Whitten Heights Assisted Living and Memory Care.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Activity Coordinator (AC) Clara Ramirez and discussed the purpose of the inspection. Chief Operating Officer (COO) Faye Shen arrived during the inspection. LPA reviewed Infection Control requirements. At about 1:00PM, LPA and AC conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is composed of a single, three-story building with an outdoor courtyard in the center, a commercial kitchen and large dining room on the first floor, a medication room on the second floor, multiple laundry rooms, a memory care unit on the second floor, a memory care unit on the third floor, resident rooms on all floors, along with multiple common areas and storage rooms. There is a total of 135 resident rooms. Resident Bedrooms: the 12 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 12 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 113 and 125 degrees F, before corrections, in the 12 resident bathrooms tested. Call system tested in multiple resident bedrooms with prompt responses from staff. LPA tested the delayed egress systems in both memory care units and noted they functioned properly. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. 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 Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the housekeeping closets and laundry rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing paid. At about 8:00AM, LPA reviewed 10 resident files and 10 staff files, interviewed 5 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money. LPA provided California Department of Public Health informational material on Legionnaires’ Disease during the inspection. During the inspection, LPA and AD observed the following: based on observations, there were multiple areas in the facility's two memory care units, especially Room 259, which smelled strongly of urine; based on observation, the water temperature tested at 122 degrees F in Room 122, 125 degrees in Room 347, and 124 degrees in room 341; based on documents, the physician's reports for R1, R6, and R9 are on the old form and do not contain required information, including behavioral expressions; and based on documents, the facility has been conducting emergency disaster drills annually, and not quarterly as required. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

It was alleged that residents with dogs are leaving dog feces in the central outdoor courtyard, both on the cement and grass, and the dog feces are not being cleaned up by the residents with dogs or staff. LPA inspected the facility and observed multiple areas with dog feces in the central outdoor courtyard, both on the grass and cement, with some feces appearing dry and old and some feces appearing flat from being stepped on. LPA reviewed photographs of the central outdoor courtyard showing similar dog feces from days prior. Out of seven residents interviewed, four residents corroborated that dog feces are not being cleaned up timely and that it negatively affects them, with one resident reporting that some residents stopped using the central outdoor courtyard because they could not handle the smell and the flies. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

Therefore based on records reviewed the allegation facility is unable to meet resident's needs and resident sustained multiple falls due to neglect is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative. 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 Per interviews with 3 out of 3 residents stated no one has been rough or mean to them while at the facility. Residents stated they have no been injured while in care. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation resident sustained unexplained injuries due to staff being rough is determined to be UNSUBSTANTIATED, meaning athough the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred. An exit interview was conducted and a copy of this report was provided.

Regarding the allegation that staff do not ensure recliners and chairs are in good condition: it was alleged that the chairs in the memory care are falling apart and the recliners are broken. LPA inspected the facility and observed multiple chairs, couches, and recliners not in good repair, including the cloth recliners in the second-floor memory care that were heavily stained and are unsanitary, and the leather recliners in the second-floor memory care where the leather was torn or flaking off. The information obtained corroborated the allegation. Regarding the allegation that staff did not ensure elevators are functional and accessible: it was alleged that one of the facility’s elevators has been broken for over a year and the elevator that is used for emergencies is covered with clutter which is dangerous in the case of an emergency. LPA reviewed the facility sketch which indicates the facility has three elevators: one on the north side near the dining room; one on the southeast side near the laundry room; and one on the southwest side. LPA inspected the facility and confirmed the elevator on the north side near the dining room is operational. Per facility staff, this elevator is the only one used by residents. LPA observed that the elevator on the southeast side near the laundry room is non-operational. Per facility staff, this elevator was used by memory care staff to enter and leave the memory care units, it has not been working for some time, efforts to repair it have been unsuccessful, and the facility has decided to decommission this elevator. LPA observed that the elevator on the southwest side is operational, but the entrance on the first floor is obstructed by furniture. Per facility staff, this elevator is used for emergencies, is not generally used, and the entrance should not be blocked by furniture. The information obtained corroborated that one of the facility’s three elevators is non-functional and that a second elevator is inaccessible due to being obstructed by furniture. Regarding the allegation that staff do not ensure urine and feces on floors and furniture is cleaned with appropriate chemicals: it was alleged that the third-floor memory care common area is covered in urine and feces and staff do not have proper cleaning supplies and have to clean with water and hand soap from time to time. LPA inspected the facility and observed the facility to be generally clean and free from foul odors. LPA observed multiple housekeepers cleaning the facility with appropriate chemicals. However, LPA inspected the third-floor memory care and noted there is no cleaning closet or access to appropriate chemicals. Per facility staff, if the caregivers on the third-floor memory care needed to clean a mess, they can call the front desk and have cleaning supplies delivered to them. However, facility staff also stated that there are no housekeepers at the facility between 4:00PM and 6:00AM and that sometimes the caregivers will leave a mess for the housekeepers to clean when they arrive because that is the job of the housekeepers. 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 Based on the information obtained, the caregivers in the third-floor memory care do not have immediate access to appropriate cleaning chemicals to clean messes as they arise and also have a practice of leaving messes for the housekeepers to clean up possibly much later as the facility does not have housekeepers available for 14 hours each day. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. 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 reviewed the facility’s pest control records which show that the exterminator comes to address pests at the facility regularly. LPA interviewed 10 residents and did not obtain information corroborating the allegation. The information obtained did not corroborate the allegation. 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.

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250416094856. LPA met with Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection. During the course of the investigation, Licensing Program Analyst (LPA) Sean Haddad inspected the facility, interviewed COO, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, and a staff statement. Per an interview with Witness #1 (W1), on May 12, 2025, at around 8:00PM, W1 was visiting Resident #1 (R1) at the facility, Staff #1 (S1) advised W1 that visiting hours were over, W1 called Regional Manager (RM) Stanic who spoke with S1 and confirmed W1 could visit longer, but then at around 9:00PM S1 called the police on W1. LPA reviewed a staff statement from S1 indicating they received RM’s guidance that family members are able to visit at any time, but ignored that guidance and chose to call the police because W1 stayed past visiting hours. LPA interviewed COO who stated that the facility generally has no issue with allowing visitors to stay past visiting hours, but that W1 is abusive to staff when they visit, the facility has had to call the police on W1 multiple times in the past, R1’s other responsible parties have warned the facility about W1, that the police were called because W1 was speaking angrily to staff, and that it was the police who arrested W1 based on W1’s behavior. . 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 COO also stated that facility staff felt scared and thought W1 could become violent, but it appears from the timeline that W1’s behavior towards the staff was a reaction to the staff trying to kick them out of the facility and there was no evidence that W1 has ever been violent at the facility in the past. While W1 may have a history of being disruptive, W1 was not committing a crime and R1 had the right for their visitor to remain as there was no negative impact to other residents. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative

It was alleged that R1 smokes in the patio in front of the building, which is not a designated smoking area, right in front of the facility’s entrance, subjecting residents and visitors to the smell of smoke when entering the building and leaving cigarette butts in the front patio. LPA reviewed a photograph of R1 smoking in the front patio. LPA inspected the facility and observed R1 smoking in the front patio about five feet from the front door, with cigarette butts on the floor and a strong smell of smoke present at the front entrance. LPA reviewed the facility’s house rules which state that smoking is only allowed in the designated smoking area and smoking is prohibited inside the building and where there are “no smoking” signs. LPA interviewed COO and a staff knowledgeable about R1 who admitted the allegation, stating that the only designated smoking area is the central courtyard and residents are not allowed to smoke in their rooms or anywhere else. Both COO and the staff stated that R1 smokes in the front patio near the front door regularly, the facility has warned R1 and worked with their social worker multiple times but has been unsuccessful in stopping R1’s behavior, and residents and visitors complain about R1 and have engaged in verbal altercations with R1 due to their smoking at the front door. The facility was previously cited for R1 smoking outside near the front door in connection with Complaint Control No. 22-AS-20250106112758. Since then, in addition to continuing to give R1 warnings and working with R1’s social worker, COO stated they served an eviction notice. LPA reviewed R1’s eviction notice which indicates the 30-day notice period ended on June 6, 2025, almost two months ago. Per COO, the facility has not proceeded with the next steps in the eviction process as required to protect the personal rights of other residents because they are still trying to work with R1’s social worker. By not proceeding with the next steps of the eviction process, the facility is not properly addressing R1’s continuing violations of the house rules which is causing residents and visitors to engage in verbal altercations with R1. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

When confronted by staff, the resident (FR1) accused of the groping, FR1 stated, they "did not remember" doing the act. FR1 was served with an eviction notice. According to S1, FR1 had a tendency to be inappropriate with women in the facility, however, no of the alleged victims/accusers ever wanted to pursue any actions against FR1. After being served with an eviction notice, FR1 moved out. After the incident took place, the facility took immediate action and served FR1 with an eviction notice. Document review revealed the eviction notice provided FR1 two examples of inappropriate behavior that contributed to the eviction: 1: An Aggressive Sexual Act against another resident 2: Foul language towards female residents. Female residents of Whitten Heights Assisted Living do not feel safe with your presence / behavior and are worried about their well being. Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report and appeal rights were provided.

It was alleged that the facility is not properly reporting incidents, including incidents involving Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5). LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA reviewed the incident reports received in the Orange County Regional Office (OCRO) and noted that the incident involving R4 was properly reported, but the incidents involving the other four residents were not reported to the OCRO. LPA interviewed AD and COO who admitted the allegation, confirming that the incidents involving R1, R2, R3, and R5 occurred more than seven days ago and the facility has not reported them yet, but is planning to report them. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

It was alleged that, due to staff’s lack of care and supervision of residents in the memory care unit, on May 3, 2025, Resident #1 (R1) was attacked by R2, who has a history of aggressive behavior, resulting in a bruise. LPA inspected the facility, conducted health and safety checks on residents, including R1 and R2, noted that R1 has a small bruise on their cheek and that R1 has been relocated to another floor in the memory care unit, and observed no health and safety issues. LPA interviewed R1 and R2 who denied engaging in any fights or sustaining any injuries, stated they receive good care at the facility, and denied having any problems at the facility. LPA interviewed the facility’s medication technician supervisor who stated that on May 3, 2025, staff in the third-floor memory care heard a fall, observed R1’s door open with R1 on the floor inside and R2 standing outside the room, noted no serious injuries on R1, offered R1 first aid and reported the fall to R1’s doctor, but did not observe whether R1 fell or was pushed by R2. Per the facility’s medication technician supervisor, three caregivers are assigned to the third-floor memory care and the facility’s resident roster indicates there are 35 residents in the third-floor memory care. Interviews with staff confirmed that three caregivers were working on the third-floor memory care at the time of the incident. LPA interviewed three staff who were witnesses to the incident, and one confirmed seeing R2 push R1 causing R1’s fall. All four staff interviewed also confirmed that R2 has a history of aggression. LPA reviewed R2’s Physician’s Report dated January 1, 2025, which indicates R2 has Dementia, and R2’s Appraisal/Needs and Services Plan dated February 1, 2024, which was not updated as required due to R2’s Dementia diagnosis, does not indicate R2 has a history of aggressive behavior as confirmed by facility staff, or provide a care plan to address R2’s aggressive behavior. Interviews with three staff confirmed that the incident was caused when R2 was left to wander around the memory care, confirming that no special care was provided to address R2’s aggressive behavior. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

The three staff also indicated R1 expressing anger only when told not to smoke in the front patio. Due to conflicting information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Licensee did not provide a safe environment is deemed Unsubstantiated. An exit interview was conducted with Chief Operating Officer Faye Shen, and a copy of this report was provided at exit. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Six out of the seven residents and three out of the three staff interviews acknowledged R1 smoking in the front patio which is a no smoking zone evidenced by the two no smoking signs and one personal sign posted for R1. Three out of the three staff indicated reminding R1 not to smoke, however R1 would not adhere to the house rules. Based on the review of the resident code of conduct, facility enforces a strict zero-tolerance policy and permits smoking "exclusively in designated areas" and prohibits in areas marked with no smoking signs. Per review of the the resident's smoking log, which was part of the Plan Correction (POC) issued on January 15, 2025, the log reveals R1 smoking at the front entrance. Based on the observations made, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Licensee did not provide a healthful environment by allowing resident to smoke at the facility entranceway is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC9099D. A civil penalty for a repeat violation is being assessed on the LIC421FC. An exit interview was conducted with Chief Operating Officer Faye Shen, and a copy of this report including the LIC811 and the appeal rights were provided at exit.

LPA interviewed the facility’s medication technician supervisor who reported there were issues in December 2024 with residents on controlled pain medications but denied that any of these medications have been stolen. LPA reviewed the facility’s MAR for December 2024 for the five residents on controlled pain medications and noted the MARs are incomplete and do not properly document the medications dispensed. Per the facility’s medication technician supervisor, the facility is using a new electronic MAR system which does not always record the information that is entered, but the facility’s as-needed medication logs are still handwritten and properly document medications dispensed. LPA inspected the controlled pain medications for the five residents, all of which were in bubble packs, and observed no errors. LPA reviewed the January 2025 as-needed medication logs for the three residents who take controlled pain medications on an as-needed basis and confirmed the logs matched the medications administered and that there were no missing or extra pills. The facility’s medication technician supervisor denied that residents were ever given smaller doses than prescribed, but revealed that in December 2024 one of these residents missed one or two doses and was offered an alternate medication (Tylenol) because the facility ran out of supply of the resident’s controlled pain medication. LPA reviewed this resident’s medication list and confirmed Tylenol is one of their prescribed medications. Per the facility’s medication technician supervisor, this resident requests and takes this controlled pain medication four times a day. LPA reviewed this resident’s as-needed medication logs and noted approximately six days in November and December 2024 when the resident missed at least one dose of their controlled pain medication. LPA also noted that these logs did not document the facility’s attempts to refill the medication, which dates and times the medication could not be provided as requested, and the reason the medication could not be provided as requested. LPA inspected the medications for an additional 10 residents and did not observe any additional medication issues. LPA interviewed two additional medication technicians and did not obtain additional information regarding the allegation. LPA interviewed the four residents on controlled pain medications who were present at the facility and did not obtain additional information regarding the allegation. The information obtained corroborated that the facility did not dispense one resident’s medications as prescribed by running out of one of supply and that the facility instead dispensed an approved alternate medication. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Clara Ramirez and discussed the purpose of the inspection. Chief Operating Officer (COO) Faye Shen arrived during the inspection. LPA reviewed Infection Control requirements. At about 8:45AM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is a 180-bedroom, 100-bathroom, 3 story building. There is 1 large central patio with patio covers for the residents. Resident Bedrooms: the 18 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 18 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 degrees F and 120 degrees in the 18 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees are paid. At about 11:00AM, LPA reviewed 10 resident files and 10 staff files, interviewed 5 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money. 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 During the inspection, LPA and AD observed the following: based on documents and admission, the current administrator's administrator certificate lapsed on February 5, 2025; based on documents, the staff files for 5 out of 10 staff did not have health screenings; based on Guardian records and admission, the licensee did not ensure staff VERONICA DIAZ VILLEGAS was background cleared prior to working at the facility for multiple years and that staff Dolores L Gonzalez was associated prior to working at the facility for multiple months; based on documents, the licensee did not maintain complete records for annual training requirements for 10 out of 10 staff; and based on documents, it has been more than three months since the facility's last emergency disaster drill. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

On this day Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit in conjuction with complaint control #22-AS-20241219124149. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the investigation for complaint control 22-AS-20241219124149 it was revealed that Resident 1 (R1) hospice records were not available. It was also reported by 2 out of 2 staff that R1's hospice does not provide updates or care plans to the facility. Based on observations made during today's visit a deficiency is being cited per Title 22 An exit interview was conducted and a copy of this report was provided along with appeal rights.

Therefore, based on the preponderance of evidence through observations and interviews the allegation that facility is in disrepair the allegation is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative . 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 Per interviews with 3 out of 3 staff stated they contract out activities’ services from Lifeskills Education Advancement Program at least 3 times a week. The classes range from music to exercise, in addition to facility activities of arts and crafts. Based on interviews with staff, staff will assist residents from 2 nd and 3 rd floor to the 1 st floor to participate in activities daily. Based on LPA Mendivil’s observations on 12/15/2023 and 12/29/2023 residents were participating in activities such as exercise. Therefore based on the preponderance of evidence through interviews, records reviewed and observations the allegations staff do not keep the facility clean or sanitary and staff do not provide daily activities for residents in care are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report was left at the facility.

Regarding the allegation that staff do not treat residents with dignity or respect: it was alleged that residents go to dinner without shoes and without showering for days, facility staff argue with and intimidate residents who bring up concerns at resident council meetings, and facility staff stand around gossiping about residents and disclosing their confidential information. LPA observed one resident walking around the facility barefoot on January 10, 2025, and the same resident walking around the facility wearing only socks on January 13, 2025. Per COO, the facility has not received complaints about residents going without shoes and has not addressed this issue with any residents. LPA did not observe any residents with offensive odors throughout the facility and out of 13 residents interviewed, none had offensive odors and none reported concerns regarding showers or the hygiene of other residents when asked if they were experiencing any problems at the facility. Per COO, residents receive showers twice a week, some residents refuse but facility staff can usually work with them and convince them to shower. LPA reviewed the facility’s shower log for December 2024 which shows only four shower refusals for the month. LPA interviewed 13 residents, none of whom corroborated that staff argue with or intimidate residents at the facility. However, two residents reported witnessing staff making fun of a resident who has issues with speech by mimicking them and one resident reported that staff shared personal information about how this resident developed their issues with speech. The information obtained corroborated the allegation. Regarding the allegation that staff allow residents to smoke in areas not designated for smoking: it was alleged that residents are allowed to smoke in their rooms leaving the building smelling like smoke. LPA inspected the facility and noted a strong smell of cigarette smoke coming out of one room and Resident #1 (R1) smoking in the front courtyard of the facility where there are multiple “no smoking” signs with dozens of used cigarettes and a lighter on the ground near R1. LPA reviewed the facility’s house rules which state that smoking is only allowed in the designated smoking area and smoking is prohibited inside the building and where there are “no smoking” signs. When interviewed, COO stated the only designated smoking areas are in the central courtyard and residents are not allowed to smoke in their rooms or anywhere else. COO could not provide information about the resident whose room smelled like smoke, but stated that R1 has been at the facility for about six months, facility staff tell R1 they can only smoke in the designated smoking areas but R1 does not listen, the facility is working with R1’s responsible party regarding this issue, and the facility has issued one written warning to R1 but has not issued an eviction notice. 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 13 residents, five of whom corroborated that the facility is not doing enough to enforce the house rules and ensure the inside of the facility is smoke-free, including one resident who asked R1 to stop smoking in non-smoking areas and was yelled at by R1. The information obtained corroborated the allegation as the facility is not properly identifying and addressing rooms that smell like smoke and has not moved quickly enough to address R1’s constant violation of the house rules. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. 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 do not keep the facility clean or sanitary: it was alleged that common areas are cluttered with trash preventing residents from enjoying these areas of the facility, residents on the second floor have pets they cannot properly care for or clean up after leaving the facility malodorous, and staff hours were cut resulting in the facility floors not being mopped. LPA inspected the facility and did not observe any clutter, trash, or unclean floors. LPA interviewed COO, who denied the allegation and stated that the housekeeping staffing levels have actually increased. LPA reviewed the facility’s housekeeping schedule for September 2024 through January 2025, which shows that the number of housekeeping staff has increased slightly. LPA noted mild, but not unpleasant, pet odors in the room of R2. LPA reviewed a photograph of R2’s dog which shows that it urinated in a common area, however it is unclear how much time elapsed before R2 or facility staff cleaned up after the dog. Per COO, R2 is a good resident, their dog is friendly and other residents like this dog, the dog generally stays outside, and R2 cleans up after their dog and facility staff will clean up after the dog if R2 does not. LPA noted strong and unpleasant pet odors in the room of R3. Per COO, R3’s dog is a problem, R3 did not move in with the dog, the facility has tried multiple times to get R3 to get rid of the dog, and the facility is in the process of evicting R3 due to the dog and other issues. LPA reviewed R3’s 30-day Eviction Notice dated September 19, 2024 and the facility’s Unlawful Detainer Complaint against R3 filed November 12, 2024, which show that the facility is taking proper measures to address R3’s violation of the house rules. Out of 13 residents interviewed, 12 reported no concerns with cleanliness or pets at the facility. The information obtained did not corroborate the allegation and shows that the facility is addressing the issues raised by R3’s dog through the eviction process. Regarding the allegation that staff do not provide a safe environment for residents: it was alleged that some residents are involved in illegal activities, treat other residents and staff in a rude manner, and argue, do illegal drugs, and drink late into the night in common areas. LPA interviewed COO who denied the allegation. However, per COO, R3 violates the house rules and when the facility tried to enforce the house rules on R3, R3 became angry and shouted profanities in the past. One witness interviewed stated they saw R3 threaten staff. LPA reviewed a video showing R3 yelling at another resident. COO stated that the facility is in the process of evicting R3 due to their violation of the house rules. LPA reviewed R3’s 30-day Eviction Notice dated September 19, 2024 and the facility’s Unlawful Detainer Complaint against R3 filed November 12, 2024, which show that the facility is taking proper measures to address R3’s behavior. 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 13 residents, 12 of whom stated they feel safe at the facility, well-treated by other residents, and have not seen any drugs at the facility, while one resident stated that other residents sometimes curse at them and they saw drug use once at the facility but the facility addressed it. LPA did not obtain information that R3 or any other resident is engaging in violence. COO stated that R3 has not engaged in violence and staff know to call police if R3 places other residents in danger pending their eviction. The information obtained did not corroborate the allegation and shows that the facility is addressing R3’s behavior through the eviction process. Regarding the allegation that staff do not keep the facility free of illegal drugs: it was alleged that some residents bring illegal drugs into the facility and do illegal drugs late into the night in common areas. LPA interviewed COO who stated that some residents claim other residents are doing drugs, facility staff have never found any proof of illegal drug use at the facility, and most of the allegations of illegal drug use have been made against R3 who the facility is in the process of evicting. LPA reviewed R3’s 30-day Eviction Notice dated September 19, 2024 and the facility’s Unlawful Detainer Complaint against R3 filed November 12, 2024, which show that the facility is in the process of evicting R3. LPA interviewed 13 residents,12 of whom stated they have not seen any drugs at the facility, while one resident stated they saw drug use once at the facility but the facility immediately put a stop to it. The information obtained did not corroborate the allegation. Regarding the allegation that staff do not safeguard resident's personal items: it was alleged that residents’ personal items are being stolen while in the facility. LPA interviewed COO who denied receiving any recent reports of lost property and stated they advise residents to lock their doors and take care of their property. Out of 13 residents interviewed, only one resident reported a theft at the facility. However, per the facility’s Admission Agreement, residents are responsible for securing their personal property and per COO, this resident did not entrust any property to the facility to safeguard so it was the resident’s responsibility to safeguard their property. In addition, COO stated that this alleged theft was not reported to the facility. It is also possible the resident misplaced their property and it was not stolen. Based on the information obtained, there is not a widespread issue of theft at the facility and the facility did not fail to safeguard any property that was entrusted to it

It was alleged that multiple large roaches were observed in Resident #1’s (R1) room, that R1’s room has had roaches for about a year, and that facility staff have not properly addressed the roach infestation. LPAs inspected 13 resident rooms and observed no roaches or insects, but LPAs did observe cat food left out in R1’s new room. LPAs interviewed 13 residents, two of whom reported seeing roaches at the facility. LPAs interviewed COO who admitted that R1’s room did have multiple roaches and that after learning of the roaches on December 4, 2024, the facility relocated R1 to another room on December 6, 2024, in order to address the infestation. COO stated that the facility’s measures to address insects in the facility include caregivers checking for food left out in residents’ rooms during their twice daily checks, a deep cleaning of residents’ rooms weekly, and regular pest control inspections and spraying approximately every 21 days by a professional exterminator. LPAs reviewed the facility’s recent pest control records which show that R1 refused the professional exterminator’s services on July 10, 2024 and September 13, 2024. Per COO, R1 sometimes refused pest control services in their room because they have a cat in their room and it is possible the infestation in R1’s room may have been caused by cat food in R1’s room. However, COO stated that the facility did not issue R1 notices of violation of the house rules for refusing pest control services and for leaving cat food out in their rooms and the information obtained corroborated that the facility’s current measures are not properly addressing roaches in the facility. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

During the initial visit on October 31, 2024 LPA tour the facility and observed that on the second and third floors there are couches with brown and black discoloration. LPA observed that the couches' leather and/or cloth is ripped or cracked. On the Memory Care units located on the second and third floors LPA observed that the wood floor is broken and missing parts of the tiles. LPA observed that some of the disrepair tiles can be a hazard trip for residents in care. On the Memory Care units LPA observed chipped tables, tables missing paint and chairs with ripped plastic covers. During the tour LPA observed that the baseboards throughout the facility are chipped and have brown and/or black discoloration. On the first floor LPA observed that the dryer is missing the top cover which exposes the flame. On the first floor LPA also observed that one of two washing machines is missing the front cover exposing the washing machine's cables. LPA also observed that the elevator by the first floor laundry room is out of service. Two of three elevators are operating properly. Based on observations and the interviews which were conducted, the preponderance of evidence standard has been met, therefore the following allegations: facility does not have a full-time activity director and facility is in disrepair are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with facility representative and a copy of this report along with the Appeal Rights were provided at the time of this visit. 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 facility is not maintaining a comfortable temperature for residents , the following was revealed: Eight of eleven individuals interviewed denied the allegation. During the initial visit LPA tested the temperature throughout the facility and it tested between 72.5 and 77.3 Degrees Fahrenheit. During the course of the interviews with residents, R1 reported that the temperature is comfortable and stated that he can adjust the temperature. Per R3 the temperature is comfortable and reported that she can adjust the air conditioning and heater. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, this allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with facility representative, and a copy of this report was provided to the facility.

However, based on the interviews with one out of the two residents, one witness resident confirmed Resident #1 (R1) falling on October 6, 2024 as a result of a black dog running in the hallway of the 1st floor. The second resident stated that they did not observe or have knowledge of the fall. Additionally, four out of the four staff confirmed R1 falling. Based on the review of the Care Note dated October 6, 2024, R1 did in fact sustain a fall because of the dog. Therefore, based on LPA's observations, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility did not ensure hallways are free from obstruction is deemed SUBSTANTIATED. A deficiency is being cited as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations is being cited on the attached LIC 9099D. An exit interview was conducted with Chief Operating Officer Faye Shen, and a copy of this report including the appeal rights were provided at the end of the visit.

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20201221092131. LPA met with Administrator (AD) Allen Nishikawa and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, Chief Operating Officer (COO) Faye Shen, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Resident File, and Medication Administration Records (MAR) for multiple residents. When interviewed, R1 stated that they had previously received the wrong medications which caused a severe reaction, so they double-check the medications they receive from the medication technician. Regarding the alleged past medication error, R1 did not specify if it occurred at this facility or another location. LPA reviewed R1’s Resident File and interviewed the staff in charge of medications and did not obtain information corroborating a medication error. LPA reviewed the MAR for R1 and noted dozens of instances of medications not being signed off as being given to R1 with no documented explanation, although LPA obtained no evidence of R1 suffering a severe reaction. The MAR for four other residents also showed similar blanks where the medications were not signed off, but the pills were no longer in the bubble packs. Per the staff in charge of medications, the reason the doses were not signed off by the medication technician is because the medication technician forgot or did not have time to sign off on the dose and this does not indicate that the medications were not given. However, the doses were still not properly documented as required to ensure residents were receiving their medications as required. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

the above allegation is deemed Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

During the initial complaint visit January 23, 2024, LPA Haley observed burn marks in R1's bathroom and smelled the odor of cigarette smoke upon entering the resident’s room. The smell of smoke was not fresh smoke, but you could tell that smoking takes place inside the room. Photos were taken in R1's room of several cigarette burn marks. Based on the evidence gathered through interviews and observations, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6. An exit interview was conducted, and a copy of this report, and appeal rights were provided.

LPA interviewed AD who stated this notice was used by the facility to provide notice of a rate change to residents, was posted at the front of the facility and distributed at a resident council meeting where 12 residents were present, and was placed in the mailbox of each resident at the facility. However, because the notice does not provide at least 60 day’s notice of a rate increase as required, the facility did not provide adequate notice of the rate change to residents. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. 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 inspected the kitchen and observed it to be clean and organized, the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations, the refrigerator and freezer were at proper temperatures, there were no spoiled or expired foods, and the perishable food appeared fresh and included fresh fruit and vegetables. LPA observed lunch being served in the dining room and via room service in resident rooms on 03/12/24 and LPA’s observations did not corroborate the allegation. The meals were generous in size and included a quesadilla with a side of rice, beans, salad and salsa, a soup with meat and vegetables, a salad, and a cookie. LPA interviewed 10 residents, including both residents who eat in the dining room and residents who receive their meals in their rooms. Of the 10 residents interviewed, none had any complaints about the quality of the food. 4 residents reported that portions are sometimes smaller, but all residents that responded confirmed they are getting enough to eat and that they are able to ask for more and always receive more food if they request it. None of the residents interviewed had any complaints about the quantity of food provided. LPA reviewed facility menus for the last three months and noted a proper variety of meat and vegetables in the meals. Residents interviewed corroborated that the meals balance meat, vegetables, and other items. LPA interviewed AD who did not corroborate the allegation and reported the facility orders its food from Sysco, US Foods, and Dairy King. LPA reviewed Sysco, US Foods, and Dairy King invoices for the month of February 2024 and those from approximately a year prior and noted the facility spent approximately 13.5% more on food in February 2024 than a year previous. 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.

Regarding the allegation, resident's representative was not informed of the bruise, the investigation revealed the following. It was reported that R1 sustained a bruise sometime in November or December 2023. 5 out of 5 staff interviewed reported seeing R1 with a bruise on their left arm but do not know when R1 got the bruise. 5 out of 5 staff reported that they remember seeing R1 with a bruise on their left arm in December 2023. 5 out of 5 staff reported that they did not report the bruise to anyone. R1 reported they did not remember when they sustained the bruise but reported they got it from the bed rail. A review of facility records and Agency records shows no incident report was sent regarding R1’s bruise. R1's responsible party reported they saw the bruise in December and it was not reported to them by facility staff. The facility could not provide any documentation that the bruise was reported to the responsible party. The preponderance of evidence standard has been met, therefore, the allegation, is found to be SUBSTANTIATED Violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report along with citation and Appeal 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 Regarding the allegation, facility staff does not communicate properly with resident due to language barriers, the investigation revealed the following. It was reported that on December 3, 2023, staff ignored resident’s request to have the TV turned off because of a language barrier between the staff and residents. 5 out of 5 staff interviewed denied this report. None of the staff interviewed recall being asked to turn of a TV on December 3, 2023. R1 reported they do not remember the incident. 4 out of 4 residents interviewed reported they had no language issues with staff. Based on the information gathered through interviews the allegation is unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. 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 Administrator and staff interviewed reported that after the request was made Staff 1 (S1) was assigned to a different area and Staff 2 (S2) replaced S1 in assisting R1. Both S1 and S2 verified this report. R1 verified this report. None of the evidence gathered supports the allegation, therefore the allegation is unfounded, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided.