Complaint·August 3, 2025

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff does not ensure residents’ personal belongings are safely secured. It is claimed that the facility staff does not secure residents' personal belongings properly. The facility staff does not ensure that the personal belongings of Resident #1 (R1) are securely stored. It was reported that (R1’s) clothing frequently goes missing from (R1's) room but is sometimes returned. Management is aware of the issue regarding the missing items, yet no action has been taken to address it. No additional details regarding this matter have been provided. On July 10, 2025, between 11:18 AM and 03:59 PM, the Department interviewed the residents identified as Resident #1 through Resident #10 (R1-R10). Nine (9) out of the ten (10) residents were not able to validate this claim. Out of the ten (10) individuals interviewed, nine (9) expressed the belief that it is mainly the responsibility of residents to take proactive measures in securing their personal property. This statement emphasizes the importance of each person taking responsibility and staying alert to protect their belongings from theft and other risks. An interview with Resident #1 (R1) shed light on the situation that has persisted within (R1's) room for the past three years. (R1) disclosed that various personal items, particularly fabric textiles and arts and crafts materials, have gone missing over time. (R1) noted the concerns have been communicated to previous Executive Directors, yet no investigations or corrective actions have ever been initiated. (R1) is not able to pinpoint the exact timing of the last incident involving missing items or is unable to describe the items in detail. (R1) explained that the textiles stored in (R1's) closet can only be accessed through a bedroom door that is supposed to be securely locked. Neither staff members nor anyone outside of (R1's) spouse or roommate has a key to this door, making the situation even more perplexing. (R1) mentioned that some missing items sometimes come back unexpectedly. This adds a sense of mystery to the situation. This pattern has left (R1) feeling unsettled about the health and safety of residents in care. During the interview, (R1) talked more about the complaint from August 31, 2023, which included similar allegations. (R1) does not remember any recent activities related to this investigation. (Evaluation Report continues LIC 9099-C) Resident #11 (R11) identified as (R1’s) spouse and roommate declined to take part in an interview. On January 23, 2025, and July 10, 2025, between 11:08 AM and 4:12 PM, the Department conducted interviews with staff members identified as Staff #1 through Staff #7 (S1-S7). Seven (7) out of the seven (7) staff members stated that they could not corroborate the claim regarding missing property from Resident #1 (R1). They unanimously reported that they were not aware of any valuables missing from (R1). Additionally, all staff indicated they were only aware of one incident involving a resident and missing items, which had been reported, investigated, and resolved by Community Care Licensing (CCL). (S7) was not aware that (R1) had installed a security lock on (R1's) bedroom door. (S7) asserted that only housekeepers and maintenance staff possess keys to residents' units. Each time staff access these units, the action is carefully registered and logged. On July 15, 2025, between 09:40 AM and 10:0 AM, the Department interviewed the witness identified as family member of (R1), Witness #1 (W1). (W1) was unable to verify this claim. (W1) clearly explained the situation. In the past, (R1) and spouse owned a home near the facility, where (R1) experienced security issues. (W1) mentioned that (R1's) unresolved experiences are believed to be the main reason behind (R1’s) ongoing trust concerns. As a result, (R1) has struggled with persistent senses of anxiety and distrust over the years, which can be incredibly challenging to manage. A review of Resident #1 (R1's) Physician's Report LIC 602A (dated 11/07/24) revealed that (R1) is diagnosed with anxiety, with no mental condition. However, a review of Physicians Prescribed Medications (dated 06/30/21) exhibited that (8) out of the (14) medications have side effects linked to the cognitive impacts, confusion, difficulty concentrating, dizziness, anxiety, or blurred vision (ref: National Institute of Health (NIH). A review of (R1's) Theft and Loss Policy (dated 06/30/21) does not include a list of any valuable inventory. Further review of (CCL) Complaint # 11-AS-20230831163759 (dated 08/31/23) verified the same allegation was investigated and determined unsubstantiated. The Department inspected Resident #1's (R1’s) room and found the space to be well-used, with evidence of creative projects and mementos. Although some disorganization was present, it serves to identify the significance of some personal items that may be displaced. Based on the information gathered, there is not enough evidence to corroborate the allegation mentioned above. (Evaluation Reports continues LIC 9099-C) Allegation #2: Staff does not ensure facility is in good repair. The complaint details an allegation that the facility staff does not ensure the facility is in good repair. Specifically, it has been reported that two out of the three elevators are out of order, a situation that has persisted since November 2024. Additionally, reports indicate that more residents are to be admitted due to the Pacific Palisades fires, raising concerns about safety with only one functioning elevator. No further details regarding this issue were provided. On January 23, 2025, and July 10, 2025, between 11:08 AM and 04:12 PM, the Department interviewed the staff identified as Staff #1 through Staff #7 (S1-S7). Six (6) out of the seven (7) staff members were unable to validate this claim pertaining to non-operable elevators. Six (6) out of the seven (7) staff members confirmed that the facility has two functional elevators. During the interview with (S1), it was mentioned that one of the elevator's cabling wires has begun to tear, so it is currently under repair. Both (S1 and S7) reported that there has never been more than one elevator out of order at the same time. Whenever an elevator malfunctions, it is immediately noted for repair on the same day the issue occurs. (S1) mentioned that elevator repairs are managed by a third-party vendor and not carried out by the maintenance crew in-house. Consequently, delays often occur while waiting for parts to be ordered. (S1 and S7) have a verified contract agreement with TKE Elevator Corporation, and the Maintenance Log and Repair Log tracks the maintenance performed. On July 10, 2025, between 11:18 AM and 03:59 PM, the Department interviewed the residents identified as Resident #1 through Resident #10 (R1-R10). Nine (9) out of the ten (10) residents were not able to support this claim. Four (4) out of ten (10) residents acknowledged that the facility had non-operational elevators. However, nine (9) out of ten (10) respondents stated that at least two functioning elevators were always available, ensuring that it has never been an inconvenience. They acknowledge that, like most equipment used daily, elevators require preventive maintenance to ensure safety. A review of the facility's Maintenance and Repair Logs, covering the period from (November 14, 2024, to July 20, 2025), revealed a comprehensive record of elevator incidents, including specific dates and times of each occurrence, alongside the actual commencement and completion dates of the corresponding repairs. (Evaluation Report continues LIC 9099-C) This review confirmed that at no point was more than one elevator undergoing maintenance simultaneously, ensuring minimal disruption to service. Moreover, it was noted that repairs are consistently carried out on the same day as each incident, underlining the facility's commitment to prompt response and effective management of elevator operations. Further examination of the contract with TK Elevator Corporation, (dated 12/18/24), confirmed the existence of a proactive service agreement for ongoing support and maintenance of the facility's elevators. The inspections conducted on (07/10/24, and 08/03/25), confirmed that all elevators were in working condition. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated . An exit interview was conducted with the Director of Enrichment, Sahar Masarati, and copies of the reports were provided.