Other·March 6, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint and an entity reported incident (ERI). Complaint Number: CA00666844 ERI Number: CA00666456 Representing the Department of Public Health: Health Facilities Evaluator Nurse: 30258 The inspection was limited to the specific complaint and ERI investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for Complaint Number CA00666844 and ERI Number CA00666456.

F602 SS=E Free from Misappropriation/Exploitation CFR(s): 483.12

F602 02/17/2020 §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from financial abuse, misappropriation of property and exploitation of property by failing to properly LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LLQ511 Facility ID: CA970000109 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055163 (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTECITO HEIGHTS HEALTHCARE & WELLNESS CENTRE, LP 4585 N Figueroa St Los Angeles, CA 90065 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE handle Resident 1's monies, funds and/or credit cards. The facility staff received money from Resident 1. This deficient practice resulted in facility staff taking advantage of Resident 1 for personal gain. Findings: A review of the Facesheet (Admission Record) indicated Resident 1 was admitted to the facility on 3/7/19 with diagnoses including respiratory failure (a condition in which not enough oxygen passes from your lungs into your blood). A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 9/13/19, indicated Resident 1 was able to make himself understood and able to understand others. Resident 1 was cognitively intact. During an interview on 12/19/19, at 1:01 p.m., Administrator 1 (Admin 1) stated three facility employees were involved in financial abuse involving Resident 1. The employees were suspended pending results of the investigation. Admin 1 stated Resident 1 was discharged to a lower level of care (independent living) on 12/3/19. Admin 1 stated on 12/4/19, Admin 2 from the independent living called the facility's case manager stating Resident 1 did not have his debit card and that he was claiming the business office assistant (BOA) had his card. Admin 1 stated according to Admin 2, Admin 2 had driven Resident 1 to the bank and Resident 1 was told he only had $5.00 in his account. Admin 1 stated Resident 1 had approximately $3700.00 in his account in July 2019. Admin 1 stated the facility's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LLQ511 Facility ID: CA970000109 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055163 (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTECITO HEIGHTS HEALTHCARE & WELLNESS CENTRE, LP 4585 N Figueroa St Los Angeles, CA 90065 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE investigation indicated Resident 1 said the BOA was telling Resident 1 about money issues so he offered money to BOA and gave her his debit card and pin number, allowing the facility BOA to withdraw money from his bank account. Admin 1 stated Resident 1 stated he also gave money to the housekeeping supervisor in the amounts of $800 and $200. Admin 1 stated Resident 1 stated the facility staff promised to pay him back. During an interview on 2/5/20, at 3:26 p.m., the business office manager (BOM) stated Admin 1 and human resources personnel interviewed the BOA, who stated she had assisted with spending Resident 1's money. The BOM stated BOA stated in the same interview, that BOA had sent Lyft (ridesharing app which connects passengers looking for ride with drivers who have a car) to transport Resident 1 from the facility to the BOA's house, then the BOA and Resident 1 went shopping and had dinner. After dinner, the BOA sent Resident 1 back to the facility through Lyft. The BOM stated the BOA produced a folder with receipts indicating the BOA's cable/Internet bills, cell phone bills, and fast food were paid for by Resident 1. There were also receipts of various ATM withdrawals using Resident 1's credit card. The BOA stated and admitted to having made the payments, purchases, and withdrawals. The BOM stated the BOA stated she was going to pay Resident 1 back. In addition, the BOM stated Resident 1 said he gave money, $800 then $200, to the Housekeeping Supervisor through multiple ATM withdrawals. During an interview on 2/6/20, at 10:08 a.m., Admin 1 stated the facility terminated the BOA, the Housekeeping Supervisor, and the housekeeping employee once the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LLQ511 Facility ID: CA970000109 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055163 (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTECITO HEIGHTS HEALTHCARE & WELLNESS CENTRE, LP 4585 N Figueroa St Los Angeles, CA 90065 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE investigation of financial abuse involving Resident 1 was completed. Admin 1 stated the facility terminated also the housekeeping employee, who was the wife of Housekeeping Supervisor (HS) because she was aware of the money given to her husband, but did not report it. Admin 1 stated it was against the facility's policy to accept any money or gifts from any residents in the facility. A review of an undated facility investigation Summary indicated the facility's investigation as follows: 1. After questioning, the HS admitted to accepting $800 from Resident 1 in July 2019. The HS stated he knew he was not allowed to do that. 2. Housekeeping personnel, wife of HS, stated she knew about Resident 1 giving money to HS but did not say anything to anyone. 3. BOA admitted that Resident 1 paid her cable bill. Per facility's verification with the cable company, Resident 1's card was used in paying BOA's other cable bills. 4. Multiple staff members reported seeing BOA accompany Resident 1 to the automated teller machine (ATM - machine that allows people to take out money from their bank account by using a special card) for cash withdrawals. A review of the facility's policy and procedure titled, "Abuse - Prevention, Screening, and Training Program," revised July 2018, indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The policy indicated facility policies, procedures, training programs, and screening and prevention systems were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LLQ511 Facility ID: CA970000109 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055163 (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTECITO HEIGHTS HEALTHCARE & WELLNESS CENTRE, LP 4585 N Figueroa St Los Angeles, CA 90065 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE developed to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The administrator as abuse prevention coordinator was responsible for the coordination and implementation of the facility's abuse prevention, screening and training program policies." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LLQ511 Facility ID: CA970000109 If continuation sheet 5 of 5