Hollywood Hills Senior Living.

Allegation: License does not ensure that facility administrator is on the premises a sufficient number of hours . It was alleged that the facility does not have an Administrator/ ED on property. The Administrator is present less than 20 hours per week with no after-hours qualified Designee. EDs lack of presence in Memory Care demonstrates a disregard for accountability." Interviews with ED, other staff and facility residents revealed that ED is present in the facility sufficient number of hours. There are designated staff responsible for Assisted Living (AL) and Memory Care (MC) units. A review of facility staff schedule verified that there are specific personnel responsible to oversee the operations in AL and MC. There is no information to verify that ED is not precent in the facility as it is required. Therefore, based on interviews and record review, there is an insufficient information to verify the allegation, Hence the allegation is unsubstantiated at this time . Allegation: Facility staff do not answer communications from residents’ representatives appropriately . Allegation: Facility staff do not properly report unusual incidents . It was alleged that family and resident requests are ignored by ED. Incident reports with falls and hospitalization aren’t submitted because ED is too busy and she can’t approve “minor” issues. ED revealed that any incidents reflecting residents’ health and safety are being reported to residents’ responsible parties, medical providers, and appropriate agencies. Staff indicated that upon knowledge of the incidents involving residents, they immediately report to their supervisor or lead. Residents interviewed during investigation addressed no concerns about incidents reported to their responsible parties. During subsequent visit LPA Comer spoke with residents’ responsible parties and they verified that ED or designees are in communication with them if needed. A review of facility records, including internal incident log and Incidents reports did not provide any measurable and verifiable information to verify the allegation. 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 Therefore, based on interviews and record review, the above noted allegations are unsubstantiated at this time . No immediate health and safety issues were noted during investigation. Exit interview was conducted and a copy of report was issued.

Regarding the allegation: Medication mismanagement contributed to residents death. It is being alleged that staff members S2 and S5 are purposely providing false information to hospice pertaining to residents’ medication which resulted in the death of two (2) residents (R1-R2). To investigate the allegation, LPA conducted record review of both R1’s and R2’s files. Record review revealed that R1 was admitted to Gentle Touch Hospice on 9/26/2023 due to a decline in their condition as a result of their medical diagnosis. On 9/02/2025, LPA requested R1’s medical records from hospice. Record review revealed that R1 was placed on various medications due to their diagnosis. The medication in question (per the Reporting Party) was allegedly discontinued by S5 which caused R1’s death on 4/17/2024. However, LPA’s record review of R1’s Interdisciplinary Group Review (IDG) showcased that R1’s attending physician had placed the order to discontinue said medication on 4/14/2024. The order to discontinue the medication was documented to be due to R1 being, “…susceptible to bruising while on anticoagulant” (page 2). Additional record review confirmed R1 was observed during hospice visits to have had a change of condition resulting in their Plan of Care being updated to meet R1’s needs until their time of death. LPA’s review of R1’s Certificate of Death documented their death to have been contributed by both cardiac arrest and cognitive decline. LPA’s record review of R2’s file revealed that R2 was admitted to Easy Care Hospice on 9/13/2024 due to a decline in their condition related to their medical diagnosis. On 9/02/2025, LPA requested R2’s medical file from Hospice. Record review revealed that R2 was placed on various medications due to their diagnosis. The medication in question (per the Reporting Party) was allegedly requested to be discontinued by S5 which caused R2’s death on 7/17/2025. However, LPA’s record review showcased that R2 had been sent to the hospital on 9/06/2024, where an order to discontinue the medication in question was placed by the attending physician on 9/11/2024. Additional record review of R2’s Physician’s Orders (6/02/2025 to 7/15/2025) showed no record of said medication listed. LPA’s record review of R2’s Certificate of Death documented their death to have been contributed to both cardiac arrest and cognitive decline. It was also alleged staff are receiving compensation for hospice enrollment. LPA’s interview with S2 regarding whether they are receiving any compensation through monetary gains for residents being admitted into Hospice were denied. LPA’s interview with S1 revealed that they would “fire” any staff that would partake in any financial gain through residents being admitted into hospice. LPA attempted to interview S5 but S5 no longer works at the facility and could not be contacted. Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Continue to 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 Regarding the allegation: Staff are not dispensing medication as prescribed. It is being alleged that staff are not administrating medication as prescribed. To investigate the allegation LPA conducted interviews with four (4) staff members. All four (4) staff members confirmed that resident’s medications are administered as prescribed. During LPA’s physical plant tour, LPA observed the medication rooms located in both the Assisted Living Unit and the Memory Care Unit. LPA observed, at random, a total of ten (10) residents’ medications. LPA observed all ten (10) residents' medications to be labeled correctly, assigned to the correct person and administered on the correct date. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to The Regional Director of Operations .

On Friday, 09/12/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived unannounced to conduct an annual inspection of the Facility. LPA met with Administrator, and reason for the visit was disclosed. Facility is licensed as a six (6) floor complex and top floor penthouse. Fire clearance approved for (110) non-ambulatory residents, and ten (10) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, fifteen (15) residents are receiving hospice care services, and two (2) residents are bedridden. At 8:40 am, LPA conducted a tour of the physical plant and observed the following: Physical plant was inspected for cleanliness and condition . Facility’s main doors are the primary entry/exit access. Screening area is located immediately upon entrance. As the Facility provides dementia care, LPA observed the delayed egress system working properly. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 74.0°F., within the required range. The facility maintains an approved Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. [Continued on LIC 809C] 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 Resident records: A total of seven (7) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, centrally stored medication logs, and resident identification. Resident records appeared to be complete and current. Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report was provided.

Allegation: Staff are not following proper medication training - The Reporting Party (RP) states that facility Medication Technicians are instructed by Staff#1 (S1) to reuse cups used to distribute medications to residents. RP states that Med Techs buy medication cups with their own personal funds in order to remain in compliance with facility's medication services policy. LPA interview with Administrator revealed the following: Administrator denies the claim that staff do not comply with the facility medication services policy, stating that all Med Tech staff are provided in-service training requiring all medication cups to be disposed of after use. Per Admin, staff managers are well aware of the medication services policy, and have not instructed staff to retain used medication cups for any reason. Per Admin, facility keeps ample supplies of medication cups in stock, and that the facility has not experienced critical shortages of any supplies to service residents. LPA conducted interviews with five (5) staff, which revealed the following: All staff interviewed by LPA deny claim of non-compliance with facility medication services policy, stating that staff have taken medication training and are well aware of the proper handling of resident medications, that medication cups used for resident meds distribution are promptly disposed after use. All staff interviewed by LPA state they have not purchased medication cups using personal funds, and that supplies of medication cups are consistently stocked at the facility. LPA conducted a tour of the facility, which revealed the following: Medication Rooms, located in the Assisted Living Unit, and Memory Care Unit, were observed and found to contain adequate supplies of packaged medication cups to service residents. Staff informed LPA that medications are transferred directly from medication containers and into resident cups, and that their hands do not touch the distributed medication pill/liquid. Moreover, LPA requested S4 and S5 to demonstrate how medications are dispensed and observed that staff are properly following medications procedures. Based on LPA observations, and interviews with Administrator, and Staff, LPA was unable to find evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time . Exit interview and copy of report provided.

Allegation: Staff (S1) yells at residents - The RP alleges Staff (S1) "constantly yells and screams" at residents. LPA interview with Administrator and Staff revealed the following: Administrator refutes this allegation, stating that S1 maintains a professional demeanor and has not heard, nor witnessed S1, nor any other staff, yelling at any residents in care. LPA conducted interviews with eight (8) staff which revealed the following: Eight (8) out of eight (8) staff state they have not witnessed, nor heard of S1, nor any other staff, yelling, nor neglecting to respect the rights of residents in care. LPA conducted interviews with eight (8) residents which revealed the following: Eight (8) out of eight (8) residents state they have not witnessed, nor heard of S1, nor any other staff, yelling nor neglecting to respect the rights of residents in care. Based on interviews with the Administrator, staff, residents, LPA was unable to find evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview and copy of report provided.

Allegation: Staff did not prevent outbreak of virus - The Reporting Party (RP) alleges that multiple residents are sick from viral outbreak which occurred at the facility approximately "a week and a half ago", or around 4/22/25, and that staff have neglected to prevent viral spread. LPA review of staff records revealed the following: On Tuesday, 4/22/25, Staff#1 (S1) reported to Los Angeles County Department of Public Health (LACDPH) and Community Care Licensing. (CCL) that five (5) Memory Care Residents were experiencing GI symptoms of loose bowel, diarrhea, and vomiting. Staff correspondence included listing of residents/staff affected by the GI Outbreak. On Wednesday, 4/23/25, LACDPH Community Outbreak Team Representative confirmed notification of GI Outbreak reported by staff, and that a district public health nurse was assigned for outbreak management. On Wednesday, 4/30/25, LPA spoke with S1,via telephone, who stated twenty-eight (28) residents and four (4) staff are affected by the GI Outbreak. Per LACDPH Community Health representative, (N1) facility staff have provided updates regarding any change in circumstances. LPA spoke with S1, during today's on-site observation, who stated the following: A total of thirty-two (32) residents [comprised of fourteen (14) Assisted Living (AL) residents, eighteen (18) Memory Care (MC) residents] and eight (8) staff are affected by the GI Outbreak. Facility observations conducted by LPA revealed the following: "Notice of Gastrointestinal Exposure", dated 4/22/25 is posted prominently on main doors of facility's entrance. Masks are available upon request. Housekeeping staff were observed cleaning exposed surfaces. (i.e., counter tops, handrails tables, floors, etc...) Staff were observed wearing the proper Personal Protective Equipment. (PPE) Therefore, based on LPA observations, records review, and interviews with staff, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided. [LIC9099C] 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 Allegation: Facility food warmer is in disrepair - RP states facility food warmer is in disrepair, yet is still in use to serve resident meals. LPA observation of facility kitchen revealed the following: Facility food warmer was tested and found to be working properly; device reached temperature of 164 degrees Fahrenheit at the time of testing. LPA interviews with staff revealed the following: Staff#2 (S2) states that resident meals are initially temperature checked when placed in the food warmer, and again on a second occasion when meals are transported and delivered to residents. Both Staff#2 and Staff#3 state that the food warmer has been working consistently at the appropriate temperature (140 f. to 165 f) in order to prevent bacterial growth. Therefore, based on LPA observations, records review, and interviews with staff, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided.

On this day at 11 am, a meeting was conducted by Assistant Program Administrator (APA) Stacy Barlow to verify Chapter 7 Bankruptcy Report filed by the Pacifica Senior Living as reported by the media . Present during the meeting are: Shelley Grace - Assistant Branch Chief, CCLD Craig Lundgren - Legal Counsel, CCLD Carl Knepler - Chief Executive Officer Marlene Nelson - Director, Quality Assurance and Risk Management APA Barlow verified with Knepler information received by CCL from the media as follows: $25M lawsuit against the community located in Bakersfield Photography lawsuit against one of the properties lawsuit against a Skilled Nursing Facility (SNF) in the Healdsburg location Knepler states that despite the lawsuits, there is no financial impact to any of the properties, residents or staff of the company. Knepler added there are no vendor issues as well. continuation on LIC 809-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 Knepler also states that management communicates with the staff and residents to make them aware of the changes. Signages have been changed . Knepler added that the bankruptcy did not affect any of the communities because Pacifica Senior Living Management was no longer the management company for any of the Pacifica Communities, that the communities had given notice to the department and residents back in October or November of last year of the changes in management companies. He said that the judgment in Bakersfield did not involve the operating entity, only the management company. He said there were no other suits pending against any of the Pacifica entities. APA requested the following documents be provided to CCL by today: Spread sheet of all facilities whose management company was/is Pacifica Senior Living Management Company management companies for each location letter provided to the residents notifying them of the changes At the conclusion of the meeting, APA emphasized to Knepler the importance of communicating with CCL any lawsuits that the company may have in the future. Knepler agreed with APA. A copy of this report was provided to Knepler .

Allegation: Staff are not able to provide care services to residents- The RP alleges that Resident#1 (R1) is not provided care by staff. LPA contacted the RP, via phone, who stated the following: Staff called 911 on several occasions to send R1 to the hospital. RP states that R1 had no medical issues which required emergency services and said to LPA that facility staff are simply "wasting public resources". LPA review of R1's file revealed the following: Physician's report identifies R1 as diagnosed with dementia and altered mental status. R1 was assessed and admitted to the facility as a Memory Care (MC) resident in October of 2024; R1's daughter is acting Power of Attorney (POA). Unusual Incident Reports, with occurrences dated 3/23/25, and 3/35/25, describe R1 as sustaining fall injuries and exhibiting aggressive behavior which necessitated staff to call for 911 emergency services. Incident reports indicate that R1's Primary Care Physician (PCP), Neurologist, and POA were informed by facility staff. LPA interview with Staff and Administrator revealed the following: Both Administrator, S1 and S2 refute this allegation, stating that R1 is provided adequate staff care and supervision, and that 911 emergency service calls made by staff on R1's behalf were necessary to provide R1 proper health assessment and timely medical treatment. LPA interview with R1's Responsible Family Member (F1) revealed the following: F1 states that facility staff provide them timely communications regarding all incidents involving R1. F1 states she is confident that facility staff are providing R1 proper care and supervision. LPA interviews with seven (7) residents revealed the following: Seven (7) out of seven (7) residents state that staff provide satisfactory care and supervision. Therefore, based on LPA interviews with staff, residents, responsible family member, and documents review, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided.

Additionally, RP alleges that Resident#2 (R2) was observed as "covered in urine and feces" lying on the floor in their facility bedroom. RP alleges the facility's night shift staff are responsible for neglect of R2. To investigate this allegation, LPA received facility resident roster, and staff roster. LPA conducted a review of resident files for R1 and R2, and interviewed facility residents and staff. Regarding the alleged incident involving R1, LPA interviews with Staff revealed the following: Staff Supervisors (S2 and S3) refute the claim, stating that the alleged incident was never reported to them. Furthermore, both S2 and S3 deny the occurrence of the alleged incident, stating that staff respect R1's personal rights, and provide R1, and all other residents, professional care and supervision. LPA interviews with five (5) Memory Care Unit (MCU) Staff revealed the following: Five (5) out of five (5) staff could not corroborate the allegation, stating they have not witnessed, nor heard of any neglect/abuse committed upon residents by staff. LPA's interview with R1's Responsible Family Member (F1) revealed the following: F1 states, "Our family visits R1 "a minimum of once, or twice per week", and asserts "facility staff respect R1's personal rights, and overall, we are happy staff treatment of R1". F1 states having no facility health or safety concerns. Regarding the alleged incident involving R2, Staff Supervisors (S2 and S3) refute the allegation, stating that R2 was "well cared for" by staff throughout their residency at the facility. Responsible Family Members were informed, and an incident report was submitted to Community Care Licensing (CCL) regarding R2's fall injury and subsequent ambulance transport to Kaiser for medical evaluation. However, S2 and S3 deny that R2 was "covered in urine and feces" as alleged. LPA interviews with five (5) Memory Care Unit (MCU) Staffers revealed the following: Five (5) out of five (5) staff could not corroborate the allegation, stating they did not witness, nor hear of any neglect\abuse committed upon R2 by staff. LPA interview with seven residents revealed the following: Seven (7) out of seven (7) residents state that staff provide adequate levels of care and assistance. All residents interviewed expressed having no concerns regarding neglect, nor abuse of residents by staff. Based on the information obtained, there was insufficient evidence to prove that staff failed to report suspected abuse/neglect of residents in care . Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of this report delivered.

Allegation: Staff do not respond timely to a resident's alerts - It was reported that R1 pressed the service call button and staff did not respond to provide assistance. LPA Interviews with seven residents (7) revealed the following: six (6) out of seven (7) residents state staff response times to service calls is both timely and acceptable. LPA entered R1's room and activated the service call button; caregiver staff arrived within six minutes of the call button's activation. Based on the information obtained through LPA observation, and interviews, it cannot be proven that staff fails to respond to resident service calls. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff dose not provide adequate care and supervision - It was reported that staff do not know how to change resident diapers. RP states that staff "do not know what they are doing". LPA's Interviews with seven (7) residents revealed the following: seven (7) out of seven (7) residents state staff are professional and provide satisfactory levels of caregiver assistance. Based on the information obtained through LPA interviews, it cannot be proven that staff fails to provide adequate service to residents in care. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation: Staff physically abused resident - The reporting party (RP) alleges that sometime in the month of Jan, 2025, Resident#1 (R1) suffered physical abuse by caregiver staff (S5). Per the RP, when caregiver staff were providing Resident#1 (R1) a diaper change, S5 was alleged to have "strangled and slapped" R1. LPA interview with the RP revealed the following: RP says she heard about the alleged abuse incident from staff med tech (S1). Per RP, S1 also reported the alleged abuse incident to their immediate supervisor (S4). LPA interviews with S1 and S4 revealed the following: S1 refutes the RP's claim, stating that she did not witness, nor hear of any abuse inflicted upon R1, nor any other facility resident. S4 also refutes the claim that an abuse of R1 was reported by S1, or any other facility staff. LPA interviewed five (5) staff who provided to care and assistance to R1. Five (5) out of five (5) staff state not witnessing, nor hearing off any abuse by committed upon R1, nor any other facility resident. LPA interviewed four (4) memory care residents, and three (3) assisted living residents: All residents interviewed by LPA state that staff respect their personal rights and have never witnessed, nor heard of any abuse committed at the facility. LPA could not interview R1 because resident passed away on 1/19/25. LPA interviewed responsible family member (F1) of R1 which revealed the following: Per F1, Facility staff treated R1 professionally and with respect to their personal rights. From the time of R1's admission as a resident, until R1's passing in Jan 2025, F1 states that R1 never displayed anxiety with staff and was comfortable interacting with facility staff until R1's passing. . Based on the information obtained, there is insufficient evidence to corroborate the allegation that resident (R1) was physically abused by staff. Therefore, the allegation is deemed Unsubstantiated at this time.

To investigate the allegation, LPA conducted observations of random bedrooms in the memory care unit: (Memory Care Bedrooms #2009, #2011A/B, #2010, #2004A, #2003, #3003, #3004, #3007, #3016) LPA observations revealed the following: All observed bedrooms appeared as clean and organized; no foul odors detected. Residents in observed bedrooms appeared to be clean and dry, blankets and bedsheets appears as clean, and residents observed wearing clean diapers, and showing no trace of urine or feces. LPA conducted interviews with the Memory Care Director which revealed the following: Current Memory Care Unit (MCU) census is twenty nine (29). During morning (6:00 am-2:30 pm) and afternoon (2:30 pm-10:00pm) shifts, the MCU comprises four (4) caregiver staff, and one (1) Med Tech. During the night shift, (10:00 pm-6:00 am), the facility comprises three (3) caregiver staff, and one (1) Med Tech. The Memory Care Director states that all incontinent residents are changed a minimum of three (3) times per shift, and as needed. Six (6) staff members interviewed by LPA corroborated statement provided by the MCD. LPA conducted interviews with three (3) residents from the memory care unit, and four (4) residents from the assisted living unit. All, a total of seven (7) out of seven (7) residents, interviewed stated that staff provide satisfactory incontinence assistance and expressed no concerns regarding this allegation. Therefore, based on LPA interviews with staff, residents and observations, this allegation is deemed Unsubstantiated , at this time.

To investigate the allegation, LPA conducted records review from 9:35 am to 10:15 am, interview with staff from 10:40 am to 11:25 am, and interview with Residents from 12:00pm to 1:30 pm. LPA review of resident records revealed that Resident#1 (R1) is identified with having incontinence issues as stated in the Physician's Report. Resident assessment documents show R1 requested staff to provide status checks at least twice per shift. Additionally, resident records indicate that R1 was provided incontinence supplies by the facility at no charge. LPA interviews with R1 revealed the following: R1 confirmed to LPA that staff do provide diaper changes regularly, and as needed. However, expressed frustration that staff's response time was unreasonable when call button is activated. Interviewed Residents (R2 through R5) revealed that staff do provide incontinence services regularly, and as needed in a timely manner. Staff state that R1 is provided incontinence services regularly, and as needed. Staff state R1 often becomes impatient and angry if staff do not show up immediately to answer R1's call button. Based on LPA records review, interviews with Staff and Residents, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not provide resident with laundry service - It was alleged that staff are not laundering Resident#1 (R1's) clothing and and linens due to R1's refusal to pay an extra $100.00 per month for laundry service. To investigate the allegation, LPA conducted records review from 9:35 am to 10:15 am, interview with staff from 10:40 am to 11:25 am, and interview with Residents from 12:00pm to 1:30 pm. LPA review of resident records revealed that Resident#1 (R1) was not charged for laundry service. Interview with Administrator revealed the following: Administrator confirms that charges for laundry services were waived on behalf of R1, and that laundry service was consistently provided to R1 once per week, and at times, twice per week, in response to R1's incontinence service needs. [LIC 809-C 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 LPA interview with R1 revealed the following: R1 confirmed to LPA that staff do provide them laundry service on a weekly basis. However, expressed frustration that staff, "should clean my things every day", due to them having incontinence issues. Interviewed Residents (R2 through R5) revealed that staff do provide weekly laundry services on a consistent basis. Based on LPA records review, interviews with Staff and Residents, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not distribute resident's medication as prescribed - It was alleged that staff are not providing Resident#1 (R1) their morning medications at 8:00 am, as prescribed. Instead, distributing R1's medications between 8:00am, and 12:00 pm. To investigate the allegation, LPA conducted records review from 9:35 am to 10:15 am, interview with staff from 10:40 am to 11:25 am, and interview with Residents from 12:00pm to 1:30 pm. LPA review of R1's Medication Administration Records (MAR) revealed that Resident#1 (R1) is provided their medications, as prescribed. LPA observed the following: A Staff medical technician attempted to provide R1 their morning medications. However, R1 refused, telling the med tech to leave it in the room for R1 to take at a time of their choosing. The med tech informed R1 that they had to witness R1 take their morning medication, as prescribed. Again, R1 refused to take their morning medication. LPA interview with Residents (R2 through R5) revealing the following: Interviewed Residents state that staff do provide them their medications throughout the day, as prescribed. LPA interviews with Staff revealed the following: Staff state that R1 is often difficult while assisting them with their medications at the times prescribed. Based on LPA records review, observation, interviews with Staff and Residents, the allegation is UNSUBSTANTIATED at this time. An Exit interview was conducted, and report was provided to the Administrator.

Allegation: Staff do not respond timely to a resident's alerts - It was reported that during the night of October 29th, 2024, R1 pressed the service call button and staff did not respond to provide assistance. LPA's review of the facility's service call log reveals that R1's activated service call button was indeed responded to, on multiple occasions, by night staff. Interviews with three (3) residents that are wheelchair bound, and require similar levels of caregiver assistance, revealed the following: three (3) out of three (3) residents state staff response times to service calls is both timely and acceptable. Interviews with three (3) staff, and R1's responsible family member (F1) state that R1, at times, refuses assistance from newly hired staff and/or staff which R1 is unfamiliar. LPA entered R1's room and activated the service call button; caregiver staff arrived within three minutes of the call button's activation. Based on the information obtained through LPA observation, records review, and interviews, it cannot be proven that staff fails to respond to resident service calls. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff did not provide adequate care and supervision LPA's Interviews with three (3) residents that are wheelchair bound, and require similar levels of caregiver assistance, revealed the following: three (3) out of three (3) residents state staff are professional and do provide adequate levels of caregiver assistance. Interviews with three (3) staff, and R1's responsible family member (F1) reveal that R1, at times, refuses assistance from newly hired staff and/or staff which R1 is unfamiliar. LPA interview and the Administrator reveals that, although there have been challenges with staff turnover, the facility has added an additional caregiver staff to its memory care unit in order to maintain adequate levels of service coverage. Based on the information obtained through LPA observation, records review, and interviews, it cannot be proven that staff fails to respond to resident service calls. Therefore, the allegation is deemed Unsubstantiated at this time.

At 10:30 am, LPA conducted a review of R1's resident files which revealed the following: Staff observations identified R1's general skin condition as "thin and fragile" and to be "monitored in order for skin integrity be maintained." Interviews with Staff corroborate documented observations, and that some of R1's prescribed medications can cause bruising with very little pressure applied to the skin. Records show that Officers of the Los Angeles Police Department (LAPD) conducted a health "well check" of R1 at the request of the reporting party. A review of LAPD notes show Officers describing R1's condition as "good" and no suspicious injuries were observed. At 11:00 am, LPA spoke with an outside vendor providing R1 with hospice services. The hospice staffer stated that R1 would sustain bruises from simply being lifted from their bed to the bathroom. Furthermore, staff states that R1 would, at times, exhibit behaviors that could potentially cause bruising . Based on the information obtained through documents review, and interviews, this allegation is deemed UNSUBSTANTIATED at this time. Allegation: Staff did not safeguard resident’s personal belongings- It was reported that R1 always wore their wedding ring, however, it was reporting as missing. The reporting party states not knowing the specific time of the ring's disappearance. To investigate this complaint, LPA conducted a records review, and interviews with administrator. A review of R1's inventory list, signed by R1's Power of Attorney, (POA) notes that the responsible party chose not to fill out the form, and that "all items of value will be left at home." Documents reviewed do not indicate responsible party communicated this issue to Staff. R1 is no longer a resident of the facility, and LPA's attempt to contact the responsible party yielded no response. Based on the information obtained, it could not be proven that Staff did not safeguard resident's personal belongings. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was proved to the Administrator.

It is alleged that, due to a shortage of facility staffing, residents are wandering, without permission, into other resident bedrooms. To investigate the allegation, LPA conducted a records review of the facility's current monthly work schedule, and work schedules for the months of March, 2023,and September, 2023; dates in which the reporting party (RP) states the alleged incident occurred. Based on LPA's review, the facility work schedules suggests the licensee provides sufficient staff coverage during all shifts to prohibit intrusion of unwanted/unauthorized persons into into resident bedrooms. LPA interviews with residents revealed the following: Seven (7) out of seven (7) residents state that staffing is sufficient; they feel safe living at the facility, and have no concerns regarding the safeguarding of their personal items kept in resident bedrooms. LPA interview with staff revealed the following: Four (4) out of four (4) staff state that facility ensures sufficient staffing during all work shifts to keep residents safe, and prohibit unwanted intrusion into resident bedrooms. Based on LPA's observations, records review, and interviews with residents and staff,the allegation is UNSUBSTANTIATED at this time. Allegation: Staff did not provide adequate food service to residents- It is alleged that as a result, resident#1 (R1) did not have breakfast, due to lack of staffing. To investigate the allegation, LPA conducted a records review of the facility's current monthly work schedule, and the work schedule for the month of March, 2023; dates in which the RP stated the alleged incidents occurred. A review of the facility's work schedule reveals that the facility maintains a sufficient number of staff personnel on all shifts to provide food service for all residents. LPA interviewed seven residents who stated the following: Seven (7) out of seven (7) residents were complimentary of staff, reporting they are well informed of mealtimes and the menu of food items provided. Residents reported that meals were satisfactory and that staff consistently provide alternative meals in the event that a resident misses an opportunity to eat during a specified meal time. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Residents reported that meals were satisfactory and that staff consistently provide alternative meals in the event that a resident misses an opportunity to eat during a specified meal time. LPA interviews with staff revealed the following: Four (4) out of four (4) staff states consistency in ensuring all residents are provided food service, and that alternatives are provided when residents miss scheduled mealtimes. Based on LPA's observations, records review, and interviews with residents and staff, the allegation is UNSUBSTANTIATED at this time. An Exit interview was conducted, and report was provided to the Administrator.

To investigate the allegation, LPA conducted a records review, interviewed two (2) staff, and eight (08) residents between 11:00 AM to 1:15 PM. A review of R1’s medication administration records reveal R1 was indeed provided their medications as prescribed. Further review shows that a dosage notation error was noticed, and corrected. LPA interviews with Staff indicates that Medical Technicians responsible for the error were counseled, and a discussion regarding due diligence took place to ensure accuracy when notating resident medical information. LPA interviews reveal that eight (8) out of eight (8) residents state having no issues, nor concerns with medication distribution services provided to them by Staff. Based on LPA's records review, and interviews, the allegation is UNSUBSTANTIATED at this time . Allegation: Staff insufficient to meet resident needs- It was alleged that the facility does not have sufficient Staff to provide adequate medication distribution services to residents. To investigate the allegation, LPA conducted a records review, interviewed two (2) staff, and eight (08) residents between 11:00 AM to 1:15 PM. A review of the facility's work schedule reveals that a minimum of two (2) Medical Technicians are staffed on all shifts to provide adequate coverage for residents. LPA interviews with Staff reveal that medical service coverage is adequately provided to residents, and that additional staff are available to provide coverage, when necessary. LPA interviews reveal that seven (7) out of eight (8) residents confirm medical staff consistently provide services, such as medication management/distribution and that residents have no issues, nor concerns with staffing sufficiency. Based on LPA's records review, and interviews, the allegation is UNSUBSTANTIATED at this time . An Exit interview was conducted, and report was provided to the Administrator.

To investigate the allegation, LPA conducted interviews with Staff from 10:00am to 11:15am, and interview with R1 from 11:25 to 12:25pm. LPA's interview with the Administrator revealed the following: On Monday, (9/16/24) R1 informed the Administrator that the leg pad on their wheelchair was very loose, causing it to irritate R1's right leg. The Administrator responded to R1 saying, although staff are not permitted to make any modifications to a resident's medical devices, staff would be sent to assess the problem. On the same day, the Administrator and a staff member, went to R1's room, and adjusted two bolts on R1's wheelchair. Once the adjustment was completed, R1 was stated to have thanked staff for resolving the issue. LPA's interview with R1 revealed that staff did indeed resolve the issue with their wheelchair, and that the problem was resolved within the same day of R1's request for staff assistance. During the interview, LPA observed R1's wheelchair, and witnessed that the leg pad was attached, and functioning as required. R1 confirmed to LPA that their mobility needs were addressed by staff in a timely manner. Based on LPA's observations, and interviews,the allegation is UNSUBSTANTIATED at this time. An Exit interview was conducted, and report was provided to the Administrator.

LPA observed the posting of the facility's theft and loss policy and procedures, which are prominently displayed for viewing by residents and the public. LPA review of Staff files confirms, that during employee orientation training, facility employees are made aware of the facility theft and loss policy and their role in safeguarding resident belongings within the first 90 days of their employment. LPA review of Resident files confirms that facility staff notify all current and new residents, upon admission, of the facility's theft and loss policy. Seven (7) out of seven (7) resident files reviewed contain a completed Client/Resident Personal Property and Valuables inventory log with signatories acknowledging they have received, and are acquainted with, facility personal property safeguard procedures. LPA's review of Resident #1's (R1) file confirms personal items were logged as described by the Reporting Party. (RP) Statements made by facility Administrator and facility business officer confirm, upon resident/conservator request, facility provides centralized storage of resident cash or valuables. LPA interviewed Residents#2 thru-#8 about the allegation; seven (7) out of seven (7) residents denied the allegation that Staff do not safeguard resident belongings. Residents interviewed state, while living at the facility, they have not had any personal items stolen and feel confident that Staff adequately safeguard their personal items. Based on the evidence gathered, interviews conducted, and records reviewed by the LPA, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of the Report was provided to the Administrator.

Six (6) out of the seven (7) residents interviewed stated they have neither heard, nor witnessed the Administrator providing false information. Five (5) out of the seven (7) staff interviewed stated they have neither heard, nor witnessed the Administrator providing false information. Thus, Staff and Resident interviews do not corroborate this allegation. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violation did, or did not occur. Based on LPA's observations, interviews, and documents review, the allegation is UNSUBSTANTIATED. An Exit interview was conducted, and report was provided to the Administrator.

To investigate the allegation, LPA obtained and reviewed relevant documents. (Resident Files, Incident Report submissions, Resident roster,and Staff roster.) According to the documents reviewed, on November 3, 2023, Staff informed the Person responsible for R1 of the incident, and filed an incident report to Community Care Licensing, which was sent in a timely manner and according to regulations. Per Interview with Administrator, Staff were aware of the incident on the day of occurrence and required notifications were submitted. Administrator states that the Responsible Party (RP) for R1 wished to consult with additional family members prior to making any emergency medical treatment efforts. However, the Administrator says they continued on with due diligence to assess and monitor R1's health and pain concerns. Therefore, the allegation that Staff failed to follow proper reporting requirements is UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. Copy of this report issued.

Licensing Program Analyst, (LPA) Raymond Comer, made an unannounced site visit to this facility as a continuation of the Required 1 Year Annual Inspection conducted on 06/06/2024. LPA met with Administrator, Vanessa Jewell and the purpose of visit was disclosed. The following remaining inspection domains were observed, reviewed and inspected : Fire Detection/Protection system is present in the facility. Multiple smoke and carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire system back up and tests are done, in house, on a monthly basis. Fire drill last conducted May 15, 2024. Fire extinguishers were observed throughout the facility on all floors . All extinguishers were last serviced on June 30, 2023. Evacuation chairs were observed in each stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Kitchen: LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons were observed near any food areas. Medications The medications were locked in the medication carts, properly labeled, and stored. Medication documentation and implementation appeared to be complete. First aid kits were observed on each medication cart stored/parked in the medication room located in the second floor. [Continued on LIC 809C] 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 Laundry: LPA observed the laundry room located on the fourth floor, across from salon. Residents have access to the laundry area to do their own laundry. Laundry area is clean and clear from obstruction. Cleaning supplies and other toxins are stored in separate locked storage area and inaccessible to residents. Commons: Activity rooms, movie theater, dining rooms, pool hall, exercise room and library observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Random resident rooms on all floors were inspected and observed to maintain required furnishing and sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction. Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 114.5°F. Within the required range. Outdoor : Courtyard area observed to have a shaded patio, with tables with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. Resident records: Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current. Staff records: Staff files were reviewed. Criminal record clearances, Health Screening, Employee Rights Records were present and Staff are associated to this facility. Staff records appear to be complete and current. There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility Administrator.

On 06/06/24, 9:45 AM Licensing Program Analyst (LPA) Raymond Comer conducted an unannounced Annual required visit and inspection of the Facility, met with Administrator, Vanessa Jewell, and reason for the visit was stated. Facility is licensed as a complex occupying six (6) floors and a penthouse. Fire clearance approved for (110) non-ambulatory, and an additional ten (10) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, there are six (6) residents receiving hospice care services, and two (2) bedridden residents. At 10:05AM , LPA conducted a tour of the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition . Facility’s main doors is the primary entry/exit access. Screening area is located immediately upon entrance. As the Facility provides dementia care, LPA observed the delayed egress system working properly. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 78.0°F. within the required range. The facility maintains an approved Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 5/15/2024. [Continued on LIC 809-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 Resident records: A total of seven (7) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, centrally stored medication logs, and resident identification. Resident records appeared to be complete and current. Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report given to Administrator, Vanessa Jewell.

However, LPAs interviewed S1 who states R1 kept their medications exposed in open bins on top of their kitchen counter and often keeps door (room #5013) open, allowing other residents access. LPAs conducted a desk review and observed the following: R1's Physician's report states that they cannot manage their own medications. R1's service plan states the Medication Assistance are to be totally assisted by the Facility's Med Tech. PCP communication, dated 4/5/24, states that R1 "Is unable to utilize arm for safe management of of medication along with a safety concern to keep all meds in a central location locked in a cabinet or have his room door locked" and confirms that "Staff continue to manage meds on hand." Allegation: Staff are not assisting resident with incontinence needs\Staff did not respond to resident's call button in a timely manner. It was alleged that R1was not responded to in a timely manner to address incontinence needs, nor provide timely response to R1's activation of call button for Staff assistance. LPAs conducted an interview with R1 requesting them to activate intercom call button. Response time to R1 service call was nine (9) minutes. LPAs interviewed a total of seven residents (including R1) asking them about the timeliness of service call response by facility staff. All residents interviews stated that Facility Staff responded in a timely manner to service calls. Based on observations, document review, and resident interviews, the above allegation(s) deemed Unsubstantiated at this time. Exit interview conducted and a copy of this report delivered.

At the time of the investigation LPA observed the Resident Care Schedule with sufficient staff scheduled to assist residents in care. Based on observations, interviews, and record review there is not enough corroborating evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. #2. Due to neglect in care resident wound got infected It is alleged that resident #1 (R1) had wounds but were uncertain if they caused R1 infection. To investigate the above allegation, LPA requested copies of documents relevant to the investigation including but not limited to the staff and resident rosters, physician reports and hospice records on 05/23/2022 at 11:48am. At the time of the investigation, Interviews with staff revealed that R1 was admitted to Premier Hospice INC for wound care on 11/09/2021. Facility staff provided care for R1 in between their personal care companion and hospice care by providing incontinent care changing, repositioning, and feeding. R1 was being assisted by the hospice agency staff two (02) times per week and (02) times pro re nata (prn). Upon record review of the Premier Hospice Care Outside Agency/Services Documentation R1 was being seen two (02) times a per week for wound care, basic comfort care treatment, and education. In the month of February 2022 R1 was being seen every day by hospice care staff for wound care and hospice care. Based on observations, interviews, and record review there is not enough corroborating evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. No health and safety hazards are noted during this visit. No deficiencies cited. Exit interview conducted and copy of report and appeal rights issued.

Between 3:00pm and 4:00pm, LPA conducted records review. Documents revealed that Resident #1 (R1) has not been given the alleged medication for over a month. Furthermore, the medication is administered in gel form and not pill form. It is prescribed as needed. Between 4:15pm and 4:35pm, staff interviews were initiated. Interviews revealed that R1 is confused and delusional at times. R1 has delusions of persecution and can be aggressive sometimes towards staff and residents. Per interviews, R1 has not been aggressive lately, therefore the medication has not been needed to be administered. R1 is re-directed when behavioral issues arise and medication is given only if necessary. Based on interviews and record review, there is not sufficient information to support this allegation. Therefore, the allegation that staff over medicated a resident in care is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.