Silverado Rolling Hills.

The investigation revealed the following : Allegation #1- Staff are hitting a resident. The details of the complaint alleged that the staff hit the resident (R1) while in care. It was reported that there was a concern of elder abuse. On 7/11/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R5) regarding the allegation. 4 of 4 staff denied the allegation that Staff are hitting a resident. All staff (S1-S4) interviewed stated that they have not witnessed nor have any knowledge of the resident being hit by anyone at the facility. They further state that any signs of abuse would be reported, and the resident’s family would be contacted. They stated that there is no evidence of abuse. The department interviewed residents (R1-R5) about the allegation and 5 of 5 residents that were interviewed denied any knowledge of residents being hit or abused in any way. All residents stated that they were satisfied with the care and supervision provided by the staff and feel safe living in the facility. The Department reviewed the Physicians Report (Dated: 05/28/2025), Comprehensive Assessment/Observation (Dated: 05/27/2025), and Service Plan (Dated: 05/28/2025, 06/13/2025, 06/19/2025) and did not observe any reported abuse of the resident or indications on the physician’s report that abuse may have happened. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are hitting a resident. 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 #2- Staff are restraining residents. The details of the complaint alleged that the facility may have restrained the resident (R1) to a wheelchair while at the facility. On 7/11/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R5) regarding the allegation. 4 of 4 staff denied the allegation that Staff are restraining residents. All staff (S1-S4) interviewed stated that they have not restrained any resident in anyway. They state that they have no knowledge of any staff restraining the resident(s) or restraining them in their wheelchair to restrict their movements. The department interviewed residents (R1-R5) about the allegation and 5 of 5 residents that were interviewed denied any knowledge of staff restricting their movements by restraining them in any form. All residents stated that they have never been restrained by any staff at this facility. Report Continued On LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The department reviewed the Physicians Report (Dated: 05/28/2025) and did not observe that the resident (R1) required any type of restraints. The department further observed that the resident (R1) was able to walk on their own without assistance and did not use a wheelchair on this visit. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are restraining residents. 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 #3- Staff are not meeting residents’ dietary needs. The details of the complaint alleged that there is a concern for the resident (R1) because they are losing weight. On 7/11/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R5) regarding the allegation. 4 of 4 staff denied the allegation that Staff are not meeting residents’ dietary needs. All staff (S1-S4) interviewed stated that the resident is eating a regular type of diet, and the consistency is regular too. Staff stated the resident does need assistance with eating, they noticed that if they just place the food at the table the resident will not eat enough. They state that when they assist the resident with eating their meal, the resident will eat more. Staff state that they are always encouraging the resident to eat more. The department interviewed residents (R1-R5) about the allegation and 5 of 5 residents that were interviewed denied that the staff are not meeting their dietary needs. All residents that were interviewed stated that the facility provides them with enough nutritious food to eat. They state further that they are getting enough food and does not feel deprived of anything. The Department reviewed the Menu (Dated: Week 1-Week 5 June & July 2025), and Diet Request Form (Dated: 05/28/2025) and observed that the resident’s are getting a variety of nutritious foods for breakfast, lunch, and dinner. The menu was a healthy diet that emphasizes a wide variety of foods from all food groups, including fruits, vegetables, grains, lean protein sources (like fish, beans, eggs, lean meats) and dairy and dairy alternatives. The department also reviewed the resident’s Face Sheet (Dated: 05/28/2025) and observed that the resident weighed 102.2 pounds when the resident moved in, and now the resident’s current weight as of 07/02/2025 is 103.8 pounds. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not meeting residents’ dietary needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No deficiencies were cited. An exit interview was conducted with Christina Hale, Administrator, and a hard copy of this Complaint Investigation Report was provided.

Allegation: Staff left resident in soaking wet clothing for extended periods The details of the complaint alleged that facility staff are leaving residents in soaking wet clothing for extended period of time. During the records review, LPA received and reviewed the Resident Incontinent List and reviewed Resident Physician’s Report, Pre-Admission Appraisal, Needs and Service Plans, Staff Notes for the past 5 months and Admission Agreement. During interviews with staff (S2-S12), were asked if a resident has been left in soiled diapers or clothing for an extended period of time, eleven (11) out of eleven (11) stated they have not seen nor heard of any residents being left in soiled diapers or clothing for an extended period of time. Additionally, staff S2-S12 were asked how often incontinent residents are changed, nine (9) out of eleven (11) stated they are checked every two hours, one stated when needed, and one stated on a regular basis. During interviews with residents (R1-R6), were asked if they have been left in soiled diapers or clothing for an extended period of time, five (5) out of six (6) stated they have not been left in soiled diapers or clothing for an extended period of time and they are assisted right away. During the visit, the department interviewed five (5) family members of residents living in the facility (spouse or children). During interviews with witnesses W1-W5, were asked if there has been a time their family had been left in soiled diapers or clothing for an extended period of time, four (4) out of five (5) stated they have not been told or observed their family being left in soiled diapers or clothing. One witness stated that was an issue they experienced 5 months ago, and there have been no issues with it recently. During the investigation, the department did not find sufficient evidence to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard was not met. 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 allegations are unsubstantiated. Allegation: Staff mismanaged residents’ medication The details of the complaint alleged that facility staff have given the wrong medication to residents. During the records review, LPA reviewed the facility’s electronic Medication Administration Record (eMAR) and compared it to the centrally stored medications for 10 residents. LPA observed ten (10) out of ten (10) resident’s eMARs and medications are consistent with properly documented records. LPA reviewed Special Incident Reports (SIR) submitted since October 1, 2023, and did not observe any SIRs reporting a medication errors. 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 an interview with staff S10, was asked if residents receive their medications as prescribed, S10 stated residents are given their medications as prescribed. Additionally, S10 was asked if there were any medication errors in the past two (2) months and S10 stated, to their knowledge there have been no medication errors. During interviews with staff S2-S9 and S11-12, were asked if residents receive their medications as prescribed, ten (10) out ten (10) stated as far as they know residents receive their medications as prescribed. During interviews with residents (R1-R6), were asked if they receive their medications as prescribed, six (6) out of six (6) stated yes, they receive their medications as prescribed. During interviews with Witnesses W1-W5, were asked if their family in the facility receive their medications as prescribed, four (4) out of five (5) stated yes, their family receives medications as prescribed. One (1) witness stated it was an issue in the past, but they have not had a problem in a long time, and it has been good. During the investigation, the department did not find sufficient evidence to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard was not met. 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 allegations are unsubstantiated. Allegation: Untrained staff The details of the complaint alleged that facility staff are untrained and administering medication. During the records review, LPA reviewed the training records for six (6) staff including two (2) med techs. LPA observed staff had over the hours of training required. Additionally, LPA received and reviewed In-Service logs conducted monthly and attended by all staff. LPA observed In-Services were conducted on all shifts so staff could attend. LPA observed Nurses have additional in-services for just them and their position. During interviews with staff (S2-S12), were asked if they are provided with regular training and in-services, eleven (11) out of eleven (11) stated they receive regular annual training on Relias and in-services are conducted a minimum of once a month, if not more. During interviews with residents (R1-R6), were asked if they have any concerns regarding staff training, six (6) out of six (6) stated they have no concerns regarding staff training. Additionally, three (3) stated the staff are good and do a great job. During interviews with Witnesses W1-W5, were asked if they have any concerns regarding staff training, five 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 (5) out of five (5) stated they have no concerns regarding staff training. During the investigation, the department did not find sufficient evidence to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard was not met. 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 allegations are unsubstantiated. Allegation: Residents are being neglected while in care The details of the complaint alleged that the facility has insufficient staffing to meet the needs of the residents. During the records review, LPA received and reviewed a copy of the staffing schedule and observed there are four (4) caregivers, and two (2) nurses on during the day and evening shift, and for the Noc shift there are three (3) caregivers and a nurse on shift. During interviews with staff (S2-S12), were asked if they feel the facility is sufficiently staffed, eleven (11) out eleven (11) stated yes, they are sufficiently staffed. During interviews with residents (R1-R6), were asked if there are enough staff to provide assistance to residents, six (6) out of six (6) stated that yes, there is enough staff to provide assistance to residents. During interviews with Witnesses W1-W5, were asked if they feel there is enough staff to provide assistance to residents, three (3) out of five (5), stated yes there is enough staff to provide care. During the investigation, the department did not find sufficient evidence to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard was not met. 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 allegations are unsubstantiated. Allegation: Staff don’t answer facility phone The details of the complaint alleged that facility staff fail to answer facility phone. During the records review, LPA reviewed Special Incident Reports (SIR) to see if there was any notification of the facility not having phone service, LPA did not observe any report. During the facility visit, LPA called the phone number posted on the door and the phone was answered right away by staff. During interviews with staff (S2-S12), was asked if there is someone responsible for answering phones throughout the day, eleven (11) out eleven (11) stated that yes, the phones are answered at the front desk throughout the day and in the evening the phones are transferred to the nurse’s station. Additionally, three 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 (3) staff stated that for some time the company’s main phone number, and not the facility number, was posted on the door. During interviews with Residents R1-R6, were asked if them or their family have called the facility phone and their phone call was not answered, six (6) out of six (6) stated no, they have there is always someone there. During interviews with Witnesses W1-W5, were asked if they have called the facility and their phone call was not answered, five (5) out of five (5) stated when they call the facility phone is answered. During the investigation, the department did not find sufficient evidence to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard was not met. 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 allegations are unsubstantiated. Allegation: Staff did not assist residents in a timely manner The details of the complaint alleged that when residents require assistance, they call for staff, but either the staff do not show up or respond very late. During the facility inspection, LPA tested the call buttons in rooms 105,106,109, and 217. Caregivers responded to the pendants call for assistance in under 8 minutes. During an interview with Staff (S

Allegation: Due to neglect, resident sustained pressure injuries The allegation alleges that medical professional has concerns of neglect resulting in pressure ulcers. During the facility inspection, LPA observed a caregiver transferring a resident from their wheelchair to their bed to relieve pressure. LPA observed a pressure cushion on the resident’s chair. The resident stated after activities the staff will assist them to their bed till the next activity or meal. During file review, LPA received and reviewed resident R1’s Physician’s Report, dated 05/04/2024 that indicates no history of skin breakdown or condition. LPA received and reviewed R1’s Service Plan details dated 12/05/2024, that states Resident’s skin condition is normal, routine skin checks are conducted, and the use of pressure reduction cushions, mattress, boots, lotion, and creams, and assist with repositioning. A routine Wellness Observation was conducted on 02/28/2025, that indicates a full body skin assessment was completed and No lesions/symptoms were noted. Additionally, LPA reviewed Discharge/Transfer Progress Note dated 03/04/2025, that indicates Resident R1’s skin is intact at time of transfer. R1 was out of the facility from 03/04/2025 through 03/28/2025. LPA reviewed staff Progress Notes from 03/28/2025 through 03/31/2025 that indicated on 03/28/2025 at 9:19 PM R1 returned from the hospital and a skin check was performed, no pressure injuries were noted. Resident was kept clean and dry. On 03/29/2025 at 1:09PM, it was noted R1 was transferred from the bed to the wheelchair and then back to bed, and R1 was assisted with repositioning every 2 hours. Staff ensured resident was clean and dry. On 03/29/2025 at 10:32 AM, it was noted R1 was assisted with repositioning every 2 hours. On 03/29/2025 at 3:09PM, it was noted R1 was in bed and repositioned throughout shift, while family was at bedside. On 03/29/2025 at 9:59 PM, it was noted R1 was in bed and assisted with repositioning every 2 hours and was kept clean and dry. During interviews with Staff S1-S8, were asked if any residents have been diagnosed with pressure injuries due to staff not assisting residents with repositioning, five (5) out of eight (8) stated no residents have sustained a pressure injury due to lack of repositioning. During interview with Resident R2-R7, were asked if they have gotten any pressure ulcers or sores due to staff not assisting with repositioning, six (6) out of six (6) state stated they have not gotten any sores from not being repositioned and that staff are always available to help them reposition their bodies in bed, in their wheelchair, and even regular chairs. During interviews with Witnesses W1-W3, were asked if their resident has sustained pressure injuries due to not being assisted with repositioning, two (2) out of three (3) stated they are not sure if the pressure injuries were caused from repositioning. One (1) out of three (3) stated there has been no concerns of pressure injuries. 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: Due to staff neglect, resident was dehydrated The allegation alleges resident was exhibiting signs of dehydration. During the facility inspection, LPA observed water and juice available in the bistro area. Additionally, LPA could periodically hear caregivers ask residents if they want something to drink or reminding them to take a drink of their beverage. During record review, LPA received and reviewed Resident R1’s Progress notes. On 03/29/2025 at 1:09 PM, it was noted that R1 drank 50% of an ensure. On 03/29/2025 at 8:36 PM, it was noted R1 was having difficulty swallowing and family was notified and asked if they wanted R1 to be transferred to the hospital for evaluation. The family denied the request. On 03/29/2025 at 10:32 PM, it was noted R1 was having difficulty swallowing liquids. R1 was able to take 3 sips of liquids. On 03/30/2025 at 3:09 PM, it was noted R1 was having difficulty swallowing. On 03/30/2025 at 9:59 PM it was noted difficulty swallowing continues. During interviews with Staff S1-S8, were asked how you ensure residents stay hydrated, eight (8) out of eight (8) stated fluids are always available in the bistro area and staff offer, remind, and encourage residents to drink water and other fluids. Additionally, Staff S1-S8 were asked if R1 was consuming fluids after their return from the hospital, eight (8) out of eight (8) stated R1 was consuming minimal fluids, was having difficulty swallowing, and in some instances the fluid would come back out. During interviews with Residents R2-R7, were asked if there are fluids available at all times, seven (7) out of seven (7) stated there is always water, juice, and coffee available and staff are always asking if they would like something to drink. During interviews with Witnesses W1-W3, were asked if their resident is getting plenty of fluids to stay hydrated, two (2) out of three (3) stated yes the resident is getting plenty of fluids and they are always offered. Allegation: Due to staff neglect, resident had malnutrition. The allegation alleges resident was exhibiting signs of malnutrition, and resident has not eaten or has eaten very little. During record review, LPA received and reviewed Resident R1’s Progress notes. On 03/29/2025 at 1:09 PM, it was noted that R1 refused breakfast but drank 50% of an ensure. At lunch R1 was transferred to the dining room but did not consume lunch. On 03/29/2025 at 8:36 PM, it was noted R1 was having difficulty swallowing and family was notified and asked if they wanted R1 to be transferred to the hospital for evaluation, the family declined. On 03/29/2025 at 10:32 PM, it was noted R1 was unable to consume dinner and was having difficulty swallowing liquids. R1 was able to take 3 sips of thickened liquids and swallowed 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 with guidance and encouragement. On 03/30/2025 at 3:09 PM, it was noted R1 was having difficulty swallowing and needs encouragement. On 03/30/2025 at 9:59 PM it was noted difficulty swallowing continues. During the facility inspection, LPA observed snacks and fruits available in the bistro area on both the first and second floor. Additionally, LPA observed caregivers and other staff offering snacks to residents throughout the facility. During interviews with Staff S1-S9, were asked how they ensure residents receive enough nutrients to prevent malnourishment, nine (9) out of nine (9) stated residents are provided three (3) meals a day and snacks are always available and offered to residents throughout the day. Nine (9) out of nine (9), additionally stated that if a resident does not want to eat their meals their doctor is contacted and often will order Ensure and Boost and/or approve a Silverado Milk Shake or Magic Cup to ensure they get their nutrients. Additionally, S1 and S9 stated the menu is developed by a dietitian to ensure they are well balanced. During interviews with Staff S1-S8, were asked if R1 was eating when they returned from the hospital, eight (8) out of eight (8) stated R1 was refusing most meals and snack, and that times R1 did take a bite R1 was having difficulty swallowing and would pocket the food in their mouth. During interviews with Residents R2-R7, were asked if they are provided with meals and snacks throughout the day, six (6) out of six (6) stated they receive three (3) meals a day and snacks anytime. During interviews with Witnesses W1-W3, were asked if their resident is provided with three (3) balanced meals and snacks throughout the day, two (2) out of three (3) stated residents are provided meals and snacks throughout the day and have no concerns of malnourishment. Allegation: Staff are not following resident’s special diet. The allegation alleges the facility is not following the special diet orders for a resident. During the facility inspection, LPA observed a binder in the kitchen that has residents Diet request Forms. LPA observed Staff S9 preparing trays for dinner and observed residents who have Dietary Orders have a card placed on their tray with their orders. During record review, LPA received and reviewed all residents Dietary Orders. Additionally, LPA received and reviewed the facility Menu created by a dietitian from Dining Manager by Dining RD. The Dining RD Meal Service Observation and Procedures form dated 03/05/2025, was reviewed by LPA, that indicated for the Menu it meets the standards and spreadsheets have all the diets for POS diets. Furthermore, the Menu Sub Log meets the standards for evidence of nutritionally equivalent substitutions. During interviews with Staff S1-S9, were asked how residents Dietary Orders are met and tracked, nine (9) 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 out of nine (9) stated the nurse receives the orders, fills out a Diet Request Form and signs and copies it, then takes the copies to the chef who signs one and puts the other in the binder, and when meals are served there is a card on the tray that has the residents name and orders. During interviews with Residents R2-R7, were asked if the food and snacks they receive meet their Special Dietary Orders, six (6) out of six (6) stated their dietary orders are followed. During interviews with Witnesses W1-W3, were asked if their residents dietary orders are met, two (2) out of three (3) stated yes their resident's dietary orders are met. Allegation: Due to lack of supervision, resident has had multiple falls. The allegation alleges resident has fallen multiple times at the facility resulting in hospitalization. During the facility inspection, LPA observed all walkways in the facility clear of hazards and obstructions. LPA observed some residents had fall mats next to their b

Allegation: Lack of supervision resulting in injury to resident in care. Resident had an unwitnessed fall after rounds were done. During file review, the department observed a Special Incident Report (SIR) was faxed to Community Care Licensing on 11/02/2024, regarding an incident that occurred on 10/28/2024 in regard to R1. The SIR stated R1 was observed on the floor with broken glass around them and bleeding was noted. The department received and reviewed R1’s Service Plan Details dated on 10/24/24 that indicates for Mobility/Ambulation, Escorts, and Transferring resident R1 may require prompts/cues for safety, does not require hands on assistance. Additionally, it indicates resident R1 has experienced a fall on 07/30/24 and was observed on the floor on 08/25/2024 resulting in interventions being put in place to minimize fall risk and decrease injury including Mobility program/physical therapy and hip savers. The department received and reviewed a copy of R1’s hospital discharge paperwork from Torrance Memorial Medical Center that states R1 was seen for an unwitnessed fall and abrasions were observed on R1’s legs. During interviews with Staff S1-S9, were asked if there is enough staff on each shift to provide proper supervision, nine (9) out of nine (9) stated there is enough staff on each shift for proper supervision. During interviews with Residents R2-R6, were asked if there are enough staff on each shift to provide supervision to residents, five (5) out of five (5) stated there is enough staff on each shift to provide proper supervision. Additionally, during interviews Residents R2-R6 were asked if they have sustained injuries due to lack of supervision, five (5) out of five (5) stated they have not sustained injuries due to 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 lack of supervision. During an interview with W1, R1’s responsible person, was asked if they have any concerns with the supervision R1 receives at the facility, W1 stated they have no concerns. Additionally, W1 was asked if they have any concerns regarding the abrasions on R1’s legs, W1 stated R1 has a history of scratching their legs and stomach. During the investigation, the department did not find sufficient evidence to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard was not met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Director of Health Services, Divine Tuzon, and a copy of this report was provided.

On 06/8/24, Licensing Program Analyst, (LPA) Antonine Richard conducted a case management other. LPA arrived at the facility above to perform a one -year required visit. Up arrival, facility Director Matthew Zarro stated that on 05/31/24, LPA Wendy Gibbs conducted a year- required annual already. LPA Richard got a copy of the report. LPA Richard decided to conduct a case management other. No deficiencies were cited. A copy of the report was provided to Director Matthew Zarro.

On 05/31/24, Licensing Program Analyst (LPA), Wendy Gibbs conducted and unannounced annual visit. LPA met with Training Administrator, Farid Taheri, and the purpose of today’s visit was explained. The facility is licensed to serve (68) of which (60) are non-ambulatory and (68) bedridden elderly adults ages 60 and above. The facility is approved for (10) hospice residents. Currently, the facility has ten (10) residents on hospice care. Physical Plant/Structure The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (47) resident bedrooms. Each room has a bathroom in the unit. There are administrative offices, a copy room, an activity area, dining areas, a kitchen, a beauty shop, medication rooms, and an outside patio. LPA observed all walkways around the building to be clean, clear, and free of obstructions, debris, and hazards. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected seven (7) resident rooms, including 101, 104, 107, 108, 203, 207, and 227, and observed them to be clean and in good repair. LPA observed all rooms to be properly furnished with a bed, dresser, nightstand, chair, and storage space for resident’s personal belongings. Residents have the option to furnish rooms with 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 their personal furniture or the facility has furniture available for them. LPA observed beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed some residents have their personal linens stored in their rooms and the facility has an ample supply in a storage room for resident use. All rooms were observed with ample lighting. Bathrooms LPA inspected seven (7) resident bathrooms and observed them to be clean, operational, and meet Tittle 22 regulations. LPA observed storage area for residents’ personal hygiene products. The facility does have an ample supply of hygiene products available for residents. The water temperature in the resident’s bathrooms measured between 111.4-degrees and 116.7-degrees Fahrenheit. Common Rooms LPA inspected all common rooms in the facility and observed them to be properly furnished to accommodate all residents. LPA observed all walkway and hallway in the facility to be clean, clear, and free of obstructions and hazards. LPA observed all common areas to have ample lighting. The facility was kept at a comfortable temperature. LPA observed resident’s participating in activities. Kitchen LPA inspected the facilities industrial kitchen and observed it to be clean and sanitary. LPA observed all appliances to be operational and in good repair. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored, packaged, and labeled. 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 Medications LPA observed all centrally stored medications secured in a locked med cart in the locked medication room and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the electronic Medication Administration Record (eMAR) for five (5) residents. LPA observed five (5) out of five (5) resident’s eMARs and medication are consistent with properly documented records. File Review/Interviews LPA reviewed five (5) resident files and found they had the required documents. LPA interviewed five (5) resident and all residents are happy with the care and treatment they receive at the facility. LPA reviewed five (5) staff file and the Administrator file and observed they had the required documents, training, and certifications. LPA interviewed five (5) staff and they were able to answer questions regarding policy, procedure, resident care, and resident personal rights. Safety LPA observed multiple fully charged fire extinguishers throughout the facility last serviced on 04/16/24. The last inspection from Fire Alarm and Life Safety System was conducted on 02/28/24. The last emergency drill was conducted on 05/17/24. LPA observed all required documents posted throughout the facility. The facility has a working landline telephone. The elevator was last inspected and serviced on 03/13/24. LPA received and reviewed a copy of the facility’s Liability Insurance. LPA inspected the generator and reviewed the logs; it was last serviced on 04/30/24 and is started and ran weekly. LPA observed all cleaning supplies secured in the locked housekeeping cart and in a locked storage room. All sharps are secured and inaccessible to residents. 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 Infection Control LPA observed required infection control signs posted throughout the facility. LPA observed sanitizing stations throughout the facility. LPA observed an ample supply of cleaning supplies. The facility has a 60-day supply of Personal Protective Equipment (PPE). LPA reviewed the facility visitor log with temperatures. During today’s visit LPA did not observe or cite any deficiencies. An exit interview was conducted with Training Administrator, Farid Taheri, and a copy of this report was provided.

Allegation: Staff did not administer medications to resident. The allegation alleges that a resident did not get their medications because the facility did not know where the resident’s medications were. LPA reviewed Resident R1’s Centrally Stored Medication and their electronic Medication Administration Record (eMAR), LPA observed on the date of 08/12/23 one medication was marked “Drug Not Given (DNG)” and the other medication on that date was not marked. Additionally, on 08/13/23 the same medication was marked “Drug Not Available (DNA)” and the other medication on that date was marked DNG. During an interview with W1, stated they came in to visit R1 on 08/13/23 and the nurse, from an outside vendor, that was working couldn’t find R1’s medications. Additionally, W1 stated R1 was not given their medications till 08/15/23 when the regular nurse returned. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. 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 left resident in soiled diapers. The allegation alleges that on dates while family was visiting, the resident was not changed for hours and was left in soiled diapers. During interviews with Resident’s (R1, R6, and R7) Responsible Party W1, W2, and W3, three (3) out of three (3), stated they have had issues, in the past, with their Resident’s (R1, R6, and R7) being left in a soiled diaper for an extended period of time. W1 stated that during a visit on 08/15/23, no staff came to check to see if R1 needed changed from 11:30am till 5:30pm, and the family did it themselves. Additionally, W1 stated on 08/16/23, family was there from 10:30am till 6:30pm and no staff came to check if R1 needed changed and they had to go ask staff twice to come and change R1. During an interview with W2, stated there were times in September and August 2023 when they would come to visit R6 at 9am and R6 was really wet and in the same diaper from the night before. During an interview with W3, stated that when R7 first moved-in, in August 2023, R7 was in soiled diapers when W3 came to visit. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director, Olivia Blaylock, and a copy of this report 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff did not shower resident. The allegation alleges that the family visited the resident, and they hadn’t been showered. LPA reviewed the facilities shower logs for August, September, October, and November, LPA observed what residents were assisted with showers and on which day. During interviews with Staff (S1-S5) five (5) out of five (5) stated residents who require assistance with bathing are assisted 2 to 3 times a week. Additionally, Staff S1-S3 stated the Residents have the right to refuse a shower and they cannot force a resident to shower. During interviews with Resident’s (R1, R6, and R7) Responsible Party W1, W2, and W3, two (2) out of three (3), stated their Resident’s (R6, and R7) receive assistance with bathing 2 to three times a week. During an interview with W1 they stated they had gone to the facility on R1’s scheduled shower days and R1 was not given a shower until later in the day when W1 went and asked if anyone was coming to assist R1 with a shower. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation 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: Due to staff negligence resident had several unwitnessed falls. The allegation alleges that resident had multiple falls and the staff could not state what happened. During interviews with Staff (S1-S5), five (5) out of five (5) stated that for resident who are a fall risk have additional procedures to help ensure the safety of those residents. Five (5) out of five (5) Staff (S1-S5), stated residents who are a fall risk are checked every hour, provided tag alarms, offered high/low beds, fall mats, and hip protectors, which are optional). During an interview with W1, they stated Resident R1 had multiple unwitnessed falls, and nobody could tell W1 how the fall occurred. LPA reviewed the facilities Special Incident Reports (SIR) and LPA observed two (2) of the three (3) falls were observed by staff and assistance was provided immediately. During interviews with Residents (R2-R8) seven (7) out of seven (7) stated they do not have concerns regarding staff’s extra preventions taken to help reduce falls. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff did not provide timely medical care for resident. The allegation alleges that the family came to visit a resident and found the client in a condition requiring medical care. During interviews with Staff (S1-S5) five (5) out of five (5) stated there is a nurse on site 24-hours a day to provide medical care to residents, and if additional care is required the Resident will be transported to the Emergency Room for further evaluation. During interviews with Residents (R2-R8) seven (7) out of seven (7) stated they receive medical treatment within a timely manner. During review of Special Incident Reports (SIR) for R1 on 08/26/23, stated R1 was being treated by the facility nurse when the W1 arrived. The nurse recommended that R1 go to the Emergency Room for further evaluation and W1 said they would take R1. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated . An exit interview was conducted with Executive Director, Olivia Blaylock, and a copy of this report was provided.

On 09/27/2023 at 8:05 am Licensing Program Analyst (LPA) David España conducted an unannounced required annual visit. Upon arriving at the facility, LPA met with the Administrator Olivia M. Blaylock and Maria Soto, Director of Association, Training and Education who assisted with the visit. LPA explained the purpose of today’s visit. Upon arrival at the facility, LPA David España conducted a risk assessment at the front door. Based on the assessment, the facility is not cleared of COVID-19 infection. There is a total of 21 COVID-19 cases, and seven 7 COVID-19 active cases at the time of visit. LPA requested for staff roster, resident roster, COVID-19 roster, and COVID-19 cleared roster. LPA conducted Inspection Staff interviews with two (2) out two (2) staff. Due to COVID-19 infection outbreak a subsequent case management visit is required. An exit interview was conducted, and a copy of this report was provided to the Administrator, Olivia Blaylock.