Complaint·May 15, 2025

Investigation Revealed the Following: Allegation: Licensee did not comply with facility theft and loss program requirements. The details of the complaint alleged that licensee did not comply with the theft and loss program requirements of the Health and Safety Code 1569.153. On May 2, 2025, at approximately 8:30 AM, the Licensing Program Analyst (LPA), Iniguez, observed a copy of (R#1) 's Admissions Agreement dated:6/30/23; the admission package did not include the Client/Resident Personal Property and Valuables or LIC 621 on it. Also, LPA Iniguez reviewed (R#1) 's second Admissions Agreement dated: 7/24/24, there was a Client/Resident Personal Property and Valuables or LIC 621 with two different dates: 7/5/24-signed by (R#1), and 7/25/24-signed by facility staff. The form has (R#1) 's name and social security number written, but no personal items were listed. Moreover, LPA Iniguez observed (R#1)’s Physicians Report for residential Care Facilities for the Elderly (RCFE) or LIC 602A dated:7/9/23, LPA Iniguez noticed that it is marked that (R#1) is not confused and disoriented, can follow instructions, and can communicate their needs. In addition, LPA Iniguez reviewed the Excel spreadsheet for the facility's Initial Employee Training, dated September 20, 2024, during a records review, LPA Iniguez noted that the spreadsheet did not include any information regarding the theft and loss program for new employees, which should be addressed within the first 90 days of employment, based on the Health and Safety Code 1569.153(b) regulation. In addition, LPA Iniguez reported that five staff members were hired in 2024, as indicated in the Personnel Report or LIC 500 dated September 1, 2024. Additionally, during a review of the facility's Course Completion History for 2024, LPA Iniguez noted that none of the five employees received training on the orientation to the policies and procedures of the theft and loss program, as required by Health and Safety Code 1569.153(b) regulation. Evaluation Report continues LIC 9099-C On 9/18/24, at approximately 12:00 PM, during an interview with (R#1), they stated that when they moved in, they felt that they were not aware of what they were signing and felt pressure to sign documents they did not understand. Also, (R#1) stated that the facility failed to provide a copy of their signed LIC 621 twice. Allegation: Staff did not safeguard resident's personal belongings. The details of the complaint alleged that facility staff did not safeguard (R#1)’s personal belongings. On September 18, 2024, during an initial complaint investigation at approximately 9:00 AM, LPA Iniguez conducted a health and safety check of the facility and (R#1) 's room, accompanied by (R#1). LPA Iniguez asked (R#1) about the missing items from their room. (R#1) mentioned that they noticed some jewelry was missing on the evening of the incident. They also discovered that five designer bags were gone a few days later. (R#1) explained that the jewelry was kept in a locked drawer, while the designer bags were in another piece of furniture in their bedroom, next to their bed. LPA observed where (R#1) stored their handbags and noted that only the dust bags bearing the designer's name were left behind. Photos were taken as evidence. Additionally, (R#1) showed LPA where their jewelry was stored. LPA observed that the jewelry was kept in a small drawer next to the bathroom and noted that (R#1) had not locked that drawer. During the records review, LPA Iniguez observed that on 8/26/24, (R#1) filled out the Los Angeles Police Department Victim's Supplemental Property Loss Report, detailing stolen jewelry and its value. (R#1) claims that an unknown individual entered the facility that day and was escorted out by facility staff after 30 minutes being inside. Additionally, LPA reviewed the facility's video footage from the day of the incident. The video shows the intruder conversing with (R#1) in the elevator, during which the intruder asked (R#1) for their room number, to which (R#1) responded. LPA also viewed photographs of (R#1) 's jewelry that a friend had taken, identified as Witness #3 (W#3). (R#1) had requested (W#3) to document the jewelry with photographs. Evaluation Report continues LIC 9099-C On 9/18/24, at approximately 11:00 AM, during an interview with the executive director (A#1), she stated that the day that (R#1) reported the missing items, a police report was made. In addition, (A#1) stated that there are no cameras on the hallways, only in the lobby and elevator, there is no video footage of an intruder going inside (R#1) 's room, and the resident's door locks use regular keys. Moreover, (A#1) stated that she observed (R#1) came down to the bistro, they would always have a purse and some jewels on her. On 9/18/24, at approximately 12:00 PM, during an interview with (R#1), they stated that they always locked their door every time they go out. (R#1) mentioned that on the evening of the event, they noticed some jewelry was missing, and a few days later, they discovered five designer bags were missing. (R#1) explained that the jewelry was in a drawer with a lock, and the designer bags were in their bedroom next to her bathroom in a drawer. (R#1) stated that there were no signs of forceful entry on the door. (R#1) noted that a passkey can only open the door; the facility staff has this passkey. Additionally, (R#1) stated that they are living independently and can do their ADLs without staff assistance. (R#1) also stated that they can make their own medical and financial decisions. On 9/18/24, at approximately 1:00 PM, during an interview with facility staff (W#2), she stated she had been (R#1) 's housekeeper since they moved into the facility. (W#2) stated that she had seen (R#1) 's jewelry and handbags in (R#1) 's room. On 9/18/24, at approximately 2:00 PM, during an interview with (W#3), they stated that they took the pictures of (R#1) 's jewelry as requested by (R#1); also, (W#3) stated that they have seen (R#1) 's handbags and jewels. Evaluation Report continues LIC 9099-C During this investigation, LPA found sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Stephanie Koffman / Senior Executive Director. Investigation Revealed the Following: Allegation: Staff did not ensure a safe environment was provided for residents. The details of the complaint alleged that facility staff did not ensure a safe environment was provided for (R#1) and the other residents in care. On May 15, 2025, at approximately 1:00 PM, during a Health and Safety check at the facility, LPA Iniguez observed that a security guard was rounding the facility grounds. LPA Iniguez also observed the video cameras placed in the common areas and the secured gate by the parking entrance. In addition, LPA Iniguez observed the electronic sign-in system to register all visitors and vendors to the facility. On May 15, 2025, at approximately 9:30 AM, during an Interview with the Administrator (A#1), she stated that the facility offers a safe environment for all residents in care. In addition, (A#1) state that the facility has a security guard available 24/7 who patrols the building. Additionally, there is video monitoring, a gated garage equipped with video surveillance and a call box, as well as an electronic sign system. On May 15, 2025, at approximately 11:00 AM, during interviews with residents (R#1-R#12), (11) out of (12) stated that they think the facility offers a safe environment for them and everyone else. In addition, (11) out of (12) residents stated that they feel safe living here. On May 15, 2025, at approximately 10:00 AM, during interviews with facility staff (S#1-S#8), (8) out of (8) stated that they think the facility offers a safe environment for all residents in care. Evaluation Report continues LIC 9099-C Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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. An exit interview was conducted, and a copy of the Complaint Report was given to Stephanie Koffman / Senior Executive Director.