Americare Assisted Living of Westchester

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) N. Galarza arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation. LPA was greeted and granted entry by caregiver staff Christina Sevilla. Licensee Leia Joaquin arrived later on to assist with inspection. Administrator has a valid administrator's certificate expiring on 1/5/2027. The following was observed during the inspection: Infection Control: The Infection Control Plan includes Environmental cleaning and disinfection activities. Operational Requirements: A Dementia and hospice waiver for 2 residents is approved. A fire clearance for 4 non-ambulatory adults 60 and over, and two (2) bedridden [rooms 4 & 5]residents 60 years and over. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 12/9/2026. Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. The facility is a two-story home located in a residential area consisting of one (1) 2nd floor staff bedroom, six (6) bedrooms, three (3) full bathrooms, one (1) half bathroom, kitchen, dining room, living room, laundry area, attached garage, and backyard with patio area. Rooms are equipped with required furniture and bedding. Cleaning supplies and toxic substances are inaccessible to residents. The facility has three fire extinguishers. Fire sprinklers, fire pull alarm, and electrical smoke and carbon monoxide detectors are operational. The facility maintains emergency food supply and water. Emergency Phone numbers, exit plan and programming schedules were posted. The building contains central air conditioning and heating. The facility has a first aid kits/Manuals that consist of thermometer, tweezers, scissors, antiseptic, bandages, gauze. Exit doors are free of any obstruction. The last Emergency Disaster drill was conducted on 5/7/2026. Deficiencies observed: Water temperature readings measured did not test within the required 105 - 120 degrees Fahrenheit.There was a knife on the counter, a pair of scissors on top of the sink counter, and another pair of scissors in an unlocked kitchen drawer. Resident (R1's) bed has full bed rails but the resident is not currently enrolled in hospice care. The facility sketch and plan of operation are not updated. Staffing: A total 8 staff members provide care and supervision to the residents. Personnel Records/Staff Training: Staff have criminal background clearance and training. Six (6) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training is current in files. Resident Records/Incident Reports: A total of six (6) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. RCFE complaint poster and Personal rights were observed posted. The poster is not 20 x 26 in size. A technical advisory. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Two residents have modified diets. Incident Medical and Dental: Centrally stored / 30-Day supply of medications were reviewed. Medical and dental transportation is provided by family. *Two medication containers were observed unlocked on top of the counter next to breakfast meals and a kitchen drawer had 4 unlocked medication cups and Advair medications. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. Residents with Special Health Needs: One (1) resident receives hospice services and there are currently no residents receiving home health care. Two residents are bedridden. *Resident (R1's) bed has full bed rails but the resident is not currently enrolled in hospice care. Half rails were installed during the visit. Pursuant to Title 22, deficiencies are cited. An exit interview was conducted with Licensee Leia Joaquin. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, May 23, 2026

Allegation investigated: Staff not allowing resident phone usage. Staff does not leave resident’s phone within reach.

On August 13, 2025, Licensing Program Analyst (LPA) Pamela Bunker conducted an initial visit to gather information regarding the above allegations. LPA met with Licensee Leia Joaquin and staff Patrick Bautsta and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On August 13, 2025, the Department requested and reviewed Resident #1's records. The following documents were reviewed and obtained as part of the investigation: Personnel Report (dated 03/29/2025 ), Resident Roster (dated 05/01/2025 ), Admission Agreement (dated 06/02/2023) Identification and Emergency Information (dated 03/30/2021 ), Physician’s Report (dated 01/30/2023 ), Medical Assessment (dated 07/11/2022 ), Medication Administration Records (MARs) (dated 08/01/2025-08/13/2025 ), Appraisal & Needs and Services Plan (dated 04/22/2025), Functional Capability Assessment (dated 03/30/2021 ), Preplacement Appraisal Information (dated 03/30/3021 ), Personal Rights (dated 03/30/2020), Telecommunications Device Notification (03/30/2021), Consent Forms (date 01/30/2023). See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Interviews were conducted with Staff Members #1–4 (S1–S4) and Residents #1-4 (R1-R4). LPA attempted to interview Residents #5-6 (R6-R5); however, R5 is nonverbal, and R6 spoke only a few words and was unable to answer any of the questions. At 11:00 A.M., the department toured the facility buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visit. Investigation revealed the following: Allegation: Staff not allowing resident phone usage. It was alleged that staff were not allowing a resident to use the phone. On August 13, 2025, between 11:00 a.m. and 4:00 p.m., the Department interviewed Staff #1-4 (S1-S4). Four (4) out of the four (4) staff stated that residents are allowed to use the phone. Residents may use the facility phone to make and receive calls. S1-S4 stated that resident #1 (R1) is deaf. S1 and S2 reported that a telecommunication device had been installed in R1's room to accommodate individuals who are deaf or hearing impaired. 4 out of 4 staff confirmed that R1’s phone was not busy for two days and that it was operable and in working condition. S1–S4 stated that R1’s Caption Telephone Device is internet-connected and may lose signal if the internet is weak. The device has cords, a plug, and other components connected to an electrical outlet; S1-S4 stated that R1 may inadvertently disconnect it by pulling on the cords. S1-S4 reported that they routinely check the phone and its connection to ensure R1 has access. When the phone rings, staff verify that R1 answers, as R1 may not notice an incoming call if she is not looking at the device. S1-S4 also stated that R1 only receives calls on that phone from a single individual, who calls numerous times throughout the morning, day, and night, often back-to-back. S1-S4 stated that sometimes R1 is sleeping. 4 out of 4 staff stated that R1's phone is not left off the hook and that staff are not preventing R1 from speaking to anyone. Four (4) out of (4) residents denied the allegation. On August 13, 2025, between 11:00 a.m. and 4:00 p.m., the Department interviewed Resident #1-4 (R1-R4). Four (4) out of the (4) residents stated that they are allowed to use the phone. Residents may use the facility phone to make and receive calls. 2 out of 4 residents reported that they have cellphones. 1 out of 4 residents stated they use the facility landline, and 1 out of 4 residents stated that they use the Caption Telephone Device. Four (4) out of (4) residents denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 On August 13, 2025, at 4:24 p.m., the Department interviewed Witness #1 (W1). W1 stated that residents are allowed to use the phone and may use the facility phone to make and receive calls. W1 states that there has never been a problem with contacting the facility phone. W1 states that they never call R1’s hearing assistance phone, which is located next to the bed and chair. W1 explained that the Licensee went out of their way to obtain the telephone device for R1. W1 also stated that only one person calls that phone, and the device is functioning properly. W1 states that it is an internet-connected phone, so if the internet or power goes down, the device would be affected. W1 states that if anyone needs to contact the facility, they can call the landline. W1 states that staff are always available to assist and are doing a wonderful job. W1 denied the allegation. During today's visit, the Department observed R1's Caption Telephone Device, reviewed the phone log, received copies showing the dates and times of incoming calls from July 15, 2025, through August 13, 2025, and tested R1's phone and volume by placing a call to it. The phone rang very loudly and could be heard throughout the facility. Allegation: Staff does not leave the resident’s phone within reach. It was alleged that staff do not leave the resident’s phone within reach. On August 13, 2025, between 11:00 a.m. and 4:00 p.m., the Department interviewed Staff #1-4 (S1-S4) and Resident #1 (R1). Four (4) out of the four (4) staff members stated that R1's phone is located next to the bed and chair, within reach. 4 out of 4 staff denied the allegation. R1 confirmed during the interview that the phone is positioned next to the bed and chair and is within reach. At 4:24 p.m., on that same day, the Department interviewed Witness #1 (W1), who also stated the phone is located next to R1's bed and chair and is within reach. On August 13, 2025, at 10:30 a.m., the Department observed the phone within reach, positioned on a table next to R1's bed and chair. Based on interviews, available evidence, observation, information received, and records reviewed, there was not enough sufficient evidence to support the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is deemed unsubstantiated. There were no deficiencies cited. LPA Bunker provided staff Patrick Bautsta with copies of the LIC9099 and LIC9099Cs Complaint Investigation Reports. An exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 11-AS-20250804161918

Type of visit: Required - 1 Year

On 05/23/25 Licensing Program Analyst (LPA) Yolanda Rosser arrived at facility to conduct an unannounced annual visit to the above facility. The purpose of today’s visit was explained. LPA met with Leia Dimalanta, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 6 residents ages 60 and over. The facility is approved for (4) non ambulatory residents, and approved hospice waiver for 2 resident. None of the residents are receiving home health. Two are on hospice or hospice care services. The facility doesn't handle any money. This home is a two story home consisting of: (6) resident bedrooms, 3) Full restrooms ,living room/family room, kitchen with dining area, laundry room (located in the kitchen) and an outdoor shaded patio area. LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked and in compliance with Title 22. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 115F - 120F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked and there is an abundance of food supply. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit and handbook was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. An exit interview was conducted, and a copy of report was provided to Leia Dimalanta, Administrator.the state’s words, verbatim · CDSS document, May 23, 2025

Allegation investigated: Facility staff do not offer engaging activities for residents

On January 07, 2025 The Department of Social Services staff Deborah Lee conducted an unannounced complaint visit to the address the allegation listed above. Department staff was greeted by staff Cherry Valencia who granted access to the facility and the purpose of the visit was discussed. Subsequently, Administrator Leia Dimalanta Joaquin joined and assisted with visit. The complaint alleges that the activities at the facility are not very engaging, and the residents mostly just watch TV. The investigation consisted of the following: The department conducted tour of facility both inside and out, observatins made, the department reviewed and obtained copies of the following: Schedule of Activities,client roster, staff roster, Appraisal/Needs and Services plans for (R1-R5), Physicians reports for (R1-R5), Nursing notes for R1 (dated 10/10/24); interviews were conducted with 3 staff, Facility Administrator, LVN (W1), and Residents (attempts made for 3 of the 5 Residents) Unsubstantiated Allegation: Facility staff do not offer engaging activities for residents The department conducted an interview with Administrator (A1) who stated that the facility offers activities and have a schedule of activities; however due the R1-R5's physical and mental capability it is difficult to do activities other than taking them for walks when weather permits and watching their favorite program/movies on TV. A1 states that they make sure relaxing music is played throughout the facility. Additionally, A1 states that 3 of 5 residents prefer to be on phone playing games, reading news papers and/or watching TV. Lastly, A1 states that she would love to do more but it’s not feasible right now because of their physical and mental capacity and facility takes into account their preferences. The department conducted interviews with Staff 1-Staff 3 (S1-S3), and asked the following questions: Do you have activities for the residents? What type of activities do you have? Do you the residents participate in the planned activities? Do you encourage participation? and Do the Residents express the type of activity they are interested in? 3 out of 3 staff stated that they do have activities for the resident but most of the residents are not alert or non-responsive and the ones who are responsive preferred to watch TV or stay in their rooms on phone or tablet. 3 out of 3 staff that they encourage residents to go on walks, go sit outside. 2 out of 3 staff state that they celebrate resident birthdays with parties and encourage participation. The department conducted interview with Witness 1 (W1) who stated that due to 1 out of 5 resident's condition, it become uncomfortable for her to do activities, so she mostly stays in room and watch TV. Witness 1 says that she has observed staff engaging with this resident and having her come out of her room and sit at the table. Page 2 of 3 The department conducted interviews with R2 and R3. 1 out of the 2 stated that they prefer to be in their room watching TV and/or being on the phone. 1 out of 2 stated they prefer reading as an activity. 2 out of 2 state that they are offered activities by the staff. Interview attempts were made for R1, R4, and R5 however due to their cognitive level they were unable to answer questions in a meaningful way. Additionally, there were not alert enough to answer the departments questions The department reviewed and obtained the following documents: copy of Schedule of Activities which shows ample activities offered to the residents. resident roster, staff roster, Appraisal/Needs and Services plans for (R1-R5), outlining their functioning level, likes and dislikes, Physicians reports for (R1-R5), provided information on physical ability and diagnoses. Nursing notes (dated 10/10/24) for 1 of 5 residents requiring nursing services. The department made the following observations: R1-R5 are between the ages of 78 and 98, all needing assistance with ambulating, they require the use of a walker or wheel chair. The department observed that R1-R5 were well groomed and their rooms were clean and sanitary, 2 of the 5 resident were siting in chairs in living room listening to music while nodding/napping. The department also noticed various board games on a table near the entrance of facility. During the visit, the department observed outside agency staff (LVN and Home health) tend to 2 of the 5 residents in the home. Based on the information provided, observations made, interviews conducted, and analysis of service records, department staff found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited. Exit interview was conducted. A copy of this report was provided to the Administrator. Page 3 of 3the state’s words, verbatim · CDSS document, Jan 7, 2025 · control 11-AS-20250102152553

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Leia Dimanlanta, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 6 residents ages 60 and over. The facility is approved for (4) non ambulatory residents, 2 bedridden residents ( Rm #4 & #5) and approved hospice waiver for 2 resident. None of the residents are receiving home health. Two are on hospice or hospice care services. The facility does not handle any of the residents’ money. This home is a two story home consisting of: (6) resident bedrooms, 3) Full bathroom,living room, kitchen with dining area, laundry room (located in the kitchen) and an outdoor shaded patio area. LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 118F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. An exit interview was conducted, and a copy of Report and Appeal Rights provided.the state’s words, verbatim · CDSS document, Jun 12, 2024