Burlington, The

Allegation investigated: Staff do not ensure the facility is free of bed bugs Staff do not allow resident to leave the facility Staff do not ensure resident's finances are safeguarded

On 05/14/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint investigation and deliver complaint findings. LPA met with Administrator Carlene Reinke. During the course of the investigation, the department received copies of records, conducted interviews, and toured the facility. The facility was observed free of bed bugs. R1 confirmed staff allows the resident to leave the facility unassisted and manage own finances. R1 confirms the resident have not borrow any money to staff or to any other residents. Therefore, based on interviews conducted, the preponderance of evidence standard has not been met, the above allegations are found to be UNSUBTANTIATED. Exit interview was conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 14, 2026 · control 24-AS-20260507113909

Allegation investigated: Staff disposed of resident's personal belongings. Staff does not allow a resident to use a physician of their choice. Staff does not allow a resident to store food in the refrigerator.

On 02/25/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Carlene Reinke. The department conducted interview, toured the facility, received copies of records, and copies of R1 files. R1 resided and relocated with all R1's belongings. Residents at the facility are able to choose their own physician. A refrigerator is available for residents to store their food in the dining area. Based on interviews conducted and observation, the preponderance of evidence standard has not been met, therefore, the above allegations are found to be UNSUBTANTIATED. Exit interview conducted. A copy of this report was provided to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 25, 2026 · control 24-AS-20260224090611

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff unlawfully evicted a resident

On 05/28/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint visit and deliver complaint findings. LPA introduced self, stated the purpose of the visit, and met with Administrator Ashley Bell. Regional Director Steven Cruz later during visit. Licensee Anthony Barbato was called via telephone. During the course of the investigation, the Department conducted interviews, records were reviewed and toured the facility. R1 was admitted to the facility on 05/19/25 and was observed at the facility. Based on interviews conducted and observation, the above allegation is UNFOUNDED, meaning they were false, could not have happened, and/or are without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted. A copy of this report was provided to Administrator. Unfoundedthe state’s words, verbatim · CDSS document, May 28, 2025 · control 24-AS-20250522110556

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff made inappropriate comments towards resident

On 05/14/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Ashley Bell. LPA discussed the purpose of the visit and delivered complaint findings. During the course of the investigation, the Department conducted interviews, records were reviewed and toured the facility. A verbal altercation had occurred between S1 and R1. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Under California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report and appeal rights was provided to the Administrator whose signature confirms received of this report. Substantiatedthe state’s words, verbatim · CDSS document, May 14, 2025 · control 24-AS-20250509163615

Allegation investigated: Staff do not ensure residents’ incontinence needs are being met. Staff are not repositioning resident as needed. Licensee does not ensure that staff are receiving required training.

On 01/09/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to delivered complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit and met with Administrator Ashley Bell. During the course of the investigation, records were received, interviews were conducted, and facility was toured. Interviews were conducted with residents that confirms resident do not need repositioning. It was confirmed by R1 and R2 that staff assists and check on residents more often than resident wants staff to. LPA observed R1 sleeping in bedroom. Records were reviewed and recorded facility staff have trainings up to date.Based on observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report. Unsthe state’s words, verbatim · CDSS document, Jan 9, 2025 · control 24-AS-20241014084136

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff forced resident to get a payee

On 08/15/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings onthe above allegation. LPA introduce self, stated the purpose of the visit, and met with Facility Manager Ashley Bell. Staff and LPA attempted to reach Licensee Anthony Barbato. Administrator Kala Gibson was called via telephone. LPA delivered findings to Administrator via telephone and Facility Manager. During the course of the investigation, LPA conducted interviews and records were reviewed. Interviews conducted the residents were not forced to get a payee. Residents were asked and provided information on having a payee. Based on the interviews conducted, the preponderance of evidence standard has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. An exit interview was conducted with Administrator via telephone and Facility Manager. A copy of this report was provided to the Facility manager, whose signature on this report confirms receipt of this report.the state’s words, verbatim · CDSS document, Aug 15, 2024 · control 24-AS-20240502113950

Allegation investigated: Staff did not comply with basic service requirements

On 08/15/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegation. LPA introduce self, stated the purpose of the visit, and met with Facility Manager Ashley Bell. Staff and LPA attempted to reach Licensee Anthony Barbato. Administrator Kala Gibson was called via telephone. LPA delivered findings to Administrator via telephone and Facility Manager. During the course of the investigation, LPA conducted interviews. A food bank organization was contacted and provided information to the residents at the facility. No resident had signed up and received any food assistances form the program. Therefore, based on the interviews conducted, the preponderance of evidence standard has not been met, the above allegation is found to be UNSUBSTANTIATED. An exit interview was conducted via telephone with Administrator and Facility Manager. A copy of this report was provided to the Facility Manager, whose signature on this report confirms recethe state’s words, verbatim · CDSS document, Aug 15, 2024 · control 24-AS-20240503104314

Allegation investigated: Staff member emotionally abuses residents in care.

On 07/17/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint inspection. LPA introduce self, stated the purpose of the visit, and met with Administrator Assistant (AA) Ashley Bell. Administrator Kala Gibson was called and stated unable to attend meeting. LPA delivered findings to AA. During the course of the investigation, the department conduct interviews with residents. Interviews conducted confirmed, S1 called R1 inappropriate name and S1 spoke to residents with attitude. Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report and appeal rights was provided to the Administrator Assistant, whose signature confirms received of this report. Substantiatedthe state’s words, verbatim · CDSS document, Jul 17, 2024 · control 24-AS-20240710163035

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility did not safeguard residents cash Facility did not provide assistance with residents medical care needs

On 03/08/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegations. LPA stated the purpose of the visit and met with Administrator Kala Gibson. During the course of the investigation, LPA toured the facility, reviewed records, and conducted interviews. R1 and Administrator confirms R1 does not have cash store at the facility. Based on iinterview which were conducted, staff provides first aid and assists upon request by resident. Therefore, the preponderance of evidence standard has not been met, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this report confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 8, 2024 · control 24-AS-20240208091113

Allegation investigated: Resident was inappropriately touched while in care. Staff did not provide adequate food service to a resident. Staff do not prevent the residents from being mistreated while in care.

On 02/12/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a subsequent complaint visit and deliver complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit and met with Facility Manager Ashley Bell. Administrator Kala Gibson was called and unable to attend meeting. During the course of the investigation, interviews were conducted, records were reviewed, and facility was toured. Adequate perishable foods were observed in the facility walk in refrigerator and large freezer. Adequate nonperishable foods were observed in facility walk-in pantry. The facility menu consists of a variety of food choices. Allegations resident was inappropriately touched while in care and staff do not prevent the residents from being mistreated while in care, although these allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur. Therefore, based on the interviews conducted, obthe state’s words, verbatim · CDSS document, Feb 12, 2024 · control 24-AS-20240111123635

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.