Ivy Park at Playa Vista.

On 04/23/2025 between 10:39AM – 02:00PM, the department requested, obtained, and reviewed the following records: LIC500 Personnel Report, Resident Roster, Chase check in the amount of $2,604.19 dated 08/06/2025, Residence and Service Agreement for R8, Notice of Care Increase dated 01/11/2024, Resident Charges/Payment Ledger (covering 01/01/2024 to 02/01/2024 and 04/16/2025) for R8, Kaiser Permanente Hospice Discharge Note/Care dated 03/15/2024 to 03/19/2024 for R8, Special Incident Report (SIR) dated 03/22/2025. A tour of the facility was conducted, and the facility was observed to be clean and in good repair. On 04/23/2025 the department interviewed Staff #1–#4 (S1–S4). On 11/20/2025 the department spoke with administrator 1 Dina Davis (A1). On 09/18/2025 between 09:10AM – 04:50PM the department interviewed Residents #1–#7 (R1–R7). An attempt to interview Resident #8 (R8) was made, but R8 could not be interviewed because they passed away on 03/14/2025. On 7/7/2025, the facility went through a change of ownership. Investigation revealed the following: Allegation: Staff did not provide responsible party with a refund. It is alleged that staff charged resident (R8) for services not rendered and that the facility owes between $10,000.00 and $20,000.00 to the resident and Responsible Party. On 04/23/2025 between 10:39AM – 02:00PM the department interviewed Staff #1–#4 (S1–S4). Out of those interviewed, 4 out of 4 staff denied the allegation. On 09/18/2025 between 09:10AM – 04:50PM the department interviewed Residents #1– #7 (R1–R7). R8 could not be interviewed because they passed away on 03/14/2025. Out of those interviewed, 7 out of 7 residents interviewed denied the allegation. On 11/20/2025 between 08:20AM – 03:30PM the department interviewed the Administrator (A1) and asked the Administrator if R8 was due and provided a refund. A1 responded yes and stated they were provided with a prorated credit of $3,270.30 per their Admission Agreement as R8 passed away on 03/14/2025. A review of records obtained from the facility showed that $3,270.30 was credited to R8’s billing and is reflected on the Resident Charges/Payment Ledger covering 01/01/2024 to 04/16/2025. CONTINUED 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 The department reviewed the Admission Agreement, and Section 9, states that “the resident shall remain liable for the monthly fees until the apartment is vacated and all property is removed from Ivy Park at Playa Vista, and that a prorated refund shall be paid to the resident or Responsible Party for any prorated unused portion of the final monthly fee payment. The department reviewed R8’s Needs and Services plan dated 03/23/2024, which showed that R8 was receiving almost total assistance with Activities of Daily Living (ADL’s} and PRN medication. Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated. Allegation: Staff did not communicate with responsible, party regarding resident’s care. It is alleged that staff failed to communicate with the Responsible Party regarding R8’s care. On 04/23/2025 between 10:39AM – 02:00PM the department interviewed Staff #1–#4 (S1–S4). Out of those interviewed, 4 out of 4 staff denied the allegation. On 09/18/2025 between 09:10AM – 04:50PM the department interviewed Residents #1–#7 (R1–R7). R8 could not be interviewed because they passed away on 03/14/2025. Out of those interviewed, 7 out of 7 residents denied the allegation. On 11/20/2025 the department conducted an interview with the Administrator (A1). A1 said that Responsible Party and/or family members are contacted whenever there are concerns or changes in a resident’s conditions or care. The department obtained charting notes from the facility dated 01/26/2025-03/22/2025 that notate communication with family, as well as letters from the facility to the family dated 01/21/2026 regarding level of care change. Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated. CONTINUED 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 charged a resident for services not rendered. It is being alleged that staff charged Resident #8 (R8) for services that were not provided. On 04/23/2025, between 10:39 AM and 2:00 PM, the Department interviewed Staff #1–#4 (S1–S4) and Residents #1–#7 (R1–R7). R8 was not available for interview as they passed away on 03/14/2025. Out of those interviewed, 4 out of 4 staff and 7 out of 7 residents denied the allegation. On 11/20/2025, the Department conducted an interview with the Administrator (A1). A1 stated that R8’s Responsible Party provided documents indicating that services billed to R8 were rendered. The Department obtained and reviewed R8’s Resident Ledger, which reflected accurate charges for the services listed on R8’s needs and services plan. The Department also reviewed R8’s Needs and Services Plan dated (03/23/2024) and R8’s facility Hospice Care Plan. The documentation shows that R8 received almost total care for activities of daily living. Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated. Allegation: Staff did not provide the Responsible Party with residents’ facility records. It is being alleged that staff failed to provide R8’s Responsible Party with R8’s hospice records. On 04/23/2025, between 10:39 AM and 2:00 PM, the Department interviewed Staff #1–#4 (S1–S4). Of those interviewed, 4 out of 4 staff denied the allegation. On 04/23/2025, between 10:39 AM and 2:00 PM, the Department interviewed Residents #1–#7. R8 was not available for interview as they passed away on 03/14/2025. Out of those interviewed, 7 out of 7 residents denied the allegation. CONTINUED 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 On 11/20/2025, the Department conducted an interview with the Administrator (A1). A1 stated that the facility’s standard protocol is to send or deliver requested records to the Responsible Party via email and verified that R8 was receiving hospice services from Kaiser Hospice agency. The department requested verification of records given to the family. On 7/7/2025 the facility went through a change in ownership, and although A1 tried, they could not verify records requested from previous owner. The facility was able to provide department some hospice notes and plan of care, Per the facilities hospice plan of care, they only maintain certain records at the facility, all others are kept by hospice agency. The department reviewed facility records and found the following: On 3/27/2024 the department was notified via fax of the initiation of hospice services for R8. The department reviewed Hospice Plan of Care for R8 dated 3/19/2024, which details the name of the hospice agency, primary contacts for the hospice agency, an outline of service to be provided by hospice to the resident, an outline of training that hospice will be providing facility staff, brief outlines of licensee vs hospice duties, communication and record keeping. The department also reviewed hospice agency care notes, which just noted recommendations from hospice to facility about residents continued care. Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated. Allegation: Staff did not provide residents with a reappraisal. This complaint alleges that staff failed to provide Resident #8 (R8) with a reappraisal. On 04/23/2025, between 10:39 AM and 2:00 PM, the Department interviewed Staff #1–#4 (S1–S4). Out of those interviewed 4 out of 4 staff interviewed denied the allegation. On 09/18/2025, between 9:10 AM and 4:50 PM, the Department conducted interviews with Residents #1–#7. Out of those interviewed 7 out of 7 residents interviewed denied the allegation. CONTINUED 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 On 11/20/2025, the Department conducted an interview with the Administrator (A1). A1 stated that a Needs and Services Plan or reappraisal is provided to residents and their Responsible Parties upon request, typically within one to two days, which is the facility’s customary practice. A1 further stated that assessments are reviewed and/or sent to the Responsible Party depending on their preferred method of receiving the information. On 04/23/2025, between 10:39 AM and 2:00 PM, the Department reviewed a letter dated 01/25/2024 addressed to R8 stating that a reappraisal and review of the service plan had been completed on 01/22/2024. The letter informed R8 that the facility wished to review the reappraisal and service plan together and offered options for doing so in person, by phone, via email, or in writing. The letter also stated that once reviewed, the service plan needed to be signed and returned to the facility for their record keeping. The department further reviewed facility records and found a

Continued LIC9099-C page 2. The investigation revealed the following: Allegation #1: Staff did not follow proper eviction protocol It is alleged that R1 was denied return to the facility following discharge from the hospital and was not provided with the required 30-day notice of eviction. LPA Bunker interviewed staff members S1 through S4 (S1-S4) regarding the allegation that staff did not follow proper eviction protocol. 2 out of 4 staff stated that they were not employees of Ivy Park at Playa Vista at the time of the incident and had no knowledge of the allegation. 2 out of 4 staff also stated that all employees mentioned in the complaint report are no longer working at the facility. 2 out of 4 staff state that the facility had no records indicating that R1 received a 30-day eviction notice, nor were there any, records or special incident reports stating R1 was told not to return to the facility after being discharged from USC Verdugo Hills Psychiatric Hospital. Interviews with S3-S4 (2 out of 4) staff stated that they were employed at the facility during the incident and reported that R1 had aggressive behavior toward staff and other residents. 4 out of 4 staff interviewed stated that there were no surveillance cameras to capture the incidents. 4 out of 4 staff confirmed that eviction protocols are handled by the Business Office Administration, not by the caregivers. 2 out of 4 staff members interviewed stated that the facility does follow eviction protocols and communication with the resident's responsible parties. No one currently employed at the facility had any additional information. See continued LIC9099-C page 3. 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 Continued LIC9099-C page 3. On 06/19/2025 at 11:48 a.m., LPA interviewed witness 1, W1, via telephone. W1 stated that the facility's Executive Director (ED) at the time, along with a nurse (name unknown), informed W1 that they were no longer working for Ivy Park after their assessment of R1 and that R1 would not be allowed to return to the facility. W1 stated that the ED offered other referrals but suggested Silverado in Rolling Hills. W1 stated on 04/05/2024, R1 was discharged from USC Verdugo Hills Psychiatric Hospital and admitted to Silverado in Rolling Hills. On 06/19/2025 at 10:32 a.m., LPA Bunker contacted Silverado in Rolling Hills (Facility #198320514) and spoke to Executive Director (ED) Christine Hale via telephone, who confirmed that R1 was admitted to Silverado in Rolling Hills on 04/05/2024. ED also confirmed that R1 was on Hospice care and passed away on 11/19/2024. LPA Bunker reviewed the facility records and found no documentation of a 30-day eviction notice or an updated resident assessment. Based on interviews and documentation, the Department has no records to prove that staff failed to follow proper eviction protocol. See continued LIC9099-C page 4. 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 Continued LIC9099-C page 4. Allegation #2: Staff did not communicate with the responsible party regarding the resident's care Interviews were conducted with staff members 1 through 4 (S1-S4) and residents 2 through 7 (R2-R7). Both staff and residents reported that staff ensures that the staff communicates with residents' responsible parties regarding their care. 4 out of 4 staff stated all incidents are reported and that residents' responsible parties are notified in a timely manner. 6 out of 7 residents interviewed stated that staff contact their responsible parties regarding any incident involving them. Resident (1) R1 no longer resides at the facility, is deceased, and was not available for an interview. Based on interviews and documentation, the Department has no evidence to support the allegation that staff failed to communicate with the responsible party regarding the resident's care. Based on interviews conducted, the department did not find 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, did or did not occur, therefore the allegation is unsubstantiated. Copies of the Complaint Investigation Report (LIC9099 and LIC9099-Cs) were provided to Dina Davis, the Executive Director. There were no deficiencies cited. An exit interview was conducted.

Investigation revealed the following: Allegation: Staff did not provide responsible party with a refund. This complaint is alleging that staff charged (R8) for services not rendered and that the facility owes between $10,000.00 and $20,000.00 to (R8’s) responsible party. On 04/23/2025 between 10:39AM – 02:00PM the department interviewed Staff #1 -#4 (S1–S4). Out of those interviewed, 4 out of 4 staff denied the allegation. On 09/18/2025 between 09:10AM – 04:50PM the department interviewed Residents #1 - #7 (R1–R7). On 09/18/2025 between 09:10AM – 04:50PM an attempt was made to interview Resident #8 (R8), but R8 could not be interviewed because according to the Special Incident Report (SIR) Death Report dated 03/22/2025, provided by Ivy Park at Playa Vista, obtained and reviewed by the department, R8 was admitted to Cedars Sanai Hospital Marina Del Rey on 03/14/2025 at 08:40PM and passed away on 03/21/2025 at approximately 05:30AM. Out of those interviewed, 7 out of 8 residents denied the allegation. On 11/20/2025 between 08:20AM – 03:30PM the department interviewed the Administrator (A1) and asked the Administrator if R8 was due and provided a refund? A1 responded yes and stated they were provided with a prorated credit of $3,270.30 per their Admission Agreement because R8 passed away. A review of records obtained from the facility showed that $3,270.30 was credited to his billing and is reflected on the Resident Charges/Payment Ledger documentation covering 01/01/2024 to 04/16/2025. The department reviewed the regulation on service charges contained in the Admission Agreement in Section 9 which states that the resident R8 shall remain liable for the monthly fees until the apartment is vacated, and all property is removed from Ivy Park at Playa Vista and that a prorated refund shall be paid to you or your Responsible Party for any prorated unused portion of your final monthly fee payment. The department has determined that R8 received credit for a prorated amount according to the Resident Agreement and was not owed any refund. CONTINUED 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 communicate with responsible party regarding resident's care This complaint is alleging that staff failed to communicate with the Responsible Party regarding R8’s care. On 04/23/2025 between 10:39AM – 02:00PM, the department interviewed Staff #1- #4 (S1–S4). Out of those interviewed, 4 out of 4 staff denied the allegation. On 09/18/2025 between 09:10AM – 04:50PM the department interviewed Residents #1-#7 (R1–R7). On 09/18/2025 between 09:10AM – 04:50PM. On 09/18/2025 between 09:10AM – 04:50PM an attempt was made to interview Resident #8 (R8), but R8 could not be interviewed because according to the Special Incident Report (SIR) Death Report dated 03/22/2025, provided by Ivy Park at Playa Vista, obtained and reviewed by the department, R8 was admitted to Cedars Sanai Hospital Marina Del Rey on 03/14/2025 at 08:40PM and passed away on 03/21/2025 at approximately 05:30AM. Out of those interviewed, 7 out of 8 residents denied the allegation. On 11/20/2025 the department conducted an interview with the Administrator (A1). A1 said that the Responsible Party and or family members were contacted whenever there were concerns, or changes in conditions. On 09/18/2025 between 09:10AM – 04:50PM the department obtained and reviewed a Notice of Increase in Monthly Rate dated 11/11/2024 and it addressed to R8’s Responsible Party. The department has determined based on interviews; records obtained and reviewed that R8’s Responsible Party received communication regarding R8’s care. Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated. Allegation: Staff charged a resident for services not rendered. CONTINUED 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 This complaint is alleging that staff charged R8 for services that were not provided. On 04/23/2025 between10:39AM – 02:00PM the department interviewed Staff #1- #4 (S1–S4). Out of those interviewed, 4 out of 4 staff denied the allegation. On 09/18/2025 between 09:10AM – 04:50PM an attempt was made to interview Resident #8 (R8), but R8 could not be interviewed because according to the Special Incident Report (SIR) Death Report dated 03/22/2025, provided by Ivy Park at Playa Vista, obtained and reviewed by the department, R8 was admitted to Cedars Sanai Hospital Marina Del Rey on 03/14/2025 at 08:40PM and passed away on 03/21/2025 at approximately 05:30AM.Out of those interviewed, 7 out of 8 residents denied the allegation. On 11/20/2025 the department conducted an interview with the Administrator (A1). A1 stated that R8’s Responsible Party has provided documents that showed R8’s services rendered. The department obtained and reviewed the Resident Ledger, which reflected accurate charges for services rendered. The Resident Charges/Payment Ledger showed rental payments from 12/01/2024 through 09/18/2025. R8’s family was not charged for services not received. The family was notified of rate increases via a letter dated 11/11/2024, effective 01/26/2025. All services billed to R8 were confirmed as rendered. The department has determined that R8’s Responsible Party was provided with documents showing R8’s services were rendered. Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated. CONTINUED 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 provide responsible party with the resident facility records. This complaint is alleging that staff failed to provide the Responsible Party with R8’s facility records. On 04/23/2025 between10:39AM – 02:00PM the department interviewed Staff #1 -#4 (S1–S4). Out of those interviewed, 4 out of 4 staff denied the allegation. On 09/18/2025 between 09:10AM – 04:50PM an attempt was made to interview Resident #8 (R8), but R8 could not be interviewed because according to the Special Incident Report (SIR) Death Report dated 03/22/2025, provided by Ivy Park at Playa Vista, obtained and reviewed by the department, R8 was admitted to Cedars Sanai Hospital Marina Del Rey on 03/14/2025 at 08:40PM and passed away on 03/21/2025 at approximately 05:30AM. Out of those interviewed, 7 out of 8 residents denied the allegation. On 11/20/2025 the department conducted an interview with the Administrator (A1). A1 was asked if staff provided R8’s Responsible Party with R8’s facility records. A1 stated that the facilities usual protocol is records are sent or delivered to the residents Responsible Party via email or written correspondence according to how it is set up by the Responsible Party. The department reviewed the Notice of Increase in Monthly Rate and the Reassessment document, both of which were addressed to R8’s Responsible Party. Interviews with 4 staff and 7 residents confirmed that facility records were provided by the facility to them when requested within a week to 24 hours. The department has determined that the staff did provide R8’s Responsible Party with facility records when requested. Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed 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 Allegation: Staff did not provide residents with a reappraisal. This complaint is alleging that staff failed to provide R8 with a reappraisal. On 04/23/2025 between10:39AM – 02:00PM the department interviewed Staff #1- #4 (S1–S4). Out of those interviewed, 4 out of 4 staff denied the allegation. On 09/18/2025, between 09:10AM – 04:50PM the department interviewed Residents #1- #7 (R1–R7).. On 09/18/2025 between 09:10AM – 04:50PM an attempt was made to interview Resident #8 (R8), but R8 could not be interviewed because according to the Special Incident Report (SIR) Death Report dated 03/22/2025, provided by Ivy Park at Playa Vista, obtained and reviewed by the department, R8 was admitted to Cedars Sanai Hospital Marina Del Rey on 03/14/2025 at 08:40PM and passed away on 03/21/2025 at approximately 05:30AM. Out of those interviewed, 7 out of 8 residents denied the allegation. On 11/20/2025 the department conducted an interview with the Administrator (A1). A1 stated that a Service Plan was and is supplied when requested to all residents and their Responsible Parties within one or two days or request which is our customary practice. A1 also stated that the assessment is reviewed and or sent to the Responsible Party depending on their preference of receiving the assessment. The department obtained and reviewed a Notice of Increase dated 01/25/2024 and a Reassessment Letter addressed to the residents P.O.A, stated that a reassessment and review of the service plan had been completed on 01/22/2024. The letter indicated a change in care from 236 points to 295 points, with a new monthly cost of $5,900.00, effective as of the reassessment date. The change was to be reflected in the next billing statement. A new assessment for R8 was conducted on 02/03/2025 and a return from the hospital resulted in a $2,43

Investigation revealed the following: Regarding the allegation, “staff sexually abused resident in care,” record review of Police Report (06/09/25) revealed that the Officers determined that no crime had occurred. Four out of four staff interviews (S2, S3, S6, S7) indicated they have not witnessed S1 sexually abuse R1. S1 denied the allegation. S4 – S7 witnessed S1 and R1 have a close relationship but did not observe sexual interactions. Two out of two resident interviews (R2 – R3) indicated they have not witnessed S1 sexually abuse R1. R1 denied the allegation. W1, R1’s Power of Attorney, denied the allegation. W2 denied the allegation. Regarding the allegation, “Staff sexually abused resident in care,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to Executive Director Nestor Mendez.

Investigation revealed the following: Allegation: Staff did not provide responsible party with a refund. On 04/25/25 LPA Watson interviewed Staff#1-Staff#4 (S1-S4). Of those interviewed 4 out of 4 staff denied the above allegation. On 09/18/2025 LPA Watson interviewed Residents #1-Resident #7 (R1-R7). Of those interviewed, 7 out of 7 residents denied the allegation. LPA Watson requested and obtained from the Executive Director evidence of a personal check that the responsible, party owed the facility $2604.19 and later paid their balance in full. Based on the information gathered and records reviewed there is insufficient evidence to support the stated 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. 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 communicate with responsible, party regarding resident's care. On 04/25/25 LPA Watson interviewed Staff#1-Staff#4 (S1-S4). Of those interviewed 4 out of 4 staff denied the above allegation. On 09/18/2025 LPA Watson interviewed Residents #1-Resident #7 (R1-R7). Of those interviewed, 7 out of 7 residents denied the allegation. LPA Watson obtained a notice of increase dared (01/25/2024) the informed the responsible party of increase in care in the amount of $5900.00. Based on the information gathered and records reviewed there is insufficient evidence to support the stated 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. 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 charged resident for services not rendered. On 04/25/25 LPA Watson interviewed Staff#1-Staff#4 (S1-S4). Of those interviewed 4 out of 4 staff denied the above allegation. On 09/18/2025 LPA Watson interviewed Residents #1-Resident #7 (R1-R7). Of those interviewed, 7 out of 7 residents denied the allegation. LPA Watson requested, obtained and reviewed the Resident Ledger and is showed the correct charges for services rendered. Based on the information gathered and records reviewed there is insufficient evidence to support the stated 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. Allegation: Staff did not provide responsible party with resident's facility records. On 04/25/25 LPA Watson interviewed Staff#1- Staff#4 (S1-S4). Of those interviewed 4 out of 4 staff denied the above allegation. On 09/18/2025 LPA Watson interviewed Residents #1-Resident #7 (R1-R7). Of those interviewed, 7 out of 7 residents denied the allegation. LPA Watson reviewed a copy of the records that were given to the resident. Based on the information gathered and records reviewed there is insufficient evidence to support the stated 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. 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 provide resident with a reappraisal. On 04/25/25 LPA Watson interviewed Staff#1- Staff#4 (S1-S4). Of those interviewed 4 out of 4 staff denied the above allegation. On 09/18/2025 LPA Watson interviewed Residents #1- Resident #7 (R1-R7). Of those interviewed, 7 out of 7 residents denied the allegation. LPA Watson reviewed and obtained a Notice of Increase that the resident received on 01/25/24. Based on the information gathered and records reviewed there is insufficient evidence to support the stated 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. An exit interview was conducted with the Executive Director, Nestor Mendez and a copy of this report was provided.

Continued LIC9099-C page #2 Appraisal, Needs and Service Plan (dated 03/06/2023), Progress Notes (dated 04/25/2025), Kaiser Permanente Hospital Admission and Discharged Records (03-15/2024-03/19/2024). Kaiser Permanente Care at Home Metro LA Hospice Program (03/19/2024, 03/26/2024, 04/04/2024), Planet Home Health Care Inc. (dated 01/26/2024). The investigation revealed the following: Allegation #1: Staff did not follow proper eviction protocol It is being alleged that Resident 1 (R1) was denied reentry to the facility after being discharged from the hospital and was not provided with the required 30-day eviction notice. LPA Bunker interviewed staff members S1 through S4 (S1-S4) regarding the allegation that staff did not follow proper eviction protocol. 2 out of 4 staff stated that they were not employees of Ivy Park at Playa Vista at the time of the incident and had no knowledge of the allegation. 2 out of 4 staff also stated that all employees mentioned in the complaint report are no longer working at the facility. 2 out of 4 staff states that the facility had no records indicating that R1 received a 30-day eviction notice, nor were there any, records or special incident reports stating R1 was told not to return to the facility after being discharged from USC Verdugo Hills Psychiatric Hospital. Interviews with S3-S4 (2 out of 4) staff stated that they were employed at the facility during the incident and reported that R1 had aggressive behavior toward staff and other residents. 4 out of 4 staff interviewed stated that there were no surveillance cameras to capture the incident. 4 out of 4 staff confirmed that eviction protocols are handled by the Business Office Administration, not by the caregivers. 2 out of 4 staff members interviewed stated that the facility does follow eviction protocols and communication with the resident's responsible parties. No one currently employed at the facility had any additional information. See continued LIC812-C page 3 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 Continued LIC9099-C page 3 On 06/19/2025 at 11:48 a.m., LPA Interviewed the reporting party (W1) via telephone. The W1 stated that the facility's Executive Director (ED) at the time, along with a nurse (name unknown), informed the W1 that they were no longer working for Ivy Park after their assessment of R1 and that R1 would not be allowed to return to the facility. The W1 stated that the ED offered other referrals but suggested Silverado In Rolling Hills. The W1 stated on 04/05/2024, R1 was discharged from USC Verdugo Hills Psychiatric Hospital and admitted to Silverado in Rolling Hills. On 06/19/2025 at 10:32 a.m., LPA Bunker contacted Silverado in Rolling Hills (Facility #198320514) and spoke via telephone to Executive Director (ED) Christine Hale, who confirmed that R1 was admitted to Silverado in Rolling Hills on 04/05/2024, ED also confirmed that R1 was on Hospice care and passed away on 11/19/2024. LPA Bunker reviewed the facility records and found no evidence of a 30-day eviction notice or an updated assessment. Based on interviews and documentation, the Department has no records to prove that staff failed to follow proper eviction protocol. See continued LIC9099-C page 4 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 Continued LIC9099-C page 4 Allegation #2: Staff did not communicate with the responsible party regarding the resident's care Interviews were conducted with staff members 1 through 4 (S1-S4) and residents 2 through 7 (R2-R7). Both staff and residents reported that staff ensures that the staff communicates with residents' responsible parties regarding their care. 4 out of 4 staff stated all incidents are reported and that residents' responsible parties are notified in a timely manner. 6 out of 7 residents interviewed stated that staff contact their responsible parties regarding any incident involving them. Resident (1) R1 no longer resides at the facility, is deceased, and was not available for an interview. Based on interviews and documentation, the Department has no evidence to support the allegation that staff failed to communicate with the responsible party regarding the resident's care. Based on interviews conducted, the department did not find 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, did or did not occur, therefore the allegation is unsubstantiated. Copies of the Complaint Investigation Report (LIC9099 and LIC9099-Cs) were provided to Nestor Mendez, the Executive Director. There were no deficiencies cited. An exit interview was conducted.

Investigation revealed the following: Regarding the allegation, “Facility does not employ adequate staffing to meet the needs of the residents,” it is alleged that there were only two staff members on floors #1, 2, 5 and 6 for the evening shift and the overnight shift and residents are not receiving showers. Record review of Assisted Living Care Schedule (05/04/25 – 05/10/25) revealed four to six staff members, including supervisors, worked Sunday through Wednesday evening (2pm – 10pm) and two to three staff members worked overnight (10:00pm – 6:00am). Seven staff members, including supervisors, were scheduled Thursday evening and three staff members were scheduled for the overnight shift. Four to six staff members, including supervisors, were scheduled for Friday and Saturday evening and two staff members were scheduled for the overnight shifts. Interview with S1 indicated that there are 42 residents in assisted living, management assist whenever there is a call off, and the memory care staff are also available to help in assisted living. Thus, the facility can have eight caregivers at one time. Four out of four staff interviews (S5, S7, S8, S10) indicated that memory care will support in assisted living when called. Three out of four staff interviews (S1-S2, S6 – S7) indicated there is enough staff to meet the needs of the residents. Three out of three staff interviews (S3-S5) indicated the facility is short staff due to call offs, but they are able to meet residents’ needs. Record review of the call logs revealed 21 resident calls were made on Friday, 5/9 from 10:00 PM – 6:00 AM. Two to four calls were made per hour. Record review of Assisted Living Care Schedule revealed two staff members worked. Both staff members indicated they were able to meet the needs of the residents. Record review of the call logs revealed 14 calls were made on Saturday, 5/10 from 10:00 PM – 6:00 AM. One to three calls were made per hour. Record review of Assisted Living Care Schedule revealed two staff members worked. Both staff members indicated they were able to meet the needs of the residents. Two out of three resident interviews (R1, R3, R8) indicated there is enough staff. Three out of three resident interviews (R4, R6, R7) indicated there isn’t enough staff but they are able to respond to care needs. One of out of two witnesses denied the allegation and the third witness declined to be interviewed due to no concerns. Regarding the allegation, Facility does not employ adequate staffing to meet the needs of the residents, based on record review and interviews, the Department found no evidence to support the allegation mentioned above. 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. 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: Regarding the allegation, “Residents are left in soiled diapers for extended periods of time,” it is being alleged that some residents are left in soiled diaper for extended periods of time. Record review of register of residents revealed there are eleven residents who require incontinence care. Six out of seven staff interviews (S1 – S7) indicated residents are not left soiled for an extended period. Interview with Executive Director and Health Services Director indicated there hasn’t been any resident nor family complaints. Three out of five resident interviews (R2 - R4, R6, R8) indicated they are not left soiled for an extended period. R1 and R5 indicated no incontinent assistance is needed. One of out of two witnesses denied the allegation and the third witness declined to be interviewed due to no concerns. Regarding the allegation, “Residents are left in soiled diapers for extended periods of time,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. 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. No deficiencies issued. A copy of this report was reviewed and provided to the Executive Director Nestor Mendez.

On 04/25/2025, Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Case Management visit to gather additional information regarding a complaint that was reported to Community Care Licensing received on 04/18/2025, Control #11-AS-20250418112036. LPA met with Kaywanee Sorrells, Health Services Director, and explained the purpose of the visit. On 04/25/2025, the Department asked for copies of the following documents: Resident 1 (R1) Record, Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Consent Forms, Functional Capability Assessment, Special Incident Reports, USC Verdugo Hills Psychiatric Hospital Records, Preplacement Appraisal Information, Appraisal, Needs and Service Plan. During today's visit, Resident 1's records were unavailable for review during the complaint visit. According to the California Code of Regulations, Title 22, Division 6, Chapter 8, the Department observed the following deficiency, the facility is being cited on the attached LIC809-D. Appeal rights were discussed, and copies of the LIC809, LIC809-D, and appeal rights were provided to Health Services Director Kaywanee Sorrells. An exit interview was conducted.

Allegation: Facility staff increased residents’ rent without the required written notice. It is being alleged that the facility did not provide the required written notice before increasing Resident #1’s (R1) monthly care level before R1’s return from a temporary stay in rehab in 2024. On 04/02/2025, LPA Richard Record review of the Residency Agreement revealed that on 11/01/2023, the facility sent a Notice of Increase in Monthly Rate to all the residents. On 04/02/2025, LPA Richard interviewed the Regional Operation Specialist (ROS) Dina Davis, who stated that the changes in services provided will be reflected in a revised service plan to the Resident/Responsible Party of such revaluation, the facility would not increase a resident monthly care level fee without inform the resident responsible party through emails, mails, or given a copy to the residents. Record review of the resident #1 (R1’s) Notice of Increase in Monthly Rate (dated 11/01/23) revealed that effective 01/01/24, care fees will increase by 10%, due to the increase in year-over-year costs. And the care fees, if any, will remain the same at this time unless the care needs of the resident change . A record review of R1’s Charges/Payment Ledger revealed R1’s monthly care fee remained consistent from 01/01/2024 to 09/01/2024, until the day R1 moved out of the facility on 09/01/2024. LPA records review of R1’s Charges/Payment Ledger indicated R1 received credit for being in rehab (dated 05/21/24 to 05/31/24), and after R1 came back to the facility. Continued 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 On 04/02/25, LPA interviewed five (5) residents (R2-R6), 5 out of 5 stated that their family member talked to them about receiving notice of the increased monthly rate, and they also stated that they understand that if the resident needed more care, the rate would go up. On 04/02/25, LPA interviewed four (4) staff (S1-S4), 3 out of 4 stated that they knew about the facility sending out a Notice of Increase in Monthly Apartment Home rent to all the residents/responsible parties. Regarding the allegation, the Facility staff increased residents’ rent without the required written notice. Based on record reviews and interviews, LPA found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiencies were cited. Exit interviewed conducted. A copy of the report was provided to the Executive Director Nestor Mendez.

Record review of the Residency Agreement revealed if the resident's condition changes so that the previously assessed Service Level is no longer appropriate, the Community will reevaluate the Resident's needs to determine which Level is appropriate and notify the Resident/Responsible Party of such reevaluation. The fee charged will be based upon the Service Level provided. Should the Resident wish to decrease the services received, prior approval from the Community is required. Changes in services provided will be reflected in a revised service plan. Record review of R1’s Care Fee Notice (10/31/25) revealed effective 01/01/25 care fees will increase 6%. S1 indicated that legacy residents, those living at the facility under the previous Licensee, received this flat rate increase. Record review of R1’s Charges/Payment Ledger revealed R1’s care fee remained consistent from 01/01/24 – 12/01/24. There is a rate increase as of 01/01/25. Four out of four staff interviews (S1, S3, S4, S6) indicated notices are provided before there’s an increase of care cost. Regarding the allegation “Staff did not provide written notice of rate increase due to level of care, based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation: Regarding the allegation "Staff do not communicate with resident's authorized representative regarding care in a timely manner,” it is being alleged Resident #1 (R1) fell in February 2025 and staff did not contact the primary point of contact (Witness #1/W1). It is alleged that the staff hasn’t called W1 for previous incidents either. Record review of Residency Agreement revealed in the event that the Resident requires emergency services or experiences a significant change in condition, the Community will attempt to contact the Responsible Party or other individual designated by the Resident, within twelve (12) hours. The Resident is responsible for ensuring that the Community has current telephone numbers for the individuals to be notified. Record review of R1’s face sheet reveals W1 as the responsible party. Record review of R1’s Face Sheet lists W1 as the responsible party. Five out of five staff interviews (S2 – S6) indicated that the authorized representative is contacted when incidents occur. Five out of nine resident interviews indicated staff communicates with authorized representatives. 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 Regarding the allegation “Staff do not communicate with resident's authorized representative regarding care in a timely manner,” based on record reviews and interviews the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Regional Operations Specialist Dina Davis.

On 01/24/25 between 10:20 am- and 12:15 pm, LPA Richard interviewed one resident #1 (R1) who denied the allegation and stated it was superficial scratches on the right leg that only needed a band-aid. On 01/24/25 between 12:00 pm and 2:30 pm, LPA interviewed six staff #1-6 (S1-S6) 6 out of 6 denied the allegation. They stated that they all received training on how to use the Hoyer lift before using it. The record review of the facility Shift Report (dated 01/19/25 to 01/20/25) indicated that R1 was seen by the facility nurse for a superficial scratch on the right leg, and first aid and a patch were administered. On 01/24/25, LPA did not observe any visible laceration on R1's right leg. Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated. Allegation #2: Staff use drugs on the facility grounds. It is being alleged that staff used drugs on work premises. On, 01/24/25, between 10:20 am, and 12:00 pm LPA interviewed eight residents #1-8 (R1-R8) 7 out of 8 stated that they had never witnessed any of the staff using drugs on the ground of the facility. On 01/24/25, between 12:00 pm and 2:30 P.m., LPA Richard interviewed six staff #1-6 (S1-S6) 6 out of 6 denied the allegation and stated that the facility has rules on using drugs or disorderly conducted inside or outside the facility premises. All the staff stated that the facility has a town hall each month with staff and residents to make sure the residents and staff can report to management anything they see outside the facility premises. Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated. Allegation #3: Staff did not follow injection procedures for the residents. It is being alleged that medication technicians instructed other staff to falsely chart insulin injections as being given on time when they had not, and the staff would administer it later. On 01/24/25, at 12: 00 p.m. LPA Richard interviewed the staff (S6) Health Services Director who denied the allegation and stated that the facility only has two residents who are in insulin injections. 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 The facility does assist them with the injections. S6 stated that when the other resident went to dialysis the family administered the injection on those days Monday, Wednesday, and Friday morning. On, 03/21/25, between 9:20 am, and 9:30 am, LPA interviewed one residents #8 (R8) R8 denied the allegation and stated that the nurse assisted R8 with the injection and R8 wanted to do it self, but the nurse refused. LPA record review of MARs dated 10/07/24 to 01/22/25 revealed no false entries and also indicated the date and time when the injections were administered. On 01/24/25, LPA observed the facility computer generate documents showing when the insulin injection was given on time in the morning, and evening but charging late entry. Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated. Allegation #4: Staff did not inadequate record keeping for the residents. It is alleged that staff has illegal chart charting and false documentation of residents' reports. On 01/24/25 LPA Richard interviewed six staff #1-6 (S1-S6) 6 out of 6 denied the allegation and stated the facility keeps adequate records on all the care provided to residents in care. LPA interviewed Staff #4 (S4) Executive Director who stated that accurate records are kept for all residents including all medical records, incident reports, visitor logs, emails, hospice records, hospital records, and notes of all residents who refuse medications. S4 also stated that all the family members can obtain and review all records of the resident. S4 also stated all facility staff take continuous training in record keeping. On 01/24/25 LPA Richard's record review of the facility record keeping of the MAR (dated 10/07/24 to 01/22/25) revealed the facility staff signed and dated all the residents who took or refused medications that day. On 01/24/25, LPA Richard reviewed the Quick Mar System that showed all the previous records keeping dated 09/10/2024 to 01/22/25 of all residents were adequate. Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated. 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 #5: Staff mishandled the resident's medications. It is alleged that medication had not been passed to the resident and the staff charted false information to the Quick Mar system and claimed the medication was given at a specific time. On 01/24/25, LPA Richard interviewed staff #6 (S6) Health Service Director who denied the allegation. S4 also stated that the Medical Administration Record (MAR) is kept for every resident in care who takes medications at the facility. The MARs are signed at the time medications are administered. The facility passed out the medication using the locked cart, and staff #3 (S3) MedTech would go to where the residents were at the time to administer the medications. On 01/24/25 LPA Richard's record review of the MAR (dated 10/07/24 to 01/22/25) revealed the facility staff signed and dated all the residents who took or refused medications that day. On 01/24/25, LPA Richard reviewed the Quick Mar System that showed all the previous medications dated 09/10/2024 to 01/22/25 of all residents were signed and given on time. Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated. Allegation #6: Staff did not seek timely medical attention for a resident. It is alleged that due to a lack of first aid supplies staff apply band-aid instead of providing proper care. On 01/24/25, between 12:00 pm and 2:30 pm, LPA Richard interviewed six staff #1-6 (S1-S6), 6 out of 6 who stated that the facility does assist residents on time. No resident has complained or informed them that they did not receive assistance in a timely manner. On 01/24/25 between 10:20 and 12:00 pm, LPA Richard interviewed eight residents #1-8 (R1-R8) 8 out of 8 denied the allegation and stated the staff was always quick to assist them as soon as they asked for assistance, and they were happy with the staff response time. On 01/24/25, LPA reviewed the S6 Shift notes dated 01/19/25 to 01/21/25, which showed R1 received proper medical attention on time. During the tour of the facility on, 01/24/25, LPA Richard observed the facility has numerous fire extinguishers and several first aid kit supplies on all floors. Based on interviews, observation, and record review LPA Richard found no evidence to support the allegation. Continue to 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 interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated. Allegation #7: Staff did not provide a safe environment to the resident. It is alleged that staff are having inappropriate behavior, arguing in a resident's room and the executive director had to intervene. On 01/24/25, between 10:20 and 12:00 pm, LPA interviewed eight residents #1-8 (R1-R8) 8 out of 8 denied the allegation. On 01/24/25 between 12:00 P.m. to 2:30 P.m., LPA interviewed six staff #1-6 (S1-S6) 6 out of 6 denied the allegation and stated that the facility has rules for the staff not to yell or speak too loud inside the resident rooms. The facility has a town hall with the resident so they can let the facility staff know what is on their mind, and what the staff are doing right or wrong. Based on interviews LPA Richard found no evidence to support the allegation mentioned above. Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated. Allegation #8: Staff did not follow infection control requirements. It is alleged that medication that have been left out from the AM shift needs to be refrigerated and discarded to prevent contamination and infecting the residents. On, 01/24/25, between 10:20 am, and 12:00 pm, LPA interviewed eight residents #1-8 (R1-R8) 8 out of 8 stated that the staff does follow infection co

On 09/26/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual continuation inspection and met with the Executive Director Khatera Bahadory . The facility is licensed to serve 102 non-ambulatory of which 18 may be bedridden. It has a hospice waiver for 20 residents. The facility currently has two bedridden residents and three hospice residents. The facility has six floors which consist of resident bedrooms, bathrooms, living room, activity rooms, dining room, laundry rooms, storage rooms, beauty shop, reflection rooms, wellness center, kitchenettes, and main kitchen. Delayed egress is located on the third and fourth floors (Memory Care). The facility has a Call Light signal system, which is monitored by a beeper carried by staff and is also registered on a central computer located in the Wellness Center on the second floor. The system is activated by a pendent or pull cord from each resident bathroom and bedroom. In addition the signal system is activated when any exit is opened (excluding Memory Care). On 09/05/24, the Administrator accompanied LPAs Cloyd and Hollie Enriquez inside the facility during this inspection. LPA Enriquez inspected the first floor, second floor (rooms 209, 212, 221, and 225), and stairwells. LPA Cloyd inspected the third floor (rooms 312, 320, and 326), fourth floor (410, 412, 421, and 426), fifth floor (rooms 508, 509, 515, and 522), and sixth floor (rooms 605, 611, and 615). Continue to 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 Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat or no-skid flooring was in place. The hot water temperature properly measured at 105.5 degree F (second floor common bathique room), around 115 degree F ( rooms 209, 212, 221, and 225), 105.1 degree F (room 410), 113.8 degree F (room 508), and 118.7 degree F (room 611). There are no security bars or weapons on the premises. LPA Enriquez toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. Common areas were clean and clear of hazards. Doorways were free of obstructions. F ire extinguisher, last serviced in October 2024, November 2024, and December 2024 was observed throughout the facility. Eleven staff records were reviewed, eleven out of eleven staff records had required criminal record clearances or criminal record exemptions. Nine resident records were reviewed and, nine out of nine resident records had medical assessments. Two residents’ medication was reviewed. On 09/26/24 11:30 AM, the Executive Director and Administrator toured outside grounds and no bodies of water were observed. Walkways around the facility were clear of hazards. First Aid kits are available on each floor. The last fire drill occurred on 09/16/24. The Executive Director indicated that fire inspection are conducted with the drills. No deficiencies are being cited. An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Executive Director Khatera Bahadory .

On 09/05/24, Licensing Program Analysts (LPA) Regina Cloyd and Hollie Enriquez conducted an unannounced required – annual inspection and met with the Executive Director Khatera Bahadory . The facility is licensed to serve 102 non-ambulatory of which 18 may be bedridden. Hospice waiver for 20 residents. Delayed egress on the third and fourth floor. The facility has 6 floors which consist of resident bedrooms, bathrooms, living room, activity room, dining room, and kitchen. Floors 3 and 4 are used for memory care. The Administrator accompanied LPAs inside the facility during this inspection. LPA Enriquez inspected the first and second floor. LPA Cloyd inspected the third, fourth, fifth, and sixth floor. Common areas were clean and clear of hazards. Doorways were free of obstructions. LPA Enriquez toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. Staff and resident records were reviewed. Emergency disaster and infection control plan was reviewed. Due to insufficient time, an annual continuation is needed. No deficiencies are being cited at this time. An exit interview was conducted and a copy of this report was discussed and left with Executive Director Khatera Bahadory .

On 08/15/24, Licensing Program Analyst (LPA) Regina Cloyd was conducting a complaint (11-AS-20240807164428) visit and informed Executive Director and Resident Care Coordinator that Community Care Licensing has not received any June, July, nor August unusual incident reports from the facility. During interviews, LPA learned that the documents were not faxed to the (424) 544-1016 number. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. A copy of this report and technical violation was provided to the Executive Director Khatera Bahadory .

The investigation revealed the following: Regarding the allegation "Staff does not respond to residents call in a timely manner," it is being alleged that the facility is severely understaffed, especially after 9:00 PM, and staff did not respond to Resident #1’s (R1) pull cord on 08/07/24. It is being alleged that on 07/13/24, R1 had to wait two hours for staff to respond to the pull cord. It is also being alleged that visitors cannot enter at night because no one is at the front desk. Record review reveals the following: The 08/07/24 SMARTcare report does not indicate that R1 needed assistance in the evening. The 07/13/24 SMARTcare report was not archived; therefore, unavailable. LPA observed pull cords in residents’ room and pendants around some residents’ neck. Four out six resident interviews indicated that night staff responds in a timely manner. Three resident interviews indicated that night staff care hasn’t been needed. One resident was unavailable. One resident interview indicated that he/she will call the after-hours number if staff did not respond to the pull cord or pendant. Record review revealed that the facility has a contact list that includes a number for concierge, assisted living after hours, and memory care after hours. Interview with the Executive Director indicated that the contact list is provided to families, and they may call the after-hour number for entry since doors lock at 8:00 PM. Seven out of eight staff interviews, including the Executive Director, indicated that staff responds immediately or within 5 – 10 minutes. Interview with the Executive Director indicated that night staff conduct at least three rounds: at the beginning of their shift, around 1:00 AM, and around 4:30 AM or 5:00 AM. The Executive Director also indicated that from 10:30 PM – 5:45 AM, there is a MedTech, three care providers for assisted living, a floater and two to three care providers for memory care who can respond to residents’ calls in a timely manner. Regarding the allegation “Staff does not respond to residents call in a timely manner," based on record reviews, observation, and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Executive Director Khatera Bahadory.

The investigation revealed the following : Allegation #1- Staff are charging resident for services not rendered. The details of the complaint alleged that R1, as of two months ago, is no longer at the facility. However, the facility is charging for services not provided for R1 as R1 was in the hospital for two months. On 06/27/24, from 11:00am-1:00pm, LPA interviewed staff (S1) regarding the allegation. R1 could not be interviewed because R1 is no longer at the facility and no new contact information was given. 1 of 1 staff denied the allegation that the Staff are charging resident for services not rendered. S1 stated that R1 was in the hospital for several months and returned on 03/22/2024 where R1 was placed in the Memory Care unit as opposed to Assisted Living where the resident was living before R1 went into the hospital. S1 stated that the resident lived at the facility until 04/23/2024 when a thirty-day notice was given by the family member that they were taking R1 home. S1 advised that they needed to give a thirty-day notice, as stated in the admission agreement. LPA reviewed the admission agreement (Dated: 03/21/2024) that states if You move out without providing thirty (30) days’ notice, You will be responsible for the amount of your monthly fee through the date You move plus one full month’s fees. However, S1 stated that the resident is not being charged for services not rendered, when in fact the resident is due a refund for $7,157.42. After the facility prorated fees and the months the resident was in the hospital the residents account had a credit due. LPA reviewed the Final Account Statement (Dated: 05/31/2024) as well as the Resident Charges/Payments Ledger for 11/13/2023-06/27/2024 (Dated: 06/27/2024) and found that a refund was due. S1 stated that the facility has the check for the resident and has tried to get in contact with the family member that has Power of Attorney, but they have not returned their calls. S1 stated that the check is here for the resident, they did not want to mail it as the address may have changed. They will continue to call the family member until the matter is resolved and the check has been issued. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are charging resident for services not rendered. 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. An exit interview was conducted with Andrea Weathersby, Administrator, and a copy of this report was provided.

The investigation revealed the following: Allegation: Staff did not give authorized representative a copy of the care plan. It is alleged that staff did not provide authorized representative with a copy of the care plan and that authorized representative was told that there was never a care plan written for the resident. R1 was admitted to this facility on 03/18/23. LPA interviewed Sabrina Tucker, Executive Director and she stated that they go over the Care Plan with the authorized representatives when going over and signing the Residency Agreement. Records review revealed that on 11/3/23 a copy of the Care Plan and Residency Agreement was provided to resident #1 family member (R1 FM1) via email from Executive Director Sabrina Tucker. On 05/15/24 LPA spoke with FM1 to verify information and confirmed the electronic email address for FM1. Based on records review, and interviews with staff, LPA did not find sufficient evidence to support the above allegation. Allegation: Due to staff negligence, resident was found unconscious on floor for an unknown time. It is alleged that on 08/23/23 the reporting party got a call from the staff at the facility saying that they found resident on the floor unresponsive, and they did not know how long she had been on the floor. Reporting party was concerned that no staff checked on the resident to verify if she was okay. Records review revealed that on 08/28/23 as a medication technician was entering the resident’s apartment suite, she found the resident on the floor. 911 paramedics were called, and the resident was transported to the hospital. On 11/06/23, LPA Montoya conducted interviews with six staff members (S1-S6) and four residents (R1-R4). On 05/15/24 LPA Gonzalez conducted interviews with Executive Director, Sabrina Tucker and four residents (R5-R8) Based on interviews conducted, five out of six staff stated that they did not know of any incident where a resident was found unconscious on the floor due to staff negligence, and six out of eight residents stated that they haven’t heard of a resident falling and staff not tending to them when they call for assistance. Based on records review, and interviews, LPA did not find sufficient evidence to support the above allegation. Continued on LIC9099 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff did not respond to authorized representative’s calls. It is alleged that on 10/30/23, reporting party called the resident and noticed the resident was having trouble using the phone. Reporting party then called the main office five times to ask staff to check on the resident. Reporting party stated that they did not get a call back until 7 PM after they had been calling the facility all afternoon. On 11/06/23, LPA Montoya conducted interviews with six staff members (S1-S6) and four residents (R1-R4). On 05/15/24 LPA Gonzalez conducted interviews with Executive Director, Sabrina Tucker and four residents (R5-R8) Based on interviews conducted, six out of six staff stated that they did not know of a family member or an authorized representatives calls not being returned. Staff stated that they try and return family members calls as soon as possible. Eight out of eight residents interviewed stated that they haven’t heard of their family members calls not being returned and that staff do their best at keeping up with the residents. Based on records review, and interviews, LPA did not find sufficient evidence to support the above 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 was conducted and a copy of the report was provided to Sabrina Tucker, Executive Director.

Allegation #1– Staff are administering resident's medication against her and POA's will. On 4/10/2024 LPA Espana conducted interviewed with 6 staff members (S1-S6). LPA asked about staff if any resident's medication was administered against their will or POA's will. Of those interviewed 6 out of 6 stated that they did not hear or know of medication being provided against residents or POA’s will. On 4/10/2024 LPA Espana interviewed 6 residents (R1-R6). Of those interviewed, 6 out of 6 communicated that they disagreed with the statement because they have had no issues with medications being provided by staff. On 4/10/2024 LPA Espana interviewed the Administrator who stated that for residents who refuse, the facility staff does not administer medication. The Administrator stated that the facility staff document resident refusal and call the doctor to let them know. The Administrator stated that, there were no residents who have refused medication at the time of visit. Based on interviews and observations there is insufficient evidence to support the allegation: Staff are administering resident's medication against her and POA's will. 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 Allegation #2: Staff are not honoring resident's POA document. On 4/10/2024 LPA Espana conducted interviewed with 6 staff members (S1-S6) regarding the allegation. Of those interviewed 5 out of 6 staff members, communicated that the facility honors all residents’ POA documents. On 4/10/2024 LPA Espana interviewed Residents #1-#6 (R1-R6). Of those interviewed, 4 out of 6 residents, communicated that they have not heard anything like that. On April 10, 2024, LPA España reviewed facility documents and found Durable Power of Attorney for Health Care signed by POA of R1. Based on interviews and observations there is insufficient evidence to support the allegation: Staff are not honoring resident's POA document. 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 Allegation #3: Staff are not allowing resident to have visitors. On 4/10/2024 LPA España interviewed 6 staff members, of those interviewed, with 5 out of 6 stated that the facility allows visits for the residents in care. Interviews with 6 out of 6 residents, communicated that they always have visitors no matter the day. There is no problem with visits at the facility. Interview with the Administrator Sabrina Tucker stated that the residents are allowed to have visitors. On April 10, 2024, LPA España reviewed files and found that the Residential Agreement allows family visits anytime, provided visitors residents' and staff rights, and follow visitation policies. Overnight stays require written notification to the Executive Director, and all visitors must register at the front desk. Based on interviews and observations there is insufficient evidence to support the allegation: Staff are not allowing resident to have visitors. 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 Allegation #4: Staff are not allowing resident use of the phone. On 4/10/2024 LPA España interviewed 6 staff members (S1-S6), of those interviewed, 5 out of 6 communicated that the facility does allow residents to use phones and receive calls from families. LPA Espana interviewed 6 residents, of those interviewed 6 out of 6 communicated that they have their personal cell phones and do understand there is a blue telephone on each floor they have access to daily. Based on interviews and observations there is insufficient evidence to support the allegation: Staff are not allowing resident use of the phone. 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 issued during this complaint investigation visit. An exit interview was conducted with the Administrator Sabrina Tucker and a copy of this report was printed and given. 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 page has been left intentionally blank

On 09/21/2023 at 8:30 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Continuation Inspection and met with the Director of Business, Andrea Weathersby and Administrator Sabrina Tucker. Weathersby and Tucker accompanied Cloyd inside the facility to inspect the kitchen, resident rooms, and review of (R2 & R6) resident medication. In addition, five residents and four staff members were interviewed, and more facility records were reviewed. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. Fire extinguishers were last serviced on 9/4/2023. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid strips was in place, hot water temperature properly measured at 114F. Common areas were clean and clear of hazards, doorways were free of obstructions. The Infection Control Policy– General Policy, (1) Resident and Services Agreement, Liability Insurance, Hospice Plan of Care Template, Employee Training Courses, Plan of Operation (including Dementia, Hospice, and Bedridden), and Quarterly Fire Drills were reviewed. Due to time constraints an Annual Continuation visit will be conducted. A copy of this report was discussed and left with the Administrator, Sabrina Tucker.

On 09/20/2023 at 8:14 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Barbara Tabb, Director of Memory Care. The facility is licensed to serve 102 non-ambulatory of which 18 may be bedridden. Hospice waiver for 20 residents. New management CO, Oakmont Management Group LLC. Effective 7/1/2023. An estimate of eighty-eight (88) residents were present during this inspection. The Annual Licensing Fees are not current. The facility has 6 floors which consist of resident bedrooms, bathrooms, living room, activity room, dining room, and kitchen. Floors 3 and 4 are used for memory care. Mrs. Tabb accompanied LPA inside and outside the facility during this inspection. The facility is in the process of having a new elevator installed. Current elevator vendor is using parking spaces near walkway, a small patio area, and indoor room to store items. 10 staff records were reviewed, but incomplete. However, all staff were cleared and associated to the facility and had current first aid certificates. 10 resident records were reviewed, but incomplete. Due to time constraints an Annual Continuation visit will be conducted. A copy of this report, LIC 859 (Review of Staff Records), LIC 859-C (Review of Staff Records Continued), LIC 858 (Resident Records Review), and LIC 858-C (Resident Records Review Continued) was discussed and left with Business Office Director, Andrea Weathersby.