Henrietta's Leven Oaks.

During today's visit the investigation revealed the following: in regard to the allegation, “Staff neglect resulted in resident sustaining a fracture.” It is alleged that on 12/01/2025, R1 fell out of bed and sustained a broken right hip. This allegation was investigated by the Investigation Bureau (IB) and was assigned to Investigator Salant. LPA reviewed IB interviews which revealed the following: There is not enough evidence to suggest that the staff members were neglectful or demonstrated lack of care and supervision resulting in R1 falling out of bed. At the time R1 fell out of R1’s bed, there were no specific doctors' orders on file recommending that R1 have a bed with rails or any type of specialized supervision. R1 was known and allowed to ambulate on and off R1’s bed on R1’s own, prior to R1’s fall without assistance. There is not enough sufficient evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations 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 was held and a copy of this report was provided to the Administrator, Claudia Sanchez.

Special Incident Report (SIR) and Record of Resident's Safeguard Cash Resources were submitted. Case Manager for Resident R1 was interviewed telephonically. In regards to the allegations Staff is hitting a client, Staff yells at a client, and Staff pulls on a client's hair based on interviews conducted and information gathered R1 stated that staff are great and they like her. Also stated staff are honorable and trustworthy and have not hit, yelled or pulled her hair. Interview with Case Manager who stated that none of the allegations happened. Stated the Administrator is good with the residents and that R1 has multiple scenarios in her head and vocalizes it and it is not true. Staff S1 and Staff S2 both stated that the allegations are untrue and there is always another staff with the Administrator when interacting with R1. R1-R6 all stated that the allegations didn't happen and that staff are professional. 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. In regards to the allegation Staff is mishandling a client's personal funds, based on interviews conducted and information gathered R1 stated that the Administrator manages her money and that staff are trustworthy. Always gets P and I each month, but not sure of the amount. Interviews were conducted today 2/24/2026 with Resident's R2, R3, R5 and R6 who all stated that the facility has never mishandled their finances. Stated it has always gone smoothly and there has never been a problem. Resident R4 no longer resides at the facility as of 2/3/2026. Case Manager stated that they are working with R1 so she doesn't give away her money and not spend it not knowing where it is going. Said there is always additional staff with the Administrator when money is dispersed. Staff S1-S2 both stated that they have both been witnesses when R1 is receiving money from the Administrator. Said that R1 lends money and forgets. At store she will want to buy too much. She has lent money to another resident and say it is missing having forgotten. Administrator stated that there is a P and I Log here. Said R1 would say money is missing. Stated that with the Case Manager it was decided that R1 will let her know she needs money and she will give to her because she has misplaced before. They make her bring back receipts to track it. Also stated that R1 has a memory issue so they safeguard her money. 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. 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's R2- R6 stated they had never heard of anyone being threatened with eviction. Staff S1-S2 stated that R1 works with her Case Manager on relocating and there is no eviction from the facility. 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. In regards to the allegation Staff mishandled a client's personal belongings, based on interviews conducted and information gathered R1 stated that another resident gave her jewelry and she didn't want to be accused of stealing so she gave it to the Administrator. Resident's 2-6 all stated that they have never had staff mishandle their personal belongings. Nothing has been stolen or missing. Staff S1-S2 stated that no belongings have been mishandled and anything missing from a resident it has been located and given back. Administrator stated that a former resident gave her belongings to R1 and she had told R1 she was holding it until the family says it is ok to give away. 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.

Also stated staff are honorable and trustworthy and have not hit, yelled or pulled her hair. Interview with Case Manager who stated that none of the allegations happened. Stated the Administrator is good with the residents and that R1 has multiple scenarios in her head and vocalizes it and it is not true. Staff S1 and Staff S2 both stated that the allegations are untrue and there is always another staff with the Administrator when interacting with R1. R1-R6 all stated that the allegations didn't happen and that staff are professional. 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. In regards to the allegation Staff is mishandling a client's personal funds, based on interviews conducted and information gathered R1 stated that the Administrator manages her money and that staff are trustworthy. Always gets P and I each month, but not sure of the amount. Case Manager stated that they are working with R1 so she doesn't give away her money and not spend it not knowing where it is going. Said there is always additional staff with the Administrator when money is dispersed. Staff S1-S2 both stated that they have both been witnesses when R1 is receiving money from the Administrator. Said that R1 lends money and forgets. At store she will want to buy too much. She has lent money to another resident and say it is missing having forgotten. Administrator stated that there is a P and I Log here. Said R1 would say money is missing. Stated that with the Case Manager it was decided that R1 will let her know she needs money and she will give to her because she has misplaced before. They make her bring back receipts to track it. Also stated that R1 has a memory issue so they safeguard her money. 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. In regards to the allegation Staff unlawfully evicted a client, based on interviews conducted and information gathered R1 stated that the Administrator is not asking her to leave. Said she has told her Case Manager she wants to move out to be with a friend. Case Manager stated that they are working on relocation. Said that there was a meeting regarding relocating and R1, Case manager and Administrator attended the meeting. Stated it is not true about eviction. Administrator stated that R1 is not being evicted and her Case Manager would be the one to relocate her. 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's R2- R6 stated they had never heard of anyone being threatened with eviction. Staff S1-S2 stated that R1 works with her Case Manager on relocating and there is no eviction from the facility. 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. In regards to the allegation Staff mishandled a client's personal belongings, based on interviews conducted and information gathered R1 stated that another resident gave her jewelry and she didn't want to be accused of stealing so she gave it to the Administrator. Resident's 2-6 all stated that they have never had staff mishandle their personal belongings. Nothing has been stolen or missing. Staff S1-S2 stated that no belongings have been mishandled and anything missing from a resident it has been located and given back. Administrator stated that a former resident gave her belongings to R1 and she had told R1 she was holding it until the family says it is ok to give away. 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.

Allegation: “Staff threw away resident’s personal belongings.” It is alleged that on 11/28/2024, R1 moved in from a different facility and that staff discarded R1’s belongings, including important documents, due to claims of rat droppings. Interviews conducted with the Administrator and (4) staff members denied the allegation. All staff stated that they would never throw away any residents personal belongings without the residents' permission. Staff interviewed also stated that in-service training regarding Safeguarding Personal belongings, Personal Rights, Residents Rights and Zero Tolerance Policy are being conducted to staff members regularly. All staff interviewed stated that there have been no complaints about the disposal of personal belongings have been reported by residents. . Administrator stated that when R1 moved in on 11/28/2024, R1 had many personal items and was asked to consolidate her items due to insufficient space in her room. Administrator stated that R1 sorted out the belongings in the presence of (2) Social workers and another staff member. Administrator stated that R1 gave her consent to discard some items, which W1 confirmed. W1 also indicated that R1 was prepped about the need to downsize before her move to the facility. A total of (7) residents were interviewed, (6) out of (7) residents interviewed indicated that they do not have any issues with their personal belongings being thrown away by staff members. (6) interviewed residents indicated that the facility staff respect their belongings and have never disposed of any of their belongings. Therefore there was insufficient evidence to corroborate with this allegation. Allegation: “Staff are not treating resident with respect.” It is alleged that R1 f eels discriminated against by a staff member and continues to feel " uncomfortable and unsafe" at facility and suffers mental distress. Administrator and (4) staff members interviewed stated that they have never heard of or witnessed any staff discriminate against or treat residents unfairly. Administrator mentioned that the facility has a zero tolerance policy regarding such behavior and that personal rights training is being regularly conducted for staff members. Administrator stated that R1 never expressed any issues to her when she interacts with R1. (4) of (4) staff members interviewed stated that they treat residents with dignity and respect. (6) out of (7) residents that were interviewed indicated that staff members treated them with dignity and respect. (6) residents stated that they have good relationships with staff members here and they feel safe and comfortable. Therefore, there was not enough supportive evidence to corroborate the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Claudia Sanchez, Interim Administrator.

The investigation revealed the following: In regards to the allegation: “Facility staff handled resident in a rough manner.” It is alleged that on Wednesday 3/19/25 between 4:30pm and 5pm, a staff "threw R1 on the bed" during a change. It is also alleged that this was not the first time a staff handled R1 in a rough manner. No other details provided including staff names or descriptions. All staff interviewed denied the allegation. LPA interviewed (3) staff members who were scheduled to work during the specified time frame and denied ever treating any resident, including R1, in a rough manner. Interviewed staff stated that throwing a resident onto a bed during care would be considered abuse and emphasized that all residents are treated with dignity and respect. Interviewed staff also stated they receive regular training on residents' rights and abuse prevention, and they have not heard any complaints about rough treatment. S1 indicated that on 03/21/2025, Monrovia PD came to investigate and determined that no further action was necessary. (5) out of (6) residents interviewed stated they are treated well and have no issues or concerns. Interviewed residents stated they have never been touched roughly. LPA’s observations of staff-resident interactions showed no concerns, and no visible bruises were seen on any residents interviewed, including R1. Therefore, there was not enough evidence to support the allegation. In regards to the allegation: “Facility staff did not ensure wheelchair was accessible to resident.” It is alleged that a staff placed R1’s wheelchair "far away from his bed" which caused R1 to fall when he attempted to get out of bed and into his wheelchair. No injuries reported or other details provided including staff names or descriptions. All staff interviewed denied the allegation and stated they always position wheelchairs close to the residents’ beds. Interviewed staff stated they place wheelchairs on the side of their beds to allow safe transfers for residents and ensure they are easily accessible to prevent falls during transfers from bed to wheelchair. Staff also indicated that they receive training on safe transfer techniques and how to assist residents with transfers. (3) out of (6) residents interviewed are wheelchair bound and they denied the allegation. Some residents interviewed stated that their wheelchairs are kept close to their beds for easy access and within a comfortable reach. Additionally, some residents stated that staff always assist them in transferring from bed to wheelchair. Therefore, there was not enough evidence to support the allegation. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 In regards to the allegation: “Facility staff covered resident's mouth with their hand.” It is alleged that a staff covered R1’s mouth with their hand so that R1 could not breathe. No specific details about the staff member were given, and no injuries were reported. Interviewed staff members denied the allegation, stating they have never covered R1’s or any other residents’ mouth with their hands. Interviewed staff stated that doing so is considered abuse or neglect. Some staff stated they would report such actions to the Administrator immediately if they witnessed them. Staff indicated that covering a resident’s mouth could be dangerous and could lead to choking. (5) out (6) residents interviewed denied the allegation and stated that staff have never placed their hands over their mouths and have not witnessed any staff doing this to other residents. Some residents stated that they feel safe and comfortable in the facility. Therefore, there was not enough evidence to support the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Claudia Sanchez, Interim Administrator.

Interviews conducted with residents revealed staff are assisting residents with ADLs and changing them as needed. Interviews conducted with staff revealed caregivers assist residents with bathroom reminders and changing residents with incontinence at least every two hours or as needed. Per administrator, residents are change every two hours. Staff have been provided training prior to employment and have provided in-service training regarding hygiene practices. Administrator added that they will be implementing a protocol to ensure that there are records regarding care provided to resident #1 (R1). Per document review R1 does require assistance with all ADLs, including toileting. On 1/16/25 Staff In-Service Training was provided on Proper Hygiene Practices. 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 . Exit interview was conducted with Madelene Sanchez and a copy of this report was provided.

Per staff, R1 also has bowel movements a few times a day and use baby wipes to clean the bottom. Staff do not know about the stool being stuck to the resident’s bottom as it had never been seen. R1 also had not reported or shown any discomfort during changes. Per the med tech, there were no reports of R1 having stuck feces on any doctor’s visits. All the residents interviewed feel that the staff meet their needs and change them when needed. They also feel that they do a good job cleaning them. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was held. A copy of this report along with the appeal rights was provided to the Assistant Administrator.

Allegation: Staff did not provide adequate food service to resident . It has been alleged that this facility provides food that R-1 cannot eat (not provided with vegetarian options) and that the food portions served are not enough. Staff interviews revealed that staff provide adequate food service (including vegetarian options and food portions) to residents. Interviewed staff indicated that the kitchen has food items that accommodate residents with vegetarian requests. LPA conducted a tour of the kitchen. LPA observed the kitchen to be stocked with vegetarian options such as vegetarian egg rolls, vegetarian lentils, Indian food, cauliflower rice, Pad Thai vegetarian noodles and fresh vegetables (carrots, cabbage, celery, asparagus, broccoli). Resident interviews revealed that the facility provides adequate food service. Interviewed residents indicated that they are provided with adequate food servings and are given the option to substitute food items (upon request). Interviewed residents did not have any concerns pertaining to this matter. Interviews do not corroborate this allegation. Allegation: Staff ignored resident's request for assistance It has been alleged that when R-1 asks for coffee, R-1 has to keep asking staff and is being ignored. Staff interviews revealed that staff do not ignore resident requests (including R-1). Interviewed staff indicated they provide residents with assistance in a timely manner. Resident interviews revealed that staff do not ignore residents’ requests. Interviewed residents indicated staff provide residents with assistance in a timely manner. Interviewed residents did not have any concerns pertaining to this matter. Interviews do not corroborate this allegation. Although the allegations 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 allegations are UNSUBSTANTIATED. Exit interview, appeal rights and a copy of this report was provided to Claudia Sanchez. NOTE: LPA was experiencing technical difficulties during this visit.

Staff stated they were being careful while providing care and dressing residents. Staff had in-service training on providing care the residents. Per LPA’s observation, residents looked happy during the physical plant. Thus, the facility did not mistreat resident while in care. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with staff#2. The findings were discussed. A copy this report was provided at time of visit.

they assess that the resident is not compatible and not a good fit. Said they avoid eviction and ensure the resident is relocated to a safe environment. Interview with Interim Administrator who stated that Resident R 1 has never faced eviction. Stated that there is an internal relocation that is done by Department of Health Services. Also stated that any special incident reports are sent to Department of Health Services. LPA reviewed e-mail exchange between Administrator and Department of Health Services Representative who communicated to family member of R 1 that she can relocate R1 or take home. Review of R1's file shows that R1 does not have a POA or Conservator. It should also be noted that R1 is still currently residing at this facility. Interviews with 6 of 6 resident's who all stated they had not seen or heard of anyone being evicted and all stated staff all act professionally. 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. In regards to the allegation Staff retaliating against the RP for filing a complaint with CCLD, based on interviews conducted and information gathered it was revealed by Department of Health Services Representative (Placement Agency) Program Manager that they have worked closely with the facility and find no reason to corroborate the allegation. Stated they never heard of anyone complain that the facility was threatening anyone who complained as a retaliation tactic. Interview conducted with Interim Administrator who stated the last complaint in November was Unsubstantiated and R 1 was not being evicted as retaliation because it was an internal relocation by Department of Health Services. Interview with 6 of 6 residents who all stated that staff do not engage in wrong doing and that they are professional and work really well with the residents. All 6 have not heard of any retaliation if someone complained to CCLD. R 1 stated that employees had done no wrong doing to her or retaliated against her. It should be noted that R 1 still currently resides at the facility. 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.

The investigation revealed the following: Allegation: Facility staff did not prevent a resident from being harmed by another resident in care. It is alleged that on 1/2/24 R1 and R2 had an altercation in which staff not prevent. R2 had allegedly spilled coffee on R1. During interview with R1, resident stated that when leaving dining in passing R2 threw coffee and a tray of food on them for no apparent reason. R1 further stated that staff arrived as soon as it happened separated the two and asked R1 if they were injured during incident, in which there were none, authorities were called, no charges were filed and there have been no further incidents between the two parties since then. LPA interviewed staff and 5 out of 5 staff denied the above allegation and stated that when there is an altercation they intervene, separate residents, allow time for them to calm down and then management will speak to each resident individually to provide the best care that is needed. 5 out of 5 staff stated that they are aware that R1 and R2 have a history and try their best efforts to keep them separate and keep a close eye on them when they are within the same area. Interview with S1, staff stated that they have offered residents to switch rooms as they both reside on the same floor and to prevent residents from passing by one another, a switch of room has been offered, however, neither resident want to switch rooms. S1 further stated that R1 and R2 have had exchange of words in the past but it had never turned physical until now, authorities were called, a police report was taken, there have not been any further incidents since, and both residents are encouraged to keep distance from each other. LPA interviewed 5 residents and 5 out of 5 residents state they feel staff responds as quick as possible when there is an argument or altercation, although, at times it happens too fast for staff to arrive right away they feel staff does their best. During interview with R1, resident stated they do not want to switch rooms, Interview with R2 stated the same, both parties stated that there were no injuries during altercation, and that there have been no other incidents. R1 & R2 stated that they avoid each other and keep distance between one another and know that this is the best way to avoid future altercations. Both R1 and R2 stated that staff have been helpful in keeping both parties separate. LPA toured dining during visit and observed R1 finishing their food in the outside patio and R2 was in the office. Dining area appears large enough to be able to create a good distance between the two parties if both parties wish to eat in the dining area. There are least 2 staff monitoring dining during meal time. Based on statements and interviews conducted with staff and residents, review of resident files and incident report, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided to Claudia Sanchez.

The investigation revealed the following: Allegation: Staff do not ensure resident rooms are kept clean. It is alleged that staff do not clean, take out trash or make beds for residents. LPA toured facility a total of 8 resident rooms were checked, beds in each room were observed to be made and rooms appeared to be clean and trash was emptied. LPA interviewed 6 staff and 5 out of 6 staff stated that rooms are maintained daily, trash is thrown out and beds are made, with a deep cleaning that includes mopping, scrubbing and dusting 2 times a week or as needed. LPA interviewed 5 residents and 5 out of 5 residents denied the above allegation and stated their rooms are cleaned daily, deep cleaning is done 2-3 times a week and trash is emptied daily. Allegation: Staff do not have appropriate training. It is alleged that the cook and/or janitor are assisting with medication administration and do not have proper training to do so. LPA reviewed 4 staff files that assist with medication and each file had the required medication administration training was documented in their personnel files. LPA interviewed 6 staff and 2 of 6 staff stated they administer medication and are trained, LPA reviewed their files and training was documented. LPA interviewed 5 residents and 5 out of 5 residents stated that the staff that administers medication is the same staff daily and have never been given medicine by a cook/janitor.(LPA reviewed files of staff mentioned, each had proper training documented) Based on statements and interviews conducted with staff and residents, review of staff files and in-service training records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided to Sasha Sanchez.

Staff stated they were not allowed to tie residents to a chair and restrained resident was against Title 22 regulation. Per LPA’s observation, no residents were tied to their chairs during the physical plant. Thus, the facility did not restrain resident while in care. In regards of facility staff do not ensure residents are appropriately clothed, it was alleged that residents were being left under dressed under cold temperatures. LPA interviewed residents, five (5) out of five (5) residents interviewed could not corroborate the allegation. Residents revealed staff clothed them appropriately and kept them warm. All four (4) staff interviewed denied the allegation. Staff stated caregivers would dress residents in layers accordingly and check residents if they were warm. Per LPA’s observation, residents were dressed in layers with sweaters, hats, socks, and gloves. Therefore, the residents were dressed appropriately to keep them warm. In regards of facility staff are not properly dispensing medication as prescribed, it was alleged that medication was not administered to residents on time. LPA interviewed residents, five (5) out of five (5) residents interviewed could not corroborate the allegation. Residents stated staff administered their medication as prescribed and dispensed medication to them every morning, afternoon and bedtimes depending on their needs. All four (4) staff interviewed denied the allegation. Staff stated Med techs administered medication according to residents’ medication record and doctors’ orders. Per record reviews, residents’ medications were administered as prescribed, and medication matched with records with no discrepancy. Therefore, facility staff dispensed medication as prescribed. In regards of facility staff do not intervene when residents engage in physical altercations, it was alleged that some residents would get into agreements and act aggressively towards others, but staff did not intervene. LPA interviewed residents, five (5) out of five (5) residents interviewed could not corroborate the allegation. Residents stated staff would intervene and separate the residents if residents got agitated or act aggressively toward others. All four (4) staff interviewed denied the allegation. Staff stated staff were trained to handle residents with aggressive behavior and residents with dementia. Staff would intervene, separate and re-direct residents to do other activities. Per record reviews, staff had in-service training on handling aggressive residents and residents with dementia. Per observation, the residents were peace and calm. Therefore, there was not preponderance evident to show staff does not intervene when residents were being aggressive towards others or engaged in physical altercation. (-continued in 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 the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with interim administrator, Claudia Sanchez. The findings were discussed. A copy this report was provided to Claudia at time of visit.

The investigation revealed the following: Allegation: Facility staff did not prevent a resident from being harmed by another resident in care. It is alleged that on 1/2/24 R1 and R2 had an altercation in which staff not prevent. R2 had allegedly spilled coffee on R1. LPA interviewed staff and 5 out of 5 staff denied the above allegation and stated that when there is an altercation they intervene and separate residents, allow time for them to calm down and then management will speak to each resident individually to provide the best care that is needed, if any. 5 out of 5 staff stated that they are aware that R1 and R2 have a history and try their best efforts to keep them separate and keep a close eye on them when they are within the same area. Interview with S1, staff stated that they have offered residents to switch rooms as they both reside on the same floor and to prevent residents from passing by one another a switch of room has been offered, however, neither resident want to switch rooms. S1 further stated that R1 and R2 have had exchange of words in the past but it had never turned physical until now, authorities were called, a police report was taken, and there have not been any further incidents since. LPA interviewed 5 residents and 5 out of 5 residents state they feel staff responds as quick as possible when there is an argument or altercation, although, at times it happens too fast for staff to arrive right away they feel staff does their best with response time. Interview with R1, resident stated they do not want to switch rooms, Interview with R2 stated the same, both parties stated that there were no injuries during altercation. R1 & R2 stated that they avoid each other and keep distance between one another and know that this is the best way to avoid future altercations. Both R1 and R2 stated that since this last incident no othe r incidents have happened and are hopeful that no further incidents will occur as they are staying distant from one another. Based on statements and interviews conducted with staff and residents, review of resident files and incident report, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided to Administrator Claudia Sanchez.

During LPA's interview with R1, R1 stated that they really cannot remember when and how the sweetener is missing and indicated that the cabinet lock is working in their room now. Staff fixed already and showed the LPA the key for the lock. LPA toured the R1's room with S1 assistance and observed that lock for the cabinet where R1 is keeping their food / cleaning supplies is working. At the time of tour R1 was present in the room. During interviews with residents, 3 out of 4 residents stated to not have lost or missing items from their rooms. They stated sometimes they misplaced items and staff help to look and find them. They did not hear that someone complains about missing items. Interviewed staff stated residents usually misplaced items and staff looks and will find items in residents' rooms. Interviewed staff indicated that R1 is often giving items away and after complaints about missing items. Items like water, juice, nuts R1 offer to residents and to staff. Staff stated that they never take any items from R1 or from other residents. They kindly decline the offers. Staff stated that they respect the residents, they do not go inside the resident's room without permission and do not touch their items. Based on the observation and interviews conducted with residents and staff, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided to Claudia Sanchez.

of the kitchen, food supply, observation of facility elevator and a random selection of resident rooms. LPA measured the water temperature in the resident rooms. LPA additionally reviewed R1’s facility file and collected copies of documents pertinent to the investigation and conducted a phone call to Silverado Hospice. Investigation revealed the following: Regarding allegation, Facility staff does not ensure that residents have hot water , it is alleged that the facility does not have hot water as of 01/11/23 and resident(s) only received a sponge bath as there was no hot water in the building. Facility also allegedly did not notify resident’s family or responsible parties of the issue with the water. It is also alleged that resident(s) are retaliated against if they speak up when things are not right in the facility. Interviews conducted with facility administrator and staff revealed that the facility does have hot water at all times. Administrator stated that water is checked weekly to ensure that the water is always set at the required temperature that is between 105 F - 120F and stated that family members and responsible parties are notified of any important issues or problems, if any, when they arise. Staff interviewed denied that residents are retaliated against if they bring up any concerns. Interviews conducted with 5 out of 5 residents revealed that the facility always has hot water. 1 out of 5 residents stated that when it is cold the water takes longer to heat up and it might be due to where their room is located which is in the rear of the facility. 5 out of 5 residents denied that staff retaliate against residents if they bring up any concerns. On 01/19/23 and 11/27/23, LPA measured the water temperature in a total of six (6) resident bathrooms and the reading for all bathrooms ranged between 110F - 115F which is between Title 22 regulation requirement. Based on interviews conducted with facility staff, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility is in disrepair, it is alleged that there is no alarm in the rear exit of the facility and there should be one as the facility provides services to residents with dementia, and the facility does not have a working elevator for the residents that live upstairs. Interviews conducted with Administrator Harvey and Assistant Administrator Claudia Sanchez revealed that the facility has 1 nonoperational elevator. They stated that the facility was licensed like that, and the facility was cleared by the Monrovia City Fire Department as well as Department of Industrial Relations (DIR). LPA Gonzalez reviewed approved STD 850 Facility Fire Inspection Request which was approved on 08/25/22 and indicates that all nonambulatory residents are to reside on the 1 st floor and all ambulatory residents are to reside on the 2 nd floor. This information is reflected on the facility license. On 11/10/22, LPA Katrdzhyan spoke to DIR Senior Inspector who informed LPA Katrdzhyan that DIR does not require the building to have an operable elevator. Senior Inspector also stated 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 that the facility elevator is recorded as dormant, and the power record has been landed which means that the elevator is inoperable. DIR will not visit the facility unless the facility decides to make the elevator operable again. Administrator and facility staff stated that the alarm in the rear exit of the facility does work. 4 out of 5 residents interviewed confirmed that the alarm in the rear exit door does work. 1 resident stated that the alarm is located right next to their room and they hear the alarm go off at times. 1 resident was not able to answer the question. LPA observed that the alarm in the rear exit door of the facility was operating properly during the visits that were conducted on both 01/19/23 and 11/27/23. LPA observed that nonambulatory residents are located in the first floor and did not observe any nonambulatory residents on the second floor during the visits conducted on 01/19/23 and 11/27/23. Based on interviews conducted with facility staff, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation. For the allegation, Facility staff does not meet resident's dietary needs, it is alleged that the facility has not been able to meet a resident(s) special dietary need such as a diabetic diet as it was stated on the resident(s) admission agreement and it is also alleged that resident(s) are supposed to get 3 meals a day and the facility has not met food needs. LPA observed the food supply on 01/19/23 and 11/27/23 and observed residents having lunch. LPA observed that the facility had an ample supply of a variety of fresh fruits, vegetables, proteins, and carbohydrates. LPA also observed facility's food storage and observed sufficient food for 2 days worth of perishables and 7 days worth of non-perishables, which consisted of different meats, vegetables and fruits, breads, dairy, cereals, and variety of canned foods. Interviews conducted with 3 out of 5 residents stated that they follow a special diet and the facility does provide them with alternate meals. 1 resident did not want to continue their interview, 1 resident stated that the food could be tastier but is overall satisfied with the food service. 5 out of 5 residents stated the food that is served is healthy and well balanced and they are served three meals a day which consist of a variety of foods. Interviews with Administrator and staff revealed if any resident follows a special diet they are provided with modified diets. LPA reviewed the food menu and toured the kitchen and observed a healthy selection of foods. LPA reviewed 5 resident's Physician's Reports and 3 reports did not indicate that the residents require a special diet. 2 Physician's Reports did indicate that the resident requires a special diet, and these reports belong to the residents that stated that the facility follows their diet. R1 is no longer a resident of the facility. Based on LPA observations, LPA review of facility menus, and statements gathered from interviews conducted with staff and residents there was not enough supportive evidence to concur with the reported allegation. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 For allegation, Facility staff does not maintain resident's room clean and free of trash , it is alleged that resident(s) room is always dirty and on 01/12/23 trash that had been observed the previous week was observed again under a resident(s) bed even after the housekeeper had just vacuumed the room. It is also alleged that the blinds in the resident(s) room are also broken and that they had allegedly been previously broken by staff when they were changing the resident(s). On 01/19/23 and 11/27/23, LPA toured the facility and did not observe that the facility or any residents' room were dirty and did not observe any trash under beds or any broken blinds. There are trash cans placed around the property for residents to use to throw their trash in. The dining tables and floors are wiped and clean. There are no obstructions to the passageways. LPA did not smell any urine nor unpleasant odor around the facility. Administrator and staff stated that the facility is cleaned on a daily basis and as needed and also stated that staff do not break any blinds when assisting residents. Staff stated that if a resident breaks the blinds in their rooms the blinds will be replaced by maintenance staff. 4 of 5 residents interviewed stated that the facility staff clean their rooms daily. 1 resident stated that their room is cleaned regularly but their daughter is the one that does not like certain things. LPA Gonzalez conducted a tour of the entire facility including 6 resident rooms including bathrooms, dining room, kitchen, TV room, outside common area, and backyard and observed the facility to be clean. LPA observed 1 staff cleaning resident rooms/restrooms. Based on interviews conducted with facility staff, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation. 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 held. A copy of the report was provided to Assistant Administrator Claudia Sanchez.

Allegation: Facility staff did not dispense medications as prescribed. Based on today's investigation LPA conducted interviews with staff, Iterm-Administrator and S1-S3 denied the above allegation and informed LPA that all residents get medication as prescribed and mediations are dispensed to residents and all medications are stored in the medication room. Iterm-Administrator and S1-S3 informed LPA that R1 gets medications as prescribed and medications are stored in the medication room. LPA conducted interviews with residents, interviewed revealed 4 out of 4 residents informed LPA that facility is providing and dispensing medications as prescribed.LPA reviewed 4 medications files and all medications are accounted for and administered according to doctor's orders. Interview with R1 revealed having no issued with medications and R1 is assisted with all prescribed medications. Interview with Former Case Manager of R1 stated facility is dispensing medication as prescribed. Allegation: Facility staff did not safeguard resident's property. Based on today's investigation LPA conducted interviews with staff, Iterm-Administrator and S1-S3 denied the above allegation and informed LPA staff are not stealing or taking things out of residents rooms and are keeping resident's property safeguarded. Staff interviews with 3 out of 4 staff revealed R1 gives personal belongings to other residents and staff are safeguarding belongings. Interviews with 4 out of 4 staff revealed staff enter residents rooms when staff need to assist residents in room cleaning, routine checks ,and /or need items like clothing to assist with residents needs and staff ensure residents property are safeguarded and residents are aware. Interviews with residents 4 out of 4 stated their belongings are safeguarded in their rooms and denied the above allegation. R1 during interview informed LPA facility staff safeguard their personal belongings and nothing it taken from R1's room and has no issues with staff not safeguarding R1's belongings, R1 admitted to giving away personal items like water. LPA reviewed R1- R5 Inventory of property and all residents refused / opted out in having items listed. Interview with Former Case Manager of R1 informed LPA that R1 is known to give personal items away to other residents and Case Manager informed LPA facility residents are able to have keys to their rooms to safeguard residents belongings and facility has cameras to assist with safeguarding property issues that can arise when living in a board and care. Based on interviews and record reviews there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted with Med-Tech Madelene Sanchez and a copy of this report will be sent via email to Interm-Administrator Claudia Sanchez

Licensing Program Analyst (LPA) Ashley Calderon, made a unannounced annual continuation case management visit. LPA met with interm-Administrator Claudia Sanchez and discussed the purpose of today's visit. The facility is licensed to serve: Elderly residents ages 60 and over. Approved for (48) ambulatory residents and (32) non-ambulatory residents. (7) non-ambulatory can be bedridden. Bedroom # B1,A2,4,5,8,9,12 are cleared for bedridden residents. During today's visit LPA Calderon did a total of (5) resident files. LPA reviewed files and did not observe any deficiencies in resident files and all residents had appropriate documentation's, physician reports and TB. LPA completed CARE inspection tool to complete annual required inspection. No deficiencies noted under California Title 22. An exit interview was conducted and a copy of this report was provided to Interm-Administrator Claudia Sanchez.

Licensing Program Analyst (LPA) Ashley Calderon, made a unannounced annual visit. LPA met with interm-Administrator Claudia Sanchez and discussed the purpose of today's visit. The facility is licensed to serve: Elderly residents ages 60 and over. Approved for (48) ambulatory residents and (32) non-ambulatory residents. (7) non-ambulatory can be bedridden. Bedroom # B1,A2,4,5,8,9,12 are cleared for bedridden residents. LPA will be using the CARE Inspection Tool for the required one year annual inspection. On today's visit, LPA Calderon interviewed (3) residents and (3) staff personnel's. LPA will continue annual visit at a further time do time constraint. No deficiencies noted. An exit interview was conducted with Interm-Administrator Claudia Sanchez and a copy of this report will be sent via email.

(Continued) LPA conducted interviews with Residents #1 (R1) - Resident #7 (R7) 6 of 7 residents could not collaborate the allegations. 6 of 7 residents stated they get their medications according to doctor's orders and are satisfied with facility administering their medications. LPA reviewed 4 medications files and all medications are accounted for and administered according to doctor's orders. Based on interviews and record reviews there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided to Claudia Sanchez, Interim-Administrator.

The investigation revealed the following: Regarding allegation of questionable death, it was alleged that a staff member (S-1) provided drugs to Resident #1 (R-1) which resulted in resident passing. Interviews with staff indicated that R-1 was self responsible, did not need assistance with activities of daily living, and often left the facility during the daytime. R-1 was able to leave the facility unassisted as noted in the physician’s report. Staff did not witness any staff giving R-1 drugs, however, one staff found substances once in R-1’s room. Staff questioned R-1 about the drug and how it was obtained but the resident did not state who provided it. Although staff could not confirm R-1 used drugs, they did observe R-1 returning to the facility intoxicated, more often prior to the death. They attempted to intervene by offering services to R-1, however, R-1 would become agitated and aggressive whenever staff reached out. R-1 passed away on 1/17/23. According to the coroner’s medical report, the immediate cause of death was due to arteriosclerotic cardiovascular disease and was determined as a natural cause. Based on the information gathered, the allegation of a questionable death for Resident #1 (R-1) was 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, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Ms. Sanchez. A copy of this report along with the appeal rights were provided.

Regarding Allegation: Facility is not following proper eviction procedures. The investigation revealed Substitute Administrator Stephany Perez, Interim-Administrator and Facility Accounting denied the above allegation, all stated residents are provided a proper eviction notice. and all eviction notice can occur due to non-payment of rent. All stated R1 is past due on rent and residents are provided a time frame to pay rent to avoid eviction. Interviews with S1 -S3 all could not contribute the above allegation stating they do not have knowledge about in proper evictions or evictions. S2 stated knowing about an eviction letter provided to R1 due to non-payment of rent. Interviews with residents were conducted. Interviews with residents revealed R1 stating they pay what they can pay for rent as they have other priorities. Interviewed with R2-R5 all revealed residents not aware of in proper evictions occurring. Interview with R1 program manager stated overseeing 18 residents at the above facility and denied the above allegation stating facility is not providing in proper evictions to the residents in care. LPA reviewed invoices of rent for R1 showing R1 has a balance that has not been paid, owing the facility rent payments. LPA reviewed and approved a proper eviction notice provided regarding R1, reason for eviction noted is: non-payments. Facility does not have other evictions in place for residents in care. There were no evidence obtained during the investigation to corroborate with the allegation. Regarding Allegation: Facility staff did not safeguard resident’s belongings. LPA interviews with staff Substitute Administrator Stephany Perez, Interim-Administrator and Facility Accounting revealed all denying the above allegation and all stated facility is safeguarding residents belongings by providing each resident with their own furniture items/ space and residents are advised before entering facility that residents are responsible of personal items and the facility has dementia residents which can occur to items being misplaced. Interview with facility accounting revealed facility not having an issues with residents belongings not being safeguarded. Interviews with staff, S1-S3 stated residents have their own space for their items and facility help relocate items if missing. S1 and S3 stated facility has Dementia residents and at times things can get relocated or misplaced and facility investigate and looks for items. Interviews with residents revealed R2-R5 all denied the above allegation stating they have their belongings safeguarded in their room and not sure if other residents items are being safeguarded or not but they do not have issues personally. R3 former roommate of R1 stated witnessing staff entering room to clean/ preform their duties and staff were not stealing from R1. Interview with Program Manager of R1 revealed R1 stating a convoluted story regarding facility not safeguarding residents belongings and is not aware of issues regarding facility not safeguarding residents belongings. There were no evidence obtained during the investigation to corroborate with the allegation. Based on interviews and record reviews there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided to Claudia Sanchez, Interim-Administrator.