Montoak Senior Living

Allegation investigated: Staff did not prevent resident from developing multiple pressure injuries while in care.

On 06/20/26, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint investigation to deliver an updated complaint investigation report, which supersedes the report dated 03/26/2026. The purpose of this updated report is to provide additional information; however, the findings remain Unsubstantiated. The investigation consisted of the following: On 03/26/2026 the Department interviewed residents (R1-R4), Staff (S1-S4), and witness (W1), and obtained the following records: Physician report (dated 02/10/2024), Incident Report (dated 08/18/2025), Unison Health Services (dated 08/29/2025 to 11/08/2025), Incident Report (dated 09/06/2025), Oso Home Care (dated 09/06/2025), Needs and Service plan (dated 09/07/2025), First Unlimited Hospice Care (dated 09/16/2025) for R1. Continue to LIC9099-C. Unsubstantiated The investigation revealed the following: Regarding Allegation: “Staff did not prevent residents from developing multiple pressure injuries while in care.” It is alleged that facility staff did not prevent R1 from developing pressure injuries. Record reviews indicate the following: Records indicate that R1 was being provided wound care by wound care providers. Based on the hospital’s clinical findings and documentation (dated 08/01/2023), the wound was determined to be related to cellulitis and not caused by pressure injury. On 08/18/2025 and 09/06/2025 the facilities incident report indicates R1 requires wound care and has been assigned home health care. Unison Health services (dated 08/29/2025 to 11/08/2025) indicate pressure injury ulcers to left heel and sacrum. Oso home Care (dated 09/06/2025 to 12/31/2025) indicates adult failure to thrive, sepsis. Resident R1 has several pressure ulcers, chronic on his heel, sacrum, buttocks. Oso Home Care (dated 09/06/2025) wound therapy 3 times a week diagnosis of adult failure to thrive, sepsis unspecified organism. San Gabriel Valley Medical Center (dated 09/06/2025) diagnosis sepsis, diabetic mellites, schizophrenia, old stroke, wound care, unstageable to left heel, and left lateral foot, dressing every 3 days or PRN if soiled/dislodged, heel protector applies to bilateral heels, old, healed stage 2 to sacrum. First Unlimited Hospice care (09/16/2025) indicates that R1 left leg wound was cleansed with solution. Interviews revealed the following: R1 could not be interviewed due to health issues. R2-R4 deny the allegation. Staff S1 indicates Staff state that S1 staff turn the residents over every 2 hours. S1 stated that the resident had pressure injury on R1 heal and that the staff kept moving the resident. S1 indicates that home health care comes every week and treats the heal wound. S1 indicates that the pressure injuries/wound are almost healed. S1 indicates that R1 do not like to be moved and scream loudly when staff moved R1. S1 indicates that due to dementia that R1 does not like to move. (S2-S4) interviews indicate that R1 had pressure injury to left leg prior to entering the facility. Witness (W1) indicates R1 was last seen by home health on 12/31/2025 and pressure injuries were caused by diabetic issues. R1 could not be interviewed due to health issues. R2-R4 deny the allegation. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; "The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.” therefore, the allegation of “Staff did not prevent resident from developing multiple pressure injuries while in care” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Najim Shaheen (S1).the state’s words, verbatim · CDSS document, Jun 20, 2026 · control 11-AS-20250919094519

Type of visit: Required - 1 Year

On 01/16/2026 at 08:00 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Montoak Senior Living Facility. LPA Calderon was allowed entry into the facility by Administrator Najma Shaheen. Facility is licensed to serve 12 non- ambulatory residents of which four (4) may be bedridden (room #1 and room #2 approved for bedridden) and approved for hospice waiver for six (6). None of the residents are diagnosed with dementia or receiving home health or hospice care services. Currently there are 11 residents in care. LPA Calderon explained to Administrator Najma Shaheen the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Six (6) client service records, six (6) client medication records, four (4) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 01/05/2026. The one-story residential home consists of eight (8) client bedrooms, four (4) client bathrooms, living room, dining room, kitchen, staff room, office area, garage with washer and dryer/ storage area. No weapons are stored on the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage area. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 108 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 109 degrees Fahrenheit. Bathroom #3 hot water temperature is properly measured at 108 degrees Fahrenheit, Bathroom # 4, hot water temperature is properly measured at 108 degrees Fahrenheit, Kitchen hot water temperature is properly measured at 115 degrees Fahrenheit. Facility one (1) Carbon Monoxide and twelve (12) Smoke Detectors, hard-wired and connected, were tested and working properly. The facility two (2) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knives are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. A working landline phone was operational. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Six (6) client files were reviewed and found to be complete. LPA Calderon reviewed six (6) resident medications, and they were all found to be administered according to doctor's orders. Four (4) staff files were checked, and they have the required documents. LPA Calderon noted the Administrator Najma Shaheen Certification # 7013300740 expiration date of 04/12/2027 was valid at time of visit. The facility does NOT handle clients’ money/cash resources, and a NO Surety bond is needed. Commercial General Liability Policy #01002931911 policy period from 04/03/2025 to 04/03/2026 underwritten by Kinsale Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. All the required documents are posted in the facility in a clearly visible area. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe any deficiencies therefore no citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Najma Shaheen.the state’s words, verbatim · CDSS document, Jan 16, 2026

Type of visit: Required - 1 Year

On 12/05/2024 at 11:20 AM, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection. LPA met with Najma Shaheen, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 12 non- ambulatory residents of which four (4) may be bedriddden (room #1 and room #2 approved for bedridden) and approved for hospice waiver for six (6). None of the residents are diagnosed with dementia or receiving home health or hospice care services. The facility does not handle any of the residents’ money. The facility fees are at a balance of $0. Liability Insurance is current with Kinsale Insurance Company (Policy #0100293191-0) effective 04/03/2024-04/03/2025 for $1,000,000 each occurrence /$3,000,000 policy aggregate limit. The last fire drill was conducted on 12/01/2024. The home is a single story home consisting of: (8) resident bedrooms, (4) full bathroom, a living room, a dining area, a kitchen with two refrigerators, an outside patio area, laundry room outside with an additional refrigerator. At 11:49 AM 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 a 111.5 F, 107.9 F, and 113.4F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. A review of (10) residents service files, (9) staff personnel files and (12 Medication Administration Records (MAR) and did observe discrepancies at the time of visit. Report continues on LIC 809-C 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. Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); LPA observed the following deficiencies: On 12/05/2024 at 11:49 am while LPA was conducting a tour of the physical plant, LPA reviewed and observed: padlock on exterior gate 10 out of 12 residents medication was not listed on the MAR, empty and or not check off by staff on consecutive days. LPA conducted a file review of the 6 out of 12 client files and did not observe an Needs and Services Plan within 30 days after admission date. An exit interview was conducted with Najma Shaheen, Administrator, and a copy of Report and Appeal Rights provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared.the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Staff mismanaged resident's medication Staff failed to meet resident's needs Resident was financially abused while in care Staff failed to provide adequate transportation for resident

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, February 14, 2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Licensee/Administrator Najma Shaheen. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: During the investigation. LPA Bunker interviewed staff 1-2 (S1-S2) and residents 2-6 (R2-R6). R1 is no longer residing at the facility. LPA Bunker asked questions relevant to the nature of the complaint. We observed and reviewed resident records, medications, MARs, and documents for accuracy. LPA Bunker requested copies of supporting documents. Administrator Najma Shaheen provided LPA Bunker with copies. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Allegation #1: Staff mismanaged resident's medication. Upon investigation, both staff members (S1-S2) and residents (R2-R6) have reported comprehensive adherence to medication management protocols. It is asserted that all medications are dispensed strictly in accordance with physician orders. Furthermore, S1-S2 has confirmed that Resident 1 (R1) received her medication as prescribed. The facility ensures all medications are appropriately labeled, and securely stored in a locked cabinet within the office area, thus inaccessible to residents without proper authorization. Notably, there is no documentation from a physician suggesting R1 is authorized to self-manage her medication. Based on these observations, both staff and residents (S1-S2 and R2-R6) refute the allegation of medication mismanagement. Allegation #2: Staff failed to meet resident's needs. Regarding Allegation #2, which posits that staff failed to meet the resident's needs, a thorough investigation has been conducted. According to statements from staff members S1-S2 and residents R2-R6, it has been consistently reported that the resident's daily care needs are being met satisfactorily. These parties have confirmed that the staff is providing adequate care and supervision, highlighting the staff's competence and specialized training to fulfill the necessary services for residents. Furthermore, it was mentioned that staff members undergo ongoing training to maintain high standards of care. It has been noted by S1 that prior to the resident's admission to the facility, the individual was briefly in hospice care. The decision to discontinue hospice services was made by the hospice provider, indicating that the resident no longer required such care. It was also observed that the resident, who has access to a walker, is capable of ambulation without it and was not dependent on oxygen gas, despite being a heavy smoker. This detail is pertinent as, typically, hospice care provides oxygen support when necessary, which would be retracted once a resident exits hospice care. S1 has emphasized that the resident's needs and the services provided are clearly outlined in their admission agreement. The staff's adherence to Title 22 Regulations, along with facility policies and procedures, ensures that care standards are consistently met. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Based on the evidence and statements provided, S1-S2 and R2-R6 have collectively refuted Allegation #2, asserting that the staff has not failed to meet the resident's needs. Allegation #3: Resident was financially abused while in care. In response to this, allegation interviews were conducted with both staff members (S1-S2) and residents 2-6 (R2-R6). The collective feedback from these interviews unanimously indicated residents are not financially abused while in care. S1-S2 and R2-R6 stated residents handle their owed debit cards and funds and staff do not handle resident's debit cards. S1-S2 stated staff did not make any online purchases from a resident's debit card. (R2-R6) expressed their satisfaction with living at the facility, highlighting the respect, dignity, and quality of care they receive. They also commended the facility for providing a secure, healthful, and comfortable living environment and they were happy. S1-S2 refuted the allegation, reinforcing the commitment to safety and well-being upheld at the facility. Allegation #4: Staff failed to provide adequate transportation for residents. In response to concerns about transportation, it has been clarified by S1-S2 and R2-R6 that the facility offers complimentary transportation services for residents requiring assistance. Access to transportation encompasses family support and arrangements made by the Licensee/Administrator to ensure residents' mobility needs are addressed. S1 has taken responsibility for escorting R1 to medical appointments, shopping, and other activities. This concerted effort by staff and the administration to provide comprehensive transportation solutions is affirmed by S1-S2 and R2-R6, thereby refuting the allegation of inadequate transportation provision. Investigation revealed the following: Interviews conducted with staff members S1-S2 and residents R2-R6 have consistently demonstrated that there is no mismanagement of residents' medication by the staff. It has been affirmed across the board that the daily needs of the residents are being adequately met by the staff. S1-S2 and R2-R6 stated that there have been no instances of financial abuse of any residents by the staff members or another resident. See continued LIC9099-C page 4 Continued LIC9099-C page 4 In terms of transportation, it was highlighted that the facility provides complimentary transportation services to residents in need. This ensures that all residents have access to necessary external appointments or engagements, irrespective of their personal transportation arrangements. Residents R2-R6 confirmed their access to this service, noting that family members and representatives also contribute to their transportation needs when required. During the comprehensive interviews with both staff members S1-S2 and residents R2-R6, all allegations regarding medication mismanagement, neglect of residents' daily needs, financial abuse, and inadequate transportation services have been categorically denied. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient 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 deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to Licensee/Administrator Najma Shaheen. There were no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Feb 14, 2024 · control 11-AS-20230726080640

Type of visit: Annual/Random

On 1/18/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Najma Shasheen/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (12) non-ambulatory residents ages 60 and above. Facility has an approved hospice waiver for (6) patients. (4) may be bedridden. Rooms #1 and #2 approved for bedridden. The facility is a single-story structure located in a residential neighborhood. It consists of the following: (8) resident's rooms, (4) common bathrooms, a living area, a dining area, a kitchen, and an outside patio area. LPA Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (5) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the carbon monoxide detectors combo were in operable conditions. The water temperature properly measured between (105°-120°F): Kitchen 111.7°F, Bathroom #1:108.7°F, Bathroom #2:109.4°F, and Bathroom #3:108.4°F Evaluation Report Continues LIC 809-C LPA Iniguez observed the facility to be clean sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. A review of (4) residents' service files, (4) staff personnel files and (4) Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit. First AID kit was checked. Last fire disaster drill was on: 12/4/2023 LPA observed the facility's infection control practices. A copy of the liability insurance was provided to LPA during visit. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Najma Shasheen /Administrator.the state’s words, verbatim · CDSS document, Jan 18, 2024

Allegation investigated: Staff did not report incident to licensing. Staff inappropriately touched resident while in care.

On 1/12/2024, Licensing Program Analysts (LPA) Alfonso Iniguez conducted a subsequent complaint visit at this facility to deliver the complaint investigation findings. LPA met with the Licensee/Administrator Najma Shaheen, who assisted with the visit. The purpose of the visit was explained. The investigation consisted of the following: On 3/30/2022, LPA Don Senaja conducted a 10-day initial complaint visit. LPA interviewed Administrator, Staff and Residents. LPA obtained copies of Staff Roster (LIC 500), Register of Facility Clients/Residents (LIC 9020), Resident’s Admission Agreement, Physician’s Report, Appraisal & Needs Services Plan, Medication Administration Records (MAR) and a Copy of SRI dated on 2/8/2022. Report continued in LIC 9099C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not report incident to licensing. The details of the complaint alleged that facility staff did not report an incident to licensing. During records review, LPA Iniguez observed Special Incident Report (SRI) regarding (R#1) event dated on 2/8/2022. A copy if the SRI was provided to LPA Iniguez during this visit. During an Interview with Administrator (A#1), she stated that she did report to CCLD the incident through an SRI. Allegation: Staff inappropriately touched resident while in care. The details of the complaint alleged that facility staff inappropriately touched a resident while in care. During an Interview with Administrator (A#1), she stated that (R#1) told her that they were touched inappropriately by (S#1) approximately one month ago on 3/30/2022. (A#1) told (R#1) that they would be assisted by (S#2). In addition, (A#1) stated that it needed (2) staff to assist (R#1) with her ADLs, (R#1) was always assisted by (2) staff members, (R#1) was never alone with (1) staff. During an Interview with Staff (S#1-S#2), (2) out of (2) stated that they have never touched a resident inappropriately, and they have never touched a resident in their private areas. Also, (2) out of (2) stated that they had never seen another staff inappropriately handling the residents. Report continued in LIC 9099C During interviews with Residents (R#1-R#9), (6) out of (9) stated that no staff had ever inappropriately touched them. (2) out of (9) were sleeping during the time of the visit. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(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 Najma Shaheen /Administrator.the state’s words, verbatim · CDSS document, Jan 12, 2024 · control 11-AS-20220328160608