Oakmont of Torrance.

On 05/01/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Olga Rayo, Executive Director, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve 126 non-ambulatory residents aged 60 and over, eight (8) of which may be bedridden on the first floor only. The facility has an approved Hospice Waiver for fifteen (15). The facility is approved for Delayed Egress for the Memory Care and Transitional Unit. Physical Plant/Structure The facility is a three (3) story structure in a commercial area. The basement consists of a parking, Wellness Center, Salon, Media Center, Exercise Room, staff offices, and a laundry room. The first floor consists of resident apartments, two (2) living areas, library, bistro area, bar, dining room, kitchen, laundry room, three (3) restrooms, and storage rooms. On the second floor are resident apartments, storage rooms, and a restroom. Apartments LPA inspected eight (8) resident apartments, rooms 103,109, 118, 127, 202, 212, 220, and 233. Residents have the option to furnish the apartment with their personal furniture, or the facility has furniture available for resident use. LPA observed resident apartments have the required furniture including a bed, dresser, nightstand, and storage space for resident’s personal belongings. Resident beds were observed with the required linens including a mattress cover, fitted sheets, flat sheet, blanket, comforter, and pillow. Residents have the option to use their personal linen, or the facility has linens available for resident use. LPA observed an ample supply of linens in a closet in the hallway. LPA observed resident apartments have ample lighting. All walkways and hallways in resident apartments were observed clean, clear, and free of hazards and obstructions. Bathrooms LPA inspected eight (8) bathrooms in resident’s apartments and all common restrooms. LPA observed bathrooms meet Title 22 Regulations and are operable. LPA observed showers clean and free of mold and/or mildew. LPA observed showers have secured safety handrails, nonskid mats, and shower chairs. LPA observed resident’s bathrooms with an ample supply of hygiene products. Residents have the option to supply their own hygiene products, or the facility has a supply available in a closet in the hallway. 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 water temperature in bathrooms measured between 105-degrees and 120-degrees Fahrenheit. Kitchen LPA inspected the industrial kitchen. LPA observed the kitchen clean and sanitary during the visit. LPA observed a three (3) day supply of perishable foods and a seven (7) day of non-perishable foods. LPA observed an ample supply of cookware, dishware, and cutlery. LPA observed a seven (7) day supply of emergency food stored in a storage closet. LPA observed a diet board in the kitchen with residents special diets and allergies. LPA observed a menu posted outside the dining room and inside the dining room. Common Areas During the time of visit, LPA observed the facility appropriately furnished. LPA observed in common sitting areas there are couches and chairs available. In the library, LPA observed a table with chairs, a poker table with chairs available for residents use. Three (3) of the common rooms have a gas fireplace that are screened and inaccessible to residents. LPA observed an ample supply of games, activities, crafts, and reading material. Medications LPA observed Centrally Stored Medications secured in locked medication carts in the locked medication rooms. LPA observed medications in their original packaging. LPA reviewed the Centrally Stored Medications and electronic Medication Administration Record (eMAR) for eight (8) residents. LPA observed eight (8) out of eight (8) residents medication are consistent with properly documented records. Files LPA reviewed files for eight (8) residents and observed they have the required documents. LPA reviewed the files for the Administrator and seven (7) staff. LPA observed staff files have the required documents, certification, clearance, and training. LPA observed the administrator’s Administrator Certificate, number 7008195740, is valid till 05/15/2027. LPA observed Licensing Fees are current. Safety LPA observed smoke and carbon monoxide detectors are operable. LPA observed fire extinguishers are fully charged and were last serviced on . The last Fire Prevention Inspection was conducted by the Fire Safety Services on 02/06/2026. The last Emergency Drill was conducted on 04/29/2026. LPA received and reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E), last reviewed 01/27/2026. LPA received and reviewed the Liability Insurance through Acord valid till 03/01/2027. LPA observed an ample supply of First Aid supplies in the medication rooms. LPA tested call buttons in apartments inspected and observed they are operable and responded to in a timely manner. LPA observed required postings throughout the facility Infection Control Upon entry, LPA observed a Visitor Log and a sanitizing station. LPA observed sanitizing stations in common areas and restrooms. LPA observed an ample supply of cleaning supplies, hand soap, hand sanitizer, and paper towels. LPA observed infections control signs posted throughout the facility. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe or cite any deficiencies . An exit interview was conducted with Olga Rayo, Executive Director, and a copy of this report was provided.

During interviews with staff S1-S8, were asked when monitoring a resident how often they check on them, eight (8) out of eight (8) stated the resident is checked every hour when being monitored. During interviews with Residents R1-R8, were asked if staff assist them when they are not feeling well, eight (8) out of eight (8) stated yes, staff assist them and check on them when they are not feeling well. Additionally, Residents R1-R8 were asked if staff meet their needs, eight (8) out of eight (8) stated yes staff meet their needs. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . During today's visit LPA did not observe or cite any deficiencies. LPA conducted an exit interview with Maintenance Director, Pedro Gonzales, and a copy of this report 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 Allegation: Staff did not seek medical attention for a resident. The allegation alleges that a resident’s blood pressure was high, and staff did not seek medical attention for the resident. During record review, LPA received and reviewed the R1’s Charting Notes and observed that when R1’s systolic is elevated over 180 paramedics have been called to assess the resident. LPA observed on 08/02/2025, 10/04/2025, and 10/07/2025 paramedics were called to assess R1 and provide transfer to the emergency room. During an interview with Staff S2 stated that when they checked on R1 a second time, before leaving for the day, R1 stated they were feeling a little better but wanted to rest a little while longer. During interviews with Staff S1-S8, were asked if resident’s receive medical attention in a timely manner, eight (8) out of eight (8) stated yes residents receive medical treatment in a timely manner. During interviews with Residents R1-R8, were asked if staff ensure they get medical attention if needed in a timely manner, eight (8) out of eight (8) stated yes, staff ensure they get medical attention when needed. Additionally, Resident R1-R8 were asked if there had been a time they did not get medical attention when needed, eight (8) out of eight (8) stated no, they have always received medical attention. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated Allegation: Staff did not reassess resident’s blood pressure in a timely manner. The allegation alleges that staff took a resident’s blood pressure and said they would be back in an hour to check on the resident and did not come back. During record review, LPA received and reviewed the Med Tech’s Shift Report for 10/12/2025 that states for the Notes (Day) “BP was high (159/60) [R1] said [they were] feeling flush. No fatigue, headache or pain. Elevated feet in supine position on the bed.” The shift notes for the Notes (PM) stated “BP was checked x2. First time was 141/64 second time was 154/60. Had resident elevate legs + rest + drink water.” During an interview with Staff S2, was asked how many times they checked on R1 when they reported they were not feeling well, S2 stated R1 informed them they were not feeling well at 1:50pm and they took R1’s blood pressure, assisted with elevating their legs and provided water. R1 stated they updated the next shift at crossover then went to check on R1 at 2:20pm before they got off shift.

On 11/19/2025, at 10:00am, an office meeting was held to discuss Complaint 11-AS- 20230117153703. Present at the meeting were Eva Alvarez, Licensing Program Manager (LPM), Wendy Gibbs, Licensing Program Analyst (LPA), Judith Uy-Villaruz, Executive Director, Jennifer Larsen, Regional Health Services Director, Jill Libhart, Vice President of Operations , and Jen Sato, Senior Vice President of Health Services. During the meeting, the LPM reviewed the details of the Complaint. On January 27, 2024, the Department substantiated an allegation of Resident wandered away from the facility due to lack of supervision resulting in hypothermia At this time the Department is considering an enhanced civil penalty, pursuant to Health and Safety Code Section 1569.49(f). The Department is reviewing the complaint for an enhanced civil penalty for serious bodily injury pursuant to H&S 1569.49(f). The total amount for the civil penalty totals $10,000 for Serious Bodily Injury. An exit interview was conducted with Judith Uy-Villaruz, Executive Director, and a copy of this report was provided.

Allegation: Facility staff did not follow resident’s dietary restrictions The allegation alleges that a resident has a prescribed diet of no-sodium, and staff provide them food containing salt, garlic, and other seasoning. During the facility tour, LPA observed on the board a Resident Dietary Information form posted for R1 that states a Special Diet of No Added Salt and has a Food Dislike of spices. LPA observed in the kitchen a clip board hanging that has the Dining Room Log that lists the Residents and Modified Diet. LPA observed R1 listed and under Modified Diet has No Added Salt, No garlic, and No onion. LPA reviewed a Medical Assessment dated 04/08/2025, that does not indicate R1 requires a special diet. Additionally, a Physician’s Report dated 03/19/2025, for R1 was reviewed and does not indicate R1 requires a special diet. LPA received and reviewed a Diet Clarification Request dated 08/08/2025 that indicates R1 is to have a “No added salt” diet. During interviews with Staff S1–S6, were asked if residents dietary orders and preferences are met, six (6) out of six (6) stated yes, resident dietary orders and preferences are met. During interviews with Resident R1-R8, were asked if staff follow their dietary order or dietary preferences, eight (8) out of eight (8) stated yes their dietary orders and/or dietary preferences are met. Allegation: Facility staff did not adequately prepare resident food The allegation alleges a resident was provided with garlic shrimp and the shrimp was rinsed in water to remove seasoning. LPA received and reviewed a photo of the order taken from Resident R1. The order is dated 10/09/2025 at 5:49pm. Resident R1 first initially ordered Special 1 at 5:40pm that was a chicken meal. During an interview with Staff S4 stated Staff S5 came down to change the order for R1 to Special 2 that consisted of Garlic Butter Shrimp with lemon parsley sauce. Staff S5 informed Resident R1 the shrimp was cooked in a garlic butter and was instructed to rinse the seasoning off the shrimp. On the order for Special 2 with the instructions to “rinse with water.” LPA reviewed a copy of the Nutricopia Consultant Dietitian Repot Card for Assisted Living (dated 09/2025) that indicates staff have “adequate training/orientation of staff,” “in-service training monthly and informal education as needed,” and “Food Service staff have Food Handler’s cards.” LPA received and reviewed the Relias Transcript for all kitchen staff. LPA observed all kitchen staff had completed the following training on Relias The Basics of Nutrition and Food Safety, Food Safety Fundamentals, and An Overview of Safe Eating and Drinking. LPA observed all kitchen staff have a current 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Food Handlers Certificate. During interviews with Staff S1-S6, were asked if residents special diet orders are followed, six (6) out of six (6) stated yes resident meals are prepared according to residents diets. During interviews with Residents R1-R8, were asked if the staff adequately prepare resident food, eight (8) out of eight (8) stated yes staff adequately prepare residents food . During the course of the investigation, LPA was unable to find evidence to support the allegations. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Judith Uy-Villaruz, and a copy of this report was provided.

(Dated: 12/31/2024 to 03/23/2025), Staff In-Service Log (Dated: 03/23/2025), Torrance Police Department Case Information/Supplemental (Dated: 03/23/2025), and Forensic Nurse Specialist, INC discharge documents (Dated:03/23/2025) from the facility. The complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigation Bureau Investigator, Sonia Torre. As a part of the investigation, Investigator Torre obtained Torrance Police Department records (911 audio, Interrogation footage, Evidence receipts,) and subpoenaed Sexual Assault Response Team (SART) exam records for suspect and victim. The investigator obtained other related documents pertinent to the investigation. Additionally, the investigator conducted interviews with staff (S1-S9), witness (W1), and residents (R1-R3). The investigation revealed the following: Allegation- Staff sexually abused resident in care. It is alleged that a staff member (S1) sexually abused a resident (R1) while in care at the residential facility. It was reported that the staff (S1) was found in the residents (R1) room by a staff member with their pants down while the resident was lying in bed. On 04/15/25, from 10:33am-12:55pm, the department interviewed staff (S2-S6) and residents (R1-R3); On 5/27/25, at 03:00pm, the department interviewed witness (W1), On 6/18/25 from 9:54am-12:30pm, the department interviewed staff (S7-S9), and on 6/26/25 at 11:56am, the department interviewed former staff (S1) about the complaint allegation. During the course of the investigation, records were reviewed, and interviews were conducted with staff, residents, and former staff. The review of the facility records Disciplinary Action Notice (Dated: 02/10/2025), revealed staff (S1) had been disciplined for being in a resident’s room (unoccupied) for a prolong period of time during their shift. The review of Torrance Police Department records revealed staff (S2) stated that, at approximately 11:20am, they were attempting to contact staff (S1) via the radio with no success, which was not uncommon. Approximately ten minutes later, (S2) decided to search for (S1) and noticed the door to (R1s) room was locked. (S2) unlocked the door and when they walked in (S2) observed (S1) standing beside the bed with their pants and underwear pulled down just below their buttocks exposing their entire buttocks with resident (R1) who was wearing a diaper and shirt laying on the bed on their right side facing away from (S1). (S2) immediately walked out, reported the incident to staff, management and Torrance PD. S1 denied the allegation that staff sexually abused resident in care but was ultimately arrested by the Torrance Police department. 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 conducted, and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff sexually abused resident in care, is found to be Substantiated . California code of Regulation, (Tittle 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. Deficiencies are issued and plans of corrections were discussed. An exit interview was conducted, appeal rights explained, and a copy of this Report was provided to Executive Director, Judy Uy.

(MAR) (dated 09/01/2025 through 09/16/2025), Senior Doc documents (dated 08/01/2025, 08/04/2025, and 08/05/2025), and Torrance Police Department card with Case # 250832470 (dated 09/06/2025). The investigation revealed the following: Allegation : Due to lack of supervision, resident physically assaulted another resident The allegation alleges that a resident was assaulted by another resident due to staff not supervising residents. During the facility visit from 9:15am till 10:30am, LPA observed staff and residents in the Memory Care Unit. LPA observed five (5) care partners and one (1) med tech working. LPA observed in the common area the activity coordinator was conducting activities, and a care partner was observing residents and available if any residents require assistance. LPA observed four (4) care partners escorting residents in and out of the activity room, providing assistance. During record review, LPA received and reviewed resident R2’s Individualized Service Plan (ISP) dated 08/03/2025, that indicates R2 requires escorting to and from all meals and activities. The ISP indicates R2 receives monitoring and assistance with mood and socialization capabilities due to preferring to be alone. Instructions for support when R2 is observed feeling expressive is to offer the interventions that will support. Additionally on the ISP, it was observed R2 has combative episodes and during their expressive behaviors staff are to redirect R2 in the right direction to prevent future encounters. LPA received and reviewed R2’s Physician’s Report dated 05/20/2025, that indicates R2 has Dementia and is confused and disoriented. LPA received and reviewed staff In-Service logs dated 09/07/2025 regarding Aggressive Behaviors. Additionally, LPA received and reviewed the training logs for Staff S4-S8 and observed four (4) out of four (4) have recent training of “Alzheimer’s Disease and Related Disorders: Psychosocial Needs,” Alzheimer’s Disease and Related Disorders: ADLs and Behaviors,” and “Alzheimer’s Disease and Related Disorders: Behaviors.” LPA received and reviewed an Unusual Incident/Injury Report for an altercation that occurred on 09/06/2025 between R1 and R2. Resident R2 was being escorted to their room from the dining area when their wheel got stuck on the leg of the chair R1 was sitting on. R1 stood up to give more room to R2 when R2 suddenly struck R1. R2 was escorted to their room and R1 was evaluated and provided first aid. During interviews with Staff S1-S8, were asked if they feel there is enough staff to provide supervision to residents to prevent altercations between residents, eight (8) out of eight (8) stated yes, they have enough staff to provide supervision to prevent altercations. Additionally, during interviews with Staff S1-S8, were asked if they have received training regarding emotional expression, eight (8) out of eight (8) stated they have received training regarding Dementia and emotional expressions. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During interviews with Residents R1-R10, were asked if they feel there is enough staff to supervise residents to prevent altercations, eight (8) out of ten (10) stated yes, they feel there is enough staff to prevent altercations between residents. Additionally, Residents R1-R10 were asked if they feel safe living here in the facility, ten (10) out of ten (10) stated yes, they feel safe living in this facility. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Judith Uy, and a copy of this report was provided.

On 05/12/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Case Management visit to the facility listed above. LPA met with Executive Director, Judith Uy, and the purpose of today’s visit was explained. LPA was granted entry into the facility. LPA conducted a Case Management visit to follow-up on an incident report that was submitted to the department on 05/01/2025 for three (3) different residents. Resident R1 had an unwitnessed fall in their room on 04/27/2025. The fall resulted in R1 being diagnosed with inferior pubic ramus fracture, not requiring surgery. Resident R2 had an unwitnessed fall in the hallway near the dining room. The fall resulted in R2 being diagnosed with right rib fracture, not requiring surgery. Resident R3 woke up with severe back pain and requested to be seen by the doctor. R3 was diagnosed with a Thoracic Vertebral Fracture, no surgery is required. During today’s visit, LPA inspected the facility, interviewed Residents R1-R3, and received and reviewed documents pertinent to the visit. LPA reviewed Resident’s R1-R3 Physician’s Report, Individualized Service Plan, Preplacement Appraisal Information, Assessments, and In-Service Logs for Fall Management Protocol 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 dated 05/07/2025. During the facility inspection, LPA observed all walkways and hallways throughout the facility to be clean, clear, and free of obstruction, and/or hazards. In the resident rooms, LPA observed the rooms of Resident R1, R2, and R3’s rooms were clean. All walkways were observed clean and clear. During an interview with Resident R1 stated they just lost their balance and fell. During an interview with Resident R2 stated they tripped over their own feet while walking and fell. During an interview with Resident R3, stated the fracture can happen with the type of medical condition they have and that the did not experience a fall. During today’s visit, LPA did not observe or cite any deficiencies. LPA did not observe any Health or Safety concerns. An exit interview was conducted with Executive Director, Judith Uy, and a copy of this report was provided.

On 4/21/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Judith Uy-Villaruz /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (126) elderly adults ages 60 and above, of which (126) can be non-ambulatory and (8) bedridden on first floor. Approved for delayed egress doors and secured perimeters. The facility has an approved hospice waiver for (15). Currently the facility has (81) residents. The facility is a three-story building with a basement and parking garage in a residential neighborhood. There is a memory care side and an assisted living side. There are (28) in memory care and (59) in assisted living. The facility's interior includes a common area, living room, dining, kitchen, activity room, theater room, and laundry area. The common area living room has a fireplace with a screen and uses gas, not wood. The common living room area included an adequate number of chairs, couches, tables, a poker table, and a library. Patios with seating and shade are available for residents and families. LPA Iniguez and the Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (6) bedrooms and (6) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The evaluation Report continues on the next page, LIC 809-C , providing further details of the inspection findings. 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 bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 109.1°F to 115.3°F, and the room temperature ranged from 76°F to 78°F. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 2/25/25. A review of (5) residents' service files and (6) staff personnel files was maintained in order. LPA reviewed (4) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Judith Uy-Villaruz /Executive Director.

On 03/25/2025 at 4:25 PM, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Case Management Visit to deliver an Immediate Exclusion of a staff. LPA met with Executive Director, Judith Uy, and the purpose of today's visit was explained. LPA was granted entry into the into the facility. During today's visit LPA delivered an Immediate Exclusion Letter for Daniel Castro due to conduct inimical. Daniel Castro is not to have contact with clients and cannot be physically at the facility. Daniel Castro was not present at the facility. LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Judith Uy, and a copy of this report was provided.

Allegation: Staff did not adequately assist resident with repositioning. The complaint allegation alleges that due to not being repositioned frequently resident has developed redness on the sacrum and a blister on their heel. During record review the department received and reviewed R1’s Physician Report dated 07/26/24 that indicated the resident is nonambulatory. Additionally, the Physician’s Report indicated R1 requires Continuous Bed Care, requires assistance with Incontinence, and is unable to transfer independently. Additionally, during record review the department received and reviewed R1’s physicians request for home health services dated 09/12/24. On the referral, the department observed, R1 was diagnosed with a “pressure ulcer of left heel stage 1.” During the facility tour, the department observed a board in the Medication Room that indicated Alert Charting that had R1 listed for wounds on both heels. Additionally, the department observed a Reminder Schedule for all shifts to assist R1 with repositioning or transferring, and incontinence care every two (2) hours. During record review, the department received and reviewed staff training logs from Relias for five (5) Staff. The department observed five (5) out of five (5), have had trainings including The skin and Pressure Injuries, Proper Positioning, and Recognizing and Reporting Skin Conditions. During interviews with Staff S1-S10, were asked how often a resident who requires assistance with repositioning is assisted, ten (10) out of ten (10) stated they help residents reposition every 2 hours. Additionally, Staff S1-S10 were asked how frequently residents are checked for pressure injuries, ten (10) out of ten (10), 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 stated residents are checked daily. During interviews with Residents R2- R10, were asked if they have sustained pressure injuries while in care, nine (9) out of nine (9) stated they have not sustained pressure injuries while in care. Additionally, R7 and R8 stated staff assist them with repositioning on a regular basis. During interviews with the Home Health Agency Nurse (W1), indicated on their visit on 09/25/2024, it was recommended to staff to reposition Resident R1 every 2 hours, apply ointment or lotion to the heels, and continue using cream the doctor ordered. During an interview with W1 on 10/03/2024, they indicated the bottom was looking better and the heels were worse. W1 recommended to elevate heels off the bed, apply lotion or ointment, cover the heels with band aids and put socks on when R1 is in the wheelchair and continue to reposition every 2-3 hours. Additionally, during an interview with W2 on 10/10/2024, indicated they showed care staff how the feet should be elevated to keep pressure off the heels, keep R1’s heels covered when in their chair and uncovered when in bed to dry out, and to continue to assist with repositioning every 2 hours. During facility visits, the department observed R1 in their wheelchair. R1 had their heel covered with a bandage and socks on. Additionally, the department observed pillows and cushions on the wheelchair to help protect the heels. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . 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 An exit interview was conducted with Executive Director, Judith Uy and a copy of the report was provided.

Allegation: Staff did not follow advanced directives and requests regarding resuscitative measures. The complaint allegation alleges that staff did not perform Cardiopulmonary Resuscitation (CPR) or use an Automated External Defibrillator (AED) when a resident was found without a pulse and not breathing. During the visit, the department conducted a file review and received and reviewed a copy of resident R1’s POLST form. The department observed on the form in section A Cardiopulmonary Resuscitation (CPR): If a patient has no pulse and is not breathing, R1 had indicated Do Not Attempt Resuscitation/DNR (Allow Natural Death). Additionally, the department received and reviewed a copy of Follow Up Encounter Notes from Senior Doc CA when R1’s Selective Code and Full Code were discussed with the Medical Power of Attorney and a medical professional. On 05/02/2023 the POLST was filled out and indicated A. Do Not Attempt Resuscitations/DNR (Allow Natural Death). The department observed on R1’s Face Sheet that the Code Status is DNAR/Do Not Attempt Resuscitation. During interviews with Staff S1-S6, were asked if R1’s POLST was followed on 01/05/2025, six (6) out of six (6) stated they knew R1 was a DNAR and did not try to resuscitate. The department interviewed the Nurse Practitioner that has been tending to R1 regularly, the Nurse Practitioner confirmed that the POLST on file was according to R1’s and his family’s wishes. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . The department did not observe or cite any deficiencies. An exit interview was conducted with Health Service Director, Angelie Pasa and a copy of this report was provided.

On 09/12/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced case management visit for an incident reported. LPA met with Executive Director, Judith Uy-Villaruz, and Health Service Director, Angelie Pasa, and the purpose of today’s visit was explained. LPA conducted a case management due to two Special Incident Reports (SIR) regarding resident falls submitted to Community Care Licensing (CCL) on 08/30/24. Resident R1 experienced a fall on 08/25/24 resulting in an injury requiring stitches. Resident R2 experienced a fall on 08/26/24 resulting in a fracture requiring surgery. During today’s visit, LPA toured the facility, checked all hallways, walkways, common rooms, and resident R1 and R2 rooms. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. All common rooms and Resident R1 and R2’s room was observed clean, clear, and free of hazards. LPA reviewed resident R1’s Physician’s Report, Needs and Service Plan (updated 06/30/24), Care Assessment, Fall Risk Assessment, hospital discharge paperwork, Internal Incident Report, and Progress Notes. LPA observed R1 has no history 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 of falls and there have been no indications of being a fall risk. LPA reviewed resident R2’s Physician’s Report, Resident Care Assessment (updated on 06/07/24), Fall Risk Assessment, and Internal Incident Report. LPA observed R2 is completely independent and does not require any assistance. R2 has not experienced any falls in the past. LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Judith Uy-Villaruz, Health Service Director, Angelie Pasa, and a copy of this report was provided.

Allegation: Untrained Staff The allegation alleges servers are not properly trained and on their phones and not attending to and assisting residents promptly. During today’s visit, LPA reviewed the Server Job Description, which details the positions responsibility, general duties, qualifications, and statement of understanding is provided to every server upon hire and signed by every server. LPA reviewed the Team Member Handbook that states on page 54 “Company-provided portable communication devices (PCDs), including cell phones should be used primarily for business purposes.” Additionally on page 55 states “Common courtesy dictates that team members not use cell phones in common areas of the community.” During an interview with the Executive Director S1, was asked if servers and kitchen staff are provided with a company cell phone, S1 stated they are not provided with a cell phone. LPA reviewed the New Team Member Orientation power point, that states in the section of Service Excellence on slide 24 “Cell phone use should be limited to breaks and meal periods. Cell phone use in common areas, hallways, and resident apartments is prohibited.” During record review LPA received and reviewed a copy of an in-service conducted on April 1, 2 and 8, 2024, by Front of House Specialist and Executive Chef, regarding Sequence of service, dining room setting, 1 st impressions, Bistro Set Up, Order taking, Uniform Standards, closing Sideworks, and Attendance tracker. During interviews with Staff S1-S8, were asked if they have received training regarding serving 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 residents, eight (8) out of eight (8) stated they have received training regarding serving meals to residents. Additionally, staff were asked if the facility has a cell phone use policy, eight (8) out of eight (8) stated phones are not to be used during work and can be used during breaks and lunch in certain areas. During interviews with Residents R1-R13, were asked if they feel staff are properly trained, twelve (12) out of thirteen (13) stated they believed staff are properly trained. Additionally, Resident R1-R13 were asked if they have observed staff in the dining room using their phones, thirteen (13) out of thirteen (13) stated they have not seen servers having their phones out since the new chef started. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. During today's visit LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Judith Uy-Villaruz, and a copy of this report 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 Allegation: Staff did not provide adequate food service The allegation alleges it takes 40-45 minutes for staff to take residents’ order and when the food arrives it is cold. During today’s visit LPA observed lunch being served and monitored the time it took for fifteen (15) different residents to receive their meal form the time they sat down. LPA observed the longest wait time to be 10 minutes before the resident received their meal. In that time the resident had been served their beverage and a soup or salad. The average wait time LPA observed was 8 minutes for a resident to receive their meal they ordered. During file review, LPA received and reviewed the Job Description of the Servers that explains what their duties and the service steps and delivery time. During interviews with Staff S1-S8, were asked if there were any incidents when a resident had to wait over 30 minutes before they received their meal, seven (7) out of eight (8) stated the longest wait time they have observed was 15 minutes due to shortage of staff when a person had call out. During interviews with Residents R1-R13, were asked if there was a time they had to wait an extended time before they received their meal, five (5) out of thirteen (13) stated about a month ago there was a time they waited almost 30 minutes before they received their meals. Additionally, Residents R1-R13 were asked if their food they received is cold, thirteen (13) out of thirteen (13) stated they have not had cold food since the new chef started. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

On 4/19/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Judith Uy-Villaruz /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (126) non-ambulatory elderly adults ages 60 and above, of which (8) may be bedridden. Facility has an approved hospice waiver for (15). Delayed egress approved for memory care and transitional. Bedridden first floor only. The facility is a 3 story with a basement and parking garage situated in a residential neighborhood. There is a memory care side with and an assisted living side. There is (28) memory care and (59) in the assisted living. The facility interior includes common area living room, dining, kitchen, activity room, theater room and laundry area. The common area living room has a fireplace with a screen and uses gas not wood. The common living room area included an adequate number of chairs, couches, tables, a poker table and a library. Patios with seating and shade available for residents and families. LPA Iniguez toured the physical plant with Executive Director. There were no bodies of water or obstructions on the premises. A total of (6) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #104, #107, #118, #129, #239 and, #225; call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 113.5F° – 115.2F°. The room temperature ranged from 76F° – 78F°. Evaluation Report continues 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 LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. Cleaning supplies, toxins, and sharps objects were stored and not accessible to residents in care. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 03/3/24. Annual fire clearance performed on 4/16/2024. Working landline phones are available on-site. A review of (6) residents' service files (R1-R6) and (6) staff personnel files (S1-S6) were maintained in order. LPA reviewed (4) Medication Administration Records (MARs) and no discrepancies were found. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted throughout the facility. Liability insurance was given to LPA during this visit. Facility Annual Fess are Current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Judith Uy-Villaruz /Executive Director.

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Resident sustained a fall while in care. The details of the complaint alleged resident #1 (R1) sustained a fall due to lack of care. The complainant reported (R1) had a fall on 11/24/22. The complainant did not have further information on this matter. (R1) transitioned from Atlantic Memorial Long Beach a skilled nursing facility to Oakmont at Torrance an assisted living facility on 11/19/22. Upon arrival, (R1) was immediately placed on hospice care with Beacon Hospice Inc. on 11/19/22. (R1) was considered a fall risk and a fall management plan was in place with hospice (dated: 03/08/24) and an Individualized Service Plan with the facility (dated: 08/10/22). The Fall Plan provided instructions to educate caregivers on how to prevent falls, fall precautions, and safety precautions, minimize fall risk factors, and interventions to manage falls. On 11/25/22 at 4:30 am, (R1) had an unwitnessed fall and was discovered by a facility staff while doing routine rounds. (R1) was assisted by the staff who was found lying on the floor in (R1’s) room with a head injury. Facility progress notes (dated: 11/25/22) and hospice visit notes (dated: 11/25/22), indicated (R1) was unable to recall the fall and unable to recall what or how (R1) fell that day. Hospice records revealed (R1) did not sustain fractures due to the unwitnessed fall. On 11/26/24 resident #1 (R1) was admitted to Torrance Memorial Hospital for general weakness and unresponsiveness according to an Unusual Incident Report LIC 624 (dated: 11/28/22). Medical records (dated: 04/23/23) indicated (R1) was admitted and treated for Septic Shock. (R1) did not sustain any fractures as a result of the unwitnessed fall, according to medical records. On 03/01/24 between 09:50 am – 11:18 am, the Department interviewed administrator (A1) and (3) out (3) staff #1-#3. (A1-S1) stated they were both aware of an unwitnessed fall incident that occurred with (R1) and that immediate medical attention was provided. (A1-S1) stated that this was the only incident involving (R1) in the fall. (A1) and (S1-S3) claimed that (R1) did not have any witness or unwitnessed falls before 11/25/22. Facility progress notes (dated: 11/19/22 – 11/26/22), (R1) was being monitored hourly by staff. Physician’s Report (dated: 07/27/22) and Individualized Service Plan (dated: 08/10/22) did not order (R1) for 24/7 one-on-one supervision. (Evaluation Report continues LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 03/01/24 between 01:10 pm – 01:48 pm, the Department interviewed (8) out of (8) residents #2-#9 (R2-R9) reported not to have experienced or observed any resident sustained a fall due to lack of supervision or care. On 03/04/24 between 01:04 pm – 02:11 pm, the Department interviewed family representative witness #1 (W1) claimed the facility was well maintained and managed. (W1) felt that (R1’s) condition improved when (R1) transitioned back to this facility from recovering at the skilled nursing facility. (W1) stated that the fall on 11/25/22 was an isolated incident and it was not the main cause for (R1) to be hospitalized on 11/26/22. Medical and hospice records revealed (R1) did not suffer fractures due to the unwitnessed fall. Based on gathered information, there is no evidence to support the allegation is due to neglect/lack of care “Resident sustained a fall while in care”. Allegation #2: Staff did not seek timely medical attention for a resident. The details of this complaint alleged the facility failed to seek medical attention for resident #1 (R1). The complainant reported (R1) had a fall on 11/24/22 at the facility and did not receive medical attention until 11/26/22. There were no further details provided by the reporting party. On 11/26/24 resident #1 (R1) was admitted to Torrance Memorial Hospital. Medical records (dated: 04/23/23) indicated (R1) was brought in and treated for Septic Shock. On 11/25/22 at 4:30 am, (R1) had an unwitnessed fall and was discovered by facility staff while doing routine rounds. (R1) was assisted by the staff who was found lying on the floor in (R1’s) room with an apparent head injury. On 11/25/22 at 6:30 am Beacon Hospice Care registered nurse conducted a complete Neurological Examination with (R1). Hospice Medical Records indicated that (R1) was at baseline awake, responsive with a slight confusion. No motor dysfunction observed. No visible fracture and no bluish discoloration were noted. (R1) was able to move all extremities without discomfort. (R1) was unable to recall a recent fall and unable to recall what or how (R1) fell earlier that day. The hospice medical physician was notified of (R1’s) fall. The facility care staff was instructed to give (R1) morning medications and to assist with pain management and instructed to call hospice for any changes in condition. (Evaluation Report continues LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 03/01/24 between 09:50 am – 11:18 am, the Department interviewed administrator (A1) and (3) out (3) staff #1-#3. (A1-S1) and stated they were both aware of a fall incident that occurred with (R1) and that immediate medical attention was provided. (S2-S3) does not recall a fall incident with (R1), however, stated that medical attention would be implemented by the facility immediately. (A1) claimed that (R1) was under hospice care with Beacon Care Hospice was notified and sent a registered nurse to examine (R1) on the same day of the fall. Beacon Hospice medical records (dated: 03/08/24) verified on 11/25/22 that medical attention was given to (R1). (A1) also reported a nurse practitioner came out to conduct a medical assessment later that day 11/25/22 from (R1’s) Scan Health Plan. A review of an Unusual Incident Report LIC 624 (dated: 11/28/22) verified (A1’s) statement that immediate medical attention was provided to (R1) on 11/25/22. On 03/01/24 between 01:10 pm – 01:48 pm, the Department interviewed (8) out of (8) residents #2-#9 (R2-R9) and claimed that facility staff are responsive to provide prompt medical assistance. On 03/04/24 between 01:04 pm – 02:11 pm, the Department interviewed family representative witness #1 (W1) claimed to have been notified by staff of the fall and that medical attention was issued promptly. Based on the gathered information, there is no evidence to support the allegation due to neglect/lack of care “Staff did not seek timely medical attention for a resident.”. Allegation #3: Resident developed multiple pressure injuries while in care. The details of this complaint alleged that resident #1 (R1) sustained multiple skin ulcers while in care. It is reported by the complainant upon medical assessment, (R1) revealed to have various skin ulcers in one or two stages. The complainant did not provide further detailed information on this matter. Resident #1 (R1) was admitted to Oakmont of Torrance on 08/11/2022. From 11/08/2022 – 11/19/2022 (R1) was at a skilled nursing facility Atlantic Memorial Long Beach. (R1) was readmitted at Oakmont of Torrance on 11/19/22 – 11/26/22 under hospice care with Beacon Hospice Inc. (R1) when admitted by Beacon Hospice with a wound care plan in place. The plan is to educate the caregiver to inspect the skin, especially bony prominences and dependent areas, for pallor, redness, and breakdown. Perform skin assessment and understand skin treatment and instructions. (Evaluation Report continues LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (R1) was medically examined on 11/19/22, 11/22/22, and 11/23/22 by a hospice nurse with no rash, wound/skin impairment, or pressure ulcers. (R1) was not prescribed with any medications to treat any skin conditions. However, on 11/25/22, (R1) was assessed with (top of head abrasion stage 1) due to the fall incident early morning on 11/25/22. The abrasion was treated with antibiotic ointment by hospice. (R1) was on blood thinning medications. It is noted blood thinner medication makes the skin and elasticity of the skin prominent for discolorations. On 03/01/24 between 09:50 am – 11:18 am, the Department interviewed administrator (A1) and (3) out (3) staff #1-#3. (A1) and (S1-S3) all claimed that (R1) did not sustain multiple stage 1 or 2 injuries. (A1-S1) only recalled (R1) being observed with a minor head abrasion due to the unwitnessed fall on 11/25/22 that hospice had treated the same day. (A1) claimed that (R1) did not have any wounds, skin tears, or rashes before (R1’s) fall on 11/25/22. (S1-S2) claimed (R1) was monitored every two hours and that body assessments were done daily with residents. On 03/01/24 between 01:10 pm – 01:48 pm, the Department interviewed (8) out of (8) residents #2-#9 (R2-R9) reported not to have any knowledge of any residents who sustained pressure injuries for staff lack of care. On 03/04/24 between 01:04 pm – 02:11 pm, the Department interviewed family representative witness #1 (W1) who is very much involved with (R1’s) care with routine visitations, stated that (R1) did not have any wounds, rashes, or ulcers before (R1’s) fall. Medical Records from Torrance Memorial (dated: 04/24/23) only mentioned (R1) was assessed with ¼ inch laceration with abrasion and hematoma to the right parietal from the fall incident on 11/25/22. Based on the gathered information, there is no evidence to corroborate the allegation due to neglect/lack of care “Resident developed multiple pressure injuries while in care”. Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance o

The investigation revealed the following: Allegation: Staff do not assist resident with grooming as needed. It is alleged that residents are not being groomed as needed. LPA reviewed weekly grooming schedule for residents, which show that most of the residents get one to two showers a week. LPA interviewed staff (S1-S3) regarding the allegation. All the staff interviewed three out three staff stated that majority of the residents receive assistance with their grooming. (R1-R3) have their own one on one private companion (care givers), who help with their daily grooming. The Oakmont care giver assisted them with the grooming when they requested assistance. LPA interviewed (R4-R5) regarding the allegation. They all stated that the staff is great at taking care of them. Especially with the toilet needs. LPA interviewed the three one on one private companion (care givers) all stated that residents received grooming every day. LPA Richard attempted to interview R1 but was unsuccessful and was unable to answer the questions. R1 have her own one on one private companion. Based on interviews, observation, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Facility do not ensure resident wears clean clothing. Allegedly, the staff do not assist residents wear clean clothing. During the visit LPA observed that all the residents wear clean clothing at the dinning room. LPA interviewed staff (S1-S6) regarding the allegation. All the staff stated that residents wear clean clothes every day, some of the residents don’t like to change their clothes, if the clothes aren’t soiled or dirty. LPA interviewed resident (R4-R5) residents stated that the staff change their clothes every day unless they don’t want their clothes to be changed. Based on interviews, observation, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated . Allegation: Facility staff do not ensure resident has clean bed linens. Allegedly, the staff do not ensure resident has clean bed linens. During the visit LPA observed that all the residents room have clean bed linens and comforter. LPA interviewed staff (S1-S6) regarding the allegation. All the staff stated that residents beds are changed every day with clean linens, pillowcases, and blankets. If the residents have an accident in bed staff will remove their linens. If the bed linens are soiled and dirty the staff will remove their linens. LPA interviewed resident (R4-R5) residents stated that the staff cleaned their beds every day. 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, observation, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated . Allegation: Facility staff do not assist resident with bathing as needed. Allegedly, the staff do not assist resident with bathing as needed. During the visit LPA interviewed staff (S1-S6) regarding the allegation. All the staff stated that residents are showering two or three times a week. Some of the residents have their own schedule for showering. If the residents have an accident the staff will bath them. If the residents are going out in the outing the resident might want to shower before leaving. LPA interviewed residents (R4-R5) residents stated that the staff do bath them according to their schedule unless they have an accident or refuse to take a bath that day. Based on interviews, observation, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated . A copy of the complaint investigation Report LIC9099 and LIC9099-C was provided to the facility. There were no deficiencies cited. An exit interview was conducted.

On 8/12/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Ryan Matthew/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (126) non-ambulatory elderly adults ages 60 and above, of which (8) may be bedridden. Facility has an approved hospice waiver for (15). Delayed egress approved for memory care and transitional. Bedridden first floor only. The facility is a 3 story with a basement and parking garage situated in a residential neighborhood. There is a memory care side with and an assisted living side. There is (28) memory care and (58) in the assisted living. The facility interior includes common area living room, dining, kitchen, activity room, theater room and laundry area. The common area living room has a fireplace with a screen and uses gas not wood. The common living room area included an adequate number of chairs, couches, tables, a poker table and a library. Patios with seating and shade available for residents and families. LPA Iniguez toured the physical plant with Administrator. There were no bodies of water or obstructions on the premises. A total of (8) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #102, #105, #106, #108, #116, #120, #122, #201 and #207; call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 106.5F° – 114.2F°. The room temperature ranged from 76F° – 78F°. Evaluation Report continues 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 LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 03/9/23. Annual fire clearance performed on 7/5/20231. Working landline phones are available on-site. A review of (8) residents' service files (R1-R8) and (8) staff personnel files (S1-S8) and Medication Administration Records (MAR) were maintained in order. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted throughout the facility. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report and Appeal Rights was provided to the Administrator/ Ryan Matthew.

The investigation revealed the following: Allegation: Staff do not afford resident dignity in their relationship. LPA interviewed staff (S1-S8) and residents (R1-R7). regarding allegation listed above. All interviewed denied the allegation including R1. During the course of the investigation, LPA was unable to find any documents or witnesses supporting the allegation above. LPA reviewed a copy of the admissions agreement including general policies and guidelines, communications – information services and member code of conduct among other topics given to each resident upon admission to the facility. All staff of the and residents denied the allegation and stated there were no issues or concerns about the facility staff not affording residents dignity. Based on information gathered, the department did not find sufficient evidence to support the allegation. Although the allegation 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 allegation is Unsubstantiated . Cont 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff do not respond timely to resident's call pendent S1 stated that resident R1 does indeed activate R1’s call device often for assistance for care and staff responds to the calls for assistance. S1 stated to LPA that S1 was unaware of any complaints from R1 regarding delayed assistance and denies the allegation. LPA reviewed call logs and found that multiple calls had occurred at or around the same time. R1 was however provided assistance. LPA interviewed Staff stated to LPA all the staff responds timely to every call for assistance from all the residents. LPA interviewed staff (S2-S7) and staff confirmed they respond quickly to the call alerts from residents promptly as trained. LPA interviewed residents (R2-R7). regarding allegations listed above -Staff did not answer resident's call button in a timely manner, of residents interviewed the residents reported they had not encountered a problem with staff not responding timely. Based on information gathered, the department did not find sufficient evidence to support the allegation. Although the allegation 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 allegation is Unsubstantiated . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff do not wake residents for breakfast LPA interviewed morning shift staff inclusive of (S1-S7) all staff confirmed all residents are offered breakfast every morning. Staff informed LPA if a resident wakes up late the resident can still have breakfast at their request. LPA interviewed residents (R2-R7). regarding allegations listed above, all residents reported they had not encountered a problem with staff not waking residents for breakfast. R1 informed LPA he had not missed breakfast since residing at the facility. R1 informed LPA that he is independent and usually sets an alarm to wake in the mornings. Based on information gathered, the department did not find sufficient evidence to support the allegation. Although the allegation 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 allegation is Unsubstantiated . Cont 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Resident did not receive copy of care plan. LPA interviewed S1, S1 denied the allegation. S1 stated all residents, or their responsible party are required sign admission agreement and care plans incorporated into their agreement and a provided a copy at the time of admission or shortly thereafter. S1 also stated that a copy of the plan is available upon request by resident or responsible. S1 was asked if R1 made any document request R1 stated “no”.LPA reviewed resident file and required documents were in the file and signed. LPA interviewed R1, R1 was asked if he received a copy of his care plan R1 stated to LPA ‘I don’t not remember but I am sure my daughter has a copy of my paperwork’. R1 was asked was he denied a copy of his paperwork? Answer no “I have not asked for it”. LPA interviewed residents (R2-R7) all stated that they have had no issues receiving documents or copies of signed agreements. Based on information gathered, the department did not find sufficient evidence to support the allegation. Although the allegation 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 allegation is Unsubstantiated . Findings Based on information gathered, the department did not find sufficient evidence to support the allegations listed above. 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 . An exit interview was conducted and a copy of the LIC 9099 was provided to Matt Ryan Executive Director