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Page 2. Resident #1 at 2:20pm and Resident #2 at 2:43pm and collected copies of documents for Resident #1 and Resident #2. Due to time constraints and the information received, further investigation was needed to make a finding for the above allegations. Exit interview was conducted and a copy of the report was provided. On February 20, 2026, LPA Yee conducted a telephone interview with Dion Gallarza, Executive Director, at 9:48am. Per information received from the investigation regarding the allegation that staff handled resident in a rough manner resulting in injuries, the investigation revealed that Resident #1 was taking Eliquis 2.5 mg, a blood thinner. It was also revealed that Resident #1 has dry skin and likes to scratch their hands and also likes to actively move their hands while talking. Per interviews conducted with staff, everyone denies that staff handle residents in a rough manner. Per Staff, they do not pick up residents by their hands. They are picked up by their arm pits. Resident #1 requires a 2 man assist and is picked up by their arm pits so it is unknown how Resident #1 would have sustained the bruises on their hands. The staff also indicated that the residents’ in Safe Haven don't have behaviors resulting in another resident being hit.. The bruises could have been sustained if Resident #1 waved their hands around while talking and could have hit something. Per information provided, Resident #1 likes to hit the underside of the table with their hands or hit the wall and easily sustained bruises due to the use of blood thinner. Per facility documentation dated October 16, 2025, Resident #1’s responsible party was notified of the bruises observed on the top of the resident’s hands on October 15, 2025. The Responsible party expressed concerns. Per facility documentation, staff from each shift who worked on October 14, 2025, were interviewed by the Executive Director. Staff indicated that Resident#1 had been observed laying their head on their hands and scratching their hands. The facility’s Nurse Practitioner was also called, and pictures of the resident’s hands were sent and the Nurse Practitioner indicated that it would not take much pressure to cause bruising due to the use of blood thinner. Per the Executive Director’s interview with Resident #1, they also indicated that the lady who shaves them was also holding their hands, lifted them up by their shirt and lifted them in the air. The lady who shaves the resident is the responsible party. Based on the information obtained from interviews 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 Page 3. conducted, there is insufficient evidence to support the allegation that staff handled the resident in a rough manner resulting in injuries, therefore the allegation is unsubstantiated at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Per information obtained regarding the allegation that staff unable to provide assistance to residents in a timely manner, the investigation reveals that the facility has 3 shifts. Safe Haven has 2 caregivers and a Medication Technician working the morning and evening shift and one caregiver on the night shift. Assisted Living has 2-3 caregivers in the morning and evening shift and one at night. There is a total of 3 staff for the night shift – one caregiver in Assisted Living, one caregiver in Safe Haven and a Medication Technician. The staff assist and cover each other. Per Laura Diaz, Wellness Director, many of the assisted living residents are independent and don’t need assistance with feeding or to be checked regularly. Residents are observed during mealtimes. Room checks are done for at risk residents based on their needs. The Safe Haven residents do not have any issues or behaviors and are asleep and room checks are conducted every hour. Incontinent residents are changed 2-3 times at night or as needed. Per Laura Diaz, they do not have any staffing issues. Staff respond to calls for assistance within ten minutes. Caregivers assist each other if an assigned caregiver is unable to respond to a resident. Another caregiver will provide coverage. Based on information received during the investigation, there is insufficient evidence to support the allegation that staff unable to provide assistance to residents in a timely manner, therefore the allegation is unsubstantiated at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Exit interview was conducted and a copy of the report was provided.

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 9:28AM to conduct an Annual Continuation visit. The LPA met with the Executive Director (ED) Dion Gallarza and explained the reason for the visit. Entrance interview conducted. At 9:31AM, the LPA and ED conducted a brief health and safety tour of the physical plants areas, and no immediate concerns were observed. RECORDS: Resident records were reviewed at 9:57AM. LPA Huynh reviewed ten (10) files for, but not limited to: admissions agreements, medical assessment, appraisals, and consent forms. Resident records reviewed were in order at this time. The LPA reviewed eleven (11) personnel records for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and appropriate trainings. Staff files reviewed were in compliance with regulation at this time. Three (3) staff did not have a certified first aid/CPR training on file, however, received Relias online module trainings and certified staff are on the premises at all times. The LPA advised the ED to ensure direct care staff receive first aid/CPR certification. Report Continued on LIC 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 INFECTION CONTROL/EMERGENCY DISASTER: The LPA reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPA noted that the facility is in compliance with regulation with both plans reviewed annually. The facility conducts emergency disaster drills monthly, with the last drill documented on 09/16/2025. Fire alarm system is tested annually with the last inspection on 05/01/2025. Additionally, the commercial kitchen was inspected on 08/30/2025 and fire doors were tested on 09/23/2025 by GFP Guard Fire Protection Services Inc. MEDICATION: Medication review began at 11:30AM. The LPA reviewed medications for five (5) residents. Medications were maintained locked inaccessible to residents in the Medication Room located on the first floor in the Memory Care Unit. Resident medications reviewed were documented and stored in compliance with regulation at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 4:20PM for a required one-year visit. The LPA met with the Executive Director (ED) Dion Gallarza and explained the reason for the visit. Entrance interview conducted. At 4:29PM, the LPA and ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The following was observed: RESIDENT ROOMS: The LPA observed ten (10) randomly selected rooms with private restrooms on the first and second floor and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in showers. Resident rooms were furnished with all required furniture within regulation. Water temperature was tested throughout the units and measured between 108.1 degrees F and 118.2 degrees F, which is within the required range per regulation. Report Continued on LIC 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 COMMON AREAS: The facility is a two-story building with a total of one hundred and six (106) units. On the first floor, there was the kitchen facilities, dining room, laundry room, lobby, two (2) outdoor courtyards, resident units, and the memory care unit. The memory care unit had its own courtyard and dining room with food delivered from the main kitchen. On the second floor, there was an activity room and resident units. The LPA observed common areas to be clean and contain furniture in good condition. There were no obstructions and/or tripping hazards throughout the facility. Required postings were found in the hallways on the first floor. LPA observed emergency evacuation chairs at each stairway in the event of an emergency and elevators are out of order. There were no bodies of water observed during today’s visit. Fire extinguishers were observed throughout the facility, which were last serviced on 09/2025. KITCHEN: The kitchen was located on the 1st floor attached to the dining room. Facility dining room and commercial kitchen were inspected and in compliance with Title 22 regulations. There was a sufficient supply of perishable and non-perishable food. The food appeared to be of good quality and labeled appropriately. Emergency food was stored with dry food items and emergency water was stored in an inoperable commercial refrigerator in the rear of the kitchen. Due to time constraints, LPA Huynh will return at a later date for an Annual Continuation. No deficiency cited. Exit interview conducted. A copy of today’s report was reviewed and provided.

made by Staff #4. The comment made by Staff #4 upset Staff #2. Staff #2 approached Staff #1, Maintenance Director, and informed them about the comment made by Staff #4. Staff #2 was told by Staff #1 that they would investigate the incident. On the same day, the Maintenance Director had all three staff submit written statements regarding what happened in the breakroom. Staff #5 was counseled on 6/11/25 and Staff #4 was counseled on 6/12/25. Staff #4 and Staff #5 were also required to take online training in Harassment in the Workplace and Violence in the Workplace. Per interviews conducted with the Executive Director and Staff #1, Staff #4 has worked at the facility for about 4 months and they have received staff complaints about Staff #4. Staff #4, who works as a housekeeper, likes to tell staff what they should be doing and what they are doing wrong. Staff #4, likes to boss other staff around and was told by their supervisor that they are to address their concerns with a supervisor, not with the staff. Staff #4 also rubs the other staff the wrong way. The Executive Director, Staff #1 and Staff #3 also indicate that Staff #2 is a very good caregiver. Staff #2 is always happy, has a good attitude, very attentive towards the residents, has a great attitude, friendly, very helpful and enjoys working with the residents. Staff #2 has not received any complaints or write ups. As a result of the breakroom incident and staff being counseled, they believe that Staff #2 is being targeted. Per interview conducted with Staff #2, staff denies ever refusing to assist a resident or leaving any resident with their legs hanging off the bed unless they requested it that way. Staff #2 will also asks residents if they want to go back to their room. Per Staff #2, they love all the residents. Per Staff #2, they may not be able to immediately assist a resident because they are assisting someone else at the time but another staff will cover them. Per Interview conducted with Resident #2, they confirm that Staff #2 is sweet and loves to help the resident. Per Resident #2, Staff #2 likes to sing, dance and is happy. Staff #2 has not refused to assist them. Staff #2 bends over backwards to help the residents. Per Resident #2, they have great caregivers here. Based on the information received during today's investigation, there is insufficient evidence to support the allegation that Staff did not provide proper mobility assistance to residents in care, therefore the allegation is unsubstantiated at this time. Exit interview was conducted.

Page 2. prior to issuing findings. No health and safety concerns noted on today’s visit. Exit interview conducted. No citations issued at this time. A copy of the report was issued On 4/24/25, Licensing Program Analyst (LPA) Christine Yee conducted a subsequent unannounced complaint visit to investigate the above allegation and met with Dion Gallarza, Executive Director. The reason for the visit was explained. On today's visit, LPA Yee conducted another interview with the Executive Director at 10:21am, Resident #2 at 11:15am, Staff #1 at 11:36am, Staff #2 at 11:52am, Staff #3 at 12:19pm, Staff #4 at 1:52pm, conducted a tour of the site of the incident at 1:25pm and obtained additional facility documents throughout the visit. Per interviews and documents reviewed during today's visit, it was again determined that additional investigation is needed before the findings of the above allegation can be made. Per the investigation conducted regarding the allegation of questionable death of Resident #1, the following information was revealed. Resident #1 was admitted to the facility on 6/8/2024. Per review of the Physician’s Report dated 5/22/24, Resident #1 was diagnosed with bipolar disorder, anxiety disorder, polymyalgia rheumatica and had mild cognitive impairment. Per interview with Witness #1, Resident #1 was not on any medications for bipolar disorder or depression when they became a client of theirs. Resident #1 had a known history of depression and was previously prescribed lithium, a mood stabilizer for bipolar disorder but it was discontinued when the resident was hospitalized for lithium toxicity. Lithium was not resumed after the hospitalization. Records reviewed also do not indicate any history of suicidal ideations. At the time of admission, Resident #1 was not on any psychiatric medications. The Physician’s report 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 3. also indicates that Resident #1 is not currently depressed. Per interview conducted with Witness #1, Resident #1 was not on any medications for depression or bipolar disorder when Resident #1 became a client of theirs in February 2024. Witness #1 also indicated that they do not treat mental disorders as it is outside their scope of practice. The family was advised to take Resident #1 to see a mental health professional or to return to the doctor who had prescribed the Lithium initially. On 9/13/24, the resident’s family took Resident #1 to their doctor appointment and on that visit the resident was observed to be very restless and was prescribed Escitalopram 5mg to treat their anxiety. Per facility records, the medication was started on 9/17/24. On the afternoon of 9/29/24, Resident #1 was found lying face down on the ground in a pool of blood by Resident #2. Resident #2 was returning to their room from the back of the building. Resident #2 returned to their room and called the front desk for assistance. Staff #1 was sent to assist Resident #2, but it was unclear whether it was Resident #2 that needed help. Per Staff #1, they went to Resident #2s room, also using the back way and found Resident#1, unresponsive and laying face down in a pool of blood. The front desk was contacted to call 911. Staff #4 called 911 and was asked to turn Resident #1 over and perform CPR. Staff #1 assisted Staff #4 with turning the resident over and chest compressions were administered by Staff #4 until the paramedics arrived to take over. The paramedics pronounced the time of death at 1324 hours. Once the paramedics were done, the police cordoned off the resident’s room and the back area as a crime scene to conduct their investigation. Per their investigation, 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 Page 4. Resident #1 was last seen by Staff #1 at 1200 hours on 9/29/24. The police observed that Resident #1 was laying on their back. Per interview conducted with Staff #1, police were informed that Resident #1 was initially found unresponsive, facing down. Per the police investigation, Resident #1 was found on the ground directly below the second-floor landing. Police also found a sandal belonging to the resident by the railing on the second-floor landing. Based on these observations, it was determined that Resident #1 fell from the second floor and determined that the resident committed suicide. There was no suicide note found. The police also contacted the coroner on the day of the incident. Upon arrival at the scene, the coroner took over the investigation from the police. Upon completion of their investigation, Resident #1 was transported to the LA County morgue due to the circumstances of the death. Resident #1 was examined on 9/30/24 and cause of death was noted as multiple blunt force trauma injuries and the manner of death is suicide. Per police interview conducted with the family, they were given the same information that was given to LPA Yee on 11/5/24 by the family member that was interviewed. The family mentioned that Resident #1 had threatened to do harm to themselves. The family member indicated that they had no reason to take these threats seriously as there was no prior history of suicidal attempts. LPA Yee was not specifically told by family member how Resident #1 was going to hurt themselves. When family was told that Resident #1 fell from the second- floor stairwell landing they suspected that Resident #1 had jumped as they threatened to do. The threats made by Resident #1 to hurt themselves to the 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 Page 5. family was never mentioned to facility staff to allow them the opportunity to seek help for the resident or implement precautionary measures to mitigate any harm to the resident. Per interviews conducted with Staff, they all stated that the resident was observed to be happy. Resident #1 was sociable to staff and residents and was beginning to make friends. Staff did not observe the resident to be depressed or showed any change in condition to raise concerns. Based on LPA Yee’s investigation, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Unless the Department obtains new evidence to change the finding of the investigation, the allegation of questionable death is unsubstantiated at this time. No deficiencies were cited on today's visit Exit interview was conducted and a copy of this report was provided.

asked by Resident #1 about the pillow and Resident #2 admitted seeing the pillow. Per Resident #2, who has mild cognitive impairment and has memory lapses, they admitted seeing the pillow and must have picked up the pillow because they believed it was theirs. Per Resident #2, stealing is not in their character, Resident #2 told Resident #1 that the pillow was in their room. When they went to Resident #2's room, the pillow was not in the room. Resident #2 stated that maybe they left their room door unlocked and someone came in and took it. Per Resident #1, the Executive Director was told about the missing pillow and they were advised that he would look into it. Resident #1 did not hear back from the Executive Director and so Resident #1 contacted the Department to see if someone would speak with Resident #2 so they would return their pillow. Per Resident #1, they did not say that staff did not safeguard their pillow. Per interview with the Executive Director, Resident #1 approached him on 10/25/24 regarding the lost pillow. Per the Executive Director, they searched Resident #2's room and the pillow was no where to be found. Resident #2 has no idea what happened to the pillow due to the memory lapses. Per the Executive Director, he is constantly reminding the residents not to leave their personal belongings in the dining room or in the common areas. Staff aren't able to keep an eye on their belongings all the time and they need to remember to pick up their personal belongings. Per the Administrator, they will continue to look for the lost pillow. Based on the information received on today's visit, there is insufficient evidence to support the allegation that the staff did not safeguard the resident's personal belongings, therefore the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided.

Report Continued from LIC9099... On the allegation, unlawful eviction, it is the concern of the Reporting Party (RP) that facility issued an unlawful eviction to Resident #1 (R1). To investigate this complaint, LPA conducted in person interviews with the Administrator and R1 between 12:45 pm – 1:30 pm. LPA also obtained pertinent documents to the investigation and reviewed facility records. Interviews with R1 revealed that they were involved in an online scheme depleting all financial funds in June of 2024, which has been reporting to local law enforcement. R1 has contacted other agencies to try and obtain funds but has been unsuccessful. R1 states that their Social Security benefits have been temporarily suspended while the investigation is ongoing leaving R1 unable to pay rent. R1 stated they have not made payments to the facility since June 2024 and have not attempted to arrange a payment plan with the facility. Interview with the Executive Director (ED) confirm the statements. Interviews with the ED revealed that the facility has tried to work with R1 in assisting R1 with payment arrangements but R1 has not complied with any arrangements discussed. The facility has made multiple attempts to assist R1 including but not limited to accompanying at the Social Security office but all attempts for assistance have been denied by R1. Records reviewed and obtained revealed that the R1 has not made payments since June 2024 with a total balance of $12,624 as to date. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of unlawful eviction is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided.

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced subsequent required Annual Inspection to continue the annual inspection that was initiated on 9/27/23. The complete CARE Inspection Tool was used and the visit was conducted with Dion Gallarza, Administrator. The reason for the return visit was explained. On today's visit the following domains were reviewed: Personnel Records Training, Resident Rec-Incident Reports, Resident Rights Information, Planned Activities, Food Service, Incidental M &D, Disaster Preparedness and Residents with SHN. Due to time constraints, LPA Yee was not able to review the Physical Plant and Environmental Safety Domain. A return visit will have to be conducted to complete the last domain. Facility files, training records, 10 resident files and the Emergency Disaster Plan were also reviewed during today's visit. Per review of the information requested for in each domain reviewed, there were no deficiencies observed. On today's visit, LPA Yee also delivered the Immediate Civil Penalties that were assessed for the deficiency cited as a result of the substantiated findings for complaint #29-AS-20220601142537 on 4/7/23. No deficiencies were cited on today's visit. Exit interview was conducted and a copy of this report was provided