Spring Senior Assisted Living

Allegation investigated: Staff does not ensure facility is kept at a cool temperature for all residents in care

On 09/01/2026 at 8:20am the Department conducted an initial visit at the facility listed above to deliver the investigation findings. The Department met with Monniece Boatwright (Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 09/01/2026, the Department conducted interviews with Administrator (A1), 6 Staff (S1 - S6) and 9 Resident (R1 - R9) between the hours of 9:12am - 11:42am. The Department requested and obtained the following documentation such as Staff Roster (dated 08/25/2026), Resident Roster (dated 08/27/2026), Sol Air Conditioning & Heating, Inc HVAC Service Order Invoice (dated 08/29/2026), and Temperatures June 2026 - August 2026 and Unusual Serious Incident Report (dated 09/01/2026). Unsubstantiated The investigation revealed the following: Allegation: Staff does not ensure facility is kept at a cool temperature for all residents in care It was alleged that residents on the second floor experienced excessively hot conditions inside the facility due to problems with the air-conditioning system, resulting in little to no air flow from the vents and reliance on large fans that only circulated warm air. On 09/01/2026, between the hours of 9:30am - 9:47am, the Department interviewed the Administrator (A1) in regards to the allegation. A1 confirmed the allegation. A1 stated in the beginning of August 2026 is when it was discovered that there was an issues with the air-conditioning on the 2nd floor. Immediately maintenance was informed by the Administrator (A1). A1 then contacted the higher ups who then had a reached out to vendor (contractor) come out to the facility and was able to discover it was a mini spit issue. The parts had to be ordered first in order to correct the issues with the AC and as a result the facility purchased 4 fan which were put in place on the 2nd floor of the hallway. SolAir came out the facility about 5 times which was a two man job to correct the issue. A1 also mentioned educating the staff and residents to keep their personal room doors closed to avoid the heat from coming into the resident room. Also A1 informed nutritionist and the medtech to make the resident stay hydrated. A1 stated not being specifically being made aware by the residents of no air flow from the vents. On 09/01/2026, between the hours of 9:12am - 11:42am, the Department interviewed 6 Staff (S1 - S6) in regards to the allegation. 6 out of 6 staff confirmed the allegation. The staff expressed that since August 2026, that some of the residents who reside on the second floor complained about the there was an issue with air-conditioning unit which was communicated to the administrator and maintenance who then contacted contractors to come out to the facility to correct the issue. Although some of the staff expressed it was very hot throughout the second floor of the hallway, the some of the resident did not communicate that there was no air blowing from the vents. In the meantime, fans were put in place throughout the hallway on the second floor while contractors were actively in the process to correct the air conditioning unit. On 09/01/2026, between the hours of 9:56am - 10:49am, the Department interviewed 9 Residents (R1 - R9) in regards to the allegation. 2 out of 9 residents confirmed the allegation. R1 explained that the room was hot and that the vents were not blowing air, and reported feeling uncomfortable until repairs were completed. R3 indicated that the air-conditioning was broken for several days and that the heat caused discomfort, and explained that a temporary room change occurred until repairs were finished. 3 out of 9 residents denied the allegation. R2 and R4 expressed that the room was cool and that air-conditioning was consistently available in their own room, and mentioned that hallway heat did not cause discomfort. R8 reported that the room and hallway were not hot and that the vents were blowing air, and explained that hallway fans kept the area cool. 4 out of 9 residents did not confirm nor deny the allegation. R5 indicated that the room was cool and that hallways were avoided, and explained that personal air-conditioning adjustments were made. R6 expressed that the room was cool and that hallway heat did not cause discomfort, and mentioned that no assistance was needed. R7 explained that the air-conditioning was not working at one point but did not report heat discomfort, and indicated that hallway conditions were unknown. R9 mentioned that room temperature could not be recalled and that the vents were blowing air, and explained that heat did not cause discomfort. On 09/01/2026, at 10:44am - 10:55am, the Department conducted a tour of the second-floor hallway and observed fans placed throughout the hallway, and the hallway was at a regular room temperature. The Department also entered several resident rooms on the second floor and observed that the rooms were at a cool temperature. The air-conditioning units were working when in use by the resident, and rooms without active air-conditioning use were at a regular room temperature. On 09/01/2026 between the hours of 1:00pm - 2:00pm the Department conducted a records review and observed the following: the LIC 624 Unusual Incident Report (dated 09/01/2026) indicated that on 08/28/2026 the Long-Term Care Ombudsman visited the facility regarding concerns about the second floor air conditioning system. The report states that the issue was identified on 08/01/2026, the HVAC vendor (SolAir) was contacted immediately, and temporary cooling measures were implemented by placing two fans in the hallway on 08/01 and two additional fans on 08/05. The LIC 624 further documents that the HVAC vendor inspected the system on 08/05 and 08/06, determined that mini split replacements were needed, ordered parts, and completed repairs through multiple service visits between 08/19 and 08/31. The report also notes that the Ombudsman acknowledged the facility was actively working to resolve the issue. HVAC service documentation corroborates that repairs required multiple visits and replacement parts. The TELS maintenance logs for June through August 2026 reflect routine hot water temperature checks but do not contain any information related to indoor cooling, HVAC performance, or ambient temperature monitoring for the second-floor hallway. No records were provided showing temperature logs or monitoring of hallway heat levels during the period of AC malfunction. The records confirm that the second-floor hallway AC system was nonfunctional for most of August 2026 and that temporary cooling measures were used while awaiting repairs. The records support that the facility experienced prolonged cooling issues affecting the second-floor hallway area and do not demonstrate that the facility maintained cool temperatures in all resident accessible areas during the period of malfunction. Overall, although the second floor air conditioning system experienced a malfunction during August 2026, the facility implemented corrective actions during the period of repair such as residents who experienced heat were relocated to rooms with functioning air conditioning units, and fans were purchased and placed in the second floor hallway and or place in resident room upon request while parts were ordered and repairs were being completed. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Monniece Boatwright (Administrator) and a copy of this report was providedthe state’s words, verbatim · CDSS document, Sep 1, 2026 · control 11-AS-20260827162957

Allegation investigated: Facility does not respect resident’s personal rights.

On 07/21/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegations listed above. LPA met with the Administrator, Monniece Boatwright, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 03/24/2026, a facility tour was conducted, interviews were conducted, and records were gathered. Resident 2 (R2) to Resident 7 (R7) and Staff 1 (S1) to Staff 5 (S5) were interviewed, additional interviews were attempted with witnesses. Facility records gathered consisted of staff roster, resident roster, Resident 1’s (R1) records, and other pertinent records. On 07/21/2026, interviews were conducted with Witness 1 (W1) to Witness 3 (W3), records were reviewed, additional interviews were attempted with witnesses and R1. Unsubstantiated Investigation revealed the following: Allegation: “Facility does not respect resident’s personal rights”, it is being alleged that the facility is restricting R1’s communication with family/visitors via phone, mail/deliveries, and visitation. Interviews conducted with R2 to R7 revealed the following: 7 out of 7 residents denied the allegation, additionally residents indicated that they are able to use the facility phone, receive mail, visitors, and phone calls. Interviews conducted with S1 to S5 revealed the following: 5 out of 5 staff denied the allegation. Interviews conducted with W1 to W3 revealed the following: 1 out of 3 witnesses denied the allegation; 1 out of 3 witnesses were unable to corroborate the allegation; 1 out of 3 witnesses agreed with the allegation, stating that they called the facility but facility staff informed them that they could not speak with R1. On 03/24/2026 observations of the facility revealed the following: There is a facility landline telephone designated for resident use on a small desk with a chair near the main entrance of the facility – a resident was observed making a phone call from that telephone; there is a facility videoconferencing device (cell phone) for resident use in the main office; there is a Personal Rights Poster in the small activity room; visitors were allowed entrance to the facility without any restrictions. Records reviewed of Visitor Log from 03/09/2026 to 03/23/2026 revealed the following: The facility received several visitors a day, ranging from over 16 visitors a day to under 7 visitors a day; R1 received visitors on 03/09/2026, 03/13/2026, 03/15/2026, 03/18/2026, and 03/20/2026. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with the Administrator, Monniece Boatwright.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 11-AS-20260319114004

Allegation investigated: Staff are taking resident's money.

On 04/30/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above mentioned allegations. LPA met with Business Office Manager, Wendy Davila, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On 03/20/26, the department obtained the staff roster, resident roster, End of Shift Report, Incontinent Resident list, and a copy of an email thread between R1’s family and facility staff. The department reviewed service records for residents #1-#3 (R1-R3) and requested copies of the following documents for their files: Admission Agreement, Facesheet, Physician’s Report, Appraisal/Needs & Services Plan, Resident Personal Property and Valuables, and Personal Rights. Additionally, the department conducted interviews with staff #1-#6 (S1-S6), witness #1-#2 (W1-W2), residents #1-#5 (R1-R5), and attempted to interview residents #6-#7 (R6-R7). Furthermore, the department conducted a tour of the facility, and inspected resident bedrooms, and common areas. Substantiated The investigation revealed the following: For the allegation: Staff are taking resident's money. It is alleged that staff took money from a resident’s drawers. On 03/19/26, the department conducted interviews with S1–S6. Of those interviewed, 6 out of 6 staff denied the allegation. On 03/19/26, the department conducted interviews with R1-R5, and attempted to interview R6-R7, but was unable to as the residents were asleep. Of those interviewed, 3 out of 5 residents corroborated the allegation. On 03/20/25, the department conducted interviews with witnesses #1-#2 (W1-W2). Of those interviewed, 1 out of 2 witnesses corroborated the allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of the report, along with appeal rights was provided to Wendy Davila. The investigation revealed the following: For the allegation: Staff left resident in soiled diapers for an extended period of time. It is alleged that staff do not change a residents diapers on a daily basis. It is also being alleged that staff let the resident sit on their own urine or feces. On 03/19/26, the department conducted interviews with S1–S6. Of those interviewed, 6 out of 6 staff denied the allegation. 6 out of 6 staff said they treat all residents with dignity and respect. On 03/19/26, the department conducted interviews with R1–R5, and attempted to interview R6-7, but was unable to as the residents were sleeping. Of those interviewed, 4 out of 5 residents could not corroborate the allegation, while 1 out of 5 residents agreed with the allegation. 5 out of 5 residents said staff treat them with dignity and respect, and that they are satisfied with the services provided to them. Based on observation, and interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the report, along with appeal rights was provided to Wendy Davila.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 11-AS-20260316113251

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: May 7, 2026

87468.1 Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money....This requirement is not met as evidenced by: Based on interviews conducted, the licensee failed to ensure resident's personal rights due to 3 out of 5 residents reported missing cash and/or personal belongings from their bedrooms. This poses a personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Administrator will conduct an in service training/meeting regarding review of resident's personal rights and will submit the sign in sheet to LPA via email to: Elvira.Gonzalez@dss.ca.gov by POC due date, 05/07/26

Allegation investigated: Staff did not prevent a resident from sustaining multiple falls while in care. Facility did not ensure that staff are properly trained. Staff did not respond to resident's call button in a timely manner. Staff did not administer medication to a resident in care.

***This report supersedes the report dated 03/13/2026. This report does not change the findings. On 03/24/2026, the updated report was provided to the Administrator, Moniece Boatwright, and the purpose of the visit was explained.*** On 03/13/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding the allegations listed above. LPA met with the Administrator, Monniece Boatwright, and the purpose of the visit was explained. LPA was granted entry to the facility. Unsubstantiated The investigation consisted of the following: On 03/12/2026, interviews were conducted, medications were reviewed, and records were gathered. Resident 1 (R1) to Resident 5 (R5), Staff 1 (S1) to Staff 5 (S5), and Witness 1 (W1) were interviewed. Facility records gathered consisted of staff roster, resident roster, Resident 1’s (R1) records, and other pertinent records. On 03/13/2026, Staff 6 (S6) to Staff 10 (S10) and Witness 2 (W2) were interviewed and records were reviewed. The investigation revealed the following: Allegation: “Staff did not prevent a resident from sustaining multiple falls while in care”, it is being alleged that due to the lack of care R1 has had multiple falls. Interviews conducted with R1 to R5 revealed the following: 1 out of 5 residents agreed with the allegation and 4 out of 5 residents denied the allegation. Resident 1 indicated that they had about four falls in the facility and staff have assisted them when they fell. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Staff 10 indicated that they worked with R1 during their Admission Process/Care Plan and R1 was informed that when they require assistance with transferring/mobility to press their pendent and wait for assistance before getting out of bed; S10 goes on to explain that R1 understood what was being informed to them. Staff 9 indicated that on 01/26/2026, they had finished assisting R1 and started assisting other residents in neighboring rooms when they heard R1 fall, as soon as S9 heard the noise they went to R1’s room to assist them. Staff 9 indicated that on 03/03/2026, they were assisting R1 in the bathroom, then R1 slipped and S9 assisted R1 in a fall; R1 had an assisted fall. Interviews conducted with W1 to W2 revealed the following: 2 out of 2 witnesses indicated that R1 has a history of falls. Resident 1’s record review revealed the following: Medical Assessment for Residential Care Facilities for the Elderly dated 01/15/2026 did not indicate that R1 has a history of falls but does indicate that they require assistance with repositioning and transferring. Appraisal/Needs And Services Plan dated 01/16/2026 indicated that R1 will use a wheelchair, walker, and care staff will assist with Activities of Daily Living (ADLs). Incident Report dated 01/26/2026, indicated that care staff found R1 on the floor in their room. Incident Report dated 03/03/2026, indicated that R1 slipped in the bathroom under the supervision of care staff. Observations in R1’s room on 03/12/2026 revealed the following: R1 has a pendant button necklace and an intercom call box with button installed on the wall; the pendant was pressed at 1:36 PM, at 1:38 PM a staff spoke through the intercom, and at 1:41 PM two staff came to R1’s room. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Facility did not ensure that staff are properly trained”, it is being alleged that Medication Technicians (MedTechs) are not trained. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Records reviewed of facility MedTechs revealed the following: All facility MedTechs have current MedTech Certificates. Observations in the Medication Room on 03/12/2026 revealed the following: Facility MedTechs knew how to do their job properly. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not respond to resident's call button in a timely manner.” Interviews conducted with R1 to R5 revealed the following: 1 out of 5 residents agreed with the allegation and 4 out of 5 residents denied the allegation. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Witness 2 agrees with the allegation. Observations in residents’ rooms on 03/12/2026 revealed the following: staff responded to the pressing of a pendent / intercom ranging from less than a minute to three minutes. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not administer medication to a resident in care”, it is being alleged that R1 is not receiving their medication as prescribed. Interviews conducted with R1 to R5 revealed the following: 1 out of 5 residents agreed with the allegation and 4 out of 5 residents denied the allegation. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. On 3/12/2026, R1’s medication along with their Medication Administration Records (MARs) were reviewed and it revealed the following: R1 is receiving all their prescribed medication. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Administrator, Monniece Boatwright.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 11-AS-20260309173117

Allegation investigated: Staff did not prevent a resident from sustaining multiple falls while in care. Facility did not ensure that staff are properly trained. Staff did not respond to resident's call button in a timely manner. Staff did not administer medication to a resident in care.

On 03/13/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding the allegations listed above. LPA met with the Administrator, Monniece Boatwright, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 03/12/2026, interviews were conducted, medications were reviewed, and records were gathered. Resident 1 (R1) to Resident 5 (R5), Staff 1 (S1) to Staff 5 (S5), and Witness 1 (W1) were interviewed. Facility records gathered consisted of staff roster, resident roster, Resident 1’s (R1) records, and other pertinent records. On 03/13/2026, Staff 6 (S6) to Staff 10 (S10) and Witness 2 (W2) were interviewed and records were reviewed. Unsubstantiated The investigation revealed the following: Allegation: “Staff did not prevent a resident from sustaining multiple falls while in care”, it is being alleged that due to the lack of care R1 has sustained multiple falls. Interviews conducted with R1 to R5 revealed the following: 1 out of 5 residents agreed with the allegation and 4 out of 5 residents denied the allegation. Resident 1 indicated that they had about four falls in the facility and staff have assisted them when they fell. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Staff 10 indicated that they worked with R1 during their Admission Process/Care Plan and R1 was informed that when they require assistance with transferring/mobility to press their pendent and wait for assistance before getting out of bed; S10 goes on to explain that R1 understood what was being informed to them. Staff 9 indicated that on 01/26/2026, they had finished assisting R1 and started assisting other residents in neighboring rooms when they heard R1 fall, as soon as S9 heard the noise they went to R1’s room to assist them. Staff 9 indicated that on 03/03/2026, they were assisting R1 in the bathroom, then R1 slipped and S9 assisted R1 in a fall; R1 had assisted fall. Interviews conducted with W1 to W2 revealed the following: 2 out of 2 witnesses indicated that R1 has a history of falls. Resident 1’s record review revealed the following: Medical Assessment for Residential Care Facilities for the Elderly dated 01/15/2026 did not indicate that R1 has a history of falls but does indicate that they require assistance with repositioning and transferring. Appraisal/Needs And Services Plan dated 01/16/2026 indicated that R1 will use a wheelchair, walker, and care staff will assist with Activities of Daily Living (ADLs). Incident Report dated 01/26/2026, indicated that care staff found R1 on the floor in their room. Incident Report dated 03/03/2026, indicated that R1 slipped in the bathroom under the supervision of care staff. Observations in R1’s room on 03/12/2026 revealed the following: R1 has a pendant necklace with button and an intercom call box with button installed on the wall; the pendant was pressed at 1:36 PM, at 1:38 PM a staff spoke through the intercom, and at 1:41 PM two staff came to R1’s room. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Facility did not ensure that staff are properly trained”, it is being alleged that Medication Technicians (MedTechs) are not trained. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Records reviewed of facility MedTechs revealed the following: All facility MedTechs have current MedTech Certificates. Observations in the Medication Room on 03/12/2026 revealed the following: Facility MedTechs knew how to do their job properly. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not respond to resident's call button in a timely manner.” Interviews conducted with R1 to R5 revealed the following: 1 out of 5 residents agreed with the allegation and 4 out of 5 residents denied the allegation. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Witness 2 agrees with the allegation. Observations in residents’ rooms on 03/12/2026 revealed the following: staff respond to the press of a pendent / intercom ranging from less than a minute to three minutes. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not administer medication to a resident in care”, it is being alleged that R1 is not receiving their medication as prescribed. Interviews conducted with R1 to R5 revealed the following: 1 out of 5 residents agreed with the allegation and 4 out of 5 residents denied the allegation. Resident 1 indicated that they had about four falls in the facility and staff have assisted them when they fell. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. On 3/12/2026, R1’s medication along with their Medication Administration Records (MARs) were reviewed and it revealed the following: R1 is receiving all of their prescribed medication. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Administrator, Monniece Boatwright.the state’s words, verbatim · CDSS document, Mar 13, 2026 · control 11-AS-20260309173117

Type of visit: Case Management - Other

On 3/13/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted a complaint investigation regarding complaint number 11-AS-20260309173117. The following technicals were observed: A technical violation is being provided regarding Home Health Records California Code of Regulation (CCR) 87609 Allowable Health Conditions and the Use of Home Health Agencies. A technical assistance is being provided regarding Reappraisals CCR 87463 Reappraisals. No deficiencies were provided. An exit interview was conducted, and a copy of this report was left with the Administrator, Monniece Boatwright.the state’s words, verbatim · CDSS document, Mar 13, 2026

Type of visit: Required - 1 Year

On 1/30/2026, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator, Monniece Boatwright. The purpose of the visit was explained and the LPA was allowed entry to the facility. The facility is licensed to serve 51 adults ages 60 and above. The facility may retain 12 residents on hospice. The Annual Licensing Fees are current. Facility Layout: The facility is a two-story house located on a main street. The outside of the facility consists of a Parking Lot and several Outside Patio Areas with shaded seating. The facility has an Elevator and 2 Emergency Exit Stair Rooms. The first floor consists of a Living Room, Front Office / Medication Room, Office, Laundry Room, Sitting Area, Storage Rooms, Dining Room, Industrial Kitchen, Activity Area, Lounge Room, 2 Public Restroom, and 15 Residential Bedrooms. The second floor consists of a Beauty Shop, Maintenance Room, Storage Rooms, 2 Sitting Areas, 1 Public Restroom, and 22 Residential Bedrooms. Kitchen: The kitchen area has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two day. Medications: Medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Medication Administration Records (MARs) were reviewed alongside resident Medications. Resident Rooms: More than 6 resident bedrooms were toured. Adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries are accessible to residents. The hot water temperature measured 106.6 Fahrenheit to 113.3 Fahrenheit. Miscellaneous: Documents are posted as mandated. There are fire extinguishers around the premises, and they were last serviced on 12/19/2025. There are landline telephones in the offices and a videoconferencing in the living room area. The facility has resident toiletries supplies, linen supplies, activity supplies, etc. The last Annual Fire Inspection was completed on by Torrance Fire Depart on 10/15/2025. The facility has a current liability insurance. Fumigators provide service to the facility once a month. The last fire drill was conducted on 12/5/2025. 5 staff records were reviewed, 5 out of 5 staff records had required documentation. 5 resident records were reviewed, 5 out of 5 resident records had required documentation. Technical Advisories are being provided regarding nutrition records and facility being in good repair. No deficiencies are being cited based observation and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report was left with the Administrator, Monniece Boatwright.the state’s words, verbatim · CDSS document, Jan 30, 2026

Allegation investigated: Staff are mismanaging resident's medication Staff did not prevent resident from having pests in their room Staff are inappropriately sharing resident's personal information

On 5/23/2024 at around 10:20 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegations listed above. LPA met with Wellness Director, Amber Lollar and the purpose of the visit was explained. LPA was granted entry to the facility. Unsubstantiated Investigation consisted of the following: On 5/23/2025, a facility tour was conducted, interviews were conducted, and records were reviewed. The facility tour consisted of 5 resident bedrooms. Interviews conducted consisted of 5 staff interviews [Staff 1 (S1) to Staff 5 (S5) were interviewed], 2 informal staff interviews [Staff 6 (S6) to Staff 7 (S7) were interviewed] and 5 resident interviews [Resident 1 (R1) to Resident 5 (R5) were interviewed]. Resident 1’s records were reviewed which consisted of Admission Agreement dated 4/30/2025, Physicians Report dated 5/1/2025, Identification and Emergency Information, Physician’s Report dated 5/1/2025, Medication Administration Record (MAR) for the month of May 2025, Medical documentation and other pertinent documents. Facility records reviewed consisted of Employee roster dated 4/21/2025, Resident Roster dated 5/12/2025, and Fumigation Records from 1/20/2025 to 5/16/2025. Investigation revealed the following: Allegation: “Staff are mismanaging resident’s medication”, it is being alleged that staff are not ordering R1’s medication and that is why R1 is not receiving their medication. Resident 1’s medical records reviewed revealed the following: The facility attempted to order medication for R1 on 5/6/2025. Interviews conducted with R1 and the Wellness Director, Amber Lollar confirmed that R1 required a follow-up medical appointment for them to receive an approved medication prescription by their physician. Furthermore, R1’s Prescription Order Summary Report dated 5/12/2025 and MAR for the month of May 2025 indicate that R1 has received their medication as prescribed. Additionally, R1 confirmed that they have not requested additional medical equipment that they require from their physician. Based on records reviewed, interviews conducted, and observations this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not prevent resident from having pests in their room”, it is being alleged that there are ants in residents’ rooms and the facility does not address the issue. Interviews conducted with R1 to R5 revealed the following: 1 out of 5 residents agreed with the allegation. Interviews conducted with S1 to S5 revealed the following: 5 out of 5 staff denied the allegation. Fumigation Records from 1/20/2025 to 5/16/2025 revealed the following: the facility receives fumigation services once a month. Observations reveled the following: on 5/23/2025 five resident rooms were toured, and no ants were observed. Based on records reviewed, interviews conducted, and observations this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff are inappropriately sharing resident's personal information.” Interviews conducted with R1 to R5 revealed the following: 1 out of 5 residents agreed with the allegation. Interviews conducted with S1 to S5 revealed the following: 5 out of 5 staff denied the allegation. Based on interviews conducted this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Wellness Director, Amber Lollar.the state’s words, verbatim · CDSS document, May 23, 2025 · control 11-AS-20250516095343

Type of visit: Case Management - Health Checks

On 1/29/2025, the Department of Social Services (DSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced case management visit and met with Administrator, Monniece Boatwritght and the purpose of the visit was explained. A total of 25 residents are currently residing in this facility. The department conducted a tour of the facility. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Jan 29, 2025

Type of visit: Case Management - Annual Continuation

On 12/10/2024, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced continuation Required – 1 Year Inspection to the above-named facility and met with Vice President of Special Projects - Stepan Sarmazian. CCLD staff explained the purpose of the visit. 4 out of 5 resident records had required documentation. 1 resident record did not have their annual Medical Assessment and Appraisal & Needs Service Plan (aka Reappraisal). 5 out 5 staff records had required documentation. A technical assistance is being provided for CCR87705 Care of Persons with Dementia. The department had a conversation with the Vice President of Special Projects regarding this regulation. Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding resident records. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Vice President of Special Projects.the state’s words, verbatim · CDSS document, Dec 10, 2024

Type of visit: Required - 1 Year

On 11/21/2024, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Vice President Special Projects - Stepan Sarmazian. CCLD staff explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection. The facility is licensed to serve 51 adults ages 60 and above. The facility may retain 12 residents on hospice. The facility currently has 26 residents. The facility has Annual Licensing Fees due on 1/9/2025 of $1,448. The facility is a two-story building located on a main street. The outside of the facility consists of a Parking Lot and several Outside Patio Areas with shaded seating. The facility has an Elevator and 2 Emergency Exit Stair Rooms. The first floor consists of a Living Room, Front Office / Medication Room, Office, Laundry Room, Sitting Area, Storage Rooms, Dinning Room, Industrial Kitchen, Activity Area, Lounge Room, 2 Public Restroom, and 15 Residential Bedrooms. The second floor consists of a Beauty Shop, Maintenance Room, Storage Rooms, 2 Sitting Areas, 1 Public Restroom, and 22 Residential Bedrooms. The kitchen area has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet. Medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. There are fire extinguishers around the premises, and they were last serviced on 11/19/2024. There are landline telephones in the offices and a videoconferencing in the living room area. Around 5 random residents' bedrooms were checked. Adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. Due to insufficient time this Annual Inspection was unable to be completed. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Vice President Special Projects.the state’s words, verbatim · CDSS document, Nov 21, 2024

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff does not assist resident with medical appointments. Staff is not seeking medical attention for resident. Staff speak inappropriately to resident.

On 11/16/2023 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Craig Weech /Administrator. LPA explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Resident interviews (R#1-R#6), Staff interviews (S#1-S#6) and a tour of the entire facility. LPA obtained and reviewed the following documents: Client’s roster, Personnel roster, (R#1-R#6) Identification and Emergency Information, (R#1-R#6) Admissions agreements, (R#1-R#6) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#6) Needs and Services Plan, (R#1-R#6) Medication Administration Record (MAR) for the month of October 2023, copy of November Activities Calendar where is marked Doctor’s appointment every Thursday, copy of facility menu and copy of last staff training regarding personal rights. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff does not assist resident with medical appointments. The details of the complaint alleged that the facility staff does not assist residents with medical appointments. During the records review, LPA Iniguez reviewed the current facility's activities calendar; it states that Thursdays are doctor's appointment days from 9:00 AM to 3:00 PM. LPA also observed a whiteboard inside the MedTech's room, where they record upcoming resident appointments. During the facility tour, LPA observed an extensive activities calendar in the hallway that announces medical appointments every Thursday from 9:00 AM to 3:00 PM. During an interview with the Administrator (A#1), he stated that the person who oversees the residents' medical and dental appointments is (S#1). Also, (A#1) noted that the facility assists residents with their medical/dental appointments, but most residents have their families to take them. However, if the family is not able to take the residents or a resident need to go to a medical/dental appointment, every Thursday from 9 to 3, our van takes the residents, drops them at the doctor's office, and when they are ready to return, the doctor's office calls us and will go to bring them back to the facility. During interviews with residents (R#1-R#6), 6 out of 7 stated that they do not need assistance with their medical/dental appointments since their families or insurance carriers take care of that. Also, 6 out of 7 stated that they have yet to need assistance from the facility to go to their medical or dental appointments, but they are sure that if they need help, the facility can provide it. During interviews with staff (S#1-S#6), 6 out 6 stated that MedTech oversees the medical/dental appointments (S#1). Also, 6 out of 6 stated that the facility will assist a resident with their medical/dental appointments, and the facility has a transportation mode to take them to their appointments every Thursday. Evaluation Report continues LIC 9099-C Allegation: Staff are not seeking medical attention for residents. The details of the complaint alleged that facility staff are not seeking medical attention for residents. During an interview with the administrator (A#1), he stated that the facility staff would help anyone who needed medical attention. During interviews with residents (R#1-R#6), 6 out of 6 stated that they felt the facility staff would provide medical attention or assistance if needed. During interviews with staff (S#1-S#6), 6 out 6 stated that the facility would assist the residents if they needed medical attention. Allegation: Staff speak inappropriately to resident. The details of the complaint alleged that facility staff speak inappropriately to resident. During the records review, LPA observed the yearly staff training the facility takes regarding residents' personal rights. Also, LPA observed the rights posted on the facility walls. In addition, LPA observed a copy of the personal rights in the resident's admissions agreement; this copy has to be signed by them or their representatives upon moving into the facility. During an Interview with the Administrator (A#1), he stated that the staff knows the residents' rights. They posted them on the facility walls; he said we do annual training when onboarding new staff. Also, (A#1) stated that no staff has spoken inappropriately to a resident. During interviews with residents (R#1-R#6), 6 out of 6 stated that they were aware of their rights and that no staff had ever spoken inappropriately to them. During interviews with staff (S#1-S#6), six out of six stated that they know the residents' rights and take training every year or during onboarding. Also, six out of six staff stated that they have never spoken to a resident inappropriately and don't know or have heard another staff member talk to the residents in that way. Evaluation Report continues LIC 9099-C During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted, and a copy of the Complaint Report was given to Craig Weech/Administrator.the state’s words, verbatim · CDSS document, Nov 16, 2023 · control 11-AS-20231107080217