Avenir Memory Care Westside.

Continued LIC9099--C page 2. LPA Bunker and Executive Director Ashley Shire toured the facility to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visit. Interviews were conducted with Staff Members #1 and #5 (S1-S5) as well as with Residents #1(R1). Investigation Findings Allegation: Staff hit a resident in care. On December 10, 2025, at approximately 8:30 a.m., it was alleged that a staff member hit Resident 1 (R1) on the hand. According to S1, the staff member who reported the incident did not do so until December 15, 2025—five days later—and did not provide a reason for the delayed reporting. On January 6, 2026, between 10:00 a.m. and 4:15 p.m., LPA Bunker interviewed staff members S1 through S5. Staff members S1, S2, and S3 stated they did not witness any staff hitting R1. S5 reported witnessing a staff member hit R1 on both hands and stated that another staff member was present during the incident. S3 reported conducting a full body check on R1 and observed no injuries, bruising, redness, or swelling to R1’s hands. Two staff members (2 out of 5) confirmed they were on duty at the time and stated that R1 was not hit by staff. S1, S2, and S3 reiterated that they did not witness any staff member hitting R1. S1 also stated that the facility completed its own investigation and determined the allegation to be unsubstantiated. On December 16, 2025, the facility self-reported the incident to Community Care Licensing, the Ombudsman, and all other appropriate agencies in a timely manner. 5 out of 5 staff members interviewed stated that R1 did not require any medical treatment. Staff members S1 through S4 denied the allegation. On January 6, 2026, at 12:50 p.m., the Department interviewed Resident 1 regarding the allegation. R1 stated that staff did not hit them on the hand and denied the allegation. See continued LIC9099-C page 2. 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 LIC9099-C page 3. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. 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 deemed unsubstantiated. There were no deficiencies cited. LPA Bunker provided Executive Director Ashley Shire with copies of the LIC9099 and LIC9099-C Complaint Investigation Reports. An exit interview was conducted.

The investigation revealed the following: Allegation: Staff did not report incidents to Community Care Licensing It was alleged that facility staff failed to report required incidents to Community Care Licensing, including resident injuries and other reportable events. On 12/23/2025, between 9:34am - 9:56am, the LPA interviewed the Administrator regarding the allegation. A1 denied the allegation and stated any unusual incidents such as falls, injuries, abuse, hospice notification, etc., are always documented and submitted to the Department. The staff notify the nurse and medtech who contact first responders. Then a report is generated, and the facility nurse and or Administrator submits the report to Community Care Licensing. On 12/23/2025, between 8:32am - 11:30am, the LPA interviewed 6 staff regarding the allegation. 6 of 6 staff denied the allegation and stated that as mandated reporters, everything must be documented, such as any kind of abuse, falls, injuries, repairs, combative behavior between residents and/or staff, sickness, and/or illness, and must be reported to Community Care Licensing. On 12/23/2025, between 12:11pm - 1:56pm, the LPA interviewed 5 residents regarding the allegation. 5 of 5 residents denied the allegation. 2 of 5 residents stated staff come to help and explain if any incident occurs, while 3 of 5 residents stated not having any history of getting hurt and/or falling. On 12/23/2025 at 11:55am, LPA interviewed R1's spouse Witness 2 (W2) by phone regarding it being alleged that R1 had a fall in the dining room in October 2025. W2 denied the allegation and stated it's possible due to R1 being non-ambulatory and using a geri-chair. W2 also mentioned the facility always notifies the family about everything pertaining to R1. On 12/23/2025 between 2:30pm - 2:45pm, LPA conducted a record review and observed the following: The facility has a LIC 624 - Unusual Incident Reports (January 2025 - December 2025) binder which has the fax cover sheet as proof of faxing the Department of all the incidents that have occurred at the facility. Upon further review, the facility submitted an Unusual Incident/Injury Report regarding Resident 5 (R5) who had fallen but sustained no injuries, with medical doctor and power of attorney being notified. Also, on 08/08/2025, R5 had an unwitnessed fall in her room with some skin tear. First responders were called and transported R5 to the hospital. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Due to staff neglect, resident sustained pressure injuries It was alleged that residents developed pressure injuries due to staff neglect. On 12/23/2025, between 9:34am - 9:56am, the LPA interviewed the Administrator regarding the allegation. A1 denied the allegation and stated Resident 5 (R5) previously had a pressure injury around August 2025- September 2025. A1 also mentioned that R3 is the only resident at the facility who has a pressure injury, which is currently at the beginning stage and is receiving wound care from a Home Health Agency. On 12/23/2025, between 8:32am - 11:30am, the LPA interviewed 6 staff regarding the allegation. 2 of 6 staff neither confirmed nor denied the allegation and stated being aware of R3 having a pressure injury and wound care being provided by a home health agency. 4 of 6 staff were unaware of the allegation and stated not having knowledge of any residents who currently have a pressure injury. On 12/23/2025, between 12:11pm - 1:56pm, the LPA interviewed 5 residents regarding the allegation. 5 of 5 residents denied the allegation and stated not currently having a pressure injury. On 12/23/2025 between 3:00pm - 3:10pm, LPA conducted a record review and observed the following: According to the Resident Notes (dated 12/14/2025 and 12/16/2025) for Resident 3 (R3), every three hours the staff check, clean, change, and apply Calazinc on the open wound in between the resident's buttocks, near the tailbone. On 12/18/2025 between 10:30pm - 5:30am, the staff checked on R3 and repositioned her on her left side and her right side every 3 hours. R3 is currently receiving wound care from Remedy Home Health (documentation dated 12/18/2025, 12/19/2025, and 12/22/2025). Resident 5 (R5) received wound care on 08/16/2025, 09/10/2025, 09/18/2025, and 09/19/2025, and as of 12/22/2025 does not have a pressure injury. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff do not ensure freezer temperatures are within range It was alleged that staff failed to maintain freezer temperatures, which could cause food spoilage and unsafe meals. On 12/23/2025, between 9:34am - 9:56am, the LPA interviewed the Administrator regarding the allegation. A1 denied the allegation and stated not having issues with food going bad, but if that was the case, spoiled food and unsafe meals would be thrown away. In the kitchen there are temperature logs for the bistro, refrigerator, and freezer. Also, A1 mentioned in the event of the freezer temperature falling outside of the required range, maintenance must be notified immediately. A1 said if the freezer temperature is found to be too warm or too cold, maintenance is notified, and food will be transferred to the deep freezer. On 12/23/2025, between 8:32am - 11:30am, the LPA interviewed 6 staff regarding the allegation. 4 of 6 staff denied the allegation and stated there have been no recent freezer temperatures out of range. Periodically the temperature for the bistro, refrigerator, and freezer are logged every day. However, if this is ever an issue, it is reported to maintenance and food will be removed and added to the deep freezer until the main freezer is repaired. 2 of 6 staff were unaware of the allegation and stated not having any knowledge of food spoilage and unsafe meals. On 12/23/2025, between 12:11pm - 1:56pm, the LPA interviewed 5 residents regarding the allegation. 5 of 5 residents denied the allegation and stated food usually appears to look okay and have not seen food look bad or spoiled. On 12/23/2025 at 1:39pm, LPA conducted a tour of the kitchen and observed the following temperatures: 0°F (freezer), 37°F - 40°F (refrigerator), and 32°F (bistro). On 12/24/2025 at 9:40am - 9:45am, LPA conducted a records review and observed the following: For the month of December from 12/1 - 12/23, the bistro measured between 28°F - 36°F, the refrigerator 32°F - 38°F, and the freezer 0°F - 3°F which is in compliance with Title 22 regulations. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff served spoiled food to residents It was alleged that residents were served spoiled or unsafe food, posing a health risk. On 12/23/2025, between 9:34am - 9:56am, the LPA interviewed the Administrator regarding the allegation. A1 denied the allegation and stated the facility has never served spoiled food to the residents, but if food appears spoiled, contaminated, or unsafe, it must first be reported and then thrown away. A1 also stated the process to follow before food is prepared and served to the residents is by following any special diets, special orders, allergies, and pureed food requirements. On 12/23/2025, between 8:32am - 11:30am, the LPA interviewed 6 staff regarding the allegation. 4 of 6 staff denied the allegation and stated there have been no recent incidents where residents were served spoiled food. However, if food ever appears spoiled, contaminated, or unsafe, food will be removed with the kitchen and the director being notified as well. 2 of 6 staff were unaware of the allegation and stated not having any knowledge of the staff serving spoiled food to the residents. On 12/23/2025, between 12:11pm - 1:56pm, the LPA interviewed 5 residents regarding the allegation. 5 of 5 residents denied the allegation and stated the meals given to the residents are breakfast, lunch, and dinner. Also, the food given to residents looks good and appears presentable. On 12/23/2025 at 1:39pm, LPA conducted a tour of the kitchen and observed the following: perishable and non-perishable food supply was checked along with the refrigerator and freezer being fully stocked with a variety of food options in good condition. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff do not follow physician orders It was alleged that staff failed to follow physician orders, including required health monitoring and treatments. On 12/23/2025, between 9:34am - 9:56am, the LPA interviewed the Administrator regarding the

The investigation revealed the following: Allegation: Staff do not provide adequate supervision resulting in residents sustaining multiple falls. At approximately 8:20 AM, LPA Allen conducted interviews with six (6) staff members 1-6 (S1-S6). 6 out of 6 staff stated they had not personally witnessed R1 fall but were aware of previous incidents that have been reported and documented. Staff stated R1 needs and service plans are always followed however because moderate assistance is required staff does allow R1 privacy while helping with incontinence needs. Staff also stated R1 is consistently encouraged to remain in common areas where they can be assisted with their mobility/transfer needs and observations. At approximately 10:25 AM, LPA interviewed five (5) Residents. LPA attempted to interview R1; however, R1 was unable to remain on topic, did not confirm or deny any falls and was unable to have a clear conversation. LPA also interviewed R2 and R3 who stated they have not had any falls and there are staff there to help them. LPA attempted to interview R4 and R5, but they were unable to have a clear conversation. At 11:20 AM, LPA Allen interviewed an external witness (W1), who reported that R1 has fallen or slid from their wheelchair on three occasions. W1 mentioned that the facility’s administrative staff had been in direct communication regarding R1's falls and expressed confidence that the staff were doing their best to ensure R1's safety. LPA Allen also reviewed the 2024 and 2025 physician reports, which indicates that stand-by to moderate assistance is required. Additionally, LPA Allen observed that there is a care plan in place for transfer and mobility, which specifies assistance with resident participation. A review of R1’s file showed no documented designation of R1 as a fall risk or a need for a one-to-one ratio, though some assistance with activities of daily living (ADLs) is required. Documentation of R1's incidents also obtained and reviewed, which shows staff did report the incidents after each occurrence. Continued 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 Further review of R1’s file revealed three incidents in which R1 sustained falls. On 2/25/2025 R1 was found on the floor in their room around 12AM, R1 was observed to have a scrape on their forehead 911 was called and transported to the Emergency Room for further observations and readmitted to the facility. On 03/28/2025 R1 sustained an unwitnessed fall in the bathroom reporting they felt dizzy falling, hitting their right elbow causing an abrasion. The resident was assessed and 911 was called and transported to the Emergency Room for further observation. On 5/5/2025 R1 had an unwitnessed fall in the common area and noted to have an abrasion on their head the resident was assessed and 911 was called and transported to the Emergency Room for further observations. On 6/16/2025 R1 was reassessed by facility staff, and a fall risk plan was put in place. The plan, which indicates moderate assistance is needed, includes the following: one-person partial assist hand hold, assistance with observations & fall management, escorted to meals and activities, and use walker and wheelchair. Additionally, during the visit, LPA Allen observed staff members actively providing care, engaging with residents, and redirecting individuals as needed. There was sufficient staffing at the time of the visit. Based on interviews, file review and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Jodi Kanowitz Administrator at the conclusion of the visit with appeal rights. This report was signed by Ashley Shire.

On December 19, 2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced Case Management-Deficiency visit. The LPA met with Ashley Shire / Interim Executive Director and explained the purpose of the visit. On December 19, 2025, during a scheduled pre-licensing/change of ownership visit, LPA Iniguez found the following deficiencies: Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -Interim Executive Director not associated on Guardian (Civil Penalty Rendered for $500 dollars) Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Ashley Shire / Interim Executive Director.

This report supersedes the report created 8/29/25 and the findings will remain unchanged. Investigation Revealed the Following: Allegation: Staff did not address a resident's change in medical condition The details of the complaint alleged that (R#1) had fallen approximately 6-7 times in the evenings, and facility staff have not been checking on them. At approximately 8:00 a.m., Licensing Program Analyst (LPA) Iniguez conducted a review of facility records, including the Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A) for resident (R#1). The LIC 602A was completed annually, with records dated February 6, 2023; May 16, 2024; and most recently, April 10, 2025. Following the completion of the April 10, 2025, LIC 602A, the facility updated (R#1)’s Needs and Services Plan, originally dated February 3, 2023, to reflect the resident’s changing condition. The revised plan outlined specific care strategies and support services tailored to (R#1)’s evolving health needs. This demonstrates the facility’s commitment to aligning care planning with regulatory requirements under Title 22, which emphasizes individualized care and the need to respond to changes in condition, particularly for residents with cognitive impairments. Additionally, LPA Iniguez reviewed (R#1)’s hospice documentation. Records indicated that (R#1) was initially enrolled in hospice services on July 12, 2024, discharged after improvement, and subsequently re-enrolled on July 25, 2025, continuing through their final days. At approximately 1:00 p.m., during an interview with the Executive Director (A#1), she stated that when (R#1) experienced a fall, the facility immediately notified the resident's physician and addressed her health condition. (R#1) was enrolled in hospice services on two separate occasions while residing at the facility. Additionally, (A#1) referenced Unusual Incident Reports dated February 7, 2024; June 9, 2025; and July 23, 2025, which documented incidents of falls sustained by (R#1). In each instance, facility staff promptly assessed (R#1) and contacted emergency services for further evaluation. 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 This report supersedes the report created 8/29/25 and the findings will remain unchanged. On August 28, 2025, at approximately 2:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez was unable to speak with (R#1) since they had passed away on August 9, 2025. On August 28, 2025, at approximately 2:00 PM, during an interview with residents (R#2-R#6), (5) out of (5) stated that they think the facility will alert their physicians and representatives in case their health condition changes. On August 28, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#5), (5) out of (5) stated that when (R#1) sustained a fall, the facility contacted their physician. The physician will provide us with orders to address any changes in conditions that occur. Allegation: Staff did not provide adequate care and supervision The details of the complaint alleged that (R#1) sustained a hand fracture due to the lack of facility staff supervision. On August 29, 2025, at approximately 9:00 a.m., during the records review, LPA Iniguez observed copies of (R#1)’s monthly facility logs for incontinence check and resident daily activities of daily living (ADL’s) check, LPA Iniguez observed that the facility conducted every day (ADLs) checks on (R#1) from 2023 until 2025. Additionally, the facility conducted nightly incontinence checks every other hour on (R#1) monthly from 2023 until 2025. At approximately 10:00 a.m., during an interview with the Executive Director (A#1), she stated that (R#1) consistently received adequate care and supervision from the facility staff. Additionally, (A#1) explained that, according to (R#1)’s current Plan of Care, the resident required minimal assistance with transferring and no assistance with mobility. However, (A#1) emphasized that the care team actively monitored for any changes in (R#1)’s condition and conducted reappraisals as needed to ensure that the care remained aligned with (R#1)’s evolving needs. 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 This report supersedes the report created 8/29/25 and the findings will remain unchanged. On August 28, 2025, at approximately 2:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez was unable to speak with (R#1) since they had passed away on August 9, 2025. On August 28, 2025, at approximately 2:00 PM, during an interview with residents (R#2-R#6), (5) out of (5) stated that the facility staff provides enough care and supervision for them. On August 28, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#5), (5) out of (5) stated that stated that (R#1) received sufficient care and supervision while at the facility. Staff reported that they followed (R#1)’s Plan of Care and documented any observed changes in the resident’s condition. Allegation: Staff did not properly report incidents involving the residents The details of the complaint alleged that facility administrator instructed facility staff not to report (R#1) falls and injuries. At approximately 9:00 a.m., during review of records, LPA Iniguez observed copies of Unusual Incident Reports (LIC 624) related to resident (R#1). The facility had documented and reported each incident involving (R#1) to the Community Care Licensing Division (CCLD) and the Long-Term Care Ombudsman via fax, in compliance with regulatory requirements. Additionally, LPA Iniguez reviewed the facility’s internal incident reports, which were consistent with the corresponding LIC 624 forms. These reports included detailed descriptions of each incident, the actions taken by staff, and the follow-up measures implemented to ensure resident safety. This documentation demonstrates the facility’s adherence to reporting protocols and its responsiveness to incidents involving (R#1). 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 This report supersedes the report created 8/29/25 and the findings will remain unchanged. On August 28, 2025, at approximately 10:00 a.m., during an interview with the Executive Director (A#1), the Executive Director stated that the Director of Health Services is responsible for recording and reporting resident incidents. In the case of (R#1), she confirmed that all incidents had been reported to the Community Care Licensing Division (CCLD) and to the resident’s representative. (A#1) denied ever instructing staff not to report incidents, stating that she has always encouraged complete transparency and compliance with reporting requirements. This statement was supported by a review of facility records, which included Unusual Incident Reports (LIC 624) for (R#1) dated 2/9/24, 3/4/24, 6/13/25, 7/31/25, 8/5/25, and 9/16/24, as well as a Death Report (LIC 624A) dated 8/12/25. Additionally, (A#1) stated that internal incident reports dated 7/23/25, 7/24/25, 6/8/25, 6/9/25, 5/15/25, 2/23/25, 11/1/24, and 9/11/24 were reviewed and found to be consistent with the official reports. On August 28, 2025, at approximately 2:00 p.m., Licensing Program Analyst-LPA Alfonso Iniguez was unable to speak with (R#1) since they had passed away on August 9, 2025. On August 28, 2025, at approximately 2:00 p.m., during an interview with residents (R#2-R#6), (5) out of (5) stated that they feel the facility will report to their representatives and physician if something happens to them. On August 28, 2025, at approximately 1:00 pm, during an interview with facility staff (S#1–S#5), (5) out of (5) stated that (R#1) falls and changes in condition were reported to the physician and to the Community Care Licensing Division (CCLD), and that they were never instructed to withhold such information. 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 This report supersedes the report created 8/29/25 and the findings will remain unchanged. These statements were supported by a review of facility records, which included Unusual Incident Reports (LIC 624) dated 2/9/24, 3/4/24, 6/13/25, 7/31/25, 8/5/25, and 9/16/24, as well as a Death Report (LIC 624A) dated 8/12/25. Internal incident reports dated 7/23/25, 7/24/25, 6/8/25, 6/9/25, 5/15/25, 2/23/25, 11/1/24, and 9/11/24 were also reviewed and found to be consistent with the official reports. Additionally, (5) out of (5) facility staff stated that daily Activities of Daily Living (ADL) logs and bi-hourly incontinence checks from 2023 to 2025 demonstrated that (R#1) received consistent care and supervision. Hospice admission notes dated 7/12/24 and 7/25/25, along with updated Physician's Reports (LIC 602A) and the revised Needs and Services Plan, further supported staff's claims that changes in (R#1)'s condition were appropriately addressed. During this investigation, LPA did not find sufficient evident 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 Ashley Shire/Interim Executive Director

On 11/5/2025, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced Case Management-Health Checks visit at the facility. LPA Iniguez met with Judy Kamenwa/ Director of Health Services and explained the purpose of the visit. On 4/4/25, a non-compliance video conference meeting was held for this facility. Jason Gurash-Board member/Licensee, Timothy Daley-Legal consult for licensee, Terri Weitzman-Interim Executive Director, Benita Yates-CCLD Regional Manager, Eva Alvarez-CCLD Licensing Program Manager and Alfonso Iniguez-CCLD Licensing Program Analyst were all present at this meeting. Regional Manager Yates started the meeting with formal introductions. This is one of the items listed at the meeting: -The Department will initiate unannounced Case Management visits to be conducted for a period of 12 months. On 11/5/2025, LPA Iniguez reviewed the Register of Facility Clients/Residents or LIC 9020 dated 10/21/25 and the Personnel Report or LIC 500 dated: 10/22/2025. in addition, LPA Iniguez conducted (5) staff interviews (S#1-S#4) and a Health and Safety check of the facility. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Judy Kamenwa/Director of Health Services.

On 9/17/2025, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced Case Management-Health Checks visit at the facility. LPA Iniguez met with Jodi Kanowitz/Executive Director and explained the purpose of the visit. On 4/4/25, a non-compliance video conference meeting was held for this facility. Jason Gurash-Board member/Licensee, Timothy Daley-Legal consult for licensee, Terri Weitzman-Interim Executive Director, Benita Yates-CCLD Regional Manager, Eva Alvarez-CCLD Licensing Program Manager and Alfonso Iniguez-CCLD Licensing Program Analyst were all present at this meeting. Regional Manager Yates started the meeting with formal introductions. This is one of the items listed at the meeting: -The Department will initiate unannounced Case Management visits to be conducted for a period of 12 months. On 9/17/2025, LPA Iniguez reviewed the Register of Facility Clients/Residents or LIC 9020 dated 9/16/25 and the Personnel Report or LIC 500 dated: 7/23/2025. in addition, LPA Iniguez conducted (5) staff interviews (S#1-S#4) and a Health and Safety check of the facility. The evaluation Report continues the next page, LIC 809-C , providing further details of the inspection findings.

Investigation Revealed the Following: Allegation: Staff did not address a resident's change in medical condition The details of the complaint alleged that facility staff did not address (R#1)’s change in condition. On August 29, 2025, at approximately 8:00 a.m., during the records review, LPA Iniguez reviewed (R#1)’s Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A, LPA Iniguez observed that the LIC 602A was done every year, the first one was done on 2/6/23, the second one was done on 5/16/24 and the most recent was done on 4/10/25. Performing LIC 602A every year indicates that the facility was following Title 22 regulations for residents with cognitive impairments and their changes in condition. Additionally, LPA Iniguez reviewed (R#1)’s hospice admission notes. On 7/12/24 (R#1) was enrolled in hospice services due to their health condition, then it was discharged since their health improved; however, (R#1) got enrolled in hospice services on 7/25/25 until their last days. On August 28, 2025, at approximately 1:00 PM, during an Interview with the Executive Director (A#1), she stated that when (R#1) sustained a fall, the facility immediately informed their physician and addressed their health condition, signing them up for hospice services twice while they resided here. On August 28, 2025, at approximately 1:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez contacted (W#1) via telephone. (W#1) did not answer the call, and LPA Iniguez left a voice message. On August 28, 2025, at approximately 2:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez contacted (W#1) via telephone. (W#1) did not answer the call, and LPA Iniguez left a voice message. On August 28, 2025, at approximately 3:30 PM, Licensing Program Analyst-LPA Alfonso Iniguez contacted (W#1) via telephone. (W#1) did not answer the call, and LPA Iniguez left a voice message. 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 August 28, 2025, at approximately 2:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez was unable to speak with (R#1) since they had passed away on August 9, 2025. On August 28, 2025, at approximately 2:00 PM, during an interview with residents (R#2-R#6), (5) out of (5) stated that they think the facility will alert their physicians and representatives in case their health condition changes. On August 28, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#5), (5) out of (5) stated that when (R#1) sustained a fall, the facility contacted their physician. The physician will provide us with orders to address any changes in conditions that occur. Allegation: Staff did not provide adequate care and supervision The details of the complaint alleged that facility staff did not provide adequate care and supervision for (R#1). On August 29, 2025, at approximately 9:00 a.m., during the records review, LPA Iniguez observed copies of (R#1)’s monthly facility logs for incontinence check and resident daily activities of daily living (ADL’s) check, LPA Iniguez observed that the facility conducted every day (ADLs) checks on (R#1) from 2023 until 2025. Additionally, the facility conducted nightly incontinence checks every other hour on (R#1) monthly from 2023 until 2025. On August 28, 2025, at approximately 10:00 AM, during an Interview with the Executive Director (A#1), she stated that (R#1) always had enough care and supervision from facility staff. 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 August 28, 2025, at approximately 1:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez contacted (W#1) via telephone. (W#1) did not answer the call; LPA Iniguez left a voicemail. On August 28, 2025, at approximately 2:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez contacted (W#1) via telephone. (W#1) did not answer the call, and LPA Iniguez left a voice message. On August 28, 2025, at approximately 3:30 PM, Licensing Program Analyst-LPA Alfonso Iniguez contacted (W#1) via telephone. (W#1) did not answer the call, and LPA Iniguez left a voice message. On August 28, 2025, at approximately 2:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez was unable to speak with (R#1) since they had passed away on August 9, 2025. On August 28, 2025, at approximately 2:00 PM, during an interview with residents (R#2-R#6), (5) out of (5) stated that the facility staff provides enough care and supervision for them. On August 28, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#5), (5) out of (5) stated that (R#1) had enough care and supervision while residing at the facility. Allegation: Staff did not properly report incidents involving the residents The details of the complaint alleged that facility administrator told staff not to report (R#1)’s incidents. On August 29, 2025, at approximately 9:00 a.m., during the records review, LPA Iniguez observed copies of (R#1) 's Unusual Incident Reports or LIC 624. LPA Iniguez observed that the facility recorded and reported every incident (R#1) to CCLD and the Long-Term Care Ombudsman via fax. Additionally, LPA Iniguez reviewed copies of the facility's Incident Report; these reports are closely tied to the LIC 624 forms. 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 August 28, 2025, at approximately 10:00 a.m., during an Interview with the Executive Director (A#1), she stated that the Director of Health Services oversees recording the resident's incidents; in this case, (R#1)'s incidents were reported to CCLD and their representative. Additionally, (A#1) stated that she has never instructed facility staff not to report (R#1)'s incidents; on the contrary, she has encouraged them to do so. On August 28, 2025, at approximately 1:00 p.m., Licensing Program Analyst-LPA Alfonso Iniguez contacted (W#1) via telephone. (W#1) did not answer the call, and LPA Iniguez left a voice message. On August 28, 2025, at approximately 2:00 p.m., Licensing Program Analyst-LPA Alfonso Iniguez contacted (W#1) via telephone. (W#1) did not answer the call, and LPA Iniguez left a voice message. On August 28, 2025, at approximately 3:30 p.m., Licensing Program Analyst-LPA Alfonso Iniguez contacted (W#1) via telephone. (W#1) did not answer the call, and LPA Iniguez left a voice message. On August 28, 2025, at approximately 2:00 p.m., Licensing Program Analyst-LPA Alfonso Iniguez was unable to speak with (R#1) since they had passed away on August 9, 2025. On August 28, 2025, at approximately 2:00 p.m., during an interview with residents (R#2-R#6), (5) out of (5) stated that they feel the facility will report to their representatives and physician if something happens to them. On August 28, 2025, at approximately 1:00 p.m., during an interview with facility staff (S#1-S#5), (5) out of (5) stated that (A#1) has not told them not to report (R#1) 's incidents; on the contrary, they must report everything. 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 During this investigation, LPA did not find sufficient evident 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 Judy Kamenwa/Director of Health Services.

Investigation Revealed the Following: Allegation: Staff do not ensure resident rooms are clean and orderly. The details of the complaint alleged that facility staff are not cleaning (R#1 and R#2)’s rooms properly. On August 29, 2025, at approximately 11:00 a.m., during a health and safety check of (R#1 and R#2)’s room, LPA Iniguez observed that their room was clean, orderly, and sanitary, including the bathroom. On August 29, 2025, at approximately 10:00 a.m., during an Interview with the Executive Director (A#1), she stated that the people who clean (R#1 and R#2)’s room are the housekeepers; we have a total of 3, they clean their room once a week and as needed. Additionally, (A#1) stated that the maintenance director supervises the housekeepers and ensures the rooms are cleaned as planned. On August 28, 2025, at approximately 11:00 AM, during an interview with residents (R#1-R#5), (5) out of (5) stated that their room is clean and it gets clean every week. On August 28, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#4), (4) out of (4) stated that the housekeepers are the ones who clean (R#1 and R#2)’s room, and they do it every week or as needed. Allegation: Staff are not providing adequate laundry services for residents. The details of the complaint alleged that facility staff are not washing (R#1 and R#2) clothes on a regular basis. 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 August 28, 2025, at approximately 11:00 a.m., during the interviews with Residents #1 and #2, LPA Iniguez observed that both residents were wearing clean clothes. Additionally, when LPA Iniguez interviewed Residents #3 to #5, all three of these residents were also found to be wearing clean clothes. On August 28, 2025, at approximately 10:00 AM, during an Interview with the Executive Director (A#1), she stated that the housekeepers and the care staff clean the sheets and towels every day. Additionally, (A#1) stated that the care staff is in charge of the residents’ clothes, including (R#1 and R#2)’s. On August 28, 2025, at approximately 11:00 AM, during an interview with residents (R#1-R#5), (5) out of (5) stated that the facility staff wash their clothes, and they do it mostly every day. On August 28, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#4), (4) out of (4) stated that the caregivers on the night shift wash the residents' clothes every night or as needed. Allegation: Staff are not meeting residents showering needs. The details of the complaint alleged that facility staff are not showering (R#1 and R#2) on a regular basis. On August 29, 2025, at approximately 11:00 a.m., during a records review, LPA Iniguez observed the facility’s weekly shower schedule for both the morning and afternoon. LPA noted that Residents #1 and #2 are scheduled to take showers every third day, as indicated on the schedule. Furthermore, during interviews with Residents #1 and #2, it was apparent that neither of them was missing their scheduled showers. 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 August 28, 2025, at approximately 10:00 AM, during an Interview with the Executive Director (A#1), she stated that the care staff provides showers for (R#1 and R#2), unless they are in a hospice, where the residents receive showers through the hospice company. Additionally, (A#1) stated that, depending on the resident’s care plan, residents can get a shower 3 to 4 times a week or as needed. On August 28, 2025, at approximately 11:00 AM, during an interview with residents (R#1-R#5), (5) out of (5) stated that the facility staff reminds them of their showers or assists them with them. In addition, (4) out of (5) residents stated that they can shower on their own, only (1) out of (5) requires assistance. On August 28, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#4), (4) out of (4) stated that they assist (R#1 and R#2) with their showers; they are scheduled to take them every 3 days. Allegation: Staff provided medication assistance to residents in care without proper training The details of the complaint alleged that facility staff are passing on medications to residents in care without proper training. On August 29, 2025, at approximately 11:00 a.m., during the records review, LPA Iniguez observed the copies of Relias training, LPA Iniguez observed that the Medtechs are trained in the following topics: Assisting with self-administration of Medications Guidelines, Medication Documentation for California, Managing Medications in Assisted Living Facilities: Knowing the side effects. 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 August 29, 2025, at approximately 10:00 a.m., during an Interview with the Executive Director (A#1), she stated that the MedTechs administer the medications to the residents. Additionally, (A#1) stated that Medtechs receive initial training before administering medications, and then they shadow another MedTech to observe how the medication is dispensed to residents. Furthermore, (A#1) stated that no facility staff is allowed to administer medicines without training. On August 28, 2025, at approximately 11:00 AM, during an interview with residents (R#1-R#5), (5) out of (5) stated that they feel the facility staff who assist them with medications are trained. Also, (5) out of (5) residents stated that they have never missed a medication dose. On August 28, 2025, at approximately 1:00 PM, during an interview with facility staff (S#1-S#4), (3) out of (4) stated that as MedTech’s, they are the ones that passes medications to the residents, only (1) out of (4) stated that they do not pass medicines since they are not trained. In addition, (4) out of (4) facility staff stated that they have never dispensed medications without the proper training. During this investigation, LPA did not find sufficient evident 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 Judy Kamenwa/Director of Health Services.

Interviews conducted revealed the following: 4 out of the 4 staff members (S1-S4) did not agree with the allegation, S1 indicated that S1 immediately diffused the situation and reported the incident to S2. S2 asked the non-resident to leave the facility and explain that it needs to be reported. 7 out of the 7 residents (R1-R7) did not agree with the allegation. R1 indicated talking to the staff about the incident and having support. LPA observations revealed the following: LPA did not observe any visible injuries from R1. Records review revealed the following: Facility incident report dated 07/17/2025 indicated that the incident that happened on 07/11/2025 did not result in serious bodily injury. LPA’s review of Title 22 Regulations 87411(b) Reporting Requirements indicates that “Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1).” During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation “Licensee did not follow mandated reporter requirements” may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this Complaint Report was given to Ashley Shire.

The investigation revealed the following: Allegation: Staff do not provide adequate supervision resulting in residents sustaining multiple falls. At approximately 8:20 AM, LPA Allen conducted interviews with six (6) staff members 1-6 (S1-S6). 6 out of 6 staff stated they had not personally witnessed R1 fall but were aware of previous incidents that have been reported and documented. Staff stated R1 needs and service plans are always followed however because moderate assistance is required staff does allow R1 privacy while helping with incontinent needs. Staff also stated R1 is consistently encouraged to remain in common areas where they can be assisted with their mobility/transfer needs and observations. At approximately 10:25 AM, LPA interviewed five (5) Residents. LPA attempted to interview R1; however, R1 was unable to remain on topic and did not confirm or deny any falls and unable to have a clear conversation. LPA also interviewed R2 and R3 who stated they have not had any falls and there is staff there to help them. LPA attempted to interview R4 and R5, but they were unable to have a clear conversation. At 11:20 AM, LPA Allen interviewed an external witness (W1), who reported that R1 has fallen or slid from their wheelchair on three occasions. W1 mentioned that the facility’s administrative staff had been in direct communication regarding R1's falls and expressed confidence that the staff were doing their best to ensure R1's safety. LPA Allen also reviewed the 2024 and 2025 physician reports, which indicates that stand-by to moderate assistance is required. Additionally, LPA Allen observed that there is a care plan in place for transfer and mobility, which specifies assistance with resident participation. A review of R1’s file showed no documented designation of R1 as a fall risk or a need for a one-to-one ratio, though some assistance with activities of daily living (ADLs) is required. Documentation of R1's incidents also obtained and reviewed which shows staff did report the incidents for each occurrence. Additionally, during the visit, LPA Allen observed staff members actively providing care, engaging with residents, and redirecting individuals as needed. There was sufficient staffing at the time of the visit. Based on interviews, file review and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Jodi Kanowitz Administrator at the conclusion of the visit with appeal rights.

Allegation: Staff did not ensure that resident was adequately fed It is alleged that the resident was not eating and as a result R-1 had lost a lot of weight. Per review of the Admission Agreement, LPA Felisa Shirley observed that there are three meals and three snacks served daily which are included in their monthly fee. LPA Shirley toured the inside and outside grounds of the facility. LPA Shirley observed residents eating in the dining area and LPA Shirley did not observe food being served as not of good quality. LPA Shirley reviewed residents service file and Physician’s Report dated, 9/7/23, and LPA observed that R-1 had a regular diet. Per Preplacement Appraisal Information dated, 8/31/23, R-1 feeds self independently. LPA Shirley observed R-1’s Narrative charting and observed that R-1 sometimes ate only 50% of his meal and sometimes refused to eat because he didn’t want to gain weight. LPA Shirley reviewed R-1’s weight chart and did not observe a drastic weight loss. Per interview with S-2, caregivers will assist if they notice that resident is not eating and will offer alternatives if desired. LPA Shirley interviewed staff-1 thru staff-6 (S-1 thru S-6). LPA asked, did staff monitor residents during meals ensuring that residents are adequately fed. Of those interviewed, 6 out of 6 staff answered yes. LPA interviewed Resident-2 thru Resident-5 (R-2 thru R-5). LPA asked, did you get enough food and are you allowed seconds if desired? Of those interviewed, 4 out of 4 answered yes. R-1 was not available. Allegation: Staff did not meet resident’s toileting needs It is alleged that staff were not changing resident as needed. LPA Shirley reviewed R-1’s Resident Daily Activities of Daily Living Sheet and log of incontinence care for the AM and PM shifts from January 2024 thru August 2024. During review of those logs LPA observed that there were entries on log sheet for incontinence changing on a consistent basis along with caregivers initials as proof of services rendered. LPA Shirley interviewed staff-1 thru staff-6 (S-1 thru S-6). LPA asked, is there a schedule for incontinence needs and if resident’s needs were being met. Of those interviewed, 6 out of 6 staff answered yes. LPA interviewed Resident-2 thru Resident-5 (R-2 thru R-5). LPA asked, are your incontinence needs being met? Of those interviewed, 2 out of 4 answered yes, and 2 stated that they were good on their own. R-1 was not available. Con-d on 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff mismanaged resident’s medication It is alleged that resident was being overmedicated. During the tour, LPA toured the medication room and LPA observed the facility maintains residents’ medication administration records in electronic QuickMAR. LPA observed that staff discontinued medications as instructed by treating physicians. LPA reviewed printouts of the resident’s eMar and LPA observed that staff made consistent entries and noted when R1 was not available and refused medications. LPA did not observe that facility staff dispensed wrong medications nor overmedicated prescribed medications to R-1. LPA Shirley interviewed staff-2 thru staff-6 (S-2 thru S-6). LPA asked, does staff mismanage residents medications. Of those interviewed, 5 out of 5 staff answered no. LPA interviewed Resident-2 thru Resident-5 (R-2 thru R-5). LPA asked, has your medications ever been mismanaged to your knowledge? Of those interviewed, 4 out of 4 answered did not believe that their medications were mismanaged. S-1 is no longer with the company. R-1 was not available. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted, and a copy of the LIC 9099 report was provided to Executive Director, Jodi Kanowitz.

On 6/5/2025, at approximately 2:30 PM, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced Case Management-Health Checks visit at the facility. LPA Iniguez meet with Jodi Kanowitz/Executive Director(just returned from medical leave on 6/4/25) and explained the purpose of the visit. On 4/4/25 at 10:00 am a non-compliance video conference meeting was held for this facility. Jason Gurash-Board member/Licensee, Timothy Daley-Legal consult for licensee, Terri Weitzman-Interim Executive Director, Benita Yates-CCLD Regional Manager, Eva Alvarez-CCLD Licensing Program Manager and Alfonso Iniguez-CCLD Licensing Program Analyst were all present at this meeting. Regional Manager Yates started the meeting with formal introductions. This is one of the items listed on the meeting: -The Department will initiate unannounced Case Management visits to be conducted for a period of 12 months. On 6/5/2025, LPA Iniguez reviewed the Register of Facility Clients/Residents or LIC 9020 dated 6/1/25 and the Personnel Report or LIC 500 dated: 6/5/2025. in addition, LPA Iniguez conducted (6) staff interviews (S#1-S#6) and a Health and Safety check of the facility. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Jodi Kanowitz/Executive Director.

At approximately 10:25 AM, LPA attempted to interview R1; however, R1 was unable to remain on topic and did not confirm or deny any falls, leading to the conversation being discontinued. At 11:20 AM, LPA Allen also interviewed R1's responsible party, who stated that the facility’s administrative staff had been in direct communication regarding R1's falls and expressed confidence that staff were doing their best to ensure R1's safety. A review of R1’s file showed no documented designation of R1 as a fall risk or a need for a one-to-one ratio, though assistance with activities of daily living (ADLs) is required. Documentation of R1's incidents was also observed. Additionally, during the visit, LPA Allen observed staff members actively providing care, engaging with residents, and redirecting individuals as needed. There was sufficient staffing at the time of the visit. Based on interviews, file review and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Judy Kamenwa at conclusion of the visit.

The investigation revealed the following: Regarding the allegation "Staff do not ensure adequate supervision is provided to residents in care". It is being alleged that staff did not provide supervision, which resulted in residents being injured by other residents on multiple occasions. Record reviews indicate the following: The facilities’ staff schedule indicates that there are two (2) staff present between the hours of 10:00PM and 06:00AM during the month of August. Staff records indicate that staff are receiving ongoing training's on resident care and supervision. Incident reports from the month of August (dated 08/02/24 through 08/29/24) indicates that only one (1) out of fourteen (14) incidents reported was related to a resident hitting another resident which did not result to an injury. Interviews revealed that nine (9) out of 9 staff, four (4) out of six (6) residents and two (2) out of 2 witnesses did not agree with the allegation. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff do not ensure reporting requirements are being followed”. It is being alleged that staff do not provide written reports to responsible parties of incidents within seven (7) days. Record reviews indicate the following: Incident reports from the month of August (dated 08/02/24 through 08/29/24) indicates that zero (0) out of fourteen (14) incidents reported was related to resident R1. Facility communication records indicate that the facility was providing updates to residents’ families via electronic messaging. Interviews revealed that nine (9) out of 9 staff, three (3) out of six (6) residents and two (2) out of 2 witnesses did not agree with the allegation. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today’s visit. An exit interview was held with Terri Weitzman (S5) and a copy of this report has been provided to Terri Weitzman (S5).

Investigation revealed the following: Allegation: Resident sustained multiple fractures while in care due to lack of care from staff On 11/13/25, LPA reviewed facility file. Review of resident’s Physician Report dated, 9/7/23 indicated that resident R1 was ambulatory. The department reviewed 7 special incident reports that were submitted to Community Care Licensing Division, (CCLD), in which R1 fell 3 times, 12/1/23, 12/6/23 and 8/25/24. Per review of the Service Plan, staff were taking fall risk precautions by providing the resident with a lowered hospital bed which was at its lowest level while resident is in bed. Per nightshift notes, undated, staff provided hourly checks on R1. Upon review of unusual incident report, on 12/1/23 R1 stated that he had fallen during the night and staff sent resident to Kaiser ER. A review of medical records from Kaiser Permanente, dated 12/1/23 indicate that R1 had a Humerus (upper arm bone) fracture from an accidental fall. According to medical records reviewed, there was only one ER visit that a fracture was sustained. LPA interviewed S1 – S5 and 5 out of 5 denied the allegation. LPA interviewed R2 – R5 and 4 out of 4 denied the allegation. The Department found there is no evidence to corroborate the allegation mentioned above. The information and evidence obtained did not support the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation, “Resident sustained multiple fractures while in care due to lack of care from staff.” 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, as a result, the allegation is Unsubstantiated.

On April 9, 2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced Case Management visit. The LPA met with Terri Weitzman, Interim Executive Director, and explained that the visit was to amend the report created on March 26, 2025. On 3/23/25, the El Segundo ASC Regional Office made aware of the property at which the facility operates is in foreclosure. On 3/26/25, the department met with the representatives for AVENIR SENIOR LIVING, LLC. The representatives for facility informed the department that, on 3/4/25, the facility property went into foreclosure and the property is currently for sale. The evaluation Report continues on the next page, LIC 809-C , providing further details of the inspection findings. 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 March 26, 2025, LPA Iniguez gathered documentation, interviewed residents (R#1-R#5) and facility staff (S#1-S#6), and conducted a facility health and safety check. At the end of this visit, LPA Iniguez did not observe immediate concerns regarding safety of residents. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Terri Weitzman / Interim Executive Director.

Based on the gathered information, there is no evidence to support the allegation mentioned above. Based on observation, interviews conducted, and records reviewed, the department found no evidence to support the allegation mentioned in the complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Executive Director, Terri Weitzman, and a copy of the report was provided. and a copy of the report was provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the gathered information, there is no evidence to support the allegation mentioned above. Based on observation, interviews conducted, and records reviewed, the department found no evidence to support the allegation mentioned in the complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: S taff did not allow resident to receive telephone calls. It is alleged that staff refused an outside caller from contacting resident via telephone. Based on interviews conducted, five (5) out of five (5) staff interviewed denied the allegation. five (5) out of five (5) staff interviewed revealed that residents are allowed to receive phone calls at any time. Based on interviews conducted, four (4) out of five (5) residents interviewed revealed they don’t know if a phone call was ever denied for a resident. Four (4) out of five (5) residents interviewed revealed that they are allowed to receive phone calls at any time. Based on the gathered information, there is no evidence to support the allegation mentioned above. Based on observation, interviews conducted, and records reviewed, the department found no evidence to support the allegation mentioned in the complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Licensee does not ensure a telephone is readily accessible to residents. It is alleged that the facility only has one cellphone for residents to use, and their phone time is limited. Based on interviews conducted, five (5) out of five (5) staff interviewed denied the allegation. S1 stated that the residents do use a cell phone, but they also have station phones, upstairs and downstairs, and that there is never an issue as far as phone use. Based on interviews conducted, three (3) out of five (5) residents interviewed revealed they don’t know if the facility has only one cell phone for residents to use. Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The investigation revealed the following: Allegation: Staff imposed restrictions on resident’s visits. It is alleged that a resident’s visitor was asked to leave by staff and was told they could not return. On 12/18/24, the department interviewed S1-S5, and R1-R5. Based on interviews conducted, five (5) out of five (5) staff interviewed denied the allegation. Five (5) out of five (5) staff interviewed revealed that the residents are allowed to have visitors at any time, with no restrictions. Based on interviews conducted, four (4) out of five (5) residents interviewed revealed that they are allowed to have visits with no restrictions. An interview conducted with R1 revealed that they have been a resident at this facility since 06/19/24 and have received visits from family and business representatives with no issues or restrictions. Four (4) out of five (5) residents interviewed said they are satisfied with the services being provided to them at this facility. A review of records of the Facility Visitor Log (dated: 08/01/24 -10/13/24), revealed that (R1) did have visits from guests and business representatives. Based on the gathered information, there is no evidence to support the allegation mentioned above. Based on observation, interviews conducted, and records reviewed, the department found no evidence to support the allegation mentioned in the complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not accord resident privacy during visits. It is alleged that a staff member was standing two feet from the resident and their visitor during a visit. Based on interviews conducted, five (5) out of five (5) staff interviewed denied the allegation. Five (5) out of five (5) staff interviewed said that the residents are given privacy when they have visitors. Based on interviews conducted, three (3) out of (5) residents interviewed revealed they are not aware of an incident involving a staff member standing two feet from a resident and their visitor. An interview conducted with R1 revealed that they do not recall an incident involving a staff member standing two feet away from them and their visitor. Continued on LIC9099-C

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff not providing safe environment for residents. The complaint alleges that the facility does not provide a safe environment for residents in its care. Resident #1 (R1) is reported to be a danger to oneself and to other residents, frequently displaying threatening behaviors such as yelling, screaming, slamming doors, and damaging property. These behaviors are causing fear among other residents, and no immediate intervention is reported from those who are aware of these incidents. No further details regarding this issue were provided. On January 14, 2025, between 12:30 PM and 2:30 PM, the Department interviewed two staff members, Staff #1 and Staff #2, regarding the allegation, which they claim is untrue. Staff #1 and Staff #2 stated that Resident #1 (R1) was admitted on May 7, 2024, and has a diagnosis of late-onset neurocognitive disorder (NCD). They explained that (R1) did not require individual one-on-one care and only needed full assistance with medication management. (R1’s) Service Care Plan, (dated May 7, 2024), indicated that no additional support or help was required for (R1's) behaviors. The plan stated that the care team would monitor for any changes in condition and conduct a reappraisal as necessary. Staff #1 and Staff #2 claimed that (R1) was reappraised on December 1, 2024, when a new service plan was established. This plan indicated that (R1) required occasional intervention to de-escalate situations, with monitoring conducted as needed. On November 20, 2024, (R1) was admitted to urgent care at UCLA Health in Santa Monica to be evaluated for a urinary tract infection (UTI). Staff #1 and Staff #2 observed a sudden change in (R1’s) behavior and notified the family representative, who admitted (R1) for observation. The medical evaluation revealed that (R1) did not have a UTI, and prescription medications were modified and returned to the facility. On December 16, 2024, (R1) was taken to St. Joseph Providence Health Center for a psychological evaluation and returned the same day. Staff #2 noted that upon (R1's) return from the hospital, (R1) was being monitored hourly by the care team. Staff #1 and Staff #2 claimed that (R1's) aggressive behaviors do not harm oneself or others. They reported that (R1's) behaviors had decreased since the medication adjustment and that the care team provides daily monitoring. Staff #1 and Staff #2 explained that (R1's) behaviors, such as aggression, agitation, verbal abuse, mood swings, and restlessness, are common among residents with (NCD) and can stem from feeling overwhelmed or unable to cope. (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 January 27, 2025, between 9:45 AM and 10:15 AM, the Department interviewed two additional staff members, Staff #3 and Staff #4, regarding the allegation, which they also claimed is false. Staff #3 and Staff #4 confirmed that they are aware of (R1's) behaviors and stated that the care team addresses any issues immediately. They reported that (R1) receives constant daily supervision, requiring mostly emotional support or redirection. Staff #3 and Staff #4 validated that (R1) has not harmed oneself or others. They noted that (R1's) aggressive behaviors have subsided since the reduction of medications. Staff #2 and Staff #3 confirmed that there is no shortage of care team staff to monitor residents' daily activities, with an average of five to six care staff members working each shift and medication technicians cross-trained as necessary. They asserted that the staff is proactive in supervision and professionally trained to handle residents with NCD. The facility is equipped with surveillance cameras in common areas to monitor activities, and staff charting notes are routinely implemented for communication. On January 27, 2025, between 10:15 AM and 11:20 AM, the Department conducted interviews with (5) out of (5) residents, identified as R#1 through R#5. None of the residents were able to verify the allegation made against the facility. Residents R#2 to R#5 reported that the care team staff provided adequate care and supervision services. Furthermore, they expressed no concerns regarding their safety while living at the facility, stating that they felt the facility provided a safe and healthy environment for all residents. Resident R#1 was also interviewed but was unable to respond or engage in a full conversation due to (R1's) mental health condition. On January 27, 2025, between 11:30 AM and 12:10 PM, the Department interviewed (3) out of (3) witnesses, identified as W#1 through W#3. None of the witnesses were able to verify the accusation made. Witnesses W#1 to W#3 claimed they had no concerns about the health or safety of the residents in care and were complimentary about the care and supervision provided by the facility staff. The Department reviewed various documents related to Resident R#1, including their Physician's Report (LIC 602A dated 05/01/24), Service Plans (dated 05/07/24 and 12/01/24), Admissions Orders (dated 05/02/24), UCLA Health medical records (dated 11/20/24), St. Joseph Providence Health Center medical records (dated 12/16/24), Progress Notes (dated 05/08/24 – 01/08/25), and Staff Communication Notes (dated 12/16/24 – 12/17/24). (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 This review revealed that Resident #1 could self-care and did not require one-on-one care. Furthermore, (R1's) mental condition did not stem from self-abuse or abuse towards others. A review of R#1's Physician's Medication Orders (dated 01/14/25) indicated that (R1) is prescribed ten medications, including five that had potential side effects of aggression, depression, confusion, and anxiety, according to the National Institutes of Health (NIH). During a facility tour, it was noted that surveillance cameras were installed throughout the common areas to monitor activities. Based on all gathered information, there was insufficient evidence to support the stated allegation. In conclusion, after reviewing the facility inspection, observations, interviews, and records analysis, the Department found no evidence to substantiate the allegation. While the allegation may have some merit or validity, there is not enough evidence to determine whether the alleged violation occurred. Therefore, the allegation is deemed unsubstantiated . An exit interview was conducted with Judy Kamenwa, and copies of the reports were provided.

Allegation: Staff did not ensure that resident was adequately fed It is alleged that resident was not eating and as a result R-1 had lost a lot of weight Per staff interviews and a review of the Admission Agreement LPA Felisa Shirley observed that there are three meals and three snacks served daily which are included in their monthly fee. Per interview with S-2, caregivers will assist if they notice that resident is not eating and will offer alternatives if desired. LPA Shirley toured the inside and outside grounds of the facility. LPA Shirley observed residents eating in the dining area and LPA Shirley did not observe food being served is not of good quality. LPA Shirley reviewed residents service file and Physician’s Report and observed that R-2 had a regular diet. Per Preplacement Appraisal Information, R-1 feeds self independently. LPA Shirley observed R-1’s Narrative charting and observed that R-1 sometimes ate only 50% of his meal and sometimes refused to eat because he didn’t want to gain weight. LPA Shirley reviewed R-1’s weight chart and did not observe a drastic weight loss. LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, does staff monitor residents during meals ensuring that residents are adequately fed. Of those interviewed, 5 out of 5 staff answered yes. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, do you get enough food and are you allowed seconds if desired? Of those interviewed, 4 out of 4 answered yes. R-1 was not available. Allegation: Staff did not meet resident’s toileting needs It is alleged that staff were not changing resident as needed. LPA Shirley reviewed R-1’s Resident Daily Activities of Daily Living Sheet and log of incontinence care for the AM and PM shifts from January 2024 thru August 2024. LPA observed that there were entries on log sheet for incontinence changing on a consistent basis. LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, is there a schedule for incontinence needs and if resident’s needs were being met. Of those interviewed, 5 out of 5 staff answered yes. LPA interviewed Resident-2 thru Resident-5 (R-2 thru R-5). LPA asked, are your incontinence needs being met? Of those interviewed, 2 out of 4 answered yes, and 2 stated that they were good on their own. R-1 was not available. Con'd on 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff mismanaged resident’s medication It is alleged that resident was being overmedicated. During the tour, LPA checked the medication room. LPA observed the facility maintains residents’ medication administration records in electronic QuickMAR. LPA observed that staff discontinued medications as instructed by treating physicians. LPA reviewed printouts of the resident’s eMar and LPA observed that staff made consistent entries and noted when R1 was not available and refused medications. LPA did not observe that facility staff dispensed wrong medications nor overmedicated prescribed medications to R-1. LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, is there a system in place that you have to ensure that resident’s medications aren’t being mismanaged. Of those interviewed, 3 out of 5 staff answered yes, and 2 staff did not know about dispensing medication. LPA interviewed Resident-2 thru Resident-5 (R-2 thru R-5). LPA asked, has your medications ever been mismanaged to your knowledge? Of those interviewed, 4 out of 4 answered did not believe that their medications were mismanaged. R-1 was not available. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted, and a copy of the LIC 9099 report was provided to Interim Executive Director, Terry Weitzman.

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not allow resident to have visitors. The details of this complaint alleged facility staff did not allow resident #1 (R1) to have visitors. It is reported that (R1) was refused a visit on 09/26/24, and the act violated (R1’s) personal rights. On 10/30/24, between 1:00 pm – 1:40 pm, the Department interviewed residents #1-#4 (R1-R4) and found that they could not corroborate this accusation. (R1) stated has only been a resident at this facility since 06/19/24 have received visits from family and business representatives with no issues. (R1-R4) reported that no individuals have been denied visitations, and they are provided privacy during visits by the facility staff. (R1-R4) were complimentary of staff and claimed they were efficient and accommodating to their needs. On 10/30/24, between 2:00 pm – 2:30 pm, the Department interviewed witnesses #1-#4 (W1-W4) and expressed they have had no problems with visits with the residents at this facility. (W1-W4) claimed they have never been restricted from visits and that staff have been accommodating with family guests to conduct visits outside of normal visiting hours. On 10/30/24, between 11:15 pm – 12:40 pm, the Department interviewed staff #1-#5 (S1-S5) reported this allegation was false. (S1-S5) stated there are no guests who are denied visits unless there is a legal court order. (S1-S5) stated that guests' visits and communications are welcome 24/7. (S1-S2) who was mentioned in this complaint explained that on 09/26/24, a family guests from out of state visited (R1). A Notary Public accompanied the family associates. Parties met outside of the facility accordingly to (S2). The notary endorser had no idea that the family guests of (R1) were not the actual Power of Attorney (POA) to (R1). (S2) did not want to allow for the notary endorser to have access to (R1) until (R1’s) power of attorney (W1) was notified and authorized. (S1-S3) were able to verify this incident on 09/26/24 and stated that family guests from out of state have come to visit in the past and were allowed visits. (S1) stated no one of (R1’s) family guests or business representatives had been denied visitations with (R1). (S1-S2 and S5) indicated there have been some conflicts between (R1’s) family representatives of legal authority who should act on behalf of (R1). (S1 and S5) stated they were only protecting the interest of (R1) who had no knowledge of the Notary visit and had no authorization from (R1's) POA. (S2 and S5) stated the family guests from out of state came back a few hours later and met with the Executive Director (S5) in the lobby and did not sign the visitors log and did not want to see (R1) on 09/26/24 on the returned visit. (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 As a result of the Department reviewing (R1’s) Admissions Agreement and Contract (dated: 06/17/24), revealed page 20, Section F included (Guest Visits and Communication), Resident Handbook (dated: 06/17/24), Physicians Report LIC 602A (dated: 06/13/24), Preplacement Appraisal Information LIC 603A (date: 06/13/24), Identification and Emergency Information LIC 601 (dated: 06/17/24) Personal Rights of Resident LIC613-C (dated: 06/17/24), Resident Service Plan (dated: 07/13/24), Facility Visitor Log (dated: 08/01/24 -10/13/24), and Resident Authorization Form-POA (dated: 0617/14) verified (W1) is the (POA) has the authority to act on behalf of (R1), and that (R1) had confirmation of visits from guests and business representatives according to Facility’s Visitors Log. Based on the gathered information, there is no evidence to support the allegation mentioned above. Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned in this complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. An exit interview is conducted with Terri Weitzman, and a copy of the report is provided.

The investigation revealed the following: Regarding the allegation “Possible elder abuse on the premises,” it is being alleged that staff have witnessed elder abuse in the facility. Interviews conducted revealed the following: 5 out of 5 staff indicated that they have not witnessed elder abuse in the facility. 6 out of 7 residents indicated that staff are nice to them. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff did not comply with infection control requirements,” it is being alleged that residents with a bad cold are not being isolated. Interviews conducted revealed the following: 5 out 5 staff indicated that facility isolates residents who have been tested positive for Covid-19, staff have been trained on infection control procedures, and they are and/or believe that the facility is following infection control requirements. 6 out of 7 residents believe that the facility is following infection control requirements. 1 witness states that the facility is isolating residents who have been tested positive with Covid-19. Observations revealed the following: There is one resident in isolation (due to health) and the facility following infection control requirements. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff used expired COVID tests to test residents,” it is being alleged that the facility is testing residents with expired Covid-19 tests. Observations revealed the following: There are non-expired Covid-19 test in the facility. The Executive Director and Director of Health Services indicated that they purchase Covid-19 test as needed to prevent test from going expired. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. 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 is in disrepair,” it is being alleged that the emergency exit door in the first floor next to the elevator cannot be opened manually. Observations revealed the following: The delay egress door on the first floor next to the elevator is in disrepair. The delay egress door was not opening after 30 seconds of pushing the door. Record review revealed the following: The facility received a quote on 07/05/2024 to fix the delay egress door. The facility is waiting on the mechanical parts to fix the door. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with the Executive Director.

The investigation revealed the following: Allegation: Staff dispensed medication not prescribed for the resident. It is being alleged that resident’s drug test which was administered at the emergency room in the Santa Monica UCLA Medical Center returned positive for fentanyl. On 11/21/23 LPA interviewed ED regarding the allegation above, ED denied the allegation. Per ED, there are no residents with a prescription for fentanyl and there are no residents taking any substances that have not been prescribed. ED continued to report that residents do not go out into the community unless a resident is with family. On 11/21/23 LPA interviewed S1-S6, 6 of 6 staff interviewed denied the allegation and reported that only med techs dispense medication and residents have not received incorrect medications. LPA reviewed the facilities sign in/out sheet which indicted R1 was signed out by family on 11/14/23 and according to medical records R1 was taken to Santa Monica UCLA Medical Center ER on 11/14/23. LPA conducted a review of medication administration records of all residents; no resident has a prescription for fentanyl. CCLD reviewed medical records obtained from the Santa Monica UCLA Medical Center and revealed the resident was taking multiple medications at Avenir Memory Care Westside for her medical conditions which were: Carbidopa-levodopa, Mirtazapine, Rivastigmine, and Sertraline. While in the ED on 11/14/23, labs and tests were ordered to see if the resident’s symptoms were from ingestion of drugs, a mass or from bleeding in the brain. The urine drug screen result on 11/14/23, was positive for fentanyl. The urine drug screen result was followed with the verbiage, “…If the screen result is not consistent with the resident's medication(s), confirmation testing should be ordered for the drug(s) of interest. "There was no documented evidence confirmatory testing was done." Based on records reviews and interviews there is insufficient evidence to determine if R1 ingested fentanyl there for the allegation is unsubstantiated. Exit interview conducted and a copy of this report was provided.

Continued LIC9099-C page 2 Allegation #1: Staff are interfering with the resident's visitations. S1-S3 and R1-R4 interviewed stated staff are not interfering with the resident's visitations. S1 stated residents are allowed visitors in the outside patio area, common area, and in front of the facility's building. S1-S3 stated staff is following COVID-19 procedures of the Department of Public Health. S1-S3 stated if there are positive COVID-19 results all team members, residents, families, responsible parties, visitors, and appropriate agencies are notified immediately via letter and email. LPA observed the facility has an approved Mitigation Plan Report and Infection Control Plan on file. S1 stated the facility is following the Mitigation and Infection Control Plan, emails and letters have been sent, and the residents are notified door to door with a memo letter, which is posted at the receptionist desk and throughout the facility if a resident or staff test results are positive for COVID-19 which made cause limitation to visitations during the COVID-19 outbreaks. S1 stated everyone is notified if there is a positive COVID-19 case. S1 stated if staff and residents had any questions staff is available to answer questions. Investigation revealed the following: Interviews with staff members 1 to 3 (S1-S3) and residents 1 to 4 (R1-R4) have confirmed that the facility maintains open visitation policies, allowing residents to engage with their families both within and outside the premises. Specifically, residents are permitted to leave the facility for community visits, utilize the courtyard for outdoor gatherings, and, in cases where a resident is bed-bound, family visits are allowed in the resident's room, contingent upon a negative COVID-19 test result and proper usage of masks. S1-S3 stated during the period from February 26, 2024, to March 5, 2024, the facility experienced a COVID-19 outbreak affecting 20 residents and 5 staff members. This outbreak, as reported by S1, was promptly communicated to the Department of Public Health, Community Care Licensing, responsible parties of the residents, and all relevant agencies, underscoring the facility's commitment to transparency and regulatory compliance. Both staff and residents (S1-S3 and R1-R4) have unanimously reported that cohabitation of COVID-19 -positive and negative residents is strictly avoided to prevent cross-infection. Consistent usage of masks among staff and residents has been observed, including during LPA's visit. Positive cases are assigned to a dedicated Med Tech or nurse, ensuring focused care and monitoring. See continued LIC9099-C page 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued LIC812-C page 3 S1-S3 have elaborated on the medical protocols in place for both staff and residents, including the administration of medications, conducting of COVID-19 rapid tests, and the arrangement for Polymerase Chain Reaction (PCR) testing for both staff and residents through external laboratory services. Additionally, measures are in place for the safe delivery of meals to residents' rooms by caregivers, ensuring minimal contact and risk of virus transmission. The facility also adheres to a rigorous testing protocol, with immediate notification of test results to all staff and residents. In situations where a resident may be absent during mass testing events, arrangements are made to test them upon their return, guaranteeing that all individuals within the facility are accounted for in the ongoing efforts to manage and mitigate the spread of COVID-19. S1 stated the facility is adequately staffed and the facility staff is trained, qualified, and competent and their respective roles. and staff undergoes continuous training to ensure their skills and knowledge remain current and effective. LPA reviewed the facility’s surveillance testing records. S1 stated the facility is following the policies and procedures set forth by the Department of Public Health. S1 also mentioned that a significant portion of the staff and the majority of the residents have completed their COVID-19 vaccinations. The facility has the ability to quarantine either non-symptomatic or positive COVID-19 residents. S1 stated the facility is following all guidance and direction regarding infection control protocol. S1 stated that whenever they receive a positive COVID-19 test result it is reported to all the appropriate agencies, Community Care Licensing, Los Angeles County Department of Public Health, resident's families, responsible parties, staff, residents, and visitors are notified immediately. Staff 1-3 (S1-S3) and residents 1-4 (R1-R4) interviewed all denied the allegations. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC 9099 and LIC9099-Cs, was provided to staff. There were no deficiencies cited. An exit interview was conducted.

Allegation: Facility is not kept clean, safe and sanitary. It is alleged that facility is not kept clean, safe and sanitary. On 6/28/2022, LPA Lourdes Montoya toured the inside and outside grounds of the facility. During the tour, LPA randomly checked resident bedrooms and bathrooms and did not observe feces on walls and floors. LPA did not observe stains on floors in hallways. Based on record review, there have been no incident reports or prior complaints indicating that facility was not kept clean, safe and sanitary. Based on interviews conducted, four out four residents (R2-R5) and five out of five staff (S1-S5) denied that facility is not kept clean, safe and sanitary. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Facility is not serving food of good quality. It is alleged that facility is not serving food of good quality. On 6/28/2022, LPA Lourdes Montoya toured the inside and outside grounds of the facility. During the tour, LPA checked the kitchen, dining area and the facility’s food supply. LPA observed residents eating in the dining area and LPA did not observe food being served is not of good quality. Based on record review, the facility maintains a daily food menu and residents have an option to choose their meal. Based on interviews conducted, four out four residents (R2-R5) and five out of five staff (S1-S5) denied that facility is not serving food of good quality. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Facility did not ensure medication was dispensed correctly. It is alleged that facility did not ensure medication was dispensed correctly. On 6/28/2022, LPA Lourdes Montoya toured the inside and outside grounds of the facility. During the tour, LPA checked the medication room. LPA observed the facility maintains residents’ medication administration records in electronic MAR called MedPass Machine. LPA reviewed random printouts of four residents’ MedPass records and LPA did not observe that facility staff dispensed wrong medications to residents. Con'd on 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on interviews conducted, four out four residents (R2-R5) and five out of five staff (S1-S5) denied that facility did not ensure medication was dispensed correctly. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Facility is not following COVID protocol. It is alleged that facility is not following COVID protocol. On 6/28/2022, LPA Lourdes Montoya toured the inside and outside grounds of the facility. During the tour, LPA checked reception desk, the hallways, resident bedrooms, and other common areas. LPA observed the receptionist screens every person entering the facility with a Face Recognition Body Measurement System Temperature Detection Scanner and Covid-19 health screening questionnaire. LPA Montoya was screened prior to entering the facility. LPA observed hand sanitizers at the reception area, masks are available, Infection Control guidelines for the prevention and spread of Covid-19 are posted. LPA observed each staff was wearing a face covering. Based on records review, the facility does not have any positive Covid-19 cases during the visit. LPA did not observe any residents in quarantine. Based on interviews conducted, four out four residents (R2-R5) and five out of five staff (S1-S5) denied that facility is not following COVID protocol. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted, and a copy of the LIC 9099 report was provided to Executive Director, Jodi Kanowitz.

Continued LIC9099-C page 2 LPA Bunker requested copies of supporting documents Allegation: Staff did not address the issues with the facility's emergency exit . In response to this, allegation interviews were conducted with both staff members (S1-S2) and residents (R1-R5). The collective feedback from these interviews unanimously indicated no issues concerning the facility's emergency exit doors. An inspection conducted during our visit affirmed that the lobby emergency exit door and the passenger elevator were fully operational and maintained in optimal working condition. Residents (R1-R5) expressed their satisfaction with living at the facility, highlighting the respect, dignity, and quality of care they receive. They also commended the facility for providing a secure, healthful, and comfortable living environment. Both staff (S1-S2) and residents (R1-R5) refuted the allegation, reinforcing the commitment to safety and well-being upheld at the facility. Investigation revealed the following: The inquiry involved detailed interviews with staff members (S1-S2) and residents (R1-R5). It was established that the facility, constructed in 2021, features relatively new emergency exit doors and elevators. The City of Los Angeles Department of Building and Safety conducted an inspection on 11/27/2023, specifically targeting the Hydro Electric Elevator. The facility holds a valid Certificate of Inspection and a Permit to Operate an Elevator (Permit ID: Q4269914, Elevator Number: 00188249), prominently displayed within the elevator car. Regular servicing of the elevator is conducted to ensure optimal functionality. In emergencies, staff at the Receptionist's desk can swiftly activate all emergency exit doors in under 30 seconds. Access mechanisms include a key card, fob, or passcode. Visitor key cards, time-limited for access, facilitate entry through emergency doors and passenger elevators to specific floors during business hours. The emergency exit doors feature a security protocol that includes a delay mechanism, audible alerts, and an automatic alarm system in case of prolonged open status. These doors are also equipped with a manual push bar for immediate egress in urgent situations, ensuring an effective delayed egress during emergencies. After thorough interviews, observation, and review of all pertinent records and evidence, it was concluded that there is insufficient evidence to substantiate the allegation. Despite the possibility of the incident occurring, the lack of a preponderance of evidence to confirm the alleged violation leads to the determination that the allegation is unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to staff. There were no deficiencies cited. Exit interview conducted.

Investigation Revealed the Following: Allegation: Licensee does not ensure staff have the ability to communicate with residents The details of the complaint alleged that the facility staff is not able to communicate with residents. During the records review, LPA Iniguez reviewed (R#1-R#4) the Admissions Agreement. Under the Statement of Resident’s Personal Rights, section 87468.2(a)(1) says: In addition to the rights listed in section 87468.2, Personal Rights of Residents in All facilities, residents in privately operated residential care facilities for the elderly shall have of the following rights: To have a reasonable level of personal privacy in accommodations, medical treatment, personal care, and assistance, visits, communications[...] Also, LPA reviewed (R#1) and all the facility staff their Relias training; these were the topics the staff already took: Communication and People with Dementia, Communication, and the Hearing impaired, Communication: Courtesy, Communication: Patronizing Language, Effective Communication Skills, Knowing the Rights of Residents and Personal Rights and Ethics. A total of 5 hours of training was used to cover these topics. In addition, LPA reviewed the overview of trainings for all staff, 19 out of 22 has 0 trainings due within 30 days, 0 due within 90 days and 0 due within 7 days, only 3 staff members have overdue trainings. Administration has a plan in place for the staff that has an overdue training on Relias. Staff will take trainings before they start their shift on 9/14/2023. During an Interview with the Executive Director (A#1), she stated that the staff takes training on Relias before they get hired in the facility; plus, we do cross-over meetings every day and once a month for staff training, and the training is assigned in the Relias portal. On the other side, the Executive Director stated that all staff can communicate with the residents; every day, the staff reviews the resident's care plan, and the nurse communicates with the team regarding each resident. This way, the staff has a plan to address their needs. In addition, the Executive Director stated that all staff could communicate with the residents, but if a staff cannot do it, they can reach out to me or the nurse; we are available 24/7. The executive director stated that (S#1) can communicate with them; (S#1) participates in the staff meetings, and they can speak about their residents and their needs. (A#1) acknowledges (S#1) first language is not English, but they assure (S#1) can understand what the residents need. 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 During an interview with (S#1), LPA asked S#1 questions regarding how often they take training. S#1 stated that every month, but LPA noticed (S#1) could not understand the question, LPA had to repeat it four times. In addition, LPA started to see that S#1 did not understand the context of the questions; LPA tried to dissect the questions, but still, (S#1) could not answer the questions. At this moment, LPA had to finish the interview and document the event. During interviews with staff (S#2-S#4), 3 out of 3 stated that they take their training on Relias. Relias has training modules with an expiration date. In addition, 3 out of 3 can communicate with the residents and need help understanding what the residents say to them. On the other hand, 2 out of 3 staff stated that S#1 has a language barrier that prevents them from communicating with the residents properly. During interviews with residents (R#1-R#4), 4 out of 4 stated that the staff helps them with their basic needs and can communicate with the staff. Also, 4 out of 4 stated that they do not have problems understanding what the staff is telling them, and they do not know a staff member who cannot communicate with them. During this investigation, LPA found did not find sufficient evident 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 is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted, and a copy of the Complaint Report was given to Jody Kanowitz/Executive Director.

The investigation revealed the following: Regarding the allegation: Facility staff not properly trained . It has been alleged that the facility staff are not properly trained. On 08/30/23 LPA Leon observed three staff folders and reviewed their training records. LPA Leon interviewed five (5) staff members (S1-S5), all of which have denied the allegation. Additionally, on 09/06/23, LPA Leon requested, and reviewed, the lobby camera footage. Upon which LPA Leon observed zero (0) non-staff individuals attending, or assisting, staff members entering the facility. According to LPA's observations, interviews and record review conducted, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is Unsubstatiated . An exit interview was held with Administrator, Jodi Kanowitz (S1), and a copy of this report was provided via email.

The investigation consisted of the following: On 08/30/23 LPA Leon toured the facility inside and out with Plant Operations staff Robert Garcia (S10), interviewed five (5) staff (S1-S5) and four (4) residents (R1-R4). LPA Leon requested and reviewed facility documents. On 08/31/23 LPA Leon conducted a subsequent visit and collected additional documents. LPA Leon interviewed facility nurse, Judy Arreaga (S9), via telephone, and further interviewed S1. The investigation revealed the following: Regarding the allegation: Facility does not have adequate supplies to meet resident’s needs. It has been alleged that the facility does not have an adequate amount of supplies to meet the resident's needs. On 08/30/23 LPA Leon observed one (1) storage room upstairs and one (1) storage room downstairs that contained ample supplies of items for the census of residents. LPA Leon interviewed five (5) staff members (S1-S5), all of which have denied the allegation. Additionally, on 08/31/23, LPA Leon requested, and reviewed, the past four (4) months of purchases through McKesson Medical-Surgical Supply Manager and have agreed that the list of supplies has met the standards set by California Code of Regulations 87625(a).According to LPA's observations, interviews and record review conducted, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is Unsubstantiated. Regarding the allegation: Resident’s personal belongings are not being safeguarded. It has been alleged that the facility does not safeguard resident's belongings. On 08/30/23 LPA Leon requested a copy of the admissions agreement directly from the marketing director's office and observed a section located after "For Family to Complete: Health Documents", noting Title 22, Division 6 Health and Safety Code: Chapter 3.2 Residential Care Facilities for the Elderly - Article 02. Licensing 1569.153 - Theft and loss program; standards, property inventories and surrender of personal effects; secured areas along with client/resident personal property and valuables list (LIC621). In addition, LPA Leon interviewed four (4) residents (R1-R4), of which two (2) out of four (4) residents have denied the allegation and two (2) out of four (4) residents were not able to provide responses due to their medical condition. LPA Leon interviewed five (5) staff members, all of which have denied the allegation and have mentioned that they "request all families to tag their members' clothing, have worked here long enough to know which items belong to whom and if the item is unknown, it is brought to the med-tech desk which is later discussed about during the 'crossover' meeting which is held between each change of shift." Report Continues, see LIC9099C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Additionally, LPA Leon has observed in the Activities of Daily Living log notes regarding residents' missing items, "please find" which shows concern regarding residents' personal belongings. According to LPA's observations, interviews and record review conducted, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is Unsubstantiated. Regarding the allegation: Staff are rough with residents in care . It has been alleged that the facility staff are rough with residents during turning and diapering. On 08/30/23 LPA Leon interviewed five (5) staff (S1-S5) regarding the allegation. S1-S5 have denied the allegation and each have mentioned "not to agitate" the residents in any fashion. Additionally, LPA Leon interviewed four (4) residents (R1-R4). Two (2) out of four (4) residents have denied the allegation, one of which had mentioned "nobody has handled me roughly." and two (2) out of four (4) residents were not able to provide responses due to their medical condition. Noted is a witnessed resident abuse without a date or time. On 08/30/23 LPA Leon requested copies of training records from three (3) staff (S6-S8). On 08/31/23 LPA Leon reviewed the documents. The transportation training's were completed through the Relias program on 08/29/23; which, according to S1, are completed through in-staff training sessions conducted with S9. All three (3) staff are current with their CPR/First Aid and their Food Handling Certificate. Additionally, LPA Leon interviewed five (5) staff (S1-S5) regarding the above allegation and requested a walk-through as to how S1-S5 would relocate a resident. S1-S5 discussed and displayed proper lifting procedures such as "hooking my arms below their armpits" and "locking their legs in-line with mine". According to LPA's observations, interviews and record review conducted, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is Unsubstantiated. Regarding the allegation: Staff do not provide residents with linens. It has been alleged that the bedding is not changed often enough. On 08/30/23 LPA Leon observed one (1) well stocked linen storage closet upstairs. On 08/31/23 LPA Leon observed one well stocked linen storage closet (1) downstairs. Each of these closets were located in the Western corner of the building. On 08/30/23 LPA Leon conducted wellness checks on four (4) residents' rooms (R1-R4), each of which were shown to have properly fitted and clean bedding. Report Continues, see LIC9099C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Additionally, four (4) out of five (5) staff (S1-S5) have denied the allegation. One staff (S5) did note that there was one (1) instance in which the facility did run out of bed linens, "possibly back in February", but since then that instance has never returned. Furthermore, LPA Leon conducted extended record review of the med-tech assignment book, which shows the requirements of the overnight staff (NOC) shift which requires various residents' laundry to be serviced. The AM/PM shower schedule of those residents are also listed, noting "all beddings to be changed on shower days and as needed if soiled". According to LPA's observations, interviews and record review conducted, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is Unsubstantiated. An exit interview was held with Lead Concierge, Charlene Gaona (S11), and a copy of this report was provided.

On 06/16/23, LPA Interviewed Staff (S7-S10), and Residents (R1-R8), reviewed and received copies of Narcotic Count, and observed resident activities, and staff interaction with residents. LPA's investigation revealed the following: Allegation: Facility Staff are not responding to resident’s call for assistance The details of the complaint alleged that Director of Health Services does not respond to emergency calls from staff on duty. During interviews with staff (S3 S4, and S6-S9), seven out of seven staff stated Director of Health Services (S2) always answer their calls when there is an emergency, no matter the day or time. Staff also stated S1 and S2 come in when needed. During interviews with staff (S1, S2, and S6-S9), six out of six staff stated when a resident comes for help or calls for assistance, staff goes right away to check on resident. Interviews with Residents (R1-R8), eight out of eight residents stated their calls and requests for assistance are met within a timely manner. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Facility staff are mismanaging resident’s medications The details of the complaint alleged that medications are not being passed correctly and narcotics are not being counted. During record review, LPA reviewed residents Medication Administration Records (MARs) and medications for 10 residents. Ten out of ten resident’s MARs and medication are consistent with properly documented records. LPA reviewed five residents Controlled Drug Records and prescribed narcotic medication, five out of five medications were counted and were consistent the Controlled Drug Records. LPA interviewed Staff (S2 & S6) two out of two staff stated all narcotic medications are counted at the beginning and ending of each shift. LPA interviewed 8 Residents (R1-R8), and eight out of eight residents stated they receive their medications daily and on time. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Resident have access to dangerous item/chemicals The details of the complaint alleged that residents could access harmful chemical because they are not being locked away after use. During tour of the facility, LPA did not observe any chemicals accessible to residents. LPA did observe the storage closet where chemicals are stored and to gain access to it you must go through three locked doors, that require an access code. LPA observed an empty bottle of disinfecting wipes in a high locked cabinet in the Bistro area. LPA inspected housekeeping cart to observe how chemicals are stored and kept inaccessible to residents. Staff (S10) showed LPA that the caddy where chemicals are stored is locked. Staff open the caddy remove the chemical they are going to use and relock it before entering room they are cleaning. Staff (S10) informed LPA that while cleaning, only one chemical is used at a time, and it is always in their hand. When they need their next product they unlock the caddy, put away the one in hand, get the next product, close, and relock the caddy. LPA interviews with Staff (S3-S10), eight out of eight stated they have not seen any dangerous chemicals left out or accessible to residents. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Facility staff is not providing adequate food service to residents in care. The details of the complaint alleged that residents are not being provided snacks. During facility tour, LPA observed snacks (sandwiches, fresh fruit, Jell-o, pudding, chips, cookies, and granola bars) and drinks (water, juice, soda, and coffee) in the upstairs Bistro area available for residents. LPA observed additional snacks in the downstairs Bistro refrigerator to be used for staff to refill the upstairs Bistro. Administrator informed LPA the Bistro is filled and refilled throughout the day, and snacks and drinks are available for residents at any time of the day. LPA interviews with Staff (S4-S9), six out of six staff stated, residents are given 3 meals a day and snacks are available all day long. LPA interviewed Residents (R1-R8), eight out of eight residents stated they receive their meals daily and on time and snacks are available in the Bistro. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Facility staff are not receiving proper training before providing care to residents The details of the complaint alleged that new staff are working on the floor without completing proper training. LPA reviewed and received copies of training for new staff hired after 02/24/23. All staff have had 40 hours of training on Relias and 20-40 hours of shadowing before working on the floor. LPA reviewed additional In-service training logs that are conducted monthly. LPA interviewed Administrator (S1), who stated all new hires are required to complete 40 hours on Relias and 20 hours shadowing before they work on the floor with residents. S1 stated In-Services are done monthly and include topics of Care of Residents with Dementia, Medication Interactions, Infection Control, Mandated Reporting and Abuse, Home Health Care, Sexual Behaviors, End of Life Options, Use and Storing Chemicals, and much more. Interviews with Staff (S1-S4), four out of four staff stated they attend in-service training or conduct in-service training. Interviews with Staff (S5-S10) stated they completed 40 initial hours on Relias, 20-40 hours of shadowing, and do continued training on Relias, and attend regular in-services. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Facility staff are utilizing cameras inappropriately throughout the facility The details of the complaint alleged that current administrator is using cameras in the facility with sound. Additionally, recordings are not being deleted and are being saved. LPA viewed video recordings and did not hear audio. LPA reviewed video feed; all surveillance cameras are in common spaces. Use of surveillance cameras was added to the plan of operations submitted to CCL on 06/21/23. It is addressed in the admission packet so new residents and families are aware recording is in progress. Additionally in the employee packet staff are informed surveillance is in progress. When you enter the facility there is a sign posted that informs you surveillance video recording in progress. Interviews with Staff S3 stated the recordings are kept up to 45-hours, possibly less depending how often the cameras are activated by motion. The recordings are then recycled after approximately 45-hours. S3 stated no sound is recorded and recording is only in common areas. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Facility administrator does not have the proper qualifications The details of the complaint alleged that the administrator is not qualified to run the community. DSS does not have her credentials. During the visit LPA reviewed the administrator’s qualifications. LPA reviewed S1’s Administrator Certificate, current Health Screening, LIC508 Criminal Background Record Statement, and resume with education and experience. Based on file review, the Administrator is qualified and has the credentials to be the Administrator. During interview with Administrator (S1), stated a Change of Administrator was submitted to Community Care Licensing on September 22, 2022. During the course of the investigation, LPA was unable to find any evidenc

Allegation: Facility staff are not appropriately addressing outbreaks The details of the complaint alleged that the facility has had cases of a communicable disease and residents are not properly being treated for current symptoms LPA interviewed Staff (S1, S2, S6, & S7), all staff stated Residents are monitored and checked for any change of conditions regularly. Four out of Four staff (S1, S2, S6 & S7) interviewed have said they have been trained on infection control and implementing infection control measures that consist of donning and doffing PPEs, regularly sanitizing common areas and staff monitor residents and conduct hourly rounds. During a review of Nurse documentation and records, LPA found 4 cases of a communicable disease had occurred in the facility and were reported to Licensing and DPH on 2/16/21,03/10/23, and two on 03/21/23. The 1 st case reported was on 02/16/23 and the last on 03/21/23. LPA reviewed the facilities Infection Control Plan, and Mitigation Plan for communicable diseases dated 11/10/22. During record review, LPA found procedure from both plans were followed, and measures were taken to control the spread and treatment was provided to those residents per physician’s orders. LPA reviewed resident’s files, and care notes and observed residents received care and treatment in a timely manner. LPA interviewed Resident’s (R1-R8), and all expressed that the facility is taking the necessary measures when infection control is needed. Based on interviews, record review, and observation LPA was unable to find evidence to support the above allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Residents are not receiving appropriate medical care The details of the complaint alleged that residents with a communicable disease are not being treated. Interview with Director of Health Services and Facility Nurse, Judy Arreaga (S2) stated oral and topical medications were administered per physicians’ orders, and residents were continually assessed by a physician and S2. S2 monitored residents’ progression of condition and was in communication with the facility physician and resident families to provide health status updates of the resident. Per S2 notes staff ensured resident’s care plan was followed and documented progression of resident’s condition. Upon Resident’s record review from 02/01/23 to 05/18/23, residents were administered treatment in a timely manner. Records are consistent with the documented care provided. During interviews, Eight out of eight residents stated they received treatment as necessary and as ordered when a communicable disease is 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 present in the facility. During interviews with Staff (S1,S2,S6 & S7) four out of four stated residents care was given in a timely manner and per physicians orders. Based on interviews, record review, and observation LPA was unable to find evidence to support the above allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Facility are not properly reporting incidents The details of the complaint alleged that facility is not reporting incidents and staff are being instructed not to report incidents During interview with Executive Director (S1), they stated all incidents are documented and reported to CCL and if necessary additional agencies. During interviews with Staff (S2, & S6-S10) six out of six staff stated they report all incidents to Executive Director S1), Director of Health Services (S2), Med Techs, and/or other designated authorities. Additionally, six out of six staff interviewed stated they have never been told not to report an incident and they are told to report all incidents no matter how minor. LPA reviewed and received copies of Incident Reports from 02/16/23 to 05/18/23. During file review of incident reports LPA matched them to Special Incident Reports (SIR) reports that were submitted to CCL. Additionally, LPA reviewed and received a copy of a Resident’s (R2) care notes, selected an incident, and asked to match the Special Incident Report submitted. Based on interviews, record review, and observation LPA was unable to find evidence to support the above allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director, Jodi Kanowitz, and a copy of this report was provided.