Sunrise of Westlake Village.

Licensing Program Analyst (LPA) Zabel Chochian made an unannounced site visit to this facility for an annual inspection. Upon arrival LPA met with staff. Executive Director was contacted. LPA initiated that physical plant tour with the assistance of staff Zinnia Martinez. Required posting were observed in the hallway of main building. There is no body of water on premises. The facility was inspected for Fire Safety, Personal Accommodations and Services, Food Service, and Medication Procedures. Facility is a 3 story building, with 3rd floor designated for the dementia care. LPA observed the reception area, lobby, dinning room, kitchen and activity room located on first floor. The kitchen was inspected for cleanliness and sanitary condition, perishable and non perishable food supply and food storage practices. The food supply was sufficient and observed were foods from all food groups available to meet requirements and/or resident preferences. Food storage and preparation area was inspected. Emergency food and water supply is sufficient at this time. Eight (8) Random units were inspected for safe accommodation. Hot water temperature was measured in random residences. Water temperature fluctuated thru out the facility between 111 and 118 degrees Fahrenheit during the tour. Residents’ bathrooms were observed stocked with sufficient soap, toilet paper and towels. Delayed egress exit doors tested and functioned properly on the 3rd floor Memory Care unit. Due to time constraints, LPA was unable to finish required annual inspection at this time. LPA will return on a later date to continue the annual inspection. No deficiencies observed during todays visit. Exit interview held, and copy of the report provided.

Additional records were requested and reviewed at approximately 1:30pm. LPA conducted interview with staff at approximately 2pm. LPA also toured the Memory care unit at approximately 3pm and attempted to interview residents in the memory care unit. Following is a summary of the allegations and investigation finding: Regarding Allegations: Staff did not ensure resident was provided fluids resulting in hospitalization and Staff did not provide medical attention in a timely manner: Information was received that on 07/13/2024, R1's blood pressure was reportedly low and therefore R1 was taken to the hospital by family; R1 was admitted for four days due to low blood pressure and dehydration. To investigate the allegation, R1 facility records were reviewed and Interview was conducted with facility staff. In additional, several attempts were made to reach the reporting party. Staff interviewed reported that R1 was admitted to the facility on 07/03/2024 and for one week staff attempted to provide care services as needed. Staff reported that R1’s responsible person visited every day and occasional stayed with R1 overnight. Staff stated that the responsible person for R1 did not allow staff to provide routine care and interfered with staff trying to understand and determine R1 level of care needs. Records reviewed and staff interviewed revealed that on 7/13/2024, R1’s blood pressure was recorded in the morning and R1's BP was 127/82; medication was provided as prescribed. Staff reported that R1’s blood pressure is checked in the morning by the nurse and medication is provided as prescribed/ordered by R1’s physician. According to staff unless there is a medical need or an order vitals are not checked regularly. Staff reported that if R1's BP was low on 07/13/2024 they would have record of the BP reading. Records reviewed did not show a low BP record for R1 on 07/13/2024. Regarding hydration, staff stated that all residents are provided and encouraged to drink fluids daily. Staff reported that R1 was given two cups of orange juice and one cup of water at breakfast; two cups of water and juice between breakfast and lunch; two cups of juice and one cup of water at lunch; two cups of water and juice between lunch and dinner. Staff reported that R1 did eat and drink with no issues. Staff reported that on 07/13/2024, R1 was exhibiting behavioral issues and was very aggressive with staff. Staff reported that they would allow R1 to calm down and return to assist care services. According to staff R1's responsible person arrived to facility on 07/13/2024 in the evening and R1 continued to be aggressive with staff and the responsible person. (Continue to 9099c.) 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 reported that there was no immediate medical issues for them to call 911; It was R1’s responsible person's decision to take R1 to the hospital due to the behavioral issues. Multiple attempts were made to reach the reporting party was unsuccessful. Based on the information obtained through record review and interviews; the allegations “Staff did not ensure resident was provided fluids resulting in hospitalization and Staff did not provide medical attention in a timely manner”, is deemed Unsubstantiated at this time. Regarding allegation: Staff did not meet the needs of resident in care and Staff forced resident to shower: Information was provided that on 07/06/2024, R1 was not assisted with incontinent care needs. It was reported that R1 was asked about using the restroom, R1 nodded yes, however staff insisted that R1 had already used the restroom. R1 was taken to the restroom later by R1's responsible person and it was reported that R1 had a bowel movement and urinated. It was also reported that R1 was forced to shower by staff (date unknown). To investigate these allegations LPA reviewed records and conducted interview with facility staff. Staff denied allegations and reported that they assist with incontinent care as needed and they never force any resident to shower. Staff reported that R1 was a new resident, and when R1 was assisted with toileting needs staff observed that R1 would not sit on the toilet therefore staff would not force R1. Staff reported that R1 was checked on at least every two hours and before/after meals. According to staff R1’s incontinent needs were met as required by staff. Regarding showers - Staff expressed that R1 was never forced to shower. Staff reported that when resident does not want to shower or receive assistance with care needs they will not force them and try again later to provide care service or shower. During the tour of the memory care unit LPAs observed staff assisting residents with daily routine; no resident observed with dirty or soiled clothing at the time of visits. Attempt made to interview residents in the memory care was unsuccessful. Multiple attempts made to reach the reporting party were also unsuccessful. Based on the information obtained through records review and interviews; the allegations “Staff did not meet the needs of resident in care and Staff forced resident to shower”, are deemed Unsubstantiated at this time. Exit interview conducted and a copy of the report provide.

Licensing Program Analysts (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at approx 01:55 p.m. Upon arrival LPA met with Executive Director Edith Kennedy and explained the reason for the visit.  staff and explained the reason for the visit.   LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: At approx. 02:00 pm, the LPA began the physical plant in the kitchen/food service area. Kitchen was observed to be inaccessible to residents in care. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored.  Refrigerator and food pantry were checked for proper labels and expiration dates. The furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 10/03/2023. LPA observed required postings throughout the common space. LPA observed the stairwells and they each had an emergency evacuation chair.  Activity Rooms were observed to be clean at the time of visit. At approx 2:15 p.m. LPA observed multiple residents participating in activities in each activity area.  Fireplaces were observed adequately screened. LPA observed eight (8) randomly selected resident bedrooms throughout the 3 floors. Each bedroom was observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water measured between 107.9 – 110 degrees Fahrenheit. Continued on 809 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 Continued from 809 The most recent fire alarm and fire sprinkler system inspection was completed on 01/08/2024 and the facility received a passing report for each. LPA observed a sufficient supply of PPE properly stored in the vestibule room. A sufficient supply of Emergency food was observed to be stored in the stairwell room in the staff area located by room #126. LPA conducted eight (8) interviews during the visit. LPA obtained the following documents - Census, Staff schedule, and Emergency Disaster plan. Due to time constraints, the annual inspection will be completed on a follow-up visit. No deficiencies cited at this time. Exit interview conducted and a copy of report was issued to the Executive Director.

Licensing Program Analysts (LPAs) Teresa Camara and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:10 a.m. Upon arrival LPAs met with Executive Director Zak Howell and explained the reason for the visit. Entrance interview conducted. At 10:15 a.m., the LPAs along with the Executive Director, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. DINING ROOM / KITCHEN: The LPAs toured the kitchen / food service area at 12:20 p.m., The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperature. There was a sufficient amount of perishable and non-perishable food in the kitchen properly stored. Food labels were inspected and checked for dates and expiration dates. At 12:25 p.m., the LPA observed perishable items in poor condition as they had passed their expiration dates. These items included: three (3) containers of yogurt and one (1) container of egg whites. Items were discarded at the time of the visit. Residents do not have access to the kitchen, dangerous items are stored inaccessible to residents. The facility menu appears to meet the daily dietary needs of residents. There were no pesticides or poisons observed near any food areas. COMMON AREAS: LPAs inspected the common areas throughout the building. The common areas were observed to be properly furnished and relatively clean at the time of the visit. Fireplaces were observed to have adequate screens at the time of the visit. LPAs observed sanitizer readily available in areas with high touch surfaces. Furniture was observed to be in good condition in each common area. The facility maintained a comfortable temperature. Carbon monoxide detectors were operational at the time of the visit. The smoke (continued on 809C; page 2) 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 (continued from 809; page 1) detectors and fire suppression system was last serviced on 8/4/2023. Fire extinguishers were observed throughout the facility, fully charged, and last serviced on 10/03/2023. An adequate supply of emergency food and water was observed. The LPAs observed required postings throughout the common spaces. Entry/exits were free of obstruction. The outdoor areas were clean and free of hazards. The patios and balconies have proper furnishings. BEDROOMS / BATHROOMS: The LPAs inspected ten (10) randomly selected bedrooms throughout the three (3) floors. The resident bedrooms were properly furnished with a bed, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPAs observed all bathrooms in each resident bedroom were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. RECORDS: Records review began at 12:45 p.m., five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were in order at this time. Five (5) Personnel records and current Executive Director files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Fire and earthquake drills were conducted within the last 6 months as per regulation; the last one conducted 10/03/2023. MEDICATIONS: Medications review began at approximately 1:30pm. The medications are centrally stored and inaccessible to residents in care. Medication carts were observed on each floor locked and inaccessible at the time of the visit. No medication errors observed at this time. (continued on 809C; page 3) 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 (continued from 809C; page 2) INFECTION CONTROL: Upon entry, there is a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promote good hand hygiene and symptoms of communicable diseases. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time. Between 10:50 a.m. and 2:20 p.m., the LPAs interviewed five (5) residents and five (5) staff members. During today’s visit, the LPAs obtained copies of the following: staff schedule, resident roster, Emergency Disaster Plan, and current liability insurance. Exit interview conducted. No deficiencies issued at this time. A copy of the report was issued.