The Preserve at Woodland Hills.

Licensing Program Analysts (LPAs) Angela Barutyan and Quoc Huynh conducted an unannounced Case Management - Incident visit at 09:49 AM. The purpose of this visit was to conduct an investigation regarding a self-reported incident that occurred on 08/01/2026. LPAs met with Executive Director (ED) Susan Weisbarth and explained the reason for the visit. During today’s visit, LPAs conducted a physical plant tour to ensure there are no immediate health and safety hazards, conducted interviews with three (3) staff members, and reviewed and obtained copies of pertinent documents. On 08/10/2026, the Department received an incident report stating that on 08/01/2026 around 06:30 PM, Resident #1 (R1) eloped through their bedroom window. R1 refused dinner that evening and returned to their room. Caregivers and front desk staff continued routine monitoring throughout the evening. During safety checks, the receptionist observed that R1's bedroom window was open. Staff searched R1’s room, the facility, and the surrounding grounds but were unable to locate R1. The facility proceeded to call 9-1-1 to report R1 missing and law enforcement responded and initiated a search. R1’s responsible party was also notified of the incident. While searching the surrounding neighborhood, a bystander reported seeing the resident walking with a shopping cart in the area. Staff continued the search and located R1 lying on the ground near a small market approximately 0.4 miles away from the facility. Law enforcement and Emergency Medical Services (EMS) responded to the location, assessed the resident, and transported R1 to the hospital for further medical evaluation. It was reported that R1 was out of the community for approximately forty-five (45) minutes. Staff interviews stated that R1 did not have any visible injuries or reported falls; however, R1 refused water and may have been dehydrated. Report Continued 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 At 10:38 AM, LPAs conducted a tour of the facility. LPAs observed R1’s room at 10:42 AM. Windows were screened and no immediate health and safety hazards were observed or noted. Staff indicated that R1 has the cognitive capacity to move furniture and bypass the window stoppers in order to remove the window screen and exit to the facility parking lot. R1 is no longer residing at the facility and LPAs observed R1’s room free of belongings. LPAs interviewed staff who stated that R1 had previously exhibited exit-seeking behavior. R1 attempted to exit through their bedroom window on 06/30/2026 but staff prevented R1 before they could get out through the window. Record review also indicates that R1 exhibited exit-seeking behavior on 07/31/2026 by attempting to exit the facility through the front entrance. Staff redirected R1 and prevented R1 from exiting unassisted. LPAs reviewed R1’s physician’s report signed and dated 06/30/2026 which documents that R1 is unable to leave the facility unassisted. Staff stated that R1’s responsible party was notified and the option to move R1 to a bedroom with a window facing the facility’s enclosed outdoor courtyard was provided, which they declined. Staff also stated that R1 would regularly express that they wanted to leave the facility. Interviews confirmed that facility staff were aware of R1’s exit-seeking behavior. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. An additional report may follow if warranted. Exit interview conducted. Appeal rights and a copy of the report were provided.

It was alleged that Resident #1 (R1) was being held in the facility against their will and they were unable to move out. LPA interviewed staff who stated that on 06/14/2026, R1 was attempting to leave the facility unassisted to board a flight. Staff stated that R1’s physician had determined that R1 is unable to leave the facility unassisted and R1 requires assistance with activities of daily living (ADLs). LPA interviewed R1 who stated that their physician determined that R1 has the capacity to live independently and that on 06/14/2026, R1 was attempting to leave the facility independently. LPA reviewed a letter from R1’s primary care physician signed and dated on 12/30/2024 that states that “due to medical conditions, [R1] is unable to manage [their] own affairs/estate, including all medical and financial responsibilities. [R1’s] care requires structured assisted living care.” LPA observed a letter from a second physician signed and dated 01/06/2025 that documents that “due to [R1’s] cognitive decline, [R1] is unable to manage [their] personal, legal, and financial affairs.” LPA reviewed R1’s most recent physician’s report by their primary care physician signed and dated 04/15/2025 that documents that R1 has “dementia” and is unable to “leave the facility unassisted.” LPA observed a letter from a third physician signed and dated 11/19/2025 stating that R1 “has major neurocognitive impairment that has rendered [R1] unable to manage instrumental activities of daily living including but not limited to [their] personal, legal, and financial responsibilities.” Lastly, LPA observed a neuropsychological assessment by a fourth physician, R1’s neuropsychologist, signed and dated 03/27/2026 stating that R1 “has the capacity to make basic financial and health care decisions” and “ongoing monitoring and support from trusted advisors will be beneficial.” The assessment further states that due to R1’s “variable difficulties with memory and other cognitive challenges, [R1] may benefit from some support for [their] safety and decision-making.” R1 stated that they will now be moving from the facility with assistance from a responsible party. LPA did not observe documentation from R1’s physician(s) indicating that R1 is able to leave the facility unassisted. Per regulation, “’Elopement’ occurs when a resident who is at risk of harm due to their cognitive condition leaves the facility unsupervised, or while in the licensee's care, leaves another safe location unsupervised.” R1’s documentation from licensed medical professionals document that R1 is at risk if they leave the facility unassisted. Therefore, based on interview and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff confine resident to facility” is deemed UNSUBSTANTIATED at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.

It was alleged that an outside vendor recorded videos and pictures of residents and subsequently posted the content to their online social media accounts. LPA reviewed the vendor’s social media accounts and found no videos or pictures posted that were taken at this facility. LPA interviewed three (3) staff members, including the activities director, who all stated that the outside vendor was hired for one performance in 2024 by previous management. The staff did not remember encountering the vendor but stated that activity vendors do not take pictures and videos of residents and vendors are not left unsupervised with the residents. LPA interviewed five (5) residents and one (1) visitor and all interviews stated that there were no concerns of the activities, outside vendors, or pictures and videos without consent. LPA reviewed the activity schedule for March and April 2026 and did not observe the vendor scheduled. During the visit, LPA observed residents participating in an exercise activity at 11AM in the common area which was supervised by the activities coordinator. LPA also randomly selected five (5) resident files and reviewed their records to observe signed and dated photo consent and release forms. Based on interviews, observation, and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff do not ensure that outside vendors are not video recording/taking pictures of residents” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was issued.

It was alleged that the facility was preventing Resident #1 (R1) from receiving gifts, specifically multiple flower deliveries and a book. LPA interviewed four (4) facility staff who stated that staff will bring any deliveries for R1 to their room and R1 has the choice to receive or decline. Two (2) staff members stated that flowers were delivered to R1 but they were unsure if R1 kept them. One (1) staff member stated that R1 received a book and kept it. LPA interviewed R1 and three (3) witnesses who all confirmed that R1 received the flowers but did not wish to keep them so they gave the flowers away. R1 and witnesses also confirmed that facility staff bring deliveries to R1's room and R1 decides to accept or decline. LPA reviewed photographic evidence confirming the flower delivery to R1. LPA reviewed the facility’s delivery logs and observed multiple package deliveries to R1. R1 and R1’s responsible parties interviewed had no concerns of R1 being prevented from receiving gifts or deliveries. Based on interview and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff are not allowing resident to receive gifts while in care” is deemed UNSUBSTANTIATED at this time. It was further alleged that R1 sustained multiple pressure injuries on their legs and heels possibly due to staff neglect. LPA reviewed records and observed that R1 was hospitalized from 12/22/2025-01/02/2026. LPA interviewed staff, R1, and witnesses who stated that R1 did not develop any pressure injuries under the care of the facility. All interviews confirmed that R1 did have some discoloration on their heel, but that this was a pre-existing condition prior to R1’s admission to the facility and not an open wound. Interviews also confirmed that during R1’s hospital stay, R1 developed minor redness/blister on their back but R1’s condition began improving after hospital discharge. LPA did not observe any open wounds on R1 during the initial visit. LPA was unable to observe R1 during today’s visit as R1 no longer resides at the facility. Record review of R1's care plan, physician's report, and appraisals contained no evidence of R1 developing pressure injuries while at the facility. Based on interview, observation, and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not prevent resident from developing pressure ulcers” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.

Licensing Program Analyst (LPA) Angela Barutyan and Licensing Program Manager (LPM) Kristin Heffernan arrived at the facility unannounced to conduct a Case Management – Health and Safety Check visit at 11:43AM to ensure there were no immediate health and safety hazards following the facility’s court appointed Receivership. LPA and LPM met with Executive Director (ED) Susan Weisbarth and explained the purpose for the visit. Entrance interview conducted. At 12:24PM, LPA, LPM and ED conducted a tour of the physical plant areas inside and outside to ensure compliance with Title 22 regulations, which included a tour of resident rooms, common spaces, outdoor area, and main kitchen. No immediate health or safety concerns were observed during the visit. On 11/20/2025, the Woodland Hills North Regional Office (WHN RO) received notice from the court appointed receiver of the facility’s Receivership Order which went into effect on 10/30/2025. The Licensee failed to inform the Department of the receivership. The receiver notified families on 11/07/2025. Per California Health and Safety Code section 1569.686, you are hereby notified that a $100 civil penalty is being assessed per day. The total civil penalty for a continuous violation shall not exceed $2000. You will receive an invoice in the mail. Payment is due when billed. Payments must be made by a personal business or cashier's check or money order made payable to the "California Department Of Social Services". Please write the facility number and invoice number on your check and include copy of your invoice with the payment. You will find the invoice number on your invoice. DO NOT SEND CASH. Report Continued 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 The Licensee was notified that a civil penalty is being assessed for failure to comply with this section and/or failure to report specified events, in writing, within two (2) business days to the Department, the State Long-Term Care Ombudsman, all residents, and their representatives. Deficiency cited under Health and Safety Code 1569.686. Pursuant to Health and Safety Code, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted/ Citations issued/ Civil Penalty assessed/ Appeal Rights discussed/ A copy of report was issued.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a Case Management - Annual Continuation visit at 10:22AM continuing the inspection that began on 07/25/2025. LPA met with Executive Director (ED) Susan Weisbarth and explained the purpose of the visit. RECORD REVIEW: Beginning at 10:37AM, five (5) staff records were reviewed for documents including, but not limited to: health screening, TB test, training records, fingerprint clearance, and first aid/CPR training. All staff files reviewed were complete and were observed to be in compliance. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: Beginning at 11:48AM, the LPA 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 quarterly as is required, with the last drill conducted on 07/08/2025. The community’s smoke detectors and carbon monoxide detectors are hard wired. Fire systems, including smoke detectors, sprinklers, and alarms, were last tested on 11/14/2024 by GFP Guard Fire Protection INC and approved by the Los Angeles Fire Department. During today’s visit, LPA obtained a copy of the facility’s liability insurance. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

It was alleged that the facility staff were preventing Resident #1 (R1) from receiving phone calls or visitors on behalf of R1’s responsible party’s request, rather than R1’s decision. On 07/25/2025, LPAs interviewed R1 and R1 expressed that they were aware of their visitor and call requests. R1 stated they told facility staff to consult their responsible party. LPAs explained to R1 that they have their own personal rights and that if they want to receive any calls or visitors, R1 can do so without getting their responsible party’s consent. R1 stated they understood and that there were no concerns. LPA interviewed R1’s responsible party and facility staff throughout the course of the investigation and all interviews confirmed that facility staff ask R1 first if they want to receive their calls or visitors, and that the choice is entirely up to R1. On 07/28/2025, ED Weisbarth broadcasted an announcement to all residents’ family members/responsible parties stating that “Residents have rights to have visitors and calls at any time. Please make sure residents are told they have a call or a visitor.” An in-service training was also conducted on 08/01/2025 with all staff regarding personal rights and that residents should be asked if they want visitors or calls. LPA observed documentation of two attempted calls, one on 07/31/2025 and another on an unknown date within the same week; R1 declined to speak with the calling parties on both occasions. A wellness check was conducted by police and by other outside agencies who interviewed R1, and no concerns about R1 receiving visitors or calls were noted. Resident and visitor interviews conducted also did not have evidence that supported allegations regarding visitation or phone call access. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the above allegations “Staff are not allowing resident to have visitors” and “Staff are not allowing resident to have phone calls” are deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.

During today’s visit at 11:55AM, LPA observed the double doors leading to the staff area by the corner of the common area. LPA observed a surveillance camera installed facing the door and a hole drilled in above the door for the camera’s cables. There were no signs on the community-facing side of the door, but LPA observed two (2) framed signs on the staff-side door that state “ATTENTION: PLEASE OPEN DOOR WITH CAUTION.” LPA also observed a staff member opening the door with relative caution at 11:57AM. ED stated that the facility is installing a surveillance camera to monitor the double door. The camera does not contain an audio component and is direct feed, no video surveillance will be stored or saved. A monitor screen will be installed next to the staff-side of the door for staff to check if residents are in the door path prior to opening. LPA reviewed proof of purchase and receipts for the camera installation. During a previous complaint visit for complaint control #29-AS-20250305161155, it was alleged that the facility door poses a safety concern for residents as there are no windows or cameras to alert staff if residents are in the way of the door. LPA visited the facility on 03/11/2025 and observed caution signs on the door on both the staff and community sides. LPA interviewed five (5) staff members on 03/11/2025 and confirmed that staff had been advised to open the door cautiously and to redirect residents when they are observed to be near door paths. LPA unsubstantiated the allegation due to there being no regulations in the California Code of Regulations, Title 22 and/or California Health and Safety Code that require facility doors to have windows, cameras, or other equipment for staff to observe if residents are behind a door, and there being no evidence of lack of supervision. On 03/11/2025, LPA had a conversation with ED about minimizing the potential risk of the facility door and ED informed the maintenance director who stated they will inquire about having a window placed on the door or some other feature that could allow staff to check for residents in the way. Information obtained through interview, record review, and observation for this investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation “Staff do not ensure a facility door is safe for the residents while in care” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

It was alleged that the facility admitted Resident #1 (R1) on 05/13/2025 and Resident #2 (R2) two to three months ago without medical assessments. During the initial visit on 05/20/2025, LPA conducted a record review and observed that R1 had a preplacement appraisal dated 05/11/2025, a signed medical assessment dated 05/11/2025, a chest x-ray TB screening dated 05/12/2025, and a signed admission agreement dated 05/13/2025. LPA also reviewed records for two (2) residents admitted on 05/15/2025 and 05/19/2025. During today’s visit, LPA conducted a record review and observed that R2 was admitted on 02/23/2025 and had a preplacement appraisal dated 12/22/2024, a signed medical assessment dated 11/25/2024, a TB test dated 12/07/2024, and a signed admission agreement dated 02/23/2025. LPA also reviewed records for one (1) resident admitted on 05/28/2025. Five (5) out of five (5) resident files reviewed contained medical assessments, preplacement appraisals, and admission agreements. Staff interviews confirmed that staff are knowledgeable in admission procedures and Title 22 requirements. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Licensee did not obtain documentation of a medical assessment prior to a person's acceptance as a resident” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.

It was alleged that Staff #1 (S1) yells at residents and handles them in a rough manner and that on 04/04/2025, S1 restrained and pushed Resident #1 (R1) and on 04/05/2025, S1 yelled at Resident #2 (R2) to leave. LPAs attempted an interview with R1, and interviewed R2 and six (6) other residents. No concerns were noted and no information supporting the allegations were found. Residents interviewed stated that staff treat them fairly and do not yell at them or handle them roughly. LPAs interviewed five (5) staff of which four (4) were on shift between 04/04/2025-04/05/2025. One (1) out of five (5) staff interviewed stated that S1 yells at residents and handles residents in a rough manner. Four (4) out of five (5) staff interviews had no evidence supporting the allegations and stated that staff have not been observed to yell at residents or handle them roughly. All staff and four (4) out of seven (7) resident interviews confirmed that R1 is combative, and staff physically redirect R1 from hitting staff or other residents as has happened in the past. LPAs observed R2 to be hard of hearing and staff interviews confirmed that R2 requires louder volume to hear. LPAs reviewed S1’s training transcript and observed all training up to date, including dementia care, ethics, and knowing the rights of residents. LPAs reviewed R1’s physician’s report dated 01/18/2023 documenting R1 with “inappropriate behavior” and R2’s physician’s report dated 04/17/2024 documenting R2 with “auditory impairment.” Based on interviews, record review, and LPAs’ observation, the information obtained during the investigation does not have sufficient evidence to corroborate the allegations. 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 above allegations “Staff handled resident in a rough manner” and “Staff yells at residents in care” are deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

It was alleged that on 02/22/2025, Resident #1 (R1) was hit with a facility door by Staff #1 (S1). S1 opened the double doors leading to the staff area at 08:01AM and was unaware that R1 was behind the doors. R1 fell and hit their head, resulting in bruising and a laceration on the right side of their face. Paramedics were called and family was notified by the facility immediately. R1 did not sustain serious injuries. During today’s visit at 10:50AM, LPA observed caution signs taped to the doors on the staff side that state “ATTENTION: PLEASE OPEN DOOR WITH CAUTION.” Per interviews, staff have been advised to open the door cautiously and to redirect R1 when R1 is observed to be near door paths. Record review and observation of R1 indicate that R1 has dementia and wandering behaviors. Staff are knowledgeable in redirecting R1. At 12:49PM, LPA observed R1 with a small pale green bruise under their right eye by their nose, slight redness above the right eyebrow, and no swelling or significant bruising. Lack of supervision, malicious intent, and concerns of negligence were not noted. It was further alleged that the facility door poses a safety concern for residents as there are no windows or cameras to alert staff if residents are in the way of the door. At this time, there are no regulations in the California Code of Regulations, Title 22 and/or California Health and Safety Code that require facility doors to have windows, cameras, or other equipment for staff to observe if residents are behind a door. LPA had a conversation with ED about minimizing the risk of reoccurrence as the door is heavy and requires force to open which could be problematic if a resident was in its path. ED informed the maintenance director and stated they will inquire about having a window placed on the door or some other feature that could allow staff to check for residents in the way. During the visit, ED placed additional signs on the community side of the door stating, “CAUTION WHEN OPENING DOOR PLEASE OPEN CAREFULLY PLEASE DO NOT STAND IN FRONT OF THE DOOR.” ED also stated that they will have staff redirect R1 if R1 gets close to the door and ED and HSD will have weekly reminders for staff to open the door cautiously. LPA observed a daily meeting agenda on 02/24/2025 with the goal of informing staff to monitor R1 and open doors cautiously. LPA observed ED reminding staff to open the door carefully at 03:07PM. Information obtained through interview, record review, and observation for this investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations “Staff negligence caused injury to resident” and “Facility door poses a safety concern for residents” are deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

Licensing Program Analyst (LPA) Emily Peraldi made unannounced case management visit regarding a self-reported incident on the relocation of 20 residents from Bentley Suites- License # 198320302 to PRESERVE AT WOODLAND HILLS, THE - License #195850091 due to mandatory evacuation orders from Fire Advisory. The LPA met with Administrator Susan Weisbarth and Administrator from Bentley Suites, Belen Taico and explained the purpose of the visit. During the visit, LPA Peraldi conducted a health and safety check and no concerns were observed. LPA reviewed and obtained resident and staff rosters for both facilities. Per interview with the Administrators, 20 residents have been relocated to The Preserve at Woodland Hills. The facility has sufficient beds, hygiene supplies, beddings, linens, and everyone has a designated room. All rooms have an ensuite bathroom. The dining room is large enough to accommodate all residents with staggered dining schedules. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. Medications and files of the Bentley Suites residents have been transferred and stored in a locked room. There is sufficient staffing available to provide care for resident of both facilities. The Administrator Belen Taico confirmed all families and responsible parties from Bentley Suites have been notified of the relocation. Current Preserve at Woodland Hills residents will not be affected by this relocation. Exit interview conducted. A copy of the report was provided.

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 02:12PM. The purpose of this visit is to conduct an investigation regarding two self-reported incidents that occurred on 12/05/2024 and 12/22/2024. Upon arrival, the LPA met with staff and Executive Director (ED) Susan Weisbarth. Entrance interview conducted. During today’s visit, LPA Barutyan conducted a brief physical plant tour to ensure there are no health and safety hazards and conducted interviews with five (5) staff members and attempted interviews with two (2) residents. On 12/10/2024, the Department received an incident report stating that on 12/05/2024 around 10PM, Resident 1 (R1) eloped and left the facility unassisted through the back Egress door and had a fall on the sidewalk. Staff heard the alarm ring and noticed that R1’s room was empty. Staff checked inside and outside the facility and found R1 outside being assisted by the Fire Department, which a neighbor called in. R1 was transported to the hospital and was diagnosed with a urinary tract infection (UTI) contributing to R1’s confusion and wandering. Facility management held a meeting with R1’s responsible party to discuss changes in care such as a 1:1 caregiver for nighttime, bed/floor alarms, or relocating R1 to a room in the front of the facility. On 12/27/2024, the Department received an incident report stating that on 12/22/2024 around 2PM, Resident #2 (R2) was spotted by Staff #1 (S1) outside of the community as R2 had eloped unnoticed. S1 recognized R2 and assisted R2 back to the facility. No injuries were noted. 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 LPA interviewed ED Weisbarth and Health and Services Director (HSD) Tony Nunez on 01/02/2025 who stated that R1 and R2 eloped from the same back Egress door. According to ED and HSD, staff reported that the alarm sounded when R1 eloped on 12/05/2024, which is why staff were able to act quickly and call a code yellow, but did not sound when R2 eloped on 12/22/2024, which is why staff were unaware that R2 had eloped. ED and HSD reviewed the alarm logs and checked the system which showed that the alarm did ring on 12/22/2024. Per HSD, the alarm rings very loud and it is unlikely that staff did not hear the alarm. ED stated they are currently in the process of installing perimeter cameras and a potential gate to secure the grounds. ED also stated that they are looking into changing the delayed egress from 15 seconds to 45 seconds. LPA requested copies of pertinent documents relevant to the investigation on 12/10/2024 and 12/31/2024, documents were received via email on 01/03/2025. On 01/03/2025, LPA reviewed preplacement appraisals and physician’s reports for R1 and R2. R1’s physician’s report dated 11/26/2024 documents that R1 has dementia, mental condition is confused/disoriented, has wandering and sundowning behavior, and is not able to leave the facility unassisted. R2’s physician’s report dated 03/27/2024 documents that R2 has dementia, requires continuous bed care, mental condition is confused/disoriented, has sundowning behavior, is not able to communicate needs or follow instructions, and is not able to leave the facility unassisted. During the visit, LPA interviewed staff who stated that R1 was away from the facility for a period of about 10 minutes. Staff heard the alarm and noticed R1’s empty room, code yellow was immediately called and all staff searched for the resident. For R2’s elopement, staff stated that two (2) door alarms sounded. When staff went to check the doors, they observed Resident #3 (R3) who has a habit of attempting to open the Egress doors and sounding the alarms. Staff assumed that the alarm was sounded by R3 and did not check if other residents were missing. During the visit, LPA observed R3 wandering in the hallways. LPA was unable to interview the residents as R1 moved out of the facility, R2 did not wish to speak to the LPA, and R3 was disoriented and unable to communicate with LPA. During the physical plant tour, LPA asked the maintenance director to demonstrate that the delayed egress door worked. Door was tested twice at 02:34PM and was functioning properly during the visit. The alarm was triggered when the bar was pushed, and each door has three (3) alarms. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.

Page 2 called 911. At 1:15 p.m. LPA obtained pertinent documents. This complaint requires further investigation. An LPA will return at a later date to continue this investigation. No deficiencies observed at this time. Copy of report was provided to the administrator. On 12/17/24, Licensing Program Analyst (LPA) Christine Yee conducted a subsequent unannounced complaint visit to conduct additional investigation for the above allegations and met with Susan Weisbarth, Executive Director. The reason for today's visit was explained. On today's visit LPA Yee conducted an interview with Staff #1 at 11:28am, Staff #2 at 12:38p, Staff #3 at 1:05pm, Staff #4 at 1:33pm, Staff #5 at 2:22pm, Staff #6 at 3:20pm and toured Bedroom #102, #126 and #127 at 2:57pm. LPA Yee also obtained copies of facility documents during the visit. Per information received during the visit, it was again determined that additional investigation is needed to make findings for the above allegations. An exit interview was conducted and a copy of this report was provided. Another unannounced subsequent complaint visit was conducted today to continue investigation of the above allegations. LPA Yee met with Lorrain Walters and Iveth Barron and the reason for today's visit was provided. LPA Yee conducted an interview with Resident #2 at 11:07am, Resident #3 at 1:33pm, Resident #4 at 12:24pm, Resident #5 at 12:35pm and Staff #6 at 1:47pm. Per information received through interviews conducted for all the above allegations, Resident #1 was admitted to the facility with dementia. Resident #1 would refuse medications and would easily be agitated and turns very aggressive. Resident #1 would be given breakfast, lunch and dinner and would eat only about half the meal. Resident#1 is able to feed themselves but was very picky with their food and would request pancakes with syrup, ice cream with whip cream, sprinkles and syrup and used syrup on all the facility meals. Resident loves ice cream and noodles and orange chicken from Panda Express. The facility staff will order food just so that the resident will not get agitated but resident would not eat the ordered food. Resident #1 demands to be served their meal first and gets what they request so that they don't get agitated. Resident #1 would get very upset and agitated when there was no syrup or did not get what they wanted. Resident would yell and scream loudly at the staff and that they were being mean and trying to kill them. Resident would also throw cups, plates and other things, rip the shower rod down and destroy their bedroom when it was cleaned, within minutes of returning to the room. Resident #1 got so agitated that 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 at the bedroom window. Staff would attempt to re-direct the resident and would call the responsible family member for assistance via telephone or in person. As a result of this behavior, the facility asked the family to speak with the resident's doctor and obtain medications to assist with controlling the agitation. An order for CBD /THC gummies 1mg was prescribed by the physician. Resident #1 refused the CBD gummies and other medications. Multiple attempts would be made to get the resident to take the prescribed gummies and was unsuccessful. Resident #1 would be constantly agitated and confused. Resident would blame the staff for not cleaning the bedroom, refused to be assisted with changing their briefs when it was soiled or it was sopping wet or let staff wash their hands when it was observed with feces from the resident putting their hands inside their briefs or when they did not wipe themselves after having a bowel movement. Resident #1 would transfer the feces on to door handles and bedding and would often not let staff into the room to clean the mess. The wet briefs would be sopping wet and dripping urine on the floor. Resident #1 would refused to be changed and also refused to be bathed. The room would smell. They would have to bribe the resident with ice cream or a trip to San Francisco. Sometimes it worked and sometimes it didn't. Resident #1 is also particular about who gives them a bath. Resident #1 will not usually allow the 2 African American staff to bath them and prefers a male staff if they agree to a shower. Staff could clean Resident #1's room and change the bedding when the resident was out of the room. The resident's belonging would be put in order and minutes after the resident returned, Resident #1 would turn it upset down again. Resident would yell at the staff and tell staff that they do not want their room cleaned and say that someone stole their stuff when things are put away or taken to be laundered. The resident Resident #1 was also a very messy eater. Resident #1 would throw food all over the room and get it all over their clothes. Resident #1 loved to eat their food in the bathroom. Resident #1 loved sweets and their food was always mixed with syrup and had sprinkles. Food was also all over the bathroom including the dirty plate. Per Staff, the food would be cleaned up once they were allowed into the room but until they could clean up, the syrup could attract ants and other pests. Per staff, they have not seen any ants, spiders or roaches in Resident #1's room. Per staff, they have to clean the resident's room everyday. Per information obtained from interviews, Resident #1 was away from the facility for about 3 months. Staff were not sure where the resident went before returning to the facility. Resident #1 was observed to have lost weight upon return. Upon return, Resident #1 was still agitated and the facility staff advised the family to 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 speak with the resident's physician and obtain medications to assist with the resident's agitation. The doctor prescribed Quetiapine Fumara 25mgs, PRN, 1 tablet, every 12 hours, 2 doses in 24 hours and Quetiapine Fumara 12.50mgs at bedtime. However, for unknown reasons, the family had the doctor discontinue the medication. Resident #1 continued to de-escalate. Resident #1 believed that people were doing things to them. Resident would also not sleep at night. Per information obtained from family, they wanted to try to reduce the number of naps taken by the resident first before using prescribe medications to aide Resident #1 with sleeping during the night. However, the doctor had submitted a prescription for the sleep medication and it was filled. Once the facility received the medications, there was no reason not to dispense the medication contrary to the family's instructions. The facility is required to dispense the medication as prescribed by the doctor unless the facility or family member obtains a discontinue order from the doctor regardless of what the family wanted. Per information provided, Resident #1 likes to leave their bedroom door unlocked. Dementia residents who wander around would enter the Resident #1's room. Resident #1 would say that they are after them or doing things to them and blame them for messing up their room. Resident #1 would imagine things. Per information received from interviews, there is not sufficient evidence to support the allegations noted above. It may have happened or may not have happened, but there is not a preponderance of evidence to support the above the allegations, therefore the allegations are unsubstantiated at this time.

It was alleged that the facility has insufficient staffing. On 08/29/2024, LPA Barutyan conducted a visit for an unrelated complaint and observed one (1) caregiver, Staff #1 (S1) attending to around twenty-five (25) residents in the dining room. At 11:28AM during LPA’s physical plant tour on 08/29/2024, Resident #1 (R1) needed incontinence assistance and S1 left to assist R1 to the bathroom. LPA observed the remaining residents in the dining room left unassisted with no care staff. Staff #2, a kitchen staff member accompanying LPA on the tour, stated that it is like this “50% of the time” and that “residents get left alone, but it's never for too long.” S2 stated that he/she tries to stay in the dining room and watch the residents when he/she does not have to be in the kitchen, in order to help lighten the work load on care staff. S2 also stated that "the facility is very short-staffed, but the staff on shift are able to handle the load." S2 stayed behind to supervise staff until S1 returned around 20 minutes later. The complainant alleged that on 08/28/2024, only one (1) care staff was on shift after 7PM and on 08/24/2024, two (2) care staff were on shift from 2PM-10PM. LPA reviewed shift timestamp records which document four (4) staff on shift on 08/28/2024 after 7PM and three (3) staff on shift on 08/24/2024 between 2PM-10PM. There are two (2) residents who require two (2) person assists. Interviews conducted between 08/21/2024 – 09/04/2024 revealed nine (9) concerns of staffing numbers. One (1) caregiver on 08/21/2024, one (1) family member on 08/26/2024, one (1) staff member and four (4) family/responsible parties of residents on 08/29/2024, and two (2) family members on 09/04/2024 had concerns of the number of staff on shift. Although there were concerns of staffing, shift timestamp records from 08/11/2024 – 08/31/2024 document more than three (3) staff on shift at all times. Per regulation, there are no staffing ratios for residential care facilities for the elderly. California Code of Regulations, Title 22 Section 87415 Night Supervision states that “In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes.” Furthermore, the facility has hired and onboarded one Health and Services Director, one Lifestyle Director, one Executive Director, one Business Operations Manager, one Resident Care Coordinator, six (6) caregivers, two (2) medication technicians, one Sous Chef, and one kitchen staff between 08/16/2024 – 11/13/2024. Record review of the current staff schedule reveals 3-4 care staff for the AM (6AM – 2PM) shift, 3-4 staff for the PM (2PM – 10PM) shift, and three (3) for the NOC (10PM – 6AM) shift. Based on record review, observation, and interviews, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation, therefore, the allegation “Facility does not have enough staff to meet the needs of residents in care” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. Copy of the report was provided.

It was alleged that staff overmedicated a resident in care. LPAs Barutyan and Dulek conducted a medication review of five (5) residents on 09/04/2024 and observed all medications being given as prescribed. Medications are stored, documented, and administered in accordance with California Code of Regulations, Title 22 and state and federal law. Interviews with the reporting party (RP) indicated concerns of medication dosages that were being administered to Resident #1 (R1) and medication-technicians administering painkillers that were “too strong.” Interviews with staff and ED Willis revealed that the painkillers were prescribed by R1’s physician and that the med-techs were administering the prescribed medications per the medication instructions on the Rx label, which is consistent with LPA observation during the medication audit. The RP also stated that R1 was “numbed and dazed” from the strength of the painkillers and that the med-techs should not have administered that strong of a dosage. Per regulation, med-techs do not need to be licensed medical professionals and therefore, cannot alter or prescribe medications. Medication review indicated that family of R1 provide over-the-counter nutrients, supplements, and medications like “fear spray” and “calming essential oils” which med-techs stated they do not know how to use as R1 cannot verbally or physically express if they are scared. ED Willis stated that they are worried that assuming how R1 is feeling and administering something that R1 cannot consent to is a violation of personal rights. LPAs Barutyan and Dulek did not observe any medication errors for five (5) residents reviewed on 09/04/2024 and for four (4) residents reviewed on 08/13/2024 by LPAs Barutyan and Emily Peraldi. LPA telephonically interviewed the co-complainant on 10/14/2024 who stated that the allegation was “inaccurate” and that they do not believe the staff are over-medicating. Co-complainant did not have any information to support the allegation. Based on interviews, medication review, and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff overmedicate resident(s) in care” is deemed UNSUBSTANTIATED at this time.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced case management visit at 9:50 a.m. Upon arrival, the LPA met with Executive Director (ED) Susan Weisbarth and explained the reason for the visit. The reason for today's inspection is to follow up on a self-reported incident report received on 09/10/2024. The report pertains to Staff #1 (S1) placing a cloth over Resident #1’s (R1’s) mouth after R1 attempted to bite S1. Starting at 9:54 a.m., the LPA conducted interviews with the ED and one (1) staff member. At 10:07 a.m., the LPA conducted a file review and obtained copies of pertinent documents. Additional report may follow if warranted. Exit Interview conducted and report was issued.

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management visit at 02:20PM. The purpose of this visit is to conduct an investigation regarding two self-reported incidents and SOC 341s that occurred on unknown dates. Upon arrival, the LPA met with Executive Director (ED) Trevin Willis and explained the reason for the visit. Entrance Interview conducted. On 08/17/2024, the Department received an incident report stating that on an unknown date, two (2) staff members, Staff 1 (S1) and Staff 2 (S2), were witnessed by Staff 3 (S3) slapping Resident 1 (R1) across the face in R1’s bedroom. According to the report, the incident occurred weeks ago and was reported to the previous ED Michael Owens and Health and Services Director Gloria Barron, but no action was taken at the time. S3 reported the incident to Staff 5 (S5) who reported to ED Willis on 08/16/2024. S1 and S2 have been placed on leave until a formal investigation can be completed by company HR. Families have been notified. The Department received another incident report on 08/20/2024 stating that on an unknown date, S1, S3, and Staff 4 (S4) took a selfie in front of Resident 2 (R2) in the bathroom who was exposed in the picture. Staff members then shared the picture among their personal circles. Staff 6 (S6) reported the incident to ED on 08/20/2024. S1, S2, S3, and S4 have been placed on leave until a formal investigation can be completed by company HR. Families were notified to call ED. During today’s visit, LPA Barutyan conducted interviews with the ED and three (3) staff members between 02:25PM-03:53PM, conducted a file review at 03:00PM, and obtained copies of pertinent documents relevant to the investigation. Prior to issuing final licensing report, it has been determined that further investigation is needed at this time. Exit Interview Conducted and Report was Issued.

Licensing Program Analysts (LPAs) Angela Barutyan and Emily Peraldi arrived at the facility unannounced to conduct a Case Management - Annual Continuation visit at 9:46AM, continuing the inspection that began on 08/07/2024. LPAs met with staff and Executive Director (ED) Trevin Willis and explained the reason for the visit. RECORD REVIEW: LPAs began record review at 10:10AM. LPAs reviewed 5 (five) resident files for documents including, but not limited to: health screening, TB test, physician’s report, needs and service appraisal, and personal rights. All resident files reviewed were complete. MEDICATION REVIEW: Medications are locked and centrally stored in the medication office. At 11:35AM, medications for 4 (four) residents were reviewed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. During today's visit, LPAs obtained a copy of the facility's liability insurance. No deficiencies were observed during the inspection. A copy of the report was provided.

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Plan of Correction (POC) visit to this facility to issue a civil penalty for a POC that has not been corrected within the required time frame. LPA arrived at the facility at 09:40AM and met with Business Office Manager (BOM) Edie Cano. Executive Director Michael Owens arrived during the visit. Entrance interview conducted. LPA Dulek had previously conducted a complaint visit on 05/08/2024 and issued a POC to the facility for not issuing a refund, per the resident's Admission Agreement. During today's visit, LPA spoke with Business Office Manager at 09:43AM, and LPA conducted a brief physical plant tour. BOM reviewed the facility records and indicated there is a check # associated with the refund related to the POC issued and the check was cut on 05/20/2024, however the POC was due on 05/15/2024. Additionally, the check that was cut on 05/20/2024 is in the incorrect amount and there is an additional $561.25 owed. A civil penalty in the amount of $900 was issued during today's visit. (See LIC 421 dated 05/24/2024, located under the LIC 9099 dated 05/08/2024). Exit interview was conducted with Business Office Manager and Executive Director. Appeal rights were discussed. A copy of the report was provided.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 3:43 p.m., the LPA met with Administrator, Trevin Wills and explained the reason for the visit. The reason for today's inspection is to follow up on two (2) self-reported Report of Suspected Dependent Adult/Elder Abuse (SOC 341), one submitted on 12/18/2023 and the other submitted on 12/20/2023. At 3:45 p.m., the LPA conducted an interview with the Administrator. At 4:03 p.m., the LPA obtained copies of pertinent documents. At 4:42 p.m., the LPA along with the Administrator conducted a physical plant tour. No immediate health and safety concerns were observed during today's inspection. Further investigation is required at this time. An additional reports may follow if warranted. Exit interview conducted. A copy of the report was provided.