Westmont of Riverside.

Licensing Program Analyst (LPA) Yolanda Delgado is conducting an unannounced case management visit on this date to check on the health, safety, and welfare of clients in care. LPA learned one hundred sixty-six (166) clients reside at the facility and forty-three (43) clients reside in Memory Care. There are twenty-seven (27) staff on duty currently for the area. LPA conducted interviews, in addition, LPA toured the facility and found no immediate H&S concerns present during today’s visit. Based on the information obtained today, there are no deficiencies that were issued per Title 22, Division 6, Chapter 8 of the California Code of Regulations. This report was reviewed with Moses Rivas along with LIC811 and copy provided at the time of the exit interview.

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry by Mary Valendez. LPA began inspection with introduction, visit purpose and provided the facility LPA identification and business card. Resident record review began- Twenty (20) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Employee records review began- Ten (10) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification expires 09/11/2027. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 108.2 degrees F. Laundry facilities located on each floor with automatic detergent dispensing and other chemicals secured and locked in the designated areas. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. (Continued on Page 2) 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 from Page 1) Food Service- Food supply meets the of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 12/26/2024. Facility is conducting emergency disaster drills monthly, last done on 09/23/2025. Corporation is active and in good standing. Based on the information received during this visit today, zero (0) deficiency is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with Judith Pierfax and a copy provided at the time of the exit interview. *LPA was away from the facility from 12:00 PM-1:00 PM

Allegation: #1 : Facility does not have the ability to accommodate non-ambulatory residents with dementia in case of fire. The complaint alleges that there aren’t a lot of emergencies or fire exits for residents in care. From 11:00 AM to 1:00 PM, the License Program Analyst (LPA) interviewed the Resident Services Director (RSD), who denied the allegations. The RSD stated that the facility has multiple exit doors and sufficient staff to assist non-ambulatory residents. During the same period, the LPA also interviewed five staff members (S1-S5), all of whom denied the allegations. They mentioned that they have been trained to assist residents during a fire, particularly those with dementia. The staff further noted that both the dementia wings and assisted living wings have numerous emergency exits. And the facility has a number of staff working on any given day. Additionally, the LPA interviewed eight residents (R1-R8), all of whom denied the allegations and stated that they knew something about evacuating in case of a fire. Records of the facility’s Memory Care layout indicated that there are several fire exits throughout the building. During the facility tour on August 23, 2025, the LPA observed multiple fire exit doors, fire extinguishers, exit lights, and an Evacuation Plan poster with instructions posted in various locations. The LPA also noted that most fire exit doors open outward, facilitating safe exits from the building. Some doors open automatically when approached, eliminating the need for a push-button feature and allowing residents to navigate the facility safely. Report 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 Based on the information gathered, and the interviewed conducted, there is insufficient evidence to support the allegation. Although the allegations above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED . Allegation: #2 : Facility does not conduct emergency drills as required. The complaint alleges that the facility hasn’t been providing fire and safety drills, and that is creating a fire hazard for residents in care. On August 23, 2025, from approximately 11:00 AM to 1:00 PM, the LPA interviewed the Resident Services Director (RSD), who denied the allegations. The RSD stated that the facility conducts fire drills and fire safety training quarterly and provides in-service training for all staff. During the same time frame, the LPA also interviewed five staff members (S1-S5), all of whom denied the allegations and claimed they had been trained to conduct fire drills monthly. Additionally, they mentioned that they receive training in earthquake and disaster preparedness quarterly, and that the facility conducts annual fire drills for residents. The LPA interviewed eight residents (R1-R8) on the same day, all of whom denied the allegations. They stated they had attended some fire drills. The LPA reviewed records of the last in-service fire drills and disaster preparedness training, which were conducted on January 27, 2023, February 23, 2023, April 2, 2023, and July 31, 2025. The last Emergency Preparedness drill for residents took place on September 30, 2024. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During a tour of the facility on August 23, 2025, the LPA observed multiple fire extinguishers mounted throughout the premises. Furthermore, on that day, the LPA noted that the facility experienced a power outage, and all staff were prepared to assist residents in their care. Based on the information gathered, and the interviewed conducted, there is insufficient evidence to support the allegation above. Although the allegations above may have happened or are 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 cited. An exit interview was conducted. A copy of this report was provided to the staff Giovanna Pazmino.

Regarding the allegation, “Resident has not received treatments that were ordered by her doctor,” it is being alleged that Resident #1 (R1) is being neglected by staff because R1 did not receive R1’s medication infusion. Record Review of R1’s Admission Orders (dated 09/02/21) does not include the medication infusion. R1’s Hospice Care Plan (dated 01/21/22) does not include medication infusion. R1’s Medication Destruction Record (dated 02/24/22) does not include medication infusion. Interview with Witness #1 indicated that R1 received medication infusion through a Home Care agency. Witness #2 indicated that there were multiple orders, including in November and in December. Seven out of seven staff interviews (S1 – S7) indicated they have not received resident complaints about being neglected for not receiving home health services such as infusions. Four out of four residents (R2 - R3, R7 - R8) indicated they receive their home health and/or hospice services and have no complaints about services. R4 indicated that they were independent and manage their own medication. R10 indicated that R10 receives non-medical care services according to the agreement but manages own medication. Three out of three residents (R5 - R6, R9) indicated that they do not receive home health and/or hospice services but receive their medication as prescribed by the doctor. Regarding the allegation, “Resident has not received treatments that were ordered by her doctor” 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 deficiencies cited. An exit interview was conducted and a copy of this report was provided to the Memory Care Director Alicia Ballard.

The investigation revealed the following: Allegation: Facility is not maintained in good repair The complaint alleges that the automatic push button assessable door did not work to the Trash/Recycle Room, and the automatic push button assessable door outside the entrance/exit nearest resident’s apartment was broken and hasn’t been repaired. On 6/25/25 the Department interviewed the Executive Director (A1), who denied allegation and stated that she has only been working at the facility for a little over a month, but the automatic push button accessible doors are functioning properly at the present time and there has been no report of any of the automatic doors not properly functioning. On 6/28/25 during the facility tour the Department tested each automatic push button accessible door and found them to be working properly. On 6/28/25 between 10:00am and 12:00pm, the department interviewed 5 staff regarding the allegation. Of those interviewed, 5 out of 5 stated the automatic doors are properly working. 1 out of 5 stated that in the past, the doors had not been working but the maintenance person “fixes” the issue “right away. On 6/28/25 between 1:00pm and 3:00pm the Department interviewed 6 residents. Of the 6 residents 5 out of 6 stated that they had had no problems with the automatic doors in the facility and they had been working properly. 1 out of 6 stated that they have had issues with the doors not working in the past, but admitted that lately, they have been working properly. On 6/29/25 at 11:15am, the Department interviewed 1 resident (R1) who stated the automatic access door that hadn’t worked in the past is now a “regular door” with no automatic push button. However, R1 stated that R1 can use other access doors (that open automatically when approached) that requires no push button feature allowing R1 to navigate the facility safely. Page 2 of 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 On 6/27/25 the Department obtained and reviewed an electronic copy of the Work History maintenance report (dated 6/27/25). The document shows that the automatic push button accessible doors are maintained on a regular basis. Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegations above 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 . There were no deficiencies cited during today's visit. Exit interview conducted, and copy of report provided to Community Care Director, Cynthia Cisneros. Page 3 of 3

On 6/25/2025, the Department conducted a telephone interview with Executive Director Judith Pierfax (A1). On 6/27/2025 the Department reviewed electronic copies of the following pertinent documents: Staff schedule and roster (date 6/26/25), Resident roster (dated 6/26/25), Facility’s Fall Policy (dated 3/1/2025), Emergency and call system monito r ing policy (date 8/1/24), and Staff training on Resident Rights (dated 1/3/25) . On 6/28/25, at 9:24am, the Department and Memory Care Director (S2) toured the facility inside and out. The Department conducted 5 staff interviews (S1-S5), Executive Director (A1), and 6 Residents (R2-R7). The investigation revealed the following: Allegation: Facility staff is insufficient to meet resident's needs The complaint alleges that “the facility is trying to save money, and they are short staffed.” On 6/25/25 at 12:26p via telephone, the Department interviewed the Executive Director (A1) who denied allegation and stated that she has only been working at the facility a little over a month, she is certain that the facility has sufficient staff to meet residents’ needs. On 6/28/25 between 10:00am and 12:30pm, the Department interviewed 5 staff (Staff #1-5) regarding the allegation; 4 out of 5 staff denied the allegation and reported that there is enough staff to meet the needs of the residents. On 6/28/25, between 1:30pm and 3:00pm, the Department interviewed 6 Residents (Residents #2-7). R1 no longer lives at the facility. Of the 6 Residents interviewed, 5 out of 6 denied the allegation. 5 out of 6 stated that their needs are taken care of and that they feel that there are enough staff to meet their needs. On 6/28/25, The Department observed sufficient staff present at time of visit. On 6/27/25, The Department obtained, reviewed, and evaluated staff schedules and resident roster (current and week of incident) and found that sufficient staffing is maintained at the facility to meet the residents’ needs. Based on the information gathered, there is insufficient evidence to support the stated allegation Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occ ur, therefore the allegation is UNSUBSTANTIATED . Page 2 of 5 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: Facility staff are not assisting resident with toileting needs in a timely manner The complaint alleges that when R1 tells the staff that R1 “has to use the restroom,” the staff takes longer to respond. On 6/25/25 at 12:26p via telephone, the Department interviewed the Executive Director (A1) who denied the allegation and stated that staff are not supposed to take more than 10 minutes to respond to a resident who calls for assistance. A1 further stated the staff are aware of the policy of responding to residents in a timely manner when they call for assistance. On 6/28/25 between 10:00am and 12:30pm, the Department interviewed 5 staff (Staff #1-5) regarding the allegation; 5 out of 5 staff denied the allegation and reported whenever a resident calls for assistance they help. 5 out of 5 staff interviewed stated that they have never waited too long to assist residents when they call. 5 out of 5 staff stated that they are aware of the Emergency and call system monitoring policy. On 6/28/25 between 1:30pm and 3:30pm the Department interviewed 6 Residents (R2-R7) regarding the allegation. 5 out of 6 residents stated that staff assist them in a timely manner when they called for assistance. On 6/27/25 the Department obtained, reviewed, and evaluated the Emergency and call system monitoring policy (dated 8/1/24) which states in part that “It is expected that emergency calls are responded to timely,” and “upon move in the Executive Director or designee will provide all assisted living residents with training on the use of emergency call devises.” Page 3 of 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the information gathered, there is insufficient evidence to support the stated allegation Although the allegations above 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 . Allegation: Resident sustained multiple falls while in care The complaint alleges that R1 was admitted to hospital due to a fall on 9/1/2021 and R1 allegedly has had multiple falls within the year. Additionally, it is alleged that R1’s medication and chronic condition is making R1 “feel faint” resulting in falls. On 6/27/2025 at 12:26p, the Department interview A1 who stated that R1 no longer lives in the facility and the facility doesn’t have any records pertaining to R1’s case due to the time frame that the facility is required to keep records (records are kept for 3 years) and this complaint is from 2021. However, during the initial complaint visit on 10/12 /21, the Department obtained copies of R1’s Service Plan (dated: 7/6/21), R1’s eMAR (for Aug 2021), Unusual Incident Report (UIR) dated 9/18/21 and 9/1/21. The Department reviewed the documents listed above which showed that R1 has had a couple falls during that time and the facility took appropriate steps to ensure that R1 was seen by a medical professional and followed up with R1’s primary care physician . It is unknown what was put in place for R1 specifically, due to the lack of information. The Department obtained and reviewed a copy of the facility’s fall policy (Dated 3/1/25), which includes: Fall risk reduction, environmental safety, and lift assistance Page 4 of 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the information gathered, there is insufficient evidence to support the stated allegation Although the allegations above 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 . There were no deficiencies cited during today's visit. Exit interview conducted, and copy of report provided to Executive Director Judith Pierfax. Page 5 of 5

Investigation Revealed the Following: Allegation: Staff inappropriately pulled on a resident while in care. The details of the complaint alleged that facility staff inappropriately pulled (R#1)’s arm. On June 22, 2025, at approximately 9:00 a.m., LPA Iniguez conducted a records review and examined copies of staff training modules in Relias, dated May 15, 2025. It was noted that facility staff receives annual training on the “Essentials of Resident Rights.” Additionally, LPA Iniguez observed other trainings, including “Person-Centered Care in Assisted Living,” that are also taken annually. On June 21, 2025, at approximately 11:00 AM, during an Interview with the Executive Director (A#1), she stated that facility staff are trained on residents' rights, and they receive training every year. Also, (A#1) stated that to her knowledge, facility staff did not pull (R#1) arm or any other resident in care in an inappropriate way. On June 21, 2025, at approximately 8:30 AM, during a telephone conversation with (W#1), LPA Iniguez asked (W#1) whether they had ever witnessed (R#1) being mistreated by facility staff or being pulled by their arm. (W#1) responded that they had not witnessed any such behavior during their visits to the facility. On 6/21/25, at approximately 10:00 AM, Licensing Program Analyst-LPA Alfonso Iniguez was not able to spoke with (R#1) since they are no longer living at the facility. On June 21, 2025, at approximately 10:00 AM, during interviews with residents (R#2-R#5), (4) out of (4) stated that they think the facility staff is trained on resident’s rights and they have never been pulled inappropriately by them. Evaluation Report continues 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 On June 21, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#3), (3) out of (3) stated that they are trained on resident’s rights, and they get trained every year. In addition, (3) out of (3) facility staff stated that they have never pulled (R#1)’s arm or any other resident in care inappropriately. Allegation: Staff did not address a resident's change in medical condition. The details of the complaint alleged that facility staff made fun of resident when they requested medical attention. On June 22, 2025, at approximately 9:00 a.m., LPA Iniguez conducted a records review and examined the copies of staff training modules in Relias. During the review, LPA Iniguez noted that facility staff had received training on "First Aid, Workplace Emergencies, and Natural Disasters: An Overview." Additionally, LPA Iniguez observed that CPR training was also listed. On June 21, 2025, at approximately 11:00 AM, during an Interview with the Executive Director (A#1), she stated that the facility staff are trained in first aid and CPR, (A#1) stated that they renew their training every two years. In addition, (A#1) stated that she has never observed facility staff making fun of residents in care when they request medical attention. On June 21, 2025, at approximately 8:30 AM, during a telephone conversation with (W#1), (W#1) mentioned that the staff was always excellent with (R#1) and the other residents and that they never saw any staff members making fun of (R#1) or any other resident in care. On 6/21/25, at approximately 10:00 AM, Licensing Program Analyst-LPA Alfonso Iniguez was not able to spoke with (R#1) since they are no longer living at the facility. Evaluation Report continues 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 On June 21, 2025, at approximately 10:00 AM, during interviews with residents (R#2-R5), (4) out of (4) stated that they think the facility staff is trained regarding medical emergencies. Additionally, (4) out of (4) residents in care state that the facility staff have not made fun of them when they requested medical attention. On June 21, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#3), (3) out of (3) stated that they are trained in first aid and CPR in case of a medical emergency, and they renew their training every two years. Additionally, (3) out of (3) facility staff stated that they had never made fun of any resident in care when they requested medical attention. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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. An exit interview was conducted, and a copy of the Complaint Report was given to Alicia Ballard/Memory Care Director.

S1 reported they had conducted a safety check on the morning of 10/09/2024 and observed R1 in bed sleeping. Interview conducted with R1 reveled they were not sure how long they were on the floor after they slipped off their recliner in their apartment. R1 reported they were on the floor for approximately “30 to 45 minutes”. R1 reported they feel safe living at the facility. R1 stated “staff are always taking care of me, feeding me, and every time I call staff they come”. LPA conducted a record review of R1’s Service Plan dated 08/15/2024 has R1’s care level set at Level 1. Service Plan reveals R1 is independent and does not require assistance with "Dressing", "Grooming", "Oral Care", "Toileting", "Transfer", "Mobility", and "Medication Management". Record review of R1’s physician’s report dated 06/27/2024 reveals R1 is able to bathe self, able to groom self, able to feed self, able to care for toileting needs, able to manage and store own medication, and able to administer own medication. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided to Operational Specialist Sheryl McCaskill.

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Operations Specialist Sheryl McCaskill who was informed of the purpose of the visit. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. The outdoor area was observed to be free of hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies, detergents, and the sharp and dangerous objects were locked and inaccessible to the residents in the facility's janitorial and maintenance supply rooms. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector, carbon monoxide, and facility sprinkler system was operational and is maintained annually. LPA tested the hot water temperature in multiple resident bathrooms which met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA was informed the facility receives multiple food deliveries a week. LPA reviewed five staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training. Eight (8) resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed a MedTech walking with a medication cart supplying the resident's with their morning medication. MedTech documented intake on the facility's electronic Medication Administration Record (eMAR). LPA reviewed resident medications for resident and found all medication listed on MARS and all required labeling was found to be in place. Facility has an updated emergency and disaster plan and Infection Control plan. LPA observed all facility exits were clear from obstructions. Facility contained multiple charged fire extinguishers located throughout the facility. Facility had performed a fire drill during August 2024 which met department requirements. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Operations Specialist Sheryl McCaskill.

the medications. A facility director was interviewed and reported S1 is an employee of a staffing agency and was contracted to provide services on 07/19/2024. S1 could not be reached prior to the conclusion of the investigation. An interview was conducted with a facility employee who worked with S1 and revealed S1 did report they received the delivery, and they did not know if the resident was allowed to self-administer their medications. Per staff, S1 reported they later delivered the medications to S1, on the same day, once realizing the resident could self-administer. R1 reported they believed they did later receive their medications. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. This report was reviewed with ED Henry and a copy was provided.

LPA obtained copies of the rate increase letters that were given to R1’s family. The rate increase letters were dated 4/26/2024, 2/7/2023, and 8/9/2022. The letters included a general explanation of the reason for increase. LPA was provided a copy of the Admission Agreement signed and dated by R1. Witness was present at the signing of the Admission's Agreement. Review of the signed admissions agreement specifically state facility may increase the rate for monthly fees upon sixty days’ written notice. In the event of a rate increase, the Community will include with the notice the amount of the increase, reasons for the increase and a general description of the additional costs that the Community incurred that led to the increase. Based on the information obtained, the allegation of facility is increasing rent more than 10% has been investigated and found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted with Monya Henry, Executive Director and a copy of this report was provided.

LPA Prieto attempted to interview R1, in question, without success. S1 confirmed that R1 has left Westmont Village, to a medical facility not licensed by State Licensing and will not be returning. Based on the information obtained there is not enough evidence that staff member steals resident's money . Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Henry and a copy was left with the facility.

Regarding the allegation that staff failed to seek timely medical attention for a resident while in care, R1 was addressed by facility staff after an un-witnessed fall and sent to the hospital for medical treatment on the same day the incident occurred. Based on the information obtained there is not enough evidence that due to lack of care and supervision resident sustained an injury from a fall while in care and staff failed to seek timely medical attention for a resident while in care . Therefore, the allegations are deemed UNSUBSTANTIATED at this time. A copy of this report was signed by LPA Prieto and Monya Henry and I copy was left with the facility.

On 9/11/2023, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Administrator Monya Henry who was informed of the purpose of the visit. LPA toured the facility’s interior and exterior with Administrator Henry. The facility is approved to care for 225 non-ambulatory elderly residents, of which 25 may be bedridden. The facility also has a hospice waiver for 25 and is approved for delayed egress. LPA was informed that the facility currently has 71 residents residing in the assisted living units, 34 in memory care, and 75 living independently. LPA observed the facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. Outside shaded seating areas are available for the residents in care. Cleaning supplies, medications, knives, and sharp instruments are locked and inaccessible to the residents. Medications were stored in the medication carts and wellness rooms. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a menu available for review, which also offers alternative meal options. LPA observed that the facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPA toured a sample of the resident rooms. LPA observed the facility had delayed egress in the memory care unit. The resident bedrooms had the required furniture and functional lighting. Continued on LIC809-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 Continued from LIC809.. LPA tested the call pendant system in the resident rooms and observed that the facility staff responded within ten (10) minutes. LPA observed grab bars and nonskid mats in the bathrooms. LPA conducted staff and resident interviews. Staff interviewed had a criminal background clearance on file and were associated to the facility. LPA was informed the last disaster drill was held on 8/31/2023 and fire drill 8/29/2023. During today’s visit, LPA did not observe any deficiencies. An exit interview was conducted where this report was discussed and provided to the Administrator Henry.

After speaking with the Executive Director it was explained to LPA that Staff One (S1) presenting the insurance information did it out of context which caused miscommunication with R1's representative. LPA was informed regarding S1 and the status of their employment at this facility, there was a mutual agreement and S1 will no longer be working at the facility after 08/08/2023. Thus, this allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where a copy of this report was discussed and provided to Executive Director Monya Henry along with a copy of the LIC811 (confidential names list).