Bethesda Home

Type of visit: Required - 1 Year

On this date, April 15, 2026, at 10:40 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA was granted entry by Board Director/Vice President Mike Clark and informed the reason for visit. LPA also met with Board Director/President Robyn Harvey. LPA toured the facility inside out with Mike Clark. LPA inspected the main building (West Wing), Azalea, Garden and Peralta Cottages. There's no sign of residents living in the Assisted Living (AL) part of the property and the AL is currently not in operation. The following were discussed with Mike Clark and over the phone with Licensing Program Manager Jeremy Fong: 1. Board Directors' intent to keep the license and have management company be part of the license. Submission of abbreviated application to Central Application Bureau. Keeping LPA informed when abbreviated application is submitted. The annual fee which was due on April 4, 2026 is not paid as of this date. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency and plan and proof of correction were discussed with Mike Clark. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87156(a) · Plan of correction due date: Apr 29, 2026

87156 Licensing Fees: (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. provides ....after initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license. -This requirement is not met as evidenced by: -Based on review, the licensee did not comply with the section above in not paying the annual fee which was due on 4/04/26.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Board Director to pay the annual fee and submit proof by 4/29/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87156(b)(1)(F) · Plan of correction due date: Apr 29, 2026

87156 Licensing Fees: (b) (1) In addition to fees set forth in subdivision (a), the department shall charge the following fees: (F) A late fee that represents an additional 50 percent of the established annual fee when any licensee fails to pay the annual licensing fee on or before the due date as... ....indicated by postmark on the payment. -This requirement is not met as evidenced by: -Based on review, the licensee did not pay the annual fee on or before the anniversary date which result to late fee charge.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Board Director to pay the late fee charge. Proof to be submitted by 4/29/26.

Allegation investigated: Staff yelled at resident. Staff forced residents to sign unknown documents. Staff did not provide residents dignity in their personal relationship. Staff did not follow resident's doctor recommended dietary needs. Staff did not safeguard resident's personal belongings.

On this day, 1/06/26, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Roselyn Chand, administrator (ADM), and informed the reason for visit. During the course of investigation, LPA reviewed and obtained copies of resident (R1) documents including but not limited to LIC602A Physician's Report, LIC625 Appraisal/Needs and Services Plan, R1's glucose readings. LPA also obtained copies of menu and kitchen's list for R1 showing R1 is diabetic. LPA interviewed the reporting party (RP), R1 and staff (S1, S2 and ADM). ....continued on 9099C Unsubstantiated Allegation: Staff yelled at resident (R1). The reporting party (RP) reported that ADM yelled at R1; however, during interview by LPA, RP stated not observing ADM yelled at R1. R1 stated ADM yelled at him but ADM denied the allegation. S1 and S2 stated not observing ADM yelled at R1 and other residents. Therefore, the allegation is unsubstantiated. Allegation: Staff forced residents to sign unknown documents. RP stated that ADM forced the residents to sign documents and that it happened when RP was not at the facility. R1 stated he was forced to sign document without allowing to read first and was not given a copy. ADM denied the allegation. ADM stated that residents were given the LIC625 Appraisal/Needs and Services Plan to sign and residents were given copies. There was only one resident who refused to sign and documents which were required to be provided to the Department. Both S1 and S2 stated not observing ADM forced any resident sign document. S1 stated whenever residents asked for copies of documents, they are provided. Therefore, the allegation is unsubstantiated. Allegation: Staff did not provide residents dignity in their personal relationship. RP stated that ADM told her and R1 they can not have relationship and that the relationship is toxic. R1 stated that ADM told them they cannot have relationship, however, ADM denied the allegation. S1 and S2 stated not hearing ADM tell RP and R1 such and that residents have rights to have personal relationship. Therefore, the allegation in unsubstantiated. Allegation: Staff did not follow resident's doctor recommended dietary needs. RP stated the facility did not follow R1's diabetic diet and observed the staff gave R1 sugar cookies, pudding and cinnamon bread. R1 stated the staff made sure he was getting the right food but a lot of times was given the wrong food. ADM confirmed R1 is on diabetic diet and the kitchen staff were aware and that R1 is very particular with his diet. Copy of kitchen list showed R1 is diabetic and listed food that R1 dislikes. S1 stated the kitchen staff knew residents who were on diabetic diet. S1 also stated that residents shared food with each other, but when S1 sees resident is given the food that the resident should not have, she takes it away. Therefore, the allegation is unsubstantiated. .......continued on 9099C Allegation: Staff did not safeguard resident's personal belongings. RP reported that R1's son purchased glucose sensors and that R1 thinks the staff were using them on other residents because they would say the sensors ran out. R1 stated he was told the sensors ran out and the staff has to do manual pricking to test his glucose level. S1 and ADM stated it's only R1 who uses glucose sensor. S1 and ADM also stated there were times when sensors were faulty and they have to do manual testing. ADM stated that on the last shipment of the sensors to the facility on December 2025, the delivery was late. ADM added that the sensor can not be use by others because the code has to be entered on sensor and the sensor sends the readings to R1's doctor so if there's multiple people using R1's sensor, the doctor will receive multiple readings of which the doctor will be alerted why he's receiving multiple readings. Therefore, the allegation is unsubstantiated. Based on information gathered, all 5 allegations were unsubstantiated. A finding that a complaint is unsubstantiated means that means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 6, 2026 · control 15-AS-20260105105331

Type of visit: Case Management - Other

On this day, 1/06/26, at 4:10 pm Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit. LPA met with Administrator (ADM) Roselyn Chand and informed the reason for visit. LPA toured facility with ADM. LPA inspected all the bedrooms in the west wing unit and assisted living cottages, bathrooms, common areas, dining room. All residents have moved out and no signs of residents in any of the assisted living bedrooms and cottages. Exit interview conducted with ADM and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 6, 2026

Type of visit: Case Management - Health Checks

On 1/2/2026 at 3:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a health and safety check of residents. LPA met with Administrator, Roselyn Chand and informed her the reason for visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, outdoor area, and separate buildings. LPA observed facility has 7-day of non-perishable and 2-day of perishable food supplies. Facility has 4 staff working during LPA's visit. LPA observed most residents have moved out. However, there's one resident still in the assisted living side of the facility. No deficiencies are being cited on this date. Exit interview conducted with Roselyn Chand. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 2, 2026

Type of visit: Case Management - Health Checks

On 12/30/2025 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a health and safety check of residents. LPA met with Administrator, Roselyn Chand and informed her the reason for visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, outdoor area, and separate buildings. Hot water temperature was measured at 114.3 degrees F in a hallway bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Administrator will be putting another order for food supplies this week. Facility has 7 staff currently for AM shift including: Administrator, 2 caregivers, 1 maintenance staff, 1 house keeper, and 2 kitchen staff. LPA requested a copy of the staff schedule (12/30/2025 to 1/5/2026) to be sent to CCLD by 12/31/2025. No deficiencies are being cited on this date. Exit interview conducted with Roselyn Chand. A copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 30, 2025

Type of visit: Case Management - Health Checks

On this day, December 23, 2025, at 10:15 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct inspection to ensure the health and safety of residents. LPA met with Roselyn Chand, administrator (ADM) and informed the reason for visit. LPA also met with Vice President Mike Clark . As of this day, facility has 10 residents. Facility has running water and electricity. Food supplies adequate. There are 7 staff present and on-duty - 3 caregivers, 2 kitchen staff, 1 maintenance staff and administrator No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 23, 2025

Type of visit: Case Management - Health Checks

On this day, December 19, 2025, at 3:15 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct inspection to ensure the health and safety of residents. LPA met with staff, Joan Acob, and informed the reason for visit. Roselyn Chand, administrator (ADM). arrived at arounf 4:00 pm. LPA conducted inspection and observed adequate supplies of perishables and non-perishable food. Facility has running water and electricity. There are 4 staff (2 caregivers, a med-tech and 2 kitchen staff) on-duty and LPA conducted interviews. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 19, 2025

Type of visit: Office

At 10:30 am on this day, December 16, 2025, a virtual meeting was called due to the closure of the facility. The meeting was attended by the following: Regional Manager Isaac Taggart Licensing Program Manager Jeremy Fong Licensing Program Analyst Alicia Delmundo Empowered Aging Program Manager Kiev Harris Bethesda President Robyn Harvey Bethesda Vice President Mike Clark Bethesda Board Member Lita Clapper Bethesda Board Member Don Westwood Bethesda Board Member/Treasurer Jonathan Wagner Bethesda Administrator Roselyn Chand The following were discussed: 1. Closure process. 2. Review of Closure Plan and approval/denial. .....continued on 809C 3. Rescission of the 60-day notification originally provided to the residents and resident's responsible person. 4. Submission of corrected closure plan that includes Relocation evaluation of each resident which includes the following: Recommendations on the type of facility that would meet the needs of the resident based on the current service/care plan. A copy of current service/care plan. A list of facilities, within a 60-mile radius of the resident’s current facility, that meet the resident’s present needs. Identification of staff who will assist in placement and/or relocation. 5. Submission of LIC500 Personnel Report. 6. Biweekly facility visit. 7. No new admission of resident. 8. Continuous provision of update to LPA. A copy of this report provided via email to Roselyn Chand, Robyn Harvey and Mike Clark.the state’s words, verbatim · CDSS document, Dec 16, 2025

Allegation investigated: Licensee did not give residents adequate notice of facility closure.

On this day, 12/11/25, at 4:00 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced for a complaint visit. LPA met with staff, Joan Acob. LPA called and spoke over the phone with Roselyn Chand, administrator (ADM), and informed the reason for visit. ADM authorized Joan Acob to sign and receive this report. It was alleged that the facility announced that it is closing and it will not guarantee 60 days. On 11/28/25, ADM notified LPA stating that the Bethesda's Board Directors have decided to cease the Bethesda's assisted living services. On 12/01/25, LPA requested ADM for copy of the notication to the residents and residents' responsilble person which showed 60-day notification. ADM stated she has been assisting the residents and residents' responsible persons in finding placements which LPA confirmed with staff (S1). .....continued on 9099C Unfounded Based on information gathered, the allegation is unfounded. A finding that a complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiency cited. Exit interview and copy of this report.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 15-AS-20251203223548

Type of visit: Case Management - Health Checks

On this day, October 20, 2025, at 3:20 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct inspection to ensure the health and safety of residents. LPA met with staff, Joan Acob, and informed the reason for visit. LPA called and spoke over the phone with Roselyn Chand, administrator (ADM). ADM can not come to the facility, and authorized Joan Acob to be with LPA during inspection, and to sign and receive this report. LPA conducted inspection and observed adequate supplies of perishables and non-perishable food. Facility has running water and electricity. There are 3 staff (2 caregivers and a med-tech) on-duty. LPA conducted interviews. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 20, 2025

Type of visit: Case Management - Health Checks

On this day, October 6, 2025, at 1:45 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct inspection to ensure the health and safety of residents. LPA met with staff, Elmer Lopez and Elise Cooks. The staff stated that Roselyn 'Rose' Chand, administrator (ADM), was at the facility earlier and left about an hour ago. LPA called and spoke over the phone with ADM and informed the reason for visit. ADM stated she'll be back but authorized Charo Figueroa, staff, to be with LPA during inspection. ADM arrived at around 2:55 pm. LPA conducted inspection and observed supplies of perishables and non-perishable food adequate. Facility has running water and electricity. LPA also conducted interviews. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 6, 2025

Type of visit: Case Management - Health Checks

On this day, September 17, 2025, at 2:35 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct inspection to ensure the health and safety of residents. LPA met with Roselyn 'Rose' Chand, administrator (ADM) and informed the reason for visit. LPA conducted inspection with ADM. There's sufficient food supplies. Facility has electricity. LPA obtained copies of resident roster and staff schedule. LPA interviewed ADM, 2 residents and 3 staff. LPA also interviewed 1 staff from Skilled Nursing side of Bethesda. ADM stated the operating cost for the Assisted Living of Bethesda is separate from the operating cost of the Skilled Nursing side. ADM further stated that the Business Office staff is gone for the day and that a copy of the document will be provided by tomorrow, September 18, 2025. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 17, 2025

Allegation investigated: -Staff observed being rough to the resident (R1). -Staff do not feed resident (R1) sufficiently resulting to weight loss.

On this day, August 15, 2025, at 11:45 am, Licensing Program Analyst (Delmundo) arrived unannounced to investigate the above allegations, and met with staff, Leatrice Ayala. LPA called and spoke over the phone with Roselyn Chand, administrator (ADM), and informed the reason the visit. ADM authorized Leatrice Ayala to sign and receive this report. During the course of investigation, LPA obtain copy of resident roster and staff schedule. LPA also interviewed R1's family member (FM) on 8/11/25 and staff (S2, ADM) on this day, 8/15/25. FM stated R1 is at the Skilled Nursing (SNF) section and was never admitted to the Assisted Living (AL) side of Bethesda. ....continued on 9099C Unfounded ADM stated staff, S1 and S2, worked in SNF and never worked in AL. S3 stated she has never worked with S1 and S2. Review of staff schedule showed S1 and S2 not listed. Based on records review and interviews, the allegations of staff observed being rough to R1 and staff do not feed resident R1 sufficiently resulting to weight loss are closed as unfounded due to R1 is a resident of facility’s SNF unit which is not under the jurisdiction of the Department and the two staff never worked in the AL. Therefore, the complaint is dismissed. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 15-AS-20250808133020

Allegation investigated: Staff did not take steps to prevent the spread of a communicable disease.

On this day, July 16, 2025, at 3:20 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation, and met with Joan Acob, staff. LPA called and left message on Roselyn Chand's, administrator (ADM) voicemail and informed of the reason of LPA's visit. It was alleged that there's acute respiratory illness outbreak/multiple pneumonia cases and 1 related death in the facility. LPA obtained copies of resident roster and staff schedule. LPA reviewed and obtained copies of residents' (R1 and R2) After Visit Summary and interviewed staff (S1, S2). .....continued on 9099C Unsubstantiated One of the staff interviewed stated the facility has 2 separate cases of pneumonia and the residents are now back to the facility and doing well. Review of After Visit Summary showed R1 was sent out in June 2025 and R2 on July 2025. Both staff stated the facility is observing universal precautions, doing disinfecting every shift and wearing masks when residents are coughing. Both of them stated there's no outbreak of communicable disease. Based on information gathered, there is not a preponderance of evidence to prove that a violation occurred, therefore, the allegation is closed as unsubstantiated. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 16, 2025 · control 15-AS-20250710162549

Type of visit: Case Management - Deficiencies

While at the facility conducting investigation of a complaint (Complaint Control # 15-AS-20250710162549), Licensing Program Analyst (LPA) Delmundo learned that three residents were sent out to the hospital, two in June 2025 and the other one on July 2025, and the facility did not submit Unusual Incident Reports. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. LPA called and left message on Roselyn Chand's (administrator) voicemail regarding the above. LPA also discussed with Joan Acob, staff, the deficiency and plan and proof of correction. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 30, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports ...(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 ..(D) Any incident which threatens the welfare, safety or health of any resident... -This requirement is not met as evidenced by: -Based on interviews and records review, the licensee did not comply with the section above in not submitting the incident reports for R1, R2 & R3 which posed a potential health and/or personal rights risks to persons in carethe state’s words, verbatim · CDSS document, Jul 16, 2025

Plan of correction: Administrator to do the following and submit proof by 7/30/25: 1. Submit incident reports. 2. Read the Regulations and self-certify timely submission of incident reports.

Type of visit: Required - 1 Year

On 4/28/2025, at 9:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Administrator (ADM) Roselyn Chand. The LPA toured the interior and exterior of the facility with the ADM, inspecting the kitchen, food and supplies storage areas, dining areas, shared restrooms, community living spaces, private bathrooms, resident rooms, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. The maximum hot water temperature was 116.2 degrees Fahrenheit in Azalea Cottage and the temperature in the common area in the Wisteria Cottage was 73.4 degrees Fahrenheit. The carbon monoxide and smoke detectors were fully operational. The fire extinguishers were last serviced on 2/19/2025. The LPA observed postings in the facility that included a complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, Rights to Resident Council, and Rights to Family Council. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. The LPA reviewed facility records, records of 5 staff members, and records of 5 residents. No citations were issued during the inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 28, 2025

Allegation investigated: -Facility does not meet residents' dietary needs. -Facility's alarm system in disrepair. -Staff do not answer residents' call buttons in a timely manner.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings on the above allegation and close the complaint. LPA met with Roselyn Chand, acting administrator, and informed the reason for visit. During the course of investigation, LPA obtained copies of resident roster, staff schedule and menus. LPA conducted inspection on 8/24/22 and 5/01/24 and interviewed previous administrator, David Martinez, on 8/24/22 and 3 residents on 5/01/24. Allegation: Facility does not meet residents’ dietary needs. Reporting party (RP) stated the staff serve residents ‘mush’ and do not serve fresh fruits or vegetables. It was further alleged that residents are served canned foods or frozen foods. ....continued 0n 9099C (apge 2) Unfounded Page 2 On 8/24/22 and 5/01/24, LPA inspected the food supplies which were observed of different varieties. LPA observed fresh fruits and fresh meat such as pork, beef, and packages of ground beef. On 8/24/22, LPA obtained copies of menus and the food prepared by kitchen staff for dinner for that day was observed consistent with what was listed on the menu. On 5/01/24, LPA observed different varieties of food supplies including but not limited to fresh pork and beef, vegetables, and fresh cantaloupes. All 3 residents interviewed stated they are served different varieties and fresh fruits. Based on information gathered, the allegation is unfounded. Allegation: Facility alarm system in disrepair. It was alleged that the facility’s alarm system did not work. On 8/18/22, LPA spoke and verified with RP the alarm system RP was referring during the complaint intake. RP stated the facility has fire alarm and smoke alarm that do not go off. RP further stated that the Independent Living (IL) has smoke alarm and that there's no notification system on the IL if something is happening on the Assisted Living (AL) and Skilled Nursing (SNF). LPA conducted inspection on 8/24/22, and interviewed previous administrator, David Martinez, on 8/24/22 and 3 residents on 5/01/24. On 8/24/22, LPA tested the smoke and carbon monoxide detectors. Previous administrator stated all the alarms were working including the fire alarm and wander guards for the SNF were working. Based on inspection, interviews and RP’s statement, and that the Department does have jurisdiction on IL and SNF, the allegation is closed as unfounded. .....continued on 900c (page 3) Page 3 Allegation: Staff do not answer residents' call buttons in a timely manner. It was alleged that staff do not answer residents' call buttons in a timely manner and that sometime in 8/2022, the residents’ call lights were not working. It was further alleged that residents scream for assistance however, staff do not assist the residents. On 8/18/22, LPA spoke with RP who stated the call buttons/lights were the ones on SNF that go off frequently and the staff won’t respond. On 8/24/22, LPA interviewed previous administrator, David Martinez, who stated when resident in AL main building west wing area pressed their call buttons, calls are transmitted to the pad on the wall in the main building. The pendant call that goes to the computer is from the Independent Living Cottages. LPA requested S1 and S2 to press the call buttons from residents rooms in AL west wing area and LPA observed the signals were transmitted to the pad. On 5/01/24, LPA interviewed 3 residents, of which one is in the cottage and 2 are in the AL main building rooms. All 3 stated staff come and assist when they call for help. Based on inspection, observation and interviews, the allegation is closed as unfounded. A finding that a complaint is unfounded means that the allegations are false, could not have happened, and/or are without a reasonable basis. No deficiency cited. Exit interview conducted and copy of this report provided to the acting administrator.the state’s words, verbatim · CDSS document, May 17, 2024 · control 15-AS-20220817121529

Type of visit: Case Management - Annual Continuation

On this day, May 17, 2024, Licensing Program Analyst (LPA) Delmundo conducted unannounced visit to continue the annual inspection that was started on May 1, 2024. LPA met with Roselyn Chand, acting administrator, and informed the reason for visit. LPA reviewed 5 staff and 5 residents files and interviewed 1 staff. Medications were checked and compared with doctor's order of medications and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. LPA observed the following: -at 12:10 pm, staff (S1) has no 4 hours required training on file on postural support/restricted health conditions/hospice care. -at 12:30 pm, S3 is CPR/AED certified but no First Aid certificate on file. -at 1:40 pm, S4 is CPR/AED certified but no First Aid certificate on file. -at 1:25 pm, resident's (R2) LIC602A indicated non-ambulatory, and R2 needs cane to move around and about but the facility is not licensed and not fire cleared for non-ambulatory -at 3:00 pm, resident (R5)'s doctor's order 1/16/24 for 1 of medications is 50 mg, 2x daily but the label on the medication filled on 4/18/24 showed 1 tablet daily. ....continued on 809C (page 2) Page 2 Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section 87202(a)(1). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalty. Deficiencies and plan, and proof of corrections were discussed with the acting administrator. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.the state’s words, verbatim · CDSS document, May 17, 2024

Type of visit: Required - 1 Year

On this day at 2:00 p.m., Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual inspection. LPA met with Roselyn Chand, acting administrator, and informed the reason for visit. LPA requested for copy of updated LIC9282 Infection Control Plan which LPA received on 4/23/24. Another updated LIC9282 is provided by acting administrator on this day, LPA inspected the facility inside out with the acting administrator. LPA inspected the main building (West Wing); Azalea, Garden and Peralta Cottages. LPA randomly selected residents rooms in the West Wing and cottages for inspection. LPA also inspected the living room, dining area, kitchen, bathrooms, toilets, shower room and yard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days. Facility uses mechanical means of cleaning/rinsing dishes and utensils. Kitchen staff check and keep record of freezers and refrigerators temperatures which were observed within Regulations range. Facility has smoke detectors that were tested, and observed functional. Hot water temperature in one of the ensuite bathrooms in the West Wing was tested, and measured at 108 degrees Fahrenheit. Fire extinguishers were checked, observed fully charge with tags showed serviced 2/27/24. LPA interviewed 2 residents. Facility does not handle residents' cash resources. LPA observed the following: -at 2:55 p.m., trash can in West Wing resident's bathroom without lid. -at 3:45 p.m., fire place in the West Wing living room not secured. -facility does not have a certified administrator. Former administrator last day at the facility was 11/2023. ....continued on 809C Page 2 -disaster drill records not readily available for review. -no carbon monoxide detectors in the West Wing, Azalea, Peralta Acting administrator to submit updated copies of the following documents by May 15, 2024: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan 4. $3M Liability Insurance certificate Due to time constraint, LPA will come back to continue the inspection. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty. Deficiencies and plan, and proof of corrections were discussed with the acting administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.the state’s words, verbatim · CDSS document, May 1, 2024