgent care (not facility staff). Interviews conducted with S1 to S6 revealed the following: 6 out of 6 staff denied the allegation. Furthermore, staff indicated that on 06/08/2025 the following occurred: Around 8:30 AM facility staff assessed R1 and determined that R1 had a cold sore, R1’s doctor was notified and responsible person. Around 10:45 AM to 11:00 AM R1 was reassessed by Staff 2 (S2) and facility staff observed that R1 had a crack tooth, one tiny tear outside the mouth and one inside the mouth; R1 was asked if they fell but they indicated that they did not fall; R1 could not explain what happened; R1’s room was searched and staff found droplets of blood and concealed wadded up paper towels under the couch; R1’s responsible person was contacted and notified with an update. Staff were unsure how R1 sustained an injury / it was an un-witnessed incident. A theory that staff came up with is that R1 slept on their couch next to their coffee table and R1 fell on the corner of the coffee table. R1’s responsible person came to the facility past 1:00 PM and with the guidance of S2 took R1 to urgent care. Additionally, staff explained that 9-1-1 nor non-emergency ambulance were called because R1 was acting like their normal self, did not express signs of pain, was alert, and did not have a serious life-threatening injury. Moreover, S2 explained that 9-1-1 is called when residents have an un-witnessed fall and head injury. 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 Records reviewed revealed the following: “Statement of Event” written by facility staff on 06/2025 revealed that on 06/08/2025 the following occurred: 5 staff indicated that R1 was assessed by facility staff and R1 was taken to urgent care. Staff 7 (S7) wrote that they assessed R1 around 8:00 AM and “saw open skin (wound) no presence of blood no broken tooth." Just an open white in color open wound…R1 is asked what happened but R1 is unable to answer…no signs of discomfort…around 11:00 AM S2 re-assess R1 and informs S7 that R1 “might had a fall and hit themself on the edge of the table that was same level of the couch.” Staff 8 (S8) wrote that around 8:30 AM they assessed R1 and observed with “a big lump on thei lip (the left) and a bruise on their chin”…R1 was asked if they hurt themselves and R1 indicates no… “the nurse looked at it” and indicates that it looks like a cold sore “since the resident had a cut from the inside of the lip. When the nurse lifted R1’s lip it did hurt the resident. I did notice a chipped tooth as well.” Staff 9 (S9) wrote that they observed R1 at around 9:00 AM and saw that R1’s “right upper lip swollen and a bruise on their right side”…R1 was assessed by facility staff and staff determined that R1 had a cold sore on the right upper lip. Unusual Incident/Injury Report (UIR) dated 06/11/2025 revealed the following: R1 was reported to have a swollen lip and cracked tooth; R1 was evaluated by facility staff and taken to the emergency room. Fax records dated 06/08/2025 revealed the following: facility staff faxed R1’s doctor four times. R1’s Physicians Report revealed the following: R1’s primary diagnosis is Alzheimer’s Dementia. R1’s mental condition is confused and disorientated. 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 Substantiated: Based on interviews and records R1 sustained an un-witnessed fall which resulted in a head injury because R1 was observed with a chipped tooth, a cut inside their mouth, a cut outside their mouth, swollen lip, and bruise on their chin. Additionally, R1’s room was searched and staff found droplets of blood in the room. Also, due to R1’s diagnosis they had difficulties expressing the events that occurred that led to their head injuries and expressing if they were in pain or not. Moreover, staff theorized that R1 slept on their couch and fell on the corner of their coffee table and sustained said injuries. Furthermore, R1 was incorrectly assessed around 8:00 AM with a cold sore and then correctly assessed around 11:00 AM but the facility did not seek emergency medical attention for R1. The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator, Judith Uy-Villaruz . 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 Investigation consisted of the following: On 07/09/2025, interviews were conducted, a tour of the Reminiscence Neighborhood was conducted, records were gathered. Interviews conducted consisted of 7 resident interviews [Resident 2 (R2) to Resident 8 (R8) were interviewed] and 6 staff interviews [Staff 1 (S1) to Staff 6 (S6) were interviewed]. Facility records were gathered which consisted of Resident Roster dated 07/01/2025; Personnel Report; Abuse, Neglect & Exploitation – Prevention, Reporting and Investigation Facility Policy, Unusual Incident/Injury Report dated 06/11/2025; Staff Certificates of Completion for Abuse & Neglect Prevention; and Reminiscence Neighborhood Residents Emergency Contact Information. On 07/10/2025, Witness 1 (W1) was interviewed. On 08/28/2025, Witness 2 (W2) was interviewed. On 11/20/2025, interviews were conducted, and records were reviewed. Interviews conducted consisted of 1 staff [Staff 2 (S2) was interviewed] and 7 witness interviews [Witness 3 (W3) to Witness 9 (W9) were interviewed]. Records reviewed consisted of pertinent Resident 1’s (R1) records. 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: “Staff did not prevent resident from being hit at the facility by an unknown individual”, it is being alleged that R1 was hit by an unknown individual. Interviews conducted with R2 to R8 revealed the following: 7 out of 7 residents denied the allegation, moreover, residents indicated that no one has ever hit them in the facility. Interviews conducted with W1 to W9 revealed the following: 7 out of 8 witnesses denied the allegation and 1 out of 8 witnesses agreed with the allegation; 8 witnesses indicated that they have never seen a resident being physically hit by another person; W2 goes on to explain that a police investigation was conducted in the facility regarding the allegation and it was unknown if R1 was hit by an individual or if R1 fell on the corner of their coffee table, W2 explains that no individual was arrested due to the allegation and there was not sufficient evidence to indicate that an individual hit R1. Interviews conducted with S1 to S6 revealed the following: 6 out of 6 staff denied the allegation, furthermore, staff indicated that they have not seen or heard that R1 was physically hit by an individual, S1 goes on to explain that the Hermosa Beach Police came to the facility, conducted an investigation, requested video footage of the facility and sign in and sign out records of the facility. Records reviewed of the Hermosa Beach Police Department DR# 25-0001355-Crime / Incident Report dated 06/11/2025 regarding the incident with R1 revealed the following: The Hermosa Beach Police Department were unable to determine if an unknown individual hit R1 or if R1 fell. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. 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 unsubst

INVESTIGATIONS REVEALED THE FOLLOWING: Allegation: Resident sustained a pressure injury while in care It is alleged resident sustained a pressure injury while in care. Based on records review, Admission Agreement indicates R1 was admitted to the facility on 5/14/2020. Physician’s Report dated 5/11/2020 and the facility’s Progress Notes dated 5/14/20 indicate R1 has a history of deep tissue pressure injury on the right lateral heel, stage not noted. R1 is non-ambulatory. R1’s Medication Administration Record (MAR) shows facility staff administered Venelax topical ointment from 5/14/2020 through 7/6/2020, 2x day on R1’s right heel for suspected deep tissue pressure injury. During the Torrance Memorial Home Health Nurse’s visit on 5/17/2020, home health nurse instructed caregivers on resident’s Stage 1 Pressure Ulcer to Right Heel to keep off pressure, leave open to air and other measures to prevent skin breakdown. The facility’s progress notes dated 5/17/2020 indicates home health nurse verbalizes nurses will continue to visit once a week and the facility staff/caregivers will continue to assist R1 with repositioning four times per shift and floating right heel on pillow. On 5/22/2020, the facility’s progress notes indicate R1 had a quarter sized open area with surrounding redness on coccyx, care team to continue to apply barrier cream and reposition resident and home health nurse is to visit on 5/23/2020. On 5/31/2020, the facility’s progress notes and the home health notes revealed R1 had developed an open bed sore on the coccyx area. According to the department’s records review, there were no records that R1 received wound care for coccyx from Home Health and no records were found that facility staff repositioned R1 between 5/23/2020 and 5/30/2020. In addition, there was no evidence that the facility made attempts to follow-up on the request for home health services or medical assessment for R1’s coccyx during this period. However, home health continued in providing wound care to RI's right heel. On 6/2/2020, a new home health service for R1's coccyx commenced and it was revealed that R1 developed an unstageable pressure injury on coccyx. On 6/28/2020, Home health notes show R1’s pressure injury in coccyx was at Stage 3 and it progressed to Stage 4 on 7/12/2020. Based on interviews conducted with four out of eight staff (S1, S2, S4 & S8), R1 developed a pressure injury while in care. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met: Due to neglect/lack of supervision, Resident #1 developed an unstageable pressure injury on coccyx, therefore the above allegation “Resident sustained a pressure injury while in care” is found to be SUBSTANTIATED. REPORT CONTINUED IN LIC 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 Pursuant to Title 22 Division 6 of the California Code of Regulations, following deficiency was cited (refer to LIC 9099-D). Civil penalty assessed. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, “a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to Administrator Eric Mensah.