Sparr Heights Estates Senior Living.

LPA de la Cerra’s interviews with staff #2 (S2) at 11:55am revealed that R1’s care and supervision was increased due to showing some signs of decline, confusion and bladder retention problems, S1 then instructed staff members to do hourly routine check for R1. Interviews with staff #3 (S3) at 3:05pm and phone interview with staff #4 (S4) on 4/30/25 who both were assigned on night shift (NOC) duty during April 2024 revealed that around the beginning of April, staff members were instructed to increase the routine check on R1 to every hour. Staff S3 and S4 did check in on R1 routinely every hour and the last check in would normally be at 6:00am when their shift would end. LPA de la Cerra’s interviews with staff members, staff #5 (S5) and staff #6 (S6) who were with the AM shift (starts at 6am) during April 2024 revealed that they checked in with R1 usually at 6:30am. and every hour thereafter. Interviews with caregivers, S3, S4, S5 and S6 revealed that although the check in with R1 was hourly but most of these check-ins with R1 would not be documented in the facility’s observation log. Caregivers are instructed that there is no need to document on the observation log if there are no changes observed with the residents or if they are just sleeping.. Interviews with residents reveal that they receive sufficient care and supervision from facility staff. Furthermore, interviews with staff # S2, S3 and S7 on 4/30/25, revealed that R1 did not like wearing incontinence underwear and the incident on 4/09/24 with the broken toilet could be due to R1 attempting to flush their incontinence underwear in the toilet which would cause the toilet to overflow and malfunction. Review of R1’s records reveal that due to R1’s change in health condition, R1’s individual service plan was modified, that facility staff will provide total assistance to R1 to ensure successful toileting. During LPA de la Cerra’s subsequent visit on 4/24/25, R1 was not available for interview, record review by LPA de la Cerra revealed the R1 no longer resides at Sparr Heights Estates Senior Living, R1’s Power of Attorney-POA moved R1 out of the facility on 3/18/2025. Based on inspection, observations, interviews and record reviews, there is insufficient information to support this allegation. Therefore, the allegation remains Unsubstantiated. CONTINUE to LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff spoke inappropriately while in front of resident. It was alleged that while the reporting party was with R1 in R1’s room, and a female staff with hair dyed pink or purple, who is Filipino said to the reporting party that R1 is “coo coo”. To investigate this allegation. LPA Rosaura Valenzuela conducted an initial visit and delivered findings on 4/15/2024. During LPA de la Cerra's subsequent visit, 0n 4/24/2025. LPA conducted physical plant tour, conducted record reviews and staff interviews between 10:30am to 12:00pm and 1:30pm to 3:00pm, resident interviews were conducted between 12:30pm to 1:30pm. LPA obtained the staff roster, resident list, and gathered additional documents pertaining to the investigation. During LPA de la Cerra’s physical plant tour, LPA did not observe any staff member with hair dyed pink or purple, who is Filipino. LPA de la Cerra’s interviews with staff #1 (S1) at 11:00am and staff #2 (S2) at 11:55am on 4/24/25 revealed that the facility did not have a Filipino staff member with hair dyed pink or purple around April 2024. Interviews with residents reveal that they have never been spoken to inappropriately by any staff members. Additionally, residents interview also revealed that no staff member ever spoke inappropriately about them in front of their family member. During LPA de la Cerra’s subsequent visit on 4/24/25, R1 was not available for interview, record review by LPA de la Cerra revealed the R1 no longer resides at Sparr Heights Estates Senior Living, R1’s Power of Attorney-POA moved R1 out of the facility on 3/18/2025. Based on inspection, observations, interviews and record reviews, there is insufficient information to support this allegation. Therefore, the allegation remains Unsubstantiated. No health and safety hazards noted at the time of this visit. Exit interview conducted and a copy of the report was issued.

Licensing Program Analyst (LPA) Abeye Duguma met with the Executive Director, Denise Gotto, for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 10:00 AM and the following was noted: The facility is fire cleared for one hundred twenty (120) non-ambulatory of which twenty (20) may be bedridden. The facility is currently occupying sixty-eight (68) residents. There is a main entrance being utilized at the facility with sign-in sheets. Each residents' room has a full bathroom. LPA inspected seven (07) rooms at random and all rooms were observed to be adequately furnished with appropriate lighting system and enough clean linen available. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at an average 109.6°F. Towels and washcloths are not shared. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. (continued on LIC 809-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The living and dining room are neat and clean. The facility maintains a comfortable temperature at 73°F but each resident has their own thermostat and can control the temperature in their rooms. The smoke and carbon monoxide detectors are hardwired, interconnected and centralized. A signal is dispatched to the Los Angeles Fire Department automatically and the system is tested monthly. Fire extinguishers are located throughout the facility, observed to be fully charged and last inspected 01/17/2025. LPA observed medication carts to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.

During todays visit, LPA Panushkina obtained copies of R1's Admission Agreement (dated on 12/22/21), Appraisal Needs and Services Plan (dated on 11/17/21) and Resident Abuse and Neglect Policy (effective date 11/01/2014) related to the complaint. This complaint investigation was conducted by Laarni Santiago, Investigator from Community Care Licensing Division’s Investigations Branch (IB). The investigation consisted of interviews, conducted between 09/07/23 to 10/26/23 with the Executive Director (ED), Health Services Director (HSD), Former Executive Director (FED), six (6) staff and attempt to interview four (4) memory care residents. Allegation: Staff sexually abused resident in care. The investigation findings revealed that R1 had been living at this facility since 12/28/2021 and resided in a Memory Care Unit. Also, during that time, S1 was working at this facility as a MedTech and it was alleged that R1 was routinely molested by S1 for a span of at least 3-6 months in 2022. Investigator conducted interviews with the Executive Director and Health Services Director and both parties could not provide any relevant information since they were not aware of any incidents between R1 and S1. Investigator also conducted an interview with S1, who denied the above allegation and advised that R1 “cried a lot” and S1 would only give a “hug” just to comfort R1. During the interview with S4, Investigator was informed that S4 and S5 witnessed S1 “kiss” R1. However, S5 refuted the claim and denied witnessing S1 commit any sexual conduct towards R1 or other residents. Moreover, S5 informed the Investigator that none of the residents or staff complained about S1. Both staff interviewed revealed inconsistent and conflicting information. Former Executive Director (FED) also informed the Investigator that no complaints from residents nor staff regarding S1’s inappropriate behavior was ever received. In addition, FED expressed that S1 was polite and reliable and voluntarily resigned to focus on school and become a Licensed Vocational Nurse (LVN). Furthermore, the Investigator conducted an interview with S6, who reported that he/she saw S1 inappropriately touched a resident. However, there were no other witnesses to corroborate the incident and S6 could not confirm that it was R1. Interviews with other two (2) staff did not indicate that they witnessed S1 touch or handle residents inappropriately and reported that S1 seemed to be a “genuine” and “caring” staff. Lastly, the Investigator attempted to conduct interviews with four (4) Memory Care residents, but they could not provide pertinent or relevant details. Based on interviews and information gathered during the investigation, there is insufficient evidence to prove the alleged violation occurred. Therefore, it deemed Unsubstantiated, at this time. Continue on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff did not report incident to the proper agencies. It was alleged that R1 was routinely molested by S1 for a span of at least 3-6 months in 2022 and upon discovering the situation, the Former Executive Director (FED) forced S1 to resign, but didn’t report S1 to the authorities. To investigate this allegation, on 10/12/23 the Investigator conducted an interview with the FED and was informed that this was the first time he/she heard about the sexual abuse allegation. FED also denied that any staff came forward about concerns involving S1 and R1; or that they witnessed S1 conduct any inappropriate behavior. In addition, FED informed the Investigator that R1’s responsible party was highly involved in R1’s care and visited R1 frequently. R1’s responsible party did not bring up any concerns about S1 or any staff. Moreover, FED dined that S1 was forced to resign due to a “very odd” allegation and informed the Investigator that S1 voluntarily left because S1 wanted to focus on school and become a Licensed Vocational Nurse (LVN). Thus, there was no reason for this information to be reported and or to be escalated to the authorities. Lastly, interview conducted on 10/24/23 with S1, confirmed that he/she resigned because the facility required staff to work longer hours, but S1 could not because of school. Therefore, based on interviews and information gathered during the investigation, this allegation is Unsubstantiated. No deficiency cited during today's visit. Exit interview conducted and copy of this report signed and delivered.

(continued from LIC 9099) Regarding the allegation that Staff are not following proper reporting requirement, it was alleged that two (2) residents were in altercation and the former Executive Director (ED) did not take the staff concern seriously and did not report to CCL. The reporting party (RP) did not provide any details of the alleged incident as to who, when and where it happened. The RP also did not provide any contact details, so no contact was made with the RP to get the details of the alleged incident that was not reported. LPA's record review today between at 1:00 PM to 1:38 PM revealed that the ED referred to on RP's report had left the facility sometime in June 2023. LPA's interview with a staff at 12:45 PM however, revealed that the only altercation happened during the time of the former ED between two (2) residents happened sometime in May of 2023. LPA's record review today between 1:00 PM to 1:38 PM revealed that the facility had submitted Unusual Incident/Injury Report (LIC 624) on 05/22/23 regarding an altercation between two (2) residents happened on 05/21/23. The incident was also reported to the local law enforcement. Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

(continued from LIC 9099-C) Regarding the allegation that residents are not provided proper medication assistance, it was alleged that there were Medication errors and late Medications pass at the facility. LPAs interviewed six (6) random residents or 10% of current census today between 12:30 PM to 2:00 PM revealed that six (6) out of six (6) residents did not experience medication error nor late medication administration. Further interviews also revealed that six (6) out of six (6) residents did not witness or aware of any resident who had medication error or late medication pass. LPAs interview with two (2) Medication staff today between 12:30 PM to 2:00 PM also revealed that there was no medication error or medication late pass and/or reported for the last two (2) years that the medication staff were employed. Based on the information gathered during this visit the allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required 1 year inspection to the facility. LPA met with Helen Kirkorian, Business Office Manager and the purpose of the visit was discussed. LPA conducted a physical plant tour of the facility. There is one main entrance being utilized at the facility. The facility consists of one main building. The Independent Living section of the facility is on the top floor and the Memory Care Unit is located on the bottom floor. The facility has a capacity for 131 residents. Currently 58 rooms are being occupied. Common areas were checked for cleanliness. Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. The residents rooms are adequately furnished with appropriate furniture and lighting system. The facility maintains a comfortable temperature at 78 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There are carbon monoxide detectors in the facility. Fire extinguishers are located throughout the facility and were last serviced in January of 2024. 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 bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at 120 degrees F. Medications-LPA observed medication carts in the nursing station to be locked and inaccessible to residents. There is one ( 01) complete first aid kit. Exit interview conducted. A copy of this report was issued and signature obtained. No deficiencies were issued at this time