Savant of Santa Monica

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature..... This requirement was not met as evidenced by:Based on interviews and records reviewed it was determined that S1 was suspended on 9/1/2025 and separated from employment on 9/19/2025 for inappropriate workplace conduct and unprofessional interactions involving resident(s) R1.

Incidental Medical and Dental CareA plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).This requirement is not met as evidenced by: Based on interviews and records review, R1 experienced an unwitnessed fall on 10/31/2024, and despite telling staff their leg was injured, R1 was not seen by a physician until they were admitted to Ronald Reagan UCLA Medical Center on 11/04/2024 and diagnosed with a distal tibial and fibular diaphysis fracture. This violation posed an immediate health, and safety risk to residents in care.

Additional Personal Rights of Residents in Privately Operated FacilitiesIn addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure adequate supervision for Resident 1. Staff failed to provide the level of care and supervision necessary to meet the residents’ needs, which resulted in R1 experiencing a fall that caused a fracture. This lack of supervision posed an immediate health and safety risk to the residents in care.

Reporting Requirements. Requires the licensee to report specified incidents and to notify the resident’s authorized representative of events affecting the resident. Based on interviews and record review, the licensee did not notify Resident 1’s authorized representative after R1 was found on the floor, as required by 87211.On 11/05/2024 LPA Watson obtained and reviewed facility records and found no documentation that indicated that R1’s responsible party was contacted and made aware of R1’s fall on 10/24/2024.This violation posed an immediate health, and safety risk to residents in care.

87211(a)(1)(D)Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...of the occurrence of any of the events... (D) Any incident which threatens the welfare, safety or health of any...This requirement is not met as evidenced by: Based on record reviews, the Licensee failed to submit incident reports for every call that was made to 911 from facility. From May 2025 to October 2025, the facility made 185 calls to 911, but only submitted 80 incident reports regarding 911 calls. This violation poses a potential health and safety risk to all residents in care.

Additional Personal Rights of Residents in Privately Operated FacilitiesIn addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure adequate supervision for Resident 1. Staff failed to provide the level of care and supervision necessary to meet the residents’ needs, which resulted in R1 experiencing a fall that caused a fracture. This lack of supervision posed an immediate health and safety risk to the residents in care.

Incidental Medical and Dental CareA plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).This requirement is not met as evidenced by: Based on interviews and records review, R1 experienced an unwitnessed fall on 10/31/2024, and despite telling staff their leg was injured, R1 was not seen by a physician until they were admitted to Ronald Reagan UCLA Medical Center on 11/04/2024 and diagnosed with a distal tibial and fibular diaphysis fracture. This violation posed an immediate health, and safety risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions..... This requirement was not met as evidenced by: which poses a potential health, safety or personal rights risk to persons in care. The interviews conducted and the review of S1 file reviewed revealed that they were terminated because of admitting to speaking inappropriatley to R1 which resulted in s1 failing to completed introductory periodand violation of company policy.

87303(a) – Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times... Based on observation the licensee did not comply with the section cited above. Licensee failed to maintain an emergency exit door in good repair., which poses/posed a potential health, safety or personal rights risk to persons in care.

Managed Incontinence. In addition to …, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidence by: Based on observations and interviews conducted, the licensee did not ensure that R1 was clean and dry, which caused R1 to be taken to the hospital with a UTI. This poses an immediate health and safety and personal rights risk for residents in care.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the licensee did not comply with the section cited above by not providing reports to CCLD regarding resident falls within seven days of the occurrence of any events listed above which poses a potential health and safety risk to persons in care.

87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and... as specified in Section 87608, Postural Supports.This was not met based on interviews and record review Administrator did not ensure resident R1 received assistance with a shower as indicated on Admission Agreement and Service Plan which could be a health and safety risk to the resident.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1,....shall have all of the following personal rights:(24) To organize and participate in a resident council...HSC1569.157. (c)If a resident council submits written concerns..respond in writing..within 14 calendar days. This has not been met as evidenced by: LPA observed email written to Administrator(S1) on 10/31/23. S1 forwarded email to fellow staff, not respond to resident(s) in writing