Pasadena Highlands.

IB Investigator Real interviewed a total of five (5) staff, three (4) residents, and the Nurse practitioner. They also collect R1 medical records from Huntington Hospital and police reports from the Pasadena Police Department. During todays visit LPA Baptiste interviewed five (5) residents, who shall be known as R5 through R9. Based on interviews conducted and records reviewed, facility staff interviews revealed that R1 did not initially recall what caused the injury to their arm but later changed their statement and stated the injury occurred while C1 was assisting them out of a wheelchair. R1 denied that C1 intentionally harmed them. C1 denied the allegation and reported that they only transferred R1 with the assistance of other caregivers. None of the caregivers interviewed provided any information to support the allegation and denied witnessing C1 harm or handle R1 in a rough manner. The interviewed residents provided no information to support the allegation. A copy of the relevant police report was obtained, and a review revealed no information supporting the allegation. Based on interviews and file review, the investigation revealed that, although the allegation may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; the allegation is UNSUBSTANTIATED. Exit interview conducted with the Administrator Thomas Rekowski and a copy of this record provided.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced required annual inspection. LPA, met with Kay Cano, Executive Director, and the reason for the visit was explained. The facility is licensed to serve 245 non-ambulatory residents ages 60 and over, of which 30 may be bedridden on 1st and 2nd floors, there is an approved delayed egress and Hospice waiver for 35. There are currently 30 residents on hospice. The facility is an 8-story building located in Pasadena. During today's visit, LPA conducted the following: Review was conducted for (10) staff files. Staff files contain criminal record clearance, current First-Aid training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training. Review was conducted for (20) resident files. Resident files have the following documents in place: Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. Tour of the medication room. Medication is centrally stored in a medication room. Fifteen (15) residents' medication was inspected and found to be administered and documented accordingly, per physician's orders. Interviews were conducted with (10) staff. Infection Control and Emergency Preparedness plan are in place and up to date. Last safety drill was conducted on 10/22/2025 and 12/10/25. No deficiencies were noted during this visit. Due to time constraints, an annual continuation will be conducted at a later time. Exit interview was conducted with Kay Cano, Executive Director, and a copy of this report was provided.

The investigation revealed the following: regarding the allegation “Staff did not provide resident records to resident's authorized representative.” It is alleged that staff did not provide resident#1 (R1’s) authorized representative with resident records that were requested on 08/18/2025. LPA Ramirez obtained a copy of Medical Records request for R1, which requested records for R1’s entire file including not limited to, medical records, business records, relating to any care, treatment diagnosis, prognosis, consultations and/or findings from 01/01/2024 to present. This record request specifically requires records to be certified, provided in electronic format/PDF format and be emailed or uploaded to R1’s authorized representative. Three (3) out of the three (3) staff interviewed denied this allegation. Interview with S1 revealed they did receive an email request for R1’s entire medical and facility file on 08/18/2025. S1 revealed the email they received looked suspicious and S1 was unsure if this was an attempt to get a residents’ confidential information. S1 revealed they consulted with other staff to ensure the request was legitime and if the documents could be released since the request was being made by someone other than R1. Interview with S2 revealed once they received the medical records request from R1’s authorized representative, they forwarded the request to upper management to gather the documents and to ensure the request was legitimate. Interview with S3 revealed the facility never denied providing R1’s resident records to their authorized representative, the facility just needed more time to gather the documents and ensure the request was legitimate since they usually receive these kinds of requests in person. S3 revealed they spoke with the requestor of R1’s file, and the requestor agreed to allow the facility to submit these documents by 09/19/2025. On 09/18/2025, LPA Ramirez received an email confirmation from S3 which indicated R1’s entire medical file and other documents were sent and received by R1’s authorized representative as requested on 08/18/2025. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies were cited during this complaint investigation. Exit interview was conducted and a copy of this report was provided.

out of 7 residents who stated that they had a fall and staff responded right away and paramedics were also here quickly. 4 residents had not had a fall or seen anyone have a fall. Staff interviewed stated that Resident R1 had an assist to ground and not falls. Stated that 2 caregivers were needed and only 1 time there was a slight fall when 2 caregivers were providing assistance in a sit to stand chair and Resident R1 caught her feet under the chair and slid back and hit her head and had slight abrasion on right hip. Administrator documented specific dates in which assist to ground was done during transfer: 01/07/24- Resident R1 fell to knees with no injury. 04/11/24- Assist to ground no injury. 06/05/21- Assist to ground no injury. 06/26/24- Assist to ground no injury. 07/02/24- With staff and slipped from shower chair 07/21/24- Transfer with 2 staff with foot stuck under the chair causing Resident R1 to slide to to the floor. Administrator stated that staff were always assisting Resident R1 with transfers and that they were not falls. Stated that they were assist to ground. Documentation from the primary care doctor reveals that Resident R1 was seen on 1/4/24, 1/11/24,1/18/24,2/1/24,2/8/24, 2/15/24, 2/22/24, 3/4/24, 319/24,6/7/24 6/14/24, 6/21/24, 6/28/24, 7/5/24, 7/12/24 and 7/19/24. 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 performed an unsafe transfer resulting in resident sustaining an injury, based on interviews conducted and information gathered it was revealed that 3 of 7 residents had needed a transfer and stated that staff did a good job. 4 residents stated that the staff are never neglectful. Staff stated that Resident R1 needed assistance by 2 caregivers and only had 1 incident in which Resident R1 caught her feet under the chair and slid back and hit her head and had slight abrasion on right hip. Stated Resident R1 was never neglected and the facility responded right away sending Resident R1 to the hospital. Documentation from the primary care doctor reveals that Resident R1 was seen on 1/4/24, 1/11/24,1/18/24,2/1/24,2/8/24, 2/15/24, 2/22/24, 3/4/24, 319/24,6/7/24 6/14/24, 6/21/24, 6/28/24, 7/5/24, 7/12/24 and 7/19/24. 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. 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 Resident developed a pressure injury due to staff neglect, it was revealed in hospital documentation from Huntington Health that Resident R1 was seen on 07/21/24 and it's noted bilateral heels not a pressure injury. Right hip listed as abrasion. Buttocks, groin- erychema not a pressure injury. Resident's 2-8 stated that they never had a pressure injury and do not know of any residents who do. Staff stated that hospital notes show no pressure injuries. Documentation from the primary care doctor reveals that Resident R1 was seen on 1/4/24, 1/11/24,1/18/24,2/1/24,2/8/24, 2/15/24, 2/22/24, 3/4/24, 319/24,6/7/24 6/14/24, 6/21/24, 6/28/24, 7/5/24, 7/12/24 and 7/19/24. 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 Resident’s condition worsened due to staff neglect, based on interviews conducted and information gathered Resident's R2- R8 stated that staff have been great at assisting them and their condition has never worsened. Staff stated that in regards to Resident R1 she was seen every hour. Also stated that Resident R1 was seen weekly by the primary care physician. Stated that some medication Resident R1 was taking can lead to bruising. In addition with 2 caregivers assisting they have to hold Resident R1 tight so not to fall to the ground which could lead to slight bruising. Documentation from the primary care doctor reveals that Resident R1 was seen on 1/4/24, 1/11/24,1/18/24,2/1/24,2/8/24, 2/15/24, 2/22/24, 3/4/24, 319/24,6/7/24 6/14/24, 6/21/24, 6/28/24, 7/5/24, 7/12/24 and 7/19/24. 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 isolated resident in her room, based on interviews conducted and information gathered Resident's R2- R8 all stated that staff will check on them daily and are never neglectful. Stated that if not in their room staff will assist if needed at dining room or other areas in the facility. Staff stated that Resident R1 would get visits hourly for assistance for Resident R1 and her spouse. Also stated they would go to their room constantly to reposition so they could prevent any sores from occurring. It should be noted that the last day Resident R1 resided at the facility was 07/21/24. 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.

**This is a subsequent visit to amend and supersede the reports dated 02/24/2025. The reason for the amendment is to remove confidential information listed on the initial report. The findings will remain unsubstantiated. ** Regarding the allegation: Staff did not adequately address a change in resident’s condition. It is alleged that R1 is experiencing progressive behavioral expressions related to dementia and the facility is not addressing the changes in R1's condition and should have R1 placed in memory care or higher-level care facility. Seven (7) out of seven (7) staff interviewed denied this allegation. According to staff, R1 resides in assisted living program at the facility. Assistance is provided with housekeeping, medications, and daily living needs only, R1 is high functioning person and can comprehend and express their needs and concerns. Staff responsible for tracking change in health conditions are charting the residents’ health and medications changes and needs and are reporting to the residents POA/primary physician as needed. Progress notes are made by each caregiver/med tech that interacts with residents under their care. According to staff the POA have been provided other placement agencies that cater to dementia resident’s needs. Ten (10) out of ten (10) residents interviewed could not collaborate this allegation. According to couple of residents stated their needs and changes with their health conditions are communicated to their doctor, family and POA and they have not had any concerns with staff communicating their medical issues and needs. One resident stated, the caregivers have prevented serious health condition by informing their doctor and getting medical assistance right away. Other residents stated caregivers and med-techs are involved with our health and wellbeing. LPA attempted to interview R1’s personal caregiver/assistant hired by the R1’s POA, they declined. Although the allegation(s) 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. Regarding the allegation: Staff did not inform resident's representative of incident(s) as required. It is alleged that the facility staff are not informing R1’s POA of incidents that happen with R1. Seven (7) out of seven (7) staff deny this allegation, staff state that resident’s behavioral are charted in the progress notes and communicated to the next staff- med-techs and caregivers, when residents fall ill, health conditions are communicated to responsible parties. Continued on 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 **This is a subsequent visit to amend and supersede the reports dated 02/24/2025. The reason for the amendment is to remove confidential information listed on the initial report. The findings will remain unsubstantiated. ** Residents are sent to the Emergency room for precautions. Nine (9) out of ten (10) residents interviewed could not corroborate this allegation. According to interview conducted with R1’s POA, R1 was having an erratic episode with delusional behaviors in R1’s apartment and the staff did not do anything to stop the behaviors and redirect the resident until R1s POA notified the staff at the front desk. The staff did not notify resident’s POA of R1’s delusional episodes. According to R1, the reasons for R1’s erratic behavior was because R1’s personal property had been confiscated by the R1s’ POA, forcing R1 to purchase new communication devices and reinstate their digital profiles. R1 stated this ordeal was very disturbing for them. R1’s POA confirmed that R1s POA removed R1’s personal electronic devices without R1s approval. LPA attempted to interview R1’s personal hired assistant, they declined. According to R1 was due to R1s’ POA physically confronting R1s companion and angrily disapproved of R1s’ domestic partner and friend. Therefore, R1s POA was present during both of R1s behavioral episodes/incidents and upon staff knowledge of R1’s behavior/incidents, staff were present and assisted R1 by redirecting and attempting to calm R1. Although the allegation(s) 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 report was provided to Kay Cano- Administrator.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced collateral visit at the facility to conduct interviews regarding a recent incident at a different licensed facility. LPA met with Marie Brooks and Kay Cano Administrator and explained the reason for the visit. The purpose of this visit was to conduct interviews with 7 residents regarding the incident that occurred at the residents' previous facility. Exit interview was conducted with administrator and a copy of this report was provided.

Seven (7) out of seven (7) staff interviewed denied this allegation. According to staff, R1 resides in assisted living program at the facility. Assistance is provided with housekeeping, medications, and daily living needs only, R1 is high functioning person and can comprehend and express their needs and concerns. Staff responsible for tracking change in health conditions are charting the residents’ health and medications changes and needs and are reporting to the residents POA/primary physician as needed. Progress notes are made by each caregiver/med tech that interacts with residents under their care. According to staff the POA have been provided other placement agencies that cater to dementia resident’s needs. Ten (10) out of ten (10) residents interviewed could not collaborate this allegation. According to couple of residents stated their needs and changes with their health conditions are communicated to their doctor, family and POA and they have not had any concerns with staff communicating their medical issues and needs. One resident stated, the caregivers have prevented serious health condition by informing their doctor and getting medical assistance right away. Other residents stated caregivers and med-techs are involved with our health and wellbeing. LPA attempted to interview R1’s personal caregiver/assistant hired by the R1’s POA, they declined. Although the allegation(s) 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. Regarding the allegation: Staff did not inform resident's representative of incident(s) as required. It is alleged that the facility staff are not informing R1’s POA of incidents that happen with R1. Seven (7) out of seven (7) staff deny this allegation, staff state that resident’s behavioral are charted in the progress notes and communicated to the next staff- med-techs and caregivers, when residents fall ill, health conditions are communicated to responsible parties. Residents are sent to the Emergency room for precautions. Nine (9) out of ten (10) residents interviewed could not corroborate this allegation. According to interview conducted with R1’s POA, R1 was having an erratic episode with delusional behaviors in R1’s apartment and the staff did not do anything to stop the behaviors and redirect the resident until R1s POA notified the staff at the front desk. The staff did not notify resident’s POA of R1’s delusional episodes. According to R1, the reasons for R1’s erratic behavior was because R1’s personal property had been confiscated by the R1s’ POA, forcing R1 to purchase new communication devices and reinstate their digital profiles. R1 stated this ordeal was very disturbing for them. R1’s POA confirmed that R1s POA removed R1’s personal electronic devices without R1s approval. LPA attempted to interview R1’s personal hired assistant, they declined. According to R1 was due to R1s’ POA physically confronting R1s companion and angrily disapproved of R1s’ domestic partner and friend. Therefore, R1s POA was present during both of R1s behavioral episodes/incidents and upon staff knowledge of R1’s behavior/incidents, staff were present and assisted R1 by redirecting and attempting to calm R1. Although the allegation(s) 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 report was provided to Adrienne Hurd, Assistant Executive Director.

Licensing Program Analyst (LPA) S Vaid conducted the required annual inspection. LPA arrived unannounced and met with Adrienne Hurd (Executive Assistance) and John Arbona (Maintenance Director) who assisted with the tour, and explained the purpose for today’s visit. The facility is licensed to serve 245 non-ambulatory residents ages 60 and over, of which 30 may be bedridden on 1st and 2nd floors, there is an approved delayed egress and hospice waiver for 30. There are currently 30 residents on hospice. The Facility is an 8-floor building located in Pasadena, CA. A tour of the facility included: 1st floor has a large dining room, common area, kitchen, salon, theater, fitness room, medication room, linen room, laundry room, trash room, club room, multipurpose room, billiard room, staff office, an elevator and public restrooms. The garden area has covered seating areas, walk around path and activities areas for the residents, a permanent garden is overseen by the residents. 2nd floor has lobby area 24 (twenty-four) rooms with bath, laundry room, employee break room, medication room, lobby, and staff office.3rd floor houses the memory care residents, 1-2 residents per rooms. Dining room, activity room, laundry room. Egress alarms on three doors exiting the floor to the stairwell and each stairwell has evacuation chairs. 4th, 5th and 6th floor houses the assisted living for residents, multi-purpose room for dining and activities. Puzzles, game room and poker room for the residents. Floors 7th and 8th : house the independent living residents, laundry room and lounge area (on each floor), and a library on the 7th floor. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Con't 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 Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training, and facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, 12 residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested daily throughout the facility resident private restrooms and measured within the required range of 105-120 degrees. There is a shaded patio and garden area for residents. Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: Staff have criminal record clearance, current First-Aid training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no issues observed. Administrator Kay Cano certificate expires on 1/16/26. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 8 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman near the resident mail room. Planned Activities: Facility provides scheduled activities with a monthly calendar. There is an outdoor activity area available for the residents. Con't 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 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. Dining staff uses emenu (electronic menu) to track residents’ meals, and special/ modified diets. I ncidental Medical & Dental: Medication is properly labeled and are centrally stored in a Medication Room and are in their original containers. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Fire and disaster drills are conducted monthly by third party company. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Facility admits residents with dementia and staff have all required training documented within personnel files. There are currently no bedridden residents at the facility. LPA observed 8 rooms that have oxygen with the required signs posted. Residents files are well organized and information is easily available. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Kay Cano.

The investigation revealed the following: Regarding allegation: Staff did not properly handle resident's wound care and Due to staff neglect, resident's wound worsened while in care. It is alleged R1 was admitted to the facility with a bedsore, it was said that “it was healed, when actually it was not”, and the wound was never packed nor were antibiotics given until October 2, 2023. On 7/5/23 R1 was referred to a hospice agency. On 7/6/23, R1 was admitted to the facility and hospice services were initiated. On 7/7/23, hospice conducted an initial evaluation which noted R1 had a stage II sacrum pressure sore and Moisture Associated Skin Damage (MASD) to the groin area. Hospice care notes were to apply ointment and cover. On 7/9/23, R1’s private caregiver reported R1 wouldn’t allow to be change or repositioned to hospice staff. On 7/10/23, hospice nurse noted that the care needs of R1 were explained to the caregiver. On 7/13/23 hospice notes were noted that wound “worsen” from a stage II to a stage III wound. On 7/18/23 Facility’s notes state, facility’s staff was notified by hospice staff that prior to admission R1 was discharge from the hospital with antibiotics and a stage one pressure ulcer which progressed into a stage II-III. On 9/25/23, Hospice noted that R1’s stage III wound reopened. On 9/30/23 Hospice noted R1 was started on antibiotics. On 10/1/23 Hospice nurse noted a second antibiotic was prescribed for R1. On 10/2/23 hospice agency noted wound was now at a stage IV. On 10/2/23 Hospice agency provided instructions to pack and oral antibiotic (ATB) for possible infection. On 10/3/23 R1 was send out to the hospital per family’s request for higher level of care. Two physician’s report were reviewed for R1 initial physician report dated 6/7/23 notes R1 had no history of skin breakdown. However, Physician’s report dated 7/7/23 notes R1’s history of skin breakdown with a stage III wound to the coccyx and ambulatory status changed to bedridden. The physician noted the change of ambulatory status is due to “continuous declining”. On 9/20/24 R1 was seen by a wound master specialist, who noted will provide services once a week. Wound care was provided per wound specialist orders by hospice and staff. Hospice visits were provided based on the care needed from once a day and additional 3 times per week, if necessary, upon initiating hospice. Staff interviewed stated to have been repositioning resident as recommended by hospice at least every two hours and sometimes more frequent. Although the wound worsened within two months, R1 was receiving Hospice services upon admission and health care provider was providing care for the wounds. 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. (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 Regarding allegation: Staff did not note changes in resident's medical condition and Staff did not seek resident timely medical attention. It is alleged wound had gotten worse and medical attention was not sought. R1 was admitted to the facility on 7/6/23, preplacement appraisal dated 6/29/23 notes a health in condition change prior being admitted to the facility. Facilities progress notes reviewed between 7/6/23 to 10/19/23 revealed facility charted R1’s changes in condition, hospice visits, R1’s routines, per resident’s need (PRN) medication provided, and communications with family members. Facility noted twelve of the visits provided by hospice in which hospice either provided additional care or instructions to the caregiving staff. There was a total of three hospital visits per family’s request and concerns on 7/13/23, 7/20/23, and 10/3/23. Hospice documents revealed upon R1 starting services on 7/7/23 was scheduled to be visit by a skilled nurse professional daily and three additional times PRN. On 7/13/23 hospice order a low air loss (LAL) mattress due to change in condition. R1 had a change of condition related to the wound which were noted and followed up by hospice care and noted by the facility. On 7/18/23, a meeting was held with R1’s family to provide information of higher level of care as well as the difference between hospice and higher level of care. Wound Master initiated services on 9/20/23, observations of R1’s condition by facility staff were reported to wound care specialist. Wound care specialist provided treatment and instructions of care to facility staff and hospice. Wound care visits were schedule for once a week after 9/20/23. Interviews conducted with residents and staff revealed that facility provides timely care and respects resident right to call for emergency services as needed. Even though R1 had a decline in condition, R1 was being provided care by a skilled nurse professional and upon family requesting hospitalization R1 was transfer to a hospital. 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 . Regarding allegation: Staff did not provide resident's family with a copy of the resident's wound care plan. It is alleged wound care specialist was to develop a plan, which the family could request a copy of, family and it was never received from the facility. Interviews conducted with 10 residents revealed that they have not had the need to request copies of records. However, they felt that the facility will provide them with copies if necessary. Interviews with staff revealed that the facility will provide copies to the resident or power of attorney upon request. Interview conducted with administrator revealed that documents were not requested for R1’s medical records. Interview conducted with family representative revealed that documents were requested to hospice agency. (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 Interview conducted with hospice agency revealed the family did not request any documents. Hospice documents reviewed revealed family was informed of resident’s condition or provided updates each time nurse provided care, which was almost daily. Wound Master provided an initial evaluation and provided care to R1 on 9/20/24, hospice agency provided updates to R1’s family on 9/20/24 and 9/21/24 no notes on family requesting documents or copies of plans were observed. Family representatives may have asked for copies of wound care plan. However, there are no records to indicate that the family requested R1’s medical records to facility staff. Therefore, there is not sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility retained a resident requiring a higher level of care. It is alleged facility staff and hospice staff attempted to have the family hold off on the ambulance to transfer R1 to a hospital. Interviews conducted with residents revealed residents feel facility staff would assist them with emergencies in a timely manner and feel confident that facility will assist them with obtaining medical assistant in a timely manner. Interviews with staff revealed, staff are aware that if a resident, power of attorney, or family representative chooses to send the residents to the hospital they are to follow the decision taken even if the resident is on hospice. Documents review revealed that R1 was taken to the hospital on three different occasions on the following dates: 7/13/23, 7/20/23, and 10/3/23 per family’s health concerns and request. Facility notes show that on 10/3/23 family requested emergency responders to be contact to take R1 to the hospital for treatment of infected wound. Per hospital records R1 arrived at hospital on 10/3/23 and was admitted on 10/5/23 to be seen for infection of sacral wound. Although the allegation may have happened, documents reviewed note R1 was receiving care by a skilled professional, as well as visited the hospital in three occasions, and was transfer to the hospital on 10/3/24 upon family’s request. 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 and a copy of this report was provided.

On 09/27/24, Program Analyst (LPA) Vaid made an unannounced visit to the facility to conduct a Case Management visit to evaluate third floor -Memory Care, Health and Safety inspection. LPA met with Executive Director Kay Cano and explained the purpose for the visit. The Facility is an 8-floor building located in commercial /residential location. The facility has been renovated to expand housing for memory care residents from first floor to the third floor, housing memory care residents only. Dementia needs will be met on case by case basis. The facility has a new approved fire clearance LIC 850 dated 09/11/2024 and is approved for 245(two hundred fourty-five) non-ambulatory of which 30 (thirty) may be bedridden, hospice waiver for 30. There are currently 28 residents on hospice. Current request for increase to hospice population, awaiting approval. Delayed egress on the third floor and passed the inspection permit BLDMF2022-00588. Bedridden clients approved floor 3. Meet California Building Code 2022 435.5.1- smoke barriers. Three doors on the 3rd floor have the egress delay, each door at the end of hallways and on exit door by the elevators. The doors alarms will engage when attempting the push door open, 15 second delay with alarm blaring before doors open as per fire code. Conducted the 3rd floor inspection with maintenance director John Arbona, whom explained the delay egress process and tested the doors. Staff will have communication via walkie-talkies. 1st floor has a large dining room, common area, kitchen, salon, theater, fitness room, medication room, linen room, laundry room, trash room, club room, multipurpose room, billiard room, staff office, an elevator and public restrooms. The garden area has covered seating areas, walk around path and activities areas for the residents, a permanent garden is overseen by the residents. 2nd floor has lobby area 24 (twenty-four) rooms with bath, laundry room, employee break room, medication room, lobby, and staff office. CONTINUED on 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 3rd floor will house the memory care residents, 1-2 residents per rooms. Dining room, activity room, laundry room. Egress alarms on three doors exiting the floor to the stairwell and each stairwell has evacuation chairs. The appliances in the memory care rooms have been disconnected and/or removed entirely. Kitchen drawers and some appliance like mini fridge remain for a homely feeling to the resident’s room and for residents to store hydrating beverages. The activities room will be used as entertainment lounge and separate locked medication room for memory care residents only. 4th, 5th and 6th floor houses the assisted living for residents, multi-purpose room for dining and activities. Puzzles, game room and poker room for the residents. Floors 7th and 8th : house the independent living residents, laundry room and lounge area (on each floor), and a library on the 7th floor. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. Stairwells have evacuation chairs. No bodies of water were observed at the facility. There is a shaded patio and garden area for residents. The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Medication rooms all observed with first aid kits in the kitchen, vehicles, activity room and in memory care. PPE storage located on the sixth floor. During tour of the physical plant with Kay Cano, LPA did not observe any concerns regarding Health and Safety. Staff were observed to be assisting and engaging with the residents. The memory care unit was observed to be ready and in full compliances to house the memory care residents. Exit interview held and a copy of the report was provided to Kay Cano.

Staff #1- # 3 all stated they have not observed any roaches or rodents in the kitchen and dining room area, Stated that pest control comes every Monday and traps are also set up as a preventative measure. Administrator stated that routine exterminators come to the facility. Stated they come 1x per week and they have not observed any roaches, rodents or flies. LPA reviewed documentation and observed that there were visits conducted in May and June 2024 of general pest control maintenance to treat rodents, roaches and flies by Western Exterminator. LPA inspected the facilities food supply, kitchen area and dining room and did not observe any rodents, roaches and flies. It should also be noted that there was a previous complaint 28-AS-20240425201839 dated 04/25/24 that included the same allegation and findings were 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.

*** This report supersedes report dated 5/2/24 to revise (1) of (4) allegations to an accurate description and provide additional details in the report . Findings delivered have not changed*** In regards to the allegation "Staff do not keep the facility free from pests" it was alleged that the facility dining area has rodents and roaches. (8) of (8) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegations. Interviews with residents did not show that they are aware of or have seen any rodents or roaches in the facility and its dining area. (2) of (8) Staff interviewed did mention that sometime in 2023 there were rodents observed by staff near the back entrances of the kitchen but not in the dining area. No interviews with staff have indicated that there are roaches in the dining rooms. Staff interviewed stated they are aware pest control will always be contacted to address any issues once reported. Staff informed LPA that pest control visits the facility almost twice a week. LPA observed that there were a total of (7) visits conducted in April 2024 of routine maintenance and inspections. Review of pest control notes for the last month do not show that rodents or roaches have been observed in the kitchen or dining area. One note dated 4/26/24 from the pest control agency does mention that there were rodent dropping observed in the air ducts and pipes; therefore, mass trapping measures were recommended. It does not mention which air ducts and pipes; however, the facility agreed to the recommended measure as of 4/30/24. This shows the facility is following through measures to keep the facility free of pests. Based on interviews, observations and files reviewed; 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 do not properly sanitize kitchen items " it is alleged that water pitchers and utensils are not being cleaned properly by staff. (8) of (8) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegations. Interviews with residents denied that they have ever been served dirty dishes or utensils. Staff interviewed explained the process of washing and sanitizing all kitchen and dining utensils requires a prewash before using a sanitization machine for all items. LPA observed kitchen staff washing utensils then sanitizing them via various machines during the visit. LPA did not observe residents being provided unsanitary utensils during the facilities lunch time. Based on interviews, observations and files reviewed; 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. Continued on LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 *** This report supersedes report dated 5/2/24 to revise (1) of (4) allegations to an accurate description and provide additional details in the report . Findings delivered have not changed*** In regards to the allegation "Staff do not keep the facility free from mildew" it is alleged that staff are not cleaning mildew around the facility sinks. (8) of (8) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegations. Staff interviewed stated the kitchen sinks are always cleans after all utensils are done being cleaned. If there is any sign of mildew build up, the staff will clean and disinfect. LPA toured the kitchen area and did not observe mildew around the sinks. LPA entered (6) random resident rooms and did not observe any mildew. File review of maintenance and order requests from residents of the facility does not show that residents are having to call in for assistance regarding mildew. Based on interviews, observations and files reviewed; 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 do not follow proper food handling techniques " it is alleged that the facility has expired sauces, milk, and food in their refrigerators. (8) of (8) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegations. LPA Villalobos observed the facilities food supply and did not see any expired sauces, milk, or food present. LPA did not observe any canned foods to be expired either. Staff stated that expiration dates are written in large letters on all boxes so it is easier to distinguish when something is going to expire. The facility Chefs make rounds throughout the week to observe if anything needs to be disposed of as replaced as new food is brought in two times a week. Based on interviews, observations and files reviewed; 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 conducted and a copy of this report was provided.

In regards to the allegation "Staff do not keep the facility free from rodents" it was alleged that the facility dining area has rodents. (8) of (8) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegations. Interviews with residents did not show that they are aware of or have seen any rodents in the facility. No residents has heard of or seen rodents in the dining area. (2) of (8) Staff interviewed did mention that sometime in 2023 there were rodents observed by staff near the back entrances of the kitchen but not in the dining area. Staff interviewed stated they are aware pest control will always be contacted to address the issues once reported. Staff informed LPA that pest control visits the facility almost twice a week. LPA observed that there were a total of (7) visits conducted in April 2024 of routine maintenance and inspections. Review of pest control notes for the last month do not show that rodents have been observed in the kitchen or dining area. One note dated 4/26/24 from the pest control agency does mention that there were rodent dropping observed in the air ducts and pipes; therefore, mass trapping measures were recommended. It does not mention which air ducts and pipes; however, the facility agreed to the recommended measure as of 4/30/24. This shows the facility is following through measures to keep the facility free of pests and rodents. Based on interviews, observations and files reviewed; 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 do not properly sanitize kitchen items " it is alleged that water pitchers and utensils are not being cleaned properly by staff. (8) of (8) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegations. Interviews with residents denied that they have ever been served dirty dishes or utensils. Staff interviewed explained the process of washing and sanitizing all kitchen and dining utensils requires a prewash before using a sanitization machine for all items. LPA observed kitchen staff washing utensils then sanitizing them via various machines during the visit. LPA did not observe residents being provided unsanitary utensils during the facilities lunch time. Based on interviews, observations and files reviewed; 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. Continued on LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 In regards to the allegation "Staff do not keep the facility free from mildew" it is alleged that staff are not cleaning mildew around the facility sinks. (8) of (8) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegations. Staff interviewed stated the kitchen sinks are always cleans after all utensils are done being cleaned. If there is any sign of mildew build up, the staff will clean and disinfect. LPA toured the kitchen area and did not observe mildew around the sinks. LPA entered (6) random resident rooms and did not observe any mildew. File review of maintenance and order requests from residents of the facility does not show that residents are having to call in for assistance regarding mildew. Based on interviews, observations and files reviewed; 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 do not follow proper food handling techniques " it is alleged that the facility has expired sauces, milk, and food in their refrigerators. (8) of (8) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegations. LPA Villalobos observed the facilities food supply and did not see any expired sauces, milk, or food present. LPA did not observe any canned foods to be expired either. Staff stated that expiration dates are written in large letters on all boxes so it is easier to distinguish when something is going to expire. The facility Chefs make rounds throughout the week to observe if anything needs to be disposed of as replaced as new food is brought in two times a week. Based on interviews, observations and files reviewed; 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 conducted and a copy of this report was provided.

(6) of (6) Staff Interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews do not show that R1 or R2 were ever provided an eviction notice from any staff of the facility either verbally or written. LPA was informed that R1 and R2 are moving out of the facility by choice. LPA confirmed that information with R1, R2 and W1. LPA reviewed R1 and R2's file and did not observe any eviction notices on file. LPA reviewed an email correspondence between the facility and W1 where W1 provided the facility a 30 day notice that R1 and R2 will be moving out of the facility. LPA did not observe wrongful eviction in place regarding R1 and R2. Based on interviews, observations and files reviewed; 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.

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Kay Cano (Administrator) and John Arbona (Maintenance Director) who assisted with the tour, and explained the purpose for today’s visit. The facility is licensed to serve 245 non-ambulatory residents ages 60 and over, of which 30 may be bedridden on 1 st and 2 nd floors, there is an approved delayed egress and hospice waiver for 30. There are currently 24 residents on hospice. The Facility is an 8-floor building located in Pasadena, CA. A tour of the facility included: 1st floor (with memory care wing), large dining room, common area, kitchen, salon, theater, fitness room, medication room, linen room, laundry room, trash room, club room, multipurpose room, billiard room, staff office, 10 private bedrooms with bathroom, an elevator and public restrooms. 2nd floor: 29 rooms with private bathroom, laundry room, employee break room, medication room, lobby and staff office. 3 rd floor: activity room, laundry room, 29 bedrooms with private bathroom, 4 th floor: 29 bedrooms with private bathroom, multi-purpose room, small dining room. 5 th – 8 th floors: 29 bedrooms with private bathroom, laundry room and lounge area (on each floor), and a library on the 7 th floor. There is a large garden area on the premises with covered tables and chairs. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training, and facility maintains the required liability insurance. (Continued on 809-D) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Physical Plant & Environment Safety: LPA toured facility, 20 residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private restrooms and measured within the required range of 105-120 degrees. There is a shaded patio and garden area for residents. Staffing : There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training : Staff have criminal record clearance, current First-Aid training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 10 staff files with no issues observed. Administrator Kay Cano certificate expires on 1/16/24, renewal has been submitted and is pending. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 10 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman near the resident mail room. Planned Activities: Facility provides scheduled activities with a monthly calendar. There is an outdoor activity area available for the residents. 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. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a Medication Room and are in their original containers. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. (Continued 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 Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Facility admits residents with dementia and staff have all required training documented within personnel files. There are currently no bedridden residents at the facility. LPA observed 2 rooms that have oxygen with the required signs posted. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Kay Cano.

• Death Certificate • Physician Orders for Life-Sustaining Treatment for R1 • Appraisal Needs and Service Plan for R1. LPA also conducted interviews with Administrator Kay Cano, S1-S5, and R2-R8. The investigation revealed the following: Allegation: Staff is not providing adequate care and supervision to a resident. The details of this allegation states that R1 was denied care and private caregiver was not allowed to administer medication. Based on interviews conducted the statements obtained all denied above allegation. Interviews with Administrator Kay Cano and S1-S5 revealed that R1 caregiver was able to administer medication until it came to the attention of the facility that R1 was no longer able to manage own treatment/medication/equipment, therefore, per facility procedures, regulations, and meeting of Title 22 regulations the facility placed R1 on medication management. Based on file review MedTechs at the facility have proper certifications and on going training for medication administration. In regards to the facility not providing adequate care and supervision to resident, interviews with R2-R8 all denied allegation. All interviews with residents were consistent and stated they receive proper care when or if needed and feel confident that the facility provides that care to all residents. Based on the information gathered, there is insufficient evidence to support the above allegation to be true. 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 and a copy of this report was provided to Administrator Kay Cano.