Ivy Park at West Hills.

Allegation: Staff restricted residents from accessing their mobility devices. It was reported that staff #1 (S1) restricted residents from accessing their mobility devices. The reporting party alleged that night shift caregiver S1 took wheelchairs and walkers and placed them out of residence reach during the NOC shift. The reporting party did not provide the names of any specific residents allegedly affected. During the course of investigation, LPA conducted interviews with seven (7) out of fifteen (15) residents residing in the Memory Care Unit. All residents interviewed denied that staff took away their mobility devices and stated that they are always able to access their wheelchairs and walkers as needed and did not report concerns related to staff interfering with their mobility equipment. Residents also added that even during nighttime, their mobility devices are next to their beds for easy access. During the visit, LPA also observed that all residents had wheelchairs or walkers next to them and by their beds. LPA also interviewed staff members, who denied witnessing or hearing of any staff restricting residents’ mobility devices and stated that residents’ mobility equipment is kept available at all times. Furthermore, staff added that they would immediately notify supervisors if they observed any conduct that interfered with residents’ care or residents’ rights. Staff consistently stated that residents are provided with care and supervision in a professional manner. LPA interviewed the Executive Director (ED) and Memory Care Director (MCD), who informed that this issue was brought to their attention with anonymously written letters and they both conducted their internal investigation by conducting surprise night visits to the facility to ensure residents are receiving appropriate care and supervision. ED and MCD further stated that staff receive regular in-service training and are expected to maintain residents’ personal rights and dignity. Based on interviews and observations, because no specific resident was identified and no corroborating evidence was obtained, the allegations that staff restricted the resident from accessing their mobility devices is Unsubstantiated at this time. Continue 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 Allegation: Staff fell asleep while on their shift. It was alleged that staff #1 (S1) working for NOC shift fell asleep while on shift. It was reported that on 4/6/25, Staff #3 (S3) found (S1) asleep in a recliner in room 117. During the investigation, LPA interviewed seven (7) residents. All residents interviewed denied observing staff asleep while on duty stated they have no concerns regarding night shift staff. Residents stated that staff is always available when needed and did not indicate any lack of supervision during nighttime hours. LPA interviewed staff members regarding the allegation, staff denied seeing S1 or any other staff sleeping while on duty. Staff also added that during the NOC shift staff get breaks and during their break time they rest. Staff stated they had not heard neither staff nor residents complain about S1 sleeping during the shift and reported that if such behavior observed, it would be immediately reported to supervisors. Staff also stated that all caregivers are expected to remain awake and attentive during their schedule shift to provide appropriate care. LPA intervied Executive Director and Memory Care Director, both of whom denied staff sleeping while on shift. Both reported that they conduct ongoing oversight of night staff, including surprise visits, to ensure staff are awake and providing sufficient care and supervision. Based on interviews, and no evidence to support the allegation that staff fell asleep while on their shift is Unsubstantiated at this time. Allegation: Staff handled residents forcefully while changing residents. It was reported that night shift caregiver Staff #2 (S2) pulled and shoved residents onto their beds while preparing to change their clothing and that residents were heard exclaiming “you're hurting me”. There were no specific names provided by reporting boarding. During the investigation, LPA interviewed seven (7) residents. Residents interviewed denied that staff handled them roughly during care or while assisting with dressing or changing. Residents did not report staff pulling, shoving, or hurting them during personal care assistance. LPA interviewed staff who denied witnessing or hearing S2, or any other staff member, handling residents in a forceful or inappropriate manner. Staff stated that residents are provided assistance with daily living in a respectful and professional manner. Continue 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 Staff also added that they are mandatory reporters and would report immediately to management if observed neglect to residents. LPA interviewed the Executive Director and Memory Care Director, who denied receiving any confirmed reports that NOC shift forcefully handled residents during care. They stated they routinely supervise and monitor staff performance, including during night shift, to ensure residents are treated with dignity and respect. ED and MCD also added that staff receive regular training regarding resident care and personal rights. Based on interviews conducted, and because no specific residents were identified, the allegation that staff handled residents forcefully while changing is Unsubstantiated at this time. No deficiencies issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.

Allegation: Staff locked residents in their rooms. It was alleged that residents in a Memory Care Unit are kept locked in their rooms. To investigate this allegation, LPAs conducted an interview with the Administrator and Memory Care Director. Both parties denied ever witnessing or hearing residents being locked in their rooms. LPAs were informed that the doors can only be locked from inside by the residents. However, all staff members have a master key and can easily gain access. Interview with three (3) staff members revealed that a Memory Care Unit currently has two (2) wandering residents. LPAs were also informed that when residents are out in common areas all residents’ doors are kept closed but not locked to prevent wandering residents from entering. Interview with staff also revealed that all Memory Care Unit residents’ doors are always unlocked when the resident is in the room, and the staff checks on them every hour. LPA visited four (4) random rooms and observed that the doors have no auto lock and can easily be opened. However, if the door is locked from the outside only a staff member with master key can gain access. Therefore, based on interviews, observation and record reviews, this allegation is deemed Unsubstantiated at this time. Allegation: Staff did not change residents in care To investigate this allegation, LPAs conducted an interview with the Administrator and Memory Care Director. Both parties denied the above allegation and informed LPAs that all incontinent residents are scheduled to be changed every two (2) hours or as needed. Three (3) staff members interviewed corroborated with the information provided by the Administrator and Memory Care Director. Additionally, LPAs conducted an interview with one (1) witness, who also denied the above allegation and stated that they visit their loved one twice a week and always witnessed staff changing residents frequently. Lastly, nine (9) out ten (10) residents interviewed also expressed no concern regarding the above allegations. During LPA's tour of the facility, there were no noticeable odors of incontinence and all residents were appropriately dressed and well taken care of. Based on information obtained through interviews and LPAs observation this allegation is deemed Unsubstantiated at this time. No deficiency issued during today's visit. Exit interview conducted, appeal rights explained and copy of this report delivered.

On 9/5/2025, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a required Annual Inspection. Upon arrival the LPA introduced herself by showing her department badge, was greeted by the Assistant Executive Director (AED) Dina Davis, and was informed that due to medical issues the current Executive Director Lidia Cauchi will be off for a couple of days. LPA explained the reason for the visit and requested staff and residents’ rosters for review. LPA Khurshudyan reviewed the required postings on a wall and used the inspection tool to complete today's visit. A tour of the physical plant was conducted at around 11:00am and the following was noted: The facility is fire cleared for ninety (90) Non-Ambulatory residents, of which eight (8) may be Bedridden. Bedridden residents may be housed in any bedrooms on ground floor, and a hospice waiver for fifteen (15). The facility is currently occupying sixty-six (66) residents. There is one main entrance being utilized at the facility. The facility is two-story building and has one elevator which operates properly. The facility has two (2) wings: Assisted living with private rooms for all residents. And Memory Care Unit with private and/or shared bedrooms. Continue on LIC809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed four (4) common bathrooms throughout the facility, all four bathrooms appeared clean and were functional. The kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. LPA observed walk in refrigerator and freezer stocked with adequate amount of frozen and fresh foods wrapped and stored appropriately. Food storage and preparation areas were clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. A dietitian visits the facility quarterly. The daily menus were posted on the wall next to the dining area. A restricted diet menu was also available for residents requiring special diets. The kitchen closes at 7:00pm and reopens at 7:00am. The common and dining room are neat and clean. The activity room and TV room were nicely furnished. The monthly activity schedule was posted and available for residents. The facility maintains a comfortable temperature at 74°F. The smoke and carbon monoxide detectors are hardwired, interconnected and centralized with automatic dispatch to the Los Angeles Fire Department. Fire extinguishers were located throughout the facility and observed to be fully charged and last inspected on 08/07/2025. LPA observed at least thirteen (13) fire extinguishers throughout the facility. LPA toured a random selection of resident rooms. All bedrooms were properly furnished and had appropriate bedding, linens and a lighting system. The call signal system was tested and functioned properly. Hallways are well lit. Residents have enough personal hygiene products. The bathrooms were checked for cleanliness and proper operations. Towels and washcloths are not shared. There was enough clean linen available in each resident room. Hot water temperature measured between 115.4 and 119.5 degrees Fahrenheit. There is a medication room for assisted living and a medication room for memory care unit. LPA observed properly labeled medications and residents’ medical files to be locked and inaccessible to residents in care. The facility maintains a complete first aid kit. The facility has three (3) laundry rooms, of which one is for the Memory Care unit. The Laundry rooms observed to be locked. There is a resident laundry room on the second floor of assisted living. Cleaning supplies, chemicals and detergents are stored inside the locked closets and inaccessible to residents. The facility has nice outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. All pathways are clear of obstruction. Continue on LIC-809C 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 Between 12:30pm -2:55pm LPA conducted records review of eight (8) staff files and eight (8) residents records. Files were complete and updated. LPA collected LIC500, LIC9020, and Certificate of Liability Insurance – Exp Date 5/1/2026. No health and safety hazards noted during today’s visit. No citations issued during today's visit. Exit interview conducted. Copy of this report provided.

At 10:15 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced case management-other vist to the above facility. LPA met with the front desk receptionist Susan Danzig and later with the Business Office Director Marilu Mampell. LPA explained the reason for the visit. LPA was informed that Resident #1 (R1) who have been relocated from Santa Clarita Hills Senior Living is currently residing in the above facility. At 10:20 AM, LPA requested resident’s roster and reviewed which confirmed that R1 is residing at the facility as of 03/17/2025. No deficiencies issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.

Allegation: Staff does not allow residents to possess personal belongings It was alleged that on 12/14/2024, 12/15/2024 and 12/16/2024, S1 took Memory Care Unit (MCU) residents' wheelchairs and walkers and placed them far away from residents, so that the residents didn't get out of bed. To investigate this allegation, LPAs conducted an interview with a Memory Care Director, four (4) staff and one (1) MedTech and all parties interviewed denied the above allegation. Moreover, LPAs conducted interviews with six (6) residents and one witness. LPAs were informed that all facility staff members provide an excellent care with dignity and respect. In addition, all residents and a witness interviewed expressed no concerns regarding this allegation. Therefore, based on interviews this allegation is deemed Unsubstantiated, at this time. Allegation: Staff does not ensure that residents' incontinence needs are met It was alleged that S1 does not change residents' diapers during the shift. To investigate this allegation, LPAs conducted interviews with the Memory Care Director (MCD) and were informed that their current census in a Memory Care Unit (MCU) is thirteen and during the morning (6:00am-2:00pm) and afternoon (2:00pm-10:00pm) shifts the MCU has three (3) staff members and one (1) MedTech and during the night shift (10:00pm-6:00am), the facility has two (2) staff members and one (1) MedTech available. LPAs were also informed that all incontinent residents are being changed at least three (3) times per shift and/or as needed. Four (4) staff members interviewed corroborated with the statement provided by the MCD. In addition, LPAs conducted interviews with three (3) residents and one witness from the Memory Care Unit and three (3) residents from the Assisted Living. All parties interviewed expressed no concerns regarding this allegation. Therefore, based on interviews and LPAs observations, this allegation is deemed Unsubstantiated, at this time. Allegation: Staff confines residents to bedrooms It was alleged that the S1 abuses residents during his/her work shift. To investigate this allegation, LPAs conducted an interview with a Memory Care Director (MCD) and were informed that this issue was brought up to her attention about two (2) weeks ago and she conducted her own investigation by interviewing with two (2) night shift staff members and made unannounced visits during the night shift to observe the staff and make sure that the health and safety of the residents are protected. During todays’ visit, LPAs contacted three (3) night shift staff members, who denied the above allegation. Moreover, three (3) residents from the MCU informed LPAs that they really like S1 and the care provided by S1 and expressed no concerns regarding this allegation. Therefore, based on interviews this allegation deemed Unsubstantiated, at this time. Continue 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 Allegation: Staff does not answer residents' call buttons in a timely manner To investigate this allegation while interviewing a sample of six (6) residents, LPAs randomly tested resident’s emergency call buttons in their rooms and bathrooms. LPAs conducted a random inspection of five (5) emergency call buttons, and staff responded within a reasonable time. Interview with the Memory Care Director revealed that the facility’s expectation for response time is three (3) minutes. Moreover, interviews with four (4) staff members revealed that they respond to residents' call buttons immediately and if, for any reason, a staff member is not available to assist, they communicate with each other to make sure the call/page is being taking care of right away. In addition, interviews with six (6) residents revealed that the staff always response immediately and expressed no concerns about the above allegation. Based on interviews, LPAs observation and review of the information received, this allegation is deemed Unsubstantiated at this time. Allegation: Staff does not ensure that resident is afforded a comfortable accommodation It was alleged that S1 placed the residents' pillows and blankets on the floor, then placed the residents on the floor to sleep, so that the residents couldn't get up. To investigate this allegation, LPAs conducted an interview with the Memory Care Director (MCD) who denied the above allegation and informed LPAs that no such approach towards residents were brought up to her attention. LPAs were also informed in the month of November S1 was recognized as an “Employee of the Month” for being so kind, caring, and favorite to residents. In addition, LPAs conducted an interview with S1 who also denied this allegation and informed LPAs that he/she always provides care to all residents with dignity and respect. Moreover, four (4) staff and six (6) residents interviewed, expressed no concerns regarding this allegation. Therefore, based on interviews this allegation deemed Unsubstantiated, at this time. Allegation: Staff speaks inappropriately to residents It was alleged that S1 yells at residents when the residents try to leave their rooms. To investigate this allegation, LPAs conducted an interview with the Memory Care Director, six (6) staff and one (1) MedTech. All parties interviewed denied the above allegation and informed LPAs that they haven’t witness nor heard S1 yelling and or inappropriately speaking with the residents. Moreover, interviews with three (3) residents and one (1) witness from a Memory Care Unit expressed no concerns regarding this allegation. Therefore, based on interviews this allegation deemed Unsubstantiated, at this time. No deficiency cited during today's visit. Exit interview conducted and copy of this report signed and delivered

On 06/18/24, 9:15 AM Licensing Program Analyst (LPA) Raymond Comer, conducted a scheduled pre-licensing inspection of the Facility. LPA met with Administrator, Matt Ryan. Facility is licensed as a two-story building with resident bedrooms, private bathrooms, and multiple public bathrooms. Fire clearance approved for (75) non-ambulatory, and an additional fifteen (15) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, there are fifty-two (52) Ambulatory residents, eight (8) Non-Ambulatory residents, none of which are bedridden, and seven (7) residents receiving hospice care services. LPA and the Administrator toured the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main doors are the primary entry/exit access point, with three (3) emergency exits being located off the dining room area, and two stairwells. Emergency exit routes are clear of obstructions. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Facility is separated into Assisted Living and Memory Care floors. LPA observed the delayed egress system working properly. Room temperature is comfortable; wall thermostat displays a setting of 73°F., within the required range. The facility maintains required Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 5/30/2024 . [LIC 809C-Continued] 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 Fire Safety: Fire Detection/Protection system is present in the facility. Multiple smoke and carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire system back up and tests are completed and documented, in house, on a monthly basis. Fire drill last conducted 5/30/2024. Fire extinguishers were observed throughout the facility on all floors. All extinguishers were last serviced on 11/08/2023. Evacuation chairs were observed in each stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Kitchen : LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. Resident food allergy info/reports are disseminated to Staff. No pesticides, nor poisons were observed near any food areas. Medications: Medications were locked in rolling medication carts located on the second floor. Medications are properly labeled, stored and inaccessible to residents. Medication documentation and implementation appeared to be complete. First aid kits were observed on each medication cart and stocked with required supplies. Laundry: At 11:25 AM, LPA observed laundry rooms located on the first and second floor. Residents in the assisted living wing of the facility have access to do their own laundry. Laundry area is clean and clear from obstruction. Cleaning supplies, and other toxins, are securely stored and inaccessible to residents. The Laundry room located in the memory care wing was observed as locked and inaccessible to residents. Commons: LPA observed multiple common areas upstairs, and downstairs. Activity rooms, movie theaters, dining rooms, and library rooms observed to be clean and furnishings to be in good condition. No obstructions, nor tripping hazards observed. [LIC 809C-Continued] 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 Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Random resident rooms were inspected and observed to maintain required furnishing and sufficient lighting, linens, blankets, closet space and dressers. All bedrooms were observed to be clean and clear of obstructions. Signaling system is present in all bedrooms to request staff assistance. LPA activated the signaling system in a randomly inspected bedroom and staff responded promptly. (Response time was within two (2) minutes) Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 115°F. Within the required range. Outdoor : Courtyard areas observed to have a shaded patio, with tables with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. Resident records: Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current. Staff records: Staff files were reviewed. Criminal record clearances, Health Screening, Employee Rights records were present, and Staff are associated to this facility. Staff records appear to be complete and current. At 2:00 PM , LPA conducted the COMP III presentation with the Administrator and Assistant Administrator, and completed at 2:25 PM There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility Administrator.