Chloie's Cottage II

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual inspection using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by facility staff and explained the purpose of the visit. Khadra Abdelghani, Asst. Administrator arrived thereafter. The facility’s fire clearance is approved for six (6) non-ambulatory residents ages 60 and over. The facility also holds a hospice waiver for three (3) residents. At the time of inspection, three (3) residents were under hospice care. Facility Tour & Observations: Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present. Physical Plant The facility is located in a residential neighborhood and is a single-story home consisting of four (4) resident bedrooms, one (1) caregiver bedroom, two (2) bathrooms, one (1) of which is a private restroom located in bedroom four (4), a living room/dining room, kitchen, attached garage, front yard, and backyard. All bedrooms observed contained the required furnishings, including a bed, mattress, linens, dresser, chair, and adequate lighting. LPA observed that sharps, cleaning supplies, and other toxic substances were inaccessible to residents. Sharps were stored in a kitchen cabinet, and cleaning supplies were secured in a closet near the laundry room. Bathrooms were observed to be equipped with required grab bars near showers and toilets, as well as non-skid mats. Hot water temperature was observed outside the required regulatory range of 105°F–120°F. (continued on 809C) Extra linens and towels were available and stored in a hallway closet. Smoke and carbon monoxide detectors were tested and found operational. Fire extinguishers were observed and available. LPA observed that the door alarms on the exit door near the laundry room leading to the outside and the exit door located in the caregiver corridor were not operational at the time of the visit. No bodies of water were present on the premises. The backyard and front yard contained shaded seating for residents. Passageways and exits were observed to be clear and unobstructed. Food Service Refrigerators and freezers were maintained at proper temperatures (refrigerators at a maximum of 40°F and freezers at 0°F) and contained a sufficient supply of food, including at least two (2) days of perishable food and seven (7) days of non-perishable food. Fresh produce, proteins, and dry goods were stocked. Health-Related Services & Records Three (3) resident files were reviewed. Files contained current required documentation including Admission Agreements, signed consents, Needs and Service Plans, Physician’s Reports documenting TB results and ambulatory status, and Resident Rights acknowledgments. Three (3) residents’ medications were reviewed. Medications were observed to be centrally stored and secured in a locked a living room filing cabinet. During the medication review, LPA observed discrepancies between the Medication Administration Records (MARs) and the medications reviewed. Disaster Preparedness Last fire/earthquake drill was conducted on July 1, 2026, with logs available. LIC 610D Emergency Disaster Plan was in process of being updated. Emergency supplies (water, food, flashlights, batteries, first aid) were observed. Personnel Records & Training Three (3) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings. An exit interview was conducted with Khadra Abdelghani, Assistant Admin. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.the state’s words, verbatim · CDSS document, Aug 31, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Sep 18, 2026

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met by evidence by: Based on medication and record review, LPA observed discrepancies between R1's Medication Administration Record (MAR) and the medications reviewed. The medications on hand did not accurately correspond with the information documented on R1's MAR which poses/posed a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee shall review and reconcile R1's medications with R1's MAR to ensure all medications are accurately documented and administered as prescribed. Licensee shall submit an updated and accurate MAR for R1, along with a written plan describing how the facility will ensure medication records are maintained accurately and remain consistent with medications on hand. Proof of correction shall by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Aug 31, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met by evidence by: Based on observation during the facility walkthrough, LPA observed that the door alarms on the exit door near the laundry room leading to the outside and the exit door located in the caregiver corridor were not operational at the time of the visit which pose/posed a potential health and safety or person rights to the residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee shall ensure all required exit door alarms are operational and functioning properly at all times. Licensee shall repair or replace the non-operational door alarms and submit proof of correction, including photographs demonstrating that the door alarms have been repaired or replaced by the POC due date.

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with Eva Tencinco and explained the purpose of today's visit. The investigation consisted of the following: During initial visit 2/12/26 LPA obtained copies of Administrator certificates, copies of Resident #1’s (R1) Physician Report and CalAIM Assessment Form, conducted interviews with 3 Staff (S1-S3) and 3 Residents (R2-R4), toured facility and inspected medication, cleaning supplies and disinfectants, restrooms, laundry area and tested all exit door chimes. After visit LPA conducted interview via phone call with R1. On 2/13/26 LPA received copies of staff trainings, restricted health care plan for R2, Admission agreement, Resident Appraisal , Consent Forms, and Emergency ID Information for R1. LPA interviewed 2 Staff via phone call (S4-S5) and delivered findings on the reported allegations. (Continued on LIC9099-C) Substantiated The investigation revealed the following: Allegation: Licensee did not ensure that the Administrator or their designee was present at the facility as required.It is alleged that Administrator Linda hasn't been in the facility for over 1.5 years and there has been no designated Administrator during Linda's absence. LPA interviewed 4 residents and 3 residents denied the above allegation and stated that the Administrators visit daily for hours at a time and when the Administrators are not present there is a live in staff (S4) that is present and is the House Manager. LPA interviewed 5 staff and each denied the allegation and stated that Administrators are present daily for a few hours at a time, are always reachable via phone/text and that the House Manager is there regularly to assist with residents or any emergencies as they are a live in staff. During LPA’s visit Administrator arrived within 15 minutes after LPA’s arrival and was present for the entire investigation. Allegation: Licensee accepted resident(s) with a higher level of care need.It is alleged that there are residents at the facility that require higher level of care. LPA reviewed resident files there is 1 resident (R2) who is on hospice and has a G-Tube, LPA obtained a copy and reviewed R2’s hospice health care plan with no issues. The facility is approved for 3 residents under hospice care. LPA interviewed 5 staff and each denied the allegation and stated that although they have a resident on Hospice, there is a hospice nurse that visits regularly to assist resident, during visit LPA observed a hospice nurse arrive and visit/assist resident. LPA interviewed 4 Residents and 3 residents denied the allegation and stated that they believe all residents are getting proper care, nurses are seen visiting facility and assisting with residents , and don’t believe any of the residents at the facility require a higher level of care. Allegation: Staff do not allow resident to get food when hungry.It is alleged that staff will not allow R1 to enter the kitchen and get a yogurt or snack out of the refrigerator when R1 is hungry and will harass and ask R1 what they are doing when in the kitchen. During visit LPA observed R1 enter the living room and kitchen area freely, staff were assisting other residents, said good morning to R1 and R1 proceeded to enter kitchen, grab a snack from the refrigerator and take it to their room with no interference or harassment from staff. LPA interviewed 4 residents and 3 residents denied the allegation and stated that they are able to get snacks freely if they wish, however, due to their diasability they prefer to ask staff to get them their food/snacks. LPA interviewed 5 staff and each denied the allegation and stated that residents are free to get their own food/snacks, however, due to a majority of the residents disabilities the staff assist with this ADL. Staff stated that there is only one resident that is able to do this independently and that is R1 and they have never harassed or tried to prevent R1 from getting their food/snack from the kitchen. (continued on LIC9099-C) Allegation: Staff do not ensure that resident is adequately fed. It is alleged that R1 has a health condition that effects their appetite and is not being adequately fed. LPA interviewed 4 residents and each denied the allegation. Interview with R1 revealed that they are provided meals, however, they feel that other residents are not being adequately fed because of meals being pureed or yogurt. LPA interviewed 5 staff and each denied the allegation and stated that they provide 3 meals and snacks to the residents, some residents are on a pureed food diet along with/or ensure due to their disability, staff stated if residents do not like what the meal is they are provided with alternative meals of their choice. LPA inspected food supply and there was a sufficient amount of food available to meet the needs of the residents. Allegation: Staff retaliated against resident. It is alleged that S4 and S5 started retaliating against R1 after Administrator Linda spoke to them of concerns brought to Linda’s attention. LPA interviewed 4 residents and 3 residents denied the allegation and stated that staff have never made them feel threatened or retaliated against and have never seen this happen to other residents. LPA interviewed 5 staff and each denied the allegation and stated they have never threatened or retaliated against a resident and have never witnessed another staff do this. Allegation: Staff are not providing adequate care and supervision to residents. It is alleged that staff put the residents to bed right after they have dinner and then for the most part don't supervise them during the overnight hours. LPA interviewed 4 residents and 3 residents denied the allegation and stated that there is always someone at the facility even in the night hours to assist with their needs, and stated that there are 2 live in staff that are always available at night. LPA interviewed 5 staff and each denied the allegation and stated that there is always a staff available to meet the needs, there are 2 live in staff that are readily available to assist with there residents. LPA conducted file review for all residents and there was nothing noted within the resident files that indicate they have wandering behaviors at night. Allegation: Staff do not answer facility phone. It is alleged that staff do not answer the phone from 7 pm until the morning. LPA interviewed 4 residents and each denied the allegation and stated that they have never heard there phone ringing at night and staff not answer. LPA interviewed 5 staff and each denied the allegation and stated that they always answer the phone unless they are busy with a resident and cannot get to the phone in time, but the facility phone is never ignored intentionally. S5 stated that sometimes if they see that it is a spam call they will not answer, LPA advised staff that all calls must be answered if they are available to answer the phone in the case that it can be licensing or another important call. (continued on LIC9099-C) Allegation: Staff did not store hazardous items as required. It is alleged that knives were accessible to the residents, and that toxic cleaning supplies were left accessible to residents. LPA toured facility, inspected knife drawer and hazardous items/cleaning supply closet and both were locked securely during visit. LPA interviewed 4 residents and 3 out of 4 residents denied the allegation and stated that they have never seen any hazardous items to be left unattended or accessible. Interview with R3 reveled that they enjoy using nail polish and sometimes use nail polish remover and staff are always present to assist and they lock up the items when not in use. Allegation: Licensee does not ensure that staff are adequately trained. It is alleged that staff do not have proper training to meet the needs of residents such as resident that have a G-Tube. LPA conducted file review and observed that R2 has a hospice care plan for G-Tube assistance that states only a nurse or qualified professional shall assist with g-tube, however, for feeding purposes trained staff are able to feed ensure through G-tube. LPA interviewed 4 residents and 3 residents denied the allegation and stated that they feel confident that the staff are well trained to meet their needs. LPA interviewed 5 staff and each denied the allegation and stated that only the nurses assist with the G-tube when cleaning, disinfecting and have been instructed if any pain or redness occurs to call hospice or take resident to the hospital, staff stated they have been trained to be able to assist with feeding through G-tube for R1 if needed, however, R1 is now able to eat on a pureed diet and no longer needs to be fed through the g-tube. During visit LPA observed staff prepare a pureed meal for R1 and R1 was eating it with no issues. Based on statements and interviews conducted with staff/residents, review of resident files, facility file records, and LPA observations, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview held, and a copy of this report was provided. The investigation revealed the following: Allegation: Resident developed an infection while in care due to staff neglect.It is alleged that a resident has developed a very bad skin infection because staff do not change their diapers at night. LPA interviewed 4 residents and 3 residents denied the allegation and stated that they have never had an infection, and that they are changed at night around 9-10pm (before bed) and if a change is needed throughout the night they can ask a staff to assist with no issues. LPA interviewed 5 staff and each denied the allegation and stated that diapers are changed regularly and they have never seen a resident have an infection due to lack of proper diaper changes. Allegation: Staff do not ensure that residents' diapering needs are met.It is alleged that staff leave residents in wet diapers all night. LPA interviewed 4 residents and 3 residents (all that require incontinence care) denied the allegation and stated that they are changed at night around 9-10pm (before bed) and if a change is needed throughout the night they can ask a staff to assist with no issues. LPA interviewed 5 staff and each denied the allegation, interviews with S2-S3 revealed that they are the morning staff that conducts the first morning rounds for residents and have never observed a resident to be neglected by night staff in this way, interview with night staff S4-S5 stated that they conducted rounds regular at night and have never left a resident with soiled diapers at night or day. Allegation: Licensee did not complete an individual written admission agreement upon acceptance of resident.It is alleged that R1 has never been provided/signed an Admission Agreement since moving in. Per interview with S1 it was confirmed that R1 moved in late in the evening on 1/24/26, due to how late the resident arrived the admission paperwork was not completed that night, S1 stated that they spoke with R1 and their mom the next day on 1/25/26 and spoke to them about the facility and went over the admission agreement and informed them both that the admission agreement needed to be reviewed and signed. LPA obtained proof of several attempts made via text and email to the resident and their mom to sign the admission agreement as early as 1/29/26, however, both parties avoided signing the agreement until 2/6/26 when S1 was finally able to sit with R1 and obtain the signatures on the agreement. Per file review R1 is self-responsible and can make their own financial decisions, there is no POA assigned for R1. Based on statements and interviews conducted with staff/residents, review of resident files, facility file records, and LPA observations, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview held, and a copy of this report was provided The investigation revealed the following: Allegation: Facility is in disrepair. It is alleged that the facility washing machine is in disrepair/leaks water, the toilet in the second bathroom also leaks water, and there is black mold in the master bathroom. LPA toured facility, toilets were tested and there were no leaks observed, there was no indication of mold in both facility bathrooms and nor in the resident bedrooms. Staff were doing laundry and there were no signs of leaks, however, there was a chuck observed on floor near washer, chuck was dry and staff stated they place one there as when clothing sometimes falls on the floor when switching to the dryer, they rather the clean clothes fall on the clean dry chuck than the floor. Interviews with 6 staff and 2 residents revealed that there was a leak in the bathroom, the toilet would overflow and leak; and there was mold observed in the bathroom that R2 resides in. S1 provided photo of mold dated 1/22/26 and request for repairs dated 1/22/26. Both the leak and mold on ceiling of bathroom have since been repaired and there have been no further issues. Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Exit interview held, a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 13, 2026 · control 28-AS-20260203110210

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 13, 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. Per interviews with 6 staff and 2 residents revealed that there was a leak in the bathroom, the toilet would overflow and leak; and there was mold observed in the bathroom that R2 resides in.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: LPA toured facility, tested toilets and washer and there were no signs of leaks. LPA toured restrooms and residnet rooms, checked for signs of mold and did not observe any. POC is cleared and the clearance letter will be emailed to Administrator at a later date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA was met by Caregiver Eva Tancinco and explained the purpose of the visit. Sub-Administrator Iren Creighton was advised via phone call. The facility is licensed to serve residents 60 and above, fire cleared for six (6) non-ambulatory and approved to accept and retain three (3) residents under hospice care. The facility is a single-story home located in a residential area of San Dimas. The home consists of living room, dining area kitchen, laundry area, one (1) staff room, four (4) resident rooms, two (2) bathrooms, front yard, back yard and attached garage. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded area located in the backyard with sufficient seating for residents in care. Passageways and exits are free of obstructions. Smoke detectors were observed throughout the facility and are operable. There is a carbon monoxide detector located in the hallway of the home. There is a fire extinguisher located near the kitchen which is charged and last serviced 06/2025. Emergency drills conducted quarterly, last drill was 10/05/25. continued on LIC 809C Continued from LIC 809 Kitchen was observed to be clean and free of pests. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to residents. Sufficient supply of two (2) days perishable and seven (7) days non-perishable foods were observed. Fireplace located in the living room was inaccessible with a covered screen. Dining room and living room are clean and free of obstructions and have sufficient seating for residents in care. Resident bedrooms have the required furniture and have sufficient closet and storage space. Resident beds have the required linen and the linen is in good repair. Washing machine and dryer were clean and operable at the time of visit. There is a locked cabinet in the hallway with detergent, cleaning supplies and disinfectants, secured and inaccessible to residents in care. Medications are centrally stored in a locked cabinet in the kitchen. Medications are documented properly and given as prescribed. First Aid kit was fully stocked with current manual. Five (5) resident and three (3) staff files were reviewed and were observed to contain required documentation. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were cited during today’s visit. Exit interview held and a copy of this report was provided to caregiver Eva Tancinco.the state’s words, verbatim · CDSS document, Oct 27, 2025

Allegation investigated: Personal Rights Personal Rights Personal Rights Personal Rights Personal Rights

Licensing Program Manager (LPA), Alberto Lopez made an unannounced visit to investigate the above allegations. LPA met with House Manager Eva Tancinco and discussed the purpose of the visit. The investigation consisted of LPA obtaining and reviewing staff and resident rosters. LPA interviewed two (2) staff (S#1-S#2) LPA noticed that R1 was not on roster and S1 stated that R1 lives at Chloie's Cottage and not this facility. LPA took a tour of the facility and did not observe any health or safety risks. The investigation revealed that the allegation could not have happened at this home as R1 does not reside at this home and has not lived at this address at least since S1 has worked at this address since 01/2025. LPA identified all 5 residents at home and R1 was not at living/present at facility during the visit. The above allegations are UNFOUNDED. A finding of UNFOUNDED means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Therefore, we have dismissed the complaint. Exit interview conducted with House Manger Eva Tancinco and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Aug 19, 2025 · control 28-AS-20250812143657

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced Annual Required Visit at 11:41 AM. LPA was met by Assistant Administrator Maria Blanco and explained the purpose of the visit. The fire clearance is approved for Six (6) non- ambulatory residents. There is a hospice waiver approved for 3 residents. During today’s visit facility was found to have one (1) bedridden resident without approved fire clearance civil penalties assessed. The facility is located in a residential area. A tour of the single-story facility included: 4 resident bedrooms, 2 resident bathrooms, living room, kitchen, dining area, front yard, backyard, and attached garage. LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in the kitchen. Cleaning supplies and toxic substances were observed to be inaccessible to clients. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The garage was observed to be converted into a bedroom with walls and a closet deficiency cited. SEE LIC 809C Four (4) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Six (6) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake drill was conducted on 07/16/2024. Infectious control plan was reviewed. The facility had expired liability insurance deficiency cited. The medications are centrally stored and locked in a cabinet in kitchen The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician. Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Maria Blanco.the state’s words, verbatim · CDSS document, Aug 13, 2024