Orchard Park Al and Memory Care

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff did not respond to the correspondence provided by the residents council in a timely manner.

On 09/02/2026, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20260625111823 investigation findings regarding the above allegation and met with Julissa Aguirre, Administrator. Reporting Party (RP) alleges that staff did not respond to the correspondence provided by the residents council in a timely manner. On 07/01/2026, LPA Florio obtained documents and conducted an interview with RP who stated that the resident council never received the required response to the May meeting minutes emailed over on May 12th, 2026. RP states that the June resident council meeting was cancelled because only two residents showed up due to not receiving a response to the May meeting minutes. Facility provided LPA with a copy of the April and May 2026 resident council meeting minutes but no signatures or responses were included. Continued on LIC9099C... Substantiated Continued from LIC9099... Based on resident council meeting notes obtained, the April and May 2026 meeting notes were not signed by the administrator nor was there a documented response to the council which is beyond the required 14-day response time frame and the notes were not signed by the resident council president as required. Based on observations made, interviews conducted and records obtained, the allegation that staff did not respond to resident council in a timely manner is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Health and Safety Code, (see LIC9099D). Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to Administrator.the state’s words, verbatim · CDSS document, Sep 2, 2026 · control 21-AS-20260625111823

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.157(c) · Plan of correction due date: Oct 2, 2026

Resident-oriented facility council §1569.157(c) If a resident council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response to those concerns or recommendations within 14 calendar days. This requirement is ot met as evidenced by: Based on record review Licensee did not ensure that the resident council meeting minutes are resonded to in required timeframe. This poses a potential Health, Safety and/or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Licensee to submit proof of a written response and meeting minutes by the facility to the residnet council for the most recent resident council meeting to CCL by POC due date of 10/02/2026.

Allegation investigated: Staff did not ensure resident had a fall plan in place after multiple falls Staff did not provide timely medical care to resident after a fall

On 09/02/2026, at approximately 11:00 AM Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a subsequent complaint investigation and deliver findings for LIC802 - Complaint Report #21-AS-20260615103720, which was received by Community Care Licensing (CCL) on 06/15/2026. LPA met with Julissa Aguirre, Administrator. Complainant alleges that staff did not ensure resident had a fall plan in place after multiple falls and staff did not provide timely medical care to resident after a fall. On 06/18/2026, LPA initiated this complaint investigation and obtained documents, made observations, and conducted interviews. Based on three incident reports submitted to the Department and dated 06/09/2026, 06/09/2026, and 06/14/2026, Resident 1 (R1) was found by staff on the floor stating they were "dizzy" on 06/07/2026 at approximately 8:30 pm, emergency medical services (EMS) were... Continued on LIC9099C... Unsubstantiated Continued from LIC9099... ...activated and R1 was transported to hospital for evaluation and imaging, a follow up appointment was scheduled with R1's primary care physician (PCP) on 06/16/2026 and R1 returned to the facility at approximately 3:50 am on 06/08/2026 with no new orders. At 5:20 am, R1 was observed by staff on the floor again attempting to stand and fell again. Staff then observed bleeding and swelling around R1's right eye. EMS were activated again and R1 was transported to the hospital again. Resident returned to the facility at approximately 10:30am with no new orders. On 06/09/2026 at approximately 10:00 am R1 was sent to the hospital via EMS after staff observed slurred peach and an inability to bear weight. R1 returned to the facility by 1:00 PM. On 06/10/2026, R1 was evaluated by a third party Hospice agency who determined he was not a candidate for Hospice services but recommended transport to a different hospital than the one previously used. R1 was taken to the suggested hospital and was admitted. On 09/01/2026, LPA obtained additional documents and conducted further interviews. The records reflect that R1 was transported to the hospital three times over a three-day period and returned to the facility after each of those transports. Facility observation notes reflect increased monitoring of R1, including documented 30-minute checks on 06/09/2026. S1 stated that the facility was considering a bed alarm and planned to fax R1's PCP to request an order. However, the facility did not contact the PCP or obtain an order for a bed alarm before R1's fourth and final hospital transport. In the interim, S1 and W1 discussed fall-prevention measures, and the facility placed R1's mattress on the floor. W1 confirmed this information during an interview conducted on 09/01/2026. R1 did not return to the facility following the fourth hospital transport. Records and interviews reflected that that facility implemented increased monitoring and placed R1' mattress on the floor as interim fall-prevention measures during the brief period between R1's repeated hospital transports. Therefore, there was insufficient evidence to establish by a preponderance of evidence that staff failed to implement fall-prevention measures for R1. LPA discussed potential personal rights concerns with S1 and Administrator and advised that written consent from R1 and/or R1's responsible party, along with documentation in an updated care plan, should be obtained when implementing such measure. Based on interviews conducted, observations made, and documents obtained, the facility responded timely to R1's medical needs after each fall and was actively working on a fall prevention plan as the situation evolved. Regarding the allegation that staff failed to provide timely medical care following R1's falls, records reflect that the staff contacted EMS and R1 was transported for medical evaluation following each incident. Continued on LIC9099C... Continued from LIC9099C... The complainant alleges that R1 remained on the floor for an extended period before receiving assistance. However, the evidence obtained did not establish when R1 fell or the length of time R1 was on the floor before being discovered by staff. Facility records reflect that staff conducted frequent checks, including documented 30-minute checks on 06/9/2026. LPA reviewed photographs depicting bruising and wounds on R1. However, the appearance of the injuries did not establish when the injuries occurred or how long R1 may have been on the floor. Therefore, there was insufficient evidence to establish by a preponderance of evidence that staff delayed obtaining medical care for R1 following a fall. Based on interviews conducted, observations made, and records obtained, the allegations that staff did not ensure resident had a fall plan in place after multiple falls and staff did not provide timely medical care to resident after a fall are UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 2, 2026 · control 21-AS-20260615103720

Type of visit: Case Management - Incident

On 05/21/2026, at approximately 11:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management- incident inspection and met with Kirendeep Bhade, Executive Director. LPA is conducting a case management visit to obtain more information and conduct a safety and wellness check regarding an incident report and a SOC341, dated 05/19/2026 and received by the Department on 05/20/2026, involving Resident 1 (R1) which was self reported by the facility. LPA interviewed R1, reviewed R1's records, obtained copies of documents including a personnel and resident rosters, conducted interviews with Staff 1 (S1) and Staff 2 (S2), and obtained statements and local police department report information. No deficiencies were cited during todays visit. Exit interview was conducted with Executive Director, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, May 21, 2026

Allegation investigated: Staff does not ensure activities are provided to residents.

On 05/19/2026, at approximately 12:45 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a subsequent complaint investigation and deliver complaint findings for Complaint Report #21-AS-20260503123731, which was received by Community Care Licensing (CCL) on 05/03/2026. LPA met with Kirendeep Bhade, Executive Director. Complainant alleges that staff does not ensure activities are provided to residents. On 05/07/2026, LPA initiated this complaint investigation and obtained documents, made observations, and conducted interviews. Based on staff schedules obtained for 04/2026 and 05/2026, staff observed on site during the visit, and interviews conducted with Staff 1 (S1), Staff 2 (S2), and Resident 1 (R1), the facility does not currently have one fulltime staff member who has the "full-time responsibility to organize, conduct and evaluate planned activities," nor is there "staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities," as required per regulation. Continued on LIC9099C... Substantiated Continued from LIC9099... Further, these interviews revealed that Staff 3 (S3) had been working in hybrid role as the activities coordinator and the bus driver two days per week until going out on leave several weeks ago, rather than in a designated activities director role as required for a facility approved for a capacity of 50 or more residents. Per interviews, facility staff have been filling in until either S3 returns or the position is filled. These interviews also revealed that activities do not occur according to the schedule either due to the coordinator driving the bus, supplies not present for the scheduled activity, or the coordinator being our on leave. Additionally, LPA's interviews revealed that monthly outings to the store, the local casino, and other routine excursions have not been occurring, nor has the facility facilitated holidays such as a mother's day celebration or other smaller holidays, such as Cinco De Mayo which have all previously been celebrated at the facility. Based on documents obtained and interviews conducted, the allegation that staff does not ensure activities are provided to residents is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). Exit interview conducted with Executive Director, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to Executive Director.the state’s words, verbatim · CDSS document, May 19, 2026 · control 21-AS-20260503123731

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(f) · Plan of correction due date: Jun 19, 2026

Planned Activities 87219(f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in... accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. This requirement is not met as evidenced by: Based on observations made, records reviewed, and interviews conducted,the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Licensee did not ensure that activities are provided to residents as required per regulation. This poses a potential Health, Safety and/or Personal Rights risk to residents in care. Licensee to submit a self certification that they have reviewed the regualtion and understand the requirement to have a designated fulltime activities coodinator in a facility this size and to submit a written plan of how the facility will meet this requirement moving forward to CCLD by POC due date of 06/19/2026.

Allegation investigated: Staff does not provide adequate supervision to residents due to lack of staff.

On 05/19/2026, at approximately 12:45 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a subsequent complaint investigation and deliver findings for Complaint Report #21-AS-20260503123731, which was received by Community Care Licensing (CCL) on 05/03/2026. LPA met with Kirendeep Bhade, Executive Director. Complainant alleges that staff does not provide adequate supervision to residents due to lack of staff. On 05/07/2026, LPA initiated this complaint investigation and obtained documents, made observations, and conducted interviews. Based on staff schedules obtained for 04/2026 and 05/2026 and staff observed on site during the visit, the facility meets and/or exceeds the minimum required staffing of at least one awake staff member in each unit on all shifts. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... During this visit, interviews with Staff 1 (S1) and Staff 2 (S2) and obtained proof of job postings revealed that although the facility meets the minimum staffing requirements per regulation, management is activity working on hiring additional staff for various roles throughout the facility, to include having two direct care staff in each unit on each shift as well as one medication technician on each shift to ensure resident's' care needs are being met. Additionally, these interviews and an interview conducted with Resident 1 (R1) did not reveal that any adverse events have occurred as the result of the current staff to resident ratios. Based on interviews conducted, observations made, and documents obtained, LPA received conflicting information. Based on interviews conducted, observations made, and records obtained, the allegations that staff does not provide adequate supervision to residents due to lack of staff is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Executive Director, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 19, 2026 · control 21-AS-20260503123731

Type of visit: Case Management - Incident

On 04/01/2026, at approximately 3:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management - incident visit and met with Alma Peralta, Vice President of Operations (VPO) . LPA is conducting a case management visit to obtain more information regarding a SOC341 Report of Suspected Dependent Adult/Elder Financial Abuse received by the Department on 02/23/2026 for concerns reported by Resident 1 (R1). LPA obtained documents and conducted interviews with VPO and R1. No deficiencies were cited during todays visit. Exit interview was conducted with VPO, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Apr 1, 2026

Type of visit: Case Management - Incident

On 02/19/2026, at approximately 12:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management - incident visit and met with Melissa Jones, Administrator. LPA is conducting a case management visit to obtain more information regarding a SOC341 Report of Suspected Dependent Adult/Elder Abuse received by the Department on 02/12/2026 for concerns reported to the facility on 02/10/2026, involving Resident 1 (R1). LPA obtained documents and conducted interviews with Administrator and R1. No deficiencies were cited during todays visit. Exit interview was conducted with Administrator, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 19, 2026

Type of visit: Prelicensing

At approximately 2:30 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a pre-licensing inspection and met with Melissa Jones, Administrator. This pre-licensing inspection is being conducted for a change of ownership of a Residential Care Facility for the Elderly (RCFE). Fire Clearance has been approved for 60 non-ambulatory residents, ten (10) of whom can be bedridden. Facility has a dementia care plan and a Hospice waiver for ten (10). At approximately 2:45 PM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story building, was a comfortable temperature, and passageways were free from obstructions. Water temperature in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed resident showers with the required non-slip mats and grab bars in place. LPA observed a supply of clean linens, hygiene products, and paper products available for residents. Residents' bedrooms have the appropriate furnishings as outlined in Title 22 regulations. Rooms, closets, and cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable foods and one week of non-perishable foods and an emergency water supply. Facility has a healthy and balanced menu of food options posted in a communal area. Facility has an activity schedule and residents were observed walking about the facility and engaged in activities and conversation. The facility has a land line which was tested and operational during inpsection. Facility has an internet access device designated for resident use and has internet services. Continued on LIC809-C... ...continued from LIC809... LPA observed a locked medication room where centrally stored medications are maintained and managed. LPA observed the facility's infection control plan, first aid kits, PPE, and other emergency supplies. Facility has fully charged fire extinguishers throughout, which were last inspected 11/2025. All magnetized fire doors were observed in working order. Facility has the required signs posted on walls around the front desk area. Facility files were reviewed 09/16/2025 during the annual inspection conducted under the current license and were found to contain the required documents per regulation. The staff and administrator will remain the same under this new license. Administrator has been informed of association and staff transfer process and agrees to ensure all staff are cleared and associated. Administrator agrees to submit proof of liability insurance upon licensure. Facility has a bus and a van for resident transportation to and from appointments and various outings. Component III orientation completed with Administrator. This pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager. Exit interview conducted with Administrator, whose signature on this document confirms receipt.the state’s words, verbatim · CDSS document, Jan 29, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for the Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 60 Census (if any clients in care): 28 COMP II Participants: Naftali Burstein, Applicant Melissa Jones, Administrator Interview Method: Virtual interview (Microsoft Teams) On January 15, 2026, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License Type, Client/Resident Populations, and Program. 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readinessthe state’s words, verbatim · CDSS document, Jan 15, 2026