Discovery Commons Whittier.

The investigation revealed the following: regarding the allegation “Staff neglect resulted in resident sustaining an injury due to a fall.” It is alleged that staff neglect resulted in a resident sustaining an injury due to a fall. Five (5) out of five (5) staff interviewed denied this allegation. Staff interviews revealed that R1 was considered a high fall risk and staff took interventions to prevent R1’s falls. Staff interviews revealed that R1 was placed on 30-to-45-minute room checks, a fall mat was placed in their room, a wheelchair was used to assist R1, and staff attempted to keep R1 in common areas so that R1 was always in line of sight of staff. Records reviewed revealed that R1 was admitted into the facility on 11/27/2024. On 12/03/2024, R1 was moved into the facility memory care due to a change in condition. Review of Unusual Incident Reports revealed the following: on 06/01/2025, R1 had a witnessed fall and was observed with discoloration to their eye and nose and R1’s responsible party was notified and took to urgent care the same day. On 11/30/2025, R1 had a witnessed fall. R1 was assessed by staff and did not see any visible injuries. Staff contacted R1’s responsible party and R1’s physician regarding the fall. On 12/25/2025, R1 was observed laying on the hallway floor with discoloration to their forehead. Staff called 911 and R1 was sent to a local hospital for further evaluation. R1 was released later that day with no new orders but staff documented R1 was placed on frequent checks as a result of this fall. On 01/15/2026, staff conducted a room check on R1 and discovered R1 on the floor with a minor cut to their forehead. Staff called 911 and R1 was taken to a local hospital for evaluation. R1’s responsible party and physician were notified of R1’s fall. R1 was admitted to the hospital and released back to the facility on 01/16/2026 with hospice care services. Review of R1’s change of condition assessment conducted on 10/26/2025, revealed that R1 was assessed as a high fall risk. LPA Ramirez attempted to interview R1’s responsible party but all attempts were unsuccessful. LPA Ramirez attempted to interview R1 but all attempts were unsuccessful. LPA Ramirez attempted to interview R2-R5 but due to cognitive impairment, responses were unreliable. Record review of R1’s observation notes documented room checks conducted by staff, R1’s falls and notification to R1’s responsible party and physician about the falls. 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 . SEE 9099-C for continued narrative 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 did not ensure resident was adequately hydrated.” It is alleged staff did not ensure R1 was adequately hydrated. Five (5) out of five (5) staff interviewed denied this allegation. Staff interviews revealed that R1 was always provided with water, however, R1 would at times refuse to eat or drink water. Staff interviews revealed that staff would encourage R1 to eat or drink water when R1 would initially refuse but R1 would get agitated if staff persisted. Review of staff observations notes revealed that staff documented R1’s refusal to eat or drink and staff notified R1’s responsible party and physician. LPA Ramirez did observe staffing notes that indicated R1 ate and drank water without resistance. LPA Ramirez attempted to interview R1’s responsible party but all attempts were unsuccessful. LPA Ramirez attempted to interview R1, but all attempts were unsuccessful. LPA Ramirez attempted to interview R2-R5 but due to cognitive impairment, responses were unreliable. 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. Exit interview was conducted. A copy of this report was provided.

In regards to the allegation Due to neglect, resident sustained wounds, based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility was responsible for Neglect/ Lack of Care, leading to the Resident R1 to sustain wounds while in care. Per the progress notes, on 12/14/2024, the Staff S1 documented that R1 sustained a red spot and scabbing on her right foot. On 12/15/2024, the staff S2 documented that the right dorsal surface (on R1's foot) had redness with open sores and skin lesions. She notified R1's family and her Primary Care Physician (PCP). On 12/16/2024, R1 was taken to the hospital for an evaluation and treatment by her sister. Per interview with the Nurse Practitioner at St. Jude Medical Center, she stated that R1 was diagnosed with cellulitis of her right foot. She added that the wounds would be consistent with this timeline; however, it could take longer for a wound like this to advance to cellulitis. She added that this could occur from hours to days. All the staff interviewed, stated that R1 would have her socks changed daily and she would have showers twice a week. Per the Hospice Nurse and the Home Health Nurse , they both stated that the facility appeared to not be neglectful of R1. They did not believe the facility was neglectful with R1's level of care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated. In regards to the allegation Staff did not provide timely medical care for resident, Based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility was responsible for Neglect/ Lack of Care, due to Staff not providing timely medical care for the Resident R1 while in care. Per the progress notes, on 12/14/2024, the Staff S1 documented that R1 sustained a red spot and scabbing on her right foot. On 12/15/2024, the Staff S1 documented that the right dorsal surface (on R1's foot) had redness with open sores and skin lesions. She notified R1's family and her Primary Care Physician (PCP). On 12/16/2024, R1 was taken to the hospital for an evaluation and treatment by her sister. Per interview with the Nurse Practitioner at St. Jude Medical Center, she stated that R1 was diagnosed with cellulitis of her right foot. She added that the wounds would be consistent with this timeline; however, it could take longer for a wound like this to advance to cellulitis. She added that this could occur from hours to days. 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 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated. In regards to the allegation Staff are not ensuring residents hygiene needs are met, based on interviews conducted and information gathered Resident R1 revealed that she felt happy and safe at the facility. R1 added that she enjoyed playing games with the staff and other residents, and there was nothing she disliked. R1 added that she would receive two showers weekly. R1 stated that staff would change her socks daily. R1 stated that she has a lot of nurses who would tend to her weekly. Interview with Hospice Agency Representative who stated that “I’m a patient care advocate and I don’t hesitate to call APS, but I don’t think they (the facility) was being neglectful.” Stated that R1's foot issue was addressed by a home health agency, and she believed that the home health agency would be responsible for caring for R1's foot. Interview with Home Health Agency representative who stated that she did not recall any foot issues with R1 as she appeared well cared for and well dressed. Her room was cleaned, and it seemed as she was showered regularly .Could not recall seeing R1 in socks as she would typically wear sandals barefoot. Interview with Staff who stated that R1 was cared for very well by the facility and other agencies. Stated she took 2 showers each week and did not go without socks. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management visit to investigate a self reported incident received by CCLD on 10/18/2024 of suspected elder abuse by staff on Resident #1. LPA met with Joshua Castillo, Executive Director and explained the purpose of the visit. The report stated that on 10/18/24 at approximately 9:15am, Witness #1 (W1) called Staff #1 (S1) to report an inappropriate conversation at a family dinner involving Resident #1 (R1) and Staff #2 (S2). W1 mentioned hearing about R1 "smooching someone," and R1 mentioned S2’s name. Other family members of R1 also thought the conversation was inappropriate. Staff spoke to R1 and S2 to investigate the allegation. R1 confirmed the dinner and conversation but denied any relationship with S2. S2 stated that he only assists with maintenance requests in R1’s apartment and denied any relationship or physical contact with R1. During today's visit, LPA interviewed (6) staff members, Resident #1 (R1) and obtained copies of the staff/resident rosters and R1's files such as Emergency and Identification Information, Admission Agreement and latest Physician's report. According to S1, he received a call at approximately 9:15am on 10/18/2024 from W1 who reported the inappropriate conversation he had with R1 during a family dinner. On the same day, S1 along with other staff members conducted an immediate investigation and spoke with R1 and S2. R1 mentioned that she finds S2 good-looking but stated that nothing has or will happen between them because of her age and denied any communication or physical contact with S2. Afterward, S1 sent SOC 341 incident report to CCL and LTC Ombudsman. According to S1, there was no credible evidence found on his investigation to substantiate it. S4 stated R1 never complained about pain in any parts of her body and no noticeable injuries found on her. All staff concluded that there is no relationship between R1 and S2. R1’s gestures and comments were perceived as light-hearted and not indicating any actual romantic interest or relationship between them. LPA reviewed R1's Physician's report which showed that R1 is ambulatory and independent. LPA spoke with R1 and S2 in person during the visit, and both denied having any type of relationship between them. There was no additional evidence of inappropriate behavior to suggest a sexual relationship between R1 and S2. Moreover, LPA was unable to find anyone to corroborate that the alleged incident or sexual abuse occurred at this time. Based on the information gathered, there is no signs of neglect or lack of supervision found. No deficiency was issued. An exit interview was held, and a copy of this report was provided to the Executive Director, Joshua Castillo.

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Joshua Castillo , Executive Director . LPA explained the purpose of the visit. The facility was licensed to serve elderly, ages 60 years old and older. Its capacity was 125 including 125 non- ambulatory and twenty (20) bedridden. The facility had dementia program in place and twenty (20) approved hospice waiver. Annual fees were current. Administrator certificate is current with expiration date on 5/3/26. The inspection consisted of using CARE tool, conducting physical plant, review of food supply, interviews staff/residents, reviews of staff/residents records and medications. The facility is a two-story building. On the first floor, it consisted of a TV room, dining room, kitchen, administrative offices, a locked medication room, the Memory Care Unit, some assisted living rooms, common bathroom, and activity room. On the second floor, it consisted of assisted living residents’ rooms, TV room, resident laundry room, and locked housekeeping storage rooms. Residents' bedrooms were furnished with required furniture and in compliance. Bathrooms, kitchen, common areas were inspected and in compliance. Smoke and carbon monoxide detectors were operable. Fire extinguishers were fully charged with last service on 4/5/24. Auditory devices were operable. Delayed egress exits were operable. Medication was centrally stored in med rooms. Resident records were stored in a locked storage room and inaccessible to residents. Two (2) days perishable and seven (7) days non-perishable were observed. Physical plant was conducted on each floor. Hot water temperature was in a range of 107.5 - 114.2 degrees Fahrenheit which was within Title 22 Regulation guidelines. Signal system was operable and staff arrived to provide assistance within 10 minutes. No deficiency is cited per California Code of Regulations, Title 22. An exit interview was conducted and this report was provided to Joshua.

During the prior visit dated 7/26/2024 Licensing Program Analyst (LPA) Angelica Rea made another visit to issue the final results of the investigation. LPA met with Joshua Castillo, who assisted with today's visit. Regarding the allegation that: Facility does not have sufficient staff which has resulted in resident leaving the facility unattended. The investigation was conducted by the department, and consisted of of interviews, review of facility documentation, and review of resident #1 medical records. Interviews conducted were unable to corroborate that resident #1 left the facility unattended. Attempts were made to interview resident #1's family member, however LPA was unable to interview resident #1's family member to obtain additional information. Resident #1 was no longer living at the facility when LPA conducted initial visit and was not interviewed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, and a copy of the report was provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegation that: Resident developed pressure wounds while in care. The investigation was conducted by the department, and consisted of interviews, review of facility documentation, and review of resident #1 medical records. Hospital records show that resident #1 was admitted to the hospital on 12/5/22 due to a fall and did not have any pressure injuries. Resident #1 was re-admitted to the hospital on 1/16/23 and was diagnosed with an unstageable pressure injury on his right hip, a deep tissue injury on his right hip, and an unstageable pressure injury on his right foot. Per facility documentation provided, on 1/10/23, the pressure injuries on resident #1 were noted. Resident #1's family member stated that they were permitted and relied upon to perform wound care from 1/11/23-1/15/23 at the facility. The investigation found sufficient evidence to show that resident #1 developed pressure wounds while in care of the facility. Regarding the allegation that: Facility is neglecting resident's care. The investigation was conducted by the department, and consisted of interviews, review of facility documentation, and review of resident #1 medical records. Per hospital records, upon admittance resident #1 had "oral cavity dryness, crusting, and debris" due to "poor oral intake and poor oral care at the facility". Resident #1 was diagnosed with a staphylococcus (staph) infection in his mouth. Additionally, hospital records show that staff neglect of resident #1, resulted in a weight loss of sixteen pounds within approximately six weeks. On 12/5/22, resident #1 was admitted to the hospital weighing 150 lbs. On 1/16/23, resident #1 was admitted to the hospital weighing 134 lbs. Per reports provided by the facility, dated 1/11/23, 1/12/23, 1/14/23, and 1/15/23, it was noted that resident #1 was unable to eat, chew, or swallow his food. Resident #1 was diagnosed with severe malnutrition upon admittance to hospital on 1/16/23. The investigation found sufficient evidence to show that the facility was neglecting resident #1's care. Regarding the allegation that: Facility failed to provide timely medical attention to resident in care. The investigation was conducted by the department, and consisted of of interviews, review of facility documentation, and review of resident #1 medical records. Upon being admitted to the hospital on 1/16/23, resident #1 was diagnosed with severe sepsis with acute organ dysfunction, pneumonia, hypernatremia, due to dehydration, severe protein calorie malnutrition, in addition to the unstageable pressure injury on his right hip, a deep tissue injury on his right hip, and an unstageable pressure injury on his right foot. The investigation found sufficient evidence to show that the facility failed to provide timely medical attention to resident #1. Based on interviews which were conducted with staff and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on the attached LIC 9099D. Immediate Civil Penalty will be issued in the amount of $500.00. The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e) or (f). Exit interview conducted and copy of report and appeal rights were provided on 7/26/2024.

The investigation consisted of interviews with Administrator, staff #1 - staff #7, resident #1 - resident #6, and review of staff files, including medication certification(s), and kitchen staff certification(s). Administrator, and staff interviewed were unable to corroborate the allegation. Eight out of eight staff interviewed stated that the medication and kitchen staff are certified and meet the required qualifications. Residents interviewed were unable to corroborate the allegation. SIx out of six residents interviewed stated that the facility staff meet the required qualifications to their knowledge. LPA reviewed staff files, and observed that the medication technicians and kitchen staff meet the required qualifications. Regarding the allegation(s) that : Staff do not address pest infestation, and staff do not address rodent infestation. The investigation consisted of interviews with Administrator, staff #1 - staff #7, resident #1 - resident #6, tour of facility, and review of recent pest control invoices. Administrator and staff interviewed denied the allegation. Administrator stated that the facility has a contract with a pest control company as a preventative measure. Eight out of eight staff interviewed stated that they have not observed any pests or rodents at the facility. Residents interviewed were unable to corroborate the allegation. Six out of six residents interviewed stated that they have not observed any pests or rodents at the facility. LPA did not observe any pests or rodents during the facility tour. Facility pest control receipts do not indicate that the facility has an infestation of pests or rodents at this time. Regarding the allegation that : Staff do not ensure facility is free of disturbances. The investigation consisted of interviews with Administrator, staff #1 - staff #7, resident #1 - resident #6, and tour of facility. Administrator and staff interviewed were unable to corroborate the allegation. Eight out of eight staff interviewed stated that the staff do ensure that the facility is free of disturbances. Residents interviewed were unable to corroborate the allegation. Six out of six residents interviewed stated that staff do ensure that the facility is free of disturbances. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, and a copy of the report was provided to Mr. Castillo.

Residents interviewed were unable to corroborated the allegation. Four out of four residents interviewed stated that they have not had any incidents which would cause them any bruising or scratches. Based on staff and resident interviews, although resident #1 sustained bruising to her left arm, there is nothing to support that this occurred due to staff negligence. 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. Exit interview conducted, and a copy of the report was provided to Mr. Castillo.

The investigation revealed : LPA toured facility on initial visit, and on subsequent visit. LPA observed that the facility was clean and sanitary on both visits. Administrator and Staff interviewed stated that the facility is cleaned daily, and resident rooms are cleaned once per week, and more often, if needed. They stated that the housekeeping department has a cleaning schedule to ensure that all resident rooms are cleaned. Regarding the allegation that : Facility has insufficient staffing to meet residents needs. The investigation consisted of review of resident and staff roster(s), and interviews with Administrator and staff #1 - staff #4. The investigation revealed : Administrator and staff interviewed stated that the facility has sufficient staff to meet resident needs. Administrator and staff stated that both the assisted living and memory care have sufficient staff. LPA observed that the facility staff roster(s), and it appears that the facility has sufficient staffing to meet resident needs. Regarding the allegation that : Facility did not conduct reappraisal for resident as needed. The investigation consisted of review of resident #1's file, and interview with Administrator. The investigation revealed : Resident #1 lived at the facility from 2/25/23 to 3/22/23. Review of resident #1's file indicated that resident #1's pre-placement appraisal was completed. Administrator stated that the facility conducts a reappraisal after 30 days of admission, and then 6 months thereafter, or as needed. However, resident #1 did not live at the facility long enough to have a reappraisal conducted. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview was conducted with Mr. Castillo, and copy of report was provided.

Regarding the allegation that: Facility staff did not seek timely medical attention for resident's pressure injuries. The investigation was conducted by the department and consisted of review of resident #1's file, including home health records, interviews with facility staff, and medical personnel who provided care to resident #1. The investigation revealed that home health records listed that resident #1 had no pressure injuries when discharged from home health upon the date of discharge from the facility. Health insurance medical records contradict this information and list that resident #1 had a stage 3 wound the day before transferring out of the facility. Health insurance confirmed that resident #1 was discovered with stage 3 wound, resident #1's daughter was informed resident #1 must be transferred out for higher level of care , and hospice care was scheduled for the following day. Interviews and documentation list that resident #1 was observed with a stage 2 wound while at the facility, but was receiving regular treatment/ wound care. On the day resident #1 was transferred out of the facility, transferring administrator advised that LVN assessment stated that resident #1 wounds were a stage 2. There was insufficient evidence that the facility did not seek timely medical attention. Regarding the allegation that: Facility staff hit resident #1 resulting in bruising, the investigation consisted of review of resident #1's file, review of medical records, and interviews with Administrator, and Staff #1 - Staff #3. 4 out of 4 staff interviewed stated that they have not observed any residents being hit by staff. Review of resident #1's flie, indicates that resident #1 was taking medication that can cause bruising. Regarding the allegation that : Facility staff did not provide resident with linens in good condition. The investigation consisted of tour of facility, including resident rooms, and interviews with Administrator and staff #1 - staff #3. LPA did not observe linens in poor condition during initial and subsequent tours of resident room(s). Administrator and staff interviewed, stated that resident family members bring their own linens to the facility, and they are laundered by facility staff. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview was conducted with Mr. Castillo, and copy of report was provided.