Sakura Gardens at los Angeles.

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit to issue additional deficiencies. LPA met with the Executive Director – Tomoko Hino, to discuss the purpose of this visit. During the complaint investigation 28-AS-20250521082826, it was discovered that R-1 had multiple falls and/or being found on the floor between September 2024 through April 2025. A total of (11) known incidents occurred, however, the facility provided reports for the falls on 10/9/24 and 4/20/25. Therefore, the facility failed to submit written reports to licensing for all of R-1’s fall related incidents. In addition, during the same complaint investigation, R-1’s bedroom had a video surveillance monitor. During the visit today, staff noted that some residents’ rooms have video surveillance. The Executive Director is unsure if a written waiver was provided to licensing regarding the monitors in the residents’ rooms. Deficiencies are being issued today on the LIC809D. An exit interview was held. A copy of this report along with appeal rights were given to the Executive Director.

Allegation: Staff are not following proper reporting requirements It is alleged that the facility failed to comply with regulatory reporting requirements regarding incidents involving R1. During staff interviews (S1–S4), staff reported the following reporting procedures: Staff are required to report incidents directly to their supervisor and provide factual information regarding incidents that occur during their shifts. Staff complete Narrative Charting and an internal incident report form following an incident. These reports are submitted to the supervisor, who is responsible for submitting an Unusual Incident Report to Community Care Licensing (CCL). During the record review of documents provided by the facility, there were no Unusual Incident Reports on file regarding any incidents involving R1. The facility did provide Narrative Charting summaries dated January 27, 2026 (a.m. shift), in which two staff members documented that R1 may have fallen in her room and that R1 was observed the following day with a bruise to her right eye. An additional internal incident report dated January 28, 2026 (a.m. shift) documented that staff observed R1 with a black eye. Additionally, a Narrative Charting entry dated February 11, 2026, indicated that an altercation occurred between R1 and their roommate, during which R1 was reported to have hit their roommate. No Unusual Incident Reports were present in R1’s file, and the facility did not have records indicating that Unusual Incident Reports were completed for these incidents. Community Care Licensing also does not have records of ever receiving Unusual Incident Reports for either of these incidents. Based on LPA's interviews which were conducted and record review, 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 1 are being cited on the attached LIC 9099D.

During the course of this investigation, Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) conducted staff and resident interviews (R-1 through R-3) and obtained medical records. All interviewed residents are residing in the Transitional Memory Care (TCM) (where allegation allegedly occurred) and the census for the memory care unit is (36). LPA was unable to interview additional residents from this unit (LPA attempted to interview R-4 through R-6). Bot h, IB Investigator and LPA attempted to interview staff #6 (S-6) and were unsuccessful. Allegation: Staff did not seek timely medical care for resident resulting in injury. Per Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) investigation, the in-room camera video for 04/20/2025, R-1 was seen falling and could be heard complaining of pain in R-1’s right leg. Caregivers were observed picking R-1 up from the floor and placing R-1 in R-1’s wheelchair, then R-1’s bed. R-1 was visibly and verbally complaining of pain throughout the process and expressed R-1’s right leg and hip area hurt. Per S-4, S-4 did not call 911 immediately because S-4 did not know if R-1 “fell” or “slid” and S-4 wanted to obtain further information prior to calling 911. Per S-1, 911 should have been called immediately. R-1 was later transported to the hospital where R-1 was diagnosed with a fractured right hip. Staff interviews and medical records corroborate this allegation. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiency cited under LIC 9099D. Due to the seriousness of R-1’s injury, an immediate Civil Penalty of $1,000.00 is being issued during today’s visit. An exit interview was conducted. A copy of this report and appeals rights were provided to Dennis Robeniol . 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 course of this investigation, Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) conducted staff and resident interviews (R-1 through R-3) and obtained medical records. All interviewed residents are residing in the Transitional Memory Care (TCM) (where allegation allegedly occurred) and the census for the memory care unit is (36). LPA was unable to interview additional residents from this unit (LPA attempted to interview R-4 through R-6). Both, IB Investigator and LPA attempted to interview staff #6 (S-6) and were unsuccessful. Allegation: Due to lack of supervision, resident was left on the floor for extended periods of time after falls. Per Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) investigation, it was alleged that on 10/04/2024, R-1 fell and was not discovered for (4) hours. Videos from R-1 in-room camera do not depict any dates or times as well as screenshots of the videos which do depict dates and times. Per the screenshots provided for 10/04/2024, R-1 is seen sitting on the couch in R-1’s room at 0153 hours and staff in R-1’s room at 0605 hours. Per the video, R-1 is seen lowering self to the floor from R-1s bed and attending to a blanket which R-1 placed on the floor. There is no video or screenshot of the time R-1 fell. The facility was unable to provide documentation regarding the time R-1 fell but documentation showed staff found R-1 in R-1’s bathroom at 0540 hours. Regarding R-1’s subsequent falls, documentation provided showed R-1 was discovered within a matter of seconds, minutes, and up to approximately one hour. Per staff interviewed, residents are checked on every (2) hours per shift. R-1 was unable to provide a meaningful statement. Staff interviews and video footage/screenshots do not corroborate this allegation. Allegation: Staff do not ensure resident's walker is within reach. Per staff interviews, R-1 had a walker and wheelchair but could walk independently. Staff interviews revealed that R-1’s would move R-1’s walker away from R-1’s bed. Interviewed staff indicated that R-1 did not always use R-1’s walker, remembered to use the walker or refused to use the walker. Interviewed staff indicated that they would remind R-1 to use R-1’s walker. Interviewed staff indicated that they did not have a log of when R-1 refused to use the walker. Staff interviews do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. 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 respond to resident’s alarm mat timely. Per staff interviews, R-1 had a mat alarm next to R-1’s bed on the floor. Interviewed staff indicated that when R-1 stepped on the mat, an alarm would ring on a mat monitor (alert box) which was located in the dining room where there is always staff present. Per staff interviews, the alarm was loud and required staff to manually turn it off when it activated. Interviewed staff indicated that when R-1’s mat alarm would activate, staff would check on R-1 following the alarm notification. Interviewed staff indicated that they did not have a log of when R-1’s mat alarm would activate nor any kind of tracking on the mat monitor (alert box). Staff interviews do not corroborate this allegation. Allegation: Staff did not follow residents fall plan. Per staff interviews, R-1 did not have fall plan in place. Interviewed staff indicated that they conducted rounds “every 2 hours” and encouraged R-1 to use R-1’s walker which R-1 often refused to use or would forget to use it. Interviewed staff indicated that they did not have a log of the rounds that were conducted for R-1. R-1 file did not contain a fall plan in place. Interviews and lack of documentation pertaining to a fall plan do not corroborate this allegation. Allegation: Staff do not ensure residents oral hygiene needs are met. Per staff interviews, staff assisted R-1 with R-1’s oral hygiene. Interviewed staff indicated that at times, R-1 refused oral hygiene and would become physically aggressive with staff when attempting to assist R-1 with oral hygiene. Interviewed staff indicated that when R-1 cooperated with R-1’s oral hygiene (denture placement), staff would ensure that R-1’s dentures had polygrip. Interviewed staff indicated that they did not have a log of when R-1 refused to allow staff assist with oral hygiene. Staff interviews do not corroborate this allegation. Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted. A copy of this report and appeals rights were provided to Dennis Robeniol.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a Case Management visit. LPA met Dennis Robeniol/Executive Director and discussed the purpose of this visit. During the course of a complaint investigation, (allegation: staff did not follow residents fall plan.), per Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) investigation, it was discovered that R-1 sustained multiple falls. During R-1’s residency from 06/22/2024 to 04/25/2025, there are at least (11) known incidents of R-1 falling and/or being found on the floor. Per S-1, the incidents did not require a reassessment as R-1 continued to have the ability to walk though R-1 fell or was found on the floor often. No fall precautions were implemented by the facility other than to check on R-1 every (2) hours and no additional accommodations were made available to R-1. Deficiency cited. Refer to LIC 809D. Exit interview and a copy of this report and appeals rights were provided to Dennis Robeniol.

Licensing Program Analysts (LPAs) Elena Mallet and Luis De Leon conducted a continuation annual required visit. LPA met with Director Dennis Robeniol and the purpose of the visit was discussed. The facility is licensed to serve elderly residents age 60 and above. It is approved for 136 non-ambulatory residents and 47 bedridden residents, approved for 10 hospice waivers. REVIEW OF FILES Resident record review consisted of Admission Agreements, Physicians Report, Needs and Service Plan, Personal Rights, and Centrally Store Medication. Staff record review consisted of Personnel Report, Health Screening, and Background Clearance. Deficiencies were noted for resident’s for missing updated Needs and Service Plan for R4, TB results missing for R1 and R2, and ambulatory status for R5. Staff records were missing health screening for S1-S5, annual training missing for S2-S4, and first aid certificate missing for S2-S4. Deficiencies were noted on 809D pages. Observations during facility tour: Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for residents. Wall and floors are in good repair. Hallways were clean and free of obstructions. Report continues on page 809C... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area. Weekly food menu is posted at facility. LPA observed list of residents with modified diets to be available to kitchen staff. LPA observed all food to be stored properly Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean. The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees. POC was cleared for previously cited hot water deficiency. Also, disinfectants and cleaning supplies are locked and secured inaccessible to residents. Combo Smoke and carbon monoxide detectors were observed and tested on all rooms. Two (2) fire extinguishers were observed on each floor and were fully charged with the last inspection date on 9/23/2024 . There has not been a fire/earthquake/emergency drill conducted since 12/19/2023. A deficiency was noted on page 809D. Front outdoor grounds provide seating and shade and are free from debris and obstructions. The facility offers residents various activities throughout the week. Residents were observed actively engaged on various activities. The medications are centrally stored and locked in the MedTech room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all five ( 5 ) residents. LPA conducted interviews with five staff and five residents. LPA reviewed Disaster Emergency Plan and noted deficiency because it calls for the use of inoperable emergency backup generator. The licensee needs to update plan to include instruction for alternate power in the event of power outage. Deficiency noted on page 809D. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D page. Reports LIC 809, LIC 809D and Appeal Rights were discussed and provided to Director Dennis Robeniol.

Licensing Program Analysts (LPAs) Elena Mallet and Luis De Leon conducted an unannounced Required- 1 year visit. LPA met with Director Dennis Robeniol and the purpose of the visit was discussed. The facility is licensed to serve elderly residents age 60 and above. It is approved for 136 non-ambulatory residents and 47 bedridden residents, approved for 10 hospice waivers. LPAs were only able to work on physical plant tour. The facility consists of three separate buildings: The retirement building is a 5-story building that consists of 127 units each with private restroom, lobby area, administrative offices, public restrooms, library, TV Room, Activity room, laundry room, Health & Wellness room. The first floor is made up of memory care residents with early symptoms of memory impairment. LPAs inspected rooms: 113, 216, 404, 424, and 521. LPA observed that on the south stairwell an evacuation chair was available while the north stairwell did not have an evacuation chair available on any floor. In room 521 the hot water temperature was measured at 121.5 degrees Fahrenheit which did not meet Title 22 regulation. Additionally, LPA tested the call signal from resident’s pendant and caregiver arrived 7 minutes later. Deficiencies were noted for hot water above Title 22 regulation and evacuation chair missing from stairwell. Report continues on page 809C... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The south building consists of a commercial kitchen and dining room for Assisted Living Residents. A secured wing housing the Memory Care which consists of 13 rooms, 5 restrooms, gated courtyard, activity room/dining room, lobby, laundry room, medication room and administrative office. On memory care floor, the hot water temperature was measured at 122.0 degrees Fahrenheit in the shower room next to reception desk and 123 degrees in residents’ dining/activity room which did not meet Title 22 regulation. LPAs tested the call signal on rooms 1003 and 1015 and there was no response from the caregiver. LPAs inspected rooms: 1003, 1010, and 1015. Deficiencies were noted for both the call signal and hot water above title 22 regulation. Activity Hall that consists of an auditorium, activity room and area for storage. Residents are allowed access to Activity Hall for planned activities and staff supervision is provided at all times. Due to time constraints, LPA will return at a later date to complete all (12) CARE Tool domains. Exit interview conducted with Director Dennis Robeniol and a copy of this report was provided.

Regarding: Staff did not ensure hot water was available at the facility for residents in care. It is alleged, the victim hasn't had hot water for the past 4 days and therefore, wants to return back home. The investigation revealed the following: Water temperature measured by LPA revealed to be between 89.6 - 91.7 degrees F in 10 out of 14 resident bathrooms inspected, which is below the compliance range of 105 - 120 degrees F. S1-S3 corroborate the allegation. Interviews with S1-S3 indicated, water temperature is inconsistent and they are aware water is not delivered at an adequate temperature especially in the morning. S1-S3 stated, residents have complained regarding the water not being hot enough. Interviews with S4-S5 indicated, residents have complained to them regarding water not being delivered hot by their restroom's tap for several days. R1-R9 also corroborate the allegation. Interviews with R1-R9. indicated, their bathroom sinks do not deliver hot water which interferes with their showers and other personal hygiene routines. R1-R9 stated, they have brought it to the attention of staff, however, the issue persists. LPA, substantiated the allegation above based on the evidence obtained during this investigation. A finding of substantiated means the allegation is valid because the evidence meets the preponderance of the evidence standard. LPA cited the deficiency below per California Code of Regulations (CCR) Title 22. ***See LIC 9099-D An exit interview was conducted with Dennis Robeniol, Executive Director. A hard copy of the report and Appeal Rights were provided at the time of visit.

Said he believed the homeless took all the copper and the wiring. Stated that the blackout was the 1st time that it happened and lasted 2 hours and that residents were in dining room where there was good lighting. Tour of the exterior of the facility where the generators are located LPA observed wires cut that lead to the motor and to the breakers which made it non-operable. Based on LPA’s observations, tour and interviews conducted, the preponderance of evidence standard has been met, therefore, the allegation has been determined to be SUBSTANTIATED . Deficiency cited on LIC 9909-D. Exit interview was conducted with Executive Director.

Licensing Program Analysts (LPAs), Mayra Cota and Blanca Gonzalez, conducted an unannounced case management visit due to deficiencies noted during a complaint visit conducted on 11/26/24. LPA met with Dennis Robeniol, Executive Director and explained reason for the visit. During complaint investigation, LPA Cota reviewed Medication Administration Record (MAR) logs for Resident 1 (R1) and Resident 2 (R2). LPA Cota noted, R2's MAR logs for September, October and November 2024 were incomplete. MAR logs reviewed were missing multiple initials. The MAR logs were missing initials for medication required to be administered daily, once or several times a day. Deficiency cited on LIC-809D per Title 22 Regulations. Exit interview conducted with Dennis Robeniol, Executive Director and a copy of the report and Appeal Rights were provided.

Allegation: Staff did not meet resident’s needs. Regarding allegation, “Staff did not meet resident’s needs,” it is alleged, staff did not provide resident with insulin and diabetic supplies to check sugar. During the investigation, interview with R1 indicates, facility staff did not have their insulin after being transferred from convalescent hospital. R1 reported to staff they were feeling sick and was transported to hospital via ambulance. Review of Special Incident Report dated 11/14/2024, indicates, R1 was assessed by paramedics with Hypoglycemia being high, at 561. Interviews with S1 indicate, facility received the insulin, however, it was not administered. Interview with S2 also confirms, R1 did not receive insulin dose at the facility. Additionally, interviews with DS indicate, R1 was transferred to facility from convalescent home with all their medication, including their insulin. Review of medication inventory lists from facility and convalescent hospital further indicate insulin was included in the medication R1 took to the facility during their transfer from convalescent hospital. Based on LPA’s observations, file and record reviews, and interviews conducted, the preponderance of evidence standard has been met, therefore, the allegation has been determined to be SUBSTANTIATED . Deficiency cited on LIC 9909-D. Exit interview was conducted with Dennis Robeniol. A copy of the report and Appeal 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 It is alleged, staff declined to listen to resident and only listened when they asked staff to call the ambulance when they did not feel well. During the investigation, eight out of nine residents interviewed stated, staff are helpful, and they meet their needs in a timely manner. Residents stated staff are nice and they have not experienced any problems during their time at the facility. Staff interviewed stated, staff ensure care and supervision of residents is met by conducting scheduled status checks. There is Life Alert necklace system in place for all residents to ensure they have a way to communicate with staff at any time. During tour of the facility, LPA observed multiple staff providing care and supervision to residents in their rooms and during daily activities throughout the facility. Based on LPA observation, file and record review, and interviews conducted, the allegation listed above could not be corroborated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview conducted with Dennis Robeniol, Executive Director. A copy of the report was provided.

Licensing Program Analyst (LPA) Christian Gutierrez generated this Case Management - Deficiencies report in conjunction with complaint control 28-AS-20241204135046 pertaining to observations made during the physical plant inspection. The purpose of the report was explained to Business Office manager Alfonso Lozoya. At 10:55 AM, during the tour of physical plant inspection LPA Gutierrez checked water temperature in rooms and observed room #137 water temperature at 133.4F, room# 212 water temperature at 134F and room# 206 water temperature at 132.3F not in between the required range of 105-120 degrees F. Based on observation, a citation is being issued. See LIC 809D. An exit interview was conducted, and a copy of the report and appeal rights were issued.

Allegation: Licensee does not ensure that residents are provided with a comfortable environment while in care. It was alleged that the residents cannot eat comfortably because facility had failed to provide adequate air conditioning and the residents are suffering tremendous heat in the dining room. LPA interviewed 12 residents and 10 out of 12 residents reported the air conditioner in the dining room was not working and the temperature was very high in the dining room. Interviewed residents stated that there are 2 portable A/C units were installed in the dining room couple of days ago but was not enough to maintain a comfortable temperature. Interviewed Administrator and staff admitted that dining room was very hot when it was extreme hot a week ago. Interviewed Administrator stated that the dining room temperature was suitable and comfortable up until recent heat wave on 09/05/24. To which they coordinated the portable AC units to be installed. Also stated more AC units will be installed in the dining room. Interviewed S2 stated that 4 AC units were provided, which had no effect in the kitchen and dining room. Allegation: Facility is in disrepair. It was alleged that the air conditioner in the dining room has not been working for the past 6 months. During visit, LPA toured the physical plant along with S1 and observed that the AC unit is missing from the cage in the back of facility. Interviewed Administrator and staff stated that about 6 mounts ago AC unit was stolen. Interviewed Administrator stated that facility was faced with theft due to trespassers who vandalized the building. Administrator stated that they communicated with the home office and construction team to look for alternative measures such as adding wrought iron gates to the back end of the property as well to better secure. The AC unit to be manufactured and once in placed they need to cage it off with the wrought iron to prevent future damage and theft. However A/C unit was stolen about 6 mouths ago and until today was not replaced / restored Based on interviews conducted and observations, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited. See LIC9099D. An exit interview was conducted with Administrator and the copy of this report and appeal right were provided.

Allegation: Staff did not safeguard residents' personal belongings. The complaint alleges that staff are instructed to wash resident's clothing and bedding linens together and as a result many of the resident's clothing/personal items are misplaced and/or lost because staff are washing all Memory Care resident's linens together in order to save time. During the course of the investigation, LPA interviewed staff, and family members and information gathered revealed that facility staff ask resident's family members to label the resident's clothing items with permanent marker or a customized name tag label. Family stated that they have noticed their loved one sometimes wearing other resident's clothing, but stated that for the most part the belongings kept at the facility do not have major value. Staff stated the clothing is washed during the NOC shift on days residents are showered. Staff acknowledged that sometimes the resident's clothing is misplaced or lost because the NOC shift staff do not place the belongings in the right resident room, and that the resident's clothing is all washed together. In November 2023, the Memory Care Unit's dryer was not working and staff had to walk to the outside laundry building. Staff stated that due to current laundry assignment protocols the resident's belongings do get mixed up. Staff also reported that some ambulatory residents take other resident's clothing and/ belongings due to cognitive impairment. Allegation: Staff are not properly dispensing medication as prescribed. It is alleged that the Memory Care Director instructed med-tech staff not to follow physician's orders and dispense extra dosages by increasing the frequency of behavioral medications for at least three (3) residents. Information revealed that resident (R3) had a physician order for Quatiapine "Seroquel" twice a day [8 AM & 8 PM], but the medication was being given 3 times a day as a routine medication per Memory Care Director's instruction, in order to immediately control the resident's behaviors instead of utilizing redirection techniques. The Memory Care Director denied the allegation, and stated that R3 had a previous physician order that was supposed to be dispensed 3 times a day, but the MD changed the order, and stated that it is a routine medication. However, staff all med-tech staff confirmed that R3 was not being given the right dosages, for example a medication of 75 mg (30 min) before breakfast, was being given as 25 mg 3 times a day. Resident (R3's) was supposed to be administered 3 pills of Seroquel at 8 AM and 3 pills at 8 PM, but the Director instructed med-techs to dispense it at 2 AM, 8 AM, 2 PM, and 2 pills at bedtime. According to interviews, the Memory Care Director changed the dosage frequency for multiple residents. Resident (R2's) family member stated that they received a phone call from staff notifying them that Seroquel 25 mg medication ran out, which meant that staff were administering the medication incorrectly and too much. R2 was supposed to be administered Seroquel 25 mg in the AM and 100 mg at bedtime, but they were dispensing Seroquel 25 mg in the AM, 25 mg at noon, and 100 mg at bedtime. Per record review of non-electronic Medication Administration Records (MARs), the findings revealed that staff did not document on MAR records that they were dispensing extra dosages to multiple residents and concealed that multiple residents were being improperly medicated, putting the residents at risk for serious mental and/or physical complications. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited. See LIC 9099D. Exit interview was conducted and a copy of the report and appeal rights was issued. 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 are not providing adequate supervision to residents. The complaint alleges that on November 3, 2023, resident (R1) who resides in the Memory Care Unit left the dining room /activity area after breakfast time and returned to their room to take a nap. It is alleged that the two (2) caregiver staff on duty on 11/3/2023, were sitting in the dining room with other Memory Care residents and failed to check on residents that were in their rooms. At approximately 10:40 AM housekeeper staff (S11) found R1 on the floor of the common shower room. Resident (R1) reported feeling pain in their hip, head, and back. The resident was transported to the hospital where the resident underwent hip surgery because of the injuries sustained after falling. Per resident (R1’s) Needs and Services Plan the resident wanders, is at risk of falling, and requires supervision and assistance when ambulating. Staff are to provide verbal reminders to R1 that they need to use a walker. A total of 11 staff were interviewed. Staff admitted resident (R1’s) injuries occurred because there was a lack of supervision due to staffing shortages i.e., only 2 caregivers in the Memory Care unit because the med-tech/caregiver sometimes must go to the Transitional Memory Care Unit to assist. As a result, many of the residents that are sleeping in their rooms are not always checked every 2 hours per protocols. According to interviews conducted the Memory Care Unit morning shift typically has three (3) staff on the floor, 2 caregiver staff and 1 med-tech staff. Family members interviewed stated they have knowledge that there have been many unwitnessed fall incidents in the Memory Care Unit, and unwitnessed resident to resident aggressive behaviors resulting in injuries. It was also reported that resident (R2) had a private caregiver, and as a result facility staff did not check on the resident as required. In addition, resident (R3) fell during the night shift and was admitted to a hospital with a brain bleed. Memory Care Director stated that caregiver staff are supposed to check on residents every 2 hours. However, the findings indicate that resident (R1) returned to their room after breakfast time at approximately 8:00 AM, and the resident was found injured on the restroom floor until approximately 10:40 AM, which indicates caregiver staff failed to provide adequate care and supervision. Three (3) family members were interviewed, all stated there is not enough supervision of residents. Based on review of records and interviews, there is sufficient evidence to corroborate the allegation. ***Narrative continues next page. 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 yell at residents. The concerns pertain to the Memory Care Unit staff. It was reported that two (2) Memory Care Unit caregiver staff yell at residents and speak loudly to them, which at times causes residents to get upset and/or have behaviors. According to information obtained, caregiver staff (S5) speaks in an impolite and teasing manner towards cognitively impaired residents. It was also reported that staff (S4) speaks to residents in a very loud voice. It was reported that a resident asked for help and staff mocked the resident in front of everyone in the dining room area. It is alleged that Memory caregiver staff (S5) has been heard speaking in an abnormally loud and aggressive tone of voice to residents. Staff (S4) denied the allegation, and stated that they speak to the residents loudly due to hearing issues. Staff (S5) denied the allegation, yelling across the hallway at residents, and stated that they speak to them in a loud tone because many residents are hard of hearing. According to both staff identified as yelling at residents, they both have high deeper voices that may come across as aggressive. However, a total of 11 staff were interviewed, eight (8) staff confirmed the allegation by stating that staff (S5) talks to residents in an impatient, abrupt tone of voice, rude, inappropriate manner, easily gets irritated by resident's requests, has a bad attitude with the residents, and says "you're crazy" to the Memory Care residents. The findings indicate that the Memory Care Director has addressed staff (S5's) conduct, but their was no disciplinary action, therefore, the behavior continued until recently when Community Care Licensing began investigating the complaint. Allegation: Staff do not treat residents with respect. It was reported that Memory Care staff sometimes speak to the residents in a disrespectful manner and laugh at residents because staff know that due to their cognitive impairment they cannot discern that they are being made fun of. Information gathered revealed that one resident carries their pillow around and staff laugh, some caregivers ask residents for massages for fun, some staff fail to refer to the residents in a culturally appropriate manner i.e., using "San" after addressing them by their first name; instead address the residents by saying "mama or papa". The findings indicate staff (S5) often verbally provokes residents, has been observed sitting in resident walkers, and inappropriately handling/lifting/pulling up a resident while toileting in the bathroom. Staff (S5) pulled the back of the resident's shirt to lift the resident, which is not an appropriate way of handling an elderly non-ambulatory resident. Seven (7) out of 11 staff acknowledged they have observed or heard other staff address and treat the residents in a disrespectful manner. Video and two (2) pictures were obtained, one depicted staff (S10) sitting on a resident's walker being given a upper back massage by a resident, and another picture depicted a resident eating a meal with a cloth napkin on their face, while the resident was holding a cup of juice. The video sound captured staff laughing. 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

During interviews with the residents, one (1) out of ten (10) residents interviewed stated that they have been uncomfortable by the homeless at the facility. This resident stated that about a week ago a homeless individual began came from the ICF building area of the facility and began following the resident, who then proceeded to retreat into the main lobby of the facility due to being uncomfortable. One (1) other resident stated that they have witnessed homeless people staying in the ICF building, however they also indicated that they have not come to the main building on the facility campus. During interviews with the staff, all indicated that homeless have been entering the abandoned ICF building by cutting through the fencing. One staff stated that the ICF building is abandoned and therefore no longer part of the facility campus, however it is true that homeless people have been coming into the campus through fencing next to the ICF building as well as along the back lot of the facility which is connected to the Santa Ana 101 Freeway. This staff further explained that the fencing along the highway belongs to Caltrans, and that they routinely fix the fencing however the homeless continue to cut new holes through the fences. Another staff interviewed stated that they call police whenever a homeless is spotted on the campus, and that they have been advised by other staff to not confront the homeless alone because they may potentially have weapons on them. During the physical plant walk through, LPA observed that there were multiple holes cut into the fencing along the ICF building, as well the fencing along the 101 freeway through which homeless have been coming into the facility campus. LPA also observed that there were rooms along the basement of the facility that had been broken into by the vagrants to use as rooms to sleep in, and found mattresses inside these rooms as well. LPA also observed that there were shards of broken glass along the floor of the main campus of the facility next to the ICF building, which were part of the windows of the ICF building that the vagrants have broken while squatting in the building. The building has graffiti on several walls and broken windows which LPA took a picture of. Additionally, according to the facility sketch obtained by the administrator, the ICF building is still listed as one of the buildings of the facility. In regards to the allegation that the "Facility is in disrepair," it is alleged that the homeless individuals who have been entering the facility have been stealing the copper wiring from the ICF building as well as from the main back up power generator from the facility as well, as wall as the phone and fax lines which has caused some of the resident phones to not work. During interviews with the residents, two (2) out of ten (10) residents confirmed that their phones were not operational. During interviews with the staff, four (4) out of four (4) corroborated the allegation that the wiring in the facility has been tampered with. 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 One resident interviewed stated that the phone in her room has not been working for one (1) to two (2) weeks and that it has been very annoying for them. One staff explained that the homeless individuals who have been entering the facility have been stealing the copper wiring from the abandoned ICF building as well as other materials from the building to sell for money. Another staff stated that they have tampered with the AT&T phone box, which has caused disruptions to the phone service for several residents as well as the fax lines for the facility. During the physical plant walk through, LPA observed that the backup power generator the facility has been completely stripped of most of its components, and is therefore not operational at the moment. It has additionally been proven that the fax lines of the facility have not worked for a period of time. Based on LPAs interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegation, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC9099D. Exit interview held and a copy of the report and appeal rights were provided.

Licensing Program Analyst (LPA) Galarza generated this Case Management - Deficiencies report in conjunction with complaint control #28-AS-20231120121606 pertaining to observations made during the physical plant inspection of the Memory Care Unit. The purpose of the report was explained to Memory Care Director Rodora Merana. All resident bedrooms in the Memory Care Unit have surveillance cameras installed in a wall corner of each room. The cameras have wiring that connects to electrical outlets. LPA spoke with Rodora Merana and she stated that the cameras were donated, but it was determined to be non-compliant with Title 22 regulations. However, maintenance staff have not removed the cameras from the resident rooms. No Exception Waiver has been submitted to the department. Per Title 22, residents shall be afforded privacy. Based on observation, a citation is being issued. See LIC 809D. An exit interview was conducted and a copy of the report and appeal rights were issued.

Allegation: Staff interfere with resident's sleep. It was reported that NOC shift staff wake up Memory Care residents between the hours of 4:30 AM - 5:00 AM in order to get them ready for breakfast and before the AM shift starts. A total of eight (8) staff were interviewed, of which five (5) out of eight (8) staff stated that the NOC shift staff wake up the residents between 4:30 AM - 5:00 AM, and start changing the residents in order to get them ready for breakfast meal time. After they are changed they are taken to the activity room at 6:00 AM. Their breakfast time is 6:30 AM. According to Memory Care Director, some Memory Care unit residents are already awake at that time. However, the majority of the staff interviewed stated that they feel the residents are awakened too early, and the primary reason for the protocol is to have the residents ready before the AM shift begins at (6:00 AM). Staff reported that sometimes residents are sleepy and fall asleep in the activity room tables. Therefore, the resident's sleep is being affected. Family interviews revealed that they did not have knowledge of the resident wake-up time and also reported that the resident are put to bed early in the evening, usually by 7:00 PM. Former Administrator Daniel Konishi was not interviewed. Assisted Living residents have Personal Rights that state they are to be free from....actions of a punitive nature, such as... interfering with daily living functions such as eating, sleeping, or elimination. Allegation: Staff do not properly store residents' personal hygiene care items. It is alleged that resident's hygiene box and toothbrushes are stored in the laundry room/cleaning tools storage room. A total of eight (8) staff were interviewed. All confirmed the allegation. They stated the hygiene products have been stored there for a long time because the Memory Care unit does not have enough storage areas. They stated that the laundry room is cleaned every 2 months. On 11/28/2023, LPA observed the storage room and confirmed the allegation. Toothbrushes and incontinence supplies were stored uncovered and the room contained cleaning supplies, dirty laundry, and had dirty floors. Pictures were taken. Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED . Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D. An exit interview was conducted with Memory Care Director Rodora Merana.A copy of the report and appeal rights were issued. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff do not provide residents with a reasonable amount of time to consume meals. It is alleged that Memory Care staff rush the residents during mealtimes and are often heard asking the residents "Are you done" in an impatient manner. Additionally, it was reported that staff do not always provide feeding assistance to residents and say that the residents did not want to eat and put the food back in the tray for removal. Three (3) out of eight (8) staff stated they do rush residents because the dining room staff want the meal trays by a certain time. One (1) staff stated that staff rush the residents and purposely feed the residents large spoonful’s so they can finish their meals faster. LPA observed several mealtimes and did not observe staff rushing the residents. Based on staff interviews, there is insufficient evidence to corroborate the allegation. Allegation: Licensee does not ensure facility administrator has an active administrator certificate . It is alleged that the Memory Care Director does not have an Administrator's certificate but is saying that they are an Administrator. It was also reported that Administrator Daniel Konishi delegates all Memory Care responsibilities to the Director and is not in charge of the facility. Based on record review, the findings indicate that the Memory Care Director does not have an Administrator Certificate. However, Executive Director Daniel Konishi has an active Administrator Certificate that expires 04/28/24. Note: Executive Director Daniel Konishi last day of employment at the facility was January 31, 2024. According to Title 22 Reporting Requirements 87211(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator.... Based upon record review and interviews conducted the findings indicate that, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted with Memory Care Director Rodora Merana. A copy of the report was issued.

After the fall R1 obtained rehabilitation at an outside facility and returned to the transitional memory care in November of 2023. R1 had two falls one on 1/15 and one on 1/24/24. Document review revealed the following: Physician’s report dated 9/6/23 notes R1 is ambulatory. Resident assessment dated 12/4/23 notes special concern – care level description fall concern. Needs and Services Plan dated 11/21/23 notes “resident will ambulate with walker”, however it does not note that the resident is at risk of falls. Incident report dated 2/2/24 to report incident on 1/15/24 notes R1 “glided on the floor hitting the knees” and does not note information on action taken or planned to prevent future falls. Incident report dated 2/2/24 to report incident on 1/24/24 notes care staff found R1 siting on the floor and was picked up. No action taken or follow ups are noted. Hospice plan of care dated 2/7/24 notes R1 has had repeated falls. Hospice plan was created on 12/13/23. One of the goals created was to prevent falls and minimize injury. Facility staff failed to follow Hospice care plan to prevent falls and to update or provide a plan of care to be followed by staff to prevent falls for R1. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . Regarding allegation: Staff did not follow protocol regarding resident falling and Facility staff did not report resident's fall to the proper agencies. It is alleged staff did not follow protocol of assessing the resident, calling hospice, and picked up resident and staff decided not to report the fall to reporting parties. Interviews with residents revealed 6 out of 8 residents stated staff are helpful and will call 911 for them in case of a fall. 2 out of residents were unable to be interviewed due to cognitive skills. Interviews with staff revealed that staff are to evaluate the resident, notify supervisor, call 911 or hospice services, notify family, and notify community care licensing (CCLD)/ Local Ombudsman (LTCO). Per Memory Care Director, for residents under hospice they are to call hospice agency and speak with a nurse who will provide instructions for care of a resident that has fallen. Interview with hospice agency revealed that facility did not notify them of the falls R1 had on 1/15/24 and 1/24/24 and only came to know of the incidents through a third party during the visits. Incident occurred on 1/15/24 does not note any action taken by the facility. Incident occurred on 1/24/24 notes “sitter said not to call 911 and was assisted to get up”. Incident reports for incidents occurred on 1/15/24 and 1/24/24 were submitted to the department on 2/2/24. Facility failed to follow their own protocol to call hospice services for R1 and obtain instructions of care for R1 and facility failed to report to CCLD within 7 days. (CONTINUED ON LIC 9099C) 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 and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . Regarding allegation: Staff administered resident medications not on medication list. It is alleged facility med tech provided medication to R1 that has not been prescribed. Interviews conducted revealed 6 out of 8 residents interviewed either managed their own medication or had no issues with medication provided. 2 out of 8 residents were unable to be interviewed due to cognitive skills. Interviews with staff revealed only Med-Techs provide medication to residents and before providing medication staff review the medication sheet and ensure they are providing the correct medication before giving it to the resident. Documents review revealed Facility’s medication administrator record for January 2024 notes R1 was provided acetaminophen 500mg, noted on a posted note dated 1/24/24 attached to medication administration record which notes “give R1 acetaminophen 500, 1 table at 10:25am” with staff initials. R1 hospice current treatment/medication/DME list does not list Tylenol 500 mg as a prescribed medication for pain between 12/13/23 – 1/26/24. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Tomoko Hino and a copy of this report, LIC 9099D, and appeal rights were provided.

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Daniel Konishi (Executive Director), the reason for the visit was explained upon arrival. There are currently (131) residents in the facility. The facility is licensed to serve 177 non-ambulatory elderly residents ages 60 and over. There is a hospice waiver for 10 residents, and 23 of the 177 to reside in the memory care wing of the facility. The facility consists of two separate buildings: Retirement building is a 5 story building that consists of 127 units each with private restroom, lobby area, administrative offices, public restrooms, library, TV Room, Activity room, laundry room, Health & Wellness room, commercial kitchen and dining room. Memory Care Wing consists of 13 rooms, 5 restrooms, gated courtyard, activity room/ dining room, lobby, laundry room, medication room and administrative office. LPA attempted to utilize the Compliance and Regulatory Enforcement (CARE) tools for the visit today, however, due to a system glitch LPA was unable to utilize Care Tools, during todays visit LPA and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Physical Plant & Environment Safety: There are a total of 127 rooms in the retirement building which each have room has its own restroom and 13 rooms in the memory care wing each with 6 shared restrooms. LPA toured the common areas, 14 resident rooms, kitchen, dining area, public restrooms and outside areas. All rooms that were inspected have private restrooms. Resident bedrooms had the required furniture for (Continued on 809-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 comfort and safety and had sufficient lighting. All indoor and outdoor passages were free of obstruction. Private resident bathrooms in rooms were inspected. Restrooms were clean, toilets and water faucets worked properly and were properly supplied. Water temperature was measured in a total of 14 resident rooms and temperatures ranged from 124.3 - 145.8 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately available. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in the basement and are inaccessible to clients. The last Fire/Emergency Drill was conducted on 06/9/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguishers located on each floor and were observed to be fully charged. Koi Ponds at facility are surrounded by a metal gate. Operational Requirements: There is an outdoor activity area that is shaded and furnished for outdoor use, indoor activity room and movie room. Staffing : There appears to be sufficient staffing at all times in the facility. Executive Director Daniel T. Konishi administrator certificate expires on 4/28/2024. Personnel Records-Training : Staff has criminal record clearance and current CPR/first aid training, also have sufficient on-going training. Resident Rights-Information: The facility provides internet and telephone access for the residents in care. Resident Records-Incident Reports: Resident files are kept in a secured location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in medication carts and are in their original containers. During the visit today, LPA observed there to be an unlocked/unmonitored medication cart on the 2 nd floor. LPA reviewed 12 residents’ medications no issues were observed. Incidental Medical & Dental: All medications for residents are stored in a locked medication cart on the 2 nd floor where the med room is. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. (continued on 809-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA conducted 5 staff interviews and 5 resident interviews during today’s visit. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on 809D. Exit interview was held, a copy of the report and appeal rights were provided to Executive Director Daniel Konishi .