The Kensington Sierra Madre.

The investigation revealed the following: Allegation: Staff allowed unauthorized individuals to be present while residents were in care. It is alleged that facility staff have their children running throughout the common areas of the facility, have unrestricted access to resident areas while engaging in behavior that could be disruptive to residents and visitors. LPA interviewed 4 staff and each denied the allegation, staff stated that although staff members do sometimes bring their children to the office, they are well behaved and always have a staff member with them when they assist with games/activities. S1 and S2 stated that there are children volunteers that visit the facility to bring joy to the residents, they just had a visit from the children, it was superhero day, both children/residents wore capes and were having fun in a controlled/supervised environment. LPA interviewed 10 residents, each denied the allegation, residents stated they see children at the facility and have never felt the children behave in a disruptive manner. Interviews with 2 visitors/family members of residents revealed they visit regularly and have never seen the children that visit be disruptive in any way and said they also enjoyed seeing the children and the happiness they bring to the residents. Allegation: Staff's personal pet poses as a risk to the residents while in care. It is alleged that the facility has a dog moving near residents, and it appeared that at least one resident nearly tripped as the dog passed by. LPA interviewed 5 staff and each denied the allegation, staff stated that the facility is a pet friendly environment, some residents have pets that are kept in their units/rooms but if they take them out for a walk, the pets are on a leash and being assisted by staff if needed. Staff stated there is not a facility pet, however, visitors and staff will bring their pets to the facility to allow pet therapy, there is a designated area with a puppy pen that is controlled for the pets and residents safety; residents that wish to interact with the pets are able to go to the designated area and pet the animals with a staff present to assist. LPA interviewed 10 residents, 9 out of 10 residents denied the allegation and stated they have never seen any pets roaming around the facility without a leash. R1-R3 who have pets at the facility stated their pets stay in their rooms, R3 stated that if they need to have their dog walked they make sure they are on a leash and staff assist with walking their dog. Residents stated this has never been a concern of theirs and have never tripped over any of the pets. Interviews with 2 visitors/family members of residents revealed they visit regularly, have never seen any dogs or pets walking about the facility freely, the pets are always on a leash with supervision, and they have never had any concerns of their family being injured by tripping over the pets. LPA toured the activity room and observed the doggy/puppy pen that houses the pets when they are there (there were no pets in the pen during visit). Based on statements and interviews conducted with staff/residents, review of policies and LPA observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.

On 4/1/2026, LPA Konishi emailed the Executive Director, Associate Executive Director and obtained pertinent documents. During today's visit the investigation revealed the following: LPA interviewed the Executive Director and Associate Executive Director. The investigation revealed the following in regards to the allegation: “Resident sustained an injury due to staff neglect or physical abuse,” it is alleged on 2/24/2026, at an outing while riding the facility bus, R1 was rubbing R1’s eyes with R1’s finger and the facility bus hit a bump which caused R1’s eye injury having a distinct black eye. CAT scan revealed that R1 was a victim of cerebral hemorrhage. LPA interviewed Executive Director, Associate Executive Director and nine (9) staff denied the allegation that stated there was no evidence that staff caused an injury to R1 on 2/24/2026 and that there were no witness of R1 sustaining the injury due to staff neglect or physical abuse. Six (6) staff stated that R1 did not report any pain on 2/24/2026. LPA interviewed R1 that denied the allegation stating that R1 cannot recall sustaining an eye injury on 2/24/2026. R1 could not recall reporting any pain on 2/24/2026. LPA interviewed one (1) resident that went on the outing of 2/24/2026 and denied the allegation stating not witnessing R1 or any resident sustain any injury. LPA interviewed an additional eight (8) residents that denied the allegation stating that the facility staff has not caused any resident’s injuries due to staff neglect or physical abuse. LPA attempted to interview an additional two (2) residents but LPA was unable to interview those two (2) residents since they were unable to answer the questions. LPA interviewed W1 that denied the allegation stating that R1 was not injured by staff neglect or physical abuse and additionally indicating that the staff have been very caring, supportive, and W1 doesn’t have any active concerns. Based on record review, LPA was unable to obtain any documents that indicated the direct cause to R1’s cerebral hemorrhage. However, LPA obtained medical notes dated 3/9/2026 of the diagnosis of R1’s cerebral hemorrhage and treatment. LPA reviewed staff training on Abuse, Neglect, and Exploitation in the Elder Care Setting. There was not enough supportive evidence to concur with the reported allegation. Allegation: “Staff did not seek timely medical attention for a resident.” It is alleged that on 02/24/2026, R1 injured her eye and was not examined by a medical doctor for this injury. It is also alleged that on 02/27/2026, R1 had a distinct black right eye. On 02/28/2026, R1 was taken to the hospital in which the CAT scan revealed that R1 was a victim of cerebral hemorrhage. [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 LPA interviewed the Executive Director, Associate Executive Director, LVN (Licensed Vocational Nurse) that denied the allegation stating that the injury observed around R1’s eye was minor and saw little to almost nothing around R1’s eye on 2/24/2026. However, the LVN stated that on 2/25/2026, LVN assessed the injury near her right eye, indicating that there was discoloration but no indication of a black eye. Executive Director stated that the facility chart by exception and notice until something is wrong. Executive Director also stated that the LVN and the facility care staff closely monitored R1’s condition for any changes in condition from 2/25/2026 to 2/28/2026 and there was no bruising and no visible injury that was observed and that R1 did not complain of any pain. The LVN cross reported the injury observed to R1’s responsible party on 2/25/2026 . R1’s responsible party then took R1 to the hospital on 2/28/2026 for a previously scheduled CT scan which revealed the cerebral hemorrhage. However, there was no evidence obtained during the investigation that revealed that R1’s cerebral hemorrhage was a result of the injury sustained on 02/24/2026. LPA interviewed nine (9) residents that denied the allegation stating that staff seek timely medical attention for residents. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was held and a copy of this report was provided to the Executive Director, C. C. De Graff.. 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 4/1/2026, LPA Konishi emailed the Executive Director, Associate Executive Director and obtained pertinent documents. During today's visit the investigation revealed the following: LPA interviewed the Executive Director and Associate Executive Director. The investigation revealed the following in regards to the allegation: “Staff did not properly report an incident involving a resident.” It is alleged that R1’s responsible party was informed by staff on 2/26/2026, which is two days after R1 sustained an injury that occurred on 2/24/2026. LPA interviewed ten out of twelve residents denied the allegations stating that incidents are immediately notified their families and doctors. LPA attempted to interview two (2) out of twelve residents but LPA was unable to interview those two (2) residents since they were unable to answer the questions. LPA interviewed five (5) staff that could not corroborate nor deny the allegation since they are not involved in notifying the incident that occurred on 2/04/2026 to appropriate parties. LPA interviewed the Executive Director, Associate Executive Director, and an additional five (5) staff that denied the allegation stating that the that the injury of a scratch and discoloration near R1’s right eye was notified to R1’s responsible party on 2/25/2026. LPA obtained confirmation from obtaining documented exchange of communication dated 2/25/2026 between R1’s responsible party and the facility staff regarding the incident. However, the facility failed to notify licensing since there was no special incident report (SIR) sent from the facility to the department of R1’s eye injury. The Executive Director, Associate Executive Director and one (1) out of ten staff also stated that the SIR was not sent to licensing since the Associate Executive Director claimed that the severity of the injury was minimal. However, facility staff felt it was severe enough to notify R1’s responsible party. It was confirmed by the Associate Executive Director that neither of the SIR were not sent to Licensing. There is enough sufficient evidence to substantiate the allegation. Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. An exit interview was held and the copy of the report and appeal rights were provided to the Executive Director, C. C. De Graff,.

Licensing Program Analyst (LPA) Daniel Konishi conducted the required annual inspection. LPA met with Daniel Orozco, Executive Director and explained the purpose of the visit. The facility is licensed to serve (106) non-ambulatory residents of which (16) may be bedridden. Facility may retain up to (20) hospice residents and cleared for delayed egress. On today's date, LPA inspected the eight (8) domains including: Infection Control, Operational Requirements, Physical Plant/Environmental Safety, Resident Rights/Information, Planned Activities, Food Services, Incidental Medical and Dental, Disaster Preparedness. Infection Control: The facility has Infection Control Plan in place. Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. Emergency and disaster plan was completed and up to date. Operational Requirements: Infection Control and Dementia plans are in place. Valid Liability insurance is in place. Fire and disaster drills were last conducted on 12/13/2025. Care and supervision to meet the residents’ needs was observed. Special equipment and supplies to meet the residents with special needs were observed. Physical Plant/Environment Safety: The Facility is two (2)-story building located in Sierra Madre, CA. A tour of the facility included: 1st floor (assisted living units with private bath), 42 resident units, large dining room, private dining room, kitchen, bistro, library, cinema, laundry room, multiple staff offices, medication/nurse station, two (2) activity rooms, an elevator, public restrooms and two (2) courtyards/patios. [Continue in 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 2nd floor: (memory care units with private bath – two (2) sections “Haven”-late-stage memory care and “Connections”-mild to moderate memory care), 25 units each with private bath; each side of memory care had their own dining area, kitchenette, activity area, living room and patio. The facility has a shaded area for residents in the outdoor patio/courtyard area for activity purposes. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. The facility has central air/heating, call buttons in each unit and emergency sprinkler system throughout. The facility has central air and heating accommodations. The fire extinguishers were observed to be fully charged and in compliance. Kitchen was inspected, knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. LPA observed two (2) fireplaces that are closed and inaccessible to residents. LPA toured ten (10) random resident rooms and observed each bedroom to contain the required furniture and linens. Bathrooms were observed to be clean and equipped with operational grab bars. The signal system was tested in various locations and is operable. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature readings measured at ten resident’s bathroom at random which measured from 106.8 degrees F to 113.7 degrees F which is within the required 105 degrees F to 120 degrees F. Residents Rights-Information: The facility has the following posters posted on each floor: Residents Rights, PUB475 Complaint Poster, and Ombudsman. Notice of visiting policy is posted. Per staff, facility provides internet services to all residents and have access to the facility phone. Planned Activities: Activities calendar is up to date and posted. The facility has a Resident Council and meet on a monthly basis. Facility provides equipment and sufficient space to accommodate both outdoor and indoor activities. Outdoor area is properly shaded for residents’ activity purposes. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incidental Medical & Dental: LPA reviewed ten (10) residents centrally stored medications with no issues. Medications were reviewed containing 30-day supply of medications. Centrally stored medications are kept in a safe and locked place not accessible to residents in care. Medications are given according to Physician directions. First aid kit is maintained. Medical and dental transportation is provided. 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 Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. The last drill was conducted on 12/13/2025. ***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection at a later date.*** Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview and a copy of this report were provided to the Executive Director, Daniel Orozco.

The investigation revealed the following in regards to the allegation: “Staff do not safeguard the resident’s confidential information,” it is alleged that staff did not safeguard the resident’s personal information by allowing a to third party business access to a resident’s personal information which resulted in the sale of resident’s personal property. LPA in terviewed Executive Director and six (6) out of six (6) staff denied the allegation staff stated that residents' personal and confidential information is never provided to anyone that is not staff or personnel who work at the facility. Executive Director and six (6) out of six (6) staff stated that the facility policy of providing the resident’s confidential information to third parties is not allowed. LPA interviewed nine (9) out of nine (9) residents, the residents denied knowledge of the allegation and stated that the facility staff safeguard the residents’ confidential information. Eight (8) out of nine (9) residents stated that the facility staff are not involved in selling residents personal property. One (1) out of nine (9) residents stated staff do not coerce or pressure the residents to sell the residents personal property. Nine (9) out of nine (9) residents stated feeling safe at the facility. LPA interviewed R1’s Power of Attorney (W1) and W2, and both W1 and W2 denied the allegation and reported that R1’s family is involved in the sale of the R1’s personal property and W1 states R1 is in agreement of the sale of R1s personal property. Two (2) out of two (2) witnesses also stated that the facility staff are not involved in the sale of R1’s personal property. W1 reported that staff did not allow access of R1’s confidential and personal information to a third party. LPA reviewed staff #1 (S1) in-service training and training records regarding Resident’s Personal Rights and HIPAA Laws. Per Executive Director, there are no staff that have been provided with verbal or written warnings regarding not safeguarding residents’ confidential and personal information. Therefore, the investigation did not reveal a preponderance of evidence to support the allegation. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was held and a copy of this report was provided to the Executive Director, Daniel Orozco.

The investigation revealed the following: regarding the allegation “Facility did not have a designated substitute administrator.” It is alleged no management was visible or available during a recent tour of the facility. Seven (7) out of the seven (7) staff interviewed denied this allegation. All staff interviewed revealed management is always available via phone and email and reply within a timely manner. All staff interviewed were knowledgeable on how to contact management and where contact information could be located. Four (4) out of the four (4) residents interviewed denied this allegation. All residents interviewed revealed management can be easily found and reply to residents’ concerns promptly. During tour of facility, LPA Ramirez observed a “Team Leaders” framed poster located on a wall near the concierge desk. This poster listed the names, picture, direct cell phone number and email to facility management. LPA Ramirez observed several management business cards located in the front entrance lobby of the facility. Business cards were observed to contain management direct cellphone number, email address and facility landline number. During record review, LPA Ramirez observed two (2) Designation of responsibility (LIC 308) forms. These records revealed Associate Executive Director- Daniel Orozco and Executive Director- April Vargas are authorized and designated by Administrator- CC Degraff, to assist in her absence. Copy of correspondence letters addressed to this licensing agency, revealed on 04/02/2025 & 05/19/2025, administrator CC Degraff advised of her temporary absence and Associate Executive Director- Daniel Orozco and Executive Director- April Vargas would be available in her absence. 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 violations were observed. Exit interview was conducted and a copy of this report was provided

Regarding allegation: Facility is in disrepair. It was alleged that the front entrance of the facility remained broken for weeks, leaving residents exposed to unnecessary security risks. At the time of visit LPA observed that front entrance of the facility not broken and functional. Interviewed staff mentioned that last week the front entrance door automatic mechanism wasn't working properly, had a mechanical malfunction, requiring manual opening and closing. The repair was completed less than 24-hour hours and SIR dated 05/08/25 about entrance door malfunction was sent to the Department (SIR was provided to LPA). Interviewed staff stated even though the entrance door had mechanical issue, the door still did lock and perform its function. and in addition facility has a 24-hour concierge who diligently monitors the entrance and exit ensuring the safety of building and residents. All interviewed residents stated that everything works at the facility and not aware of facility being in disrepair. Regarding allegation: Staff did not provide adequate supervision to residents in care. It was alleged that there have been repeated incidents of injuries involving residents, and the police have been called to the facility. At the time of visit LPA observed that facility have enough staff who provide adequate supervision to residents. Interviewed staff denied the allegation. They stated that there are always enough staff to assist the residents and always adequate supervision and do not recall that there were repeated incident of injuries involving residents. Interviewed S1 and S2 stated that they have 45-50 employees per shift including caregivers, housekeepers, medical staff, dining servers and activity coordinators. Also, in the event of urgent staffing need, facility closely work with three staffing agencies to help cover it. Interviewed staff stated that they have had several visits the past few weeks from Law enforcement due to complaint that reported to them ( Copies of SIR, SOC 341 were provided to LPA) Police department came to the facility to conduct the interviews with various staff members as part of their standard procedures, but these visits did not disrupt the daily operations of the community and no further investigation was reported. (Copies of Police Officer business card with the case number was provided to LPA). Continue 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 Interviewed residents stated that there is always enough staff at the facility, and they provided adequate supervision. They stated that they don't have any concerns about the staff and not aware of any incidents of injuries involving residents. LPA reviewed the staff roster / schedule which indicated adequate staff coverage at all times. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegations. Although the allegations may have happened or is valid, there are not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and the copy of this report was provided to Daniel Orozco, Associate Executive Director

Allegation: Licensee is falsely advertising, promoting, and holding themselves out as providing special care. It is alleged that staff made several misleading statements regarding the operation of the facility and the behavior of the staff was unprofessional and disrespectful. (5) out of (5) staff interviewed denied the allegation. Staff interviewed stated this is the first time they heard someone complain about false advertising. Staff interviewed indicated all staff get along well and respect each other. Staff also indicated there are no restrictions on visiting family members. All staff interviewed stated the concierge staff have schedules with breaks. S2 stated that when the concierge staff take their breaks, they request another staff member to cover and manage the front desk to watch residents going in and out of the main entrance. (7) out of (7) interviewed residents denied the allegation and stated that the facility delivered what they promise. All residents interviewed stated they are happy, content and couldn't think of anything bad to tell about the facility. LPA's review of the facility's promotional packet showed that the services and amenities listed are being provided to the residents. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Cecilia DeGraff, Executive Director.

Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection . LPA met with Cecilia DeGraff, Senior Executive Director and explained the purpose of the visit. The facility is licensed to serve (106) residents non-ambulatory residents of which (16) may be bedridden. Facility may retain up to (20) hospice residents and cleared for delayed egress. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. Emergency and disaster plan was completed and up to date. Operational Requirements: Infection Control and Dementia plans have been added to the Plan of Operation. The facility passed the annual fire inspection conducted by Hill Top alarms on 09/05/2024. Liability insurance in the amount of ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 06/01/2025. Fire and disaster drills were last conducted on 01/21/2025. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the residents with special needs were observed. Physical Plant/Environment Safety: The Facility is 2 story building located in Sierra Madre, CA. A tour of the facility included: 1st floor (assisted living units with private bath), 42 resident units, large dining room, private dining room, kitchen, bistro, library, cinema, laundry room, multiple staff offices, medication/nurse station, 2 activity rooms, an elevator, public restrooms and 2 courtyards/patios. 2nd floor: (memory care units with private bath – 2 sections “Haven”-late-stage memory care and “Connections”-mild to moderate memory care), 25 units each with private bath; each side of memory care had their own dining area, kitchenette, activity area, living room and patio. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. The facility has central air/heating, call buttons in each unit and emergency sprinkler system throughout. The facility has central air and heating accommodations. The fire extinguishers were observed to be fully charged and in compliance. Kitchen was inspected, knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. Kitchen staff were observed wearing hairnets and gloves while preparing lunch for residents. LPA toured random resident rooms and observed each bedroom to contain the required furniture and linens. Bathrooms were observed to be clean and equipped with operational grab bars. The signal system was tested in various locations and is operable. Exit doors are free of any obstruction and there are no pools or large bodies of water. There are no security bars or weapons on the premises. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature readings measured within the required 105-120 degrees Fahrenheit which complies with Title 22 Regulations. ***CONTINUED ON LIC 809-C** 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Staffing : A total of (139) staff members on the roster list including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Night shift staff are trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training : Ten (10) staff files were reviewed and confirmed fingerprint clearances, health screenings, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 04/27/2026. Resident Records-Incident Reports: A total of (10) resident files were reviewed. They contained Admission Agreements, current Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Identification & Emergency Information , Physician's Orders, Medical Consent, and Medication Records. Residents Rights-Information: The facility has the following posters posted on each floor: Residents Rights, Complaint Poster, and Ombudsman. Notice of visiting policy is posted. Per staff, facility provides internet services to all residents and have access to the facility phone. Planned Activities: Activities calendar is up to date and posted. The facility has a Resident Council and meet on a monthly basis. Facility provides equipment and sufficient space to accommodate both outdoor and indoor activities. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen staff workers were observed to be wearing hairnets and using disposable gloves while working and preparing food. Incidental Medical & Dental: Medications were reviewed containing 30-day supply of medications. Medications are centrally stored, properly labeled and are in their original containers. First aid kit is maintained. Medical and dental transportation is provided. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. The last drill was conducted on 01/21/2025. Residents with Special Health Needs: Facility admits and retains residents with dementia and staff files reviewed today all have required training documented. No deficiencies cited. Exit interview held and a copy of the report was provided to Administrator/Executive Director Cecilia “CC” Degraff.

The investigation revealed the following: Regarding allegations: resident sustained unexplained injuries while in care and staff did not seek medical assistance for resident in a timely manner, it is alleged that R1 sustained fractured ribs, an injury to the wrist and a minor injury to the toe while in the care of the facility and facility did not seek medical assistance in a timely manner. On 01/04/2022 around 8am, a facility staff became aware of a possible left hand/wrist injury. S3 took a picture of the hand and send it to the Facility Medical Director via text. S3 placed an ice pack on the hand and the Facility Medical Director agreed with that treatment. On the same day around 7:09pm, S4 expressed concerns about the injury to the Facility Medical Director by email. S4 sent the Facility Medical Director the photo from the morning along with a photo recently taken for comparison. S4 inquired about getting an x-ray to rule out fracture because the injury appeared to be worsening compared to the photo taken that morning. Also, R1 was complaining of pain by that evening. However, the Facility Medical Director did not examine the hand or discuss the option of an x-ray with R1’s responsible party until the afternoon of 01/05/2022 at the facility. The Facility Medical Director told R1 that an x-ray could be done at the facility within a few hours. However, R1’s responsible party decided to take R1 to a nearby hospital emergency room but was told that the wait was going to be long and to go back to the facility and call the paramedics to be admitted quicker. R1’s responsible party attempted to do this, but the facility’s Director of Nursing Services told R1’s responsible party that they would not be calling the paramedics and explained that because the hand injury did not appear to be a medical emergency, R1 would still be triage and prioritized at the hospital. After this R1 and R1’s responsible party did not return to the facility and R1 was taken back to R1’s desert home. Eventually R1’s responsible party successfully managed to get the paramedics to take R1 to an emergency room. On 01/06/2022, R1 was diagnosed with three fractured left ribs, a contusion of his left hand and a small toe bruise. A specialist ultimately diagnosed tendon injuries to two of the fingers on his left hand. Though an unwitnessed fall was reported on the evening of 01/04/2022, no one at the facility could explain how R1 sustained these three injuries. On 06/15/2023, this case was referred to a Community Care Licensing Program Clinical Consultant and it was determined that when R1 was admitted to facility, R1 was not identified as a fall risk. However, everything points to resident being a fall risk – R1 had confusion/disorientation, anxiety, used an assistive device (walker) for ambulation, R1 advanced age (93 y/o); and R1 was on psychotropic meds. Despite not having a history of falls, R1 should have been identified as a fall risk, thereby there should have been monitoring to prevent falls/injuries. Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining unexplained injuries and facility not seeking medical assistance in a timely manner (refer to LIC 421IM). Exit interview held and a copy of the report and appeal rights was provided. 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 investigation revealed the following: Regarding allegation: staff did not notify resident's authorized representative of an injury, it is alleged that the facility never called the R1's family to report that the was injury. Interview with S1 revealed that it was S1 along with S2 that called R1's responsible party and left a voicemail. The voicemail they left just stated who they were and where they were calling from and it was regarding R1. They did not want to provide other details due to HIPAA law. R1's responsible party confirmed that the voicemail was received and did not call the facility back because the voicemail did not seem like it was something urgent. Also, R1's responsible party was planning on going the next day to visit R1. IB Investigator obtained a screenshot of the voicemail transcription which is dated 01/04/2022 with a time of 3:33pm which is the same day that R1's injury was discovered. Regarding allegation: resident's hygiene needs were not met, it is alleged that R1 has dirty clothes and nails. Staff interviewed denied the allegation and stated that all resident's hygiene needs are being met. Residents interviewed could not corroborate the allegation and stated their hygiene needs are being met. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was provided