Ivy Park at Culver City.

Allegation: Due to staff neglect resident was covered in ants It is being reported that R1 was found covered in ants during her demise due to staff neglect. LPA Shirley reviewed Culver City Fire Departments report dated 8/12/24. Per the report, when paramedics entered the room to conduct assessment of R1, they found that R1 was covered in ants. The department interviewed Witness 1 (W1) who stated that on 8/12/24, W1 arrived at the facility and observed S1 spraying R1 with Lysol because, as he was told by S1, her body was infested with ants. W1 also observed the ants on R1. The department also interviewed witness 2 (W2), who stated that when they arrived at facility R1’s body was covered in ants. The department reviewed pest control service reports from Eco Lab Pest Control, service date 8/13/24. Per the service reports, multiple ant colonies were observed during treatment of the exterior areas. Per interview with facilities Regional Operations Specialist, the facility was also serviced on 6/24/24, 7/8/24 and 7/18/24. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. Allegation: Staff are not adequately trained in an emergency It is being alleged that staff are not properly trained to assist in an emergency. LPA interviewed staff 9 – staff 18 (S-9 – S-15). Of those interviewed 4 denied the allegation and 3 agreed. LPA interviewed resident 2 – resident 8 (R2 – R8). Of those who interviewed 3 denied the allegation, 2 confirmed the allegation and 2 were not sure. The department interviewed witness 1(W1). Per interview with W1, on 8/12/24, facility staff could not find residents paperwork when the fire department arrived. On 4/30/25, the Department reviewed S8’s Disciplinary action Notice, dated 9/12/24. Per the notice, there was a lack of staff training, and staff trained on Safety/Care protocols. During a further review of the Disciplinary Action Notice, emergency personnel and were concerned about the inability of staff to answer certain basic questions regarding R1. Emergency 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 personnel reported that several functions of S8’s job duties were not in line with Oakmont Management Group, OMG policy or standards and thought there was a lack of staff training Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. Allegation: Staff wiped resident’s body down with chemicals It is being alleged that facility staff was observed wiping down a resident’s body with Lysol. The department reviewed records, and observed that per Culver City Fire Departments report dated 8/12/25, paramedics arrived at facility and observed S1 spraying R1 with Lysol. The department interviewed Witness 1 (W1) who stated that on 8/12/24, W1 arrived at the facility and observed S1 spraying R1 with Lysol because, as he was told by S1, her body was infested with ants. W1 also observed the ants on R1’s body. The department reviewed Lysol use, and per Lysol website: “Lysol disinfecting and cleaning products are for surfaces and not for personal use. They cannot be used on the body or on food and always should be used as directed.” LPA interviewed staff 9 – staff 18 (S-9 – S-15). Of those interviewed 7 out of 7 denied the allegation. LPA interviewed resident 2 – resident 8 (R2 – R8). Of those who interviewed 7 out of 7 denied the allegation. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. Allegation: Lack of care and supervision It is being alleged that facility staff did not follow residents plan of care, which could have contributed to R1’s death. R1 entered Ivy Park of Culver City on January 8, 2024. Physicians assessment dated 1/24/24 states that R1 needs assistance eating. Plan of Care, 2/7/24 from Dr. Patel Nehall, M.D., AA Family Hospice Care, Inc., 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 stated R1 needed assistance with her meals, as she was known to pocket food and was on a mechanical soft diet on 2/7/24. Per hospice notes, dated 7/17/24, the facility follows aspiration precautions. The patient is noted to be pocketing food, so the facility performs oral care after each meal. The Department reviewed the menu for 8/11/24. Beef and broccoli was served that evening. The Department interviewed six (6) staff and out of (6) staff interviews, (3) staff stated they did not assist R1 with eating that day. The Department interviewed six (6) staff and out of (6) staff interviews there was no one (0), who stated that they had checked on R1 after she was put to bed on the night that she passed. LPA Shirley reviewed Culver City Fire Departments report dated 8/12/25. Per report, staff stated it had been three to five hours since they had seen R1. During interview, W2 also admitted to failing to document her findings in her death visit report. W2 stated that it looked like vomit with thick pieces and strains of meat, which was not normal. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement. Deficiencies were cited during today's visit. An exit interview was conducted, and plans of corrections were developed with the Executive Director, Tierre Thornton. A copy of this report and appeals rights were 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 Allegation: Staff did not perform CPR timely It was reported that staff did not perform Cardiopulmonary Resuscitation, (CPR) on R1. The department reviewed records, and found that per Ivy Park CPR policy in R1’s Resident Service Agreement, staff are trained and on duty 24 hours a day who can administer CPR. If you indicate that you wish to have CPR performed, staff will initiate CPR until emergency medical personnel arrive. If you indicate that you do not wish to have CPR, we will honor your wish by not initiating CPR and informing emergency medical personnel of your decision. LPA Shirley reviewed facility records and found signed Physician Orders for Life-Sustaining Treatment (POLST) dated 7/3/24 stating Do Not Attempt Resuscitation, (DNR) for R1. Per Culver City Fire Department report dated 8/12/24, CPR was declined by facility and Emergency Medical Dispatch (EMD) was refused. The department interviewed Witness 1 (W1). Per W1, the staff withheld doing CPR because it was beyond help and would not help R1. LPA interviewed staff 9 – staff 18 (S-9 – S-15). Of those interviewed 6 out of 7 denied the allegation and knows how to and when to perform CPR. 1 staff does not know CPR. Of those interviewed, 3 staff knew protocol if there is a DNR in place and 4 did not. 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 of “Staff did not perform CPR timely,” is found to be unsubstantiated. Allegation: Questionable death It is being alleged that R1 died at this facility under suspicious circumstances. The Department reviewed death certificate for R1, and The Department observed cause of death to be Cardiopulmonary Arrest and Alzheimer’s listed as cause of death. The department requested a coroner’s reports, but no autopsy was conducted. LPA Shirley reviewed Culver City Fire Departments report dated 8/12/25, per report paramedics arrived at facility 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 at 1:20am and found resident 1 (R1) pulseless and cold with fixed and dilated pupils. Facility staff provided paramedics with Physician Orders for Life-Sustaining Treatment (POLST) stating Do Not Attempt Resuscitation. Per review of R1’s Physician’s Report, dated 2/7/24, R1 was diagnosed with Alzheimer disease, HTN, Seizures, HLP, insomnia and depression. Per review of AA Family Hospice Care, Inc. Patient Consent for Care and Service Agreement, R1 began receiving hospice services 7/3/24, having been advised by her physician of her diagnosis and prognosis. LPA interviewed staff 9 – staff 15 (S-9 – S-15). Of those interviewed, 2 out of 7 denied the allegaton, 2 were not working at the facility at that time, 1 did not know and 2 were not available. 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 of “Questionable Death,” is found to be unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Business Office Manager,

Regarding Allegation #1 : Staff do not respond to residents’ calls for assistance in a timely manner. This complaint alleged that staff did not respond to R1 pressing R1 call button timely. LPA Calderon and S1 toured the facility. LPA Calderon did not notice any negative interactions between staff and residents. LPA Calderon and S1 walked into rooms 104, 205, 225, 305 and pressed the call button. On average it takes 5 minutes for staff to respond to the call button being pushed. Records indicate the following: The Needs and Service Plan indicate that R1 has cognitive issues and is non-verbal. The call button log notes indicate that staff responded to the call button being pushed 16 times from 09/03/2025 to 09/17/2025 for an average wait time of 8 minutes. The interviews indicate the following: S1-S5 deny the allegation ever happened. R1 is non-verbal and could not answer any questions. 2 out of 9 residents indicate that there is enough staff to take care of residents’ needs, and their call button is answered within 10 minutes. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not respond to residents calls for assistance in a timely manner” is found to be 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 Allegation #2 : Staff did not provide the residents responsible party with written notice of rate increase. This complaint claimed that staff did not provide written notice of a rate change. LPA Calderon and S1 toured the facility. LPA Calderon did not notice any negative interactions between staff and residents. Records indicate the following: The Admission Agreement page 4 “personal assistance and care” assigns points to a resident’s care for services. Page 6 “adjustments to fees” or services spell out how and why the facility charges for services. Email between the facility and R1 conservator, regarding the increase in cost of services was noted by LPA Calderon. Email between R1 conservator and the facility dated 05/22/2025 to 09/15/2025. The facility emailed the balance due, and a payment schedule emailed from 06/01/2025 to 09/01/2025, appears total charges $9175.00. A breakdown of the points assigned to R1 was forwarded to R1 conservator. The interviews indicate the following: S1 indicates that on 05/22/2025 S1 emailed a written notice of increased fees based on the admission agreement and the care assessment that was provided to R1 conservator. 2 out of 9 residents indicate that their families take care of the bill for services with the facility. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not provide residents responsible party with written notice of rate increase” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Tirre Thornton (S1).

On August 28, 2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced Case Management visit. The purpose of the visit was to serve the facility with an Immediate Exclusion Order for Staff #1 (S1). Upon arrival, LPA met with Executive Director Tierre Thorton and informed her of the purpose of the visit. LPA confirmed that S1 was not present at the facility during the visit. Executive Director Thorton stated that S1 had not been permitted to work, as the hiring process had not been completed. LPA was provided with documentation, including: Email correspondence between Ivy Park Culver City and S1 outlining the required forms prior to the intended hire date of January 11, 2025 (correspondence dated January 14, 2025), A printout of submitted and required documents dated January 14, 2025, A payroll report covering the period from January 1, 2025, through April 30, 2025, which did not list S1 on payroll. During the visit, LPA was informed that S1’s association date would be updated to reflect the correct separation date of January 11, 2025. An exit interview was conducted, and a copy of this report was provided to Executive Director Tierre Thorton at the conclusion of the visit.

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility staff do not treat residents with dignity or respect. The complaint alleges that the staff at the facility fail to maintain standards of dignity and respect in their treatment of residents in the memory care unit. While specific examples have not been provided, concerns have been raised about the interactions between staff members and residents. Reports indicate that staff members are rude and seem unwilling to assist, suggesting that residents may be experiencing neglect. No additional information about this situation was provided. On August 27, 2025, between 11:30 AM and 03:30 PM, the Department interviewed staff members identified as Staff #1 through Staff #6. Six (6) of the six (6) staff members were unable to recount any incident between a staff member and a resident. All staff members confirmed that residents receive professional assistance, treatment, and services. Additionally, all staff are required to complete mandatory training every 30 days. This training includes topics such as personal care assistance, cognitive and emotional support, behavioral management, safety and supervision, health monitoring, communication, documentation, and resident rights. On August 27, 2025, between 01:10 PM and 03:30 PM, the Department interviewed residents identified as Resident #1 through Resident #4 (R1-R4). Three (3) out of the four (4) residents could not support this claim. (R2-R4) commended all facility staff, noting that their interactions with the staff were amiable. They also stated that they had never witnessed any inappropriate behavior from any of the staff. (R1-R4) affirmed that the services delivered by staff were not only responsive but also fully adequate. Despite (R1) reporting unpleasant interaction with one staff member, (R1) was unable to provide specific details about the individual, raising concerns about the consistency and accountability of staff interactions. On August 27, 2025, and August 28, 2025, between 10:00 AM and 04:00 PM, the Department interviewed family representatives identified as Witness #1 through Witness #4 (W1-W4). Four (4) out of the four (4) witness members are not able to validate this claim. All four witness members have reported not having observed any inappropriate behavior during their visits to the facility. (W1-W4) determined that the care services provided to residents are satisfactory and indicate that residents are not being neglected. On August 27, 2025, the Department conducted a thorough inspection of the facility, with particular emphasis placed on the memory care unit. 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 inspection involved observing staff interactions with residents and examining how caregivers approached their responsibilities. The Department monitored the quality of communication, the appropriateness of activities, and the overall atmosphere within the unit to assess the level of care provided to each resident. The Department observed a staff member professionally interacting with residents. During the visit, the Department identified that the facility promotes the rights of its residents. Posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. This helps residents know their rights, which supports their well-being. A review of staff training records confirmed that personnel staff had completed the mandatory Workplace Sensitivity Training Courses, including ADLs and Behaviors, Psychosocial Needs, Challenging Behaviors, Essentials, Person-Centered Care, and Medication Management, Recognizing and Reporting Abuse, Essential Resident Rights, Resident Rights in Assisted Living, Communication and People with Dementia, and Respecting Diversity: Residents, Staff, and Families are some of topics are essential for mandated training. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above 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 with Tierre Thorton, and copies of the reports were provided.

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Facility is malodorous. T he complaint details that the facility is malodorous. It is reported that the facility has a strong and pervasive unpleasant odor noticeable in the hallway and throughout the facility. No further details have been provided on this matter. On August 20, 2025, between 11:30 AM and 02:30 PM, the Department interviewed residents identified as Resident #1 through Resident #8 (R1-R8). Six (6) out of the eight (8) residents could not support this claim. (R1-R6) reported that they had never experienced any unpleasant odors while receiving care at this facility. (R7-R9) mentioned that they have encountered an unpleasant smell, but it occurs only occasionally and is promptly addressed. Overall, (R1-R8) expressed general satisfaction with the facility's condition, providing positive feedback. They appreciate the cleanliness of the facility and indicated that they would report any issues to the staff if they arose. On August 20, 2025, between 10:00 AM and 11:15 AM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Three (3) out of the five (5) staff members are not able to corroborate this claim. No one reported this issue, nor were they made aware that it was a concern, according to (S1-S5). (S4-S5) indicated that unpleasant odors have been noticed in the hallways of the memory care unit after residents after meals. They mentioned that these odors are not constant; they vary over time and usually occur only after mealtimes, particularly when residents are being assisted with incontinence care. According to (S5), there is no shortage of staff to assist with incontinence care. The facility has three caregivers for the morning shift, four caregivers for the afternoon shift, and three for the evening shift to assist with incontinence care. (S3) stated that housekeeping staff are responsible for managing a total of 10 rooms daily, as well as common areas. Ensuring that no malodorous odors are present is a crucial aspect of the housekeeping duties. The Department inspected the facility on August 20 and 21, 2025. The inspection covered three floors of assisted living and memory care units, focusing on the maintenance and cleanliness of the environment. The facility was free of any unpleasant odors, and both housekeeping and maintenance staff were observed actively engaged in their responsibilities. (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 A review of the facility’s Personnel Report LIC 500 (dated 08/01/25) confirmed the number of care staff, housekeeping, and maintenance available for each shift. Further review of the Communication Work Orders, (dated 07/01/25 to 08/21/25), reveals that there were no reports of unpleasant odors during this period. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Allegation #2 : Staff do not ensure the facility is clean and sanitary. The complaint details that the facility is not maintained in a clean and sanitary condition. It is reported that the dining area is filthy, with food on the chairs, tables, and floor, which need to be cleaned. No further details have been provided on this matter. On August 20, 2025, between 11:30 AM and 02:30 PM, the Department interviewed residents identified as Resident #1 through Resident #8 (R1-R8). Eight (8) out of the eight (8) resident members could not validate this claim. (R1-R8) reported to have no issues or concerns about this matter. (R1-R8) indicated a favorable assessment of the facility's condition, especially regarding the main dining area. They specifically noted the commendable cleanliness of the space. Furthermore, they expressed a readiness to report any issues to the staff if they were to occur. On August 20, 2025, between 10:00 AM and 11:15 AM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5).  Five (5) out of the five (5) staff members are not able to corroborate this claim. It appears that nobody had raised this issue, nor were they informed that it was a problem, as indicated by (S1-S5).  (S3-S4) suggested that the dining areas in the assisted living and memory care sections are thoroughly cleaned after each meal. The cleaning process includes several steps: wiping down tables and chairs with a disinfectant cleaner, sweeping and mopping the floors, checking for spills or spots, and emptying the trash bins. These tasks are essential daily activities that help maintain a safe and healthy environment. The Department inspected the facility on August 20 and 21, 2025, with a focus on the dining areas of the assisted living and memory care units. The purpose was to assess the overall maintenance and cleanliness of these environments. During the inspection, the Department identified that the dining chairs, tables, and floors were well-maintained and met cleanliness and sanitation standards. (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 A review of the facility’s Personnel Report LIC 500 (dated 08/01/25) confirmed the number of servers, and kitchen staff for each shift. Further examination of the Communication Work Orders (dated 07/01/25 to 08/21/25) showed no reports of issues in the dining room areas of both assisted living and memory care. Based on the information gathered, there is not enough evidence to support the allegations mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated . No deficiencies were cited An exit interview was conducted with Tierre Thorton, and copies of the reports were provided.

Investigation revealed the following: Allegation: Staff don't respond promptly to residents' calls On 12/18/24 LPA Watson reviewed the facility files and found no incident reports relating to the allegation. On 12/18/24 between 9:30AM – 12:30PM 7 out of 7 staff interviewed denied the allegation. and 1 out of 7 stated that sometimes responses are delayed depending on the urgency of the call, but each call is addressed. On 12/18/24 between 1:30PM-4:30PM. LPA Watson interviewed Residents #1- #7 (R1-R7). Of those interviewed, 6 out of 7 residents denied the allegation; 1 out of 7 residents stated that there was a delayed response to their call. On 07/16/25 between 4:30PM – 5:00PM LPA Watson interviewed the Administrator Tierre Thornton Staff #7 (S7), and she stated that the facility did not have call logs or documentation of each call. Based on information gathered and records reviewed there is insufficient evidence to support the stated allegation. Allegation: Staff did not ensure that a doctor's appointment was scheduled for a resident On 12/18/24 between 9:30AM – 12:30PM LPA Watson interviewed Staff #1- #6 (S1-S6). On 07/16/25 between 4:30PM – 5:00PM LPA Watson interviewed the Administrator Tierre Thornton Staff #7 (S-7). 7 out of 7 staff interviewed denied the allegation. On 12/18/24 between 1:30PM-4:30PM LPA Watson interviewed Residents #1- #7 (R1-R7). Of those interviewed, 6 out of 7 residents interviewed denied the allegation. LPA Watson interviewed the Administrator Tierre Thornton, and she stated that the residents’ families were responsible for making their appointments and contacting the wellness director if needed to arrange and inform them of transportation to and from the hospital. Based on the information gathered and records reviewed there is insufficient evidence to support the stated allegation. Allegation: Staff are not complying with residents' admission agreements On 12/18/24 between 9:30AM – 12:30PM, LPA Watson interviewed Staff #1- #6 (S1-S6). On 07/16/25 between 4:30PM – 5:00PM LPA Watson interviewed the Administrator Tierre Thornton Staff #7 (S-7). 7 out of 7 staff interviewed denied the allegation. On 12/18/24 between 1:30PM-4:30PM LPA Watson interviewed Residents #1- #7 (R1-R7). 6 out of 7 residents denied the allegation. LPA Watson requested and obtained Admission Agreements for (R1) and observed that the facility followed the residents Admission Agreement. Based on the information gathered and records reviewed there is insufficient evidence to support the stated allegation. 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 Allegation: Untrained staff It is being alleged that staff are untrained and lack adequate knowledge of how to do their jobs. On 12/18/24 between 9:30AM – 12:30PM LPA Watson interviewed Staff #1- #6 (S1-S6). On 07/16/25 between 4:30PM – 5:00PM LPA Watson interviewed the Administrator Tierre Thornton Staff #7 (S7). 7 out of 7 staff interviewed denied the allegation. On 12/18/24 between 1:30PM-4:30PM LPA Watson interviewed Residents #1- #7 (R1-R7). 6 out of 7 residents interviewed denied the allegation. LPA Watson interviewed the Administrator Tierre Thornton, and she answered that all staff are required to take Relias training with a minimum passing score of 80%. The Administrator Tierre Thornton also stated that job shadowing is required of all employees before being officially installed into their positions. LPA obtained and reviewed Relias Transcripts for all employees interviewed, and it showed minimum scores of 80% and above for required employee training. Based on the information gathered and records reviewed there is insufficient evidence to support the stated allegation. Although the allegation may have happened or is valid, there is not a 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 the Administrator Tierre Thornton, and a copy of this report was provided.

On 12/18/24 LPA Watson reviewed and obtained copies of the Staff Roster and Resident Roster. On 07/17/25 LPA Watson obtained copies of the Relias Training Transcripts, and Admission Agreement. On 12/18/24, LPA conducted interviews with Residents #1- #6 (R1-R6), and Staff #1- #6 (S1-S6). On 07/16/25 LPA Watson interviewed the Administrator Tierre Thornton, Staff #7 (S7).LPA Watson toured the facility with the Business Office Director Armi Uchiyama. Investigation revealed the following: Allegation: Staff don't respond promptly to residents' calls On 12/18/24 LPA Watson reviewed the facility files and found no incident reports relating to the allegation. On 12/18/24 between 9:30AM – 12:30PM, 7 out of 7 staff interviewed denied the allegation and 1 out of 7 stated that sometimes responses are delayed depending on the urgency of the call, but each call is addressed. On 12/18/24 between 1:30PM- 4:30PM, LPA Watson interviewed Residents #1- #6 (R1-R6). 5 out of 6 residents interviewed denied the above allegation. 1 out of 6 residents stated that there was a delayed response to their call. On 07/16/25 between 4:30PM – 5:00PM LPA Watson interviewed the Administrator Tierre Thornton Staff #7 (S7) and she stated that the facility did not have call logs or documentation of each call. Based on information gathered and records reviewed there is insufficient evidence to support the stated allegation. 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 On 12/18/24 between 9:30AM – 12:30PM LPA Watson interviewed Staff #1- #6 (S1-S6). On 07/16/25 between 4:30PM – 5:00PM LPA Watson interviewed the Administrator Tierre Thornton Staff #7 (S-7). 7 out of 7 staff interviewed denied the allegation. On 12/18/24 between 1:30PM-4:30PM LPA Watson interviewed Residents #1- #6 (R1-R6). 6 out of 6 residents interviewed denied the allegation. 6 out of 6 residents interviewed stated that they were responsible for scheduling their own doctors’ appointments. LPA Watson interviewed the Administrator Tierre Thorton and she stated that the residents and their families were responsible for scheduling their own appointments and could contact the wellness director if the clients needed to arrange for transportation to and from the hospital. Based on the information gathered and records reviewed there is insufficient evidence to support the stated allegation. Allegation: Staff are not complying with residents' admission agreements On 12/18/24 between 9:30AM – 12:30PM, LPA Watson interviewed Staff #1- #6 (S1-S6). On 07/16/25 between 4:30PM – 5:00PM LPA Watson interviewed the Administrator Tierre Thornton Staff #7 (S-7). 7 out of 7 staff interviewed denied the allegation. On 12/18/24 between 1:30PM-4:30PM LPA Watson interviewed Residents #1- #6 (R1-R6). 6 out of 6 residents interviewed denied the allegation. LPA Watson requested and obtained Admission Agreements for (R1) and observed that the facility followed the residents Admission Agreement. Based on the information gathered and records reviewed there is insufficient evidence to support the stated allegation. 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 Allegation: Untrained staff It is being alleged that staff are untrained and lack adequate knowledge of how to do their jobs. On 12/18/24 between 9:30AM – 12:30PM LPA Watson interviewed Staff #1- #6 (S1-S6). On 07/16/25 between 4:30PM – 5:00PM LPA Watson interviewed the Administrator Tierre Thornton Staff #7 (S7). 7 out of 7 staff interviewed denied the allegation. On 12/18/24 between 1:30PM-4:30PM LPA Watson interviewed Residents #1- #6 (R1-R6). 6 out of 6 residents interviewed denied the allegation. LPA Watson interviewed the Administrator Tierre Thornton, and she answered that all staff are required to take Relias training with a minimum passing score of 80%. The Administrator Tierre Thornton also stated that job shadowing is required of all employees before being officially installed into their positions. LPA obtained and reviewed Relias Transcripts for all employees interviewed, and it showed minimum scores of 80% and above for required employee training. Based on the information gathered and records reviewed there is insufficient evidence to support the stated allegation. Although the allegation may have happened or is valid, there is not a 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 the Administrator Tierre Thornton, and a copy of this report was provided.

The investigation revealed the following: Allegation: Facility staff handles residents in a rough manner. It is being alleged that a staff member handled a resident in a rough manner and hurt them. It is also being alleged that other staff members are afraid of this staff member, and that management is aware as it has been reported to them. On 03/19/25, between 02:30 PM and 04:00 PM, LPA interviewed S1-S5. Based on interviews conducted, 4 out of 5 staff interviewed denied the allegation. 4 out of 5 staff interviewed stated that they are not aware of any staff member being afraid of a staff member. 5 out of 5 staff interviewed stated that they are not aware of any rough handling of a resident. 5 out of 5 staff interviewed stated they treat all residents with dignity and respect. On 04/29/25 between 11:30 AM and 02:20 PM, LPA interviewed R1-R6 and attempted to interview resident #7 (R7). Based on interviews conducted, 5 out of 6 residents interviewed stated that staff has never handled or treated them in a rough manner, 1 out of 6 residents interviewed stated that staff has handled or treated them in a rough manner, and LPA was unable to interview R7. 6 out of 6 residents interviewed stated that staff treat them with dignity and respect, and LPA was unable to interview R7. 6 out of 6 residents interviewed stated that they are satisfied with the services being provided to them at this facility. Based on interviews, file review and observation during the investigation, the above 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 violation did or did not occur. No deficiencies were cited during this investigation. An exit interview was conducted with Executive Director,Tierre Thornton, and a copy of the report was provided.

On 04/23/2025 at 9:15am, Licensing Program Analyst (LPA) Zina Brown and conducted an unannounced collateral visit. LPA meet with the executive director, Tierre Thornton and explain the purpose of today's visit is to interview Staff #1 regarding a complaint investigation unrelated to Ivy Park at Culver City. Between the hours of 9:21am - 9:38am, LPA conducted inteview with Staff #1 in regards to the complaint investigation unrelated to Ivy Park at Culver City. No deficiencies were cited during the unannounced collateral visit. Exit interview conducted with Tierre Thornton (Executive Director) and a copy of the report was provided.

On 04/21/2025 at 8:15am, Licensing Program Analyst (LPA) Zina Brown and conducted an unannounced collateral visit. LPA meet with the executive director, Tierre Thornton and explain the purpose of today's visit is to interview Staff #1 regarding a complaint investigation unrelated to Ivy Park Culver City. LPA obtain a copy of the LIC 500: Personal Roster and the following staff records for Staff #1: Job Application Background Check Clearance Bloodborne Pathogen Exposure Letter LIC 503: Health Screening Report Concentra Physical Examination Non-Injury Work Status Report TB Skin Test Results No deficiencies were cited during the unannounced collateral visit. Exit interview conducted with Tierre Thornton and a copy of the report was provided.

Licensing Program Analyst (LPA) Bernadette Allen and Licensing Program Manager (LPM) Stephanie Cifuentes conducted an unannounced visit to conduct an annual inspection. LPA/LPM were greeted by Tierre Thornton-Executive Director upon arrival. LPA/LPM introduced themselves, explained the purpose of the visit, to Tierre Thornton who granted access into the facility. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of three floors which includes resident rooms, common area, kitchen, dining area, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of resident rooms, dining area, common area, outdoor activity area and delayed egress doors. The facility has a signal system with the switch board in the reception area and is operational from all resident living units. At 1:39 PM, LPA/LPM reviewed seven (7) clients files for admission agreements, updated physician reports, and needs and services plans which were up to date. At 2:37 PM, LPA/LPM and Tierre Thornton- Executive Director toured the physical plant. There were no bodies of water or obstructions on the premises. LPA/LPM inspected a total of seven (7) bedrooms and seven (7) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were in good condition and operational. Smoke and carbon monoxide detectors were operational. The water temperature ranged from 105°F to 118. °F, and the bedroom temperatures ranged from 72°F to 78°F. At 3:15, LPA/LPM observed that the facility appeared to be clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 2/4/2025. 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 At 4:15 PM LPA/LPM also reviewed seven (7) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings which were all current. Based on the observations made during today’s visit, no deficiencies were cited. An exit interview was conducted, and this report was discussed and provided to Tierre Thornton- Executive Director at the conclusion of the visit.

Regarding Allegation 1: Facility staff do not respond to call buttons in a timely manner. This complaint alleged that staff did not respond to R1 pushing the call button in a timely manner. LPA Calderon toured the facility and noted staff providing services to residents. LPA Calderon noted staff interacting with residents, making lunch, and helping with resident’s care needs. Records indicate the following: Individual Service Plan (ISP) (date 06/20/2024). No health issues noted for resident. Reviewed call button logs (date July – August 2024), R1 pressed the button many times and the wait time was between 3 minutes to 32 minutes. 5 out of 5 staff indicate that there is a 10-to-15-minute wait time for resident that push the call button. 6 out of 8 residents indicate a 5-to-10-minute wait time for pushing the call button for service. Regarding Allegation 2: Facility staff does not serve nutritious meals. This complaint alleged that staff did not serve meals that taste good. Toured the facility to include the dining room around lunch time. LPA noted a daily menu and monthly meal plan. Food appeared to look and smell fine. 5 out of 5 staff indicate that the kitchen staff serve nutritious meals to residents. 6 out of 8 residents indicate that the food could be better, but they have no issues with the food served. Regarding Allegation 3: Residents barking dog is interfering with daily living of other residents. This complaint alleged that R3 dog barks and interferes with other residents daily living. LPA toured the facility. LPA visited R3 room and noted small dog in a cage. Dog was not barking or making a sound. Knocked on R1 room door and noted there was no issue with dog barking. LPA knocked on other doors no one was home. Reviewed admission agreement for R1. Animals are allowed by the facility. 5 out of 5 staff indicate that the small dog does bark, but no resident has complained except R1. 6 out of 8 residents have no issues with dog or dog barking. 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 Allegation 4: Licensee does not ensure the facility has an active director on site. This complaint alleged that there is staffing issues and no director that works the night shift. LPA Calderon toured the facility and noted many staff working and taking care of residents needs. Reviewed the staff roster and noted a mix of day and night staff shifts for the facility. S1 indicates that S1 works until 10 pm and residents can find S1 in S1 office. 5 out of 5 staff indicate no staffing issues for day and night shifts. 6 out of 8 residents indicate that there are no staffing issues for the night shift. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “Facility staff do not respond to call buttons in a timely manner”, “facility staff does not serve nutritious meals”, “residents barking dog is interfering with daily living of other residents”, “licensee does not ensure the facility has an active director on site” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted and copy of the Complaint Report were provided to the Manager Armida Uchiyama (S1)

The investigation revealed the following: Allegation: Staff did not respond to resident’s requests for assistance in a timely manner. It is alleged that a resident fell on the floor and was left unattended for a couple of hours. It is also alleged that a resident did not receive assistance from staff at their scheduled time, and when assistance was requested from staff using their pendant there was no response. On 07/24/24, LPA interviewed S1-S5. 5 out of 5 staff stated that they frequently check on their residents, and always go to them when the resident calls for them. On 07/24/24, LPA interviewed R1-R2, and on 08/07/24, LPA interviewed R3-R7. 6 out of 7 residents interviewed stated that staff checks on them promptly when needed. 6 out of 7 residents interviewed stated they are satisfied with the services being provided to them at this facility. Based on LPA observations 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. Allegation: Staff did not assist resident with mobility needs following a fall. It is alleged that after a resident fell, they called the front desk but there was no answer, and the resident then left a message. It is also alleged that the resident was left on the floor until the fire department arrived, then after fire department left, the resident was moved to a toilet chair and was left there. It is also alleged that staff refused to move the resident from the toilet chair to their bed using the Hoyer lift, so the resident sat in the toilet chair all night until AM shift assisted the resident to their bed. On 07/24/24 LPA interviewed Business Office Director, Armida Uchiyama (S1), and she stated that the resident had advised her of them falling, and that no one came to assist them. The resident told her that when someone finally came to them, they did not pick them up. Business Office Director, Armida Uchiyama stated she told the resident that that is their protocol, and that staff must make sure an EMT tells them resident is fine before moving them. She stated that this resident is a two-person assist and has a Hoyer lift. The resident told her that staff did not know how to use the Hoyer lift. She said she advised the resident that staff is trained, but the resident insists that they do not know how to use the Hoyer lift to their liking. 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 On 07/24/24 LPA interviewed S1-S5. 3 out 5 staff interviewed revealed that no resident was left unassisted after a fall. LPA asked staff if a resident was left on a toilet chair all night on 07/4/24. 2 out 5 staff interviewed said no, and 3/5 staff interviewed said they did not know. On 07/24/24 LPA interviewed R1-R2, and on 08/07/24 LPA interviewed R3-R7. LPA asked residents if they were aware of a resident falling and staff not assisting them. 6 out of 7 residents interviewed stated that they were not aware of a resident falling and staff not assisting them after. LPA asked residents if they knew if a resident was left on a toilet chair all night on 07/4/24. 6/7 residents interviewed said they did not know. Based on LPA observations 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. Allegation: Licensee does not ensure sufficient staffing to meet residents’ care needs. It is alleged the night shift (NOC) at the facility only has one staff to assist the residents because caregivers regularly call out. On 07/24/24 LPA interviewed S1-S5. 3 out 5 staff interviewed revealed that this facility has sufficient staff to meet the resident’s care needs. On 07/24/24 LPA interviewed R1-R2, and on 08/07/24 LPA interviewed R3-R7. 6 out of 7 residents interviewed stated that this facility has sufficient staff to meet their care needs. 6 out of 7 residents interviewed stated they are satisfied with the services being provided to them at this facility. Based on LPA observations 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. No deficiencies cited during today's visit. An exit interview was held with Executive Director, Brittney Buchannan, and a copy of this report has been provided.

Interviews revealed that all three (3) staff and all eight (8) residents have denied that the allegation has taken place. All eight residents have verified there is no malodorous scent throughout the facility. LPA's Leon and Calderon toured the facility and did not observe or detect any malodorous scents in both the AL and MC wing unit. Based on LPA's observations 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 residents beds are in good repair.”, it has been alleged that residents have broken their hospital beds, which have not been replaced, which has resulted in staff not being able to lift residents from their beds to assist residents and change the residents’ clothing. Interviews revealed that all three (3) staff and all eight (8) residents have denied that the allegation has taken place. LPA's Leon and Calderon toured the facility and inspected five (5) beds in the MC wing, which included room numbers as follows: two (2), three (3), seven (7), nine (9) and eleven (11) and were denied entry to room (13). Based on LPA's observations 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 old food is being properly discarded.”, it has been alleged that old left over food is being left in the fridge located in the memory care unit for a long time instead of being thrown out. Interviews revealed that all three (3) staff and all eight (8) residents have denied that the allegation has taken place. LPA's Leon and Calderon observed the large refrigerator, located in the dining room within the MC wing, and did not observe or detect old or moldy food(s). LPA's also observed all small refrigerators in kitchen area and in the AL dining room area and did not observe or detect old or moldy food(s). Based on LPA's observations and interviews conducted, the preponderance of evidence standard has not been met. 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 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 facility is kept free of insects.”, it has been alleged that the facility has a problem with ants and roaches in the residents’ rooms. Interviews revealed that all three (3) staff and all eight (8) residents have denied that the allegation has taken place. Record reviews revealed that the facility continues to have pest services done by ECOLAB, and that staff one, Delroy Grant – Maintenance Director (S1) has discarded one rodent that had been caught on Sunday, 07/21/2024, after a door to the central patio area was left open in the MC wing. LPA's did not observe, or detect, any insect remnants nor any rodent remnants in five (5) rooms that were inspected. LPA's searched for rodent remnants throughout the kitchen and did not detect any insect or rodent remnants. Based on LPA's observations, 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 infection control guidelines are being followed.”, it has been alleged that one of the residents on the assisted living side has an infection called MRSA and the staff let the resident roam around the facility and do not follow any infection control guidelines with isolation and use of personal protective equipment (PPE). Interviews revealed that all three (3) staff and all eight (8) residents have denied that the allegation has taken place. One staff had confirmed there was Covid in the facility, but that the infected staff was tested positive and was requested to depart from the facility. According to one staff, the facility had one (1) case of Covid-19, but has not been declared an outbreak by the Los Angeles Department of Public Health. Furthermore, one resident (R1) has departed from the facility due to personal issues and is currently staying at the hospital. Internal incident reports were not provided to LPA Leon. Record reviews revealed that the facility does have the Emergency and Disaster Plan for Residential Care facilities for the Elderly (LIC610E), as mandated, on file. 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 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 residents are provided with fresh clean linens.”, it has been alleged that not all the residents are being changed out of their soiled clothing in a timely manner and as a result the residents are soaking through their incontinence supplies and into their linens, which are not being replaced. Interviews revealed that all three (3) staff and all eight (8) residents have denied that the allegation has taken place. One staff has confirmed that, during their AM shift, they do make rounds to all rooms to verify that all rooms have laundered all residents' clothing appropriately during the PM shift the day before. Record reviews revealed that the facility does have a weekly laundry schedule for both AL and the WC wing, though the schedules are missing any logged notation from staff. LPA's Leon and Calderon observed five (5) rooms and did not detect any resident being left in soiled clothing or bedding. Based on LPA's observations, 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 Armida Uchiyama, Business Office Director (S2), and a copy of this report has been provided.

On 6/15/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Armida Uchiyama/Business Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (150) elderly adults ages 60 and above, of which (150) can be non-ambulatory and (10) Bedridden. The facility has an approved hospice waiver for (15). The facility has a memory care unit and an assisted living unit; the assisted living unit consist of three units which includes resident rooms, common area, kitchen, dining area, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of resident rooms, dining area, common area, delayed egress doors. The facility has a signal system with the switch board in the reception area and is operational from all resident living units. LPA Iniguez and the Businnes Oficce Director toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (10) bedrooms and (10) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 117°F to 118.°F, and the room temperature ranged from 76°F to 78°F. 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 During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 5/10/24. A review of (5) residents' service files and (5) staff personnel files was maintained in order. LPA reviewed (5) Medication Administration Records (MARs) no discrepancies were found by LPA. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA . Facility Annual Fess current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Armida Uchiyama/Business Office Director.

On 07/26/2023 around 10:00AM Licensing Program Analyst (LPA) Jose Calderon initiated an investigation for Ivy Park at Culver City Facility for the allegation complaints listed above. Today’s complaint investigation was conducted face to face Administrator Brittney Buchannan. During today’s visit, LPA Jose Calderon conducted face to face with Administrator Brittney Buchannan. LPA Calderon interviewed S1-S5 and R1-R9 for complaint.On 10/24/2022 around 10:00AM Licensing Program Analyst (LPA) Jose Calderon initiated an investigation for Ivy Park at Culver City Facility for the allegation complaints listed above. Today’s complaint investigation was conducted face to face Administrator Brittney Buchannan. During today’s visit, LPA Jose Calderon conducted face to face with Administrator Brittney Buchannan. LPA Calderon and Administrator Buchannan toured the facility including all common areas, kitchen, dining room and the Memory Care Unit. LPA Calderon requested copies of the following: Staff and Resident Roster, SIR reports for current complaint, physician report, needs and service plan, UCLA x-rays records and any other medical records, Color picture of right hand and finger for R1, maintenance records for facility van, meal plan for facility to be given to LPA Calderon by 10/24/2022. Allegation(s): Resident sustained an unexplained fracture while in care. The investigation revealed the following: Regarding the allegation " Resident sustained an unexplained fracture while in care,” it is being alleged that on 10/17/22 Resident #1 (R1) sustained a broken finger while in care. Interview with Caregiver (Contact #5) indicated that on 10/15/22, Contact #5 completed a full body check and found no issues with R1. Interview with Caregiver (Contact #6) indicated that on 10/16/22, Contact #6 conducted a body check with MedTech (Contact #7) and found no issues with R1. Record review reveals on 10/17/22 5:00 AM, another MedTech completed an internal incident report for an abrasion on R1’s right elbow only. Interview with MedTech (Contact #8), indicated that on 10/17/22 early AM, R1’s private companion reached out to Contact #8 to assess R1’s finger. Contact #8 called R1’s doctor and family member. On 10/18/22, x-rays were completed and R1 was diagnosed with a fractured right index finger. Interview with the Administrator indicated that R1’s fracture was reported on 10/17/22. R1’s private caregiver told Contact #8 and Contact #8 called R1’s doctor. Continue to 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 Regarding the allegation “Resident sustained an unexplained fracture while in care,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. 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. No deficiency was cited for this allegation. Allegation(s): Staff did not observe a change in resident’s condition. The investigation revealed the following: Regarding the allegation "Staff did not observe a change in resident’s condition,” it is being alleged that on 10/17/22, Resident #1 (R1) black and blue index finger was not reported by staff. Interviews indicated that on 10/15/22, the facility’s caregiver (Contact #5) completed a full body check and found no issues with R1. On 10/16/22, the facility’s caregiver (Contact #6) conducted a body check with MedTech (Contact #7) and found no issues with R1. Record review revealed that on 10/17/22 5:00 AM, another MedTech completed an incident report for an abrasion on R1’s right elbow only. Interviews indicated that on 10/17/22 early AM, MedTech (Contact #8) was contacted by R1’s private companion to assess R1’s finger. Charting notes reveal that Contact #8 observed the swelling and bruising at 7:00 AM on 10/17/22. Contact #8 called R1’s doctor and family member. Interview with the Administrator indicated, staff conduct routine body checks while clients showered and superficial body checks during diaper changes. Administrator indicated that the staff does not do intrusive body checks where they would undress clients and inspect their skin daily. Regarding the allegation “Staff did not observe a change in resident’s condition,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. 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. No deficiency was cited for this allegation. Continue to 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 Allegation(s): Staff left resident unattended in soaking wet diaper for extended period. The investigation revealed the following: Regarding the allegation “Staff left resident unattended in soaking wet diaper for extended period,” it is being alleged that Resident #1 (R1) was left in a wet diaper one year ago (2021). Interviews indicated that 4 out of 5 staff members change residents with incontinence needs an average of 3 times per shift. The Administrator indicated that residents are checked every hour for diaper change. Seven (7) out of eight (8) residents indicated that toileting and/or incontinence assistance is provided by staff. Regarding the allegation “Staff left resident unattended in soaking wet diaper for extended period,” based on interviews, the Department found no evidence to support the allegation mentioned above. 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. No deficiency was cited for this allegation. Allegation(s): Staff did not report unusual incidents involving resident. The investigation revealed the following: Regarding the allegation "Staff did not report unusual incidents involving resident,” it is being alleged that staff did not inform R1’s family of the 10/17/22 incident. Record reveals that the facility completed an internal incident report on R1’s injury, contacted R1’s doctor and Power of Attorney (POA) on 10/17/22, left a voicemail with the POA on 10/19/22 2:08 PM, and faxed an incident report to Community Care Licensing on 10/21/22 3:36 PM. Interview with the Administrator indicated that the process for reporting a incident report is to fax the incident report within 2 days, but staff states they make a report within Department of Social Services’ dates. Five (5) out of five (5) staff interviews indicated that incident reports are completed. Regarding the allegation “Staff did not report unusual incidents involving resident,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. 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. No deficiency was cited for this allegation. Continue to 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 Allegation(s): Staff do not provide proper food services to resident. The investigation revealed the following: Regarding the allegation "Staff do not provide proper food services to resident,” it is being alleged that the food is not edible for Resident #1. Interviews with the Sous Chef, Lead Server, and Caregiver indicated that special diet accommodations are met for residents. Chef and Server also indicated that accommodations are made for residents who needs assistance with cutting their meats. The Chef indicated that meats are left to simmer for softness. The Lead Server assists with orders and indicated that real potatoes opposed to boxed potatoes are used for mash potatoes. Interview with the Administrator indicated that the food is well made, they have no issues regarding the food, the facility provides a weekly meal plan, the facility provides 3 meals per day and snacks, and no resident goes without food. Six (6) out of 7 resident interviews indicated that three meals and snacks are provided by the facility. Regarding the allegation “Staff do not provide proper food services to resident,” based on interviews, the Department found no evidence to support the allegation mentioned above. 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. No deficiency was cited for this allegation. Continue to 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 Allegation(s): Facility does not have a vehicle to transport wheelchair-bound residents. The investigation revealed the following: Regarding the allegation "Facility does not have a vehicle to transport wheelchair-bound residents,” it is being alleged that the facility does not have a driver nor a van. Interview with the Administrator indicated that the facility has a van, vehicle, and bus. However, on R1’s finger (10/17/22) incident date, the facility’s driver was sick, had medical issues, and stopped working for the company. The Administrator stated that anyone who drives their vehicle must have a special license and, on that day, they worked around the problem and had a x-ray machine come to the facility the next day. Record reviews reveal that the x-ray was completed on 10/18/22. Five (5) out of five (5) staff interviews indicated that the facility offers transportation. Two of the five staff interviews specifically stated that the facility provides transportation to residen

The investigation revealed the following: Regarding the allegation "Facility is in disrepair". It is being alleged that residents’ fireplaces in their bedrooms are in disrepair. Interviews conducted indicated the following: 4 out of 13 residents interviews disagreed with the allegations and indicated that the gas has been cut off due to fire hazardous, 7 out of 13 residents hasn’t heard complaints about residents’ fireplaces being in disrepair, 1 out of 13 residents was unsure if the fireplace discussion was a complaint, and 1 out of 13 residents stated that the gas was cut off and has heard of one fireplace in disrepair complaint. Staff interviews conducted indicated the following: 4 out of 8 staff members have not heard residents complain about fireplace being in disrepair and 4 out 8 staff members have heard of one fireplace complaint and indicated that the gas was cut off. During the facility tour, LPA saw fireplaces in 3 out of 11 residents’ room. One fireplace on the first floor lit up and two fireplaces on the second floor did not light up. One resident verbally indicated that the fireplace did not work due to the gas being turn off, but the LPA was unable to view her room. The facility sketch and price sheet indicates that room rates are based on layout styles. The Administrator stated that fireplaces are not an additional charge. LPA reviewed six admission agreements and did not see fireplace charges. Regarding the allegation “Facility is in disrepair," based on observations, interviews, and record reviews, the Department found no evidence to support the allegation mentioned above. 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. No deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and left with the Business Office Director Armida Uchiyama.

On 02/22/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R8) regarding the allegation. The details of the complaint alleged that the facility staff members are handling residents in an aggressive manner. 5 of 5 staff denied the allegation that Facility staff handle residents in an aggressive manner. All staff (S1-S5) stated that they are trained through in-service and RELIAS trainings that teaches them how to care for residents and take care of their specific needs. LPA reviewed in-service trainings and verified that the trainings in resident care were completed. LPA interviewed R1-R8 about the allegation that Facility staff handle residents in an aggressive manner. 8 of 8 residents denied the allegation and stated that they are happy with the care and supervision the staff is giving them. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff handle residents in an aggressive manner. 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 # 2-Facility staff leave residents soiled for an extended period of time. On 02/22/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R8) regarding the allegation. The details of the complaint alleged that the facility staff members are not attending to their hygiene needs by letting them sit in soiled and urine-stained clothing for an extended period. 5 of 5 staff denied the allegation that Facility staff leave residents soiled for an extended period of time. All staff (S1-S5) stated that they have no knowledge of residents being treated this way. They state that residents who are incontinent are changed on average, about every two hours. Those that are in Memory Care are checked on every hour. And if they have soiled themselves, they are changed, given a shower, and their bed linens and clothing are washed that day. LPA interviewed R1-R8 about the allegation that Facility staff leave residents soiled for an extended period of time. 8 of 8 residents denied the allegation and stated that they have no knowledge of anyone that this has happened to, and it has never happened to them. Based on interviews, there is insufficient evidence to support the allegation that the Facility staff leave residents soiled for an extended period of time. 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 . Report 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 Allegation # 3- Facility staff are not meeting residents' laundering needs. On 02/22/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R8) regarding the allegation. The details of the complaint alleged that the facility staff members are not meeting the laundering needs of the residents and are letting the residents clothing pile up without being laundered. 5 of 5 staff denied the allegation that Facility staff are not meeting residents' laundering needs. All staff (S1-S5) stated that there is a laundry schedule in the facility which is Monday, Tuesday, Wednesday, and Friday. They further state that those residents that are in Memory Care and have incontinence issues are washed more often. They state that if they have an accident and soil themselves, their clothing, or the bed linens, those items are laundered that day. LPA interviewed R1-R8 about the allegation that Facility staff are not meeting residents' laundering needs. 8 of 8 residents denied the allegation and stated that they do not have any issues with the laundry service in the facility. Based on interviews, there is insufficient evidence to support the allegation that the Facility staff are not meeting residents' laundering needs. 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 . No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to, Director, Brittney Buchannan.

Continued LIC9099-C page 2 Allegation #1: Staff did not provide assistance to residents in a timely manner. LPA Bunker initiated a series of interviews with both staff members (S1-S3) and residents (R1-R8). S1-S3 and R1-R8 all affirm that assistance is provided to residents in a timely manner. R1-R8 all agreed and further articulated their contentment with their living conditions, specifically praising the respect, dignity, and quality of care extended to them. S1-S3 stated the facility staff is providing a secure, healthful, and comfortable living environment. R1-R8 stated they were happy with the care and supervision staff is providing and their individual care needs are being met in a timely manner. S1-S3 and R1-R8 denied the allegation. Allegation #2: Staff not providing adequate food service for residents. In response to the claim of inadequate food service, interviews were conducted with staff members (S1-S3) and residents (R1-R8) all agreed the facility is providing adequate food service to the residents. The unanimous response from S1-S3 and R1-R8 interviews indicated that residents are provided with three nutritious meals daily, breakfast, lunch, and dinner plus snacks, with options for seconds if desired. Observations confirmed an ample supply of both non-perishable food items for one week and perishable food for two days, effectively dispelling concerns regarding food service adequacy. Staff provided LPA with a copy of the weekly food menus. S1-S3 and R1-R8 denied the allegation. Allegation #3: Staff does not provide activities for residents. The allegation concerning the absence of activities for residents was thoroughly investigated through interviews with staff (S1-S3) and residents (R1-R8) all agreed, alongside an examination of the facility's activity calendar. S1-S3 and R1-R8 verified the provision of daily activities designed to engage and enrich the lives of those residing in the facility. During the inspection, I during the visit I witnessed residents actively participating in scheduled activities. R1-R8 stated they have a list of activities that they participate in bingo, crossword puzzles, charades, drawing, guessing games, Taboo, chess, brain teasers, board games, word search games, storytelling, exercising, social hours, water coloring, movie night, happy hours, arts and crafts, etc. S1-S3 and R1-R8 denied the allegation. Allegation #4: Staff does not wear hair nets while cooking and serving food. S1-S3 and R1-R4 stated staff wear hair nets while cooking, and serving food, in the dining room, and kitchen during breakfast, lunch, dinner, and snack times S1-S3 and R1-R8 all agreed, during today's visit I observed staff wearing hair nets while cooking and serving food. S1-S3 confirmed that kitchen staff consistently adhere to food safety practices by wearing hair nets during food preparation and service, thereby maintaining high standards of hygiene and safety. S1-S3 and R1-R8 denied the allegation. See continued LIC812-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 Investigation revealed the following: LPA Bunker conducted detailed interviews with staff members (S1-S3) and residents (R1-R8) all agreed, alongside meticulous observations. It was unanimously affirmed by S1-S3 and R1-R8 that staff provides timely and effective assistance to all residents. S1-S3 and R1-R8 stated staff are providing residents with the necessary care and supervision. R1-R8 stated their daily care needs are being met. The feedback highlighted the residents' satisfaction with the level of respect, dignity, and quality of care they receive, alongside their appreciation for the secure, healthful, and comfortable living environment maintained by the facility. Investigations into the food service operations revealed that the facility provides three nutritious meals daily, supplemented by snacks, with ample provisions allowing for second servings. This dispels any concerns regarding the adequacy of food service, supported by observations of substantial food supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA Bunker observed the facility's monthly food menu staff is following. Resident's also has food options. S1-S3 and R1- R8 confirmed the availability of a diverse range of daily activities, aimed at enriching the residents' lives and fostering a vibrant community. This was further corroborated by direct observations of active resident participation. LPA Bunker observed the facility's monthly activity calendar and Daily Chronicle. LPA observed staff wearing hair nets. S1-S3 and R1-R8 stated staff does wear hair nets while cooking and serving food. Allegations of non-compliance with food safety practices, specifically regarding the use of hair nets by kitchen staff, were found to be without merit. Interviews and direct observations confirmed adherence to stringent food safety standards, ensuring the health and safety of all residents. S1-S3 and R1-R8 stated staff is providing residents with a safe, healthy, and comfortable environment. R1-R8 stated they get plenty of food to eat, residents participate in daily activities, and staff wear hair nets while cooking and serving food. S1-S3 stated the facility is providing an environment where residents are treated with dignity and respect. S1-S3 and R1-R8 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 LIC9099, and LIC9099-C, was provided to staff. There were no deficiencies cited. Exit interview conducted.

The investigation revealed the following: Regarding the allegation "Facility staff does not assist residents after falling" it is being alleged that facility calls first responders for every slip and fall and would leave residents on the floor until first responders arrive. During the tour the team observed a total of 8 staff in the memory care unit and that signal systems are in place inside resident bedrooms, and common areas. 8 out of 8 staff interviews indicate that residents are immediately assessed for injuries and are provided assistance after falls. Staff also indicated that the facility will immediately call 911 for memory care residents who suffer un-witnessed falls to ensure that memory care residents receive a professional medical assessment since they are not able to articulate if they are in pain due to their medical condition. 6 out of 8 resident interviews indicate that residents get helped whenever they need it and like the way they are being treated by staff. 2 out of 8 residents were not able to provide interviews due to their medical condition. Record reviews indicate that the facility conducted an in-service training on 11/16/2023 about Fall Management Protocol which included safety measures that the facility is taking to reduce the risk of resident falls and reporting procedures for staff. Regarding the allegation "Facility staff does not assist residents after falling" 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. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to Memory Care Director Jessica Navarro.

On 12/14/2023 at 8:11 am Licensing Program Analyst (LPA) David España conducted an initiated a 10-day complaint investigation visit for the allegation listed and developed a case management-other. Upon arriving at the facility, LPA met with S#1 who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections. The care management consisted of the following: On 12/14/2023 at 8:11 am LPA España conducted a tour of facility plant with S#1; and requested to review records of Six (6) out of Eighty-One (81) residents in care records. LPA toured the outside and indoor memory care unit with S#1 and with S#3. LPA met on tour Seven (7) out of Twenty-Five (25) staff members at the time of visit on 12/14/2023. During the course of the visit LPAs smelled gas in a storage shed by memory care unit entrance door next to the outdoor green generator in front of the memory care unit. According to maintenance staff the gas company customer service agent was called, and the regional office has been informed. LPA requested for records of services from the maintenance staff maintenance records: LPA requested records of (1) Generator maintenance (log for the past three months); (2) A/C maintenance (log for the past three months); (3) Gas company maintenance (log for the past three months); (4) Facility maintenance of lighting of both floors and back area (log for the past three months); (5) Records of maintenance of toilets, bathtub, sink, washer, dryer, kitchen, parking lot, facility lights, facility vents, gas, A/C, and other (log for the past three months); (6) Records of maintenance of A/C if any (log for the past three months) and (7) a written narrative stating the amount of months gas leak has been on going at the facility as of 12/14/2023. Continued on LIC 809-D. 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 LPAs observations, the gas company did not service the gas valves and a large amount of gas smells have been observed by S#4. The maintenance staff stated they will send the gas company report to CCL today 12/14/2023. LPA with S#1 observed the facility window screens, and hinges, needing of repairing on thel back side of the facility. LPA noted damaged screens in the courtyard and the front of the facility. LPA noted memory care unit screen material to be dated and in need of repair 8 plus screens observed. This poses a risk to residents in care. LPA noted trash bins open with disposal or solid trash and other. The following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87303 (a-e) Maintenance and Operation and Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87303(f)(1-2) Maintenance and Operation on the LIC 809D. An exit interview was conducted at 1:10 PM, and a hard copy with appeal rights was provided to S#1.