Ivy Park at Woodland Hills.

During today’s visit, the LPAs and HSD conducted a physical plant tour at 1:01PM and no immediate concerns were observed. The following was then determined: Allegations: “Facility staff are not properly addressing bed bugs in the facility,” “Facility staff did not safeguard resident's personal property,” “Facility staff did not ensure that resident was adequately fed,” and “Facility staff did not ensure that resident was accorded dignity” It was reported that the facility did not properly address bed bugs in Resident #1’s (R1) room, did not safeguard or maintain documentation of R1’s personal property, did not provide R1 with lunch, and did not ensure R1 was accorded dignity. Between 05/20/2026 and 05/21/2026, R1 disclosed to Staff #1 (S1) that they were experiencing bug bites on their skin, prompting S1 to inspect R1’s room. The room inspection revealed a bed bug infestation originating from R1’s sofa recliner and found throughout R1’s clothing and the remainder of the room. The ED and S1 consulted with a treatment company and their Regional Manager, who advised the facility to pursue chemical spray treatments, despite the ED and S1 advocating for heat treatments. The treatment company instructed the facility to remove R1 from the room, empty the room of personal belongings as much as possible, and prepare for a second spray treatment to occur twenty-four (24) hours after the first. The ED noted that R1 often refused housekeeping services and described R1 as a “hoarder.” Staff entered R1’s room utilizing personal protective equipment (PPE) and began bagging R1’s belongings per the treatment company’s guidance. S1 reported that belongings were bagged by general category and that items identified as excessively infested–including sandals, clothing, a comforter, and recliner–were discarded. S1 confirmed that no inventory list was completed. During the removal process, Staff #2 (S2) conducted a skin assessment and instructed staff that R1 required a shower. It was reported that staff stripped R1 of their clothes and R1 showered independently with staff supervision. Staff then completed the removal of belongings and S1 stated that restroom contents were not collected because R1 was in the restroom without clothes on and all other belongings had already been bagged. Report Continued on LIC 9099-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 S2 later returned to R1’s apartment for a follow up skin assessment and observed R1 unclothed and standing in their hallway between the restroom and front door. R1 reported to S2 that they were not provided lunch. S2 then requested food delivery to R1’s room. It was reported that between approximately 11:30AM and 1:30PM, R1 remained in the infested room without clothing. S2 stated that they notified staff to provide R1 clean clothes and expressed concerns to the ED regarding R1 being left unclothed in an infested room. The facility attempted to contact R1’s Power of Attorney (POA) throughout the day and was unsuccessful. The POA later returned the facility’s call and inquired about available/vacant rooms for relocation. The ED informed the POA that the facility was “at capacity.” It was reported by staff that the ED did not want R1 placed in any available room due to concern about spreading the infestation. The ED stated that R1 was independent and had agreed to be relocated to a hotel. The ED reported that they personally purchased clothing and essential items prior to R1’s hotel check-in. R1 was checked into a nearby hotel between approximately 6PM and 7PM same day on 05/21/2026. On 05/22/2026, S2 visited R1 at the hotel. R1 reported being cold and was observed to only have two (2) pairs of pajamas. S2 purchased R1 additional clothing including a jacket and essential items after observing R1 brushing their hair with a fork. Records showed the first chemical spray treatment occurred on this day. On 05/23/2026, S2 returned to the hotel, provided clean clothing, and collected items to be laundered at the facility. Meals and activity sheets were delivered to R1 throughout their hotel stay. On 05/24/2026, R1’s hotel reservation ended and R1 was at risk of being escorted out. The facility transported R1 to a second hotel and reserved a room for one (1) day. A second chemical spray treatment was completed at approximately 9PM. S1 believed that the previously established twenty-four (24) hour interval was not followed due to the holiday weekend. Staff reported that the technician cleared R1 to return to their room after 3PM the following day (05/25/2026). Report Continued on LIC 9099-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 On 05/25/2026, R1 checked out of their hotel. R1 and the POA inspected the room and observed dead bed bugs on the clean linens and noted that no bed sheet was provided. The ED and S1 explained this could occur as bugs crawled out and died, indicating the treatment was effective. R1 and the POA were not comfortable returning under these conditions. The ED stated it was their choice, and R1 returned to the hotel. On 05/26/2026, the POA visited the facility and observed R1’s bed had new linens presumably from the model room. Upon inspection, dead bugs were found on top of and underneath the blanket, similar to the previous day. The POA explained that had R1 returned, the bugs would have crawled onto R1 and died. The POA also reported that R1’s wallet and cash were missing and requested access to R1’s bagged belongings. Staff escorted the POA to the basement parking garage, where several black bags containing R1’s belongings were observed scattered in a corner. On 05/27/2026, S1 reported they had washed and disinfected R1’s belongings and had begun the process the previous day, completing approximately fifteen (15) bags. S1 and the ED stated all belongings were returned to R1’s room. LPA Huynh inquired why R1 was not temporarily placed in another room at the community. The ED stated the facility and sister facilities were at capacity. The LPA pointed out vacant rooms observed during the tour. The ED stated those rooms were reserved for incoming move-ins and that the only available room was the model room in the memory care unit. The ED stated R1 could not be placed in the model room due to risk of spreading infestation and that the room was not suitable for living despite being fully furnished. The LPA noted a bed could be obtained; the ED responded that this would risk introducing more bed bugs and that no extra beds were available in storage or at sister facilities. The ED stated that relocating R1 into another unit would risk infestation to other residents. The LPA clarified that R1’s room was infested, not R1. The ED replied that R1 was in fact infested because “bed bugs lay eggs on the skin.” Report Continued on LIC 9099-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 LPA noted that if this were the case, the facility should not have allowed R1 to return on 05/25/2026 under unacceptable conditions and then state it was R1’s choice to return to the hotel. On 06/03/2026, a temporary room became available and R1 returned to the facility. The date R1 returned to their original room is unknown. Interview with R1 revealed the entire bed bug situation was distressing. R1 confirmed that staff stripped them of their clothing when the infestation was discovered. R1 stated that they felt awkward, uncomfortable, and vulnerable. After showering independently, no clothing was provided because all belongings had been removed. R1 remained unclothed for an extended period and missed a meal. Staff later requested a meal be delivered to R1’s room and provided pajamas purchased from a nearby store. R1 also reported that restroom items were not removed and that upon returning to the facility, they again observed bed bugs on the bed and in the restroom. R1 and the POA declined to return under those conditions and remained at the hotel until later placed in a temporary room. On 08/19/2026, LPA Huynh inspected R1’s room. Despite S1 and the ED stating all belongings had been returned, the closet, dresser, and nightstand were mostly empty. The closet contained three (3) shirts, three (3) pants, a safe box, two (2) pairs of house slippers, one (1) set of bed linens, and several empty hangers. The six (6) drawer dresser contained three (3) pairs of undergarments and socks. R1 reported most of their jewelry was missing and described additional missing items, including shoes, clothing, towels, paperwork, their sofa recliner, and kitchen items. R1 also stated the key to their safe box was stored in a shoe that was not returned, preventing access to the safe box. R1 stated they have been re-wearing the same limited clothing. Photos and videos confirmed that numerous bags of belongings were collected which was inconsistent with the small number of items returned, the ED’s characterization of R1 as a hoarder, and the facility’s assertion that belongings were returned. Record review showed additional chemical treatments and inspections on 05/30/2026 (which recommended the room be taken out of service), 06/01/2026, 06/15/2026, 07/11/2026, and 07/26/2026. Report Continued on LIC 9099-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 A recorded call with the treatment technician on 05/29/2026 revealed that the technician instructed the facility to fully clear R1’s room—including restroom contents—and recommended steam cleaning the carpet and removing the mattress and recliner. Because the mattress and restroom contents were not removed, the technician stated the treatment was not completed as required. For safety reasons, the technician reported they did not advise the facility to allow R1 to return to the room on 05/25/2026. Based on interview

Licensing Program Analysts (LPAs) Quoc Huynh and Angela Barutyan conducted an unannounced case management visit in conjunction with complaint #29-AS-20260526120211. The LPAs arrived at 12:50PM and met with Business Director (BD) Aurora Israelson and Health Services Director (HSD) Reina Rubi. Entrance interview conducted. During today’s visit, the LPAs and HSD conducted a physical plant tour at 1:01PM. The LPAs observed the facility’s salon was under renovations and was accessible to residents in care as the door was unlocked. The salon was observed to have exposed wires, paint, and sharp objects. The HSD and BD stated that the door should have been locked and believed that the contractors had taken their break during this time. The salon was locked during the visit. The complaint investigation revealed that the facility did not properly address the bed bug infestation in Resident #1’s (R1) room. Staff failed to follow treatment company instructions, did not fully clear the room of required items, and left R1 in the infested room without clothing for an extended period. The infestation persisted across multiple treatments, and both R1 and the Power of Attorney (POA) observed dead bed bugs and incomplete preparation even after the facility stated the room was ready. The Executive Director (ED) Lilit Mnatsakanyan declined to place R1 in available rooms, provided conflicting explanations about infestation risks, and relied on hotel relocation instead of implementing an adequate on-site solution. 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 Statements from the treatment technician confirmed the initial treatments were not completed properly and that R1 should not have been cleared to return on 05/25/2026. R1 returned to the community on 06/03/2026. Upon returning to the community in a temporary room, R1 was not provided with adequate furniture, including a lamp, blankets, and bed linens. Staff reportedly laundered R1’s linens and clothing daily; however, linens were not consistently replaced or returned, with some being returned as late as 11PM. Photos provided to the Department showed R1 sleeping on an exposed mattress and on pillows without pillowcases. Due to insufficient lighting, R1 reportedly read their Bible in the restroom each night, as it was the only functional light source in the temporary room. Additional incidents occurred during this period, including a popcorn-related smoke event in the common area that triggered the Los Angeles Fire Department’s (LAFD) response. Interview with additional residents confirmed the incident and described it as a “false alarm.” A medical emergency in approximately July 2026 resulting from R1 experiencing significant bleeding from a bite they scratched. On 08/19/2026, LPA Huynh observed blood splattered on the carpet of R1’s room, which the facility attempted to clean at R1’s expense. Per R1’s admission agreement, the resident is responsible for any damages to their room outside of “normal wear and tear;” however, R1’s incident was an unplanned medical emergency. Interview with the BD revealed that a maintenance request form was completed by staff who subsequently notified R1's Power of Attorney . The BD confirmed that a signed acknowledgement and addendum to the admission agreement for the service charge was not completed. The facility did not provide the Department with incident reports for either occurrence. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). A civil penalty in the amount of $250 was assessed for a repeat violation within a twelve (12) month period (Refer to LIC 421FC). The BD was advised that failure to correct and continued violation may result in additional civil penalties. Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.

Licensing Program Analysts (LPAs) Quoc Huynh and Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 09:40AM. LPAs met with Executive Director (ED) Lilit Mnatsakanyan and Business Office Director (BOD) Aurora Israelson. Entrance interview conducted. Beginning at 10:08AM, the LPAs, along with ED Mnatsakanyan and BOD Israelson, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: FACILITY LAYOUT: The facility is a five (5) story building, including an underground parking garage. There are sixty-two (62) private-use units throughout the assisted living (AL) levels and twenty-seven (27) units in the memory care (MC) level which is the entirety of the third floor. KITCHEN: At 10:08AM, LPAs observed the kitchen to have a sufficient supply of perishable and non-perishable food at the time of the visit. Appliances in the kitchen were clean and appeared functional. Snacks and beverages are available for residents. Food is prepared in the main kitchen, which is located on the first floor and is delivered to the common dining areas and MC Unit. Emergency water supply is stored in the locked laundry room in the basement. 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 BEDROOMS: The LPAs toured a total of twelve (12) randomly selected resident rooms. LPAs observed two (2) resident rooms in the MC Unit. Lighting in the rooms appeared adequate. The rooms were properly furnished and were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. BATHROOMS: LPAs observed the bathrooms to be equipped with grab bars near the toilet and shower/tub, and slip-resistant surfaces and mats in the shower/tub. LPAs tested hot water temperatures in resident bathrooms which were measured to be between 105.4-110.3 degrees Fahrenheit, which is within the required range. COMMON AREAS: LPAs inspected the common areas throughout the facility including the Activity Room, Lobby, reading room, lounge, café, health center, theater, and salon. All rooms were furnished appropriately, and no immediate health and safety concerns were noted. The fire extinguishers are located on every floor in each building and were observed to be fully charged and serviced on 10/24/2025. There is a functioning telephone on the premises. Required postings were posted in the facility entryway and LPAs observed the Ombudsman Poster, DSS Complaint Poster, and emergency exiting plans/sketch posted in the hallways throughout the community. The signal system can be activated in the resident bedrooms and restrooms by a pull cord. At 10:47AM, LPA Barutyan pulled the signal cord in a resident restroom. After ten (10) minutes of waiting for staff response, LPA informed ED to have a staff member come clear the signal. Staff #1 (S1) arrived at 10:59AM, approximately twelve (12) minutes after pulling the pull cord, to clear the signal. Staff members stated that the resident was in the common area; ED explained to staff that signals should still be cleared regardless. LPA observed the signal system to be in working order. Staff provided clarification on signal clearing protocol to S1. Residents also have pendants they can wear to signal staff. All systems go directly to a central tablet and to hand-held devices. Designated staff carry a handheld device, which displays the location of the alarm that has been pulled. Staff also utilize walkie-talkies to communicate accordingly. There are two (2) delayed egress doors in the MC unit. LPAs tested one (1) delayed egress door at 11:05AM which was operational at the time of the visit. 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 The community’s smoke detectors and carbon monoxide detectors are hard wired and were last tested on 07/16/2026 by American Eagle Fire Protection and approved by the Los Angeles Fire Department. OUTDOOR AREAS: LPAs toured the outdoor perimeter and observed self-latching gates. All exits were observed to be clear and free of hazards. There are several enclosed patios. No health and safety hazards observed. MEDICATION REVIEW: Medications are locked and centrally stored in the medication office on the second floor and the MC unit medication room. Beginning at 4:06PM , medications for two (2) residents were reviewed for compliance. Both residents’ medications were not labeled and maintained on the centrally stored medication and destruction record. RECORD REVIEW: Beginning at 4:05PM, five (5) resident and five (5) staff records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, personal rights, and first aid/CPR training. All resident and staff files reviewed were complete and were observed to be in compliance. During today’s visit, LPAs obtained a copy of the facility’s liability insurance. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: The LPAs reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted at least quarterly as required, with the last drill conducted on 07/12/2026. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.

Allegation: “Staff mismanage residents medications” It was reported that facility staff did not refill four (4) of Resident #1’s (R1) medications, resulting in R1 not receiving these medications for over thirty (30) days. Interview with Staff #1 (S1) confirmed the oversight and revealed that there had also been a miscommunication regarding R1’s primary care physician (PCP). R1’s PCP had changed, and the facility was not notified. After S1’s attempt to resolve the issue, it was discovered that R1’s pharmacy had not been informed of the PCP change, preventing renewal of R1’s medication orders. S1 additionally reported that the facility’s Medication Technicians noted the medication discrepancies on the Medication Administration Record (MAR) but did not conduct any further follow up. The Medication Technicians listed the medications as “not on hand” in the MAR. Record review showed that R1’s medications were documented as “not on hand” from varying start dates to 05/20/2026 when medications were filled and resumed: Citracal+D 600MG starting 03/24/2026, Donepezil 10MG starting 04/17/2026, Memantine 10MG starting 04/11/2026, Mirtazapine 15MG starting 05/01/2026, and Losartan 25MG starting 05/05/2026. On 04/29/2026, the facility requested R1’s PCP to provide a new order for Citracal+D, and on 05/05/2026, requested new orders for the remainder of R1’s medications. The PCP provided the new orders on 05/06/2026. The facility’s MAR documented that R1 resumed receiving the missing medications on 05/20/2026, resulting in discrepancies of up to fifty-seven (57) days. Additionally on 07/06/2026, the Department received an Incident Report stating that on 06/30/2026 Resident #2 (R2) was scheduled to receive a dose of ten (10) units of Tresiba and it was not administered. Based on interview and record review, the preponderance of evidence standard has been met; therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.

Licensing Program Analyst (LPA) Sandra Urena conducted a Case Management - Deficiencies visit in conjunction with a complaint visits (Complaint Control # 29-AS-20260701152144 and C# 29-AS-20260624155120). The purpose of the visit is to issue a citation for deficiencies observed during the initial complaint investigations unrelated to the complaints. During today’s visit, LPA Urena met with Lilit Mnatsakanyan, Executive Director and the reason for the visit was explained. During the course of the investigations, it was discovered that the facility failed to inform the department of several incidents involving a resident; furthermore, the facility failed to inform the department of renovation work being done at the facility prior to all commencement of such work. Per CCR regulations, all incidents must be reported to the CCLD via the LIC 624 (Report of unusual incidents...) Data search of the incidents involving the resident and the renovation/alterations to the facility were not submitted to the office within the specified time frame of seven(7) days. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Exit interview conducted, and a copy of this report and appeal rights were provided.