Vista Del Mar Senior Living

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

Allegation investigated: Staff hit resident. Staff pressured resident to change health plan. Staff attempted to relocate resident without consent. Staff prevented resident from leaving the facility.

On 09/24/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegation listed above. LPA met with the Resident Care Director, Sidonia Cordis, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 09/24/2026, interviews were conducted and records were reviewed. Interviews conducted consisted of Staff 1 (S1) and Resident 1 (R1). Records reviewed consisted of facility records such as Personnel Report dated 09/24/2026 and Resident Roster. R1’s records reviewed consisted of Vista Del Mar Senior Living Residence and Care Agreement dated 08/11/2022, Physicians Report dated 04/13/2026, Service Plan dated 07/23/2026, Unusual Incident/Injury Report dated 08/03/2026 and 09/18/2026, Observations for 09/11/2026 and 0919/2026. Unsubstantiated Investigation revealed the following: Allegation: “Staff hit resident”, it is being alleged that S1 hit R1 on the shoulder. Interviews conducted with S1 revealed the following: S1 denied the allegation. S1 explained that they never hit R1. Interviews conducted with R1 revealed the following: R1 agreed with the allegation. R1 indicated that they do not remember when the incident occurred. R1 then goes on to demonstrate how S1 hit them on the shoulder, it looked like and felt like a tap on the shoulder. Furthermore, R1 stated that it did not hurt nor were they in pain. Unsubstantiated: 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. Allegation: “Staff pressured resident to change health plan”, it is being alleged that R1 was pressured to change health plan by S1. Interviews conducted with S1 revealed the following: S1 denied the allegation. Interviews conducted with R1 revealed the following: R1 denied the allegation, moreover, R1 indicated that they have the same health plan as before. R1’s records reviewed revealed the following: There are no records indicating that R1 has changed their health plan. Unsubstantiated: 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. Allegation: “Staff attempted to relocate resident without consent”, it is being alleged that S1 attempted to relocate R1 without their consent. Interviews conducted with S1 revealed the following: S1 denied the allegation. Interviews conducted with R1 revealed the following: R1 agreed with the allegation, additionally, R1 stated that S1 pressured them to go to another place to receive more assistance but R1 refused. Furthermore, R1 indicated that they have no current arrangements to leave the facility. On 09/24/2026 at around 09:28 AM, R1 was observed in their room. R1’s records revealed the following: There were no documents indicating that R1 will be moving out of the facility. Unsubstantiated: 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. Allegation: “Staff prevented resident from leaving the facility”, it is being alleged that staff prevented R1 from leaving the facility. Interviews conducted with S1 revealed the following: S1 denied the allegation. Interviews conducted with R1 revealed the following: R1 agreed with the allegation. R1 indicated that S1 and other staff have attempted them from leaving the facility, but they were able to leave the facility. Furthermore, R1 explained that staff informed them that they were weak and afraid for them to go out by themselves. Additionally, R1 stated that last night (09/23/2026) and on Sunday (09/20/2026) they exited the facility. Also, R1 stated that every time they have wanted to leave the facility, they have been able to do so. Observations on 09/24/2026 revealed the following: Staff were not observed, denying residents the ability to exit the facility. R1’s records reviewed revealed the following: There are no records indicating that staff refused R1 from exiting the facility. Unsubstantiated: 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. An exit interview was conducted, and a copy of this report was provided to the Resident Care Director, Sidonia Cordis.the state’s words, verbatim · CDSS document, Sep 24, 2026 · control 11-AS-20260915152119

Allegation investigated: Staff did not seek medical treatment for residents Staff allowed resident to ingest an unsafe substance Staff did not follow infection control guidelines to properly address a scabies outbreak Staff did not follow reporting requirements

On 09/24/26, the Department conducted an unannounced subsequent visit to continue investigation of the above allegations and to deliver findings. The Department met with Suzette Johnson (Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 9/16/26, the department obtained and reviewed the following documents: Staff roster (dated 9/16/26), Resident roster (No date), staff training on infection control/Scabies (dated 3/14/26), R1’s Admission Agreement (7/8/26), R1’s discharge summary (7/13/26),R1’s service plan (dated 7/13/26), Medication order summary (dated 7/13/26), SIR (dated 9/5/26, and 7/31/26), and progress notes (dated 7/14/26). On 9/16/26, the Department interviewed Administrator (A1), 5 staff (S1-S5), and 8 Residents (R3-R10) and an observation of the grounds. On 9/24/26, the Department interviewed 2 residents (R1-R2) Page 1 of 5 Unsubstantiated The investigation revealed the following Allegation: Staff did not seek medical treatment for residents The detail of the complaint alleges that on 09/05/2026, the resident told a staff member they were itching, and no one would help them. On 09/16/26, at 9:30am, the Department interviewed Administrator (A1) regarding the allegation. A1 denied the allegation stating that R1 received medical treatment. A1 stated that R1 was admitted from another facility and R1 was diagnosed with scabies however A1 made sure R1 was cleared before entering. Although R1 was cleared, he still was itching. So as a precaution A1 stated that they applied the treatment again and treated R1’s roommate. There have been no other residents who were diagnosed with scabies including this resident’s roommate. On 9/16/26, the department reviewed an SIR (dated 9/5/26) which confirmed that R1 received medical attention. On 9/16/26, between 10:30am and 12:00pm, the Department interviewed 5 staff members and of those interviewed 5 out of 5 stated that R1 didn’t report itching to them on 9/5/26. On 9/24/26, the Department interviewed R1 at 10:30am who stated he had been itching badly. R1 stated that staff were very responsive when they told staff that they were itching. R1 went on to state, “they applied my cream right away.” Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. Page 2 of 5 Allegation: Staff allowed resident to ingest an unsafe substance The detail of the complaint alleges that staff told the R1 they would stop itching if they ate mushrooms that were growing in the middle of the patio. The resident allegedly hallucinated and vomited after eating the mushrooms. On 09/16/26, at 9:30am the department interviewed Administrator (A1) regarding the allegation. A1 denied the allegation, stating that the incident involved R1 taking it upon themself to ingest mushrooms that were growing on the property, but noted that the issue had been addressed because the mushrooms growing were removed. A1 went on to state that staff did not advise R1 to ingest mushrooms as staff are all aware they do not give any medical advice to residents. On 9/16/26 between 10:30am and 12:00pm, the Department interviewed 5 staff members. Of those interviewed, 5 out of 5 denied the allegation stating that they have never told R1 or any other resident to ingest mushrooms to stop the itch. On 9/16/26 and 9/24/26, between 12:00pm and 2:00pm, the Department interviewed 10 residents. Of those interviewed all 10 denied that staff had told them to ingest mushrooms for any reason. 1 out of 10 admitted that they ate the mushrooms because they wanted to and not at the urging of staff. The one resident went on to state that “their roommate ate one and nothing happened, so they thought it was okay to ingest.” On 9/16/26, the Department toured the facility grounds and found no evidence of mushroom growth in the patio lawn. A1 and staff informed the Department that the grounds are maintained weekly and any growths such as mushrooms are removed. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. Page 3 of 5 Allegation: Staff did not follow infection control guidelines to properly address a scabies outbreak The detail of the complaint alleges that at the end of July, there was a scabies outbreak in the facility and allegedly, resident went to the hospital but was not treated for scabies. On 09/16/26, at 9:30am, the department interviewed Administrator (A1) regarding the allegation. A1 denied the allegation, stating that there was no scabies outbreak at the facility at the end of July. On 9/16/26 between 10:30am and 12:00pm, the Department interviewed 5 staff members. Of those interviewed, 5 out of 5 denied the allegation stating that there was no scabies outbreak at the end of July. 5 out of 5 stated that they have had training on infection control/scabies. On 9/16/26 and 9/24/26, the Department interviewed 10 residents (R1-R10). All 10 residents stated that they were not aware of any scabies outbreak at the facility. On 9/16/26, the Department obtained and reviewed staff training on infection control/Scabies (dated 3/14/26) Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. Page 4 of 5 Allegation: Staff did not follow reporting requirements The detail of the complaint alleges that did not follow reporting requirements. On 09/16/26, at 9:30am, the department interviewed Administrator (A1) regarding the allegation. A1 denied the allegation, stating that she submitted incident report of R1’s ER. A1 provided the Department with a copy of the SIR (dated 9/5/26). The SIR was sent within the required time frame for reporting incidents. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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 Suzette Johnson Administrator. There were no deficiencies cited during today’s visit. Copy of report provided. Page 5 of 5the state’s words, verbatim · CDSS document, Sep 24, 2026 · control 11-AS-20260914091614

Allegation investigated: Resident became malnourished and dehydrated due to staff neglect while in care Staff did not ensure resident's hygiene needs were met while in care Staff did not prevent resident from being bitten by bed bugs while in care

On 9/1/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Executive Director, Suzette Johnson and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 9/1/26 LPA Felisa Shirley reviewed copies of the following records: Staff and Resident Roster, face sheet, Identification and Emergency Information, Physician’s Report, Service plan, Physicians Orders, Hospitalization list, and service schedules. LPA Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 8 (S1 – S8), and Resident 2 – Resident 7 (R2-R7). LPA attempted to talk to R1 three times. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Resident became malnourished and dehydrated due to staff neglect while in care. It is being alleged that R1 has been in the hospital due to being malnourished and dehydrated. LPA Felisa Shirley reviewed an incident report dated 7/30/26, which informed Community Care Licensing that R1 had an unwitnessed fall and was laying supine on the floor and couldn’t remember how they got on the floor. Staff called 911 and notified R1’s family and was then transported to Long Beach Memorial for treatment and has not returned back to the facility. During file review on 9/1/26, LPA Shirley observed that R1 has been diagnosed with dementia per physician’s report dated, 4/9/25. Per the physician’s orders dated 10/17/25, R1 was prescribed Metformin CL ER 500 mg on 3/15/25 which causes mild weight reduction over time. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 2 – resident 7 (R2 – R7). Of those who interviewed 6 out of 6 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Resident became malnourished and dehydrated due to staff neglect while in care,” therefore, the allegation is unsubstantiated. Allegation: Staff did not ensure resident's hygiene needs were met while in care. It is being alleged that R1’s fingernails were long and dirty and that R1 had not been shaved. On 9/1/26, LPA Shirley observed the Services Schedule for the residents which included grooming for residents in Assisted Living. LPA Shirley inquired as to why there was no schedule for servicing for the residents in Memory Care; S1 stated that the residents in Memory care are all on total care/assistance constantly and no schedule was needed. During interviews on 9/1/26, S1 stated that the facility does offer light grooming. S1 also stated that there is a licensed beautician that services residents upon request. During LPA Shirley’s interviews with R4, R5 and R6 on 9/1/26, LPA Shirley observed that their fingernails were clean. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 2 – resident 7(R2 – R7). Of those who interviewed 6 out of 6 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not ensure resident's hygiene needs were met while in care,” therefore, the allegation is unsubstantiated. Con'd on 9099-C Allegation: Staff did not prevent resident from being bitten by bed bugs while in care It is being alleged that R1 had scars and bite marks due to a bed bug infestation. Due to a review of incident reports on 9/1/26, LPA Felisa Shirley did not observe any incident reports indicating that Vista Del Mar has experienced a bed bug infestation. On 9/1/26, LPA Shirley interviewed S8, the Maintenance Director who stated that there have been no reports or complaints of bed bugs at this facility. LPA Shirley interviewed S1 – S8 and R2 – R7 on 9/1/26, all of whom stated that they have not observed or experienced any bed bugs at this facility. LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 2 – resident 7 (R2 – R7). Of those who interviewed 5 out of 6 denied the allegation, and 1 confirmed it. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not prevent resident from being bitten by bed bugs while in care,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, Sep 1, 2026 · control 11-AS-20260824102815

Allegation investigated: Staff did not provide residents with medication as prescribed

On 08/27/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced continuation complaint investigation visit regarding the allegation listed above. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 08/19/2026, interviews were conducted with Staff 1 (S1) to Staff 5 (S5) and Resident 1 (R1), and records were reviewed. On 08/27/2026, interviews were conducted with Staff 6 (S6) to Staff 8 (S8), and records were reviewed. Records reviewed consisted of Medication Administration Records (MARs) for R1 to Resident 4 (R4) along with their medications, Medical Assessments for R1 to Resident 3 (R3), Resident Roster, Staff Roster, and Unusual Incident/Injury Report dated 08/10/2026 for R1. Substantiated Allegation: “Staff did not provide residents with medication as prescribed.” The investigation revealed the following: Plan of Operation states the following: · “Medication Refills…Medication refills will be obtained in a timely manner to ensure residents have all physician ordered medication available. 1. The designated staff member contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to running out of medication…When the medication is ordered it entered onto the Refill Roster…3. Medications are never allowed to run out.” · “Permanent Discontinuance: Permanently discontinued medication will not be retained in the Community.” · “Expired Medications: Expired medication will not be…retained in the Community.” · “Missed or Refused Medications…1. Missed/refused medications are documented in the resident’s medication record…” · “Blood Pressure and/or Pulse Reading to Determine the Need for a Medication…resident’s vital signs are taken to determine the need for admiration of medications: a)…A written record is made on the MAR. b) When the medication is given, the date, time, and initials of the person who took the vital signs and/or gave the medication are documented. · “Assisting with Administration: Oral Medications…5. Document administration of medication on them Medication Assistance/Administration Record.” · “Assisting with Administration: Oral Medications…4. Assist resident with self-administration…b. Identify that this is the correct resident. Use photos if necessary as resident’s response may be inaccurate…5. Document administration of medication on the Medication Assistance/Administration Record.” · “Assisting with Administration: Eyedrops…e. Identify that this is the correct resident. Use photos if necessary as resident’s response may be inaccurate. f. Allow resident to ask questions and provide appropriate answers. Be aware of body language and position. Sit next to resident at eye level and use calm voice…5. Document administration of medication on the Medication Assistance/Administration Record.” On 08/19/2026, R1 to R4’s MARs were reviewed along with their medications in the Memory Care Unit and Assisted Living Unit; medications were reviewed with the assistance of staff. · Resident 1’s (R1) Medications o Routine Medication - Acetaminophen 500 milligrams (mg) tablet § Medication was not found during the record review. Staff 1 (S1) indicated that the last time they provided said medication was on 08/10/2026 or 08/11/2026 because they do not know where the medication is located. (Later that day another Medtech assisted and was able to find R1’s medication). § MAR states that the medication was not recorded at 8:00 AM on 08/03/2026, 08/09/2026, 08/12/2026, 08/13/2026, 08/14/2026 & 5:00 PM at 08/03/2026, 08/09/2026, 08/10/2026, 08/13/2026, 08/16/2026, and 08/17/2026. § On 08/15/2026 MAR states “need to contact the pharmacy for refill.” § On 08/18/2026 MAR states “Refused.” o Routine Medication - Donepezil HCL 5 mg tablet § Medication bottle was empty and S1 indicated that they request for a refill today. o The following Prescription or Nonprescription PRN medications were not found during the record review: Chest Congestion Relief EM 10-100 mg/5 ml syrup; Ibuprofen 600 mg tablet; Melatonin 3 mg capsule; and sunscreen lotion. o Unusual Incident/Injury Report dated 08/10/2026 states that 08/09/2026 at approximately 7:44 AM “resident was given the wrong medication. The resident was given a fellow residents medication.” § Staff 2 (S2) indicated that R1 received R3’s morning medications (R3 received their morning medication). § R1 indicated that they received another resident’s medication. · Resident 2’s (R2) Medications o Routine Medication – Cetirizine HCL 10 mg tablet § Medication was not found during the record review. § MAR states: on 08/07/2026 requested refill; on 08/14/2026 “out of stock”; on 08/15/2026 “waiting on medication”; medication provided on 08/03/2026 to 08/13/2026 and 08/16/2026 to 08/19/2026. § Staff 6 (S6) indicated that they did not provide medication on 08/19/2026. o Routine Medication – Donepezil HCL § Medication was not found during the record review. Staff 3 (S3) indicated that they called this morning for a refill. o No PRN medications were found during the record review. · Resident 3 Medications o Routine Medication – Prednisolone Acetate 1% Drops Susp § Medication was not found during the record review. § MAR states that the medication was not recorded at 8:00 AM on 08/03/2026, 08/06/2026, 08/09/2026, 08/14/2026, 08/17/2026 & 5:00 PM at 08/03/2026, 08/06/2026, 08/09/2026, 08/10/2026, 08/16/2026, 08/17/2026, 08/18/2026. § MAR states that on 08/04/2026 the medication was placed on hold and waiting for it to be discontinued. § MAR states that medication was provided at 8:00 AM on 08/05/2026, 08/07/2026, 08/08/2026, 08/10/2026 to 08/14/2026, 08/15/2026, 08/18/2026, and 08/19/2026 & 5:00 PM 08/04/2026, 08/05/2026, 08/07/2026, 08/08/2026, 08/11/2026 to 08/12/2026, 08/14/2026, and 08/15/2026. · Resident 4 Medications o The following medications were not found during the record review - Acetaminophen 500 mg tablet, Milk of Magnesia 400 mg/5 ml, and Glucosamine Relief 500 mg Capsule Substantiated: Based on observations, interviews, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. An exit interview was conducted, a civil penalty was provided regarding repeat violation, appeal rights were reviewed, and plans of corrections were developed. A copy of this report was left with the Executive Director, Suzette Johnson. The investigation revealed the following: Allegation: “Staff did not give resident their medication, resulting in hospitalization”, it is being alleged that R2 did not receive their medication and because of that they were hospitalized. R2’s records reviewed revealed the following: MAR dated 07/2026 indicated that on the morning of 07/19/2026 R2 received all their medication by Staff 7 (S7); S8 checked R2’s blood glucose at around 8:00 AM and 11:00 AM. Medical Records dated 07/19/2026 showed that R2 went to the hospital and was observed at approximately 12:17 PM. R2 diagnoses was “Altered Mental Status and Transient Hypotension.” There is no documentation indicating that R2 did not take their medication, moreover, there is no clear explanation as to why R2’s mental status was altered nor why R2 had low blood pressure (transient hypotension). R2 was back to normal and cleared to back to the facility on 07/20/206 at approximately 12:14 AM. Unusual Incident/Injury Report (UIR) dated 07/23/2026 states at on 07/19/2026 at approximately 11:41 AM R2 was observed drooling, staff called 911 and transported to Long Beach Memorial Hospital for further evaluation. Interviews conducted revealed the following: An interview was attempted with R2. R2 was observed to be well groomed and appropriately dressed. S7 indicated that on 07/19/2026, R2 received all their medication. S7 goes on to explain that R2 does not have a history of refusing medication. S8 indicated that on 07/19/2026, R2 received all their medication, and they checked R2’s blood sugar. W1 was unable to provide additional information regarding the allegation. Unsubstantiated: 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. An exit interview was conducted, and a copy of this report was left with the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, Aug 27, 2026 · control 11-AS-20260812153030

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87208(a) · Plan of correction due date: Aug 28, 2026

Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by: Based on observations, interviews, and record review the licensee did not comply with the section cited above by not following the facility’s Plan of Operation and not providing medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2026

Plan of correction: Executive Director has agreed to create a plan and email said plan to Socorro.Leandro@dss.ca.gov

Allegation investigated: Resident has sustained multiple unwitnessed falls. Staff do not respond timely when resident falls. Staff are not adequately caring for resident's wounds. Staff are not meeting resident's hygiene needs. Staff did not ensure the facility is kept sanitary and free from pests.

On August 20, 2026, California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Antonine Richard conducted a follow-up complaint visit. LPA Richard met with Suzette Johnson, Executive Director, and explained that the visit's purpose was to investigate the allegations and deliver findings. The investigation included a collection of records, and interviewed: The Department reviewed several documents, including the Facility Staff Roster (dated 03/18/26), Personnel Report LIC 500 (dated 03/18/26), and Resident #1 (R1)'s Identification and Emergency Information LIC 601 (dated 07/06/23), Physician's Report LIC 602A (dated 05/01/26), Service Plan (dated 02/21/26), Resident Assessment (dated02/21/26), Dowey Pet Control invoice (date) scheduled residents rooms treatments, and residents shower schedules, Bayview Hospice Notes. As well as other pertinent records associated with this complaint. On August 19, 2026, LPA interviewed the Administrator (A1), the Licensed Vocational Nurse (LVN), Medical Technician (MT1), and two staff (S1-S2), and ten residents (R2-R11). LPA was unable to interview R1 because R1 moved R1 out of the facility on June 15, 2026. Unsubstantiated Allegation #1: Resident has sustained multiple unwitnessed falls. The complaint alleged that resident R1 had experienced multiple un-witnessed falls and that facility staff was delayed in responding to R1's needs. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegations. A1 stated that when staff found R1 on the floor of R1's room, they called the Med Tech or Nurse to evaluate R1. However, R1 consistently refused assistance, insisting that they were fine and had no pain. A1 also explained that for any resident who experienced an un-witnessed fall, staff would always call the Med Tech or Nurse to assess if the resident was in pain; if there were any injuries, they would immediately call Medical Emergency Services (MES). The department also interviewed the Licensed Vocational Nurse (LVN), who denied the allegations, stating that when staff discovered an un-witnessed fall, they would call the Med Tech and Nurses to conduct evaluations. If any injuries were found, they would contact MES right away. On the same date, the department interviewed the Medical Technician (MT1), who also denied the allegations and confirmed that they follow procedures regarding un-witnessed falls by contacting the LVN for resident assessment. Additionally, the department spoke with two staff members (S1 and S2), who similarly denied the allegations and stated that for un-witnessed falls, they would call both the MT1 and LVN to assess the residents, regardless of whether the residents reported pain or injuries. The department reviewed the facility notes dated (02/20/26, 02/22/26), in which staff found R1 on the floor lying with the pillow. R1 had no injuries or pain and refused to go to the hospital. The facility staff notified R1's family. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated. Allegation #2: Staff do not respond timely when resident falls. The complaint alleged that the facility staff delayed their response to Resident 1's (R1) care. On August 19, 2026, the department interviewed the Administrator (A1), who denied this allegation. A1 stated that each resident has a call button around their neck or in their pocket that, when pressed, prompts a staff member to respond. The Administrator also mentioned that R1 knows how to ask for help and communicates very effectively. A1 also stated R1 had multiple un-witnessed falls without any injuries; R1 always refuses Medical Emergency Services (MES) and stated there was no pain and that they were feeling fine. On the same day, the department interviewed the Licensed Nursing Volunteer (LNV), who also denied that staff delayed their response to residents. According to LNV, residents pressed the call button for assistance, and a staff member responded within minutes. Additionally, the department spoke with the Medication Technician (MT1), who similarly denied the allegation, stating that when residents requested help, staff responded immediately. Two staff members (S1 and S2) were also interviewed and denied the claim. They confirmed that when a resident pressed the call button, a staff member responded right away. The department interviewed ten additional residents (R2-R11), all of whom reported no neglect while seeking help. On August 19, 2026, the department observed two residents pressing their call buttons, and staff arrived eight minutes later. The department also reviewed the hospital discharge papers for R1, dated from February 3, 2026, to March 4, 2026, which indicated that R1 had been hospitalized several times for various symptoms. Additionally, the department examined the physician's report for R1, which confirmed that R1 was capable of performing activities of daily living independently and managing self-medication. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated. Allegation #3: Staff are not adequately caring for resident's wounds. The complaint alleged that a family member is concerned about wounds on the resident's left heel that allegedly have not healed properly. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that the facility nurse had observed a wound on the resident R1's left heel. After the wound evaluation and treatment, the facility contacted Bayview Hospice, and R1 agreed. On April 04, 2026, R1 started Hospice care treatment with Bayview Hospice. A1 stated after enrolling in Bayview Hospice, R1 decided to discontinue hospice care services. On April 23, 2026, the facility, staff members, a representative from Bayview Hospice, and R1's family were present when R1 decided to discontinue hospice care. Staff explained to R1 the benefits of receiving hospice assistance for wound care. Because the facility is not a medical center, staff took the time to explain R1's wound situation to the resident, who is independent and does not have a Power of Attorney (POA). On August 19, 2026, the department interviewed the Licensed Vocational Nurse (LVN), who denied the allegations and stated that the facility could not provide wound care to residents. Instead, the facility would contact Hospice Care and home health services to assist residents with wounds. The LVN emphasized that R1 needed support from one of these services, as the facility is not a medical facility. The department also reviewed the Bayview Hospice notes from the same date, which indicate that services were started and then discontinued for resident R1. The department also viewed a picture of R1's left foot tapes, which shows that R1 had a wound on the left foot. Allegation #4: Staff are not meeting resident's hygiene needs. The complaint alleged that a family member had several concerns about safety, hygiene, and the care provided in the resident's assisted living. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that Resident 1 (R1) can perform activities of daily living (ADLs) independently. R1 has a scheduled shower three times a week. A1 also stated that all staff members must follow the resident's physician reports and the service plan to assist residents with their hygiene needs. If a resident can’t, the staff would assist with the (ADLs) activities. On August 19, 2026, the department interviewed the Licensed Vocational Nurse (LVN), who also denied the allegation and confirmed that the staff adheres to the resident's physician report, doctor’s orders, and service plan to meet the resident’s hygiene needs accurately. The department also interviewed the Medication Technician (MT1), who denied the allegation and stated that they follow the resident's service plan to meet hygiene needs. The department interviewed two staff members, referred to as S1 and S2, both of whom denied the allegations. They confirmed that they have access to residents' face sheets, service plans, and shower schedules for each resident. They clarified that residents in a specific program are entitled to three showers per week. For private-pay residents, the number of showers is determined by how many the residents choose to purchase. On August 19, 2026, the department reviewed the physician's report and the service plan needs for Resident 1 (R1), which indicated that R1 was capable of self-care. Additionally, the department reviewed the facility’s shower schedule, which included dates, times, and room numbers, along with residents' names for the personal shower schedule. The staff also stated that if a resident refuses to shower, they document the refusal. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated. Allegation #5: Staff did not ensure the facility is kept sanitary and free from pests. The complaint alleged that the complainant saw rodents and cockroaches in resident R1's bedroom. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that Dewey Pest Control visits the facility weekly. A1 also stated that the facility rotates residents' rooms weekly. If a resident complained that a room had pets, the company would service the rooms and follow up the following week. On August 19, 2026, the department interviewed two staff members (S1-S2), both of whom denied the allegation and stated that pest control visits the facility weekly; if there is a problem with a resident's room, they let them know. Additionally, the department interviewed ten residents (R2-R11); 9 of 10 residents denied seeing any pets in their rooms and stated that pest control visits the rooms sometimes. On August 19, 2026, the department visited eight rooms: 315, 316, 317, 318, 272, 219, 217, and 114. On August 19, 2026, the department reviewed the physician's report and the service plan needs for Resident 1 (R1), which indicated that R1 was capable of self-care. Additionally, the department reviewed the facility’s shower schedule, which included dates, times, and room numbers, along with residents' names for the personal shower schedule. The staff also stated that if a resident refuses to shower, they document the refusal. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated. Allegation #5: Staff did not ensure the facility is kept sanitary and free from pests. The complaint alleged that the complainant saw rodents and cockroaches in resident R1's bedroom. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that Dewey Pest Control visits the facility weekly. A1 also stated that the facility rotates residents' rooms weekly. If a resident complained that a room had pets, the company would service the rooms and follow up the following week. On August 19, 2026, the department interviewed two staff members (S1-S2), both of whom denied the allegation and stated that pest control visits the facility weekly; if there is a problem with a resident's room, they let them know. Additionally, the department interviewed ten residents (R2-R11); 9 of 10 residents denied seeing any pets in their rooms and stated that pest control visits the rooms sometimes. On August 19, 2026, the department visited eight rooms: 315, 316, 317, 318, 272, 219, 217, and 114. The department observed no pets or cockroaches during the room inspection. The department observed no pets or cockroaches during the room inspection. The department reviewed the Dewey pest control invoice dated 06/01/2026, 07/01/2026, and 08/01/2026 for monthly services rendered to the facility. Additionally, include the apartment services log for each resident's room, dated 01/01/2026 to 06/01/2026. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to Administrator Suzette Johnson.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 11-AS-20260316124852

Allegation investigated: Staff did not prevent a resident from causing harm to another resident.

On August 19, 2026, Licensing Program Analyst (LPA) Antonine Richard conducted an initial visit to gather information regarding the above allegation. LPA Richard met with Executive Director Suzette Johnson and explained the purpose of the visit. The investigation consisted of the following: On 08/19/2026, LPA Richard reviewed and obtained the following documents: Staff and Resident Roster and Unusual Incident Report (dated 08/12/2026/UIR). The investigation also included documents for residents (R1-R2), the admission agreement, and the physician report. LPA interviewed ten residents (R1-R10) and three staff members (S1-S3), including a Licensed Vocational Nurse (LVN). Report continued on LIC9099C. Unsubstantiated Allegation: Staff did not prevent a resident from causing harm to another resident. The complaint alleged that on August 12, 2026, at 8:30 p.m., R1's roommate attempted to hit R1 while R1 was lying in bed. On August 19, 2026, LPA Richard interviewed the facility administrator, who denied the allegation. The administrator (A1) explained that R1 had recently moved into the facility. On the night of the incident, R2's roommate asked R1 to turn off the TV because it was late (around 8:55 p.m.), and R1 refused. At that moment, a staff member passing by the room heard the argument and called the Licensed Vocational Nurse (LVN) to intervene, which the LVN did. At the same time, LPA interviewed the LVN on August 19, 2026. The LVN reported that upon arrival in the residents' room, both R1 and R2 were lying on their beds and stated they were fine. The LVN asked whether either wanted to move to another room by the next morning, but both declined. On August 13, 2026, R2 requested a room change and was subsequently reassigned. During the investigation on August 19, 2026, LPA interviewed three staff members (S1-S3), all of whom denied the allegations. They stated that they supervise residents in common areas, provide activities to keep residents engaged, and intervene when they observe any issues. Additionally, LPA interviewed ten residents (R1-R10) that day. Eight of the ten residents reported that they had never experienced a conflict with their roommate and were trying to get along. At the same time, LPA also interviewed R1 and R2. Both stated that they had been fined; there were no physical altercations. During the facility inspection, LPA observed staff in common areas supervising residents and ensuring they were available to assist them. During the record review, LPA received and reviewed an Unusual Incident/Injury Report dated 08/12/2026, which the facility sent to the Community Care Licensing Department (CCLD), indicating that Resident R1 had a verbal altercation with Resident R2 and that there was no physical altercation. 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. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator Suzette Johnson.the state’s words, verbatim · CDSS document, Aug 19, 2026 · control 11-AS-20260813161607

Type of visit: Office

On July 17, 2026, a virtual office meeting was held as requested by Executive Director/Administrator Suzette Johnson. Attendees included Licensing Program Manager (LPM) Ulysses Coronel, Licensing Program Analyst (LPA) Socorro Leandro, Vice President of Operations James Bender, and Executive Director/Administrator Suzette Johnson. The following topics were discussed: · Patterns or recurring issues noticed among the complaints. · Facility’s ongoing efforts to build community partnerships. · Facility’s ongoing efforts to build relationships with residents. · Facility’s employment development plan. · Improvements being implemented by the facility regarding medications. · The Department’s offer of the Technical Support Program (TSP). This report was emailed to the Executive Director/Administrator Suzette Johnson.the state’s words, verbatim · CDSS document, Jul 17, 2026

Allegation investigated: Staff did not ensure that resident received showers while in care. Staff did not ensure that resident's clothing was changed.

On 07/15/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. California Department of Social Services (CDSS) was met by staff one, Suzette Johnson (S1), and the purpose of the visit was explained. The investigation consisted of the following: CDSS requested resident and staff roster (dated 07/15/26) and a care plan for a resident (R1) (dated 06/27/26), PM shower log of residents in care. Between 10:30AM and 2:00PM CDSS interviewed three (3) staff (S2-S4) and eight (8) residents (R1-R8). Report continues, please see 90999C Unsubstantiated The investigation revealed the following: Regarding the allegation “Staff did not ensure that resident received showers while in care.”, it is being alleged that residents are only showered two times per month. Record reviews of the PM shower log shows a resident (R1) on three (3) days to be showered. Record reviews of R1's care plan has bathing as "maximum assist", which indicates staff are now aware of R1's care plan. Interviews revealed that all three staff and six out seven residents have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff did not ensure that resident's clothing was changed.”, it is being alleged that residents have been wearing the same pants for a month. Record reviews of R1's care plan indicate dressing as "moderate assist", which indicates staff are now aware of R1's care plan. Interviews revealed that all three staff and all seven residents have denied the allegation has taken place. Based on record reviews, interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff one, Suzette Johnson, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 11-AS-20260707112422

Allegation investigated: Staff do not prevent residents from using illegal drugs on the facility premises while in care.

On July 08, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, a subsequent an unannounced complaint visit. Suzette Johnson, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, record reviews, and a tour of the facility. Investigation conducted by Investigator Dennis Seng of the CDSS Investigation Branch. Interviews with Staff member S#1 - S#7 (S1-S7), Resident #1 - #6 (R1- R6) and Witness #1 (W1). The Department reviewed several documents, including the Facility Resident Roster (dated 03/18/26), Personnel Report LIC 500 (dated 03/18/26), (R1’s and R2’s) Physicians Report LIC 602 A (dated 03/03/26 and 04/17/25), Appraisal/Needs & Service Plan LIC 625 (dated 10/12/23, 08/01/25 and 09/13/25) (Evaluation Report continues LIC 9099-C) Unsubstantiated Preplacement LIC 603 (dated 10/17/21 and 08/01/25) Physicians Orders Medication (dated 04/04/25 and 07/22/25) Residence and Care Agreement (dated 10/19/21). Additional review of Resident Warning Notice-Contraband Items (dated 03/14/26), Unusual Incident Report LIC 624 (dated 03/18/26), Photographs of Evidence (dated 03/14/26), and Long Beach Police Department Report DR 260111793 (dated 03/16/25). INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff do not prevent residents from using illegal drugs on the facility premises while in care. It is alleged that the facility staff fails to prevent residents from using illegal drugs on the premises. Reports indicate that staff discovered drug paraphernalia related to methamphetamine on March 14, 2026. Two residents, referred to as Resident #1 (R1) and Resident #2 (R2), are using illegal drugs on the premises while under care and are providing these substances to other residents. On April 3, 2026, May 19, 2026, June 10, 2026, and June 11, 2026, between 1:45 PM and 3:27 PM, the department conducted interviews with staff members identified as Staff #1 through Staff #7 (S1-S7). Seven (7) of the seven (7) staff members were unable to corroborate the claim that staff were accountable for neglect or a lack of supervision to prevent Residents #1 and #2 (R1 and R2), from using illegal drugs on the premises. On March 14, 2026, during a routine medication round, Staff #2 (S2) checked on (R1 and R2). (S2) observed a white powdery substance on the table, which (S2) believed to be illegal methamphetamine. (S2) reported that (R2) placed a box over the powder to conceal it. (S2) then left the room and informed Staff #3 (S3), who came to assist (S2). Together, (S2 and S3) attempted to confiscate the drugs but were unsuccessful. After the incident, (S2 and S3) notified Staff #1 (S1), who instructed Staff #4 (S4) to confiscate the described powdery substance found on (R2’s) nightstand. (S1) also ordered (S4) to conduct several unannounced inspections following the incident. (S4) then handed the drugs, along with a pipe, to Staff #5 (S5), who returned to (R1 and R2) to issue them a Resident Warning Notice on March 14, 2026, which they signed. (S5) reported that (R1 and R2) did not want to disclose who provided the drugs or where they were obtained. Staff #1 through Staff #7 (S1-S7) reported that they had never witnessed (R1 or R2) using drugs and that neither had a prior history of drug use. (Evaluation Report continues LIC 9099-C) On the same day, (S7) reported that law enforcement had been notified and had confiscated the methamphetamine. The responsible parties, (R1 and R2), along with their primary physician, were informed. Additionally, the California Department of Social Services Community Care Licensing, was notified of an Unusual Incident Report (LIC 624) on March 18, 2026. On April 3, 2026, and June 4, 2026, between 02:09 PM and 05:26 PM, the Department interviewed resident members identified as Resident #1 through Resident #6 (R1-R6). Six (6) of the six (6) resident members cannot support this claim. (R1 and R2) denied any use of illegal drugs on the facility premises. (R1) explained to have spoken to (R2) on March 14, 2026, and notice that a staff gave (R1) notice to sign. (R1) reported that (S2) found the drug on the round table on (R2’s) side of the room. Three (3) of the four (4) residents (R2-R6) stated that they did not witness (R1 or R2) under the influence of illegal drugs. However, (R6) mentioned that there was one occasion when (R2) had methamphetamine at the facility, specifically in the patio smoking area. (R6) suggested that the staff probably did not know about the drugs because, had they been aware, the drugs would have been taken away, and (R2) would have ended up being evicted. On April 3, 2026, and June 4, 2026, between 01:42 PM and 04:51 PM, the Department interviewed witness identified as Witness #1 (W1). Witness #1 (W1), who had firsthand knowledge of the incident, asserted that Resident #1 (R1) was not involved in the drug abuse and never used methamphetamine at the facility. (W1) believed that it was Resident #2 (R2) who procured the drugs and misused them in their room. Furthermore, (W1) expressed skepticism about the facility staff's awareness of any drug abuse; had they known, they surely would have acted by evicting (R2) or confiscating the drugs and reporting the incident appropriately. The Department reviewed the facility complaint history and incident reports; there was no previous indication that Resident #1 and Resident #2 (R1-R2) had engaged in drug abuse while receiving care at the facility. Further review of (R1’s and R2’s) Physicians Report LIC 602 A (dated 03/03/26 and 04/17/25), Appraisal/Needs & Service Plan LIC 625 (dated 10/12/23, 08/01/25 and 09/13/25) Preplacement LIC 603 (dated 10/17/21 and 08/01/25) Physicians Orders Medication (dated 04/04/25 and 07/22/25) Residence and Care Agreement (dated 10/19/21). Additional review of Resident Warning Notice-Contraband Items (dated 03/14/26), Unusual Incident Report LIC 624 (dated 03/18/26), and Long Beach Police Department Report DR 260111793 (dated 03/16/25). (Evaluation Report continues LIC 9099-C) Based on the gathered information, it appeared that the facility was unaware of any previous instances of drug abuse involving Resident #1 and Resident #2 and that they acted promptly by reporting and confiscating the drugs once staff found them. There is insufficient evidence to corroborate the allegation. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted with SUZETTE JOHNSON, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 11-AS-20260316164851

Allegation investigated: Rooms are malodorous Facility is not equipped with sufficient hygiene supplies

On 07/07/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced continuation complaint investigation visit regarding the allegations listed above. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 01/29/2026, a facility tour was conducted and Resident 1 (R1) to Resident 10 (R10) and Witness 1 (W1) to Witness 2 (W2) were interviewed. On 04/09/2026, a facility tour was conducted and Staff 1 (S1) to Staff 13 (S13) and Resident 11 (R11) to Resident 14 (R14) were interviewed. On 04/10/2026, nine resident Medication Administration Records (MARs) were reviewed along with their medications. On 05/05/2026, Witness 1 (W1) to Witness 9 (W9) were interviewed. On 05/06/2026, Witness 10 (W10) was interviewed. On 05/08/2026, Witness 11 (W11) to Witness 13 (W13) were interviewed. Records were gathered and reviewed. On 07/03/2026, documentation/records were reviewed. Substantiated The investigation revealed the following: Allegation: “Rooms are malodorous”, it is being alleged that residents’ rooms are malodorous. Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation, moreover, staff explained that housekeepers are continuously working to keep up with the needs of residents. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 6 out of 14 residents agreed with the allegation, moreover they indicated that the facility has incontinent and cigarette smells; 5 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 11 out of 13 witnesses denied the allegation, furthermore, witnesses stated that facility staff clean up after residents; 2 out of 13 witnesses agreed with the allegation. On 01/29/2026, resident rooms were toured and the following was observed: room 267 had strong incontinent smells and room 284 had strong odors. On 04/09/2026, resident rooms were toured and the following was observed: room 242 was malodorous; room 121 had strong incontinent smells; room 126 had strong cigarette odor; room 127 had strong incontinent odor; room 272 had strong incontinent smells; room 115 had strong incontinent smells, resident visitor stopped facility staff in the hallway and informed them that they have been attempting to reach staff and have not been assisted, additionally, resident visitor informed staff the room is “smelling so bad” requesting for the diapers in the trash bin to be removed and the bed sheets to be removed and replaced with clean bed sheets, resident visitor had on two disposable medical face masks, staff called for assistance. Records reviewed revealed the following: the facility has a laundry schedule and cleaning schedule for the Memory Care Unit and the Assisted Living Unit; on 04/27/2026, the facility implemented a plan to ensure that resident appliances (e.g. refrigerators) were to be maintained cleaned, resident rooms will be cleaned and “residents requiring additional support will be flagged for staff follow-up.” Substantiated: Based on observations and interviews, 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 and Chapter 8 are being cited on the attached LIC 9099D. Allegation: “Facility is not equipped with sufficient hygiene supplies,” it is being alleged that residents are not provided with sufficient hygiene/bathroom supplies such as paper towels, hand soap, and so on. Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation, staff explained that residents receive a clean hand towel but do not receive paper towels and there are no electric hand dryers in the resident bathrooms. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 2 out of 14 residents denied the allegation; 9 out of 14 residents agreed with the allegation, furthermore, they explained that the facility provides them with toilet paper and a hand towel, and at times they provide them with hand soap, moreover, residents explained that they purchase their own hand soap and hygiene supplies. Observations of resident rooms on 01/29/2026 and 04/09/2026 in the Memory Care Unit and Assisted Living Unit revealed the following: Resident bathrooms are provided with a hand towel even if there are two residents per room; residents are not provided with paper towels nor an electrical hand dryer. There were five bathrooms that did not have hand soap, and there were several bathrooms that did not have toilet paper and a hand towel. Substantiated: Based on observations, interviews and record review, 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 and Chapter 8 are being cited on the attached LIC 9099D. The investigation revealed the following: Allegation: “Unqualified staff are providing medication assistance to residents in care”, it is being alleged that untrained staff are providing medication assistance to residents in care which have resulted in medication errors. Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation, moreover, staff indicated that staff are trained in medication administration and staff are not aware of any medication errors. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation and 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. Records reviewed of Medication Administration Trainings from 01/2025 to 01/2026 revealed the following: Medical Technicians (MedTech’s) and Licensed Vocational Nurses (LVNs) received in-service trainings on Medication Destruction, Receiving Medication, Centrally Storing Medication, Expired Medications, Managing Orders, Communication Documentation, Refusal of Medication, Counting Narcotics, Medication Crushing, Discontinued Medication, MAR Documentation, and so on. Records reviewed revealed that in 2026 MedTech’s received a Certificate of Completion for successfully completing 8 hours of in service of Medication Administration Techniques & Medication Forms Documentation. Records reviewed revealed that LVNs have a current Vocational Nurse License. Unsubstantiated: 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. An exit interview was conducted, and a copy of this report was left with the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 11-AS-20260122103758

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(2) · Plan of correction due date: Aug 3, 2026

Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observations and interviews the licensee did not comply with the section cited above by not providing residents with comfortable accommodations by not having rooms free of malodors which included incontinent odors, cigarette smoke odors, etc. which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Executive Director has agreed to create a plan to ensure that residents are provided with comfortable accommodations by maintaining a facility that is clear of malodors. Plan should include the following: removal of used incontinent supplies from resident rooms, the number of times staff will go into residents rooms to remove items that are/can cause malodorous and smoking prevention inside the facility. The Executive Director will train staff on said plan. Email plan & trainings to Socorro.Leandro@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C)(D) · Plan of correction due date: Aug 3, 2026

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. (D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Based on observations and interviews the licensee did not comply with the section cited above by providing residents with a common hand towel and not ensuring that residents had hand soap and toilet paper are available to them at all times which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Executive Director has agreed to create a plan to ensure that the use of common (hand) towels are prohibited in the facility. And residents have hand soap, toilet paper, and hand drying material (e.g. paper towels, hand dryer, individual hand towels) available to them at all times. Email plan & trainings to Socorro.Leandro@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 07/07/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of this visit is to deliver deficiencies observed during the course of the investigation regarding complaint control number 11-AS-20260122103758. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility. Deficiencies observed were as follows: Record review of the facility Plan of Operation revealed the following: · “Medication Refills…Medication refills will be obtained in a timely manner to ensure residents have all physician ordered medication available. 1. The designated staff member contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to running out of medication…When the medication is ordered it entered onto the Refill Roster…3. Medications are never allowed to run out.” · “Missed or Refused Medications…1. Missed/refused medications are documented in the resident’s medication record…” · “Blood Pressure and/or Pulse Reading to Determine the Need for a Medication…resident’s vital signs are taken to determine the need for admiration of medications: a)…A written record is made on the MAR. b) When the medication is given, the date, time, and initials of the person who took the vital signs and/or gave the medication are documented. · “Assisting with Administration: Oral Medications…5. Document administration of medication on them Medication Assistance/Administration Record.” On 04/10/2026, resident MARs were reviewed along with their medications in the Memory Care Unit and Assisted Living Unit and the following was revealed: · Resident 2 (R2) did not have their prescription or nonprescription PRN medication available to them which was “Hyoscyamine 0.125 mg tab”. MedTech was unable to locate PRN medication. · Resident 15’s (R15) March 2026 MAR shows the following: o “Furosemide 40 mg tablet – take 1 tablet by mouth daily for CHF Hold for SBP <110” § On 03/01/2026 medication was not provided to R15 and Blood Pressure (BP) was not documented. § On 03/05/2026 medication was provided to R15 and BP was not documented. § On 03/25/2026 medication was provided to R15 and BP was not documented. o “Digoxin 125 mcg tablet – take 1 tablet by mouth once daily at 12 PM for a-fib (Hold if apical pulse below 60)” § On 03/05/2026 medication was provided to R15 and pulse was not documented. § On 03/25/2026 medication was provided to R15 and pulse was not documented. § On 03/31/2026 medication was provided to R15 and pulse was not documented. o “Sacubitril-Valsartan 24-26 mg – take 1 tablet by mouth twice daily (hold if sbp below 110)” § On 03/01/2026 at 8:00 AM R15 medication was not provided to R15 and BP was not documented. § On 03/05/2026 and 03/25/2026 at 8:00 AM R15 medication was provided to R15 and BP was not documented. § On 03/05/2026, 03/06/2026, 03/07/2026, 03/13/2026, 03/14/2026, 03/29/2026, and 03/31/2026 at 5:00 PM R15 medication was provided to R15 and BP was not documented. ·Resident 16 (R16) April 2026 MAR shows the following: o “Vitamin D3 50,000 unit capsule – take capsule by mouth once weekly on Fridays” was not available to R16. MedTech was unable to locate the routine medication. Records reviewed revealed that a refill was not submitted and no notes were written. o “Alum-Mag Hydroxide-Simeth Susp” – PRN medication was not available for R16. MedTech was unable to locate PRN medication. Said medication has not been provided to the resident. o “Loperamide 2 mg capsule” - PRN medication was not available for R16. MedTech was unable to locate PRN medication. Said medication has not been provided to the resident. o “Milk of Magnesia Suspension” - PRN medication was not available for R16. MedTech was unable to locate PRN medication. Said medication has not been provided to the resident. · Resident 7 (R7) April 2026 MAR shows the following: o “Pantoprazole sod dr 40 mg tab – Take 1 tablet by mouth twice daily before meals for 14 days.” § There were 9 medication errors for this medication. § The medication bubble states that the medication was dispensed on “03/28/2026” with “no refills” and a “quantity of 28 tablets” (28 divided by 14 equals a total of 14 days of medication, the last day of the medication would have been 04/10/2026 if R7 started to take medication in the morning of 03/28/2026); the bubble pack has an “AM” sticker. There is no bubble pack with a “PM” sticker. The April 2026 MAR shows that R7 received medication at 8 AM and 5 PM from 04/01/2026 to 04/09/2026 and R7 refused 8 AM medication on 04/10/2026. The bubble pack has 12 tablets popped out and 16 tablets in the bubble pack (there should have been one more tablet left over if R7 started to take medication in the morning of 03/28/2026). According to interviews with staff in the Medication Room, they only provide this medication to R7 at 8 AM but not at 5 PM. Physicians Orders and Hospice records confirmed that this medication was prescribed to be taken twice a day for 14 days. · Resident 10 (R10) April 2026 MAR shows the following: o There are 14 medication errors. § 14 Medication bubble packs for “AM” are popped out for 04/09/2026. § April 2026 MAR for 04/09/2026 at 8 AM are left blank with no initials for 14 different medications. · Resident 13 (R13) April 2026 MAR shows the following: o 2 routine medications were not found in the Medication Room; MedTechs were unable to locate the medications. According to MAR the resident has been taking the medication as prescribed. The medications were “Spiriva Handihaler 18 mcg cap” and “Bacitracin 500 unit/gm ointment.” Physician’s Orders confirmed that said medications were prescribed. o 8 PRN medications were not found in the Medication Room; MedTechs were unable to locate the medications. Physician’s Orders confirmed that said medications were prescribed. Said medications have not been provided to the resident. Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, Jul 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Aug 3, 2026

Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by: Based on observations, interviews, and record review the licensee did not comply with the section cited above by not following the facility’s Plan of Operation and not providing medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Executive Director has agreed to review the facility’s Plan of Operation regarding medication and train MedTechs & LVNs. Confirmation of reviewed Plan of Operation regarding medication and trainings shall be emailed to Socorro.Leandro@dss.ca.gov

Allegation investigated: Staff do not provide adequate food service.

On 06/25/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. California Department of Social Services (CDSS) was met by staff one, Suzette Johnson (S1), and the purpose of the visit was explained. The investigation consisted of the following: On 06/25/26 CDSS requested and reviewed facility documents which included resident roster (dated 06/25/26), staff roster (dated: 06/25/26), a resident's care plan (R1) (dated: 06/14/26), R1's Medication Administration Record (MAR) (dated: 06/25/26), weekly menu (dated: 06/21/26 through 06/27/26) and CDSS toured the facility. Between 10:45AM and 3:15PM, LPA interviewed nine (9) residents and three (3) staff. The investigation revealed the following: Regarding the allegation “Staff do not provide adequate food service.”, it is being alleged that staff do not wake a resident for breakfast and lunch mealtimes. Interviews revealed that seven (7) residents and all three (3) staff have denied the allegation has taken place, while one (1) resident refused CDSS' interview. Report continues, please see LIC9099C. Unsubstantiated CDSS made the following observations: CDSS observed a "PM" meal in a to go box, which had been brought up to R1 on 06/24/26. The meal appeared to be dinner from the night before, which included a cup of soup, a roll, a slice of cantaloupe and Shepherd's pie. The meal had not been altered, meaning the meal had not been touched. CDSS record reviews consisted of R1's MAR, R1's service plan and weekly menu along with an alternative menu which is available each day. All of these files were reviewed and appeared to have no discrepancies. Based on interviews conducted, observation and record reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was conducted with Suzette Johnson, Executive Director, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jun 25, 2026 · control 11-AS-20260618154401

Allegation investigated: Staff do not provide adequate food service.

On 06/25/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. California Department of Social Services (CDSS) was met by staff one, Suzette Johnson (S1), and the purpose of the visit was explained. The investigation consisted of the following: On 06/25/26 CDSS requested and reviewed facility documents which included resident roster (dated 06/25/26), staff roster (dated: 06/25/26), a resident's care plan (R1) (dated: 06/14/26), R1's Medication Administration Record (MAR) (dated: 06/25/26), weekly menu (dated: 06/21/26 through 06/27/26) and CDSS toured the facility. Between 10:45AM and 3:15PM, LPA interviewed nine (9) residents and three (3) staff. The investigation revealed the following: Regarding the allegation “Staff do not provide adequate food service.”, it is being alleged that staff do not wake a resident for breakfast and lunch mealtimes. Interviews revealed that seven (7) residents and all three (3) staff have denied the allegation has taken place, while one (1) resident refused CDSS' interview. Report continues, please see LIC9099C. Unsubstantiated CDSS made the following observations: CDSS observed a "PM" meal in a to go box, which had been brought up to R1 on 06/24/26. The meal appeared to be dinner from the night before, which included a cup of soup, a roll, a slice of cantaloupe and Shepherd's pie. The meal had not been altered, meaning the meal had not been touched. CDSS record reviews consisted of R1's MAR, R1's service plan and weekly menu along with an alternative menu which is available each day. All of these files were reviewed and appeared to have no discrepancies. Based on interviews conducted, observation and record reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was conducted with Suzette Johnson, Executive Director, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jun 25, 2026 · control 11-AS-20260618154401

Type of visit: Office

On May 26, 2026, at 1:30 pm, an office meeting was held to discuss Complaint 11-AS-20240429113918. Present at the meeting were Eva Alvarez, Licensing Program Manager (LPM); Antonine Richard, Licensing Program Analyst (PLA); Suzette Johnson, Executive Director (ED), People Operations; Claudia Crowley; and James Bender, Vice President. During the meeting, LPM reviewed the details of the Complaint. On May 16, 2025, the Department substantiated an allegation that a resident sustained a fracture due to lack of care from staff. At this time, the Department is considering an enhanced civil penalty under Health and Safety Code Section 1569.49(f). The department is reviewing the complaint to determine whether to assess an enhanced civil penalty for Serious Bodily Injury pursuant to H&S 1569.49(f). The total civil penalty for Serious Bodily Injury is $10,000. An exit interview was conducted with Suzette Johnson, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 26, 2026

Allegation investigated: Staff speaks inappropriately to resident in care

On 05/20/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. California Department of Social Services (CDSS) was met by staff two, Sidonia Cordis - Resident Care Director (S2) and later by staff three, Suzette Johnson - Executive Director (S3), and the purpose of the visit was explained. The investigation consisted of the following: On 05/20/26 CDSS requested and reviewed facility documents and toured the facility. Between 8:00AM and 11:00AM, LPA interviewed ten (10) out of two-hundred and forty-three (243) residents (R1-R10) and six (6) out of one-hundred and twenty-two (122) staff (S1-S6). S1 was not available for CDSS interview, as S1 did not answer CDSS phone call. The investigation revealed the following: Regarding the allegation “Staff speaks inappropriately to resident in care”, it is being alleged that staff speak inappropriately to the residents during medication rounds. Report continues, please see LIC9099-C. Unsubstantiated Record reviews have indicated that S1 has fulfilled all staff requirements under personnel requirements and personnel records and is eligible to work at and are associated to the facility. Interviews revealed that nine (9) out of ten (10) residents and all six (6) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was conducted with Suzette Johnson - Executive Director, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 11-AS-20260512153126

Allegation investigated: Staff did not keep facility free of vermin.

THIS REPORT SUPERSEEDS THE REPORT DATED 04/09/2026 TO CHANGE COMPLAINT INVESTIGATION FINDING(S). On 04/09/26 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director as the purpose of today’s visit was explained. The investigation consisted of the following: On 04/01/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre placement appraisal dated: 02/20/25, Admission agreement dated: 02/18/25 , resident assessment dated: 03/05/25, Physicians report dated: 02/13/25, service plan dated: 06/17/25, updated service plan dated 03/26, shower schedule, facility notes dated: 03/2026, facilities laundry schedule, pest control service logs dated: On 01/2026-04/2026. On 04/01/26 from 10:00 am- 12pm LPA conducted Interviews with Residents #2-10 (R2-R10). On 04/01/26 LPA was unable to interview R1 as R1 was out of the Unsubstantiated facility at the time of visit. On 04/01/26 LPA conducted interviews with staff #1-3 (S1-S3) and conducted a tour of the facility. On 04/09/26 LPA conducted interviews with staff #4-6 (S4-S6). On 04/09/26 at 2pm LPA conducted interview with R1. The investigation revealed the following: Allegation: Staff did not keep facility free of vermin. It is alleged that the facility has a rat problem as rat feces have been observed at the facility. On 04/01/26 and 04/09/26 LPA conducted Interviews with R1-R10 regarding the allegation above. 8 of the 10 residents interviewed denied the allegation above, 2 of the 10 residents interviewed confirmed the allegation above. 10 of 10 residents interviewed confirmed that the facility is being treated by pest control. On 04/01/26 and 04/09/26 LPA conducted interviews with S1-S6. 4 of the 6 staff interviewed denied the allegation above, 2 of 6 staff interviewed confirmed the allegation above and reported seeing mice at the facility. 5 of the 6 staff confirmed that pest control services are coming out to service the facility. 1 of the 6 staff interviewed reported having no knowledge of pest control services at the facility. On 04/01/26 LPA observed pest control to be servicing the facility at the time of the visit. On 04/01/26 LPA conducted a review of pest control service report dated: 3/25/26. Per the report, 20 rooms were serviced, interior and exterior inspected and baited, no activity found, EZ snaps are inspected each time facility is serviced, sanitation conditions listed as Fair. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 12, 2026 · control 11-AS-20260325122703

Type of visit: Case Management - Deficiencies

On 05/12/26, Licensing Program Analyst (LPA) Villegas conducted an unannounced case management visit in association with complaint visit 11-AS-20260325122703 conducted on 04/09/26. LPA met with Executive Director Suzette Johnson as the purpose of the visit was explained. On 04/09/26, while LPA Villegas walked down the facility hallway the following deficiency was observed: 87303(a) LPA observed live cockroach in facility hallway. Deficiency cited on 809D page. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 12, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 9, 2026

87303 Maintenance and Operation 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 deficiency was not met as LPA observed a live cockroach in facility hallway which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Executive Director to submit plan to LPA by POC due date detailing what the facility is going to do regarding pest control throughout the facility. What measure will be added to cleaning procedures to ensure pests at the facility is under control to ensure residents’ health and safety. Deficiency was cleared on 04/27/26, prior to LPA Villegas superseding report.

Allegation investigated: Staff did not shower residents in care Staff did not wash residents’ clothing Staff do not practice proper hand hygiene when handling foods Staff did not provide housekeeping services to residents Staff did not maintain facility restrooms in a clean condition Intoxicated residents engage in loud and disruptive behaviors in the facility

On 05/08/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced continuation complaint investigation visit regarding the allegations listed above. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 1/29/2026, a facility tour was conducted and Resident 1 (R1) to Resident 10 (R10) and Witness 1 (W1) to Witness 2 (W2) were interviewed. On 04/09/2026, a facility tour was conducted and Staff 1 (S1) to Staff 13 (S13) and Resident 11 (R11) to Resident 14 (R14) were interviewed. On 4/10/2026, nine resident Medication Administration Records (MARs) were reviewed along with their medications. On 05/05/2026, Witness 1 (W1) to Witness 9 (W9) were interviewed. On 05/06/2026, Witness 10 (W10) was interviewed. On 05/08/2026, Witness 11 (W11) to Witness 13 (W13) were interviewed. Records were gathered and reviewed. Unsubstantiated The investigation revealed the following: Allegation: “Staff did not shower residents in care.” Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 11 out of 13 witnesses denied the allegation; 2 out of 13 witnesses agreed with the allegation. Records reviewed revealed the following: The facility has a shower schedule for the Memory Care Unit and the Assisted Living Unit. Observations revealed the following: residents in the Memory Care Unit and Assisted Living Unit appeared to be groomed on a routine basis. Unsubstantiated: 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. Allegation: “Staff did not wash residents’ clothing.” Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. Records reviewed revealed the following: The facility has a laundry schedule for the Memory Care Unit and the Assisted Living Unit. Observations revealed the following: laundry rooms were toured in the Memory Care Unit and Assisted Living Unit, and staff were washing clothes and taking clean clothes to residents’ units. Resident rooms were toured in the Memory Care Unit and Assisted Living Unit and residents had clean clothes available to them. Unsubstantiated: 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. Allegation: “Staff do not practice proper hand hygiene when handling foods.” Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. Records reviewed revealed the following: On 06/15/2025, staff were trained on hand washing for handling food. Observations revealed the following: staff appeared to be in good hand hygiene during mealtimes in the Memory Care Unit and Assisted Living Unit. Unsubstantiated: 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. Allegation: “Staff did not provide housekeeping services to residents.” Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 11 out of 13 witnesses denied the allegation; 2 out of 13 witnesses agreed with the allegation. Records reviewed revealed the following: The Memory Care Unit has a cleaning/organizing schedule for residents’ rooms. The Assisted Living Unit has a Deep Cleaning Schedule. Observations revealed the following: Housekeepers were present in the facility providing housekeeping services to residents in care, for example, cleaning resident rooms and cleaning communal areas. Tours of the Memory Care Unit and Assisted Living Unit were conducted, and rooms appeared to be clean; Memory Care Unit Rooms were very well organized. Unsubstantiated: 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. Allegation: “Staff did not maintain facility restrooms in a clean condition.” Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. The Memory Care Unit has a cleaning/organizing schedule for residents’ rooms. The Assisted Living Unit has a Deep Cleaning Schedule. Observations revealed the following: Housekeepers are present in the facility providing housekeeping services to residents in care, for example, cleaning resident bathrooms. Tours of the Memory Care Unit and Assisted Living Unit were conducted; resident bathrooms appeared to be clean and sanitary. Unsubstantiated: 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. Allegation: “Intoxicated residents engage in loud and disruptive behaviors in the facility.” Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. Records reviewed revealed the following: there were no unusual incident reports indicating that residents were intoxicated engaging in loud and disruptive behaviors in the facility. Observations revealed the following: residents were not observed intoxicated engaging in loud and disruptive behaviors. Unsubstantiated: 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 were cited. An exit interview was conducted, and a copy of this report was left with the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, May 8, 2026 · control 11-AS-20260122103758

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide adequate supervision, resulting in resident sustaining fractures

On 05/01/26 The Department conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director as the purpose of today’s visit was explained. The investigation consisted of the following: On 02/18/26 The Department obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre-appraisal dated: 01/04/24, Physicians report dated: 04/21/2025, needs and service plan dated: 04/12/25, communication notes for February 2026, and unusual incident report dated: 02/15/26. On 03/02/26 The Department conducted interviews with staff #1-3 (S1-S3), and interviews with residents #1-2 (R1-R2). On 03/02/26 The Department reviewed police report from the Long Beach Police Department. On 03/03/26 The Department reviewed medical records from Long Beach Memorial Hospital for (R1). On 03/12/2026 The Department conducted a review of medication compliance list for (R2). On 05/01/26 The Department conducted interviews with Residents #3-10 (R3-R10) regarding the allegation above. The investigation revealed the following: Unsubstantiated Allegation: Staff did not provide adequate supervision, resulting in a resident in care sustaining fractures. It is alleged that facility staff did not respond in a timely manner when a resident in care called for help. On 03/02/26 and 05/01/26 The Department conducted interviews with R1-R10 regarding the allegation above. During interview with R1, R1 confirmed being assaulted but could not provide detailed information regarding the above allegation, however, R1 believes it took 5 minutes for staff to respond and assist. Additionally, R1 states feeling safe to return to the facility for care. During interview with R2, R2 confirmed the assault however R2 did not provide any information regarding the allegation above. During interviews with R3-R10, 7 of the 8 residents interviewed denied the allegation above and reported that assistance from staff is provided when requested, 1 of the 8 residents interviewed reported being independent and assistance from staff is not required. Furthermore, 6 of the 8 residents interviewed on 05/01/26 indicated that staff response time is within minutes, 1 of the 8 residents reported staff response time can take up to an hour, 1 of the 8 residents interviewed reported being unaware as staff assistance is not required. On 03/02/26 The Department conducted interviews with S1-S3 regarding the allegation above. 3 of 3 staff interviewed denied the allegation above. Per 2 of the 3 staff interviewed, they were on shift the night of the incident and assisted as soon as they were notified of the situation. Per 3 of 3 staff interviewed, there was no history of violence between R1 and R2 nor individually with other residents in care. On 03/12/26 The Department conducted a review of medical records from Long Beach Memorial Hospital date: 2/15/2025 which indicated that R1 was admitted to Long Beach Memorial Hospital with a diagnosis of: Assault, Closed non displaced fracture of head of left radius sequela, and Closed fracture of multiple ribs of left side, initial encounter. On 03/12/2026 The Department conducted a review of medication compliance list for R2, per medication administration record R2 had been refusing to medications from 02/6/26- 02/13/26. Upon review it is unclear if the refusal of these medications during this period contributed the assault/battery that occurred between R1 and R2. 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. Exit interview conducted, and a copy of this report was not provided.the state’s words, verbatim · CDSS document, May 1, 2026 · control 11-AS-20260217132633

Allegation investigated: Staff gave resident the wrong medication.

On 05/01/26 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director as the purpose of today’s visit was explained. The investigation consisted of the following: On 04/09/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre placement appraisal dated: 07/20/21 Physicians report dated:12/09/25, Physicians orders, Medication Administration Record (MAR) for 03/2026- 04/2026, service plan dated: 09/12/25, and facility notes dated: 07/2023-03/2026. On 04/09/26 from 11:00 am- 12pm LPA conducted Interviews with Staff #1-4 (S1-S4), and on 04/09/26 from 1pm- 2:30pm LPA conducted interviews with residents # 1-10 (R1-R10). On 04/22/26 LPA Villegas conducted a review of documents obtained. On 04/22/26 The Department addressed similar complaint allegation which was found to be unsubstantiated. On 05/01/26 LPA Villegas conducted a medication administration records review. The investigation revealed the following: Unsubstantiated Allegation: Staff gave a resident the wrong medication. It is alleged that facility staff gave a resident in care medication for two days that were prescribed to a different resident in care. On 04/09/26 from 11:00 am- 12pm LPA conducted Interviews with S1-S4 regarding the allegation above. 4 of the 4 staff interviewed denied the above allegation. Per 4 of 4 of the staff interviewed, residents with the same or similar name staff are verifying birth dates prior to administering medications. Additionally, 2 of the 4 staff interviewed reported that the facilities electrical medication administration record (EMAR) has some of the resident’s pictures which are also used to confirm that the medication is being administered to the correct resident. On 04/09/26, 4 of the 4 staff interviewed reported that a supervisor is notified if a medication error occurs. On 04/09/26 from 1pm- 2:30pm LPA conducted interviews with R1-R10 regarding the allegation above. 7 of the 10 residents interviewed denied the allegation above. 1 of the 10 residents interviewed reported managing their own medications therefore they have no knowledge of the allegation above. 2 of the 9 residents interviewed confirmed the allegation above and report they made the staff aware of the error. On 04/22/26 LPA Villegas conducted a review of documents obtained, per preplacement appraisal dated: 07/20/21, Physicians report dated:12/09/25, and Service plan dated: 09/12/25 R1 requires assistance with medication and R1 cannot store nor administer their own medications. On 04/22/26 The Department addressed similar complaint allegation which was found to be unsubstantiated. 05/01/26 LPA Villegas conducted a medication review and observed all medications to be accounted for and documented on EMAR. 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. Exit interview conducted, and a copy of this report was not provided.the state’s words, verbatim · CDSS document, May 1, 2026 · control 11-AS-20260403114442

Allegation investigated: Lack of care and supervision.

On 04/22/2026, at approximately 1:00 PM, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent visit to deliver findings. LPA met with the Administrator Suzette Johnson. This report supersedes the previous report issued on 03/19/2026. The purpose of this report is to provide additional information; the findings have not changed and remain SUBSTANTIATED. The investigation consisted of the following: On 04/22/2026, The Department toured the memory care unit. Reviewed records including the personnel report, staff roster, February 2026 memory care staffing schedule, grouping sheet, incident reports, resident progress notes, and facility procedures. Conducted interviews with six staff (S1–S6) and seven family witnesses (W1–W7). On 04/22/2026, additional interviews with five residents (R1–R5) were conducted. The investigation revealed the following regarding the allegation: “Lack of care and supervision.” It is alleged that facility staff failed to provide adequate supervision, resulting in a resident sustaining an unwitnessed fall during the night with no staff awareness of when or how the fall occurred. Please see (LIC9099-C) for report continuation. Substantiated Interviews conducted revealed the following: Staff (S1) reported the incident was unwitnessed and discovered at approximately 6:00 AM during morning rounds. Staff (S2–S3) reported the resident was found with a bump on the head at approximately 5:30 AM. Staff (S1–S3) reported they were unable to determine when or where the fall occurred. Staff (S1) reported four staff were scheduled for the overnight shift; however, three staff were present due to staffing changes. Staff (S2–S3) confirmed three staff were assigned to the overnight shift. Staff (S6) reported that three staff provide care for approximately 35 memory care residents during the overnight shift. Witnesses (W1–W5) reported concerns regarding night supervision, staffing levels, and prior unwitnessed falls. Witnesses (W6–W7) reported no concerns. Of the residents interviewed, (2) out of (5) residents reported staff do not check on them during the night or do not recall staff presence. (3) out of (5) residents were unable to confirm whether staff conducted nighttime checks. (4) out of (5) residents reported prior falls or being on the floor, including (1) resident who reported a fall that was not reported to staff. (6) out of (6) residents were not able to provide interviews due to their medical conditions. Observations revealed the following: LPA toured the memory care unit and observed multiple hallways and resident rooms extending in different directions, not visible from a single central area. The unit houses approximately 35 residents, including residents requiring incontinence care. Staff reported grouping residents in a common area for visibility. At the time of the visit, approximately 4–5 staff were observed present with residents. Records review revealed the following: Review of the February 2026 staffing schedule confirmed that three staff, including registry staff, were assigned to the overnight shift on 02/13/2026–02/14/2026. Incident reports and progress notes confirmed that (R1) sustained an injury consistent with a fall that occurred overnight. Documentation did not identify the time or circumstances of the fall. Progress notes dated 02/14/2026 document that caregivers reported the injury in the morning and indicated limited information was available from the overnight shift regarding the incident. Review of incident reports and progress notes dated 02/06/2026, 02/10/2026, and 02/14/2026 document residents were found on the floor with injuries during morning hours, with no documentation identifying when or how the falls occurred. Resident records indicate that all 35 out of 35 memory care residents require incontinence care and supervision due to behaviors such as wandering/exit seeking behaviors. Based on the evidence gathered, including interviews, observations, and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87411(a), which requires sufficient staff to meet resident care and supervision needs. A citation is issued on the attached LIC 9099-D. An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 11-AS-20260218190506

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 26, 2026

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 is not met as evidenced by: Based on interviews, observations, and records review, the licensee failed to ensure sufficient staffing to meet the needs of 35 residents during overnight hours. Records review confirmed that three staff were assigned to provide care during the overnight shift. Incident reports and progress notes document a pattern of residents found with injuries during morning hours, with no documentation identifying when or how the incidents occurred. This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Licensee agreed to submit a plan of correction to LPA Jose Anguiano at Jose.Anguiano@dss.ca.gov by due date.

Allegation investigated: Staff did not assist resident with dressing

On 4/22/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Executive Director, Suzette Johnson and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 4/22/26 LPA Felisa Shirley reviewed copies of the following records: Staff and Resident Roster, Medical Assessment for Residential Care Facilities for the Elderly, Service Plan 4/21/26, Service Plan 4/8/26, and Resident Assessment 4/8/26. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-5 (S1 – S5), and Resident -1 – Resident – 10 (R1-R10). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not assist resident with dressing It is being reported that resident was not assisted with getting dressed. Resident was admitted to this facility 4/8/26. Per review of Admission Resident Assessment dated, 4/8/26, R1 was assessed as Independent, and self-care for level of assistance with dressing and grooming. LPA also observed the Service Plan for R1 dated 4/8/26 indicating resident as, Independent, self-care for both dressing and grooming. During interviews on 4/22/26, LPA Felisa Shirley spoke with a family member, W1. W1 stated she’d been contacted for a care plan meeting regarding R1. W1 stated that R1 was reassessed and R1 was reclassified as requiring complete, hands-on assistance with dressing and grooming. LPA Shirley reviewed new Service Plan for R1 dated 4/21/26. Service plan indicated that R1 requires full assistance with dressing in the morning and full assistance with undressing at bedtime. LPA interviewed staff 1 – staff 5 (S-1 – S-5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 10 out of 10 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not assist resident with dressing,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 11-AS-20260417082655

Allegation investigated: Facility staff are not dispensing medications as prescribed Facility staff are not keeping accurate resident records

On 04/22/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. California Department of Social Services (CDSS) was met by staff one, Suzette Johnson (S1), and the purpose of the visit was explained. S1 and CDSS toured the facility. The investigation consisted of the following: On 04/22/26 CDSS requested and reviewed facility documents, including medication administration records (MAR) of R2, R11-R13 and toured the facility. Between 09:30AM and 3:00PM, CDSS interviewed ten (10) residents (R1-R10) out of two-hundred forty-two (242) residents and nine (9) staff out of one-hundred twenty-one (121) staff (S1-S9). The investigation revealed the following: Regarding the allegation “Facility staff are not dispensing medications as prescribed”, it is being alleged that facility staff are not dispensing residents’ medication as prescribed. Report continues, please see LIC9099-C. Unsubstantiated Interviews revealed that eight (8) out of ten (10) residents (R1 through R4 and R6 through R9) and all nine (S1-S9) staff have denied the allegation has taken place. Record reviews have indicated that the MARs have been marked and there are no discrepancies observed. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Facility staff are not keeping accurate resident records", it is being alleged that MARs are being backdated in order to cover up any errors. Interviews revealed that all ten (10) residents (R1-R10) and six (6) out of nine (9) staff (S1, S2, and S6 through S9) have denied the allegation has taken place. Record reviews have indicated that the MARs have been properly marked, which include whether a medication has been denied by a resident or if the medication is out of stock at the pharmacy. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Staff one, Suzette Johnson - Executive Director (S1), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 11-AS-20260416144522

Allegation investigated: Staff did not keep facility free of vermin.

On 04/09/26 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director as the purpose of today’s visit was explained. The investigation consisted of the following: On 04/01/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre placement appraisal dated: 02/20/25, Admission agreement dated: 02/18/25 , resident assessment dated: 03/05/25, Physicians report dated: 02/13/25, service plan dated: 06/17/25, updated service plan dated 03/26, shower schedule, facility notes dated: 03/2026, facilities laundry schedule, pest control service logs dated: On 01/2026-04/2026. On 04/01/26 from 10:00 am- 12pm LPA conducted Interviews with Residents #2-10 (R2-R10). On 04/01/26 LPA was unable to interview R1 as R1 was out of the facility at the time of visit. On 04/01/26 LPA conducted interviews with staff #1-3 (S1-S3) and conducted a tour of the facility. On 04/09/26 LPA conducted interviews with staff #4-6 (S4-S6). On 04/09/26 at 2pm LPA conducted interview with R1. Substantiated The investigation revealed the following: Allegation: Staff did not keep facility free of vermin. It is alleged that the facility has a rat problem as rat feces have been observed at the facility. On 04/01/26 and 04/09/26 LPA conducted Interviews with R1-R10 regarding the allegation above. 8 of the 10 residents interviewed denied the allegation above, 2 of the 10 residents interviewed confirmed the allegation above. 10 of 10 residents interviewed confirmed that the facility is getting treated by pest control. On 04/01/26 and 04/09/26 LPA conducted interviews with S1-S6. 4 of the 6 staff interviewed denied the allegation above, 2 of 6 staff interviewed confirmed the allegation above and reported seeing mice at the facility. 5 of the 6 staff confirmed that pest control services is coming out to service the facility. 1 of the 6 staff interviewed reported having no knowledge of pest control servicing the facility. On 04/01/26 LPA observed pest control to be servicing the facility at the time of the visit. On 04/01/26 LPA conducted a review of pest control service report dated: 3/25/26. Per the report, 20 rooms were serviced, interior and exterior inspected and baited, no activity found, EZ snaps are inspected each time facility is serviced, sanitation conditions listed as Fair. On 04/09/26 while LPA walked down facility hallway LPA observed a live cockroach. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Division (6) and Chapter (8) are for RCFE Exit interview conducted, appeal rights explained, and a copy of this copy is provided. The investigation revealed the following: Allegation: Staff left resident in a soiled diaper for a long period of time. It is alleged that resident in care is left in a soiled diaper as staff are not using residents’ diapers located in residents dresser. On 04/01/26 and 04/09/26 LPA conducted Interviews with R1-R10 regarding the allegation above. 6 of the 10 residents interviewed denied the allegation above and reported they change themselves when soiled. 3 of the 10 residents interviewed denied the allegation above and reported they have not been left soiled as staff are assisting. 1 of the 10 residents interviewed confirmed the allegation above and reported being left soiled a few times by staff. Additionally, 7 of the 10 residents interviewed denied needing assistance with incontinence care, 3 of the 10 residents interviewed confirmed needing assistance with incontinence care. On 04/01/26 and 04/09/26 LPA conducted interviews with S1-S6 regarding the allegation above. 2 of the 6 staff interviewed reported being unaware of the allegation above, 2 of the 6 staff interviewed denied the allegation above, 2 of the 6 staff interviewed confirmed the allegation above and reported that residents have been found to be soiled upon arrival to the morning shift. On 04/01/26 LPA conducted a review of R1s’ preplacement appraisal dated: 02/20/25 which indicated R1 can toilet self. Per service plan dated: 06/17/25 R1 can toilet self. On 04/01/26 LPA observed an updated service plan dated March 2026 that R1’s responsible party has not signed. Allegation: Staff did not ensure that residents’ clothing was changed. It is alleged that resident in care is left in the same clothing. On 04/01/26 and 04/09/26 LPA conducted Interviews with R1-R10 regarding the allegation above. 10 of the 10 residents interviewed denied the allegation above and reported having clean clothes available after bathing. On 04/01/26 and 04/09/26 LPA conducted interviews with S1-S6 regarding the allegation above. 5 of the 6 staff denied the allegation above, and 1 of the 6 staff interviewed reported being unaware of the allegation above. On 04/01/26 LPA conducted a review of R1s’ preplacement appraisal dated: 02/20/25 which indicated R1 can bath/shower self without assistance, dressing- self, grooming- partially depends on others. Per service plan dated: 06/17/25 R1 can dress- self-care, grooming- verbal queuing and set up. Per shower schedule, R1 is scheduled 2x a week Tuesday and Friday mornings. Per facilities laundry schedule, R1's laundry day is scheduled for Wednesday mornings. On 04/01/26 LPA observed an updated service plan dated 03/26 that R1’s responsible party has not signed. Athough 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 11-AS-20260325122703

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 30, 2026

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 deficiency was not not met as as LPA observed a live coackroach in facility hallway which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Executive Director to submit plan to LPA by POC due date detailing what the facility is going to do regarding pest control throughout the facility. What measure will be added to cleaning precedures to ensure pest at the facility is under control to ensure residents health and safety.

Allegation investigated: Lack of care and supervision

On 03/19/2026, at approximately 11:00 AM, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent visit to deliver findings. LPA met with the Administrator Suzette Johnson. The investigation consisted of the following: LPA toured the memory care unit, conducted interviews with six staff (S1–S6) and seven family witnesses (W1–W7), and reviewed records including the personnel report, staff roster, February memory care staffing schedule, staff contact information, grouping sheet, incident reports, resident progress notes, physician discharge note, plan of operation, and registry staff schedule. The investigation revealed the following regarding the allegation: “Lack of care and supervision” It is being alleged that staff failed to provide adequate supervision, resulting in a resident with dementia sustaining an unwitnessed fall during the night with no staff awareness of when or how the fall occurred. Please see (LIC9099-C) for report continuation. Substantiated Observations revealed the following: The memory care unit has a spread layout and houses approximately 35 residents, including residents requiring incontinence care and identified as fall risks. Staff reported grouping residents in a common area for visibility. At the time of the visit, approximately 4–5 staff were present. Based on the layout and resident care needs, this level of staffing may limit the ability to provide continuous supervision, particularly during overnight hours. Interviews conducted revealed the following: Staff (S1–S5) reported the fall was unwitnessed and discovered during morning rounds, and staff were unable to determine when or where the fall occurred. Staff (S1) reported four staff were scheduled; however, only three staff were present on the night shift due to staffing changes. Staff (S2–S3) confirmed three staff were assigned to the nocturnal shift. Staff (S6) reported that three staff typically care for approximately 35 memory care residents during night shift and stated this may not be sufficient to meet resident care needs. Witnesses (W1–W5) reported concerns regarding night supervision, staffing levels, and prior unwitnessed falls. Witnesses (W6–W7) reported no concerns. Records review revealed the following: Review of the February 2026 staffing schedule confirmed that three staff, including registry staff, were assigned to the overnight shift on 02/13/2026–02/14/2026. Records confirmed the resident sustained an injury consistent with a fall that occurred overnight. Documentation did not identify the time or circumstances of the fall and did not demonstrate staff awareness at the time of the incident. Nursing notes indicate limited information was available from the overnight shift regarding the incident. Review of incident reports and resident records identified a pattern of unwitnessed falls in February 2026, including incidents on or about 02/06/2026, 02/10/2026, and 02/14/2026, where residents were found on the floor with injuries during morning hours. Documentation consistently indicated staff were unaware of when or how the falls occurred. While appropriate medical care was provided after discovery, records do not demonstrate effective overnight monitoring. Based on the evidence gathered, interviews conducted, observations, and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is issued on the attached (LIC-9099D). An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 11-AS-20260218190506

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 26, 2026

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 is not met as evidenced by: Based on interviews, observations, and records review, the licensee failed to ensure sufficient staffing to meet residents needs during overnight hours, resulting in an unwitnessed fall and a pattern of unwitnessed falls where staff were unaware of when or how incidents occurred, posing an potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Licensee agreed to submit a plan of correction to LPA Jose Anguiano at Jose.Anguiano@dss.ca.gov by due date.

Allegation investigated: Staff handled resident in an aggressive manner.

On February 23, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Suzette Johnson Executive Director greeted the LPA. LPA explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included a collection of records, interviews and tour of the facility. The Department collected service records for Resident #1 (R1), Physician's Report LIC 624 (dated 12/15/25), Face Sheet and Emergency Informaition (dated 12/29/25), Service Plan (dated 12/31/25), Medication Administration Record and Physicians Orders (dated 02/23/26), Unusual Incident Report LIC 624 (dated 02/20/26) and other documents pertinent or associated with this complaint. (Evaluation Report contnues LIC 9099-c) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff handled residents in an aggressive manner. The complaint alleges that staff at a facility handled Resident #1 (R1) aggressively. On February 14, 2026, both (R1) and Resident #2 (R2) attempted to use the restroom at the same time. According to reports, a staff member aggressively grabbed (R1), pulled (R1) out of the restroom, pinched (R1's) arm, and hit (R1's) head. Further investigations revealed no visible markings or bruises on (R1); however, the administrator stated that an internal investigation was conducted, resulting in the termination of the staff member involved. No further information has been provided regarding this situation. On February 23, 2026, between 10:20 AM and 02:10 PM, the Department interviewed residents members identified as Resident #1 through Resident #11 (R1-R11). Ten (10) out of eleven (11) residents could not validate this claim. (R2-R11) were under the care and supervision of Staff #1 (S1) on February 14, 2026. All residents praised the staff for their professionalism and courteous behavior. They confirmed that they had never experienced or witnessed any aggressive mistreatment of residents. (R2-R11) stated that if such inappropriate behavior were observed, it would be reported to management or Community Care Licensing (CCL). During the interview (R1) reported a mistreatment incident involving Staff #1 (S1), claiming that the (S1) roughly grabbed (R1) by the left arm and struck (R1) several times on the head. (R1) stated that (R2) was present during the incident but not in any way involved in the restroom issue. (R1) did not provide the staff’s name or a clear description and claimed to have called 9-1-1 for law enforcement, but they did not arrive. The statement from (R1) disputes the information reported to (CCL). (R1) mentioned that, despite being struck multiple times on the head, no medical attention was deemed necessary, and this was not reported to management. According to (R2), no such incident occurred. (R2) stated that any inappropriate behavior by staff will be reported immediately and clarified that no such incident has ever occurred on February 14, 2026. On February 23, 2026, between 09:30 AM and 12:00 PM, the Department interviewed staff members identified as Staff #2 through Staff #5 (S2-S5). Four (4) out of the four (4) staff members could not corroborate this claim involving (R1) and (S1). All staff members were verified to have acted appropriately, both verbally and physically, towards the residents. (Evaluation Report continues LIC 9099-C) (S3) and (S4), who were working on the day of the incident, did not witness any inappropriate behavior by staff members. However, they received inconsistent accounts of what transpired between (R1) and (S1). (S3) reported to have walked in during the incident involving (R1) and noted that (R1) appeared agitated while getting out of the shower. According to (S3), (S1) left the scene after supervising (R1) out of the shower, and there was no physical engagement with (R1). (S3-S4) examined (R1) and did not observe any injuries or bruises on (R1). Both (S3) and (S4) confirmed that (R2) was present in the room when this incident occurred. Both (S2 and S5) stated that an investigation was conducted. They clarified that S1 is not an employee of Vista Del Mar but rather of Great Comfort Home Care, which the facility uses for staffing. Additionally, (R1) provided inconsistent accounts of what occurred. (S5) further clarified that (S1) was not terminated, as was previously reported. On February 23, 2026, between 02:00 PM and 02:30 PM, the Department interview witness identified as Witness #1 (W1) by telephone. (W1) has information about the incident from (R1) but did not witness it. (W1) also noted that (R1) tends to distort statements unintentionally and may have confabulation issues. The Department made several attempts to contact Staff #1 (S1) for an interview, but the calls went unanswered and were not returned. During the investigation on February 23, 2026, the Department observed staff members interacting with residents and noted that their conduct was appropriate. The Department found that the facility upholds the rights of its residents. Posters detailing Resident Rights, Personal Rights, were displayed prominently throughout the facility. The Department inspected for bodily injuries on (R1) and found none. Furthermore, recent phone records show no log of (R1) making any 9-1-1 calls on February 14, 2026, confirming that there was no emergency. The Department reviewed Resident #1 (R1’s) Medical Assessment for Residential Care Facilities for the Elderly LIC 624A (dated 12/15/25), Face Sheet and Emergency Information (dated 12/29/25), Service Plan (dated 12/31/25), Preplacement Appraisal Information LIC603A (dated 12/30/25) and Unusual Incident Report LIC 624 (dated 02/2025) revealed that (R1’s) medical diagnosis contributes to (R1’s) line of thinking/belief system. Further review of Medication Administration and Physician’s Orders (dated 02/23/26) revealed (R1) is on 19 prescribed medications and (8) of the (19) contribute to risk of unusual bruising and mental status conditions of dizziness and confusion (ref: National Institute of Health). (Evaluation Report continues LIC 9099-C) Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information gathered from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with Suzette Johnson, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 11-AS-20260220150636

Allegation investigated: Staff mishandled a resident's medications.

On 02/09/26 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted a initial/subsequent complaint visit regarding the allegation(s) above. LPA met with Collene Rosatti as the purpose of today’s visit was explained. The investigation consisted of the following: On 02/09/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre-appraisal dated:06/08/25, Physicians report dated: 03/01/23, current physicians orders, service plan dated:04/26/25, and the Medication Administration Record (MAR) for December 2025- February 2026. On 02/09/26 from 10:00 am- 12pm LPA conducted Interviews with residents# 1-10 (R1-R10), and from 1pm- 2:15 pm LPA conducted interviews with staff #1-4 (S1-S4). On 02/09/26 LPA conducted a review of R1's file including medications review, and conducted an interview with witness #1 (W1). The investigation revealed the following: Unsubstantiated Allegation: Staff mishandled a resident's medications. It is being alleged that medications were left sitting alone on a cluttered counter rather than being safely administered by facility staff. On 02/09/26 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 8 of the 10 residents interviewed denied the allegation above and reported that staff watch them take their medications before exiting their bedroom. 1 of 10 residents interviewed reported handling their own medications and do not require staff to watch them take their medications. 1 of 10 residents interviewed confirmed the allegation above and reported they have found medications left in their bedroom, and reported that there have been times where staff will hand over the medication and walk away. On 02/09/26 from 1pm- 2:15 pm LPA conducted interviews with S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported they watch the residents take their medications before leaving the room. On 02/09/26 LPA conducted an interview with W1 regarding the allegation above, per W1 there have not been any concerns with the care and assistance R1 is receiving. On 02/09/26 LPA conducted a review of R1's file, per the pre-appraisal dated:06/08/25, Physicians report dated: 03/01/23, and Service plan dated: 04/26/25 R1 requires assistance with medication administration. On 02/09/26 LPA and S1 conducted a review of R1's medications and Medication Administration Record (MAR) for December 2025- February 2026, during the review it was determined all medications were administered. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 11-AS-20260201205407

Type of visit: Case Management - Deficiencies

On 02/09/26 Licensing Program Analyst (LPA) Villegas conducted an unannounced Case Management visit to the facility in connection with complaint #11-AS-20260201205407. LPA met with Collene Rosatti as the purpose of the visit was explained. The department determined that the facility is not in compliance with Title 22 Regulations in connection with the complaint and issued a citations for Resident Records 87506(a). Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. An exit interview was conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Feb 23, 2026

87506 Resident Records 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: based observation, records review, and interview LPA observed that MAR for R1 was not properly documented from 12/2025- 02/09/26. Medications were provided but MAR is missing several signatures which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: Licensee/Administrator to train all staff that assist with medication administration by 02/23/26, and provide LPA with a copy of all materials reviewed and the sign in sheet with signatures of all who participated. LPA to obtain copies by POC due date.

Allegation investigated: Questionable death. Staff did not seek medical attention for resident.

On 01/27/26 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit for the allegation(s) above. LPA met with Interim Executive Director Collene Rozatti (S1) as the purpose of the visit was explained. The investigation consisted of the following: On 01/20/26 LPA obtained copies of the resident and staff rosters, as well as the following for resident #1 (R1): Emergency ID form, Admission Agreement dated: 09/14/25, Pre -appraisal, Physician Report dated: 09/18/25, Individual Service Plan, Physicians orders, facility notes, and a list of all staff that worked from 01/01/26- 01/05/26, and Administration Records (MAR) for 11/01/25- 01/2026. LPA also obtained a copy of the physicians attestation form dated: 01/14/26. On 01/20/26 and 01/27/26 LPA conducted interviews with staff #1-6 (S1-S6), and on 01/27/26 from 11am-12:30pm LPA conducted interviews with resident #2-11 (R2-R11). On 01/27/26 LPA conducted a review of of R1's file. The investigation revealed the following: Unsubstantiated Allegation: Questionable death. It is being alleged that facility staff did not respond or take appropriate action when resident in care requested medical assistance, which resulted in residents death. On 01/20/26 and 01/27/26 LPA conducted interview with S1-S6 regarding the allegation above. 6 of the 6 staff interviewed denied the allegation above and reported staff do not refuse to call 911 when needed. Additionally, 6 of 6 staff reported that a nurse or med tech will conduct an assessment when a resident is feeling unwell. On 01/27/26 from 11am-12:30pm LPA conducted interviews with R2-R11 regarding the allegation above. 6 of the 10 residents interviewed denied the allegation above and reported that facility staff assist them when assistance is requested. 1 of 10 residents interviewed confirmed the allegation above and reported that staff does not provided assistance when needed. 3 of 10 residents interviewed reported they have not had the need to ask for assistance but state they believe the staff would provide assistance. On 01/27/26 LPA conducted a review of R1's file. LPA observed that the physicians report dated: 09/18/25 indicates that R1's primary diagnosis were: acute and chronic respiratory failure with hypoxia, COPD, diabetes mellitus type 2, hypertensive heart disease with heart failure,dysphagia, muscle weakness, morbid obesity due to excess calories, difficulty walking, incentive spirometry, CPAP, and oxygen via nasal canula. On 01/27/26 LPA conducted a review of physicians attestation form dated: 01/14/26. Per attestation form the immediate cause of death was a cardiac arrest. Allegation: Staff did not seek medical attention for resident. It is being alleged that facility policy prohibits caregivers from calling 911 directly. On 01/20/26 and 01/27/26 LPA conducted interview with S1-S6 regarding the allegation above. 6 of 6 staff denied the allegation above and reported that caregivers are allowed to call 911 in an emergency situation and to not wait until they find a med tech or nurse to call 911. Additionally, 4 of 6 staff interviewed reported that a meeting was held where caregivers were told that they are allowed to call 911 when needed. On 01/27/26 from 11am-12:30pm LPA conducted interviews with R2-R11 regarding the allegation above. 6 of 10 residents interviewed denied the allegation above and reported that staff have not refused to call 911 when needed. 4 of the 10 residents interviewed reported they have not needed 911 to be called but believe staff would call 911 if needed. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 11-AS-20260115161934

Allegation investigated: Staff do not ensure the residents shower is properly working Staff do not ensure the facility is free of cockroaches Staff do not ensure the residents are assisted with meals

On 01/07/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Vista Del Mar Senior Living and was greeted by Administrator Colleen Rozatti (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S5, residents R1-R24. LPA Calderon obtained the following records: Housekeeping (dated 01/2026), work order for room 120 (dated 12/29/2025), deep cleaning schedule (dated 01/01/2026), Dewey Pest Control (dated 10/01/2025 to 12/26/2025) The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff do not ensure the residents shower is properly working. This complaint alleged that the facility did not provide a working shower for residents’ needs. LPA Calderon inspected room 120 and noted the shower head dripping but working. LPA Calderon inspected rooms 125, 132, 134 and room 206. All showers were working. Records review indicate the following: Work order (dated 12/26/2025) to fix shower head in room 120 was ordered. Interviews indicate the following: S2 indicates that resident in room 120 the shower head was dripping, and a new part was ordered. S2 states that the shower works. 5 out of 5 staff deny the allegation. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the residents shower is properly working” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff do not ensure the facility is free of cockroaches. This complaint alleged that the facility did not provide a free environment with no cockroaches. LPA Calderon inspected room 120 and found no cockroaches. LPA Calderon inspected rooms 125, 132, 134 and room 206. All rooms clear and did not find any cockroaches. LPA Calderon checked the dining room, kitchen and common areas and did not see any cockroaches. Records review indicate the following: Dewey Pest Control (dated 10/01/2025 to 12/26/2025), work orders show rooms were treated and common areas showed no sign of cockroaches. Deep cleaning order (dated 01/01/2026) showed room 120 was cleaned and no cockroaches were found. Interviews indicate the following: 5 out of 5 staff deny the allegation. S2 indicates that 20 rooms are treated per day to include room 120. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the facility is free of cockroaches” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff do not ensure the residents are assisted with meals. This complaint alleged that the facility did not provide meals for residents in care. LPA Calderon toured the facility and noted many residents taking their meals in the dining room. LPA Calderon noted a food cart for those residents that cannot take their meals in the dining room. Resident meals include a food tray and fork, spoon and the meal. Interviews indicate the following: S1 indicates that residents in room 120 takes meals in the room. Staff indicate that meal staff from the dining room provide the residents with meals and a fork. 5 out of 5 staff deny the allegation. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the residents are assisted with meals is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Colleen Rozatti (S1).the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 11-AS-20251229153904

Allegation investigated: Staff do not ensure the residents shower is properly working Staff do not ensure the facility is free of cockroaches Staff do not ensure the residents are assisted with meals

On 01/07/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Vista Del Mar Senior Living and was greeted by Administrator Colleen Rozatti (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S5, residents R1-R24. LPA Calderon obtained the following records: Housekeeping (dated 01/2026), work order for room 120 (dated 12/29/2025), deep cleaning schedule (dated 01/01/2026), Dewey Pest Control (dated 10/01/2025 to 12/26/2025) The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff do not ensure the residents shower is properly working. This complaint alleged that the facility did not provide a working shower for residents’ needs. LPA Calderon inspected room 120 and noted the shower head dripping but working. LPA Calderon inspected rooms 125, 132, 134 and room 206. All showers were working. Records review indicate the following: Work order (dated 12/26/2025) to fix shower head in room 120 was ordered. Interviews indicate the following: S2 indicates that resident in room 120 the shower head was dripping, and a new part was ordered. S2 states that the shower works. 5 out of 5 staff deny the allegation. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the residents shower is properly working” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff do not ensure the facility is free of cockroaches. This complaint alleged that the facility did not provide a free environment with no cockroaches. LPA Calderon inspected room 120 and found no cockroaches. LPA Calderon inspected rooms 125, 132, 134 and room 206. All rooms clear and did not find any cockroaches. LPA Calderon checked the dining room, kitchen and common areas and did not see any cockroaches. Records review indicate the following: Dewey Pest Control (dated 10/01/2025 to 12/26/2025), work orders show rooms were treated and common areas showed no sign of cockroaches. Deep cleaning order (dated 01/01/2026) showed room 120 was cleaned and no cockroaches were found. Interviews indicate the following: 5 out of 5 staff deny the allegation. S2 indicates that 20 rooms are treated per day to include room 120. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the facility is free of cockroaches” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff do not ensure the residents are assisted with meals. This complaint alleged that the facility did not provide meals for residents in care. LPA Calderon toured the facility and noted many residents taking their meals in the dining room. LPA Calderon noted a food cart for those residents that cannot take their meals in the dining room. Resident meals include a food tray and fork, spoon and the meal. Interviews indicate the following: S1 indicates that residents in room 120 takes meals in the room. Staff indicate that meal staff from the dining room provide the residents with meals and a fork. 5 out of 5 staff deny the allegation. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the residents are assisted with meals is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Colleen Rozatti (S1).the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 11-AS-20251229153904

Allegation investigated: Staff do not ensure that resident's medical needs are met. Staff do not ensure that resident's dietary needs are met.

On 12/29/25 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Colleen Rozatti as the purpose of today’s visit was explained. The investigation consisted of the following: On 12/22/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, Physicians report dated: 5/23/24, needs and service plan dated: 9/8/25, and facility notes dated: July 2025- December 2025. On 12/22/25 from 11:00 am- 1pm LPA conducted Interviews with Residents #2-10 (R2-R10). On12/22/25 and 12/29/25 LPA unable to interview R1, as R1 did not wish to be interviewed. On 12/22/25 and 12/29/25 LPA conducted interviews with S1-S6 and conducted a tour of facility. The investigation revealed the following: Allegation: Staff do not ensure that residents’ medical needs are met. It is being alleged that staff are not assisting a resident in care with getting ready for weekly schedule medical appointments, causing scheduled transportation services to cancel. Unsubstantiated On 12/22/25 from 11:00 am- 1pm LPA conducted Interviews with R2- R10 regarding the allegation above. 5 of 9 residents interviewed denied the allegation above and stated that staff assist as needed and staff provide reminders the day before the upcoming appointment. 4 of the 9 residents interviewed reported they do not need assistance with getting ready for appointments. Additionally, 5 of the 9 residents interviewed reported that the facility provides transportation to appointments, 4 of the 9 residents interviewed reported that they do not obtain transportation from the facility if the transportation calendar is fully booked. On 12/22/25 and twice on 12/29/25 LPA attempted to interview R1 but was unsuccessful. On 12/22/25 and 12/29/25 LPA conducted interviews with S1-S6 regarding the allegation above. 5 of 6 staff interviewed denied the allegation above and reported that the staff provide a reminder to residents about upcoming appointments, staff also assist residents get ready for the appointment prior to staff bringing resident down to the lobby to wait for transportation. 1 of 6 staff confirmed the allegation above and reported that there is a lack of communication regarding scheduled appointments, and states that due to lack of communication staff do not have enough notice to get residents ready in a timely manner. On 12/29/25 LPA conducted a review of facility notes dated: December 19th, 2025, LPA observed that an updated schedule for weekly appointments was provided to R1 as R1 arranges own transportation. On 12/29/25 LPA conducted a review of needs and service plan dated: 9/8/25. Per service plan, R1 needs ongoing assistance with care coordination with outside healthcare and home care providers. Additionally, service plan states care team supports R1 with receiving quality healthcare services by helping coordinate healthcare appointments. Allegation: Staff do not ensure that residents’ dietary needs are met. It is being alleged that staff have failed to provide resident in care with food prior to weekly scheduled appointments. On 12/22/25 from 11:00 am- 1pm LPA conducted Interviews with R2- R10 regarding the allegation above. 6 of the 9 residents interviewed denied the allegation above and reported having meals prior to leaving for a scheduled appointment. 2 of the 9 residents interviewed confirmed the allegation above and reported not having a meal prior to scheduled appointment. 1 of 9 residents interviewed stated that they sometimes have a meal as it depends on appointment time. On 12/22/25 and twice on 12/29/25 LPA attempted to interview R1 but was unsuccessful. On 12/22/25 and 12/29/25 LPA conducted interviews with S1-S6 regarding the allegation above. 6 of 6 staff interviewed denied the allegation above and reported that residents are provided with a meal before appointment, or are provided with a packed meal, or are saved a meal for when they return.On 12/29/25 LPA conducted a review of needs and service plan dated: 9/8/25. Per service plan, R1 requires a special diet. On 12/29/25 LPA conducted a tour of the kitchen facility, LPA observed all special diets, and dietary needs are printed and displayed on kitchen wall. The Kitchen staff also have a binder with all residents and their dietary needs. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 11-AS-20251218154121

Allegation investigated: Staff are not properly addressing scabies in the facility. Staff do not ensure residents hygiene needs are being met. Staff do not ensure that residents have clean bedding.

On 12/29/25 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Colleen Rozatti as the purpose of today’s visit was explained. The investigation consisted of the following: On 12/18/25 LPA Villegas obtained copies of the staff and resident roster, cleaning schedule, laundry schedule, shower schedule, list of residents that require assistance with ADL's. On 12/18/25 LPA obtained copies of the following for resident #1 (R1): physicians report dated: 5/10/25, physicians orders, after visit summary dated: 11/12/25, Kaiser Permanente dated: 08/16/25, and copies of communication between facility and family. On 12/18/25 from 10:00 am- 12pm LPA conducted Interviews with resident #1-10 (R1-R10), and from 1pm-1:45pm LPA conducted interviews with staff #1-5 (S1-S5). On 12/18/25 LPA conducted tour of memory care unit. The investigation revealed the following: Allegation: Staff are not properly addressing scabies in the facility. Unsubstantiated It is being alleged that residents in memory care may have scabies, and the facility is unable to control the spread of scabies. On 12/18/25 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 10 of 10 residents interviewed denied the allegation above, 2 residents reported having rashes that are being treated. On 12/18/25 from 1pm-1:45pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above. 1 of the 5 staff interviewed stated that there was a resident that was taken to urgent care for scratching, however it was determined that the scratching was due to an allergic reaction for a medication that has since been discontinued. On 12/24/25 LPA conducted a review of after visit summary dated: 11/12/25, it is indicated in the after visit summary that R1 was seen for generalized rash which was found to likely be an allergic reaction and was provided with a prescription. Allegation: Staff do not ensure residents’ hygiene needs are being met. It is being alleged that residents are not being bathed properly and are dressed in dirty clothes. On 12/18/25 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 7 of the 10 residents interviewed reported they do not require assistance with bathing needs, 3 of 10 residents reported obtaining bathing assistance from staff .10 of 10 residents interviewed denied the being dressed in dirty clothes. On 12/18/25 from 1pm-1:45pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above. On 12/24/25 LPA conducted a review of laundry schedule. Per laundry schedule, laundry is done daily, each resident gets their laundry done once a week unless the service plans indicate that a resident requires laundry service multiple times a week. Allegation: Staff do not ensure that residents have clean bedding. It is being alleged that residents' bedding isn't being changed. On 12/18/25 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 10 of 10 residents interviewed denied the allegation above. On 12/18/25 from 1pm-1:45pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above, and reported linen exchange is done weekly, unless a resident has an accident then linen exchange is done more than once a week. On 12/18/25 LPA conducted tour of the facility and observed laundry actively being done, LPA observed 5 bedrooms that were observed to have clean linen. On 12/24/25 LPA conducted a review of laundry schedule. Per laundry schedule, laundry is done daily, each resident gets their laundry done once a week unless the service plans indicate that a resident requires laundry service multiple times a week. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 11-AS-20251211153009

Allegation investigated: Staff dispose resident’s food.

On 12/22/25 at 10:55 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Colleen Rozatti as the purpose of today’s visit was explained. The investigation consisted of the following: On 12/22/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, Physicians report dated: 2/06/25, needs and service plan dated: 11/20/24, and physicians orders. On 12/29/25 LPA obtained a copy of R1's admission agreement. On 12/22/25 and 12/29/25 LPA conducted Interviews with Residents #1-10 (R1-R10). On 12/22/25 and 12/29/25 LPA conducted interviews with S1-S6 and conducted a tour of facility. The investigation revealed the following: Allegation: Staff dispose resident’s food. Unsubstantiated It is being alleged that staff threw away the lunch a resident in care left in residents’ refrigerator. On 12/22/25 and 12/29/25 LPA conducted Interviews with R1-R10 regarding the allegation above. 7 of the 10 residents interviewed denied the allegation above. 1 of the 10 residents interviewed reported that staff will throw away anything in the refrigerator that is no longer good, resident reports being okay with staff doing so. 1 of the 10 residents interviewed reported they do not have a refrigerator in their bedroom therefore does not have any information on the allegation above. 1 of 10 residents interviewed confirmed the allegation above, and reported that staff admitted to doing so per supervisor’s orders. On 12/22/25 and 12/29/25 LPA conducted interviews with S1-S6 regarding the allegation above. 4 of the 6 staff interviewed denied the allegation above. 2 of the 6 staff interviewed confirmed the allegation above and stated that food is only thrown away if it is rotten or molded. Per the 2 of 6 staff who confirmed the allegation above, the resident is informed of what was thrown and why. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 11-AS-20251222112624

Allegation investigated: Staff did not ensure facility was free from pests.

On 11/06/2025, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent complaint investigation regarding the above allegation to deliver findings and met with Interim Administrator Colleen Rozatti. On 11/05/2025, Licensing Program Analyst (LPA) Jose Anguiano conducted an initial complaint investigation. Investigation consisted of the following: LPA toured the facility inside and out, including resident rooms, common areas, kitchen, and storage areas. LPA interviewed eleven (11) residents (R1–R11) and eight (8) staff members (S1–S8). LPA also reviewed and collected the following records: Admissions Agreement, Personnel Report, Resident Roster, Housekeeping/Laundry Task Legend and Work Log, four (4) Dewey Pest Control Apartment Service Logs, three (3) Dewey Pest Control Invoices for the months of August, September, and November, four (4) Waxie Sanitary Supply Invoices for cleaning products, one (1) carpet cleaning invoice, and two (2) CR&R invoices for Monday through Saturday trash and recycling pickup. Please see LIC9099-C for report continuation. Substantiated Investigation revealed the following: Regarding the allegation, “Staff did not ensure the facility was free from pests,” it was alleged that staff did not ensure the facility was free from pests, specifically cockroaches. LPA interviewed eight (8) staff members and eleven (11) residents. Of those interviewed, one staff member and three residents confirmed ongoing issues with pests, specifically cockroaches. Residents reported sightings in their rooms and expressed concern about the facility’s ability to maintain a pest-free environment. Interviews with housekeeping staff confirmed that they alternate shifts and clean 2–3 times per day. However, despite these efforts, the presence of live and dead cockroaches observed during the visit indicates that current cleaning practices have not been effective in preventing pest activity. Records reviewed included pest control documentation from Dewey Pest Control, which showed that in October 2025, only 40 out of 165 resident rooms were fogged for cockroaches. Service logs dated 10/01, 10/15, 10/18, and 10/22 each documented fogging of only 10 rooms per visit. Sanitation conditions were marked as “Fair” in most rooms, with two rooms on 10/01 noted as “Poor.” Additionally, LPA reviewed the facility’s housekeeping and maintenance work logs. The logs confirmed that 165 resident rooms require cleaning, not including common areas. The housekeeping work log showed that two housekeeping staff (S3–S4) are assigned to clean the floor where Resident (R1) resides. During the tour, LPA observed and photographed three live cockroaches and four dead cockroaches inside Resident Room R1, confirming the presence of pests. Although the facility has a pest control contract and cleaning protocols in place, the limited scope of treatment, inconsistent cleaning practices, and direct observation of live pests support the allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is being issued on the attached (LIC-9099D). An exit interview, a copy of this report and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 11-AS-20251027112748

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(f) · Plan of correction due date: Nov 20, 2025

Maintenance and Operation…facility shall be clean…sanitary…at all times…for the safety…of residents...(f) All waste shall be located…and disposed of in a manner that will not…provide a breeding place or food source for insects or rodents. This requirement was not met as evidence by: Based on observations and record review, the licensee did not maintain a clean and sanitary environment. On 11/05/2025, LPA observed and photographed live and dead cockroaches in one resident room.This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: Administrator and staff will meet to develop a plan to address and eliminate the cockroach infestation. The facility agreed to submit proof of treatment and corrective actions to LPA Jose Anguiano atjose.anguiano@dss.ca.gov by due date.

Allegation investigated: Staff are not providing adequate care and supervision to resident in care. Facility staff failed to provide transportation to resident to and from medical appointment.

On 10/08/25 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Sidonia Cordis as the purpose of today’s visit was explained. The investigation consisted of the following: On 10/07/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Face sheet, Preplacement appraisal dated: 4/30/24, Service plan dated: 9/13/25, Physicians report dated: 5/24/24 , Physicians orders, facility notes and Transportation policy. On 10/07/25 and 10/08/25 LPA conducted interviews with Staff #1-5 (S1-S5), and on 10/08/25 from 1:45pm-2:15 pm LPA conducted interviews with residents #2-10 (R2-R10). On 10/07/25 and 10/08/25 LPA attempted to conduct interview with R1, however R1 refused interview. On 10/08/25 LPA conducted a review of R1's file. The investigation revealed the following: Allegation: Staff are not providing adequate care and supervision to resident in care. Unsubstantiated It is being alleged that residents in care are missing appointments due to staff not providing assist in a timely manner. On 10/07/25 and 10/08/25 LPA conducted interviews with S1-S5 regarding the allegation above. 5 of 5 residents interviewed denied the allegation above, per 5 of 5 staff residents have refused assistance and have refused to attend medical appointments. On 10/08/25 from 1:45 pm-2:15 pm LPA conducted interviews with R2-R10 regarding the allegation above. 9 of 9 residents interviewed denied the allegation above, 1 of 9 residents reported they have refused to attend scheduled medical appointment. On 10/07/25 and 10/08/25 LPA attempted to conduct interview with R1, however R1 refused interview. On 10/08/25 LPA conducted a review of R1's file. LPA conducted review of facility notes, LPA observed documentation indicating R1 has refused medical appointments on multiple occasions. Allegation: Facility staff failed to provide transportation to resident to and from medical appointment. It is being alleged that the facility is not providing residents in care with transportation to and from medical appointments. On 10/07/25 and 10/08/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 residents interviewed denied the allegation above. Per 5 of 5 staff, some residents have Access accounts, some residents are transported by families, and some obtain assistance by the facility. On 10/08/25 from 1:45 pm-2:15 pm LPA conducted interviews with R2-R10 regarding the allegation above. 9 of 9 residents interviewed denied the allegation above, 5 of 9 residents reported having their own means of transportation, 1 of 9 residents reported the facility assist with all medical appointments, 1 of 9 residents is now aware of how they get to medical appointments, 2 of 9 residents reported that a physician comes to the facility to see them. On 10/07/25 and 10/08/25 LPA attempted to conduct interview with R1, however R1 refused interview. On 10/08/25 LPA conducted a review of R1's file. LPA conducted review of facility notes, LPA observed documentation indicating R1 has cancelled transportation arrangements on multiple occasions. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 11-AS-20251001161907

Allegation investigated: Staff did not keep facility free of rodents.

On 09/26/25 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Interim Executive Director Sidonia Cordis, as the purpose of today’s visit was explained. The investigation consisted of the following: On 09/24/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for resident #1 (R1) face sheet, service plan dated: 04/14/25, Physicians report dated: 03/10/25, physicians orders, housekeeping schedule, deep cleaning schedule, Dewey pest control report dated: 9/18/25, and work order dated 09/17/25. On 09/24/25 from 9:30am-12:00 pm LPA conducted Interviews with residents 2-10 (R2-R10), and from 1:35pm- 2:32pm LPA conducted interviews with staff #1-6 (S1-S6). On 09/24/25 LPA conducted tour of the facility and conducted check of 6 bedrooms. On 09/26/25 LPA conducted an interview with R1. Unsubstantiated The investigation revealed the following: Allegation: Staff did not keep the facility free of rodents. It is alleged that a resident in care observed 6 rodents in the residents’ bedroom. On 09/24/25 from 9:30am-12:00 pm LPA conducted Interviews with R2-R10 regarding the allegation above. 6 of the 9 residents interviewed denied the allegation above. 3 of the 9 residents interviewed confirmed the allegation above and reported observing pest, per the 3 of 9 residents interviewed pest was reported to staff and staff services bedrooms. Additionally, 9 of 9 residents reported bedrooms being cleaned daily by staff, and 8 of 9 residents interviewed confirmed that the facility has a pest services come out to service. On 09/26/25 LPA conducted an interview with R1 regarding the allegation above, per R1 staff have addressed R1’s concerns and R1 has not observed any rodents in bedroom. On 09/24/25 from 1:35pm- 2:32pm LPA conducted interviews with S1-S6 regarding the allegation above, 6 of the 6 staff interviewed denied the allegation above. Per 6 of the 6 staff interviewed, the facility common areas, and bedrooms are cleaned daily. 6 of 6 staff also confirmed that the facility has a pest control contract, and that pest control comes out regularly to service the facility. 6 of the 6 staff interviewed also stated that if and when a resident reports observing pest, a work order will be created, maintenance staff will inspect, and pest control will come out to further service the reported area. On 09/24/25 LPA conducted a check of bedrooms: 119, 135, 137, 217, ML 21, and ML22, LPA observed bedrooms to be clean and pest free. On 09/26/25 LPA conducted a review of the work order dated 09/17/25, per work order resident’s bedroom was inspected for mice infestation and a hole behind residents’ refrigerator. On 09/26/25 LPA conducted a review of Dewey pest control service agreement, per agreement 10 bedrooms are treated weekly as well as common areas, and the building exterior. Per Dewey pest control service agreement dated 9/18/25 resident’s bedroom was inspected and there was no activity found. A review of the housekeeping schedule was conducted, and it reads that every housekeeper cleans 8 bedrooms per shift. Bedrooms are deep cleaned once a week. 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. Exit interview conducted, and a copy of this report was provided to Sidonia Cordis.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 11-AS-20250917144609

Type of visit: Required - 1 Year

On 09/24/25 Licensing Program Analyst's (LPA's) Villegas and Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA's met with Executive Director Suzette Johnson as the purpose of today’s visit was explained. The facility is licensed to serve 300 non-ambulatory elderly adults 60 and over of which 10 may be bedridden, there is an approved hospice waiver for 50 residents. The facility has a dementia wing w/ delayed egress. Annual fees are current, the facility has an active liability insurance with expiration date of 10/26/25. The facility is a 3-story structure located in a residential neighborhood and consists of the following: 278 bedrooms, 4 common bathrooms, multimedia rooms, commercial kitchen, activity room, large dining room, medication room, a large outside patio, laundry room, and administrative offices. There is an memory care unit is located on the 2nd floor of the facility which contains delayed egress doors that were observed to be operable, a common space, dinning/kitchen area, med room, administrative office, and laundry area. LPA’s conducted a records review of 6 staff records, 10 resident records, and 10 medication administration records, records were maintained accordingly with no discrepancies. LPAs observed medications were centrally stored and properly locked. The last fire and disaster drill was conducted on 09/15/25 by the fire safety services inc., fire extinguishers fully charged and observed throughout the facility, carbon monoxide detectors, smoke detectors and auditory signals are operational. Fire/Smoke door inspection conducted on 06/05/25 by DC Electronics, inc. Evacuation chair observed on on each floor at the stairwell. During facility tour 6 Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, showers were free of mold/mildew, and there are sufficient toiletries accessible to residents. Pull cords observed in every bathroom, Water temperatures were tested in the kitchen(s), and in 6 bedrooms. LPAs conducted tour of commercial kitchen, LPAs observed an adequate supply of perishable and non-perishable food. Toxins and knifes were observed to be inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 24, 2025

Allegation investigated: Staff do not ensure residents dietary care plan is being followed Staff do not ensure resident is provided with breakfast, lunch and dinner each day Staff does not ensure adequate care and supervision is provided to residents

*** The purpose of the visit is to add additional information not included in the report dated 04/28/2025 and 08/05/2025; findings remain the same. *** On 09/17/2025 at 1:30 p.m., the Department conducted a subsequent visit to gather information regarding the above allegations. The Department met with Executive Director Brittney Buchannan and explained the purpose of today's visit. LPA was granted entry to the facility. The investigation consisted of the following: On 04/28/2025, the Department requested, reviewed, and obtained copies of the Resident Roster (dated 04/28/2025), Personnel Report (dated 04/28/2025), Dietitian's Report (dated 03/28/2025), Weekly Menu (dated 02/16/2025–05/03/2025), Resident 1's Records (dated 04/28/2025), Resident 1's Progress Notes (dated 06/01/2024–04/28/2025), and Tray Service Request. Interviews were conducted with staff members #1–#5 (S1–S5) and residents #1–#10 (R1–R10). The facility kitchen was toured. At 11:30 a.m., the Department observed residents eating well-balanced and nutritious meals. An ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days was observed. See continued LIC9099-C, page 2. Unsubstantiated Continued LIC9099-C, page 2 Investigation revealed the following: Allegation: Staff do not ensure the residents' dietary care plan is being followed. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. Five out of five (5 out of 5) staff members and nine out of ten (9 out of 10) residents stated that staff ensure residents' dietary care plans are being followed. They confirmed that staff consistently adhere to physician-prescribed dietary menus and that residents are served well-balanced, nutritious meals according to the doctors' orders. 5 out of 5 staff members and 9 out of 10 residents also stated that the facility does have a dietitian. R1 reported that staff do not ensure the residents' dietary care plans are being followed. LPA requested R1's physicians' report and reviewed the resident's special diet documentation. 5 out of 5 staff members confirmed that R1 is on a diabetic diet, and R1's physician's report, dated 05/28/2024, also indicated that R1 is on a diabetic diet. LPA observed both the facility's regular menu as well as the diabetic alternative menu available for residents on a special diet. Staff stated that according to the residents' physicians' orders, they will accommodate special diets, including low sugar, carbohydrate, mechanical soft, and pureed options. S1-S5 and R2-R10 all denied the allegation. Allegation: Staff do not ensure the resident is provided with breakfast, lunch, and dinner each day. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. All five staff members (5 out of 5) and nine out of ten residents (9 out of 10) stated that staff ensure the residents are provided with breakfast, lunch, dinner, and snacks. Residents (9 out of 10) confirmed they receive three meals per day, and alternative food choices are offered. The facility provides a diverse range of food options, and if a resident requests a second serving, staff accommodate the request. Residents #2-#10 (R2-R10) stated they receive plenty of food to eat, and if they don't want to dine in the dining lounge, they can complete a tray service request. Staff will collect the request slip and deliver the meal to the resident's room. R1 stated that staff do not ensure residents are provided with breakfast, lunch, and dinner each day. LPA observed residents eating lunch and dinner and reviewed the food menus. LPA also observed an ample supply of perishable and non-perishable food items, as well as staff serving meals during breakfast and lunch. Additionally, LPA reviewed the resident's tray service form. S1-S5 and R2-R10 all denied the allegation. Staff members #1-#5 (S1–S5) and residents #2-#10 (R2–R10) all denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation: Staff do not ensure adequate care and supervision are provided to residents On 04/28/2025, between 10:00 a.m. and 11:30 a.m., the Department interviewed five (5) staff members identified as Staff #1 through #5 (S1-S5), regarding the allegation that staff do not ensure adequate care and supervision is provided to residents. The concern involved an incident in which a resident allegedly entered Resident #1's (R1) room without permission while R1 was sleeping. Staff #1, #3, #4, and #5 (4 out of 5) staff members stated they had no knowledge of any resident entering R1's room without permission while R1 was sleeping, and that this matter was never brought to their attention. S #2 stated that R1 reported another resident had entered their room; however, there were no witnesses to the incident, and a review of the facility’s surveillance cameras dated 04/20/2025 did not reveal any unauthorized entry. S2 also stated maintenance checked R1's door and confirmed it was in operable condition. All five staff members (5 out of 5) stated that adequate care and supervision are provided to all residents. 5 out of 5 staff members explained that care staff conduct wellness checks on residents every two hours. 5 out of 5 staff members stated that residents have pendants and call buttons to alert staff if they need assistance. 5 out of 5 staff members confirmed that no unauthorized individuals were observed entering residents’ rooms. 5 out of 5 staff members stated residents’ doors remain locked, and each resident has a personal key to their own room. S1-S5 reported that the facility currently has about 93 staff members employed and is fully staffed, and that residents are receiving appropriate care, supervision, and assistance with their daily needs. All five staff members interviewed (5 out of 5) confirmed the facility is sufficiently staffed and denied the allegation. On 04/28/2025, the Department observed R1's room and confirmed the doorknob was in operable condition; once locked, the door required a key to be unlocked. The surveillance footage dated April 20, 2025, did not show a resident entering Resident #1's room at night. See continued LIC9099-C page 4 Continued LIC9099-C page 4 On April 28, 2025, between 11:45 a.m. and 12:00 p.m., the Department reviewed the facility’s Personnel Report (LIC 500), which listed the following staff positions: Executive Director; Human Services Director; Vice President of Operations; Business Office Manager; Human Resources Director; Resident Care Director; ALW Coordinator; 4 Licensed Vocational Nurses (LVNs); 2 Community Liaisons; 2 Maintenance Staff; 4 Cooks; 5 Kitchen Staff; 4 Food Servers; 2 Dishwashers; 6 Dietary Aides; 9 Medication Technicians; 7 Memory Care Caregivers; 1 Memory Care Activity Director; 2 Activities Assistants; 25 Caregivers; 7 Housekeepers; 4 Receptionists; and 1 Driver a total number of employees listed: 93, confirmed the facility is adequately staffed. On April 20, 2025, there were 10 staff members on the night shift at 9:30 p.m. No incident reports were filed regarding the allegation. None of the caregivers reported witnessing anything, and nothing was documented or found in the residents' records. On April 28, 2025, between 12:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with ten residents #1-#10 (R1–R10) regarding the allegation of inadequate care and supervision. 9 out of 10 residents stated that the facility is adequately staffed and confirmed they are receiving the necessary care and supervision. 9 out of 10 also states that staff are consistently present every shift. 1 out of 10 residents expressed concern about staffing and did not feel care and supervision were adequate. Nine out of ten (9 out of 10) residents reported that they were happy living at the facility and had no problems or complaints. The majority of residents (9 out of 10) denied the allegation and stated that their daily needs were being met. Based on interviews, available evidence, observation, information received, and records reviewed, there was not enough sufficient evidence to support the allegations. 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 deemed unsubstantiated. LPA Bunker provided Executive Director Brittney Buchannan with copies of the LIC9099 and LIC9099Cs Complaint Investigation Reports. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 17, 2025 · control 11-AS-20250421123647

Allegation investigated: Staff are threatening resident. Staff did not prevent resident from smoking in the room. Staff did not prevent a resident from threatening another resident.

On 09/11/25 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 09/10/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1- 2(R1-R2): face sheets, Pre-appraisals, Service plans, physicians reports, medication administration record (MAR) for August and September 2025, ALW info for R1, admission agreements and facility notes. On 09/10/25 and 09/11/25 LPA conducted Interviews with Residents #1-11 (R1-R11). On 09/10/25 and 09/11/25 LPA conducted interviews with staff #1-7 (S1-S7). On 09/11/25 LPA conducted interview with witness #1 (W1). The investigation revealed the following: Allegation: Staff are threatening residents. It is being alleged that staff are threatening residents in care. On 09/10/25 from 9:30 am- 12pm LPA conducted Interviews with R1-R11 regarding the allegation above. 11 of 11 residents denied the allegation. Unsubstantiated On 09/10/25 and 09/11/25 LPA conducted interviews with S1-S7 regarding the allegation above, 7 of the 7 staff interviewed denied the allegation above. On 09/11/25 LPA conducted interview with W1 regarding the allegation above, per W1 there are no safety concerns. Allegation: Staff did not prevent residents from smoking in their bedroom. It is being alleged that facility staff are allowing residents in care to smoke cigarettes in their bedroom and bedroom balcony. On 09/10/25 and 09/11/25 LPA conducted Interviews with R1-R11 regarding the allegation above. 10 of the 11 residents interviewed denied the allegation above. 1 of the 11 residents interviewed confirmed the allegation above and reported calling staff members for help, however, by the time the staff arrives to the bedroom the resident smoking is no longer in the bedroom and there is no evidence that smoking occurred. On 09/10/25 and 09/11/25 LPA conducted interviews with S1-S7 regarding the allegation above, 6 of the 7 staff interviewed denied the allegation above, however report that residents that have been caught smoking in a bedroom are redirected to the smoking patio and are reminded of the facility rules. 1 of the 7 staff interviewed did not have any information regarding the allegation above. On 09/11/25 LPA conducted interview with W1 regarding the allegation above, per W1 there are no safety concerns. On 09/11/25 LPA conducted review of facility notes dated 8/11/25 and 09/03/25, facility notes indicated that resident in care has made reports of peer smoking in the bedroom, however staff have not observed any proof that cigarette smoking has occurred. Allegation: Staff did not prevent a resident from threatening another resident. It is being alleged that facility staff are not calling the police when a resident is threatened by a peer. On 09/10/25 and 09/11/25 LPA conducted Interviews with R1-R11 regarding the allegation above. 9 of the 11 residents interviewed denied the allegation above and reported feeling safe at the facility. 1 of the 11 residents interviewed denied the allegation above, however stated that a peer has threatened resident but it was not reported to staff. 1 of the 11 residents interviewed confirmed the allegation above and stated that staff was able to assist but the police was not called. On 09/10/25 and 09/11/25 LPA conducted interviews with S1-S7 regarding the allegation above, 7 of the 7 staff interviewed denied the allegation above. On 09/11/25 LPA conducted interview with W1 regarding the allegation above, per W1 there are no safety concerns. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 11-AS-20250904103516

Allegation investigated: Staff are not properly addressing pest infestation in the facility.

On August 22, 2025, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Suzette Johnson, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, a collection of records, and a tour of the facility. Interviews were conducted with Resident #1 through Resident #9 (R1-R9), Staff #1 through Staff #6 (S1-S6). The Department reviewed several documents, including the Facility Resident Roster (dated 08/22/25), Personnel Report LIC 500 (dated 08/22/25), Dewey Pest Control Service Agreement (dated 12/20/24 & 06/17/25), Dewey Pest Control Control Sevice Log (dated 06/20/25 & 08/19/25) and (R1's) Physicians Report LIC 602A (dated 05/25/25) as well as other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff are not properly addressing pest infestation in the facility. The complaint states that the staff are not adequately addressing the pest infestation in the facility. It has been reported that Resident #1 (R1) is facing a vermin infestation in their room. Despite multiple attempts to contact the person responsible for resolving the issue, (R1) has been unable to obtain assistance. Additionally, (R1) must deal with exterminating various small and large bugs daily and have experienced pest bites. No further details regarding this matter have been provided. On August 22, 2025, between 09:05 AM and 11:09 AM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members expressed that they could not support this claim. (S1-S2) emphasizes its commitment to ensuring the safety and well-being of residents by implementing effective, environmentally friendly pest management measures. The facility has an active service agreement with a reputable pest control company that performs weekly pest control services. (S2) stated that these scheduled services treat ten rooms and common areas each week. (S1-S2) reported that (R1's) room was serviced, with treatments conducted on June 20, 2025, and August 19, 2025, along with adjacent rooms on the same floor. (S1-S6) noted that (R1) has not recently informed staff about any pest issues and prohibits them from entering (R1's) room for cleaning and care assistant services. Furthermore, all six staff members interviewed reported that (R1) has made it clear that they will not permit anyone to enter their room without their presence. They have stated that if this boundary is not respected, they will not hesitate to contact law enforcement or legal counsel to enforce their rights. This situation creates challenges for the facility in maintaining a safe and healthy environment for (R1). On August 22, 2025, between 10:45 AM and 12:08 PM, the Department interviewed resident members identified as Resident #1 through Resident #9 (R1-R9). Seven (7) out of the nine (9) residents could not validate this allegation. Residents from (R3-R9) have stated that they have no issues or concerns as they have not encountered any pest in their rooms or common areas. Additionally, they have observed pest control professionals actively performing treatments throughout the premises, ensuring a safe and pest-free environment for everyone. (R10), identified as( R1's) roommate, declined to be interviewed. (Evaluation Report continues LIC 9099-C) (R1-R2) expressed concerns regarding a pest issue in their rooms and mentioned that they have informed the staff, but no action has been taken yet. (R1) indicated that they have reported the issue to the care staff daily; however, (R1) was unable to recall the names of the staff members involved. Additionally, (R1) did not remember if the room had been treated on June 20, 2025, or August 19, 2025. (R1) verified that staff must not enter the room without the presence of (R1), nor should they provide any cleaning or care assistance services without (R1's) presence. This rule is crucial to maintain proper standards according to (R1's) preference. (R1) stated she has not seek any medical assistance for bites due to pest problems. The Department inspected the facility on August 22, 2025, focusing on the first floor, second floor, and common areas. Rooms inspected included #284, # 285, 286, 287, and #289. The rooms were found to be maintained and clean. The rooms are in order to prevent pest infestations, ensuring a comfortable environment for everyone. Housekeeping and maintenance staff were observed carrying out their responsibilities. (R1's) room was found to be disorganized, with clothes and tableware left soaked for an extended period. There was also standing water, which could attract and create a breeding ground for flies. Additionally, uncovered food packages and drinks left in glassware are likely to attract various types of flies. The Department did not observed any sign vermin or pest infestation. The Department did not observed what appear to be pest bites on (R1). The Department reviewed a Dewey Pest Control Service Agreement dated December 12, 2024, and another dated June 17, 2025, which provided evidence of an annual service contract. This contract indicated that ten service visits were performed each month, totaling 40 treatments per month. Additionally, an examination of the Dewey Pest Control Service Log, covering the period from June 20, 2025, to August 19, 2025, confirmed that service treatments were performed for (R1's) room. Telecommunications records from July 13, 2025, indicated that (R1) had prohibited staff from entering the room for cleaning assistance. Further review conducted on (R1's) Physician's Report LIC 624 A and the Service Plans dated May 25, 2025, and June 21, 2025. (Evaluation Report continues LIC 9099-C) Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with Suzette Johnson, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 11-AS-20250820152434

Allegation investigated: Facility staff did not provide adequate food service to resident in care.

On 08/21/25 Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Executive Director Suzette Johnson (S1) as the purpose of today’s visit was explained. The investigation consisted of the following: On 08/21/25 LPA Villegas obtained copies of the staff and resident roster, and requested the following documents for resident #1 (R1) admission agreement dated: 11/19/24, physicians report dated: 02/06/25 , preplacement appraisal dated: 11/19/24, needs and service plan dated:11/19/24. On 08/19/25 LPA conducted interview with Resident #1 (R1), and on 08/21/25 LPA conducted interview with staff #1-2 (S1-S2) regarding the allegation above. The investigation revealed the following: Allegation: Facility staff did not provide adequate food service to resident in care. Unsubstantiated It is being alleged that facility kitchen does not provide lunch to go when requested. On 08/19/25 LPA conducted interview with R1 regarding the allegation above, R1 reported the allegation is being addressed however R1 has been dealing with the allegation above for 3 months. on 08/21/25 LPA conducted interview with S1-S2 regarding the allegation above, 2 of 2 staff interviewed denied the allegation above, Per 2 of 2 staff interviewed residents have requested to go meals and the kitchen staff has completed the request. Additionally 2 of 2 staff interviewed reported that the requested packed meal are not always picked up by R1. 1 of 2 staff interviewed reported that the kitchen cooks big quantities of food to ensure that residents who are out during scheduled meal services can have food available upon their arrival. On 08/21/25 LPA reviewed the admission agreement page A-3 letter E titled meals, upon review of the admission agreement, LPA did not observe any documentation stating that the facility will provide packed meals for residents in care. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 11-AS-20250811140929

Allegation investigated: Resident fell due to staff neglect resulting in injury Staff did not seek medical attention for resident

On 08/14/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted a subsequent unannounced complaint investigation visit regarding the allegations listed above. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility Unsubstantiated Investigation consisted of the following: On 07/02/2025, interviews were conducted, and records were gathered. Interviews conducted consisted of 10 resident interviews [Resident 2 (R2) to Resident 11 (R11) were interviewed]. Resident 1’s (R1) records were gathered which consisted of Medication Administration Record (MAR) from 03/2025 to 04/2025; Unusual Incident Report dated 05/16/2025; Progress Notes from 03/2025 to 04/2025; Admission Agreement dated 04/07/2025; Emergency Information dated 07/02/2025; Resident Assessment dated 02/25/2025; Preplacement Appraisal Information dated 02/28/2025; Appraisal/Needs & Services Plan dated 03/05/2025; Consent Forms dated 03/09/2025; Personal Rights dated 03/09/2025; and other pertinent information. Facility records were gathered which consisted of Resident Roster; Personnel Report dated 04/2025; Personnel Report dated 07/02/2025; LVN-Medication Technician Job Role Description; Time-Sheets from 04/05/2025 to 04/06/2025; Fall Risk Mitigation and Prevention Policy; Inservice Training from 03/05/2024 to 03/19/2025; Plan of Operation; and other pertinent information. On 8/14/2025, interviews were conducted, and records were reviewed. Interviews conducted consisted of 9 staff interviews [Staff 1 (S1) to Staff 9 (S9) were interviewed] and 2 witness interviews [Witness 1 (W1) to Witness 2 (W2) were interviewed]. Allegation: “Resident fell due to staff neglect resulting in injury”, it is being alleged that R1 fell due to staff neglect which resulted in R1 sustaining an injury. Interviews conducted with R2 to R11 revealed the following: 10 out of 10 residents denied the allegation. Interviews conducted with S1 to S9 revealed the following: 9 out of 9 staff denied the allegation. Interviews conducted with W1 to W2 revealed the following: 2 out of 2 witnesses denied the allegation. Records reviewed of R1’s facility notes revealed the following: on 04/05/2025 at 11:15 PM R1 had an unwitnessed fall; R1 was seen by Caregivers and by a Licensing Vocational Nurse; R1 was unhurt. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. 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. Allegation: “Staff did not seek medical attention for resident”, it is being alleged that staff did not seek medical attention for R1. Interviews conducted with R2 to R11 revealed the following: 9 out of 10 residents denied the allegation. 1 out of 10 residents agreed with the allegation. Interviews conducted with S1 to S9 revealed the following: 9 out of 9 staff denied the allegation. Interviews conducted with W1 to W2 revealed the following: 2 out of 2 witnesses denied the allegation. Records reviewed of R1’s unusual incident report dated 04/06/2025 revealed the following: on 04/06/2025 at 3:00 PM, resident had a low oxygen level and 911 was called. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. 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. No deficiencies were provided. An exit interview was conducted, and a copy of this report was left with the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, Aug 14, 2025 · control 11-AS-20250625150231

Allegation investigated: Staff are not properly addressing pest infestation in the facility.

On 08/12/25 at 10:45 am Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director Suzette Johnson, as the purpose of today’s visit was explained. The investigation consisted of the following: On 08/12/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for resident #1 (R1) face sheet, service plan dated: 06/21/25, Physicians report dated: 05/25/25, medication administration record (MAR) for 08/2025, communication notes, housekeeping schedule, deep cleaning schedule, Dewey pest control agreement, Dewey service logs dated June 2025-August 2025. On 08/12/25 from 12pm-1:25pm LPA conducted Interviews residents #2-10 (R2-R10), and from 1:35pm- 2:32pm LPA conducted interviews with staff #1-5 (S1-S5). On 08/12/15 LPA unable to interview R1 as R1 refused interview. On 08/12/25 LPA conducted tour of the facility and conduct check of 5 bedrooms. Unsubstantiated The investigation revealed the following: Allegation: Staff are not properly addressing pest infestation in the facility. It is being alleged that a resident in care has bugs crawling on body and face throughout the night. On 08/12/25 from 12pm-1:25pm LPA conducted Interviews with R2-R10 regarding the allegation above, 3 of 9 residents interviewed reported observing pest in the bedrooms, and reported having their bedrooms treated after staff was made aware. 6 of 9 residents interviewed denied the allegation above and reported their bedrooms have been treated for pest as a precaution. On 08/12/15 LPA unable to interview R1 as R1 refused interview. On 08/12/25 from 1:35pm- 2:32pm LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above, and reported that R1 does not allow staff to come into R1's bedroom to provide cleaning services. Additionally 5 of 5 staff interviewed stated that R1 threatens to call law enforcement and a Lawyer if staff attempt to enter R1's bedroom. On 08/12/25 LPA conducted a review of Dewey pest control services logs, per service log R1's bedroom was services on 6/20/25. LPA conducted a review of Dewey pest control service agreement, per agreement 10 bedrooms are treated weekly as well as common areas, and the building exterior. On 08/12/25 LPA conducted a review of communication notes, LPA observed documented communication from staff reported that R1 does not allow entry into R1's bedroom. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 12, 2025 · control 11-AS-20250807142442

Allegation investigated: Licensee did not ensure bathroom was in good repair. Licensee did not ensure required notices were visibly posted in the facility. Staff did not allow resident to leave their room.

This report supersedes report dated 07/17/2025 to obtain additional information. On 08/06/2025 at 10:40 AM, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint findings. During today's visit, LPA met with Suzette Johnson and the explained the purpose of the visit. The investigation consisted of the folloing: On 07/17/2025, LPA interviewed Administrator (A1), Staff #1 - Staff #10 (S1 - S10) and Resident #2 - #9 (R2 – R9) ; Resident 1 (refused to be interviewed during the investigation). LPA requested copies of the staff roster (dated 07/17/2025), resident roster (received 07/17/2025), Face Sheet & Emergency (for R1 - received on 07/17/2025), LIC 602: Physician Report (for R1 - dated 05/29/2025), Admission Agreement (for R1 - dated 06/24/2025), LIC 603: Preplacement Appraisal Information (for R1 - dated 06/24/2025), Service Plan (for R1 - dated 06/24/2025) and Work Order for R1's room. Unsubstantiated The investigation revealed the following: Allegation 1: Licensee did not ensure bathroom was in good repair. It was alleged bathroom, is not working for days and they have not ask someone to come fix it. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated she is not aware of any recent issues with R1's bathroom and residents can report to the front desk where a work order is placed and maintenance will complete the order. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 2 of out of 10 staff confirmed the allegation. 7 out of 10 staff denied the allegation. 1 out of 10 staff were unsure of the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 8 out of 9 residents denied the allegation. 1 out of 9 residents unsure or unaware of the allegation. On 07/17/2025 at approximately 1:03pm and on 08/06/2025 between the hours of 11:09am - 11:29am LPA conducted a tour with S9 of the following rooms 118,135,208,211,237,247,283,285 and 306 & observed the following: the sink, shower and toilet are operable and in good repair. On 07/17/2025 at approximately 1:30pm, LPA conducted a records review of the work order (created on 06/25/2025) and did not observe any documentation to support the allegation. Based on interviews conducted, records review and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. Allegation 2: Licensee did not ensure required notices were visibly posted in the facility. It was alleged that the facility its just plain walls with no emergency information or telephone. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated the required posting are publicly visible in the common areas of the facility which is a standard protocol. Between 8:51am - 10:06am, LPA interviewed 10 staff regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 3 out of 9 residents confirmed the allegation. 4 out of 9 residents denied the allegation. 2 out of 9 residents were unsure or unaware of the allegation. On 07/17/2025 between the hours of 8:35am -8:40am, LPA conducted a tour of the facility with S8 and observed in the main lobby area posted on the wall are following: the facility license, the Emergency Disaster Plan for Residential Facilities, the Long Term Ombudsman contact information (also posted on the 2nd floor in the library area which was observed during the tour by LPA with S9 on 08/06/2025 between the hours of 11:09am - 11:28am), and the California Department of Social Services Community Care Licensing Division Centralized Complaint & Information Bureau contact information. Report continues on LIC 809-C On 08/06/2025, between the hours of 11:09am - 11:28am, LPA conducted a tour with S9 and observed a working telephones at the front desk, the first and the second floor of the facility which are easily accessible for all residents to use. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. Allegation 3: Staff did not allow resident to leave their room. It was alleged the facility won't let resident out of the room. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated residents are only restricted from common areas in the event that a resident is on isolation due to testing positive for COVID. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 9 out of 9 residents denied the allegation. Between the hours of 8:35am -8:40am, LPA conducted a tour of the facility and observe residents throughout the facility in common area. Upon records review, R1 is diagnosed with dementia as stated in R1's - LIC 602A Physician's Report for Residential Care Facilities for the Elderly (RCFE). On the LIC 602 under Section 14. Mental Condition it states (k). Able to Leave Facility Unassisted is check of NO. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. On 07/17/2025, LPA attempted to interview Resident #1 (R1) who declined to be interviewed about the three allegations. 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. Exit interview conducted with Suzette Johnson (Administrator) & copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 11-AS-20250714095011

Allegation investigated: Staff do not ensure residents dietary care plan is being followed Staff do not ensure resident is provided with breakfast, lunch and dinner each day Staff does not ensure adequate care and supervision is provided to residents

On 08/05/2025 at 3:00 p.m., The Department conducted an initial visit to gather information regarding the above allegations. The Department met with Executive Director Suzette Johnson and explained the purpose of today's visit. LPA was granted entry to the facility. Investigation consisted of the following: On 04/28/2025, the department requested, reviewed and obtained copies of Resident Roster (Dated 04/28/2025), Personnel Report (Dated 04/28/2025), Dietitian's Report (Dated 03/28/2025) Weekly Menu (Dated 02/16/2025 - 05/03/2025) Resident 1's Records (Dated 04/28/2025) Resident 1's Progress Note (Dated 06/01/2024 - 04/28/2025), and Tray Service Request. Interviews were conducted, with staff 1-5 (S1-S5) and residents 1-10 (R1-10). We toured the facility kitchen. At 11:30 a.m., the Department observed residents eating well-balanced and nutritious meals. We observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Investigation revealed the following: Allegation: Staff do not ensure residents' dietary care plan is being followed. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. Five out of five (5 out of 5) staff members and nine out of ten (9 out of 10) residents stated that staff ensure residents' dietary care plans are being followed. They confirmed that staff consistently adhere to physician-prescribed dietary menus and that residents are served well-balanced, nutritious meals according to the doctors' orders. 5 out of 5 staff members and 9 out of 10 residents also stated that the facility does have a dietitian. R1 reported that staff do not ensure the residents' dietary care plans are being followed. LPA requested R1's physicians' report and reviewed the resident's special diet documentation. 5 out of 5 staff members confirmed that R1 is on a diabetic diet, and R1's physician's report, dated 05/28/2024, also indicated that R1 is on a diabetic diet. LPA observed the facility's regular menu as well as the diabetic alternative menu available for residents on a special diet. Staff stated that according to the residents' physicians' orders, they will accommodate special diets, including low sugar, carbohydrate, mechanical soft, and pureed options. S1-S5 and R2-R10 all denied the allegation. Allegation: Staff do not ensure the resident is provided with breakfast, lunch, and dinner each day. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. Staff members (5 out of 5) and 9 out of 10 residents stated that staff ensure the residents are provided with breakfast, lunch, dinner, and snacks. Residents confirmed they receive three meals per day, and alternative food choices are offered. The facility provides a diverse range of food options, and if a resident requests a second serving, staff accommodates the request. R2-R10 stated they receive plenty of food to eat, and if they don't want to dine in the dining lounge, they can complete a tray service request. Staff will collect the request slip and deliver the meal to the resident's room. R1 stated that staff do not ensure residents are provided with breakfast, lunch, and dinner each day. LPA observed residents eating lunch and dinner and reviewed the food menus. LPA observed an ample supply of perishable and non-perishable food items. LPA observed staff serving meals during breakfast and lunch. LPA also reviewed the resident's tray service form. S1-S5 and R2-R10 all denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation: Staff do not ensure adequate care and supervision is provided to residents On 04/28/2025, between 10:00 a.m. and 11:30 a.m., the Department interviewed two staff members #1 and #5 (S1-S5), regarding the allegation. S2 stated that a resident reported another resident had entered their room; however, there were no witnesses to the incident, and a review of the facility’s surveillance cameras did not reveal any unauthorized entry. Maintenance checked the resident's door and confirmed it was in operable condition. S1 and S5 explained that care staff conduct Wellness checks on residents every two hours. All residents have pendants and call buttons to alert staff if they need assistance. Staff confirmed that no unauthorized individuals were observed entering residents’ rooms. S1 and S5 stated residents’ doors remain locked, and each resident has a personal key to their own room. S1-S5 states the facility currently has about 93 staff members employed and is fully staffed, and that residents are receiving appropriate care, supervision, and assistance with their daily needs. Both interviewed staff (5 out of 5) confirmed the facility is sufficiently staffed and denied the allegation. On April 28, 2025, between 11:45 a.m. and 12:00 p.m., the Department reviewed the facility’s Personnel Report (LIC 500), which listed the following staff positions: Executive Director; Human Services Director; Vice President of Operations; Business Office Manager; Human Resources Director; Resident Care Director; ALW Coordinator; 4 Licensed Vocational Nurses (LVNs); 2 Community Liaisons; 2 Maintenance Staff; 4 Cooks; 5 Kitchen Staff; 4 Food Servers; 2 Dishwashers; 6 Dietary Aides; 9 Medication Technicians; 7 Memory Care Caregivers; 1 Memory Care Activity Director; 2 Activities Assistants; 25 Caregivers; 7 Housekeepers; 4 Receptionists; and 1 Driver a total number of employees listed: 93, confirmed the facility is adequately staffed. On April 20, 2025, there were 10 staff members on the night shift at 9:30 p.m. No incident reports were filed regarding the allegation. None of the caregivers reported witnessing anything, and nothing was documented in the residents' records. See continued LIC9099-C page 4 Continued LIC9099-C page 4 On April 28, 2025, between 12:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with ten residents #1-#10 (R1–R10) regarding the allegation of inadequate care and supervision. 9 out of 10 residents stated that the facility is adequately staffed and confirmed they are receiving the necessary care and supervision. 9 out of 10 also stated that staff are consistently present every shift. 1 out of 10 residents expressed concern about staffing and did not feel care and supervision were adequate. 9 out of 10 residents reported that they were happy living at the facility and had no problems or complaints. The majority of residents (9 out of 10) denied the allegation and stated that their daily needs were being met. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. 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 deemed unsubstantiated. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 11-AS-20250421123647

Allegation investigated: Licensee did not ensure bathroom was in good repair. Licensee did not ensure required notices were visibly posted in the facility. Staff did not allow resident to leave their room.

On 07/17/2025 at 8:27p, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint findings. During today's visit, LPA met with Suzette Johnson and the explained the purpose of the visit. The investigation consisted of the following: On 07/17/2025, LPA interviewed Administrator (A1), Staff #1 - Staff #10 (S1 - S10) and Resident #2-#9 (R2 – R9) ; Resident 1 (refused to be interviewed during the investigation). LPA requested copies of the staff roster (dated 07/17/2025), resident roster (recieved 07/17/2025), Face Sheet & Emergency (for R1 - received on 07/17/2025), LIC 602: Physician Report (for R1 - dated 05/29/2025), Admission Agreement (for R1 - dated 06/24/2025), LIC 603: Preplacement Appraisal Information (for R1 - dated 06/24/2025), Service Plan (for R1 - dated 06/24/2025) and Work Order for Room 285 (created 06/23/2025) Report continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation 1: Licensee did not ensure bathroom was in good repair. It was alleged bathroom, is not working for days and they have not ask someone to come fix it. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated she is not aware of any recent issues with R1's bathroom and residents can report to the front desk where a work order is placed and maintenance will complete the order. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 2 of out of 10 staff confirmed the allegation. 8 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 8 out of 10 residents denied the allegation. 1 out of 10 residents were unsure or unaware of the allegation. At approximately 1:03pm, LPA conducted a tour of room 285 where Resident 1 (R1) resides and observed the following: the sink, shower and toilet operable and in good repair. At approximately 1:30pm, LPA conducted a records review of the work order (created on 06/25/2025) and did not observe any documentation to support the allegation. Based on interviews conducted, records review. and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED Allegation 2: Licensee did not ensure required notices were visibly posted in the facility. It was alleged that the facility its just plain walls with no emergency information or telephone. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated the required posting are publicly visible in the common areas of the facility which is a standard protocol. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 3 out of 9 residents confirmed the allegation. 4 out of 9 residents were unsure or unaware of the allegation. 2 out of 9 residents denied the allegation. Between the hours of 8:35am -8:40am, LPA conducted a tour of the facility and observed in the main lobby area posted on the wall are following: the facility license, the Emergency Disaster Plan for Residential Facilities, the Long Term Ombudsman contact information, and the California Department of Social Services Community Care Licensing Division Centralized Complaint & Information Bureau contact information. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. Report continues on LIC 9099 Allegation 3: Staff did not allow resident to leave their room. It was alleged the facility won't let resident out of the room. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated residents are only restricted from common areas in the event that a resident is on isolation due to testing positive for COVID. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 10 out of 10 residents denied the allegation. Between the hours of 8:35am -8:40am, LPA conducted a tour of the facility and observe residents throughout the facility in common area. Upon records review, R1 is diagnosed with dementia as stated in R1's - LIC 602A Physician's Report for Residential Care Facilities for the Elderly (RCFE). On the LIC 602 under Section 14. Mental Condition it states (k). Able to Leave Facility Unassisted is check of NO. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. On 07/17/2025, LPA attempted to interview Resident #1 (R1) who declined to be interviewed about the three allegations. 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. Exit interview conducted with Suzette Johnson (Administrator) & copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 11-AS-20250714095011

Allegation investigated: Resident sustained an unexplained fracture. Staff did not seek medical attention to resident in a timely manner.

On 07/15/25 The Department conducted a subsequent to deliver complaint findings, LPA Villegas met with Executive Director Suzette Johnson as the purpose of today's visit was explained. The investigation consisted of the following: On 12/10/24 LPA Villegas obtained copies of resident #1 (R1) complete file, copies of the staff and resident rosters, copy of unusual incident report for 12/06/24, and copy of communication between staff regarding R1 from dates 12/01/24-12/09/24. On 01/22/25 The Department conducted interviews with staff #1-3 (S1-S3), and interviews with residents #2-4 (R2-R4). The Department was unable to conduct an interview with Resident #1 (R1) due to communication barrios. On 04/23/25 The Department obtained a copy of R1’s Kaiser Permanente Medical Records. On 05/05/25 The Department conducted a records review. The investigation revealed the following: Allegation: Resident sustained an unexplained fracture. Unsubstantiated It is being alleged that a resident sustained an acute minimally displaced LI fracture while in care. On 01/22/25 The Department conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. Per 1 of 3 staff interviewed, on 12/01/24 resident reported sliding off bed, resident was assessed, resident denied any pain or injury, resident refused to go to the hospital, and resident was placed on “watch alert.” On 01/22/25 The Department conducted interviews with R2-R4 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. The Department was unable to conduct an interview with Resident #1 (R1) due to communication barrios. The Department conducted a review of medical records for R1, medical records revealed that R1 has a history of Osteopenia, subsequent L1 fracture, and mild degeneration (grade 2) to both the right and left hip, which has a higher risk of subsequent fractures. The Department conducted a review of R1’s file, per preplacement assessment dated 08/17/23 R1 is independent in bed mobility and transfer. Allegation: Staff did not seek medical attention for resident in care in a timely manner. It is being alleged that resident did not have a medical evaluation done after fall. On 01/22/25 The Department conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. Per 1 of 3 staff interviewed, on 12/01/24 resident reported sliding off bed, resident was assessed, resident denied any pain or injury, resident refused to go to the hospital, and resident was placed on “watch alert.” On 01/22/25 The Department conducted interviews with R2-R4 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. The Department was unable to conduct an interview with Resident #1 (R1) due to communication barrios. The Department conducted a review of R1’s file, per preplacement assessment dated 08/17/23 R1 is independent in bed mobility and transfer. Per review of communication log dated 12/01/24-12/19/24 R1 was being checked on by staff, per communication log there were no complaints of pain or discomfort, and resident refused to go to the hospital. The Department confirmed that an unusual incident report was sent to CCLD regarding R1’s fall on 12/01/24. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 11-AS-20241209092305

Allegation investigated: Staff are not safeguarding resident's belongings.

On 07/15/25 Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with (S1) Executive Director Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 07/15/25 LPA Villegas obtained copies of the staff and resident roster, surety bond and requested the following documents for resident #1 (R1); emergency ID form, admission agreement dated: , physicians report dated: 12/24/24 preplacement appraisal dated:9/10/24, service plan dated:9/13/24, resident personal property and valuables dated 9/11/24, resident theft and loss record, P&I account log from October 2024-July 2025. On 07/15/25 from 10:15 am- 12:18 pm LPA conducted Interviews with Residents#00-10 (R0-R10), and between 1:00pm- 2pm LPA conducted interviews with staff # 1-00 (S1-00). On 07/15/25 LPA conducted a review of R1's file. The investigation revealed the following: Unsubstantiated Allegation: Staff are not safeguarding resident's belongings. It is being alleged that someone is stealing money from a resident in care. On 07/15/25 from 10:15 am- 12:18 pm LPA conducted Interviews with R1-R10 regarding the allegation above, 9 of 10 residents interviewed denied the allegation above and stated their money have not been stolen or misplaced at the facility. 1 of 10 residents interviewed confirmed the allegation above, per resident money has gone missing twice, however it was not reported to staff. On 07/15/25 from 1:00pm- 2pm LPA conducted interviews with S1-S6 regarding the allegation above, 6 of 6 staff denied the allegation above. 6 of 6 staff interviewed reported that if a resident reports having their property stolen, staff will document it on the communication log, and report it to management for investigation. On 07/15/25 at 2:30 pm LPA spoke to W1 regarding the allegation above, W1 has no concerns regarding the allegation above. On 07/15/25 LPA conducted a review of R1's file, per physicians report dated: 12/24/24, R1 cannot handle own cash resources, R1 has a financial power of attorney. On 07/15/25 LPA reviewed the Resident theft and loss record, LPA did not observe R1 to be listed as reporting any loss or theft. On 07/15/25 LPA reviewed P&I account log from October 2024-July 2025, per log R1 has been receiving funds weekly. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 11-AS-20250708103808

Allegation investigated: Staff did not keep the facility free of rodents

On 07/10/2025 Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent visit to deliver findings regarding the above allegation; this report supersedes the investigation report that was delivered on 07/02/2025. The purpose of this report is to provide additional information gathered during the investigation. LPA met with Suzette Johnson and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 07/01/2025 at approximately 1:50 PM, LPA Anguiano interviewed 10 staff members (S1–S10). Around 3:00 PM, LPA conducted inspections of ten resident rooms: 204, 259, 265, 253, 246, 211, 112, 135, and 138 (seven rooms on the second floor and three on the first floor), and interviewed 11 out of 251 residents (R2-R11). On 07/02/2025 at approximately 8:40 AM, LPA Anguiano conducted a physical plant inspection of the kitchen, and dining room and conducted record reviews. Unsubstantiated On 07/09/2025 around 9:00 AM, LPA interviewed Resident (R1). Investigation revealed the following: Interviews conducted revealed the following: 9 out of the 10 staff members did not agree with the allegation, S1 stated that the facility has pest control measures in place and is currently in preventative mode. S2 indicated that kitchen cleaning is performed regularly. 9 out of the 10 residents did not agree with the allegation. R1 indicated that mice have been seen however had been taken care of in a slow manner when it’s brought up to the staff. LPA observations revealed the following: No live rodents were observed at the time of the visits. Records review revealed the following: LPA Anguiano reviewed a Dewey Pest Control Service Agreement, which indicated proof of an annual service contract. This contract indicated that the services are performed monthly on Wednesday’s. Additionally, a review of the Dewey Pest Control Service Log, covering the period from March 1, 2025, and April 29, 2025, confirmed that treatment services are being performed monthly. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation “staff did not keep the facility free of rodents” 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. An exit interview was conducted, and a copy of the Complaint Report was given to Suzette Johnson.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 11-AS-20250625084748

Allegation investigated: Staff are not disposing of medications. Staff did not safeguard residents medications. Staff are not administering medications to residents. Staff are not following residents care plans Staff left residents in a soiled diaper for a long period of time. Staff are not bathing residents in care. Staff are not feeding residents in care. Staff are teasing residents in care.

On 07/03/2025 around 08:00AM Community Care Licensing Division (CCLD) staff initiated an investigation with Vista Del Mar Senior Living for the allegations listed above. Today’s complaint investigation was conducted face to face with Administrator Suzette Johnson S1. During today’s visit, LPA Calderon, and Administrator Suzette Johnson S1 toured the facility including all common areas and the medication room on the second floor. LPA Calderon requested copies of the following: A copy of the admission agreement, Physician Report for R1-R9, Medication Administration Record (MAR) for April, May, June 2025 for R1-R9, shower logs, toileting assistance logs (dated 05/04/2025 to 05/29/2025), service plans for R1-R9, weekly menu for April 27 to May 31, 2025. LPA Calderon interviewed residents R1-R12 and staff S1-S8. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. LPA Calderon toured the facility with S1. LPA Calderon did not notice any negative interactions with residents. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff are not disposing of medications. This complaint alleged that the facility staff did not dispose of resident medication. LPA Calderon toured the facility with S1. LPA Calderon walked into the medication room on the second floor and witnessed staff preparing medications to be given to residents in care. LPA Calderon noted that staff work with an electronic Medication Administration Record (MAR) for dispensing the residents’ medications. The medications were locked in drawers and moved to locked medication carts which are used to move the resident’s medication. LPA Calderon noted there is a disposable bin for expired medications. LPA Calderon was shown the cabinet that holds liquid medications such as eye drops which were stored and locked. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not disposing of medications.” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff did not safeguard resident’s medications. This complaint alleged that the facility staff did not safeguard resident’s medications. LPA Calderon toured the facility with S1. LPA Calderon walked into the medication room on the second floor and witnessed staff preparing medications to be given to residents in care. LPA Calderon noted that staff work with an electronic Medication Administration Record (MAR) for dispensing the residents’ medications. The medications were locked in drawers and moved to locked medication carts which are used to move the resident’s medication. LPA Calderon noted there is a disposable bin for expired medications. LPA Calderon was shown the cabinet that holds liquid medications such as eye drops which were stored and locked. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff did not safeguard resident’s medications.” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not administering medications to residents. This complaint alleged that the facility staff did not administer medication to residents. LPA Calderon toured the facility with S1. LPA Calderon walked into the medication room on the second floor and witnessed staff preparing medications to be given to residents in care. LPA Calderon noted that staff work with an electronic Medication Administration Record (MAR) for dispensing the residents’ medications. The medications were locked in drawers and moved to locked medication carts which are used to move the resident’s medication. LPA Calderon noted there is a disposable bin for expired medications. LPA Calderon was shown the cabinet that holds liquid medications such as eye drops which were stored and locked. Records review indicate the following: Reviewed the MAR for April, May and June 2025 for R1-R9. Medications given to residents with no errors. Reviewed Physician orders for R1-R9, noted staff ordered medications for resident in care. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not administering medications to residents.” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not following residents care plans. This complaint alleged that the facility staff did not follow the residents’ care plan. Records review indicate the following: Reviewed service plan for R1-R9, staff following service plan. Reviewed Physician report for R1-R9, staff following physician report for residents in care. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not following residents care plans” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff left residents in a soiled diaper for a long period of time. This complaint alleged that the facility staff did not dispose of soiled diapers for a long period of time. Records review indicate the following: Service plan for R1-R2 indicates full assistance with all aspects of bathroom activities and hygiene. Shower and Toileting logs indicate that bathing, grooming and toileting are provided to R1-R2 multiple times per day or per week. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff left residents in a soiled diaper for a long period of time.” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not bathing residents in care. This complaint alleged that the facility staff did not bathe residents. Records review indicate the following: Reviewed Service plan for R1-R9, assistance needed for showering noted by staff. Shower and Toileting logs indicate that bathing, grooming and toileting are provided to R1-R2 multiple times per day or per week. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not bathing residents in care.” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not feeding residents in care. This complaint alleged that the facility staff did not feed bedbound residents. Records review indicate the following: Reviewed Weekly Menu for residents in care, noted wide range of options to eat for residents. Breakfast, lunch and dinner are served. There is 1st seating and 2nd seating starting at 7am to 9am, lunch from 11 am to 1pm and dinner from 4pm to 6pm. Alternative menu is offered. Standard admission agreement indicates page A3-A4, section E meals: We will serve 3 nutritionally balanced meals and snacks daily to residents. Tray Service, we will provide a tray service to your apartment during an illness at no extra charge. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not feeding residents in care.” is found to be UNSUBSTANTIATED Regarding the Allegation: Staff are teasing residents in care. This complaint alleged that the facility staff did not treat residents with respect. Toured the facility and did not notice any negative interactions with residents in care. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are teasing residents in care.” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Suzette Johnson (S1).the state’s words, verbatim · CDSS document, Jul 3, 2025 · control 11-AS-20250626115305

Allegation investigated: Staff did not keep the facility free of rodents

On 07/02/2025 at 8:11 AM, Licensing Program Analyst (LPA) Jose Anguiano conducted an initial visit to gather information regarding the above allegation. LPA met with the Resident Care Director Sidonia Cordis, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 07/02/2025 at approximately 8:40 AM, LPA Anguiano conducted a physical plant inspection of the kitchen, and dining room. During the kitchen inspection, rodent droppings were observed on multiple areas, including: • On the floor beneath the prep tables • Behind the refrigerators • Underneath the water container storage area Please see LIC9099-C for additional documentation. Unsubstantiated No live rodents were observed at the time of the visit. Per interview with (S2), who has been employed at the facility for approximately one month, kitchen cleaning is performed regularly; however, no formal cleaning logs or documentation are maintained. Photographs of the observed droppings were taken by LPA. LPA Jose Anguiano also reviewed a Dewey Pest Control Service Agreement, which provided valid proof of an annual service contract. This contract indicated that the services are performed monthly on Wednesday’s. Additionally, a review of the Dewey Pest Control Service Log, covering the period from March 1, 2025, and April 29, 2025, confirmed that treatment services are being performed monthly. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of the Complaint Report was given to Suzette Johnson.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 11-AS-20250625084748

Allegation investigated: Resident sustained an unexplained injury while in care.

On 07/02/25 Licensing Program Analyst (LPA) Villegas conducted a subsequent visit to deliver complaint findings. LPA met with (S1) Executive Director Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 06/18/25 LPA Villegas obtained copies of the staff and resident roster, and the following documents for resident #1 (R1) face sheet, admission agreement dated:3/24/23, physicians report dated:04/24/2024 , physicians orders, resident preplacement appraisal dated: 3/23/23, needs and service plan dated: 09/08/2024, unusual incident reports dated: 05/19/25, 06/4/25, 06/16/25, fall risk Evaluation dated: 6/4/25, 6/9/25, 06/16/25, and an order from provider dated: 6/16/25 for R1 to be sent to ER. On 06/18/25 at 10:00 am-11:45am LPA conducted Interviews with residents # 2-10 (R2-R10), and between 1:00 pm-2:00pm LPA conducted interviews with staff #1-7 (S1-S7). On 06/18/25 LPA unable to interview R1 as R1 is out of the facility at the time of visit. On 06/26/25 LPA conducted a review of R1's file and obtained a copy of a Physicians order for PT/OT. On 06/27/25 LPA conducted telephone interviews with S8 and R1. Unsubstantiated The investigation revealed the following: Allegation: Resident sustained an unexplained injury while in care. It is being alleged that a resident in care had swelling and bruising around their right eye that was not there 2 days prior. On 06/18/25 at 10:00 am-11:45am LPA conducted Interviews with R2-R10, 9 of 9 residents interviewed denied the allegation above, and reported feeling safe living at the facility. On 06/18/25 and 6/27/25 LPA conducted interviews with S1-S8 regarding the allegation above, 8 of 8 staff interviewed denied the allegation above. Per 8 of 8 staff interviewed, families and Primary Care Physicians are notified of any falls or injuries a resident may experience while in care. On 06/26/25 LPA conducted a review of R1's file, LPA observed incident reports dated: 05/19/25, 06/04/25, and 06/16/25, per incident reports R1 experienced un-witnessed falls and declined medical attention. LPA confirmed incident reports dated: 05/19/25, 06/04/25, and 06/16/25 were sent and received by CCLD. During file review LPA observed documented fall risk assessments conducted on 06/04/25, 06/09/25, and 06/16/25, per fall risk assessments R1 was at high risk of falls. In addition, during file review LPA observed an order from provider dated 6/16/25 for residents to be sent to ER due to recent falls and refusal of medical attention. On 06/27/25 LPA conducted telephone interview with R1 regarding the allegation above, R1 denied the allegation above. Per R1, R1 is clumsy and has fallen quite a bit. R1 states that the facility has offered medical service after each fall, however R1 did not see it necessary as R1 is able to take care of self. R1 stated the staff at Vista Del Mar have been very kind since R1’s has been admitted. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 11-AS-20250609110500

Type of visit: Case Management - Deficiencies

On 07/02/2025 at around 9:20 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced visit for complaint 11-AS-2025062515023. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility. On 07/02/2025, LPA Leandro observed the following deficiency in room 316 at around 2:23 PM: · R1’s bed had no fitted bed sheets. A deficiency is being cited based on LPAs observations. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, and plans or correction were developed. A copy of this report was left with the Executive Director, Suzette Johnson.the state’s words, verbatim · CDSS document, Jul 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3)(C) · Plan of correction due date: Jul 22, 2025

Personal Accommodations and Services (3) Equipment and supplies necessary for personal care...the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets...The quantity shall be sufficient to permit...prohibited. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by R1's bed not having fitted bed sheets which poses a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: The licensee has agreed to place fitted sheet R1's bed. The licensee has agreed to create a plan to stay in compliance with CCR 87307(3)(C). The licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Allegation investigated: Staff did not prevent resident from engaging in inappropriate behaviors. Staff are not providing a comfortable environment for resident.

On 07/1/25, at 09:00am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Suzette Johnson, Executive Director. LPA explained the purpose of this visit is to gather information about the complaint, gather facility files, interview staff/residents, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R10) from 10:00am-02:00pm. The department received the following: Resident Roster (No Date) Staff Roster (Dated: 07/01/2025), ID/Emergency Information (Dated: 01/13/2023, 08/03/2024) Admission Agreement (Dated:01/13/2023, 08/03/2024), Pre-Placement Appraisal (Dated: 08/06/2024, 01/13/2023), Physicians Report (Dated:08/01/2024, 04/23/2025), Appraisal/Needs and Service Plan (Dated: 09/08/2024, 04/14/2025), Vista Del Mar Senior Living Work Order (Dated: 06/28/2025) and Facility Notes (Dated: 07/01/2025) from the facility. Report Continued On Lic9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Staff did not prevent resident from engaging in inappropriate behaviors. The details of the complaint alleged that the resident (R1) has a roommate that is sundowning and is up during the night, and R1 has caught the roommate messing with their oxygen tank. It was reported that the resident feels unsafe with their current roommate and would like to change rooms. On 7/1/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not prevent resident from engaging in inappropriate behaviors. All staff (S1-S4) interviewed stated that they had no knowledge that R1s roommate had allegedly interfered with their oxygen tank. They stated that no one told them about this issue and now that they know they will address the issue and take appropriate action. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied any knowledge of ongoing issues with resident’s engaging in inappropriate behaviors. The majority of the resident’s stated that they either do not have a roommate or that they do not have any such issues with their current roommate and/or other resident’s. The Department reviewed the Vista Del Mar Senior Living Work Order (Dated: 06/28/2025) and Facility Notes (Dated: 07/01/2025) and observed that a work order was created on 06/28/2025 to move the resident (R1) to another room in the facility. The department also observed that management was made aware of the issue between the two roommates and started the process of taking appropriate actions to resolve the concern. S1 stated that R1 was given an option to switch sides within the room to help resolve the disagreement but R1 declined the offer and chose to stay on their side of the room. Subsequently, the facility decided to move R1 and created a work order to do so on 06/28/2025. R1 is scheduled to be transferred to a new room within a week or so. Once the room has been prepped, the team will assist R1 with their move to their new location in the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not prevent resident from engaging in inappropriate behaviors. 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. Report Continued On LIC9099-C Allegation #2- Staff are not providing a comfortable environment for resident. The details of the complaint alleged that the resident (R1) has a roommate that is causing the resident to live in an uncomfortable environment, but the facility has not moved or changed the resident to a new room. It was reported that the roommate and their family members turn off the air condition in the bedroom when it is hot, causing the resident (R1) to feel uncomfortable. On 7/1/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff are not providing a comfortable environment for resident. All staff (S1-S4) interviewed stated that when they learned of the issue with the roommates, they took appropriate action to resolve the issue. They stated that they had a discussion with both resident’s and concluded that they would relocate R1 to another room in the facility. Staff stated that they are in the process of making that happen and it should not take more than a week to find a room and prepare it for R1 to move in. They further state that R1 will be assisted with the move by a team within the facility. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that they were comfortable with the environment within the facility and were satisfied with the care and supervision provided by the staff. The majority of the resident’s stated that they are provided a comfortable environment to live in by the facility. The Department reviewed the Vista Del Mar Senior Living Work Order (Dated: 06/28/2025) and Facility Notes (Dated: 07/01/2025) and observed that a work order was created on 06/28/2025 to move the resident (R1) to another room in the facility. The department also observed that management was made aware of the issue between the two roommates and started the process of taking appropriate actions to resolve the concern. R1 is scheduled to be transferred to a new room within a week or so. Once the room has been prepped, the team will assist R1 with their move to their new location in the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not providing a comfortable environment for resident. 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. No deficiencies were cited. An exit interview was conducted with Suzette Johnson, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 11-AS-20250626084043

Allegation investigated: Staff did not ensure resident's catheter care was properly managed.

* This report supersedes the report dated 05/14/2025. It does not supersede the findings but is being used to clarify the findings. On 05/30/2025 Licensing Program Analyst (LPA) Troy Watson made a subsequent unannounced complaint visit to the above listed facility. LPA Watson was greeted by the Administrator Suzette Johnson and explained the purpose of this visit is to deliver findings for the allegation mentioned above. CONTINUED ON LIC9099-C Unsubstantiated The investigation consisted of the following: LPA Watson conducted interviews with residents and staff. LPA Watson requested and received the following: Staff and Resident Roster, SIR reports, Physician's report.A tour of the facility was conducted with the Administrator Suzette Johnson on 05/13/2025. The investigation revealed the following: Allegation: Staff did not ensure resident's catheter care was properly managed. It is being alleged that staff did not ensure that resident’s catheter was regularly emptied and cleaned. On 05/08/2025 the department conducted interviews with Residents #2 - Residents #11 (R2-R11). An attempt to interview Resident #1 (R1) was made but they were no longer at the facility and did not respond to several calls and messages left on their phone/voice mail. The department asked the residents if staff catheters were properly emptied, cleaned and managed? Of those interviewed, 10 out of 10 residents denied the above allegation. On 05/08/2025 the department interviewed Staff #1- Staff #11 (S1-S11). The department asked the staff if catheters were properly emptied, cleaned and managed? Of those interviewed, 11out of 11staff denied the above allegation. Based on interviews and observations there is insufficient evidence to support the allegation: Staff did not ensure resident’s catheter care was properly managed. 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. An exit interview was conducted with the Administrator Suzette Johnson and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 30, 2025 · control 11-AS-20250430092910

Allegation investigated: Facility staff did not dispense medications as prescribed.

On 05/16/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the facility to deliver findings. LPA was met by staff one, Suzette Johnson Exective Director (S1), and the purpose of the visit was explained. The investigation consisted of the following: On 11/22/24 LPA requested staff and resident roster, three (3) resident admissions agreement (R1, R6, R7) and toured the facility and interviewed ten (10) out of two-hundred and thirty-eight (238) residents (R1-R10) and five (5) out of one-hundred and five (105) staff (S1-S5). Resident seven (R7) was sleeping and denied LPA's interview. On 12/05/24 CCLD staff interviewed four (4) residents (R11-R14) and two (2) staff (S5 & S6). LPA requested further records, including home health service visit notes for a resident. The investigation revealed the following: Regarding the allegation, "Facility staff did not dispense medications as prescribed.". It has been alleged that a resident did not receive their weekly dosage of a medication, as ordered by resident's physician (Dr.), due to medication being misplaced by staff. Report continues, see LIC9099-C. Substantiated Record reviews of the medication administration record (MAR) reveal that a doctor's order had been placed for the medication in question (M1) on September 5th, 2024 (09/05/2024). Though M1 is to be provided once per week (1x/week), M1 had been marked as having been administered to a resident nineteen (19) times during the month of September (09/2024). The MAR, following M1, indicates that a resident's Dr.'s order had been followed between the dates of 10/25/2024 through 11/07/2024. M1 was provided to the resident on November the eighth, 2024 (11/08/2024) and November the fifteenth, 2024 (11/15/2024), again following a resident's Dr. order, yet no more administration marks had been placed on the MAR during the month of November (11/2024). Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D. One deficiency has been cited during today's visit, please see LIC9099-D. An exit interview was held with Suzette Johnson, Executive Director, and a copy of appeal rights, this deficiency and this report have been provided. The investigation revealed the following: Regarding the allegation, "Resident developed a pressure injury due to staff neglect". It has been alleged that a resident has not been rotated as often as needed. Although the facility does not keep a rotation log for the residents requiring this service, LPA interviews revealed that nine (9) out of fourteen (14) residents and all six (6) staff interviewed, out of one-hundred and five (105) staff, have not agreed with the allegation. Record reviews revealed that a resident did have a stage two (2) pressure injury, but on November nineteenth, 2024 (11/19/24) the same resident requested discharge from their home-health services provided by Excel Home Health in order to choose an alternate service(s) which are also related to a resident's health condition. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violation did occur. Therefore, the above allegation is found to be Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Suzette Johnson, Executive Director, and a copy of appeal rights and this report have been provided.the state’s words, verbatim · CDSS document, May 16, 2025 · control 11-AS-20241119135616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: May 23, 2025

87465 Incidental Medical...care (a) A plan for incidental medical...care shall be developed by each facility. The plan...provide for assistance in obtaining such care...: (6) When requested by...a record of dosages of medications shall be maintained by the facility. This requirement has not been met as evidenced by: R1's medication admission record (MAR) in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: LPA and licensee have agreed that med-tech staff will undergo training to reiterate how important medication (med) management, including focus on med storage, is for residents in care. Licensee has agreed that facility will send inservice conference information, including the time included & sign-in sheet, on or prior to the POC due date 05/23/2025, via email to LPA at mario.leon@dss.ca.gov

Allegation investigated: Resident sustained a fracture due to lack of care from staff.

On 05/16/2025, the department conducted a subsequent complaint visit in order to render investigation findings. The department met with Resident Care Director Sideonis Cordis and the purpose of the visit was explained. The investigation consisted pf the following: On 04/30/2024, the department obtained and reviewed the following: Needs and Service Plan (dated 03/19/2024), Pre-Placement Appraisal (dated 05/06/2023), Physicians Report (dated 03/15/2024), Incident report (dated 04/19/2024 and 04/20/2024), Physician’s Orders (dated 03/19/2024), Memorial Care Long Beach Medical Center medical records (dated 04/24/2024), and Providence St. Joseph Hospital medical records (dated 4/19/2024) for R1. The departmetnt interviewed four staff (S1-S3), including the Executive Director Janie Acosta. The department interviewed three residents (R1-R3). Report continued on LIC9099-C Substantiated Allegation #1: Resident (R1) sustained a fracture due to a lack of care from staff. It is alleged that Resident (R1) fell and sustained a vertebral fracture injury due to falling from R1’s wheelchair. This investigation revealed that R1 was admitted to Vista Del Mar Senior Living on 03/03/24. A record review of R1’s Physician Report (dated: 03/15/24) revealed that R1 is non-ambulatory and requires staff assistance to transfer to and from bed. On 4/22/25, staff found R1 sitting on the floor in R1’s room. Staff observed R1’s forehead was bleeding, and an abrasion under the left eye. Staff reported R1 experienced an unwitnessed fall and called 911. R1 was transported to Memorial Care Long Beach Medical Center, where an imaging test was performed. The department conducted a review of Memorial Care of Long Beach's medical records and found that the imaging test results detected R1 sustained a cervical spine fracture and soft tissue swelling. The department conducted a record review of the facility’s notes and found that R1 experienced unwitnessed falls from R1’s wheelchair in R1’s room on 03/25/24, 3/26/24, and 3/28/24. The department conducted a review of the facility notes and found that R1 did not prefer to sleep in a bed and would sleep in R1’s wheelchair. The department conducted interviews with S1-S4 and found that staff were aware that R1 would fall asleep in R1’s wheelchair, fall forward, and fall from the wheelchair. Report continued on LIC9099-C The department found no record of the facility implementing a fall risk management plan for R1. The department conducted interviews with three residents (R1-R3). 3 out of 3 expressed no issues with staff supporting their needs. During this investigation, the department found sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and a citation was issued (ref. LIC 9099D). An immediate civil penalty of $500 is warranted in accordance with the California Health and Safety Code. See LIC421IM. An exit interview was conducted. A copy of this report, along with the appeal rights were provided to the Executive Director Suzette Johnson. Allegation #2: Staff refused to accept the resident back at the facility following a hospital visit. It has been alleged that staff refused to accept a resident back at the facility following a hospital visit, despite the resident being cleared for return. On April 22, 2024, the resident was admitted to Memorial Care Long Beach Medical Center (MCLBMC) after experiencing an unwitnessed fall from a wheelchair. On April 30, 2024, between 10:00 AM and 12:00 PM, the department interviewed Staff Member 1 (S1), who denied the allegation. S1 stated that on April 23, 2024, R1 arrived in the office on a gurney without a cervical collar (C-collar), prompting S1 to send the resident back to the hospital. S1 indicated that she had spoken with the emergency room physician at MCLBMC regarding the resident's condition. The physician explained that the resident had two cervical spine fractures and required a C-collar and further treatment; however, the R1 refused care. S1 informed the physician that the resident needed to be placed in a skilled nursing facility before returning to the assisted living facility, as the facility could not provide the necessary level of care. The physician agreed with this plan and consented to find an alternative placement. S1 also noted that R1 was not cooperating with the hospital staff, resulting in the hospital discharging R1. Report continued on LIC9099-C On 04/30/2024, the department interviewed four staff members (S1-S4), 4 out of 4 denied the allegation and stated that R1 was not refused readmission to the facility, the facility wanted R1 to go to skilled nursing for more treatment, in then come back to the facility after treatment. On 05/16/2025, the department interviewed 5 Residents (R1-R5) 5 out of 5 denied the allegation. The department reviewed medical records from Memorial Care Long Beach Medical Center dated 04/22/24 to 04/24/24, indicated that R1 refused multiple attempts for an MRI and refused to wear a C-collar for R1's neck fractures, and demanded to be discharged from the hospital. On 04/23/24 at 11:07 am, the hospital called the facility and spoke to S1 and stated that R1 does not want any further care and does not want to wear a C-collar; therefore, R1 will be discharged back to the facility. Based on the records reviewed and interviews conducted, there is insufficient evidence to support the allegation that the staff refused to accept the resident back at the facility following a hospital visit. 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. No citations were issued. An exit interview was conducted, and a copy of this report was provided to the Executive Director Suzette Johnson.the state’s words, verbatim · CDSS document, May 16, 2025 · control 11-AS-20240429113918

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 19, 2025

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. Based on interview and record reviews, the licensee failed to provide R1 with more assistance and supervision following discharge from the hospital on 04/19/24 due to being a high fall risk. R1 continued to experience multiple falls that resulted in a fracture of C5 and C6 vertebrae on 04/22/24, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: The Executive Director will provide a fall risk plan, and the facility will provide in- service training to all staff. The Executive Director will email LPA the POC. POC due date 05/19/25.

Allegation investigated: Facility staff did not dispense medications as prescribed.

On 05/16/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the facility to deliver findings. LPA was met by staff one, Suzette Johnson Exective Director (S1), and the purpose of the visit was explained. The investigation consisted of the following: On 11/22/24 LPA requested staff and resident roster, three (3) resident admissions agreement (R1, R6, R7) and toured the facility and interviewed ten (10) out of two-hundred and thirty-eight (238) residents (R1-R10) and five (5) out of one-hundred and five (105) staff (S1-S5). Resident seven (R7) was sleeping and denied LPA's interview. On 12/05/24 CCLD staff interviewed four (4) residents (R11-R14) and two (2) staff (S5 & S6). LPA requested further records, including home health service visit notes for a resident. The investigation revealed the following: Regarding the allegation, "Facility staff did not dispense medications as prescribed.". It has been alleged that a resident did not receive their weekly dosage of a medication, as ordered by resident's physician (Dr.), due to medication being misplaced by staff. Report continues, see LIC9099-C. Substantiated Record reviews of the medication administration record (MAR) reveal that a doctor's order had been placed for the medication in question (M1) on September 5th, 2024 (09/05/2024). Though M1 is to be provided once per week (1x/week), M1 had been marked as having been administered to a resident nineteen (19) times during the month of September (09/2024). The MAR, following M1, indicates that a resident's Dr.'s order had been followed between the dates of 10/25/2024 through 11/07/2024. M1 was provided to the resident on November the eighth, 2024 (11/08/2024) and November the fifteenth, 2024 (11/15/2024), again following a resident's Dr. order, yet no more administration marks had been placed on the MAR during the month of November (11/2024). Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D. One deficiency has been cited during today's visit, please see LIC9099-D. An exit interview was held with Suzette Johnson, Executive Director, and a copy of appeal rights, this deficiency and this report have been provided. The investigation revealed the following: Regarding the allegation, "Resident developed a pressure injury due to staff neglect". It has been alleged that a resident has not been rotated as often as needed. Although the facility does not keep a rotation log for the residents requiring this service, LPA interviews revealed that nine (9) out of fourteen (14) residents and all six (6) staff interviewed, out of one-hundred and five (105) staff, have not agreed with the allegation. Record reviews revealed that a resident did have a stage two (2) pressure injury, but on November nineteenth, 2024 (11/19/24) the same resident requested discharge from their home-health services provided by Excel Home Health in order to choose an alternate service(s) which are also related to a resident's health condition. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violation did occur. Therefore, the above allegation is found to be Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Suzette Johnson, Executive Director, and a copy of appeal rights and this report have been provided.the state’s words, verbatim · CDSS document, May 16, 2025 · control 11-AS-20241119135616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: May 23, 2025

87465 Incidental Medical...care (a) A plan for incidental medical...care shall be developed by each facility. The plan...provide for assistance in obtaining such care...: (6) When requested by...a record of dosages of medications shall be maintained by the facility. This requirement has not been met as evidenced by: R1's medication admission record (MAR) in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: LPA and licensee have agreed that med-tech staff will undergo training to reiterate how important medication (med) management, including focus on med storage, is for residents in care. Licensee has agreed that facility will send inservice conference information, including the time included & sign-in sheet, on or prior to the POC due date 05/23/2025, via email to LPA at mario.leon@dss.ca.gov

Allegation investigated: Staff did not ensure resident's catheter care was properly managed.

On 05/14/2025 Licensing Program Analyst (LPA) Troy Watson made an unannounced complaint visit to facility listed above to deliver findings and was greeted by the Administrator Suzette Johnson. LPA explained the purpose of the visit and was granted access to the facility grounds. The investigation consisted of the following: On 5/8/2025 LPA Watson conducted interviews with Residents #1- Residents #10 (R1-R10) and Staff #1- Staff #11 (S1-S11). LPA Watson requested and received the following: Staff and Resident Rosters, Special Incident Reports, Physician's reports. CONTINUED ON LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure resident's catheter care was properly managed. It is being alleged that staff did not ensure that resident’s catheter was regularly emptied and cleaned. On 05/08/2025 the department conducted interviews with Residents #1- Residents #10 (R1-R10). The department asked the residents if their catheters were properly emptied, cleaned and managed. Of those interviewed, 1 out of 10 residents had a catheter and stated he had no issues with staff’s management of his catheter while the out 9 of 10 residents did not have catheters but had not heard about anyone having issues with their catheters. On 05/08/2025 the department interviewed Staff #1- Staff #11 (S1-S11). The department asked staff if catheters were properly emptied, cleaned and managed. Of those interviewed, 11 out of 11staff denied the allegation. Based on interviews and observations there is insufficient evidence to support the allegation: “Staff did not ensure resident’s catheter care was properly managed”. 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. An exit interview was conducted with the Administrator Suzette Johnson and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 14, 2025 · control 11-AS-20250430092910

Allegation investigated: Staff does not provide comfortable water temperature for resident(s). Staff does not keep resident’s room free from pests.

On May 1, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced visit to gather information regarding the above allegations. LPA met with Executive Director Suzette Johnson, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1-#5 (S1 to S5), and resident members #1-#10 (R1 to R10). List of documents reviewed/obtained Resident Roster (dated 05/01/25), Personnel Report LIC 500 (dated 05/01/25), Dewey Pest Control Service Agreement (dated 12/12/24),Dewey Pest Control Service Log (dated 04/01/25 through 04/29/25), and other documents pertinent with this complaint. (Evaluation Report continues LIC 9099C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff does not provide comfortable water temperature for resident(s). The complaint details the staff allegedly failing to provide a comfortable water temperature for residents in care. Reports indicate that there is no hot water available. The common shower area fails to provide consistent hot water, and despite notifying a staff member about this issue, no actions have been taken to resolve it, and no further information has been provided. On May 1, 2025, between 9:30 AM and 10:30 AM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the (5) staff members could not validate this allegation. (S1-S2) acknowledged since April 22, 2023, there have been some issues with the water pressure due to one of the boilers that operates by gas not operating correctly. (S1) notified Community Care Licensing (CCL) by submitting an incident report on April 23, 2025. (S1) provided a subsequent report to (CCL) on April 26, 2025, written notification to Residents and Families of Vista Del Mar Senior Living of Hot Water Service Disruption for the first and second floors. In the notice that it described, the HVAC contractor and Southern California Gas have been working to identify and resolve problems with the facility’s boiler system. The notice offered temporary accommodations with vacant rooms and common area shower rooms for residents affected by this problem. (S2) stated that all rooms have access to hot water because there is still one operational boiler. This boiler effectively transfers heat to the water by passing it through a pipe within the heated gas chamber. Consequently, while the water may take slightly longer to heat up, it remains universally available in every room. Utilizing two separate boilers enables a quicker heat transfer process that residents recognize. Staff member #3 (S3) stated that (S3) does not recall discussing the hot water issues with residents. Additionally, (S3) indicated that no residents have reported any concerns related to this matter. On May 1, 2025, between 10:35 AM and 12:00 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of the ten (10) resident members could not corroborate this allegation. (R1-R10) have access to running hot water in their rooms. Five (5) out of the ten (10) residents acknowledged receipt of the written notification regarding alternative amenities. (Evaluation Report continues LIC 9099-C) On May 1, 2025, between 1:30 PM and 2:30 PM, the Department conducted inspections of rooms #105, #117, #235, #236, #237, #238, and #239, as well as the kitchen and public restrooms. During the inspection, heated water was available, with temperatures ranging from 105.1°F to 118.0°F, which complies with Title 22 Regulations. Additionally, the Department observed the HVAC technician servicing the boiler systems. The Department also reviewed written communication reports dated April 23, 2025, and April 26, 2025, which indicated that the facility is taking proactive measures to address the boiler system issue. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Allegation #2: Staff does not keep resident’s room free from pests. The staff allegedly neglected to ensure that the residents were free from pests. Three cockroaches were reportedly found in a resident's room. Although a staff member was notified about the issue, no action has been taken to address it, and no further details have been provided. On May 1, 2025, between 9:30 AM and 10:30 AM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the (5) staff members expressed no pest activity in the facility, including resident’s rooms. (S1-S2) emphasizes its commitment to ensuring the safety and well-being of residents by implementing effective, environmentally friendly pest management measures. Their proactive approach protects their residents and promotes a healthier living environment for everyone. The facility has an active Service Agreement with a reputable pest control company that performs weekly routine pest control services. (S2) stated that these scheduled services are done every Tuesday and will treat 10 rooms and common areas weekly. Staff member #3 (S3), referenced in this complaint, indicated that (S3) do not remember conversing with residents regarding pest control issues. On May 1, 2025, between 10:35 AM and 12:00 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of the ten (10) resident members could not validate this allegation. All residents from (R1-R10) have stated that they have not encountered any pests within their rooms or in the facility's common areas. Additionally, they have observed pest control professionals actively performing treatments throughout the premises, ensuring a safe and pest-free environment for everyone. (Evaluation Report continues LIC 9099-C) On May 1, 2025, between 1:30 PM and 2:30 PM, the Department conducted inspections of rooms #105, #117, #235, #236, #237, #238, and #239, as well as the kitchen, activity rooms, and dining room. Upon inspection, no signs of pest activity were present in the area. The Department also reviewed a Dewey Pest Control Service Agreement dated December 12, 2024, which provided valid proof of an annual service contract. This contract indicated that ten units of service were performed monthly, totaling 40 treatments per month. Additionally, a review of the Dewey Pest Control Service Log, covering the period from April 1, 2025, to April 29, 2025, confirmed that treatment services are being performed weekly. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview with Executive Director, Suzette Johnson and reports were provided.the state’s words, verbatim · CDSS document, May 1, 2025 · control 11-AS-20250428095622

Allegation investigated: Staff do not ensure residents dietary care plan is being followed Staff do not ensure resident is provided with breakfast, lunch and dinner each day Staff does not ensure adequate care and supervision is provided to residents

On 04/28/2025 at 9:26 a.m., The Department conducted an initial visit to gather information regarding the above allegations. The Department met with Executive Director Suzette Johnson and explained the purpose of today's visit. LPA was granted entry to the facility. Investigation consisted of the following: On 04/28/2025, the department requested, reviewed and obtained copies of Resident Roster (Dated 04/28/2025), Personnel Report (Dated 04/28/2025), Dietitian's Report (Dated 03/28/2025) Weekly Menu (Dated 02/16/2025 - 05/03/2025) Resident 1's Records (Dated 04/28/2025) Resident 1's Progress Note (Dated 06/01/2024 - 04/28/2025), and Tray Service Request. Interviews were conducted, with staff 1-2 (S1-S2) and residents 1-10 (R1-10). We toured the facility kitchen. At 11:30 a.m., the Department observed residents eating well-balanced and nutritious meals. We observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Investigation revealed the following: On 04/21/2025, it was alleged that a resident was unable to eat the food served due to the resident's dietary restrictions. It was reported that the facility maintains a record of residents’ special dietary needs; however, it does not consistently follow them. It was also reported that the facility does not have a dietitian. The facility does not provide substitutions that residents can eat on a regular basis. Although the facility uses meal menu slips for residents who are unable to make their way to the dining hall, staff have at times forgotten to pick up residents’ meal slips from their rooms, resulting in residents not receiving meals on multiple occasions. It was reported that on 04/20/2025 at 9:30 p.m., a male resident with dementia entered a resident’s room without permission while the resident was sleeping. The resident woke up, yelled at the male resident to leave, and pressed the pendant for assistance. The staff responded within three minutes and removed the male resident. Allegation: Staff do not ensure residents' dietary care plan is being followed. On 04/28/2025, the Department interviewed staff members 1-2 (S1-S2) and residents 1-10 (R1-R10) regarding the allegation. Staff members (2 out of 2) and 9 out of 10 residents stated staff does ensure residents' dietary care plans are being followed. They confirmed that staff consistently adhere to the physician-prescribed dietary menu, and residents are served well-balanced, nutritious meals according to the doctors' orders. S1-S2 and R2-R10 stated that the facility does have a dietitian. R1 stated that staff do not ensure residents' dietary care plan is being followed. S1-S2 and R2-R10 all denied the allegation. Allegation: Staff do not ensure the resident is provided with breakfast, lunch, and dinner each day. On 04/28/2025, the Department interviewed staff members 1-2 (S1-S2) and residents 1-10 (R1-R10) regarding the allegation. Staff members (2 out of 2 ) and 9 out of 10 residents stated staff does ensure the residents are provided with breakfast, lunch, dinner, and snacks. Residents confirmed they receive three meals per day, alternative food choices are offered. The facility provides a diverse range of food options, and if a resident requests a second serving, staff accommodates the request. R2-R10 stated they receive plenty of food to eat, and if they don't want to dine in the dining lounge, they can complete a tray service request. Staff will collect the request slip and deliver the meal to the resident's room. R1 stated that staff do not ensure residents are provided with breakfast, lunch, and dinner each day. S1-S2 and R2-R10 all denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation: Staff do not ensure adequate care and supervision is provided to residents On 04/28/2025, between 10:00 a.m. and 11:30 a.m., the Department interviewed two staff members #1 and #2 (S1-S2), regarding the allegation. S2 stated that a resident reported another resident had entered their room; however, there were no witnesses to the incident, and a review of the facility’s surveillance cameras did not reveal any unauthorized entry. Maintenance checked the resident's door and confirmed it was in operable condition. S1 and S2 explained that care staff conduct Wellness checks on residents every two hours. All residents have pendants and call buttons to alert staff if they need assistance. Staff confirmed that no unauthorized individuals were observed entering residents’ rooms. S1 and S2 stated residents’ doors remain locked, and each resident has a personal key to their own room. S1-S2 states the facility currently has about 93 staff members employed and is fully staffed, and that residents are receiving appropriate care, supervision, and assistance with their daily needs. Both interviewed staff (2 out of 2) confirmed the facility is sufficiently staffed and denied the allegation. On April 28, 2025, between 11:45 a.m. and 12:00 p.m., the Department reviewed the facility’s Personnel Report (LIC 500), which listed the following staff positions: Executive Director; Human Services Director; Vice President of Operations; Business Office Manager; Human Resources Director; Resident Care Director; ALW Coordinator; 4 Licensed Vocational Nurses (LVNs); 2 Community Liaisons; 2 Maintenance Staff; 4 Cooks; 5 Kitchen Staff; 4 Food Servers; 2 Dishwashers; 6 Dietary Aides; 9 Medication Technicians; 7 Memory Care Caregivers; 1 Memory Care Activity Director; 2 Activities Assistants; 25 Caregivers; 7 Housekeepers; 4 Receptionists; and 1 Driver a total number of employees listed: 93, confirmed the facility is adequately staffed. On April 28, 2025, between 12:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with ten residents #1-#10 (R1–R10) regarding the allegation of inadequate care and supervision. 9 out of 10 residents stated that the facility is adequately staffed and confirmed they are receiving the necessary care and supervision. 9 out of 10 also stated that staff are consistently present every shift. 1 out of 10 residents expressed concern about staffing and did not feel care and supervision were adequate. 9 out of 10 residents reported that they were happy living at the facility and had no problems or complaints. The majority of residents (9 out of 10) denied the allegation and stated that their daily needs were being met. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. 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 deemed unsubstantiated. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Apr 28, 2025 · control 11-AS-20250421123647

Allegation investigated: Resident had unknown exposure to fentanyl while in care.

On 12/31/2024, at 9:25am, the department made an unannounced initial visit to the facility and was greeted by Suzette Johnson, Administrator (S1). The purpose for today’s visit was to obtain facility files pertaining to the above-mentioned allegation. The investigation consisted of the following: On 12/31/24 the department conducted an initial visit and met with Administrator, Suzette Johnson (S1). A subsequent visit was completed by the department on 04/4/2025. During the initial visit, the department conducted a tour of the facility’s physical plant and observed residents in care. The department obtained copies of the following documents: Resident Roster (No Date), Staff Roster (Dated: 12/31/2024), and In-Service Medication Training for Staff (Dated: 10/18/2023-11/05/2024) for the facility. Records for resident (R1): ID/Emergency Information (Dated: 12/31/24) Admission Agreement (Dated:09/06/2024), Appraisal & Needs Service Plan (Dated: 09/18/2024), Physicians Report (Dated: 07/24/2024), After Visit Summary (Dated: 12/24/2024), Unusual Incident/Injury Report (Dated: 12/20/24 & 12/31/2024)..... Page 1 of 3 LIC9099 Unsubstantiated Medication Administration Records (Dated: 10/01/2024-12/31/2024), and current Physician’s Orders (Dated: 12/31/2024) were also obtained from the facility. This complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigation Bureau Investigator, Olivia Spindola. As a part of the investigation, Investigator Spindola subpoenaed copies of College Medical Center medical records for resident (R1) which included: progress notes, physicians orders, psychological exam, lab results, and medication list. Additionally, the investigator conducted interviews with staff (S1-S4), witness (W1), and residents (R1-R3). The investigation revealed the following: Allegation-Resident had unknown exposure to fentanyl while in care. It is alleged that resident had exposure to an illegal drug while living at the facility. On 12/18/24 the resident was admitted to College Medical Center where they tested positive for the illegal drug Fentanyl. On 01/15/25, from 11:30am-1:00pm, the department interviewed staff (S1-S3); On 2/11/25, from 11:00am-3:30pm, the department interviewed residents (R1-R3) and staff (S4), and on 3/18/25, from 4:00pm-4:30pm, the department interviewed witness (W1) about the complaint allegation. 4 of 4 staff denied the allegation that the Resident had unknown exposure to fentanyl while in care. Staff denied knowing how the resident tested positive for the illegal drug. Staff also stated the resident resides in a locked area and cannot leave without supervision or assistance from staff. They further deny that the resident had access to illegal narcotics inside the facility or that anyone would provide the resident with Fentanyl. The department interviewed residents (R1-R3) about the allegation and 2 of 3 residents denied the allegation, while one resident was unable to participate in the investigation due to poor health. The residents that were interviewed stated that they have not witnessed any illegal drug use in the facility and was not aware of anyone providing illegal narcotics to residents. The department reviewed medical records from College Medical Center for R1 and observed that (R1) tested positive for Fentanyl on 12/18/2024, and 12/31/2024, when hospitalized at College Medical Center (CMC). The CMC records revealed that (R1) was hospitalized on an involuntary psychiatric hold for reported increased aggression and combativeness. Although the medical records indicated (R1) tested positive for Fentanyl during both hospitalizations, the department did not uncover any evidence or obtained any witness statements indicating that (R1) had access to Fentanyl or any other illegal narcotics, as (R1) resides in the Memory Care Unit of the facility, which is a locked area. The CMC records also indicated that (R1) takes several psychotropic medications to treat schizoaffective disorder, which included Olanzapine, Risperidone, Lorazepam, Quetiapine, and Trazadone. According to www.pubmed.ncbi.nlm.nih.gov, antibiotics, analgesics, and antidepressants medications such as Quetiapine and Risperdal are known to give false-positive for Fentanyl in laboratory testing. The nurse assistant (W1) stated that Quetiapine and Risperidone are drugs known to give false-positive for Fentanyl. Page 2 of 3 LIC9099-C Based on records reviewed and interviews conducted, there is insufficient evidence to support the allegation that the Resident had unknown exposure to fentanyl while 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. No citations were issued for this complaint. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Suzette Johnson, Administrator. Page 3 of 3 LIC9099-Cthe state’s words, verbatim · CDSS document, Apr 4, 2025 · control 11-AS-20241226135225

Allegation investigated: Facility memory care unit is not properly staffed.

On 02/20/25 Licensing program analyst (LPA) Villegas conducted an unannounced initial compaint visit regarding the allegation above. LPA met with Executive Director Suzette Johnson as the purpose of the meeting was explained. The investigation consisted of the following: On 02/20/25 LPA obtained copies of the following: resident and staff rosters, memory care staff time cards, and memory care schedules for the month of February 2025 and March 2025. On 02/20/25 LPA conducted a tour of the facility and there were no health and safety concerns. On 02/20/25 from 10am-11am LPA conducted interviews with staff #1-4 (S1-S4), and from 11:15 am to 12:45pm interviews were conducted with R1-R6. The investigation revealed the following: Allegation: Facility memory care unit is not properly staffed. It is being alleged that resident falls are a result of insufficient staffing in the Memory Care unit. Unsubstantiated On 02/20/25 from 10am-11am LPA conducted interviews with (S1-S4) regarding the allegation above, 4 of 4 staff interviewed denied the allegation above. Per 1 of 4 staff interviewed, the facility works with a registry/agency if there is a shift that needs to be covered. On 02/20/25 from 11:15 am to 12:45pm LPA conducted interviews with R1-R6, 4 of 6 residents denied the allegation above, 2 of 6 residents interviewed reported experiencing an un-witnessed falls in the past. 6 of 6 residents reported feeling safe when assisted by staff. On 02/20/25 LPA conducted a review of memory care staff time cards and schedules, LPA observed that there is a total of 42 memory care residents which are split into 4 groups daily. LPA observed memory care to have 6 staff for the morning, 4 staff in the evening shifts, and 2 staff for NOC shift. 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. Exit interviewed conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 11-AS-20250212143057

Allegation investigated: Facility staff did not provide resident with a bedroom chair.

On 2/05/25, at 1:30pm, Community Care Licensing Division (CCLD) Staff conducted an initial complaint visit to the facility and was greeted by Suzette Johnson, Executive Director. CCLD explained the purpose of this visit is to gather information about the complaint, interview staff and residents, and deliver findings for the allegation mentioned above. The investigation consisted of the following: An initial complaint visit was completed by (CCLD) staff on 2/05/2025. The department investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R10). Resident Roster (Dated: No Date) and Staff Roster (Dated: 2/05/2025) were obtained from the facility. The investigation revealed the following: Allegation- Facility staff did not provide resident with a bedroom chair. Report Cpontinued On LIC9099-C Unsubstantiated The details of the complaint alleged that the facility does not provide the required personal accommodations to residents. It is alleged that residents are not provided a chair in their room per Title 22 regulations. On 02/05/25, from 1:00pm-3:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Facility staff did not provide resident with a bedroom chair. All staff (S1-S4) interviewed stated that the facility does provide the required items per Title 22 regulations. S1-S4 stated that when a resident moves in they are provided with a bed, nightstand, chair, lamp, and dresser. Staff also stated that sometimes a resident brings their own furniture, but the option is still available to them if they need it. S1 stated that one resident recently asked if they could provide them with a gamer chair in their room. S1 stated no because the facility does not offer that kind of chair but could provide the resident with a standard chair. S1 stated the resident was not happy and wanted the gamer chair. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Facility staff did not provide resident with a bedroom chair. The majority of the residents (9 of 10) stated that they did not have a problem with the facility. 4 of 9 residents stated that they brought their own furnishings with them when they moved in and 5 of 9 residents stated that the facility did provide them with a chair and the other furnishings for their bedroom. The department toured the facility and observed bedrooms # 109, 116, 118, 137, 138, 242, 245, 271A, 271B and 293; and all rooms had the required furnishings per Title 22 regulations. Based on interviews conducted, there is insufficient evidence to support the allegation that the Facility staff did not provide resident with a bedroom chair. 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. No citations were issued on this complaint visit. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Suzette Johnson, Executive Director.the state’s words, verbatim · CDSS document, Feb 5, 2025 · control 11-AS-20250127155801

Allegation investigated: Staff do not ensure medication is stored in originally received container. Staff do not ensure the facility is free of insects. Staff mismanaged residents' medication. Staff are falsifying residents' medication administration record.

On 01/31/25 Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Executive director (ED) Suzette Johnson as the purpose of the visit was explained. The investigation consisted of the following: On 01/23/25 LPA requested copies of the following documents; staff and resident rosters, pest control reports for December 2024 and January 2025, and the following documents for residents #1-6 (R1-R6), emergency ID form, physicians reports, medication list, and Medication administration records (MAR) for January 2025. LPA requested copies of previous medication inservices held, ED to send copies via email by 01/24/25. On 01/23/25 between 10:20am- 11:43am LPA conducted interviews with R3-R10,LPA unable to interview R1-R2 as residents were out of the facility at the time of the visit. On 01/23/25 between 12 pm-12:25pm LPA conducted a medication review for R1-R6, and on 01/23/25 between 12:25pm- 1pm LPA conducted interview with Staff #1-2 (S1-S2). On 01/31/24 at 11:15am LPA conducted interviews with S3-S4, R1-R2, and ED. Unsubstantiated On 01/31/25 LPA obtained copies of progress notes where it is Documented that physicians have been contacted regarding medication refusals. The investigation revealed the following: Allegation: Staff do not ensure medication is stored in originally received container. It is being alleged that staff are preparing medications several days in advance. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff denied the allegation above. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 9 of 10 residents interviewed denied the allegation above and reported meds are prepared in front of them by med room staff, 1 of 10 residents interviewed reported resident is provided with meds already in a med cup. On 01/23/25 LPA conducted a tour of the medication room and observed medications to be in their originally bottle or bubble packs. Allegation: Staff do not ensure the facility is free of insects. It is being alleged that there are roaches in the medication room. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 3 of 5 staff interviewed reported pet have been observed in the past, it was reported, and the med room was treated by pest control. 2 of 5 staff interviewed denied the allegation above. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 6 of 10 residents interviewed denied the allegation above, 4 residents interviewed reported pest has been observed in the past however, it was reported to maintenance treatment has been provided. On 01/23/25 LPA conducted a tour of the medication room and did not observe any signs of pest, and med room was clean. On 01/31/25 LPA reviewed the pest control reports for December 2024 and January 2025, it is documented that the pest control company is coming out every week to treat rooms where pet have been reported as well as common areas. Allegation: Staff mismanaged residents' medication. It is being alleged that staff are being instructed to give a resident a medication that belongs to another resident because the resident was out of a particular medication. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. 4 of 5 staff interviewed reported there is an over flow of medications located in the med room to ensure a resident does not run out of medications. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 9 of 10 residents denied the allegation above and reported they have not run out of medications. 1 of 10 residents interviewed reported running out of medications from Kaiser due to a payment mis-communication with family. On 01/23/25 LPA observed there is an over flow of medications for residents stored in med room cabinet. Over flow was observed to be organized and labeled with residents name. LPA reviewed in-service held and attended by all medroom staff dated 09/25/24 and 10/16/24 for ordering and documenting medications. Allegation: Staff are falsifying residents' medication administration record (MAR). It is being alleged that med techs are entering meds as given even when they don't administer it. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. 4 of 5 staff interviewed reported MARs are documented in real time. On 01/23/25 LPA conducted a medication review for R1-R6, LPA did not observe any discrepancies on the MAR. 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. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 31, 2025 · control 11-AS-20250114124633

Allegation investigated: Staff did not seek medical attention for resident in a timely manner . Staff did not keep resident's authorized person informed about incidents involving the resident.

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Allegation investigated: Staff do not assist resident with obtaining medical care. Staff do not allow resident to choose care provider. Staff did not safeguard resident's personal belongings.

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Allegation investigated: Staff allowed resident in care to leave the facility without supervision.

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Type of visit: Case Management - Deficiencies

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Allegation investigated: Facility staff did not respond to resident's calls for assistance

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Allegation investigated: Facility staff did not respond to resident's calls for assistance

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Allegation investigated: Staff do not ensure facility is free from pests. Staff does not ensure that facility is adequately cleaned.

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Allegation investigated: Staff do not ensure the facility is free from pests. Staff do not ensure the facility is clean and sanitary. Staff do not ensure resident has hot water.

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Allegation investigated: Staff is serving food that is not of good quality. Foods are not properly labeled.

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Allegation investigated: Staff do not answer resident's calls for assistance Staff do not ensure facility is free from pests Staff do not maintain facility in good repair.

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Allegation investigated: Staff neglect resulted in the death of residents Staff did not prevent a resident from causing self harm

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Type of visit: Required - 1 Year

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Allegation investigated: Staff does not ensure resident is allowed to leave the facility at anytime with visitors.

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Allegation investigated: Staff do not ensure the facility is free from pests. Staff do not ensure resident’s room is adequately cleaned.

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Allegation investigated: Staff did not administer medication to resident.

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Allegation investigated: Staff did not prevent a resident from attacking another resident.

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Allegation investigated: Staff are not ensuring that facility is free of pests. Facility staff failed to meet residents needs. Staff are not safeguarding resident’s personal items. Staff made inappropriate comments to resident. Staff are not meeting resident’s laundry needs. Staff are not ensuring resident's room is cleaned.

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Allegation investigated: Staff did ensure universal precautions were taken.

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Allegation investigated: Staff did not seek medical attention for resident. Facilty staff failed to meet residents needs.

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Allegation investigated: Staff did not provide resident an admission agreement. Staff did not pick resident up after a medical appointment. Staff prohibit resident form eating in their room.

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Allegation investigated: Staff did not allow resident to use a doctor of their choice Staff did not provide resident medication as prescribed Staff do not treat resident with dignity or respect Staff do not respond in a timely manner to resident's call for assistance

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Allegation investigated: Questionable death. Resident fell while in care. Resident was left on floor for an extended period of time. Staff did not seek medical attention to resident. Staff mishandled resident's medications. Staff do not answer facility phone.

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Type of visit: Case Management - Other

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Allegation investigated: Resident sustained multiple pressure injuries while in care

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Allegation investigated: Staff did not ensure prescribed medical equipment was provided to resident in care.

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Allegation investigated: Staff did not assist resident with obtaining prescribed medication Staff did not administer resident's medication as prescribed

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Allegation investigated: Facility is in disrepair. Staff did not administer resident's medication as prescribed. Staff do not treat residents with respect. Staff do not assist residents in a timely manner. Staff cannot communicate effectively with residents due to language barrier.

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Allegation investigated: Staff neglected resident resulting in dehydration.

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Allegation investigated: Resident sustained multiple injuries while in care. Facility staff are not properly trained Facility vehicle is not in good repair

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Allegation investigated: Resident sustained a pressure injury while in care Staff left resident in soiled diaper for extended period of time Facility has roaches

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Allegation investigated: Staff did not prevent a resident from assaulting another resident.

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Allegation investigated: Staff is not preventing the spread of scabies Staff are not preventing resident from engaging in inappropriate behaviors

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Allegation investigated: Facility staff are not dispensing medications as prescribed for resident. Facility staff are not providing meals for resident.

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Allegation investigated: Facility staff fails to change resident's diaper. Facility staff fails to re-position bedridden resident. Facility staff fails to provide resident with basic services.

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Allegation investigated: Staff did not prevent resident from physically assaulting another resident in care.

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Allegation investigated: Staff did not prevent a resident from hitting another resident in care. Staff did not prevent facility from becoming malodorous. Staff did not keep facility free of insects. Staff did not check resident's blood sugar.

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Allegation investigated: Resident burned another resident with a cigarette.

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Allegation investigated: Staff are not properly addressing scabies at facility.

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Type of visit: Case Management - Deficiencies

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