Avantgarde Senior Living of Tarzana.

No eviction letter or warnings were found in R1’s file. Interview with the Director at 2:15 p.m. today revealed they never threatened to evict R1. The Director explained to R1 that eligibility for part of their funding source, the Assisted Living Waiver (ALW) program, may be at risk if R1 kept going in and out of the hospital. Interview with the Wellness Director at 1:00 p.m. today confirmed R1 was never threatened with eviction. The Wellness Director also clarified the ALW program rules with R1. Interviews with Staff #2 (S2) at 1:30 p.m. and Staff #3 (S3) at 2:30 p.m. today also confirmed no eviction or threat of eviction was ever given to R1. R1 later requested this complaint be closed without investigation. Based on interviews and record review, he facility did not evict or threaten to evict R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety issues observed during today’s visit. Exit interview conducted. Copy of report provided.

Interview with the administrator at 9:00 a.m. on 07/31/25 revealed they spoke with R1 about the issue. R1 liked to watch television to ignore the snoring. When R1’s headphones broke, the administrator bought R1 a new pair of headphones. Interview with the wellness director at 9:00 a.m. on 02/12/26 revealed facility staff provided R1 incontinence care every two (02) hours at night. R1 did not like being woken up by the staff, but the wellness director explained it was necessary for their health. Interview with R2 revealed they and R1 had resolved any prior issues between them. Record review of R1’s care plan confirmed staff checked on R1 every two hours for incontinence care. Interviews with twelve (12) out of thirteen (13) residents on 02/12/26, which was at least 10% of the total number of residents, revealed the facility had accommodated their choice of roommates. Interview with Resident #3 (R3) at 11:10 a.m. on 02/12/26 revealed they were not happy with their roommate, though the administrator had already addressed their concern and would soon change R3 to a new room. Based on interviews, and record review, the facility appropriately accommodated residents’ choice of roommates. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.

The facility also got a referral for a specialist to assess the growth on R1’s chest. At 12:30 p.m. today LPA reviewed the referral and R1’s physician orders. Record review indicated the facility had provided timely medical care and attention for R1. Interviews with thirteen (13) out of thirteen (13) residents today, which was at least 10% of the total number of residents, revealed the facility had provided sufficient care and met their medical needs through regular physician visits and referrals. Based on interviews, and record review, the facility sought medical attention for R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.

At 8:30 a.m. on 01/16/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and later the administrator and disclosed the reason for the visit. A file review was conducted prior to the visit. The facility was last visited on 12/05/25 for a complaint visit. It is a three-story building with separated areas for assisted living residents and memory care residents. The areas are separated by fifteen (15) second delayed egress doors, activated by numeric keypads. In total, the facility has one hundred eight (108) bedrooms in assisted living, nineteen (19) bedrooms in memory care, private and shared bathrooms, dining areas, recreation spaces, and indoor and outdoor common areas. Its most recent fire clearance was approved on 12/18/25 for a capacity increase from one hundred thirty-eight (138) residents to one hundred sixty (160) residents, of which one hundred twenty-seven (127) may be non-ambulatory, twenty three (23) may be bedridden, and ten (10) may be ambulatory only. The facility serves residents with dementia. Approved hospice waivers for twenty-five (25). LPA and staff toured the facility inside and out at 11:00 a.m. The main entrance has automatic sliding doors and manual doors for entry. The walkway is covered, maintained, and free of hazards. A designated smoking area is present near the main entrance. Sanitizer and masks are available at the front. Sign-in sheets for guests, residents, and outside agencies were posted. The main lobby contained furniture in good repair, art supplies, music, televisions, and activities. LPA observed a Zumba class with approximately 20 residents at 11:00 a.m. and Bingo at 2:00 p.m. A bistro and beauty salon were located at the southern edge of the lobby area. 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 Behind the reception area, LPA observed postings for confidential complaint contacts, Ombudsman contacts, emergency disaster plan, COVID precautions, fire safety certificates, activity calendar, staff list, rights of resident councils, facility license, facility sketch with evacuation routes clearly labelled, administrator’s certificate, a blank copy of the admission agreement, personal rights, and the non-discrimination notice. At approximately 11:10 a.m. – 11:30 a.m. LPA observed fully charged fire extinguishers in the main hallways on the first and second floors. They were last inspected on 10/17/2025 with tags attached. LPA conducted a medication review in the assisted living and memory care medication rooms at 11:30 a.m. LPA reviewed and staff counted quantities of five (05) residents’ medications and controlled narcotics. All medications were accounted for and matched the digital and paper records. The medication room was locked from the outside. Medications were further locked in medication carts within the room. Between 12:00 p.m. and 1:00 p.m. LPA and staff inspected rooms #108, #257, #227, and Memory Care #9. LPA tested the water temperatures to be 111.2 degrees, 112.1 degrees, 108.7 degrees, and 107.4 degrees Fahrenheit. The call systems in all four (04) rooms were tested. Staff arrived within five (05) minutes of each test. Smoke and carbon monoxide alarms were also tested and operational. All bedrooms contained a chair, lamp, nightstand, storage, and beds with adequate bedding. All furnishings were clean and in good condition. Bedrooms were accessed by key cards. Bathrooms and showers contained grab bars, non-skid surfaces, liquid soap, paper towels, and trash cans. A locked laundry area upstairs contained four operable (04) washing machines and four (04) dryers. All machines were in use and attended by staff. Detergent was stored in a locked storage area near the laundry area. A sign was posted showing resident laundry days and hours. The facility has three (03) elevators. All were in working condition today. Third floor access was available through the northern elevator which required a key. It was permitted as of 08/21/25. The third floor was under construction and inaccessible to residents. It contained a cable room, CCTV room, office spaces, emergency water supply, and a future laundry room. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. At 1:45 p.m., the walk-in refrigerator and freezer temperatures were recorded at 39 and -2 degrees Fahrenheit, respectively. Appliances were in good condition. Surfaces were sanitary. The food preparation area was free of chemicals and insects. Dietary cards, food handling certificates, and daily and weekly menus were posted. The activity room contained a television and theater-style seating, board games, puzzles, and sporting equipment. 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 memory care unit contained a separate dining room, indoor and outdoor activity areas, and a television room with furniture in good repair. Delayed egress exit doors were tested at 2:00 p.m. and deemed and functional. All emergency exit paths were free from obstructions. Exit doors and gates were unlocked. Emergency evacuation chairs were observed at the top of each stairwell. LPA reviewed resident and staff files between 9:30 a.m. and 3:00 p.m. All files were complete and available for audit. LPA also reviewed Reg 4 testing from the fire department. All systems passed on 10/13/25 and 12/09/25. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.

At approximately 11:00 a.m. on 11/20/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit. Today's case management visit was conducted to ensure facility compliance and ensure the health and safety of residents. LPA interviewed residents, staff, and family between 11:30 a.m. and 1:45 p.m. and toured the facility at 12:00 p.m. No immediate health or safety concerns were observed during today's visit. Exit interview conducted. Copy of report provided.

Interview with S1 revealed they observed increased agitation in R1 and reported it to R1’s physician and a nurse practitioner from the physician’s office about medication changes. A nurse who worked with R1’s physician reported the suggested medication change of prescribing Seroquel to R1’s conservator, and the conservator denied the medication change. Interview with R1’s conservator at 3:00 p.m. on 07/10/25 confirmed that R1 was never prescribed Seroquel and never took Seroquel. R1’s conservator also confirmed that the suggested medication change was reported to them by the physician’s assistant. Record review of R1’s medication list confirmed no orders for Seroquel were ever prescribed. Record review of facility emails revealed the executive director informed R1’s conservator that S1 reported R1’s increased aggressive behaviors directly to R1’s physician and nurse practitioner prior to scheduling a care plan meeting with R1’s conservator. Interview with the executive director confirmed these details and further confirmed that R1 was never prescribed Seroquel or assisted in taking Seroquel per the orders of R1’s conservator. Based on interviews and record review, staff reported a behavioral change in R1 and suggested a medication change. R1’s conservator was notified of the potential change, and R1’s conservator denied the medication change, so R1 was never prescribed new medication. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.

Interviews with four (04) other residents, including R1’s roommate; Resident #2 (R2) between 10:15 a.m. and 1:00 p.m. on 04/24/25 revealed they had never witnessed S1 in R1’s room nor any sexual abuse towards R1. No residents had experienced any inappropriate contacts and/or sexual abuse in the facility either. S1 denied performing any sexual acts upon R1 or any other residents. S1 noted they were assisting residents with activities at the times that sexual abuse allegedly occurred. S1 further stated that they were aware of the facility’s policy that staff are not allowed to have relationships with residents and sexual contact between staff and residents is strictly prohibited. Review of an LAPD police report from 04/17/25 revealed that S1 had two (02) sexual encounters with them in the past four (04) months and both encounters were consensual. Hence, the police did end their investigation. A review of R1’s facility records, including Physician’s report, need and service plan and incident reports, did not reveal any information to verify the allegation. Based on observations, interviews, and record review, although the allegation may have been valid, the investigation did not provide sufficient evidence to verify that S1 sexually abused R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.

The SSI standard rates for Non-Medical Out-of-Home Care (NMOHC) Payment Standard have been $1492.82 for 2023, $1575.07 for 2024, and $1599.07 for 2025. Record review of R1’s admission agreement revealed they were admitted on 11/18/23. R1’s admission agreement was signed by their representative, Visitor #1 (V1). R1’s funding source was listed as both their Social Security and family. R1 was initially charged $1344.82 for basic services with Assisted Living Waiver (ALW) funds covering their cost of care. Since R1 and V1 elected for a private room, the facility charged an additional fee. Review of the Social Security Administration’s Program Operations Manual System (POMS) Chapter SI SF01415.120 California Optional State Supplement indicates “The State provides a breakout of standard charges each year for NMOHC facilities... However, a recipient’s written admission agreement may include additional charges if a resident chooses a private room when a double room is available... The facility should be able to provide the actual charges for room and board as specified in the written agreement”. Interview with Staff #1 (S1) at 10:15 a.m. today revealed a meeting was held in 2024 to discuss R1’s monthly rent rate. In the meeting, S1 and R1’s ALW service coordinator, Visitor #2 (V2) explained to R1's representatives that a private room fee can be established by the facility and documented in the admission agreement. Telephonic interview with V2 at 10:40 a.m. today confirmed that they explained the conditions of private room fees to R1's representatives. Based on interviews and record review, V1 signed R1’s admission agreement which included the private room fee. R1 paid rent each month from their SSI funds in accordance to the applicable payment standards, and the remaining balance was paid from family. The facility did not charge a base fee more than the SSI rate. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.

R1 receives minimal assistance and can perform most aspects of daily living on their own. Record review of R1’s admission agreement and preadmission appraisal revealed R1 is self-responsible and does not require assistance with bathing, dressing, grooming, or eating. R1 also manages their own medications. R1’s medical assessment indicated that they had no cognitive impairment and are able to communicate their needs. Record review of R1’s discharge instructions revealed R1 was to rest, wear an arm sling, exercise, wait to bathe to allow stitches to heal, continue all regular medications, and take their temperature once daily to check for a fever. Interview with R1 at 1:30 p.m. today revealed facility staff did not check their temperature until today. R1 stated they tried to use the mounted thermometer in the lobby but were unsuccessful. Interview with Staff #1 (S1) at 2:00 p.m. today revealed care staff were aware of R1’s discharge orders. S1 was told by R1 that they did not need any assistance with following the discharge orders. Based on observations, interviews, and record review, R1 was capable of following all discharge orders on their own and able to communicate to staff when they needed assistance with taking their temperature. R1 did not report any need for assistance. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.

At 9:30 a.m. on 01/15/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. A file review was conducted prior to today’s visit. At 9:45 a.m., LPA reviewed resident personnel files. All files were complete and available for audit. The facility was last visited on 12/27/2024 for a complaint visit. It is a three-story building with one hundred eight (108) bedrooms in assisted living, nineteen (19) bedrooms in memory care, private and shared bathrooms, dining areas for assisted living and memory care, and indoor and outdoor common areas. It has an approved fire clearance for one hundred thirty eight (138) nonambulatory residents, of which eighteen (18) may be bedridden. The facility is currently in the process of increasing its capacity. The facility serves residents with dementia. Approved hospice waivers for twenty-five (25). Cameras are used in common areas. The main entrance has automatic sliding doors and manual doors for entry. The walkway is covered, maintained, and free of hazards. Sign-in sheets for guests and residents were observed. Postings for confidential complaint contacts, Ombudsman contacts, emergency disaster plan, COVID precautions, fire safety certificates, daily and monthly activity calendars, daily and weekly menus, staff list, rights of resident councils, personal rights, facility license, facility sketch with evacuation routes clearly labelled, administrator’s certificate, and a blank copy of the admission agreement were observed behind the reception area. At approximately 1:35 p.m., the house telephone was called and deemed operational. Fire sprinklers and fire extinguishers were observed throughout the building and on both floors. At approximately 1:50 p.m. LPA observed fully charged fire extinguishers which were last inspected on 10/18/2024. The facility call system was tested at 2:15 p.m. in Room #105 and at 3:00 p.m. in the Memory Care bathroom. Staff responded within four (04) minutes of each test. At 2:20 p.m., the smoke and carbon monoxide detector in room #105 was tested and deemed operational. 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 At 2:22 p.m., the hot water temperature in the restroom of room #105 was measured to be 118.8 degrees Fahrenheit. At 2:55 p.m. the room temperature was measured to be 71 degrees Fahrenheit. At 2:57 p.m., the rear exit to the Memory Care portion of the facility was tested. The delayed egress alarm sounded for about fifteen (15) seconds. The main activity room contained games, appropriate seating, and reading materials. Around 3:00 p.m. residents were observed singing karaoke. Around 3:05 p.m. LPA observed about five (05) residents in the memory care section engaged in a painting activity. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The kitchen was locked form the outside and inaccessible to residents. At 3:15 p.m., the walk-in refrigerator and freezer temperatures were recorded at 40 and -2 degrees Fahrenheit, respectively. Appliances were in good condition. Surfaces were sanitary. The food preparation area was free of chemicals and insects. The kitchen manager showed LPA dietary restriction cards of residents. LPA inspected three (03) bedrooms on the first and second floors. Bedrooms all contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Signs indicating “No Smoking: Oxygen in Use” were posted. Private and shared bathrooms and showers contained grab bars, non-skid flooring, liquid soap, and trash cans. Walls, floors, windows, screens, and blinds were clean and in good repair. A café at the front contained seating and food and drink items. The lounge area at the main entrance contained ample seating with furniture in good condition and a grand piano. LPA conducted medication reviews in the assisted living and memory care medication rooms between 2:45 p.m. and 4:00 p.m. Five (05) out of five (05) supplies of routine medications and controlled narcotics matched the dates and records. All medications were accounted for and matched the digital records. Both medication rooms were locked from the outside. The facility uses medication carts to dispense medications. A locked laundry area contained four (04) washing machines and four (04) dryers. Detergents were stored in a locked storage area. All storage areas and maintenance rooms were inaccessible. All emergency exit paths were free from obstructions. Exit doors and gates were unlocked. Emergency stair chairs were observed at the top of each stairwell. Roof access was inaccessible in a stairwell due to a locked gate. At 4:45 p.m., LPA reviewed fire safety inspections from 11/26/24. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.

Regarding the allegation "Resident sustained injury from a fall due to lack of supervision" it was alleged the facility did not prevent Resident #1 (R1) from falling due to insufficient supervision. Record review of resident supervision logs revealed staff had checked on R1 every two (02) hours prior to their fall. R1’s care plan indicated that “staff will have fall precautions in place” and “staff are to document resident’s 2 hour checks”. Interview with S3 revealed they were the first to see R1 on the floor. R1 had fallen out of bed around 4:30 a.m. on 12/01/24. S3 noted R1 was alert and oriented. S3 called Staff #4 (S4) to assess R1 for injury. Interview with S4 at 4:00 p.m. on 12/13/24 revealed R1 did not have pain and did not want medical assistance. S4 reported the fall to R1’s representative and physician. Interviews with the administrator and staff revealed that R1 has had half bed rails in place as a fall precaution. Based on interviews and record review, facility staff provided sufficient supervision to R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Resident did not receive timely medical attention” it was alleged the facility did not provide or seek proper care for R1 after their fall. Interview with S4 revealed R1 refused medical attention after their fall. Interview with S3 revealed they notified R1’s home health agency of their fall on 12/01/24. Interview with S1 revealed they scheduled home health to assist R1 on 12/01/24. Record review indicated that R1’s home health agency visited on 11/30/24, 12/03/24, and 12/10/24. R1 showed no signs of distress during the visits. X-rays were performed on 12/03/24 and revealed R1 sustained no fractures or broken bones. S1 also noted that R1 reported not having any pain after the fall. R1 had no bruising until “several hours after” their fall. Based on interviews and record review, the facility offered immediate medical attention in a timely manner which R1 refused. Facility staff ordered follow-up medical attention in a timely manner as well. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.

Interview with Staff #1 (S1) at 11:35 a.m. on 02/21/24 revealed that the injury occurred during the night shift. S1 believed S2 reported the injury to R1’s family. Interview with S2 today revealed they reported the injury to R1's responsible party over voicemail. Record review revealed the cut was reported to R1’s hospice agency by 10:58 a.m. on 04/05/2023. The hospice order described it as a “left forearm skin tear” which was treated by an antibiotic ointment and a dressing. Based on record review and interviews, facility staff followed reporting requirements. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety hazards were observed during this visit. Exit interview conducted. Copy of report provided.

Regarding the allegation “Staff did not safeguard resident’s personal belongings”, it was alleged some of R1’s belongings were not transferred to their current residence. Interview with R1 revealed they were missing a dresser, a monitor, a blanket, shirts, compression socks, sodas, waters, and a wheelchair. Record review of R1’s personal property sheet from 09/10/2021 revealed they listed compression socks, shirts, a monitor, and a blanket on their property sheet upon admission. Another personal property sheet from 08/07/23 revealed a t-shirt, blanket, and computer screen were provided by the facility upon discharge. Interview with the administrator revealed S4 is responsible for transferring resident belongings upon leaving. Interview with S4 revealed the SNF had limited space, so about half of R1’s belongings were boxed up and sent to the SNF. S4 said some time later, they boxed up the rest of R1’s belongings and sent them to their current residence. S4 also stated that the wheelchair was not R1’s but was loaned from the facility. The SNF social worker confirmed that the SNF had limited space for belongings, but they did not recall what belongings R1 had at the SNF. S5, who works at R1’s current residence, stated they were in charge of resident belongings and new admissions. S5 had no recollection of R1’s belongings transferred during intake. Interviews with S2 and S3 revealed that they remembered R1’s belongings getting boxed up and driven to their new facility. S2 also recalled that two employees from R1’s SNF came to pick up some of R1’s belongings around June 2023. Based on interviews and record reviews, the facility properly safeguarded R1’s belongings and sent them to R1’s SNF and new residence. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during this visit. Exit interview conducted. Copy of report provided.

Interview with the administrator revealed they never issued an eviction notice to R1 nor did they tell R1 they could not return. R1 was noncompliant with medical advice from their physician, so the facility and R1’s physician recommended to R1, R1’s family, and R1’s case coordinator that the facility may not be suitable for R1. Interview with S1 revealed R1 often had desserts and snacks high in sugar against medical and caregiver advice. Interview with S3 confirmed that R1 was not compliant with medical advice and was eventually admitted to the hospital due to a skin infection. Record review of R1’s physician’s report revealed R1 had a diagnosis of diabetes and a history of skin breakdown. An incident report from 05/09/23 confirmed R1 was sent to the hospital due to an infection of their amputated leg. Interview with R1 confirmed they never received an eviction notice. R1 stated that the SNF social worker told R1 they would move to a different assisted living facility upon discharge. Interview with the case coordinator and social worker revealed R1 was provided placement at an alternate facility based on the recommendation of the social worker. Although R1 was not consulted on the placement at a different facility, R1 was never evicted. Based on interviews and record review, the facility did not evict R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during this visit. Exit interview conducted. Copy of report provided.

Interview with R1's case manager revealed that the facility did in fact report R1's relocation. R1's case manager had no issue with facility reporting. Interview with F1 at 10:50 p.m. on 05/26/24 revealed they were also notified of R2's relocation. F1 had issue with the relocation itself as they claimed to be responsible for R2's medical decisions. Interview with the ED at 4:15 pm. on 05/29/24 confirmed the facility did in fact notify R1's case manager of R1's relocation and F1 of R2's relocation. The ED and S2 stated the legal document which F1 submitted to show authority over R2's medical decisions was expired. Record review of that legal document revealed it expired on 05/04/24. Record review of an incident report revealed R2 was admitted to Encino Hospital on 05/23/24 after consultation with a wound nurse determined R2 required medical attention. The incident report also noted F1 was notified of the relocation. Based on interviews and record reviews, the facility properly notified the proper individuals and agencies of resident relocations. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.

Interview with the ED and review of an incident report revealed R1 was admitted to the hospital on 04/05/2024 due to a fall. Interview with F1 revealed R1 was ready to be readmitted to the facility on 04/07/2024 but the facility refused to accept R1 back. Interviews with the ED, case worker and hospital discharge planner revealed the facility would not readmit R1 due to their unstageable pressure injury. The ED stated they arranged for two (02) different skilled nursing facilities to admit R1 so their unstageable pressure injury could heal. The ED also received medical advice supporting the skilled nursing admission from R1’s primary care physician. The ED stated that the doctor and nurses at the hospital did not find R1 suitable for admission to a skilled nursing facility and insisted R1 return to Avantgarde Senior Living of Tarzana. Review of discharge paperwork revealed R1 was admitted for “generalized weakness” and diagnosed with a “right lateral heel unstageable pressure ulcer 1x1x0 centimeters 100% eschar”. Mayo Clinic defines “eschar” as “dead tissue that eventually sloughs off healthy skin after an injury”. The hospital discharge planner clarified that the right heel pressure ulcer was “lower than a level one pressure injury”, but the nurses would not peel back the scab to measure the wound to allow it to heal. The hospital discharge planner further clarified that all wounds with healing scabs are deemed unstageable regardless of their depth, and the ED did contact the hospital for a measurement. Interview with the ED and review of the facility attendance record revealed R1 was readmitted on 04/09/2024 at 4:48 p.m. Based on interviews and record review, the facility complied with Title 22 regulations by refusing to readmit R1 due to their unstageable pressure injury. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.

At 10:30 a.m. on 03/01/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced continuation of the 2024 annual inspection. LPA met with the Executive Director (ED) and disclosed the reason for the visit. Today, LPA reviewed resident and personnel files at 10:45 a.m. and conducted staff and resident interviews at 1:00 p.m. During the inspection today and yesterday, 02/29/2024, the facility was in compliance with Title 22 regulations. Exit interview conducted. Copy of report provided.

Regarding the allegation “Staff do not assist resident with obtaining medical care" it was alleged the facility did not provide advanced notice to R1 before their medical appointments. Interview with S2 revealed R1 requested medical appointments, so the facility arranged vision, dental, and medical appointments outside of the facility for R1. R1 refused to attend the appointments. S2 then arranged for an optometrist service, a dentist, and a podiatrist to come to the facility to assist R1. R1 again refused to attend the appointments. S2 asked R1 the reason for refusing the appointments, and R1 stated they do not need the appointments and they are fine as they are. R1 declined to be interviewed by LPA at 12:45 p.m. on 02/29/2024 and today at 1:05 p.m. Based on interviews, the facility assisted R1 with obtaining medical care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not provide resident with a notice of rate increase” it was alleged the facility did not provide sufficient notice prior to issuing an increase to R1’s rent. Interview with the ED revealed all residents were notified of the annual rental increase on 11/28/2023. Record review revealed that on 11/28/2023, the Department of Social Services issued Provider Information Notice (PIN) 23-20-CCLD detailing the estimated Social Security Income (SSI) payment standards for 2024. Review of R1’s monthly charges revealed the facility charged R1 rent in accordance with the Department’s guidelines. Interview with S1 revealed R1 has the money to pay the rent but has not paid the full rent. Based on interviews and record review, R1 was provided notice of the annual rent increase. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are charging resident for unspecified fees” it was alleged the facility did not provide an explanation for the increased rent. Record review revealed the letter issued by the ED on 11/28/2023 detailed the reason, amount, and effective date of the rent increase for all participating residents. The letter also described the charges for Room and Board, Care and Supervision, and the Personal and Incidental Needs Allowance. Review of R1’s monthly charges showed R1 was charged the rate explained on the rent increase letter. Interview with ED confirmed the details of the letter. Also, besides the standard annual rent increase, R1 was not being charged any additional or unexplained fees. Based on interviews and record review, R1 was provided notice of the annual rent increase. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. 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 allegations “Staff do not assist resident with showering” and “Staff do not assist resident with grooming” it was alleged staff do not assist R1 with showers and grooming prior to their medical appointments. Interview with S2 revealed R1 was difficult to work with as they repeatedly refused assistance with bathing and grooming. R1 also refused to participate in bathing and grooming. S2 expressed concerns for R1’s hygiene to R1’s family. R1’s family told S2 to try to influence R1 more. S3 confirmed that R1 frequently refuses assistance and requests to bathe and groom. Based on interviews, staff offer assistance with showering and grooming but R1 refuses assistance. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are not providing a comfortable environment for resident” it was alleged R1 was not allowed to open the blinds in their room for natural light or turn on their lamp. LPA toured R1’s room at 12:45 p.m. on 02/29/2024 and saw the blinds open with natural light filling the room. During today’s tour, LPA saw the blinds were closed. Interview with R1’s roommate R2 revealed they had no issue with R1 opening the blinds or turning on lights. Each resident has a personal lamp, and there is a shared overhead light for the room. R1 again declined to be interviewed. Interviews with the ED, S1, and S2 revealed they had not heard any concerns expressed by R1 regarding the lighting of their room. S3 stated R1 likes the room lit up, and R2 likes the blinds closed. Based on observations and interviews, R1 was allowed to use their light and open the blinds. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during this visit. Exit interview conducted. Copy of report provided.

At 10:30 a.m. on 02/29/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the Executive Director (ED) and disclosed the reason for the visit. A file review was conducted prior to the visit. The facility was last visited on 02/21/2024 for a complaint visit. It is a three-story building with one hundred eight (108) bedrooms in assisted living, nineteen (19) bedrooms in memory care, private and shared bathrooms, dining areas for assisted living and memory care, and indoor and outdoor common areas. It has an approved fire clearance for one hundred thirty eight (138) nonambulatory residents, of which eighteen (18) may be bedridden. The facility is currently in the process of increasing its capacity to 160. The facility serves residents with dementia. Approved hospice waivers for twenty-five (25). LPA and staff toured the facility inside and out at 11:45 a.m. The main entrance has automatic sliding doors and manual doors for entry. The walkway is covered, maintained, and free of hazards. Sanitizer and masks are available at the front. Sign-in sheets for guests and residents were observed. Behind the reception area, LPA observed postings for confidential complaint contacts, Ombudsman contacts, emergency disaster plan, COVID precautions, fire safety certificates, a recent licensing report, activity calendar, staff list, rights of resident councils, facility license, facility sketch with evacuation routes clearly labelled, administrator’s certificate, a blank copy of the admission agreement, personal rights, and the non-discrimination notice. At approximately 11:50 a.m. LPA observed fully charged fire extinguishers in the main hallways. They were last inspected on 10/30/2023. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. At 11:55 a.m., the walk-in refrigerator and freezer temperatures were recorded at 38 and -10 degrees Fahrenheit, respectively. Appliances were in good condition. Surfaces were sanitary. The food preparation area was free of chemicals and insects. The kitchen manager showed LPA temperature logs from January and February 2024. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The assisted living dining room uses robots to bus away dirty dishes. A menu was posted out front. At 12:00 p.m. LPA measured the room temperature to be 70 degrees Fahrenheit. The activity room contained a television and theater-style seating, board games, puzzles, and sporting equipment. Bathrooms and showers contained grab bars, non-skid surfaces, liquid soap, paper towels, and trash cans. At approximately 12:05 p.m. and 12:20 p.m. LPA measured the water temperature in bathrooms on the first and second floors to be 105.0 and 106.8 degrees Fahrenheit. The memory care unit contained a separate dining room, indoor and outdoor activity areas, and a television room with furniture in good repair. The entrance requires a code and exits used 15-second delayed egress measures which were tested and functional at 12:10 p.m. LPA observed a shared room with sufficient space, television, a chair, and beds with sufficient and clean linens. A sign was posted stating “No smoking – Oxygen in use”. LPA observed three (03) bedrooms on the first and second floorfloors of the assisted living unit. Both bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. The pull cord to the call system was tested at 12:13 p.m. in Room 103. By 12:14 p.m., staff responded to the call. Signs were posted in the upstairs and downstairs rooms showing staff cleaned the room and provided laundry services on a designated day of the week. Walls, floors, windows, screens, and blinds were clean and in good repair. A café at the front contained seating and food and drink items. The lounge area at the main entrance contained ample seating with furniture in good condition and a grand piano. Staff stated a pianist comes to the facility once a week to perform. Staff were observed playing card games with residents around 2:00 p.m. LPA observed a musician perform for residents at 2:30 p.m. LPA conducted medication checks in the assisted living and memory care medication rooms at 12:35 p.m. and 2:30 p.m. LPA reviewed and staff counted quantities of three (03) residents’ medications and controlled narcotics. All medications were accounted for and matched the digital records. Both rooms were locked from the outside. The facility uses medication carts to dispense medications. A minor repair was noted in the ceiling outside of the assisted living medication room. A locked laundry area contained four (04) washing machines and four (04) dryers. Detergent was stored in a locked storage area. 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 All emergency exit paths were free from obstructions. Exit doors and gates were unlocked. At approximately 12:40 p.m. Emergency stair chairs were observed at the top of each stairwell. Roof access was inaccessible in a stairwell due to a locked gate. At approximately 12:40 p.m., smoke and carbon monoxide detectors were tested and operational. LPA toured the third floor with staff. The third floor was only accessible by elevator and required a key. The third floor served as storage and also had a camera area. LPA and ED reviewed the Compliance and Regulatory Enforcement (CARE) Tools at 2:45 p.m. today. Due to time constraints, LPA will return on 03/01/2024 to conduct staff and resident interviews and complete record review on an LIC 809 Case Management – Annual Continuation form. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.

After admission to the hospital. R1 was diagnosed with a pulmonary embolism. Interviews with five (05) out of six (06) staff members revealed that in the days leading up to the event, R1 had not reported any signs of labored breathing, shortness of breath, or other health-related conditions. R1 did report labored breathing to a family member (F1) on 01/09/2024. R1’s hospice nurse (H1) was called for an assessment. Interview with H1 at 11:00 a.m. on 01/19/2024 revealed R1 reported shortness of breath on the morning on 01/09/2024, but R1 had no visible signs of distress when H1 arrived. R1’s vital signs were taken and were normal. R1 reported no pain to H1 during the visit. H1 ordered additional medication for R1. F1 called 9-1-1 for R1 and R1 was taken to the hospital. Record review of R1’s care plan revealed facility staff and the hospice agency had followed all protocols outlined for R1. Based on interviews and record review, R1 did not report any sign of distress to staff, and R1’s vital signs were normal, indicating no medical attention was necessary. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety hazards were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.

LPA spoke with Staff #1 (S1) in the memory care unit who explained that calls may be delayed if another resident is using the line. At 10:40 a.m. today LPA was able to call out from the facility phone. At 10:45 a.m. today, Staff #2 (S2) told LPA that the memory care unit phone was recently misplaced by a resident. The facility promptly replaced the phone. Based on interviews and observations, the facility phone is operational. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety hazards were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.

Interview with residents revealed R1 did not want to fill out an inventory sheet or use the lockboxes provided by the facility. Resident #2 (R2) believed cash was stolen from them while they were sleeping about 5 months ago, and Resident #3 (R3) believed they had perfume taken from them within the past month. R2 and R3 believed staff or residents took the items. Neither R2 nor R3 reported the missing items and did not log their missing items on inventory forms. Eleven (11) out of fourteen (14) residents interviewed reported no instances of theft or missing items. Based on interviews and record review, there was no evidence supporting a theft as opposed to items that went missing or were lost. The facility followed the theft an loss policy, made reasonable efforts to safeguard residents’ property, and attempted to reimburse residents for missing items. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety hazards were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.

Staff report all injuries to the proper parties. Residents are observed and assessed every 2 hours by staff. Resident interviews confirmed they are observed often and checked for injuries. No residents reported any unexplained injuries. Record review of the supervision log revealed staff observe residents every 2 hours. LPA did not observe any unexplained injuries on residents during this visit. Based on interviews, record review, and observations, residents have not sustained unexplained injuries. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff handled residents in care in a rough manner” it was alleged staff have aggressively grabbed and pulled residents. Fourteen (14) out of fourteen (14) residents interviewed stated they have never experienced or witnessed staff handling residents in a rough manner. Six (06) out of six (06) staff interviewed stated they have not handled residents roughly nor have they seen staff handling residents in a rough manner. S1 also noted at 11:00 a.m. today that no reports have been documented of staff handling residents in a rough manner. Based on interviews, residents were not handled roughly manner by staff. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Residents in care are not provider proper medication assistance” it was alleged residents are overmedicated or not receiving medication at all. Residents interviewed stated they receive medication assistance at the correct dosages. Staff interviewed stated they follow physician’s orders to ensure medications are the correct dosages. Interview with S1 at 11:00 a.m. today revealed the facility consults with resident physicians prior to any medication changes. The medication review conducted at 2:30 p.m. today revealed three (03) out of three (03) residents’ medications checked were assisted with the proper prescribed dosages. Based on interview and medication review, residents are provided proper medication assistance. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Residents sustained rashes due to staff not meeting resident's incontinence needs” it was alleged staff do not change resident diapers in a timely manner. Resident interviews revealed their incontinence needs were met by the facility, and none experienced rashes. Six (06) out of six (06) staff interviewed confirmed that residents are checked every two hours and changed as needed. No staff reported observing any rashes on residents. Record review of resident supervision logs at 1:00 p.m. today confirmed residents were observed every 2 hours and changed as needed. Based on interviews and record review, staff are meeting residents’ incontinence needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. 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 yelled at residents in care” it was alleged staff have yelled at residents. Residents interviewed confirmed they are not yelled at by staff, nor have they heard staff yelling at residents. Staff interviews revealed they do not yell at residents. Interview with S1 at 11:00 a.m. today revealed staff raise their voices if a resident is hard of hearing. LPA did not observe staff yelling at residents today while in the facility. Based on interviews and observations, staff do not yell at residents in care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety hazards observed during this visit. Exit interview conducted. Copy of report provided.

Record review of R1’s Individual Service Plan revealed R1 “has poor judgement and needs monitoring for safety. Needs constant supervision” The Service Plan further noted that the facility was responsible for monitoring R1 for changes in condition, repositioning R1 frequently, transferring R1 with 2 staff members, and communicating with physician and family regularly. Email correspondences revealed facility staff observed and reported all injuries to the appropriate parties in a timely manner. Staff interviews revealed that although staff observed and reported the injuries, no staff witnessed or knew of the cause of the injuries. LPA interviewed Staff #1 (S1) at 11:30 a.m. on 04/13/2023, Staff #2 (S2) at 12:00 p.m. on 04/13/2023, and Staff #3 (S3) at 12:15 p.m. on 04/13/2023. S1 and S2 both noticed R1 was closer to their bed rails than usual after the elbow bruising. S2 and S3 stated R1’s facial injury was noticed after their dental appointment. S2 and S3 further noted that they always use 2 staff to transfer R1 as instructed in R1’s care plan, and R1 was monitored at least every 2 hours and daily for changes in condition. No staff observed other residents enter R1’s room. Residents interviewed stated they had not injured anyone nor witnessed any other residents be injured. Residents also mentioned that staff are quick to respond when a resident needs assistance. LPA’s attempts to interview R1 at 12:45 p.m. on 04/13/2023 and at 11:30 a.m. on 09/12/2023 did not yield any pertinent information. Based on record review and interviews, the licensee followed R1’s care plan, and there is not enough information to confirm the allegation is true. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety hazards were observed during the time of this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.

(Cont from 9099) Also revealed hired as administrator only works in that capacity. Records review reveal current administrator license on file. Administrator had current trainings on file to include but not limited to Dementia and memory care. Interview with five (5) residents reveal administrator to be pleasant, informative, professional, and helpful. Interview with eight (8) staff reveal administrator to be knowledgeable, helpful, and professional at all times. Staff # 2 (S2) shares office with administrator and revealed that the administrator is always respectful, kind and professional. Based on interviews and record review during this and previous licensing visits there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time

Record review at 3:00 p.m. today revealed R1 was taken to the hospital where it was discovered that R1 broke a bone in their elbow. R1’s care plan stated staff were to check on R1 every two hours. A supervision log revealed R1 was checked last at 9:00 a.m. on 09/09/2023. Therefore, the facility properly attended to and supervised R1. Based on interviews and record review, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff handled resident in a rough manner causing bruises” it was alleged Staff #2 (S2) caused bruising on the hand of Resident #2 (R2) after squeezing too hard. LPA observed R2’s hand today at 2:15 p.m. today and observed no bruising or discoloration. Interview with R2 today at 2:15 p.m. revealed R2 was not in pain and S2 did not squeeze too hard during the alleged incident. Interviews with other residents between 10:00 a.m. and 2:25 p.m. today revealed staff do not handle residents roughy. Interview with S2 at 1:25 p.m. and Staff #3 (S3) at 2:00 p.m. today revealed R2 often punched S2, S3, and other staff members. Based on interviews and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Residents sustained unexplained injuries due to neglect” it was alleged Resident #3 (R3) had unexplained bruising on their legs. Observations at 4:30 p.m. today revealed R3 had no bruising or discoloration on their legs. Interviews with residents between 10:00 a.m. and 2:25 p.m. today revealed no residents had unexplained injuries. Interview with S2 at 1:25 p.m. and S3 at 2:00 p.m. today revealed staff performed daily body checks for R3 and did not observe any bruising or discoloration. Record review at 3:00 p.m. today revealed R3 fell at the facility and was properly assisted by staff afterwards. Based on interviews, record review, and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are inappropriately medicating residents”, it was alleged residents were provided medication to make them sleepy. Resident interviews between 10:00 a.m. and 2:25 p.m. today revealed no residents took or were provided medication which was not prescribed. Staff interviews between 9:35 a.m. and 2:40 p.m. today revealed physician orders were followed when assisting residents with medication. Record review today at 3:00 p.m. confirmed staff followed physicians orders when assisting with medications. No additional medication was provided to make residents sleepy. During observations of the medication room at 2:40 p.m., LPA observed medication matched physician’s orders and medication lists. 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 interviews, record review, and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff is force feeding resident” it was alleged Resident #4 (R4) was fed too fast and choked. Attempted interview with R4 today at 11:25 a.m. did not reveal any information. Interviews with S2 at 1:25 p.m. and S3 at 2:00 p.m. today revealed staff are trained on proper feeding techniques. S2 recalled approximately 3 weeks ago, R4 choked during lunch. S2 assisted with removing the food and reassessed R4 for any further pain. LPA observed staff feeding residents during lunch today between 11:30 a.m and 12:15 p.m. and noticed proper feeding techniques applied. Based on interviews and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Appeal rights discussed. Copy of report provided.

also reveals that R1 is repositioned every two hours. Review of R1's records reveal that R1 is receiving hospice care, and only indicates a stage II at the coccyx, being treated by hospice and facility staff. No indication on file that R1 has anything greater than a stage II injury. Also observed during review of R1's records is confirmation that staff has been changing R1's diaper and repositioning R1 every two hours. No indication that the injury has progressed. Moreover, R1's medical assessment and appraisals does not indicate a history of any skin condition or breakdowns. Based on the information obtained, there was insufficient evidence to prove that R1 developed a pressure injury due to staff neglect in not repositioning R1. Therefore, the allegation is deemed Unsubstantiated at this time. Facility staff failed to monitor resident's water and food intake resulting in hospitalization: In regards to the allegation, it was reported that R1 was taken to the hospital, on or about 07/12/23 for a high fever and possible UTI. It's alleged that R1 had not been fed enough to keep their weight up, was dehydrated, and had a pressure injury. Interview with four (4) of four (4) staff reveal that R1 was sent to the hospital for weakness and loss of appetite. Copy of the Incident Report was obtained to confirm that R1 was sent to the hospital, despite hospice orders. Staff stated R1 does have a pressure injury, but it was being monitored by hospice and facility staff, R1 was being repositioned, and the injury wasn't greater than a stage II. Also, at admission, R1 weighed 161, but because R1 was experiencing a loss of appetite, R1 was last weighed at 158 lbs. Review of R1's discharge papers did not indicate an admitting diagnosis of a high fever and UTI. R1 was admitted to the hospital for another diagnosis on or around 07/02/23 and discharged with new orders to treat their infection approximately seven days after. LPA was able to interview R1 who did admit there are times that they had no appetite to eat, despite staff's encouragement to have their meals. R1 gave no indication, nor alleged staff failing to monitor their water and food intake causing them to go to the hospital. Based on the information obtained, there was insufficient evidence to prove that facility staff failed to monitor resident's water and food intake resulting in hospitalization . Therefore, the allegation is deemed Unsubstantiated at this time.

(continued from LIC 9099) LPA's interview with the staff today at 2:00 PM revealed that R1's POA came to the facility to pick up R1's belongings a week after R1 passed, though most of it was donated by the POA to the facility. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

R-1 ceased to pay rent at that time and departed with R-1’s personal belongings. There is no evidence that R-1 requested re-admission subsequent to leaving in November of 2022. Allegation: Staff is withholding residents' personal belongings The complainant advised that the facility withheld the personal belongings of Resident #1. Based on interview with the administrator and Resident Personal Property and Valuables (LIC621), R1's belongings were picked up on 11/07/2022. In addition, S1 and S2 have confirmed that the facility's front desk hasn't got any phone calls from R1. Moreover, S1 was a witness when R1's belongings were picked up. S1 and S2 denied the above allegation. There's insufficient evidence to either confirm the above allegations. The allegations are deemed UNSUBSTANTIATED. Copy of the report provided and exit interview conducted