The Havens at Antelope Valley Assisted Living

Allegation investigated: Staff did not prevent outbreak of scabies.

On 6/15/2026 at approximately 9:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Administrator, Penda Hodges and stated the reason for their visit. To investigate the allegation(s), at approximately 09:40 AM, LPA requested relevant documentation such as but not limited to: Physician’s Report, Hospice documentation, and Los Angeles Public Health documentation. By 10:00 AM, LPA conducted a physical plant tour. From 10:00 AM to 12:00 PM, LPA attempted interviews with one (1) resident (R1), two (2) staff members (S1-S2) and conducted record review. (continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff did not prevent outbreak of scabies. It was alleged staff did not prevent the outbreak of scabies within the facility due to negligence. To investigate the allegation, LPA attempted to interview one (1) resident and two (2) staff members. LPA’s interview with S2 revealed once the facility became aware of the possible exposure, infection control protocols were implemented. S2 stated no other residents tested positive for scabies nor showcased any indication of said infection including R1. LPA attempted to interview R1, but they have since passed due to their terminal condition and not related to the investigation. LPA attempted to interview S1, but they were not present during LPA’s visit. LPA’s supplementary record review of the facility’s history revealed on 5/04/2026, the facility self-reported possible exposure of scabies along with an Unusual Incident/Injury Report (SIR). Per LPA’s conversation with S1 the following was documented: On 5/04/2026 LPA Segovia received a call from Latanya Jules | Operations Specialist, Staff one (S1) regarding the incident report that was submitted to CCLD. Per S1, multiple staff members reported, “dermatologic symptoms consistent with scabies exposure”. All staff members exposed were placed on leave pending further testing. They stated a resident (R1) who may have been exposed was isolated for precautionary reasons until testing was completed with results given. Results did not come back positive for scabies. Per incident report and S1 the Los Angeles County Public Health was contacted. S1 stated infectious control plans were implemented along with staff training. LPA’s record review of R1’s Hospice Visit Chart log documented on 5/01/2026, R1 was observed to have, “…rash present to abdomen and bilateral arms…Skin remains intact with no open areas, drainage or signs of infection…” Further record review of R1’s Hospice Visit Chart log revealed, “Nurse reported receiving communication…of possible scabies concern by care staff…new orders were received for a one-time treatment to rule out scabies…Resident has been placed on contact precautions…”. Additionally, LPA confirmed the following precautions taken by the facility: In-service training regarding infectious control, correspondences between the facility and Los Angeles Public Health regarding the possible exposure (ID#319), pre-cautionary exposure containment for both R1 and staff. (Continue to LIC 9099-C) Additional record review of R1’s Physician’s Report dated 3/29/2026 revealed R1 to have various diagnosis which caused rashes. Per the Physician’s Report, “…ongoing generalized rash…” Based on interviews and record review, the facility implemented infectious control procedures and self-reported to the corresponding agencies per regulations. Additionally, R1 never tested positive for said infection, therefore the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 15, 2026 · control 31-AS-20260612103620

Allegation investigated: Staff did not call emergency services for resident.

On 5/28/2026 at approximately 9:40 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Administrator, Penda Hodges and stated the reason for their visit. To investigate the allegation(s), at approximately 10:00 AM, LPA requested relevant documentation such as but not limited to: Staff schedule, Staff Timecard Report, Hospital discharge paperwork. By 11:00 AM, LPA conducted a physical plant tour. From 10:00 AM to 1:00 PM, LPA conducted interviews with one (1) resident (R1), two (2) staff members (S1-S2) and conducted record review. (continue to LIC 9099-C) Substantiated Regarding the allegation: Staff did not call emergency services for resident. It was alleged that S2 did not call emergency services for R1. Per the Reporting Party (RP), when they spoke with S2, S2 revealed they did not call emergency services for R1 due to them being on break and they have been directed to follow this per the facility’s policy. To investigate the allegation, LPA conducted interviews with one (1) resident and two (2) staff members. LPA’s interview with R1 revealed the night of said incident they alerted staff to their room due to severe abdominal pain but were informed by S2 that they would not assist them with calling emergency services due to them being on break. R1 stated that, as a result, they needed to contact emergency services themselves. LPA’s interview with S1 revealed S2 informed them of what had occurred with R1 where it was revealed S2 proceeded to clock back in from break prior to calling emergency services for R1. When questioned if it is the facility’s policy for staff not to call emergency services for residents when on break/lunch, S1 stated, “No”. LPA’s interview with S2 confirmed R1’s interview. Per S2, they stated they told R1, “…once I clock back in, I will call 911”. Based on interviews, S2 confirmed they did not contact emergency services for R1, resulting in R1 having to contact emergency services themselves. Therefore, the allegation is SUBSTANTIATED at this time. No other immediate health and safety issues observed during the day of the visit. Exit interview was conducted, appeal rights given, and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, May 28, 2026 · control 31-AS-20260521164911

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87415(a)(2) · Plan of correction due date: Jun 11, 2026

87415 Night Supervision.(a) The following persons providing night supervision...shall be available...to assist in caring for residents in the event of an emergency...(2)employee shall be on call, and capable of responding. This requirement was not met evdienced by: Based on interviews, S2 confirmed they did not call emergency services for R1 which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: The Licensee/Administrator will conduct in-service training with staff including S2 and email LPA Segovia the staff training regarding policy/procedure regarding emergency services by POC due date. POC due date: 6/11/2026

Type of visit: Required - 1 Year

On 3/24/2026 at approximately 09:45 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by staff and stated the reason for their visit. The Administrator, Penda Hodges along with the Operational Specialist, Latanya Jules assisted with today’s visit. LPA asked for the census, Staff/Resident Roster and Liability Insurance. LPA conducted a physical plant tour at approximately 01:00 PM and the following was noted: The facility is a two-story building with an Assisted Living unit located on both floors and a Memory Care unit located on the first floor. The facility is currently occupying ninety-four (94) residents. The facility has an approved fire clearance for one hundred fifteen (115) Ambulatory/non-ambulatory and/or bedridden residents. Hospice waiver approved for twenty (20). Common areas: The common areas were observed to be neat, clean and organized. Such included are: Dining room, Activity room, Theater/Chapel, Mail room and Beauty Parlor. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 75°F. The hallways and passageways were observed to be free of obstruction. The stairways were observed to be equipped with evacuation chairs. LPA observed there to be two (2) elevators which were observed to be functional. The fireplace was observed to be covered and inaccessible to residents. LPA observed multiple fire extinguishers to be located throughout the facility on both floors and dated 2/03/2026. LPA observed required postings such as Long-Term Care Ombudsman, See/Say Something and facility’s license to be located throughout the common areas. Office/Work Station: The Administrative offices were observed to be located near the main entrance, near the front desk. (continued on LIC 809-C) Kitchen: The kitchen was observed to be clean and free from pests. The kitchen was observed to be a commercial kitchen with a variety of commercial-grade appliances and fixtures such as but not limited to: high-capacity gas ranges, convection ovens, fryers and stainless steal prep tables. LPA observed the kitchen appliances to be working and in proper condition. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. The cleaning solutions/toxins were observed to be kept in a locked storage closet. (continued on LIC 809-C) Surrounding Grounds: The Memory Care unit is located on the first floor with thirteen (13) rooms and a capacity of eighteen (18) residents. LPA observed both dining room and living room to be in good repair and free of obstructions. LPA observed delayed egress to be in good repair and working condition. Outside of the memory care, LPA observed there to be an enclosed courtyard with an open space Gazebo. The outside area of the Assisted Living unit was observed to be equipped with a gazebo and sufficient shaded areas with outdoor furniture for residents. There is no body of water located in the facility. Laundry Room: There are four (4) laundry rooms. One (1) commercial laundry room was observed to be located on the first floor, besides the medication room. LPA observed the commercial laundry room to be kept locked. There is an additional comunity laundry room located on the first floor. There are two (2) community laundry rooms located on the second floor for residents to use. LPA observed the community laundry rooms to be accessible to residents, but no detergents or cleaning supplies were accessible. Bathrooms: LPA observed a total of four (4) public restrooms. Three (3) located on the first floor and one (1) located on the second floor. The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition. Bedrooms: The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. The bathrooms within the residents’ rooms were checked for cleanliness and proper operation. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition. The hot water temperature was measured at a range of 116.4°F-120°F. Medication Room: LPA observed the medication room to be located on the first floor and to be kept locked, inaccessible to residents. The medication usage was observed to be recorded and stored properly. LPA along with the Business Office Director, Ashley Lopez conducted a review of the medication to ensure compliance. First-aid kit was observed. (continue to LIC 809-C) Smoke detectors and carbon monoxide: The facility was last inspected for maintenance and operational use of their automatic sprinkler system on 10/01/2025. The facility was last inspected for maintenance and operational use of all fire alarms on 10/01/2025. The last Fire Drill was conducted on 02/27/2026 where the smoke detectors and carbon monoxides were documented to be working properly and tested. Residents/Staff Records: LPA conducted a complete file review of nine (9) resident records. Resident records appeared to be complete. Staff records: LPA conducted a complete file review of six (6) staff records. Staff records appeared to be complete and updated. There were no immediate health and safety hazards observed during the day of inspection. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 24, 2026

Allegation investigated: Staff did not report an incident involving resident as necessary.

On 1/14/2026 at approximately 9:10 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Health and Wellness Director, Penda Ebondy Hodges and stated the reason for their visit. To investigate the allegation(s), at approximately 9:30 AM, LPA conducted a physical plant tour. By 10:00 AM, LPA requested relevant documentation. From 10:00 AM to 1:30 PM, LPA attempted to interview six (6) staff members (S1-S6), one (1) resident (R1) and conducted record review. (Continue to LIC 9099-C) Substantiated Regarding the allegation: Staff did not report an incident involving resident as necessary. It was alleged that staff did not report an incident involving R1 and an unknown staff member (S5). To investigate the allegation, LPA attempted interviews with five (5) staff members and one (1) resident. LPA’s interview with S2 revealed on 1/01/2026, R1’s Responsible Party informed them of an incident regarding R1 and an unknown caregiver (S5). S2 stated they were informed that when S5 attempted to transfer R1 to their desk chair, R1 lost balance and their face landed on a bin located on top of their desk. When S2 questioned if R1 had fallen, they were told no. LPA’s interview with S4 revealed that on 1/02/2026, R1’s additional Responsible Party reported to them that R1 had in fact fallen on 1/01/2026 and hit the side of their head on the bin when S5 was transferring them to their desk, resulting in them not appearing to act like oneself. Per S4, they asked R1 if they wanted to go to the hospital but R1 refused. S4 disclosed to R1’s additional Responsible Party that they would be placed on a Head Injury Monitoring Chart and if any symptoms were to change, they would be sent to the hospital. When LPA questioned S4 if they had reported the incident to Community Care Licensing Division (CCLD) they stated, “No”. LPA’s interview with S1 revealed when they became aware of the incident involving R1 they identified the caregiver at the time to be S5. When questioned whether the facility had submitted an incident report to CCLD they too stated, “No”. LPA’s interview with S5 denied R1 had fallen nor hit their head when they assisted them to their chair. LPA’s interview with R1 revealed that on 1/01/2026 a caregiver (whom they could not name) had assisted them to their chair when they lost their balance and hit the side of their head on a bin located on their desk. When questioned if they had reported the incident, R1 stated they reported to staff what had occurred on 1/02/2026. LPA’s record review of the facility’s Unusual Incident/Injury Report (SIR) confirmed CCLD did not receive a SIRs pertaining to R1’s incident on 1/01/2026. Based on interviews and record review, the facility did not report R1’s incident of 1/01/2026 to CCLD, therefore the allegation is SUBSTANTIATED at this time. Citation issued, Please refer to LIC 9099-D. No other immediate health and safety hazards observed during the time of the visit. Exit interview conducted, Appeal Rights given and a copy of this report was provided to the Health and Wellness Director. Regarding the allegation: Staff did not seek medical attention for resident as necessary. It was alleged that staff did not seek medical attention for R1 due to an incident on 1/01/2026. To investigate the allegation, LPA attempted interviews with five (5) staff members and one (1) resident. LPA’s interview with both S3 and S4 revealed when they became aware of the incident pertaining to R1, where they may have hit their head when being transferred to their desk by S5, R1 refused medical treatment. Both S3 and S4 stated R1 was placed on a Head Injury Monitoring chart for no less than 72 hours following the alleged incident to ensure the health and safety of the resident. LPA’s interview with R1 confirmed their refusal of medical treatment on 1/02/2026. LPA’s record review confirmed R1’s Head Injury Monitoring chart to be dated 1/02/2026 to 1/05/2026, as well as R1’s refusal of Emergency Transport and Care form with their signature. Based on interviews and record review, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. No immediate health and safety hazards observed during the time of the visit. Exit interview conducted and a copy of this report was provided to the Health and Wellness Director.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 31-AS-20260105144832

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jan 21, 2026

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as...the following:...(1) A written report shall be submitted to the licensing agency...(D) Any incident which threatens the welfare, safety or health of any resident,... This requirement was not met by: Based on interviews and record review, staff did not report an incident pertaining to R1 on 1/01/2026 to CCLD which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: The Licensee will review the regulation and email LPA Segovia a statment of understanding by the POC due date.

Allegation investigated: Staff does not answer resident's call button in a timely manner. Staff does not allow resident access to call button. Staff not meeting residents needs. Staff does not ensure resident's showering needs are being met. Staff did not ensure resident was properly secured in wheelchair. Staff does not ensure resident is receiving physical therapy. Staff does not communicate with resident's responsible party. Staff does not ensure resident's room is clean.

On 1/10/2026 at approximately 10:00 AM Licensing Program Analyst (LPA), Angelica Segovia conducted a subsequent complaint visit to the facility. LPA was greeted by the Health and Wellness Coordinator, Elizabeth Chavez and stated the reason for their visit was to deliver the findings of the complaint. On 4/01/2025 at approximately 10:15 AM, LPAs Angelica Segovia and Huma Rahimi conducted an initial visit to the facility to investigate the allegation(s). At 10:25 AM LPAs requested pertinent documentation pertaining to the investigation. By 10:30 AM, LPAs conducted a physical plant tour. From 10:40 AM to 3:40 PM, LPAs conducted interviews with ten (10) residents (R1-R10), seven (7) staff members (S1-S7) and conducted record review. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff does not answer resident's call button in a timely manner. It was alleged that staff have not responded to R1’s call button and have left them waiting for an excessive amount of time. To investigate the allegation, LPAs conducted interviews with nine (9) residents and five (5) staff members. Interviews with six (6) of the nine (9) residents stated they have used their call-button and have had no issues with staff not responding. LPA’s interviews with R4, R7 and R10 revealed that they have not had to use their call-button, as of yet. LPA’s interview with R1 (who was observed to be alert at the time of the visit) revealed that when they ask for help from staff, they do come and it takes them, “10 to 15 minutes” to arrive. LPA’s interview with all five (5) staff members stated that staff respond to residents’ call alerts in a timely manner. During LPAs physical plant tour, LPAs pressed on R1’s pendant where staff were observed to arrive promptly. Based on interviews and observations there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff does not allow resident access to call button. It was alleged that R1’s call button was kept inaccessible from them by staff. To investigate the allegation, LPAs conducted interviews with seven (7) residents and five (5) staff members. LPA’s interviews with all residents revealed that they have access to their call-buttons. LPA’s interview with four (4) of the five (5) staff members confirmed that they have not kept residents’ call-buttons inaccessible nor have they witnessed that to be done. During LPA’s physical plant tour, LPAs observed R1 to be wearing their portable call pendant around their neck to which they then pressed to call for help from staff. However, LPAs witnessed R1’s call-button cord to appear tangled and knotted. LPAs questioned S7 as to why R1’s cord was tangled to which they could not provide an answer and were unsure of themselves. LPA Segovia’s record review of R1’s staff shift notes, documented R1 was visited on 3/26/2025 by Sheriff, Alejandro. Documentation revealed Sheriff Alejandro stating R1 had their pendant on their person. Based on interviews and observations, the allegation may have occurred, however there is not a preponderance of evidence to prove the alleged allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Staff not meeting residents needs. It was alleged that R1’s needs were not being met by staff. To investigate the allegation, LPAs conducted interviews with ten (10) residents and four (4) staff members. LPA’s interview with all ten (10) residents revealed that their needs are met, such as but not limited to: showers, food and wheelchair assistance. LPA’s interviews with all four staff members confirmed that they help residents with their needs. LPA Segovia’s interview with S5 revealed that if a particular resident needs help with their food being chopped, they assist. LPAs interview with R1 stated that staff come to assist them when needed. During LPAs physical plan tour, LPAs observed R1 being assisted by two (2) staff members. Based on interviews and observations, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff does not ensure resident's showering needs are being met. It was alleged that R1 was not given their required showers of two times a week. To investigate the allegation, LPA Segovia conducted a record review of R1’s file. LPA’s review of R1’s re-assessment dated 3/01/2025, revealed R1’s bathing requirements were documented to be provided by a third-party provider. Further record review revealed the third-party provider to be R1’s Hospice agency. On 9/25/2025, LPA Segovia requested R1’s medical records from the Hospice agency. LPA Segovia’s record review of R1’s Hospice Aide visits dated 1/26/2025 to 3/21/2025 confirmed R1’s showering needs were met twice a week and documented per visit. Based on record review of R1’s showering needs being met by the Hospice agency, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure resident was properly secured in wheelchair. It was alleged that staff did not properly secure R1 in their wheelchair resulting in them falling more than once. To investigate the allegation, LPA Segovia conducted record review. LPA Segovia’s record review of R1’s Hospice Aid visits dated 1/26/2025 to 3/21/2025 documented R1’s wheelchair to have been used for ambulatory purposes. Further record review of the facility’s staff notes documented occurrences of when R1 had fallen due to them not waiting for their two-person assistance as documented by their Functional Evaluation plan. During LPA’s physical plant tour on 4/01/2025, R1 was observed to be positioned up-right in their wheelchair. LPAs observed R1 to be seated and did not observe any signs of R1 not to be secured correctly to their wheelchair nor observed R1 to fall from their wheelchair. Based on record review and observations, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Staff does not ensure resident is receiving physical therapy. It was alleged that R1 did not receive their required Physical Therapy. To investigate the allegation, LPA Segovia conducted record review where it was revealed that on 2/04/2025, the facility contacted Hospice inquiring about R1’s status for Physical Therapy, where they were informed (by Hospice) that they would be following up and be in contact with R1’s family. Based on record review, that the facility contacted R1’s Hospice regarding R1’s Physical Therapy, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff does not communicate with resident's responsible party. It was alleged that R1’s Responsible Party had not been promptly contacted when R1 became ill with a communicable or infectious disease. To investigate the allegation, LPAs conducted interviews with seven (7) residents. LPA’s interviews with all seven (7) residents confirmed that the facility communicates with their responsible parties. LPA Segovia’s record review of the facility’s Unusual Incident/Injury Report (SIR) revealed the facility had self-reported to Community Care Licensing Division (CCLD), where it was documented that R1’s Responsible Party and Hospice were both notified regarding R1’s recent illness dated 3/07/2025. Additional record review of Resident’s Notes documented that R1’s illness was disclosed to R1’s Power of Attorney (POA) on 3/07/2025. Further record review of R1’s Hospice file showcased Physician Orders to treat R1’s communicable or infectious disease were ordered 3/07/2025. Based on interviews and record review, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff does not ensure resident's room is clean. It was alleged that R1’s room was not clean. To investigate the allegation, LPAs conducted interviews with nine (9) residents. LPA’s interviews with all residents confirmed their rooms are cleaned by staff. LPAs interview with R1 revealed that their room is cleaned every day. During LPAs physical plant tour, LPAs tour of R1’s bedroom was observed to be neat, clean and organized. LPAs did not observe trash on the floor. LPAs did not observe any foul odor to have been present. Further tour of resident’s room revealed the rooms to be clean and in proper condition. Based on interviews and observations, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Health and Wellness Coordinator.the state’s words, verbatim · CDSS document, Jan 10, 2026 · control 31-AS-20250324153245

Allegation investigated: Staff did not reappraise resident for a change in condition

On 12/17/2025 at approximately, 10:00 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced initial complaint visit to the facility to investigate the above allegation(s). LPA was greeted by staff and stated the reason for their visit. LPA was informed that the Executive Director, Katherin Aleman no longer works at the facility. LPA was greeted by the temporary Executive Director, Jeff Gollihar who assisted with today's visit. At 10:05 AM, LPA requested census, resident, and staff roster. At approximately 10:20 AM, LPA conducted a physical plant tour, to ensure the health and safety of the residents. At 11:00 AM, LPA requested pertinent documentation pertaining to the investigation such as but not limited to: Pre-placement Appraisal, Needs and Services and Physician’s Report. In between 11:30 AM – 1:30 PM, LPA conducted interviews with two (2) staff members (S1-S2) and conducted record review. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff did not reappraise resident for a change in condition. It was alleged that staff failed to conduct a proper reassessment for Resident 1 (R1). To investigate the allegation, LPA conducted interviews with two (2) staff members. LPA’s interview with S2 revealed that residents are reappraised every six (6) months, or first 30 days upon their move-in date or if there is a change of condition noted. During LPA’s record review, LPA observed R1’s latest re-appraisal (listed as Functional Evaluation for this investigation) to have been done on 6/16/2025. R1’s Admission date was documented as 6/06/2025. When questioned as to why R1’s re-appraisal documented them to have “Short term/memory impairment” with “…occasional confusion and some difficulty in recalling, “details”, S2 stated that although R1 has not been diagnosed with any cognitive impairments, they have been observed to have some forgetfulness. LPA’s review of R1’s Pre-placement Appraisal dated 5/30/2025 confirmed R1’s mental condition was documented as Mild Cognitive Impairment (MCI) which collaborated with their current Functional Evaluation. LPA’s review of R1’s Physician Report dated 5/30/2025, R1’s diagnosis were documented as various medical conditions but no indication of MCI’s notated nor discussed. R1’s Physician's Report documented them as followed but not limited to: Lack of Hazard Awareness- No Lack of Impulse Control- No Unsafe Wandering- No Sundowning Behavior- No Elopement- No Additional, record review of R1’s Unusual Incident Reports (SIRs) dated 11/26/2025 and 12/9/2025 documented R1 to have had unwitnessed falls near their bedside where they sustained injuries requiring them to be sent to the hospital. LPA’s record review of R1’s current Functional Evaluation report documented R1’s fall Risk to have, “non slip shoes when transferring/ambulating…”. However, due to R1’s falls, S2 stated that they ordered a fall mat to be placed by R1’s bedside and a high-back wheelchair. LPA confirmed the orders dates of 12/11/2025 and 12/15/2025 of said items. During LPA’s physical plant tour, LPA observed R1’s bedroom to be neat, clean and organized. LPA observed R1’s fall mat next to their bed and their high-back wheelchair. LPA observed R1 to be asleep. LPA observed no obstructions or tripping hazards in R1’s bedroom. (Continue to LIC 9099-C) Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the temporary Executive Director.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 31-AS-20251212205153

Allegation investigated: Staff did not administer medication as prescribed resulting in death. Staff did not prevent the facility from being unsanitary. Staff are serving uncooked foods to residents.

On 9/13/2025 at approximately 1:30 PM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Community Sales Director, Christine Ellis and stated the reason for their visit was to deliver the findings of the complaint. The Executive Director, Katherine Aleman was unavailable to assist with today's visit and designated the Community Sales Director to sign today's report. To investigate the allegation(s), on 7/19/2025 at approximately 10:00 AM, LPA conducted a physical plant tour. By 11:00 AM, LPA requested relevant documentation. From 11:30 AM to 3:30 PM, LPA attempted interviews with ten (10) residents (R2-R11), nine (9) staff members (S1-S9) and conducted record review. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff did not administer medication as prescribed resulting in death. It was alleged that S2 did not administer R1’s medication accordingly resulting in death. To investigate the allegation, LPA attempted interviews with four (4) staff members and conducted a record review of R1’s medical records. LPA’s interview with three staff members stated that they have not witnessed nor heard of any residents being over-medicated. LPA attempted to interview S2 but S2 was on leave and could not be contacted. LPA’s record review of R1’s Centrally Stored Destruction Medication Record (CSDMR) noted that on 7/25/2024 (the day prior to R1’s passing) R1 was not assisted with medication by S2. Further review showcased that S2 had not assisted R1 with their medication since 7/19/2024. LPA’s review of S2’s file revealed that S2 had been demoted at the end of July 2024 from Medication Technician (Med Tech) to Care Partner due to various disciplinary incidents, however, no medication errors were documented. Further review of R1’s medical record revealed that R1 had been placed under the care of Caremark Healthcare Hospice services from 7/02/2024 to 7/26/2024, following a medical diagnosis of terminal illness with a life expectancy of less than six months. Additionally, R1’s Certificate of Death listed R1’s leading cause of death to be a result of Cardiopulmonary Arrest. Also, R1’s decline of health was documented during various visits from hospice care. On 7/23/2024 the Hospice service visit documented, R1 was observed to be within their, “…transitioning” period. Based on interviews and record review, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not prevent the facility from being unsanitary. It was alleged that the facility’s kitchen and bathrooms are left in unsanitary conditions. To investigate the allegation, LPA attempted interviews with ten (10) residents and four (4) staff members. LPA’s interview with nine (9) out of the ten (10) residents revealed that they have not seen the bathrooms dirty. Interview with R3 stated that the bathrooms, “…are cleaned regularly”. LPA attempted to interview R11 but they declined to be interviewed. LPA’s interview with S1 and S7 confirmed that the bathrooms are cleaned daily. Interview with S7 revealed that the bathrooms are cleaned throughout each shift and if, “…there is an accident, they call us and we take care of it”. Regarding the kitchen, LPA’s interview with S6 revealed the kitchen is cleaned… “every day… multiple times a day”. LPA’s record review of the Kitchen’s Daily Cleaning Schedule confirmed a morning and night schedule of various cleaning tasks kept and documented. During LPA’s physical plant tour, LPA observed all publicly accessible bathrooms to be clean and in sanitary conditions. (Continue to LIC 9099-C) During LPA’s observation of the kitchen, LPA observed the kitchen to be clean and free from pests. LPA observed kitchen staff washing pots and dishes after use. LPA observed the stove and kitchen appliances to be clean and in proper condition. Based on interviews, record review and observation, the facility’s bathrooms and kitchen were observed to be in sanitary conditions. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are serving uncooked foods to residents. It was alleged that staff are serving uncooked food to residents. To investigate the allegation, LPA interviewed nine (9) residents and four (4) staff members. LPA’s interview with all residents revealed that they have never been served uncooked meat by staff. LPA’s interview with R6 revealed that they have never been served uncooked meat and that, “…the food is delicious”. LPA’s interview with S9 revealed that the meat is checked with a cooking thermometer to ensure the meat has reached a safe and desired temperature prior to being served to the residents. During LPA’s physical plant tour, LPA observed a cooking thermometer and kitchen appliances to be in proper working conditions. LPA observed food preparation stations to be clean. LPA observed a variety of food being prepared for consumption. LPA observed the food being served to be edible and not appear uncooked. Based on interviews and observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Community Sales Director. Regarding the allegation: Staff did not ensure that dishes are cleaned. It was alleged that the facility’s ice machine and dishes served to residents are not cleaned. To investigate the allegation, LPA conducted a physical plant tour of the kitchen, LPA observed a variety of dishes and utensils to be clean and washed properly. In the dining room, LPA observed a variety of plates, utensils and cups to be clean and in sanitary conditions. However, during LPA’s review of the facility’s Ice Machine Cleaning Log, it was revealed that the cleaning of the ice machine had not been documented since April of 2025. LPA’s interview with S8 stated that the ice machine is to be, “cleaned monthly but it hasn’t been cleaned…”. Based on interviews, observation and record review, the facility has failed to keep the ice machine properly clean, therefore the allegation is SUBSTANTIATED at this time. Citation issued, please refer to 9099-D. No other immediate health and safety hazards observed during the time of the visit. Exit interview conducted, Appeal Rights given, and a copy of this report was provided to the Community Sales Director.the state’s words, verbatim · CDSS document, Sep 13, 2025 · control 31-AS-20250207120648

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(29) · Plan of correction due date: Sep 19, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply....(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair.... This requirement was not met by: Based on LPA's interviews, record review and observation of the Ice Machine Cleaning Log, the ice machine had not been cleaned since April of 2025 which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 13, 2025

Plan of correction: The Licensee will create a monthly cleaning list log which includes the cleaning of the ice machine. Additionally, The Licensee will review the monthly cleaning log to ensure the ice machine and other equipment are maintained in clean and safe conditions.

Allegation investigated: Staff did not ensure facility was kept clean, safe and sanitary.

On 8/06/2025 at approximately 9:45 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Executive Director, Katherine Aleman, and stated the reason for their visit was to deliver the findings of the complaint. To investigate the allegation(s), on 7/19/2025 at approximately 10:00 AM, LPA conducted a physical plant tour. From 11:30 AM to 2:30 PM, LPA conducted interviews with nine (9) residents (R1-R9), two (2) staff members (S1-S2) and conducted record reviews. (Continue to LIC 9099-C) Substantiated Regarding the allegation: Staff did not ensure facility was kept clean, safe and sanitary. It was alleged that the facility’s laundry room was not kept clean and staff were neglecting their residents from maintaining safe and sanitary conditions. To investigate the allegation(s), LPA conducted interviews with nine (9) residents and two (2) staff members. LPA’s interview with all residents confirmed that staff do not neglect them nor have they witnessed other residents to be neglected. During LPA’s interview with residents, LPA did not observe residents’ rooms to emit foul odors. LPA observed residents throughout various areas of the facility such as in the seating area, the dining area and activity center. LPA observed the residents to appear to be in good health and interacting with their peers. During a physical plant tour of the laundry rooms and an interview with S1 revealed that the laundry rooms are cleaned weekly but there have been a few residents who have made it a habit not to throw their trash away properly. LPA’s interview with S2 revealed that the laundry rooms are cleaned throughout each shift, “…Morning, afternoon, and night shift”. However, during LPA’s physical plant tour, LPA observed two (2) out of the four (4) laundry rooms not to be clean. LPA observed both laundry rooms located on the second floor, which are accessible to Residents, had unsecured waste bin lids. Additionally, one (1) of the two (2) laundry rooms were observed to have Personal Protective Equipment (PPE) gloves left unsecured on the floor, an uncovered waste container, canned alcoholic beverages left on the floor, and bagged garbage placed outside of the designated waste containers. Based on LPA’s observations, the facility did not maintain two (2) out of the four (4) laundry rooms clean, safe, and in sanitary condition, therefore the allegation is SUBSTANTIATED at this time. Citation issued, please refer to 9099-D. No other immediate health and safety hazards observed during the time of the visit. Exit interview conducted, Appeal Rights given, and a copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 31-AS-20250711120809

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Aug 20, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary...at all times… Maintenance shall include… well-being of residents…(1)... laundry…areas shall be maintained in a clean, sanitary…condition. This requirement was not met by: Based on LPA’s observations 2 out of the 4 laundry rooms were not kept clean or in sanitary conditions which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: The Executive Director will email LPA Segovia photos of the new trash bins with secured lids in each laundry room, a statement of communication with residents/staff regarding proper disposal of trash and agreement of laundry rooms being checked on twice a day for cleanliness and upkeep.

Allegation investigated: Staff are leaving residents in soiled clothing for extended periods of time. Staff are not meeting residents toileting needs.

On 7/29/2025 at approximately 10:00 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Executive Director, Katherine Aleman and stated the reason for their visit was to conduct interviews, review documentation and deliver the findings of the complaint. To investigate the allegation(s), at approximately 10:30 AM, LPA conducted a physical plant tour. By 11:30 AM, LPA requested relevant documentation. From 11:30 AM to 2:30 PM, LPA attempted interviews with eleven (11) residents (R1-R11), seven (7) staff members (S1-S7) and conducted record review. (Continue to 9099-C) Unsubstantiated Regarding the allegation: Staff are leaving residents in soiled clothing for extended periods of time. It was alleged that residents were left unattended for hours causing them to urinate all over themselves. To investigate the allegation, LPA attempted interviews with eleven (11) residents and seven (7) staff members. LPAs interview with six (6) residents revealed that staff have never left them soiled for extended periods of time. Interview with R2 stated, “…I just push my button and they will come to change me”. Interview with R5 stated that the staff do not let them stay soiled, “…they don’t let me…the staff is great”. LPA attempted to interview R7-R11 but they were asleep during the time of the visit. LPA’s interview with five (5) staff members confirmed that residents are checked on hourly to ensure their incontinent needs are being met. Interview with S4 and S5 revealed that they have witnessed R2 and R5 being left soiled. LPA’s record review of R2 and R5’s Care Rounds revealed that both residents have had documented refusals of not allowing staff to assist them. During LPA’s physical tour, LPA conducted room checks of residents listed under incontinence care. In the memory care unit, LPA toured five (5) bedrooms and in the assisted living unit, LPA toured eleven (11) rooms. LPA observed the residents to be clean, well-groomed and did not experience any malodor. LPA did not witness any leak pads left soiled. LPA observed residents’ chairs, beds and flooring to be clean and in proper condition. LPA witnessed staff members conducting their rounds and assisting residents. Based on LPA’s interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not meeting residents toileting needs. It was alleged that residents’ incontinence needs are not being met by staff. To investigate the allegation, LPA attempted interviews with eleven (11) residents and five (5) staff members. LPA’s interview with six (6) residents revealed that staff do meet their toileting needs. Interview with R1 stated the staff keep them, “clean and dry”. Interview with R6 stated that they will push their button and staff will assist them with their toileting needs. LPA attempted to interview R7-R11 but they were asleep during the time of the visit. LPA’s interview with all staff members confirmed that residents who have incontinent needs are checked on to ensure their toileting needs are being met. During LPA’s physical plant tour, LPA observed residents to appear in good health. LPA observed residents to be clean and well-groomed. LPA did not experience any malodors within the facility. (Continue to 9099-C) Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 31-AS-20250723151134

Type of visit: Case Management - Incident

On 5/20/2025 at approximately 10:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent Case Management visit to the facility. LPA was greeted by staff and stated the reason for their visit was to deliver the findings regarding the incident reported to Community Care Licensing Division (CCLD) on 5/2/2025. Executive Director (ED) Katherine Aleman arrived shortly after to assist with today’s visit. Upon arrival, LPA requested Census, Staff and Resident Roster. At approximately 10:40 AM LPA requested additional documentation pertaining to the incident. Between 11:00 AM – 12:00 PM, LPA conducted additional interviews with Staff members (S5-S6). To investigate the incident, on 5/5/2025 LPA conducted a physical plant tour, requested pertinent documentation, and conducted interviews with one (1) Resident (R1) and four (4) Staff members (S1-S4). The facility reported that R1 had reported that S1 used inappropriate physical force towards them causing them pain. LPA spoke with the ED regarding the incident between R1 and S1. The ED stated that when they became aware of the alleged incident, they proceeded to conduct their own internal investigation as well as reporting the incident to the appropriate domains. The ED stated they interviewed both R1 and S1 but since there were no witnesses their investigation was inconclusive. LPA’s interview with R1 revealed that S1 had arrived in their room in the morning to assist them in bed with their incontinent care needs. R1 stated that S1 pushed their head down twice by placing their finger onto their forehead to get their head onto the bed. When LPA asked if they could name the staff member, R1 could not remember and stated, “I am not good with names”.When LPA asked if they had told anyone what had occurred, R1 stated they told S3 what had occurred. LPA’s interview with S3 revealed that R1 had told them that a staff member had “manhandled” them when assisting them in the morning. When LPA asked if R1 had told them the name of the staff member, S3 stated that R1 did not know the name of the staff member. (Continue to LIC 809-C) LPA’s interview with S1 revealed that they went to R1’s room in the morning to assist them with changing in bed. S1 stated that R1 has had surgery to their neck causing them to keep their neck in an upward position. S1 stated that when they changed S1, they placed a pillow behind their neck to help with their positioning. When LPA asked if they ever used their fingers to push R1’s head back towards the bed, S1 stated, “No, that is why I use the pillow to help position them”. While interviewing R1, LPA observed R1 keeping their neck in an upward position creating distance from their pillow to their neck. LPA’s Interview with S6 revealed that R1 did name S1 as the person involved in the incident however, interviews with S2-S6 revealed although R1 stated that said incident occurred, there were no witnesses. Furthermore, based on interviews, record review and observation there is not enough evidence to prove that S1 physically hurt R1. No deficiencies cited at this time. No immediate health and safety hazards observed during the visit. Exit interview conducted and a copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, May 20, 2025

Type of visit: Case Management - Incident

On 5/5/2025 at approximately 10:00 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced Case Management visit to the facility regarding an incident reported to Community Care Licensing (CCL) on 5/2/2025. LPA was greeted by the Business Director, Shannon Bailey and LPA stated the reason for their visit. The facility reported that Resident one (R1) had reported that a Staff member (S1) used inappropriate physical force towards them causing them pain. LPA requested Census, Staff, and Resident Roster. At approximately 10:30 AM, LPA requested pertinent documentation related to R1's needs/services and S1’s training. At around 10:40 AM LPA conducted a Physical Plant Tour. In between 11:00 AM - 1:00 PM LPA conducted interviews and record review. LPA may return to the facility at a later time, pending further review of the reported incident. There were no health or safety hazards observed during the visit. Exit interview conducted and a copy of this report was provided to the Business Director.the state’s words, verbatim · CDSS document, May 5, 2025

Type of visit: Case Management - Deficiencies

On 4/1/2025 at approximately 10:15 a.m. Licensing Program Analysts (LPAs) Angelica Segovia and Huma Rahimi conducted an unannounced Case Management visit to this facility in conjunction with a complaint control #31-AS-20250324153245. LPAs met with the Executive Director (ED) Katherine Aleman and LPAs explained the reason for the visit. During the visit, LPAs were informed that R2 had fallen in their room and were taken to the hospital. However, no incident report was submitted to the Community Care Licensing Department (CCLD). Upon record review, it was revealed that the facility failed to report the incident to the Regional Office (RO). In addition, the ED admitted that no incident report was submitted to the RO and that they were not aware they needed to report the incident. Based on Title 22 Regulation: a written Unusual Incident / Injury Reportshall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the ED that all staff members are mandated reporters and they are all responsible for reporting. LPAs reviewed all incident reports on CCLD's system and did not observe an Incident Report regarding R2. ED will submit Incident Report to CCLD for R2. Per the California Code of Regulations, Title 22, Division 6, Chapter 8 a deficiency was issued. Exit interview conducted, appeal rights given, and a copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Apr 1, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 8, 2025

87211 Reporting Requirments: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R2's multiple falls and hospitalization on or before 03/24/24, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 1, 2025

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. The Licensee also agreed to submit a statement of understanding of the regulation and the incident report by the POC due date.

Type of visit: Case Management - Incident

On 1/21/25 at 10:00 AM, Licensing Program Analysts (LPAs) Angelica Segovia and Gary Tan conducted an unannounced visit to the facility to conduct a Case Management visit. LPAs were greeted by Executive Director Katherine Aleman. LPAs stated the reason for their visit. The purpose for the visit was to follow up on a self-reported incident (1-13-25) which alleged that Resident 1 (R1) was involved in a physical and verbal altercation with Staff 1 (S1) on 1-10-25. LPAs requested census, staff, and resident Rosters at 10:15 AM. LPAs reviewed pertinent documents from 10:20 AM-12:30 PM. A physical plant tour was conducted at 12:35 PM. LPAs interviewed staff members and Resident 1 (R1) from 12:50 PM to 2:30 PM. Interview with R1 revealed that they had called down for their medication request around 3:30 PM. R1 stated they waited, and no one came to their room until 6:30 PM. R1 stated they were upset because they wanted their medication for pain. R1 stated they suffer from frequent migraines. LPAs record review revealed that R1 had a PRN medication for pain every six (6) hours and the last PRN pain medication administered to R1 was at 12:00 PM and the next one is not due until 6:00 PM as this is a narcotic pain medication. During the medication pass conducted to R1 at own room by Staff #1 (S1) at around 6:30 PM, R1 stated that there was a physical altercation with S1 as R1 argued that S1 was late in giving R1’s medication. An altercation ensued when R1 initially refused medication and S1 allegedly tried to grab R1’s medication on R1’s hand resulting to scratches on R1’s hands. LPAs record review and interview with the Executive Director (ED) revealed that ED talked to R1 by phone at around 8:28 PM and R1 told ED that R1 was okay when R1 mentioned he had a cut on their hand. At 9:31 PM, however, the ED received a picture from R1 showing a fresh scratch on R1’s hands. Record review showcased that R1 has a history of false reporting, self-inflicting wound, and aggressive behavior. During the interview with S1, S1 denied having any physical contact with R1. Based on LPAs’ record review and interviews, there is not enough information to prove that S1 physically hurt R1. No further actions needed at this time and no immediate health and safety issues observed during this visit. Exit interview conducted. A copy of this report was given to the Executive Director.the state’s words, verbatim · CDSS document, Jan 21, 2025

Type of visit: Required - 1 Year

On 12/23/2024 at approximately 09:45 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. Upon arrival LPA was greeted by the Director of Engagement Marhlyn Sapugay. LPA stated the reason for their visit. The Administrator was phoned shortly after and made aware of today’s visit. LPA asked for census, staff, and resident file. LPA along with Director Sapugay conducted a physical plant tour at approximately 12:30 PM and the following was noted: The facility is a two-story building. The facility is fire cleared for one hundred fifteen (115) non-ambulatory residents and a Hospice waiver for six (6). The facility consists of Assisted Living located on both floors and Memory Care located on the first floor. Smoke detectors and carbon monoxide observed to be working properly and in good repair. Smoke alarms were last inspected on 10/31/24. There are fire extinguishers located throughout the facility hallways. Fire extinguishers dated 05/02/24. Required postings such as Emergency Disaster Plan, Facility License, and Facility sketch are located at the main entrance. Screening area is located immediately upon entrance. Common areas: observed to be neat, clean, and organized. Common areas observed to be properly furnished and in good repair. Such included are: Dining room, Activity room, Theater/Chapel, Mail room, Beauty Parlor and Fitness center (located on the second floor). Hallways and passageways are free of obstruction. Stairway observed to be equipped with an evacuation chair. Elevators, two (2), were functional. The facility maintains a comfortable temperature at a range of 71°F - 74°F throughout the facility. Fireplace observed to be covered inaccessible to residents. Office/Work Station: The Administrator's office and sales and marketing room are located near the main entrance, near the front desk. (continued on LIC 809-C) The kitchen is commercial. Appliances and fixtures were functional. The kitchen observed to be fully stocked with two (2) days perishable and seven (7) days non-perishable food. Kitchen observed to be clean and inaccessible to pests. Surrounding Grounds: The Memory Care is located on the first floor with thirteen (13) rooms and a capacity of eighteen (18) residents. LPA observed both dining room and living room to be in good repair and free of obstructions. LPA observed delayed egress to be in good repair and working condition. Outside of the memory care, there is an enclosed courtyard with open space Gazebo. Outside area of the Assisted Living is equipped with a gazebo and sufficient shaded areas with outdoor furniture for residents. There is no body of water in this facility. Laundry Room: There are three (3) laundry rooms. One commercial laundry room is located on the first floor, besides the medication room. There are two (2) community laundry rooms located on the second floor for residents to use. The commercial laundry room is kept locked. The community laundry rooms have resident access, but no detergents or cleaning supplies accessible. Residents who wish to do their laundry, are to bring their own. The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. The bathrooms were checked for cleanliness and proper operation. LPA observed proper handrails and non-skid mats. The hot water temperature was measured at a range of 113.5°F-120°F. Towels and washcloths are not shared. Medications: LPA observed medication room located on the first floor. Medication room is kept locked and inaccessible to residents. Medication usage recorded and stored properly. LPA along with Director Sapugay conducted a review of the medication to ensure compliance. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and manual. Resident records: LPA conducted a file review of resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a file review of staff records. Staff records appeared to be complete and updated. There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was provided to the Director.the state’s words, verbatim · CDSS document, Dec 23, 2024

Allegation investigated: Staff do not provide residents with activities

At approximately 11:00 a.m. on 11/01/24 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA interviewed staff and residents between 11:00 a.m. and 1:00 p.m. today, conducted a record review of pertinent records, including but not limited to staff and client rosters, activity schedules, and facility notices at 11:30 a.m., and toured the facility inside and out at 11:45 a.m. Regarding the allegation "Staff do not provide residents with activities" it was alleged that the facility does not provide the residents with activities, specifically that arts and crafts and rides to outings are not provided. From the facility tour, LPA observed a resident returning from an outing around 11:30 a.m. in the facility van. Unsubstantiated At approximately 11:40 a.m., LPA observed five (05) residents playing cards, two (02) residents playing a board game, and two (02) residents engaged in arts and crafts in the activity room. LPA also observed sufficient supplies of paper, colored pencils, pens, beads, and strings in the activity room. The upstairs activity area contained a pool table, puzzles, and a library of reading material. Paper and digital activity schedules were posted near the main entrance. Activity postings throughout the facility notified residents of holiday festivities. LPA also observed the daily facility newspaper and a drop box for residents to schedule use of the facility van for appointments and activities. Interviews with eight (08) out eight (08) residents today confirmed the facility provides adequate activities to their likings. Interview with Resident #1 (R1) at 12:00 p.m. revealed they have played cards with other residents for the past fifteen (15) years at the facility. Interview with Resident #2 (R2) at 12:30 p.m. revealed the facility provides more than enough art supplies for their daily activities. Interview with the administrator at 11:30 a.m. revealed the facility van has always been functional and the facility recently introduced scenic drives into their activity program. Interview with Staff #1 (S1) at 12:45 p.m. revealed residents and their families enjoy the billiards table, daily newspaper, and holiday activities. Based on observations, interviews, and record review, the facility provides residents with activities and accommodates sufficient space for activities. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 1, 2024 · control 31-AS-20241025121758

Allegation investigated: Licensee is not following proper infection control protocols.

At 10:10am, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with the receiptionist and later met with Wellness Specialist and explained the reason for the visit. During course of the investigation, interviews and record review were made. At 10:20am, LPA requested resident and staff roster and copies of pertinent information which include, but not limited to an Approved Infection Control Plan, Hospital Discharge Papers, Notes, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:35am, LPA conducted a physical plant tour. Between 10:45 am – 1:20 pm, LPA conducted an interviewed with the Wellness Specialist, Memory Care Director, Executive Director, two (2) staff, and nine (9) out of eleven (11) residents. Continue on LIC 9099C Unsubstantiated Licensee is not following proper infection control protocols: It was alleged that the facility is exposed to Scabies and was not disclosed to family members. To investigate this allegation, LPA conducted interviews with the Wellness Specialist, Executive Director, and Memory Care Director and it was revealed that in March 2024 one of the residents (R1) was having a skin rash. Upon observation, the facility informed the family member of R1. The family member took R1 to the physician on 03/14/2024, 04/03/2024, and 05/28/2024, for the skin rash. Finally, on 06/20/2024, R1 was taken to Kaiser Permanente Dermatologist for the ongoing skin rash by a family member and R1 was diagnosed for Scabies without any confirmed tests. Upon diagnosis of the doctor, the facility followed proper infection control protocols by quarantining R1 in their room for five (5) days and immediately all the beddings were changed. Interview with the family member of R1 confirmed that the facility did inform them in a timely manner and as well isolated R1 immediately and washed all their beddings and clothes. Additionally, the facility also followed proper reporting procedures by reporting to the Community Care Licensing Department (CCLD). Lastly, interview with nine (9) out of eleven (11) residents also confirmed that the facility always follows proper infection control plan and they have no concerns regarding the above allegation. Based on the interviews and record review this allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 31-AS-20240703123202

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Gary Tan and Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the community sales director, Christine Ellis and explained the reason for the visit. At approximately 09:30am, with the assistance of the community sales director and maintenance staff, LPAs took a tour of the physical plant. The facility is a two story building. The smoke alarms and carbon monoxide detectors are dual, hardwired and interconnected. Smoke alarms were last inspected on 04/03/24. Facility also have a functional sprinkler system. There are fire extinguishers located throughout the facility hallways. The charge date for the fire extinguishers was 05/02/24 and pull system. Fire drill was last held 04/02/24. Kitchen: The kitchen is commercial. Appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food properly stored. Bedrooms: The facility is two stories, with resident bedrooms on both the first and second floors. Random rooms were inspected on both floors, and LPAs observed appropriate beddings and linens with sufficient lighting. Bathrooms: Each resident unit on both floors have their own bathrooms. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was between 113.4 to 118 degrees Fahrenheit. No cleaning supplies observed stored in resident bathrooms. Common Areas: These include the lobby, activity area, theater, bistro, beauty shop (on second floor), library (also on second floor), and dining area. The common areas were properly furnished, observed to be in repair. Floors were mopped and clean. Hallways and passageways are free of obstruction. Elevators, two (2), were functional. Surrounding Grounds: There is a memory care, with twelve (12) rooms and and a total of eighteen (18) beds. Delayed egress was tested and is functional. Outside of the memory care, there is an enclosed courtyard with open space Gazebo. Exterior door/perimeter fence, cleared. Hallways in the assisted living area, on the first and second floor were inspected and observed free of obstruction. Outside area of the assisted living also has a gazebo, with patio furniture, appropriate for outdoor use. Laundry Room: There are three laundry rooms. One commercial laundry room is located on the first floor, besides the medication room. There are two smaller laundry rooms located on the second floor, for resident use. The commercial laundry room is kept locked. The two smaller laundry rooms have resident access, but no detergents or cleaning supplies accessible. Residents who wish to do their laundry, are to bring their own. Resident Files: Resident files are maintained in the medication room. LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: Staff files are maintained at the business office. LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: Medication Room is located on the first floor, in between the memory care unit and assisted living. There were three medication carts and electronic MARS. Random review of resident medications and medication records were made for proper documentation. Medication room is locked at all times. Office/Work Station: The administrator's office and sales and marketing room is located near the front entrance, near the front desk, where LPA's checked in with the receptionist. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, May 11, 2024

Allegation investigated: Staff did not accurately assess resident's needs.

At 11:50am, Licensing Program Analyst (LPA) Angela Panushkina conducted a subsequent visit to deliver final findings.LPA met with the Regional for Health and Wellness and Regional Operations Specialist and explained the reason for the visit. During the initial visit conducted by LPAs Panushkina and Khurshudyan on 04/16/24, interviews and record review were made. At 10:45am, LPAs requested resident and staff roster and copies of pertinent information which include, but not limited to Admission Agreement, Pre-Admission Appraisal, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:55am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 11:00am – 12:40pm, LPAs conducted an interviewed with the Community Sales Director, Regional for Health and Wellness, three (3) staff members, eight (8) out of ten (10) residents and Director of Nurses from the Hospice agency. Continue on LIC9099-C Unsubstantiated It was reported that the staff did not accurately assess R1, and R1 was inappropriately placed in the Assisted Living Unit instead of Memory Care Unit. To investigate this allegation, LPAs conducted an interview with the Community Sales Director and Regional Vice President for Health and Wellness and were informed that R1’s Physician’s Report was complete prior to R1’s admission, and based on the information provided on the form the facility placed R1 in an Assisted Living Unit. In addition, interview with the Director of Nurses (DON) from R1’s Hospice agency revealed that although R1 cannot leave the facility unassisted, R1 is still alert, oriented and does not require to be placed in a Memory Care Unit at this time. During today's visit, LPA an additional information was provided to LPA. Regional for Health and Wellness informed LPA that R1 no longer resides at this facility as of 04/16/2024. Based on interviews and record reviews this allegation is deemed Unsubstantiated. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 2, 2024 · control 31-AS-20240412163855

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Angela Panushkina and Perchui Milena Khurshudyan conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240412163855. LPAs met with the Community Sales Director and explained the reason for the visit. During the visit, LPAs conducted an interview with three (3) staff members and the Director of Nurses from hospice and were informed that at least twice R1 left the facility premises unassisted. These two (and or more) incidents, involving R1, took place between 03/24/24 to 04/13/24 and were not submitted to the Community Care Licensing Department (CCLD) in a timely manner. In addition, the Kristine Ellis admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. Deficiency cited on LIC809-D Exit interview conducted, appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B,C&D · Plan of correction due date: Apr 23, 2024

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding the two (2) incidents that occured between 03/24/24 -04/13/24, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 16, 2024

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copies of two (2) incidents, shall be submitted to LPA by POC date.

Allegation investigated: Staff did not administer resident's medications as prescribed.

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit at this facility to investigate the above allegation. At 9:40 AM LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Allegation: Staff did not administer resident's medications as prescribed. It was alleged that staff hasn't administered prescribed medications to R1 since their discharge date from the hospital. LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. LPA interviewed the Executive Director, One (1) staff member, and nine (9) residents. Interview with the Executive Director revealed that there was a miscommunication between S2 and S3. According to the Executive Director R1 was discharged late from the hospital on 03/08/24 which resulted in a time gap for new medications to get listed on the system. (Continue on 9099C) Substantiated Record reviews indicated that R1 missed medications on 03/8/24 and on 03/09/24. Based on interviews and record reviews, the allegation is deemed substantiated at this time. Exit interview conducted, citations cited, appeal rights given and copy of this report delivered.the state’s words, verbatim · CDSS document, Mar 15, 2024 · control 31-AS-20240311081634

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 16, 2024

87465(a)(4) Incidental Medical and Dental Care: The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: based on interviews and records review R1 missed medication on 03/08/24 and 03/09/24.This poses an immediate risk to the residents in care.the state’s words, verbatim · CDSS document, Mar 15, 2024

Plan of correction: Executive Director agreed to hire a licensed vendor to provide medication training to all staff. Training certificates must be submitted by the POC date.

Allegation investigated: Staff pushed resident(s) Staff do not ensure resident is bathed Staff do not clean resident rooms Staff do not provide laundry service to resident(s)

On 1/12/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator and LPA explained the purpose of this visit was to deliver findings for this complaint. The investigation consisted of the following: On 05/03/2023, LPA Spaeth conducted a 10-day visit and requested the resident roster, staff roster/phone numbers, and a list of residents who receive assistance with showering. LPA received the documentation request and LPA interviewed nine residents and nine staff members. During today’s visit, LPA interviewed two residents, two staff members, two managers and three resident family members. It was alleged that residents have been pushed by staff members and staff members have pushed each other. It was alleged that the incidents have been communicated to management but management has not addressed the incidents because the manager(s) have become upset. Also, it was alleged that some Unsubstantiated residents have asked some staff members not to enter their room. LPA interviewed 12 out of 91 residents and 12 out of 47 staff members. The residents unanimously stated staff members have not pushed them, have not witnessed a staff member push another resident, have not witnessed a staff member push another staff member, and residents have not asked some staff members not to enter their room. The 12 staff members stated they have not pushed a resident, and they have not witnessed another staff member push a resident. The two managers confirmed this type of behavior has not been observed and has not been reported to the managers. The allegation, staff pushed resident(s) is unsubstantiated. It was alleged that residents are not receiving the proper care such as showering because some employees are related to other employees. Twelve out of the 91 residents receive assistance with showering. Six out of the 12 residents who receive assistance with showering stated the staff assist them twice a week. The six residents stated the staff never miss assisting them. The 12 out of the 47 staff members interviewed stated they observe all other staff members performing their jobs and stated the management team treat all staff members the same. LPA interviewed three family members who stated there are no issues with residents receiving assistance with showering. The two managers stated have not received complaints from residents or family members regarding this allegation. Therefore, the allegation staff do not ensure resident is bathed is unsubstantiated. It was alleged that residents’ rooms have not been cleaned by staff members. Twelve out of the 91 residents unanimously stated staff never miss cleaning their room. The 12 out of the 47 staff members interviewed stated the residents and their family members have not complained about the cleaning services provided by the housekeeping staff. Therefore, the allegation staff do not clean resident rooms is unsubstantiated. It was alleged that residents’ laundering had not been washed by staff members. Twelve out of the 91 residents unanimously stated staff do launder their clothing and bedding. The 12 out of the 47 staff members interviewed stated the residents and their family members have not complained about the laundering service. Therefore, the allegation staff do not provide laundry service to resident(s) is unsubstantiated. An exit interview was conducted, and a hard copy of this report was given.the state’s words, verbatim · CDSS document, Jan 12, 2024 · control 31-AS-20231221093054