Evergreen Court

Allegation investigated: Staff yells at a resident in care. Staff is denying food to a resident in care. Staff does not ensure that residents bedding is kept clean. Staff left a resident in soiled clothing for a long period of time. Staff are not meeting the hygiene needs of the residents in care. Staff are locking a resident in a room. Staff did not administer medication as prescribed. Staff did not seek medical attention for a resident in care in a timely manner.

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations listed above. LPA met with facility Administrator Zachary Costie, and explained the purpose of today's visit. Regarding the allegation Staff yells at a resident in care. During the investigation, LPA conducted interviews with residents and staff. Resident 2 stated staff speaks to them in a regular tone and stated staff were not mean to residents. Residents interviewed generally reported feeling safe at the facility.Based on conflicting information obtained during interviews and insufficient corroborating evidence, there is not a preponderance of evidence to prove that staff yelled at a resident in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Unsubstantiated Regarding the allegation Staff is denying food to a resident in care. During the investigation, LPA conducted resident and staff interviews regarding food provided to residents. Resident 1 reported that staff sometimes denied his request for an additional banana after he had already received multiple, and told him he would need to wait until the next meal. Resident 2 stated that they receives enough food, staff provide their meals, and staff have not denied them any food. The investigation did not establish that residents were deprived of meals or sufficient food. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation Staff does not ensure that residents bedding is kept clean. During the investigation, LPA conducted resident interviews and made observations regarding resident bedding. Resident 3 reported that staff change his sheets. Resident 2 reported that staff wash their bedding. During a facility visit, LPA observed staff placing clean sheets on a resident’s bed. Staff reported that bedding is changed following residents’ showers. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation Staff left a resident in soiled clothing for a long period of time. Staff 1 described an occasion when Resident 3 requested to be changed while she was administering medications. Staff 1 reported that she informed Resident 3 she would return after completing the task and subsequently returned and changed him. Although Resident 3 reported experiencing delays in being changed, the investigation did not establish the length of time he remained wet or soiled or establish that staff failed to provide necessary incontinence care for a prolonged period. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation Staff are not meeting the hygiene needs of the residents in care. During the investigation, LPA interviewed residents regarding assistance with bathing and personal hygiene. Resident 3 confirmed that staff assist him with showers. Resident 1 reported receiving assistance with showers approximately two to three times per week. Resident 2 reported that they are able to perform some bathing and dressing independently and receives assistance from staff as needed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation Staff are locking a resident in a room. During the investigation, LPA conducted interviews and observations regarding the allegation. The complaint did not identify specific dates, times, or circumstances regarding when the alleged incident occurred. LPA attempted to contact the reporting party to obtain additional information and clarification; however, the reporting party could not be reached. Resident 1 stated he feels safe at the facility and has an exit near his room. Resident 2 reported that her door is left open and she is able to enter and exit her room. LPA inspected resident rooms and did not observe an exterior locking mechanism that would allow staff to lock a resident inside a room. Resident 4 was unable to provide sufficient information regarding the allegation. Licensing records reflect that a previous complaint involving Resident 4 being locked in their room was previously investigated and addressed. Due to the lack of specific dates and details in the present complaint, the investigation could not establish that the current allegation involved a separate occurrence. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation Staff did not administer medication as prescribed. During the investigation, LPA conducted interviews and reviewed available medication related information. The investigation did not identify a specific prescribed medication that was missed or administered contrary to a physician’s order. Information obtained during the investigation did not establish that a resident failed to receive prescribed medication due to the actions of facility staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation Staff did not seek medical attention for a resident in care in a timely manner. The Department investigated the allegation that staff did not seek timely medical attention for Resident 3 (R3). It was alleged that Resident 3 fell to the ground and was left there for an extended period of time and that staff failed to call 911 or obtain medical treatment until the following morning. During the investigation, LPA interviewed R3 and facility staff and reviewed documentation related to the incident. R3 did not report being left on the ground for an extended period of time and did not provide information indicating that staff refused or significantly delayed medical assistance following the incident. Documentation reviewed did not establish the length of time R3 was on the ground or demonstrate that R3 exhibited symptoms requiring an immediate emergency medical response that staff failed to provide. Although R3 subsequently received medical evaluation/treatment, the evidence obtained during the investigation was insufficient to establish that facility staff failed to seek timely medical attention. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with facility, Administrator Zachary Costie, and copy of report providedthe state’s words, verbatim · CDSS document, Sep 10, 2026 · control 24-AS-20260121130218

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sarah Hurt conducted a Case Management visit at the facility. LPA met with Administrator Zachary Costie. During a visit to the facility on 02/10/2026, LPA observed a deodorizing/fabric spray, stored inside a resident’s bedroom and accessible to the resident. Additionally, LPA learned that the facility had been sold/transferred to a new licensee. The former licensee did not provide Licensing with the required written notice of the intent to sell the facility prior to the transfer/change of licensee. The licensee failed to comply with the notification requirements pertaining to the sale/transfer of a Residential Care Facility for the Elderly. The following deficiencies are being cited in accordance with California Code of Regulations, Title 22. Exit interview conducted with Administrator Zachary Costie, and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 10, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Sep 24, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. The following requirement has not been met as evidenced by: LPA observed a deodorizing spray accessible to facility residents during visit to them facility on 02/10/2026, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Licensee/Administrator will ensure all cleaning products, chemicals, and other potentially hazardous substances are stored inaccessible to residents as required. Licensee will conduct a walkthrough of all resident rooms and common areas to ensure such products are appropriately secured. Proof of correction, including a written statement confirming completion, will be submitted to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87109(b) · Plan of correction due date: Sep 24, 2026

87109 Transferability of License .(b) The licensee shall notify the licensing agency and all residents receiving services, or their representatives, in writing as soon as possible and in all cases at least thirty (30) days prior to the transfer of the property or business, or at the time that a bona fide offer is made, whichever period is longer, as specified in Health and Safety Code Section 1569.191. The following requirement has not been met as evidenced by: The Licensee did not inform State Licensing in writing upon sale of this facility, which poses a potential, health, safety, or personal rights to residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Licensee will review applicable Title 22 requirements regarding notification to Licensing of a proposed sale/change of ownership and will submit written documentation regarding the sale/change of ownership to CCL by POC due date.

Allegation investigated: Staff lock resident's door to prevent resident from leaving Staff do not ensure toxins are inaccessible to residents Staff yells at residents Staff handles residents in a rough manner Licensee does not ensure that staff have fingerprint clearance Staff are mismanaging residents' medication Staff do not ensure residents' bathing needs are met Staff do not ensure residents' have privacy in their bedroom(s)

On 10/28/25 Licensing Program Analysts (LPAs) M. Garza and M. Yang arrived at the facility to complete an unannounced complaint visit to deliver findings. LPAs met with Care Givers, Nendr Ghotre and Santosha "Nikki" Kumari, explained reason for visit and was permitted entry into the facility. Licensee/Administrator, Minakshi Roychoudhury was contacted and arrived some time later. Tour of the facilty was completed by LPAs inside and out. A health and safety check was completed on residents in care. Residents observed in common area watching television and in rooms. During investigation LPA completed visits, requested and reviewed documentation and completed interviews. During visit conducted on 5/31/25, LPA observed bedroom #1 with the door knob installed with the lock on the outside of the door. Door knob lock could only be unlock from the outside of the room in the hallway by staff. Bedroom is unable to unlock from the inside of the room. Locks were observed on the top of the exit sliding doors. Exit sliding doors were locked during visit on 05/31/25. Based on LPA observations, the allegation staff locked resident’s door to prevent resident from leaving is SUBSTANTIATED. Deficiency was cited and an immediate civil penalty was assessed during case management visit on 05/31/25. CONT... Substantiated CONT... During visits conducted on 5/31/25 and 10/28/25 LPA observed chemicals, sharps and medications unlocked and accessible to residents in care posing a danger. This allegation staff do not ensure toxins are inaccessible to residents is SUBSTANTIATED. Deficiency cited on attached 9099D. Interviews were conducted with staffs and residents. LPA was informed staff argues with their significant other and afterward would get upset with residents and yell at them. Residents are handled in a rough manner by staff after staff’s arguments with their significant other. During complaint visit on 05/13/25, LPA observed staff attempting to lift a resident in living room from the resident’s chair. LPA observed the staff having difficulty lifting the resident. The allegations staff yells at residents and staff handles residents in a rough manner are SUBSTANTIATED. Deficiency cited on attached 9099D. During complaint visit on 5/31/25, LPA observed S1 providing care to the residents. Records were reviewed, facility staff roster showed S1 was fingerprint cleared but not associated to the facility. This allegation Licensee does not ensure that staff have fingerprint clearance is SUBSTANTIATED. Deficiency was cited on a case management visit conducted on 5/31/25. During complaint visit conducted on 5/31/25, LPA completed a tour of the facility. LPA observed Lantus Solostar 100unit.ml medications for R4 unlocked in a medication lock box inside the bottom shelf of the refrigerator. During an interview conducted with Administrator, Administrator informed LPA, R4 was no longer taking the medication per physicians’ orders. R4’s file was reviewed, no order for Lantus medication was discontinued. During medication audit, discontinued medications for 2 of the 6 residents were not properly destroyed and recorded. This allegation staff are mismanaging residents medications is SUBSTATIATED. Deficiency issued on attached 9099D. During complaint investigation, interviews were conducted, and records were reviewed. Interviews conducted with staff and residents confirmed residents were being showered two times a week. Licensee and Administrator confirm 2 out of 6 residents requesting or needing to be showered more than 2 times a week and are not being showered as request/needed due to "limited staffing to accommodate the residents’ request". Residents receiving hospice care are being showered by their hospice care agency weekly. Facility shower log records show all residents are showered two times weekly. Staff records in the facility computer system show when staff are giving showers. Based on interviews conducted and records reviewed, the allegation staff do not ensure residents’ bathing needs are met is SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. During visit conducted on 5/31/25, LPA observed surveillance cameras in the hallway facing directly into bedroom #1 and bedroom #4. The allegation staff do not ensure residents have privacy in their bedroom(s) is SUBSTANTIATED. Deficiency cited on attached 9099D. The preponderance of evidence standard has been met per Title 22. Deficiencies cited per California Code of Regulations, Title 22. If not corrected, deficiencies will have a direct impact to residents in care.Exit interview completed with Licensee/Administrator, Minakshi. Plans of correction was developed by Licensee and reviewed by LPA. A copy of this report, deficiencies and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 24-AS-20250530080715

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Nov 7, 2025

87309 Storage Space and Access (a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidence by: LPA observations. The licensee did not comply with the section cited above in that LPA observed chemicals, sharps and medications throughout the facility during complaint visit on 5/31/25, unlocked and accessible to residents in care. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee immediately removed and locked up items during visit conducted on 05/31/2025. This POC has been cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Nov 7, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In 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: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidence by: interviews conducted and LPA observations. The licensee did not comply with the section cited above in that interviews confirmed staff would be upset and yell at the residents. LPA observation of resident being transferred by staff with difficulty and a rough manner. The poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee stated they will provide a plan of correction in writting to include the type of training that will be provided to staff by 11/03/2025. An in-service sign in sheet and training material will be provided to CCL by POC date of 11/07/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 7, 2025

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidence by: review of records and LPA observations. The licensee did not comply with the section cited above in that LPA observed 2 unused Lantus Solostar 100unit.ml insulin pens for R4 in refrigerator filled on 3/11/5. Interviews with Licensee, Administrator, staff and R4 disclosed R4 does not get injections as prescribed. No discharge of medication was observed in R4’s file. Interviews with Licensee, Administrator, staff and residents disclosed residents are only being showered 2x weekly and not as needed or requested. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee stated they will provide a plan of correction in writting to include the type of training that will be provided to staff by 11/03/25. An in-service sign in sheet and training material will be provided to CCL by POC date of 11/07/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 7, 2025

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: LPA observation. The licensee did not comply with the section cited above in that surveillance cameras in the hallway facing directly into bedroom #1 and bedroom #4. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee stated they will provide a plan of correction in writting to include the type of training that will be provided to staff by 11/03/25. An in-service sign in sheet and training material will be provided to CCL by POC date of 11/07/25.

Allegation investigated: Licensee is operating beyond the conditions and limitations specified on the license Staff are unable to communicate with residents due to a language barrier Staff do not provide adequate food service Staff do not ensure residents' bedding is clean

On 10/28/25 Licensing Program Analysts (LPAs) M. Garza and M. Yang arrived at the facility to complete an unannounced complaint visit to deliver findings. LPAs met with Care Givers, Nendr Ghotre and Santosha "Nikki" Kumari, explained reason for visit and was permitted entry into the facility. Licensee/Administrator, Minakshi Roychoudhury was contacted and arrived some time later. Tour of the facilty was completed by LPAs inside and out. A health and safety check was completed on residents in care. Residents observed in common area watching television and in rooms. During investigation LPA completed visits, requested and reviewed documentation and completed interviews.Althought the allegations may or may not have occured the preponderance of evidence standard has not been met per California Code of Regulations, Title 22. The allegations listed above were UNSUBSTANTIATED. Exit interview completed with Licensee/Administrator, Min Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 28, 2025 · control 24-AS-20250530080715

Type of visit: Required - 1 Year

On 10/28/25 Licensing Program Analysts (LPAs) M. Garza and M. Yang arrived at the facility to complete an unannounced annual visit. LPAs met with Care Giver, Santonsh Kumari, explained reason for visit and were permitted entry into the facility. Licensee/Administrator, Minakshi Roychoudhury was contacted and arrived some time later. LPAs completed a tour of the facility inside and out. A health and safety check was completed on residents in care. 6 resident was present during visit observed in family room. 2 of 6 residents receiving hospice services and 1 of 6 receiving home health services. Pathways and doors were clear and free from obstruction. Common areas were adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 09/11/25. Resident rooms observed to have the required furnishings and with adequate lighting. LPA observed sufficient seating under covered patio areas. The following issues were observed during today’s visit: Chemicals observed under hallway sink unlocked and accessible. Peri care bottles observed in bedroom #3 unlocked and accessible. Chemicals unlocked and accessible under kitchen sink. Sharps accessible and not properly closed near stove. Chemical in first aid kit accessible. Nutritional supplements in pantry unlocked and accessible. Paint in bedroom #1, in living room unlocked and accessible. Medications unlocked and accessible. No orders for crushed medications for R2. Medications short for R1 (medication error). No appraisals for 1 of 6 residents. No needs and services plans for 2 of 6 residents. No medical consent forms for 2 of 6 residents. Records reviewed shows 2 of 6 resident went to hospital, facility did not report to CCL. CONT... CONT... No home health care plan for 1 of 6 residents. Records review, shows R6 has a stage 3 pressure injury. Walk in closet is locked and inaccessible to R6. Deficiencies cited per California Code of Regulations, Title 22. Deficiencies are being cited on the attached 809D. If not corrected, the violation with have a direct impact to the health, safety and/or personal rights of residents in care. LPAs requested the following documents to be submitted to CCL by 10/31/2025: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file. Exit interview was conducted with Licensee/Administrator, Minakshi. A plan of correction was developed by Licensee/Administrator and reviewed by LPAs. A copy of this report, deficiencies, and appeal rights were discussed and provided to Licensee/Administrator.the state’s words, verbatim · CDSS document, Oct 28, 2025

Type of visit: Case Management - Deficiencies

On 5/31/2025 Licensing Program Analyst (LPA), M. Garza completed an unannounced case management visit. LPA met with Care Giver, Noelia Luna, explained reason for visit and was permitted entry into the facility. Administrator, Steve Patel was contacted and arrived some time later. LPA completed a health and safety check on residents in care. 6 residents observed in dining room having breakfast. A tour of the facility was completed inside and out. This case management visit is being conducted due to LPA's observation of: R1's records. LPA reviewed facility unusual incident reports provided by the facility. No reporting has been submitted from 2/14/24 through 5/15/25, with the exception of R3's death on 9/25/24. LPA observed a hospice care plan provided by Administrator, Steve dated 09/05/2024-12/03/2024. The plan provided was observed to be outdated and reveals a head wound treatment. LPA has requested a copy of R1's current hospice care plan and incident report for the injury that hospice was treating. LPA observation of the Guardian Roster at 9:15 am on 5/31/25. Staff 1 was not associated to the facility. If not corrected this poses an immediate risk to the health safety and or personal rights of residents in care. ***An immediate civil penalty in the amount of $500 is hereby assessed.*** LPA observed R2's physicians report dated 2/24/25 stating Insulin Lispro 7 units TID with meals. LPA observed medication in a lock box located in the refrigerator. Interview with R1 disclosed R1 is not being provided medication because "their hand is too unsteady and are unable to administer themselves". Interview with Administrator disclosed home health is coming in 1x weekly and providing R1 the injections. LPA requested Centrally Stored Medication Destruction Records (LIC 622) and Home Health Care Plan. Administrator stated Home Health Care Plan is not at the facility. CONT... CONT... During tour of facility LPA observed large white locks secured to the door blocking fire exit door from being opened. Locks were located at the top of 3 sliding doors to outside, inaccessible to residents reach and preventing exit (photos taken). 1 located in hallway near R1's bedroom, 1 located in the family room and 1 located in living room. LPA observed facility sketch and fire clearance to read exit #1, exit #8 and exit #7. All hidden by the curtains. ***An immediate civil penalty of $500 is hereby assessed*** LPA has requested a copy of R1 and R2's Admission Agreements and R3's death report dated 9/26/24, admission agreement and hospice care plan to be provided to CCL no later than 6/2/2025. Deficiencies cited per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809D. If not corrected, the violation with have a direct and immediate risk to the health safety and or personal rights of persons in care. ***Civil penalties are being assessed in the amount of $500 for criminal record transfer and fire clearance.*** Exit interview was conducted with Administrator, Steve Patel. A copy of this report, deficiencies, civil penalties and appeal rights were discussed and provided to Administrator. A plan of correction was developed by Administrator and reviewed by LPA.the state’s words, verbatim · CDSS document, May 31, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(b) · Plan of correction due date: Jun 2, 2025

87633 Hospice Care of Terminally Ill Residents (b) A current and complete hospice care plan shall ...(4) A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility. This requirement was not met as evidence by: LPA observation of R1's hospice care plan provided by Administator, Steve dated 09/05/2024-12/03/2024. This poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 31, 2025

Plan of correction: Administrator stated they will contact hospice agency to update hospice to get a current care plan. Administrator stated they will provide a copy to CCL by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(g)(2) · Plan of correction due date: Jun 2, 2025

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement was not met as eivdence by: LPA observation of the Guardian Roster at 9:15 am on 5/31/25. Staff 1 was not associated to the facility. If not corrected this poses an immediate risk to the health safety and or personal rights of residents in care. ***An immediate civil penalty in the amount of $500 was assessed.***the state’s words, verbatim · CDSS document, May 31, 2025

Plan of correction: A review of Guardian Roster at 12:16 pm on 5/31/25, verifies Licensee has added S1 to their roster. POC cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: May 31, 2025

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidence by: LPA observation of 3 exit doors (exit #1, exit #8 and #7) to have a door lock at the top preventing residents from exiting. If not corrected this poses an immediate health safety and or personal rights risk to residents in care. ***An immediate civil penalty in the amount of $500 is hereby assessed for fire clearance***the state’s words, verbatim · CDSS document, May 31, 2025

Plan of correction: Administrator immediately removed locks during LPAs visit. POC cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Jun 2, 2025

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 in (A) through (D) below. 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.(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 was not met as evidence by: LPA observation of R1s hospice plan indicating R1 was being treated for a head wound. Review of facility incident reportings does not show facility reported to CCL. If not corrected this poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 31, 2025

Plan of correction: Administrator will provide a POC in writting. Administrator stated all incidences will be reported to all required parties. In-service training will be completed on reporting requirements. In service sign in sheet and training material will be provided to CCL by POC date.

Type of visit: Office

On 1/27/25 an Informal Meeting was conducted at the Regional Office. Present were: CCL Staff: Licensing Program Manager (LPM), See Moua, LPM, Alexandria Walton, Licensing Program Analyst (LPA), Mary Garza, Licensee, Rajat Roychoudhury, Administrator, Minakshi Roychoudhury and Designee, Shailesh "Steve" Patel. The purpose of the office meeting is to discuss concerns regarding the Facilities. Facility was licensed 10/18/23. The Department has completed the annual inspection on 10/22/24. Facility was offered and declined Technical Support (TSP) on 10/30/24. A case management visit was completed on 01/08/25. Deficiencies were issued during both of visits. During the meeting discussions of concerns and operations of the facility. Meeting covered the deficiencies cited. 1) Personal Accommodations and Services: storage area accessible through bedroom 2) Oxygen Administration -Gas and Liquid: signs posting and reporting to Fire Department 3) Resident Records: pre-admission, reappraisals, medical assessments, TB, etc. 4) Personal Accommodations and Services: Open patio area without railing/lighting The following were also discussed and explained: - Compliance does not mean just completing POCs after the Department issue citations. The facility should aim and be proactive in making sure its operation meets Title 22 regulations. The Department is transparent that the regulations and CARE Tools are available. CONT... - The Licensee has declined TSP services. TSP is not mandatory. By declining, the licensee communicates that it can be compliant. Although the LPA has a consultative role, the Administrator by maintaining an active certificate, understands all the laws, regulations, and Title 22 to operate. - Clearing Proof of Corrections – Clearing the POC is the responsibility of the LPA. The LPA was there during the inspection. The facility should communicate with the LPA when there are questions regarding the POC. - Administrative Actions - Continued non-compliance means the Department may take Administrative Action. This includes any of the following: revocation of the licensee, exclusion of staff, Administrator certificate de-cert, etc. The inimical conduct of any staff, administrator and licensee, including false statements to the LPA or Department, falsifying records and jeopardizing the health and safety of the residents, may result in Administrative Actions. - ALW Program and Hospice – residents being in the ALW Program, on Hospice, or Home Health does not negate the facility and its staff of the responsibility for providing care and supervision. Licensee was informed that deficiencies can affect the facility/residents and their license. Enforcement laws and regulation for licensed facilities were covered. The following POCs were not cleared and a new date of 2/7/25 was provided to submit the POC: 1) Open patio is without hand railing/lighting. The following deficiency was cited during today’s office meeting: Resident Records Exit interview completed with Licensee, Rajat and Administrator, Minakshi. A copy of this report, deficiency and appeal rights given.the state’s words, verbatim · CDSS document, Jan 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Feb 7, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement was not met as evidence by: LPA observation of resident files. During the annual records were observed incomplete. Physicians report was incomplete/inaccurate. Pre-admission/reappraisals missing. Physicians’ orders missing for hospital beds/bed railing.the state’s words, verbatim · CDSS document, Jan 27, 2025

Plan of correction: Administrator stated they will provide a plan of correction in writting. Records will be reviewed for completetion and accuracy. Written plan will be sent to CCL by POC date.

Type of visit: Case Management - Deficiencies

On 1/8/2025 Licensing Program Analyst (LPA) M. Garza completed an unannounced case management visit. LPA met with Designee, Shailesh "Steve" Patel, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. 3 of 5 residents observed in living room area watching television. Administrator, Minakshi Roychoudhury arrived some time later. This case management visit is being completed to review and clear POC's from visit previously conducted. LPA completed a tour of the facility inside and out. The following deficiencies have been cleared: Hallway filter observed changed. Bathroom #2 bathtub observed cleaned. The following issues were observed during todays visit: Attic space door observed dirty and in need of painting. Vent in hallway near office observed hanging and in need of cleaning. Vent in living room near television observed dirty and in need of cleaning. Doorway from living room to sitting area observed in need of touch up paint. Food in staff refrigerator observed improperly covered/without dates. Food in freezer observed packed and not allowing for proper ventilation. Bedroom #6 observed with storage area only accessible through resident bedroom. Gates on right and left side of facility not self latching. Storage area near shed observed with chemicals/items posing a danger, unlocked and accessible. Shed observed with chemicals unlocked and accessible. open patio on back of facility observed without hand railing and lighting posing a hazard. Trash can observed near bedroom #6 without tight fitting lid. Chemicals/medications observed in restroom #3. Facility observed to be in need of towels, wash cloths and hand towels adequate for residents in care. Deficiencies cited per Title 22. Exit interview completed with Administator, Minakshi and Designee, Steve. Due to IT issues a copy of this report, deficiencies and appeal rights provided via email. A delivered and read receipt serves as confirmation.the state’s words, verbatim · CDSS document, Jan 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Jan 20, 2025

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidence by: LPA observation of chemicals/items posing a danger on bathroom #3 countertop, in storage area in back yard and in storage shed all unlocked and accessible to residents in care. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2025

Plan of correction: Administrator stated items were removed from the bathroom and placed in locked cabinets. Storage area will a locking device added. The storage shed will have a pad lock added. Administrator stated they will provide CCL with pictures for proof of correction by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(9) · Plan of correction due date: Jan 20, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidence by: LPA observation of food in refrigerator was not properly stored/dated. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2025

Plan of correction: Adminstrator provided training to staff. Items that have been open will be dated. Pictures will be sent to CCL for verification. In-service sign in sheet will be provided to CCL by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(21) · Plan of correction due date: Jan 20, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement was not met as evidence by: LPA observation of freezer being packed and not having adequate air circulation to maintain temperature. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2025

Plan of correction: Administrator will rearrange freezer to allow proper air circulation. In-service training sheet with training material will be provided to CCL by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(2)(C) · Plan of correction due date: Jan 20, 2025

87307 Personal Accommodations and Services (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement was not met as evidence by: LPA observation of storage area accessible through R6’s bedroom. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2025

Plan of correction: Administrator stated they will remove all of the facility items out of the storage area in R6's bedroom. Administrator stated they will provide a picture that items have been removed as proof of correction by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(4) · Plan of correction due date: Jan 20, 2025

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement was not met as evidence by: LPA observation of open patio on back of facility without hand railings or lighting. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2025

Plan of correction: Administrator will get a bid for railing and ramp on the open porch area. Administrator will submit the quote and completion date by POC date in writting.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a)(3)(C) · Plan of correction due date: Jan 20, 2025

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement was not met as evidence by: LPA observation of linen. The facility has 7 towels for 5 residents in care. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2025

Plan of correction: Adminitrator stated they have purchased 10 new towels. WIll put inside of cupboard. Administrator will provide a picture of additional items for resident nand submit to CCL by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Jan 20, 2025

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement was not met as evidence by: LPA observation of residents beds with hand railing. A written order for this postural support was not observed in resident files reviewed. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2025

Plan of correction: Administrator stated they will be seeking prescriptions for bed railing from the residents physicians. Order will be provided to CCL as proof of verification.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jan 20, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: LPA observation of: attic space door observed dirty and in need of painting. Vent in hallway near office observed hanging and in need of cleaning. AC/heating vents in facility observed dirty and in need of cleaning. Doorway from living room to sitting area observed in need of touch up paint. Gates on right and left side of facility not self-latching. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2025

Plan of correction: Administrator stated items will be corrected. Pictures/video will be provided as proof of correction by POC date.

Type of visit: Required - 1 Year

On 10/22/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Direct Care Staff, Noelia Luna, introduced self, explained reason for visit and was permitted entry into the facility. Administrator, Minakshi Roychoudhury was contacted and arrived a short time later. LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. Residents observed in common areas and in rooms. There is currently 2 residents on hospice at the time of the inspection. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 09/18/2024. Last fire drill on 07/17/2024. Water temperature measured 116.4 degrees F in restroom #2. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets in hallway. Sharps and medications were located in locked cabinets. LPA observed sufficient seating under covered patio areas. The following issues were observed during todays visit: Chemicals observed in 3 of 3 restrooms unlocked and accessible, vents in hallways in need of dusting/air filters, restroom #2 tub in need of cleaning, food in freezer not dated/stored properly, chemicals/items posing a harm in office unlocked and accessible, walls and doors in need of wiping down, chemical observed in resident #6 bedroom, storage area accessible through resident #6 bedroom, chemicals/items posing a harm next to storage shed and outside back door accessible and unlocked, open patio on back of facility observed without railing and lighting posing a hazard, left side gate not self-latching. CONT... CONT... LPA requested the following documents to be submitted to CCL by 10/29/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file. Deficiencies cited per Title 22 on attached 809D. TV's and TA's provided. Exit interview completed with Administrator, Minakshi. A copy of this report, deficiencies, TV's, TA's and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 22, 2024