The Pinnacles at Burton.

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not present the residents’ advance directive form to the responding emergency medical personnel. The complaint alleges that the staff failed to provide Resident #1's (R1) directive form to the emergency medical personnel. Reports indicate that (R1) experienced chest pains on October 6, 2025, and was transported to Cedar Sinai by Emergency Medical Technicians (EMT) without a Physician's Orders for Life-Sustaining Treatment (POLST) form. As a result, because no (POLST) form to indicate "Do Not Resuscitate," (R1) underwent repeated cardiac diagnostic testing over several days. On November 6, 2025, between 09:30 AM and 11:15 AM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) out of the three (3) staff members were able to validate Resident #1 (R1) was transported to Cedar Sinai without a (POLST) or an Advance Directive form was provided to the (EMT). (S1) admitted to having failed to provide a (POLST) form when presented with a copy. (S1) explained that the documents given to the (EMT) included only a Face Sheet Emergency Information and a Verification of Medication Order form, which only listed medications (dated 07/08/24). (S1) understood that it was an unintentional mistake, given the urgency of the situation. In that moment, (S1) genuinely believed that (R1) was experiencing cardiac arrest and felt it was crucial to get (R1) the immediate medical attention needed. On November 6, 2025, between 11:16 AM and 11:31 AM, the Department interviewed resident member identified as Resident #1 (R1). (R1) confirmed that (R1) left the facility and was transported by (EMT) to the hospital. However, (R1) does not remember the details of that incident. (R1) recalled experiencing deep, sharp chest pains, and (S1) took the necessary steps to ensure immediate medical attention was provided. On November 6, 2025, between 11:32 AM and 01:30 PM, the Department interviewed resident members identified as Resident #2 through Resident #7 (R2-R7). Six (6) out of six (6) resident members cannot support this claim. All residents reported being hospitalized, and hospital staff received the necessary documentation to treat them properly. A review of (R1’s) Face Sheet and Emergency Info (dated 10/07/25 and 10/16/25), Service Plan (dated 02/05/25 and 06/29/25), Resident Assessment (dated 06/29 25), Physician’s Report LIC 624A (dated 02/24/25), and Unusual Incident Report LIC 624 (dated 10/07/25). (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 Further review of the Physician Orders for Life-sustaining Treatment (POLST) (dated 02/05/25) indicate in section A Cardiopulmonary Resuscitation (CPR) box was checked off - Do Not Attempt Resuscitation/DNR (allow Natural Death) was selected. Based on the information gathered, there is enough evidence to support the allegation mentioned above. Allegation #2: Staff did not follow resident’s hospice care plan. The complaint alleges that the staff failed to follow Resident # 1’s (R1) hospice care plan. Reports claims that (R1) Resident is enrolled in hospice and that hospice protocol requires that hospice be notified as a part of the decision to seek medical intervention. Further reports stated that facility staff contacted hospice after the resident was transported to Cedars Sinai Hospital on October 6, 2025. On November 6, 2025, between 09:30 AM and 11:15 AM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) of the three (3) staff members confirmed that Resident #1 (R1) was transported to Cedar Sinai Hospital. Comfort Hospice Care was contacted after the fact, once (R1) was already being transported by Emergency Medical Technician services (EMT). Staff member (S1) was responsible for the emergency incident involving (R1), who was claimed to have failed to adhere to hospice care protocols by not contacting Comfort Hospice Care before calling 9-1-1. (S1) believed (R1) was in cardiac arrest and felt it was vital to get immediate medical help, unintentionally bypassing hospice protocols. On November 6, 2025, between 11:16 AM and 11:31 AM, the Department interviewed resident member identified as Resident #1 (R1). (R1) confirmed to be receiving hospice care when hospitalized. Unfortunately, (R1) does not have any recollection of the events from that day. (R1's) hospitalization was due to severe chest pains, and (R1) can only remember the intensity of the discomfort (R1) experienced. (S1) was there to ensure that (R1) received immediate medical attention during this difficult time. On November 6, 2025, between 11:32 AM and 01:30 PM, the Department interviewed resident members identified as Resident #2 through Resident #7 (R2-R7). Six (6) out of six (6) resident members cannot support this claim. All residents had no issues or concerns about this matter, as the staff followed their care plans accordingly. On November 14, 2025, between 04:30 PM and 04:47 PM, the Department interviewed staff member of Comfort Hospice Care identified as Witness #1 (W1). (W1) confirmed that the facility staff failed to adhere to the care plan. (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 The facility is instructed to contact the hospice agency first, rather than calling 9-1-1, in the event of a medical emergency or death. According to (W1), Comfort Hospice Care was notified only after (R1) was already admitted to the Emergency Department. A review of (R1’s) Face Sheet and Emergency Info (dated 10/07/25 and 10/16/25), Service Plan (dated 02/05/25 and 06/29/25), Resident Assessment (dated 06/29 25), Physician’s Report LIC 624A (dated 002/24/25), and Unusual Incident Report LIC 624 (dated 10/07/25). Further review of Comfort Hospice Plan of Care (dated 03/2024) revealed that hospice service “may require procedures performed in a hospital outpatient setting, and that Comfort Hospice Care will arrange for these services as needed, as indicated on the plan of care”. Based on the information gathered, there is enough evidence to support the allegation mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegations are found to be SUBSTANTIATED. An exit interview was conducted with Robin Culver, and copies of the reports 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 INVESTIGATION REVEALED THE FOLLOWING: Allegation #3: Staff mismanaged resident’s medication. Allegation#4: Staff did not properly report the resident’s incident to the resident’s authorized representative. The complaint alleges that staff mishandled Resident #1's (R1) medication and failed to inform (R1’s) authorized representative about an incident involving (R1). Reports indicate that staff administered “Nitroglycerin”, prescribed by (R1's) cardiologist, before (R1’s) hospice designation. Incident report show (R1's) initial vital signs recorded a blood pressure of 95/55, but this was omitted from the initial incident report; only the readings taken after administering “Nitroglycerin” were noted. After receiving “Nitroglycerin” twice, (R1's) blood pressure dropped to 78/53, resulting in a hypertensive condition, and (R1) was sent to the hospital. On November 6, 2025, between 09:30 AM and 11:15 AM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) of the three (3) staff members disputed both allegations. They confirmed that Resident #1 (R1) experienced chest pains that felt like stabbing sensations in the chest and radiated around the neck at a pain level of 10 out of 10. (R1) was given "Nitroglycerin" as a PRN medication prescribed by (R1's) primary physician from Comfort Hospice Care. The staff also stated that the information provided in the incident report to (R1's) authorized representative was accurate. (S1) indicated that they followed (R1's) medication plan by administering "Nitroglycerin" in an emergency setting to relieve chest pain and improve circulation. (S1) reported that when "Nitroglycerin" was given, (R1's) blood pressure was measured, with the systolic blood pressure (SBP) exceeding 90 mmHg. (S1) stated that the incident report submitted to the authorized representative and Community Licensing is accurate, and that no amendments have been made to the reports. On November 6, 2025, between 11:16 AM and 11:31 AM, the Department interviewed resident member identified as Resident #1 (R1). (R1) reported experiencing chest pains that radiated in (R1's) back and neck. Although (R1) does not remember much about the incident, (R1) recalls being assisted by (S1), who provided pain medication that did not ease (R1's) symptoms. Despite that, (R1) was grateful that (S1) was there to take urgent measures and get medical assistance. (Evaluation Report continues LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On November 6, 2025, between 11:32 AM and 01:30 PM, the Department interviewed resident members identified as Resident #2 through Resident #7 (R2-R7). Six (6) out of six (6) resident members cannot validate these claims. (R2-R7) stated medications have been handled appropriately, and there have been no reports of incorrect or unreported medication to their authorized representatives. On November 14, 2025, between 04:30 PM and 04:47 PM, the Department interviewed staff member of Comfort Hospice Care identified as Witness #1 (W1). According to (W1), Nitroglycerin is included in (R1's) prescribed medications. Comfort Hospice Care prescribes it as needed (PRN), starting July 8, 2024, for use at the first

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not seek timely emergency medical treatment for resident. Allegation #2: Staff did not notify resident's responsible party of change in resident's condition. The complaint alleged that the facility staff did not seek timely emergency treatment and did not notify Resident #1 (R1)’s responsible party of change in condition. It is reported on January 25, 2025 (R1) had an unwitnessed fall and hit (R1’s) head on the bathroom tub. On January 27,2025, (R1) was found incoherent and with loss of conciseness and in both incidents no medical attention was provided. On February 11, 2025, between 10:15 AM and 12:40 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the three (3) acknowledge the incidents occurred with (R1). (S1-S3) claimed the standard procedures are that when a fall occurs, the care staff performs a triage, an assessment is done, and if necessary, 911 is dispatched. (S1-S2) stated that medical attention is requested if the fall involves a head injury. After a fall, the registered nurse monitors the resident for seven consecutive days. (S1) claimed was unaware of the fall on January 25, 2025, while (S2) was not on duty and was only made aware of the incident by staff. (S1-S2) both admitted that medical attention was required as the fall with (R1) involved a head impact. On March 21, 2025, between 12:15 PM and 12:55 PM, the Department interviewed a staff member identified as Staff #4 and Staff #5. Two (2) out of the two (2) staff members (S4-S5) stated they was aware of (R1)’s fall and no medical attention was provided ordered by (R1). (S4) stated that the family representative of (R1) was notified and refused medical attention following the fall. (S4-S5) reported caregivers are trained to respond to resident falls. The on-duty supervisor assesses the resident and decides if medical attention is needed, especially in head impact cases. Two (2) out of the two (2) staff members identified as Staff #2 and Staff #4 were only made aware of (R1) 's change in medical condition on January 28, 2025, by (R1) 's family representative who informed them about the resident's change in condition. (S2 and S4) claimed they did not notice (R1)'s decline or seek medical attention until the family representative informed them that (R1) was incoherent and had lost consciousness. On March 21, 2025, between 10:00 AM and 11:07 AM, the Department conducted interviews with resident members identified as Resident #1 through Resident #7 (R1-R7). Four (4) out of the seven (7) residents reported experiencing falls while in care at this facility. They indicated that they received appropriate care from staff and did not require any medical attention. (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 INVESTIGATION REVEALED THE FOLLOWING: Allegation #3: Staff did not provide resident with food. Allegation #4: Staff did not provide resident with fluids. The complaint alleged that the facility staff did not provide Resident #1 (R1) adequate food and fluids. (R1)'s recent hospitalization required monitoring of food and fluid intake. No additional information was provided concerning these allegations. On February 11, 2025, between 10:15 AM and 12:40 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the (3) staff members denied the claim. (S1-S3) explained that (R1) receives three meals daily without a special diet. Along with the meals, a variety of liquid fluids are provided. All residents are offered a daily 60 oz pitcher of drinking water. According to (S1), the meals are both nutritious and have been approved by dieticians at Calson Management. (S1-S3) reported with (R1)'s recent hospitalization, (R1) was medically reassessed, and the service plan was updated. (R1) returned from the hospital on February 1, 2025, and was monitored by care staff daily through February 10, 2025. On March 21, 2025, between 12:15 PM and 12:40 PM, the Department interviewed a staff member identified as Staff #5. (S5) claimed to be one of the primary care staff for (R1) and verified that (R1) was being monitored routinely after (R1)'s hospitalization. (S5) claimed that it was challenging oftentimes when it came to meals as (R1) preferred only a Cheeseburger, and if (R1) was not provided that request, they would refuse to eat. (S5) also stated that (R1) preferred only to drink sodas and that water was not of preference and would have to make (R1) must do better on water intake. On March 21, 2025, between 10:00 AM and 11:07 AM, the Department interviewed resident members identified as Resident #1 through Resident #7 (R1-R7). Seven (7) out of the seven (7) residents claimed to have no issues or concerns with lack of meals and fluids. (R1-R7) all verified the facility provided three meals daily and fluids are provided with meals. (R1-R7) confirmed that care staff provided residents with daily water pitcher and it refilled in the afternoon. (R1) reported to have a preference for cheeseburger and soda for liquid drinks and claimed (R1) needed to better at consuming water. (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 The Department reviewed (R1)'s Progress Notes (dated 01/26/25 through 02/10/25) and revealed that (R1) was being monitored for food and liquid consumption. A review of (R1's) Physicians Report LIC 602 (dated 05/20/24 and 02/04/25) and Service Plan (dated 11/05/24 and 02/05/25) made no indication that (R1) is on a special diet. An additional review of the facility's menu (dated 03/01/25 through 03/31/25) revealed that certified board nutrition specialists approve meals. Upon further review of (R1)'s Medication List (dated 02/05/25), it was noted that two (2) of the nine (9) prescribed medications has side effects related to loss of appetite (ref. National Institutes of Health). The Department observed (R1) was supplied with a bedside water pitcher on both visits on February 11, 2025 and March 21, 2025. Based on the gathered information, insufficient evidence supports the stated allegations. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted with Chanel Sanchez, and copies of the reports 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 Resident #1 (R1) recalled having a fall but did not believe that medical attention was necessary at the time. However, (R1) did remember hitting their head on the bathroom tub during the fall. Six of the seven residents, identified as Resident #2 through Resident #7, stated that the staff are attentive in observing any decline or change in a resident's condition. (R1) mentioned being hospitalized after the fall, but only after a family representative requested medical attention. (R1) noted a change in condition due to symptoms of a urinary tract infection that staff should have noticed. The Department reviewed (R1)'s Progress Notes (dated 01/26/25 through 02/10/25) and revealed that had fall with head impact on January 26, 2025 and 911 was not ordered. It also revealed that on January 28, 2025, facility staff was ordered by the family representative to call for paramedics due to the change with (R1)'s condition. Further review of (R1)'s Medication List (dated 02/05/25) revealed nine (9) out of the nine (9) prescribed medications all had side effects of dizziness, anxiety, confusion, seizure or fainting (ref National Institute of Health) symptoms could contribute to falls. Upon reviewing the available information, it is evident that the facility failed to comply with its established fall prevention protocols. In this instance, immediate medical attention was not sought for resident (R1) following a fall that resulted in a significant head impact. Such an oversight in care is concerning, as prompt hospitalization could have revealed that the resident may have been experiencing a urinary tract infection. This condition can lead to further complications if left untreated. This lapse underscores the critical importance of adherence to safety guidelines and the need for timely intervention. Based on observations, interviews, and record reviews, the preponderance of evidence standard for "NEGLECT and LACK OF CARE AND SUPERVISION" has been met. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted with Chanel Sanchez, the Executive Director. During the interview, a hard copy of the report and information on appeal rights were provided.

Investigation Revealed the Following: Allegation: Licensee did not provide copies of resident records in a timely manner The details of the complaint alleged that facility staff did not provide copies of (R#1)’s records in a timely manner. On March 19, 2025, at approximately 1:30 PM, LPA Iniguez observed the e-fax cover sheet from (W#1) dated 2/24/25 at around 5:30 PM. This cover sheet requested records regarding (R#1), and the e-fax transmission was successful. On March 13, 2025, at approximately 1:00 PM, during an interview with witness 1 (W#1), (W#1) stated that they represent (R#1)’ Power of Attorney (W#2). On February 24, 2025, they had requested copies of (R#1)’s file from the facility, but the facility had not responded to their request. (W#1) reported that they called the facility on March 5, March 6, March 7, March 10, March 11, and March 12 to follow up on the records, but the facility did not address their requests. On March 13, a facility staff member emailed (W#1) partial records related to (R#1). However, (W#1) has still not received the complete records they requested. On 3/19/2025, at approximately 10:30 AM, LPA contacted (W#1). He asked them if the facility had sent them all the required records. (W#1) stated no, "I have only partial records, not everything we have requested". Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On March 19, 2025, at approximately 11:15 AM, during an interview with Executive Director (A#1), she stated that she was not aware of (W#1)’s records request regarding (R#1), however, (A#1) stated that as 3/18/25, they send some of the records to (W#1). In addition, (A#1) stated that she will send all the records today. On March 19, 2025, at approximately 11:45 AM, during an interview with facility staff (S#1). They mentioned that they had received a records request from (W#1) and were currently working on it since they had just located (R#1)’s records. (S#1) also noted that they had already sent some records to (W#1) on March 18, 2025. During this investigation, LPA found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Chanel Sanchez/Executive Director.

The investigation revealed the following: Regarding the allegation “staff does not administer residents medication as prescribed”, it is being alleged that staff administers residents’ medication 2 hours after prescribed scheduled time. Interviews conducted revealed the following: 7 out of 7 residents denied the allegation and 5 out of 5 staff denied the allegation. Records reviewed of MARs do not indicate that medications were provided after prescribed scheduled time. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “staff does not maintain residents hygiene”, it is being alleged that residents hygiene is not being maintained. Records reviewed of Facility Shower Schedule revealed the following: the facility has a shower schedule for residents in care. Interviews conducted revealed the following: 7 out of 7 residents denied the allegation and 5 out of 5 staff denied the allegation. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “staff left resident soiled in urine and feces”, it is being alleged that residents are left in soiled diapers for long periods of time. Interviews conducted revealed the following: 7 out of 7 residents denied the allegation and 4 out of 5 staff denied the allegation. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff did not provide medical attention to resident after fall”, it is being alleged that after resident(s) fell staff did not provide medical attention. Interviews conducted revealed the following: 7 out of 7 residents denied the allegation and 5 out of 5 staff denied the allegation. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegation “Staff does not ensure resident has running water”, it is being alleged that staff is aware that resident(s) do not have running water in their apartment(s) and the facility has done nothing to fix the problem. Interviews conducted revealed the following: 7 out of 7 residents denied the allegation and 5 out of 5 staff denied the allegation. Observations revealed the following: 7 out of 7 resident apartments had running water. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with the Executive Director/Administrator, Chanel Sanchez. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The investigation revealed the following: Regarding the allegation “staff does not keep facility free of pests”, it is being alleged that the facility has vermin. Observations revealed the following: a live vermin (cockroach) was observed in the kitchen area as well ad dead vermin. Pest control records for the year of 2024 revealed the following: pest control comes to the facility at least once a month or more and provides services; pest control also provides recommendations in each visit and indicates if it is pending or completed as well as states the severity of the recommendation; pest control record dated 12/2/2024 has recommendations dating back to 4/5/2023 and under General Comments it states “Cockroach activity has worsened in kitchen”. Regarding the allegation “staff does not keep facility free of pests”, the preponderance of the evidence standard has been met therefore the allegation is substantiated. Deficiencies cited based on observation and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director/Administrator, Chanel Sanchez.