Kinah Mae Home

Type of visit: Annual/Random

On 09/14/26 Licensing Program Analyst (LPA) Villegas conducted an unannounced annual visit, a physical CARES Inspection Tool was used. LPA met with Renette N De La Cruz as the purpose of the visit was explained. The facility is licensed to serve (6) elderly developmentally disabled residents ages 60 years and older of which (1) may be bedridden. Facility fees are past due, due date was 08/25/26 for the amount of $495. Administrator certificate is active. The facility has active liability insurance (Sanders &co insurance Exp: 08/07/27). The facility is a one-story home located in a residential neighborhood. The facility consists of (4) resident bedrooms, (2) bathrooms, living room, kitchen, den and dining area, there is a shaded sitting area in the backyard, a garage used for storage and has a laundry area. Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there were sufficient toiletries accessible to residents. The water temperature properly measured at 108.4. A supply of perishable and non-perishable food was observed, toxins and knives were stored and inaccessible to residents. A land line was observed. There are no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards. Exit signs are posted in the inside and outside of the facility. LPA conducted a records review of 3 staff records, 4 resident records, and 4 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last documented fire drill was conducted on 09/01/26, the last documented disaster drill was conducted on 07/20/26, 2 fire extinguishers fully charged, carbon monoxide and smoke detectors observed to be operational. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 14, 2026

Allegation investigated: Staff do not provide adequate supervision, resulting in residents falling. Staff did not communicate with residents authorized representative. Staff do not respond to residents call bells in a timely manner. Staff do not answer phone calls in a timely manner. Staff are not ensuring to meet the residents’ needs in a timely manner. Staff speak inappropriately to residents in care. Staff do not ensure that residents are provided with activities.

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on the report created 2/25/26. On 2/25/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Renette De La Cruz and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 2/25/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Identification and Emergency Information form, Physicians Report and an Incident report. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-3 (S1 – S3), and Resident -1 – Resident - 5(R1-R5). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff do not provide adequate supervision, resulting in residents falling. It is being reported that a former resident fell and staff did not report to the resident’s family right away. On 5/19/26, LPA Shirley reviewed the staff schedule and observed that there are two staff per shift for the mornings through evenings, Monday through Friday. One staff tends to the residents and the other staff does the cooking and chores, and monitors bedbound resident or residents who sleep in. There is one staff scheduled for the nightshift as the caregiver-to-resident ratio aligns with the individual care plans and risk assessments. The night shift has a slower pace because the residents are generally asleep. Per interview with S1 on 5/19/26, the staff maintains a structured schedule which involves activities which assist with emotional wellness and helps prevent falls. On 2/25/26, LPA Felisa Shirley reviewed a letter to Community Care Licensing Department, CCLD, LPM Stephanie Cifuentes dated 2/2/26, reporting a fall by a former resident in which staff treated the resident and called the resident’s emergency contact. LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not provide adequate supervision, resulting in residents falling,” therefore, the allegation is unsubstantiated. Allegation: Staff did not communicate with residents authorized representative. It is being reported that R1 fell out of the bed several times and these incidents were never reported to the resident’s emergency contact person. On 2/25/26, LPA Shirley requested the incident reports for the prior 6 months. LPA Shirley reviewed incident reports requested, however, there were no reports for R1 falling. Per interview with S1, staff monitors the rooms for bedbound resident or residents who are in bed. LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident was not aware of the situation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not communicate with residents authorized representative,” therefore, the allegation is unsubstantiated. Con'd 9099-C Allegation: Staff do not respond to residents call bells in a timely manner. It is being reported that R1 called a family member to report that he needed assistance in the facility and the staff weren’t responding when he pressed the call bell. Per interview with S1 on 5/19/26, when call bells are heard by the staff, there is an immediate response if the staff is not assisting another resident. On 5/19/26, LPA Shirley had S1 trigger the call button while I went to the kitchen to assess the alert volume. LPA Shirley did not hear an alert, as the system was unplugged. The system was unplugged today, but I can’t confirm if it was unplugged at the time of the residents’ request or initial investigation. Per interview on 2/25/26 with R4, staff responds to their call after they are done assisting another resident. R4 stated that she understands she is not the only one. 2/25/26, S3 stated if the direct call lines to the facility go unanswered, families sometimes utilize the personal contact numbers of the staff, and staff answers or return calls at their earliest convenience. LPA interviewed staff 1 – staff 3(S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 3 out of 5 denied the allegation. Two Residents confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not respond to residents call bells in a timely manner,” therefore, the allegation is unsubstantiated. Allegation: Staff do not answer phone calls in a timely manner. It is being reported that calls go unanswered to the facility during the evening hours despite numerous attempts. During the interview with the Administrator, 2/25/26, she indicated that staff promptly handles all incoming calls. Per interview, 2/25/26, S3 stated if the direct lines to the facility go unanswered, families sometimes utilize personal contact numbers of the staff, and staff return calls at their earliest convenience. Per S3, if they are working with a client, they can’t return calls until they are done with the client. LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 3 out of 5 denied the allegation. Two neither confirmed nor denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not answer phone calls in a timely manner,” therefore, the allegation is unsubstantiated. Con'd on 9099-C Allegation: Staff are not ensuring to meet the residents’ needs in a timely manner. It is being reported that a resident needed assistance in the facility and the staff weren’t responding when he pressed the call bell. Per interview, 2/25/26, S3 stated that once he’s completed working with the current resident, he checks in with the other residents to offer support. Per interview, 2/25/26, R4 stated at times the staff informs her they are working with other residents. R4 states that she knows she’s not the only one that needs assistance, but she doesn’t wait too long. LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not ensuring to meet the residents’ needs in a timely manner,” therefore, the allegation is unsubstantiated. Allegation: Staff speak inappropriately to residents in care. It is being reported that staff are using disrespectful and inappropriate language to the residents. Based on interviews on 2/25/26, with staff and residents, there is no evidence of inappropriate verbal communication. Based on review of requested incident reports, there is no report of staff speaking inappropriate to residents. LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff speak inappropriately to residents in care,” therefore, the allegation is unsubstantiated. Con'd on 9099-C Allegation: Staff do not ensure that residents are provided with activities. It is being reported that the staff does not provide residents with activities and keeps them in their rooms for most of the day. During each of my unannounced visits as a Licensing Program Analyst, I have observed residents spending their time in the main living area. Today, 3/4/26, when LPA Shirley arrived to this facility, I observed and heard R4 and her visitor singing a gospel song being sung on the music channel that they were watching. LPA Shirley observed, R3 engaged on her phone enjoying mobile gaming. On 2/25/26, LPA Shirley observed videos and pictures of the residents doing chair exercises, pedaling and walking in the backyard. Per interview with R4, 2/25/26, she doesn’t participate in the exercises anymore as she has grown tired of doing them. Per observation on 5/19/26, LPA Shirley observed R4 doing chair exercises by herself with a pleasant look on her face. LPA interviewed staff 1 – staff 3(S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that residents are provided with activities,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Renette DeLaCruz.the state’s words, verbatim · CDSS document, May 19, 2026 · control 11-AS-20260220083424

Allegation investigated: Staff did not follow resident’s dietary needs

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on the report created 3/23/26. On 3/23/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Marylou Santos, Caregiver and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 3/19/26 LPA Shirley reviewed copies of the following records: Physicians Report, Skin/Body Check dated 1/7/26, Incident reports for 1/7/26 and 1/29/26, and picture of wheelchair ramp in living room, screenshot of conversation dated 1/21/26. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff- 4(S1 – S4), and Resident -1 – Resident - 6(R1-R6). R1 an R6 did not respond to questions. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not follow resident’s dietary needs It is being reported that R1 is lactose intolerant and staff were not aware as staff were giving him dairy products. On 5/19/26, LPA Felisa Shirley reviewed R1’s Admission Agreement, dated 9/28/29, states in the Food Services section, Special diets if prescribed by a doctor. LPA Shirley reviewed R1’s Physician Report dated, 12/16/25, stating that R1’s special diet was to limit dairy, limit ice cream, (ok once in a while). On 5/19/26, LPA Shirley observed a text message to a family member from S1 on 1/21/26, advising them that she purchased almond milk for R1 and the family member responded back saying the purchase was fine and thanked S1 for buying this for R1. On 3/23/26, LPA Felisa Shirley observed the special diets for residents R3 and R4 posted on the refrigerator. Per interview with S4 on 3/23/26, R1’s special diet was posted on the refrigerator during his stay at Kinah Mae Home, LLC. During file review, LPA Shirley did not observe instructions to staff regarding the special diet of R1. On 5/19/26, LPA Shirley interviewed S1 and S4 regarding the special diet of R1. Both staff acknowledged that R1’s special diet was no diary. During interviews, S4 stated that she was told by R1’s family member to give him water every 20 minutes. On 5/19/26, LPA Shirley did not observe R1’s special diet posted on the refrigerator as he has not been at this facility since 1/29/26. LPA interviewed staff 1 – staff 4(S-1 – S-3). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 1 out of 6 denied the allegation. Three residents were not on special diets and 2 residents did not respond. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not follow resident’s dietary needs,” therefore, the allegation is unsubstantiated. Allegation: Staff did not ensure resident received medical care in a timely manner It is being reported that the facility staff failed to notify the family that R1 had a fall during the night of 1/6/26 and failed to seek medical treatment. Per interview with a family member of R1, during a visit on 1/8/26 the facility staff informed them that R1 had bruises and a skin tear on his right arm and they didn’t know how it happened. Per the family member the skin tear was already beginning to scab. On 3/19/26, LPA Shirley observed a Skin/Body Check form completed by S1 on 1/7/26 indicating an abrasion with mild pain and light bleeding on R1’s right arm. The family member took R1 to urgent care to be assessed on 1/9/26. Per review of an incident report dated 2/2/26, R1 tripped and fell in the facility on 1/29/26. Staff rendered first aid and called his designated emergency contact. On 5/19/26, S1 stated that R1 seemed to be stable and was still mobile following the fall so emergency services where not called. Due to the nature of the fall and assessment the family member called 911 when she arrived at the facility. When the paramedics arrived, they conducted an assessment which warranted a transfer to Kaiser for further diagnostic evaluation and ongoing medical care. After R1 was discharged from the hospital he did not return to Kinah Mae Home, LLC. LPA interviewed staff 1 – staff 4(S-1 – S-4). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 4 out of 6 denied the allegation. Two residents did not respond. Based on interviews, 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 LIC9099-D. Allegation: Staff do not follow reporting requirements It is being reported that the facility staff failed to notify the family that R1 had a fall the night of 1/6/26. Per interview on 3/10/26, the facility administrator, S1 stated that R1 had an incident on 1/7/26, but she did not know that she was supposed to report the fall to Community Care Licensing Division, (CCLD). Per S1 she did not complete nor submit an incident report to CCLD. LPA Shirley advised S1 to complete an incident report and report the incident to CCLD right away. On 3/19/26, S1 sent a picture of a notice of an incident to LPA Shirley by text message advising of an incident involving R1 that occurred on 1/7/26 at 2am. LPA interviewed staff 1 – staff 4(S-1 – S-4). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 4 out of 6 denied the allegation. Two residents did not respond. Based on interviews and records reviewed, 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 LIC9099-D. Allegation: Staff do not ensure the facility is free of hazards It is being reported that the wheelchair ramp located in the living room of this facility is dangerous and a tripping hazard. On 3/19/26, LPA Shirley reviewed a notice of an incident dated 2/2/26, advising of an incident involving R1 tripping and falling within the facility that occurred on 1/29/26. LPA Shirley has been to this facility previously for required annuals/inspections and observed the wheelchair ramp without the handrail. On 3/10/26, LPA Shirley observed that there was a handrail installed along the right side of the wheelchair ramp. Per interview with S-4, the handrail was installed after the trip and fall of R1. LPA interviewed staff 1 – staff 4(S-1 – S-4). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 4 out of 6 denied the allegation. Two residents did not respond. Based on interviews and records reviewed, 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 LIC9099-D.the state’s words, verbatim · CDSS document, May 19, 2026 · control 11-AS-20260306103138

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80075(a) · Plan of correction due date: Apr 6, 2026

80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement is not as evidenced by: Based on interviews and a review of Skin/Body Check form, staff did not seek timely medical care for R1. This poses a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: The Administrator shall review regulation and train all staff on getting timely medical services for residents in care. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 4/6/26, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(11) · Plan of correction due date: Apr 6, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (11) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not as evidenced by: Based on interviews and a review of a notice of an incident letter, staff did report incident to responsible party nor Community Care Licensing, (CCLD). This poses a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: The Administrator shall review regulation and train all staff on proper reporting of incident involving residents. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 4/6/26, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(4) · Plan of correction due date: Apr 6, 2026

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not as evidenced by: Based on interviews and a review of a notice of an incident letter, facility staff failed to provide a safe environment for residents in care. This poses a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: The Administrator shall review regulation and train all staff on creating reasonably safe conditions and environments for residents in care. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 4/6/26, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.

Allegation investigated: Staff did not follow resident’s dietary needs

On 3/23/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Marylou Santos, Caregiver and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 3/19/26 LPA Shirley reviewed copies of the following records: Physicians Report, Skin/Body Check dated 1/7/26, Incident reports for 1/7/26 and 1/29/26, and picture of wheelchair ramp in living room. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff- 4(S1 – S4), and Resident -2 – Resident - 5(R2-R5). R1 and R6 did not respond. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not follow resident’s dietary needs It is being reported that R1 is lactose intolerant and staff were not aware as staff were giving him dairy products. On 3/23/26, LPA Felisa Shirley observed the special diets for residents R3 and R4 posted on the refrigerator. Per interview with S4 on 3/23/26, R1’s special diet was posted on the refrigerator during his stay at Kinah Mae Home, LLC. On 3/23/26, LPA Shirley did not observe R1’s special diet posted on the refrigerator as he has not been at this facility since 1/29/26. LPA interviewed staff 1 – staff 4(S-1 – S-3). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed resident 2 – resident 5 (R2 – R5). Of those who interviewed 1 out of 6 denied the allegation. Three answered other than yes or no. Two residents did not respond. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not follow resident’s dietary needs,” therefore, the allegation is unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to Reynaldo Martinez. Allegation: Staff did not ensure resident received medical care in a timely manner It is being reported that the facility staff failed to notify the family that R1 had a fall during the night of 1/6/26 and failed to seek medical treatment. Per interview with a family member of R1, during a visit on 1/8/26 the facility staff informed them that R1 had bruises and a skin tear on his right arm and they didn’t know how it happened. Per the family member the skin tear was already beginning to scab. On 3/19/26, LPA Shirley observed a Skin/Body Check form completed by S1 on 1/7/26 indicating an abrasion with mild pain and light bleeding on R1’s right arm. The family member took R1 to urgent care to be assessed on 1/9/26. LPA interviewed staff 1 – staff 4(S-1 – S-4). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed resident 2 – resident 5 (R2 – R5). Of those who interviewed 4 out of 6 denied the allegation. Two residents did not respond Based on interviews, 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 LIC9099-D. Allegation: Staff do not follow reporting requirements It is being reported that the facility staff failed to notify the family that R1 had a fall the night of 1/6/26. Per interview on 3/10/26, the facility administrator, S1 stated that R1 had an incident on 1/7/26, but she did not know that she was supposed to report the fall to Community Care Licensing Division, (CCLD). Per S1 she did not complete nor submit an incident report to CCLD. LPA Shirley advised S1 to complete an incident report and report the incident to CCLD right away. On 3/19/26, S1 sent a picture of a notice of an incident to LPA Shirley by text message advising of an incident involving R1 that occurred on 1/7/26 at 2am. LPA interviewed staff 1 – staff 4(S-1 – S-4). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed resident 2 – resident 5 (R1 – R5). Of those who interviewed 4 out of 6 denied the allegation. Two residents did not respond. Based on interviews and records reviewed, 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 LIC9099-D. Con'd on 9099-C Allegation: Staff do not ensure the facility is free of hazards It is being reported that the wheelchair ramp located in the living room of this facility is dangerous and a tripping hazard. On 3/19/26, LPA Shirley reviewed a notice of an incident dated 2/2/26, advising of an incident involving R1 tripping and falling within the facility that occurred on 1/29/26. LPA Shirley has been to this facility previously for required annuals/inspections and observed the wheelchair ramp without the handrail. On 3/10/26, LPA Shirley observed that there was a handrail installed along the right side of the wheelchair ramp. Per interview with S-4, the handrail was installed after the trip and fall of R1. LPA interviewed staff 1 – staff 4(S-1 – S-4). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed resident 2 – resident 5 (R2 – R5). Of those who interviewed 4 out of 6 denied the allegation. Two did not respond Based on interviews and records reviewed, 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 LIC9099-D. Deficiencies are issued and an exit interview is conducted with Reynaldo Martinez. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 23, 2026 · control 11-AS-20260306103138

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80075(a) · Plan of correction due date: Apr 6, 2026

80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement is not as evidenced by: Based on interviews and a review of Skin/Body Check form, staff did not seek timely medical care for R1. This poses a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: The Administrator shall review regulation and train all staff on getting timely medical services for residents in care. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 4/6/26, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(11) · Plan of correction due date: Apr 6, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not as evidenced by: Based on interviews and a review of a notice of an incident letter, staff did report incident to responsible party nor Community Care Licensing, (CCLD). This poses a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: The Administrator shall review regulation and train all staff on proper reporting of incident involving residents. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 4/6/26, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(4) · Plan of correction due date: Apr 6, 2026

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not as evidenced by: Based on interviews and a review of a notice of an incident letter, facility staff failed to provide a safe environment for residents in care. This poses a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: The Administrator shall review regulation and train all staff on creating reasonably safe conditions and environments for residents in care. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 4/6/26, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.

Allegation investigated: Staff handled resident in a rough manner Staff do not ensure that resident's toileting needs are being met Staff mismanaged resident’s medication

On 03/19/2026 at 12:05pm, Licensing Program Analyst (LPA) Brown conducted a subsequent visit at this facility to deliver the complaint investigation findings for the allegations above. During today’s visit, LPA met with Renette De La Cruz (Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 02/24/2026 at 10:15am, LPA interviewed Administrator (A1), Staff (S1-S4), and Residents (R2-R5) and Resident 1 (R1) between the hours of 12:15pm - 12:19pm. LPA received received the following documents: Resident Roster (received on 02/24/2026, Resident records such as LIC 601 Personnel Record (for R1-R4), LIC 602: Physician Report (for R1-R4), LIC 603: Pre-Placement Appraisal (for R4), LIC 604: Admission Agreement (for R1 - R4), Medication Administration Record (for R1-R4 - dated 01/2026 - 02/2026), Communication Logs (12/02/2025 - 02/20/2026), Staff Schedule, Eviction Notice Letter ( for R1 dated 02/19/2026). The investigation revealed the following: Unsubstantiated Allegation: Unlawful eviction It was alleged that the facility unlawfully issued a 30-day eviction notice to a resident. On 02/18/2026, a text message stated the resident's voice had become loud and other residents had complained about the resident's behavior. As a result, the resident was given a 30-day notice via text. On 02/24/2026 at 10:48am -11:28am, LPA interviewed A1 regarding the allegation. A1 acknowledge the allegation and stated a 30-day notice was issued to Resident 1 (R1). A1 stated the reason R1 would receive a 30-day notice at this facility is because the other residents have complained about R1's behavior such as yelling, inappropriately touching female staff, and occasionally exposing themselves every night. A1 stated the facility's policy on addressing resident behavior concerns before issuing an eviction notice is to notify the family by phone to express the concerns of their family member. A1 stated all the residents have complained about the noise and behavioral issues with the resident. A1 mentioned the facility accommodates residents with dementia or Parkinson's disease who may exhibit behavioral changes by getting a reassessment from the resident's physician, and the administrator will express the resident's behavior to the doctor and ask if there is a medication to help assist with the behavioral changes. On 02/24/2026 between the hours of 11:34am -12:26pm, LPA conducted 4 staff interviews regarding the allegation. 4 of 4 staff were aware of the allegation and stated a resident received an eviction notice recently. Staff stated that the other residents and their families have complained about the R1's behavior at night, particularly R3 who share a room with R1 and the other residents who live at the facility. Staff mentioned the facility has not evicted a resident because of the family raising concerns about care. Staff indicated they believe Community Care Licensing was informed about the eviction. On 02/24/2026 between the hours of 10:24am -1:22pm & on 03/19/2026 between the hours of 12:15pm - 12:19pm, LPA conducted 5 resident interviews regarding the allegation. 3 of 5 residents were aware of the allegation and stated they know of a resident, who have been asked to leave the facility, everyone knows the situation and it affects everyone, and they have heard staff talk about evicting someone. 2 of 5 residents were unaware of the allegation and stated they do not know of any residents who have been asked to leave the facility and have not heard staff talk about evicting someone. Residents stated they feel safe talking to staff about problems or concerns and do not know if anyone has been told to leave because their family complained about care. Report continues on LIC 9099-C On 03/17/2026, between the hours of 10:00am – 11:00am, LPA conducted a records review and observed the following: A Notice Letter (signed and dated on 02/19/2026) and a copy of the US Postal Service Certified Mail Receipt with the postmark date of 02/21/2026 with an estimated delivery date to R1's responsible party on 02/24/2026. The eviction notice issued to the R1's responsible party is not in compliance with Title 22 regulation and is missing the following information: 87224 (a) – (i) Eviction Procedures. Also a copy of the notice letter was not sent to the Department within 5 days of issuance. Substantiated: Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. Exit interview conducted with Renette De La Cruz (Administrator) and a copy 87244 (a) - (i) Eviction Procedures was provided with a copy of this report and Appeal Rights. Allegation: Staff handled resident in a rough manner It was alleged that facility staff handled a resident in a rough manner. When a specific staff member is on duty, the staff member handles the resident roughly, such as pushing the resident onto the bed without waiting for the resident to position properly, and placing covers over the resident while the resident was lying diagonally. The staff member is abrasive and rough when removing the resident's clothes and handling the resident, causing physical discomfort. The resident has told the staff member that it hurts, but the staff member continues to be rough. On 02/24/2026 at 10:48am -11:28am, LPA interviewed A1 regarding the allegation. A1 acknowledge the allegation and stated receiving complaints about staff handling residents roughly from the resident's family. A1 stated staff have completed Safety in the Home: Fall Prevention training on file. A1 stated the facility's policy when a resident or family reports staff being rough or causing discomfort is to have a discussion with the caregivers. A1 denied receiving complaints about a specific staff member's care techniques and stated the residents love the caregivers. On 02/24/2026 between the hours of 11:34am -12:26pm, LPA conducted 4 staff interviews regarding the allegation. 4 of 4 staff denied the allegation and stated they have not handled any resident roughly and have not witnessed other staff do so. Also staff mentioned all residents are treated with proper care. Staff indicated one of the resident's family member advise for the staff to be more careful with their loved one. On 02/24/2026 between the hours of 10:24am -1:22pm & on 03/19/2026 between the hours of 12:15pm - 12:19pm, LPA conducted 5 resident interviews regarding the allegation. 1 of 5 staff confirmed the allegation and stated staff have been rough and hurt them while helping them. 4 of 5 residents denied the allegation and stated staff help them gently when getting them dressed or into bed. Also no staff member has been rough with them or hurt them while helping them, and they have not seen staff be rough with other residents. On 03/17/2026, between the hours of 4:00pm - 4:05pm, LPA conducted a records review & observed the following: The department did not received any LIC 624 Unusual Incident/Injury Report in regards to a staff handling residents in a rough manner. 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. Report continues on LIC 9099-C Allegation: Staff do not ensure that resident's toileting needs are being met It was alleged that facility staff do not ensure that the resident's toileting needs are being met. Between the hours of 10:00pm - 4:00am, the resident's call button often goes unanswered for over an hour. During these times, the resident has had to call their responsible party at home, and the responsible party then contacts the caregiver by phone to request assistance. The staff do not always turn on the resident's bed alarm. Also its been stated the resident once needed to urinate, but the urinal was full. The resident got up to use the restroom, fell, and hit the resident's knee in the process. On 02/24/2026 at 10:48am - 11:28am, LPA interviewed A1 regarding the allegation. A1 was aware of the allegation and stated receiving complaints about delayed responses to call buttons from the resident's family member. A1 stated the facility's policy for responding to call buttons is to attend to the call button right away. If the caregiver is busy, the caregiver will explain being busy with another resident and will help as soon as possible. In the event of an emergency, the caregiver will prioritize the emergency first. A1 stated staff are expected to respond right away when a resident calls for assistance. A1 mentioned bed alarms and motion alarms are used for residents who are fall risks and staff ensure the bed alarm is always on. A1 stated the procedures in place for nighttime toileting assistance are upon request from the resident, staff will assist the resident with toileting in the night. Also, staff conduct random checks during the night, especially for dementia residents, by taking the resident to the bathroom or changing diapers. A1 stated one time a caregiver explained to the resident that the caregiver was assisting another resident who had vomited and told the resident once the caregiver was done assisting that resident, the caregiver would help the resident. On 02/24/2026 between the hours of 11:34am -12:26pm, LPA conducted 4 staff interviews regarding the allegation. 4 of 4 staff denied the allegation. The staff mentioned responding to the call light button promptly while conducting nighttime routines to assist the residents with toileting as needed. On 02/24/2026 between the hours of 10:24am -1:22pm & on 03/19/2026 between the hours of 12:15pm - 12:19pm, LPA conducted 5 resident interviews regarding the allegation. 1 of 5 residents confirmed the allegation and mentioned when they use the call button staff does not come to help and waits a long time (about 10 minutes) for help going to the bathroom. The resident who confirmed the allegation also stated that staff does not help right away when needing to use the bathroom at night. 2 of 5 residents denied the allegation and mentioned staff respond promptly with no significant delay with toileting. 2 of 5 residents did not confirm nor deny the allegation as one of the resident does not go to the bathroom due to wearing diapers and does not have to wait a long time to be changed. The other resident stated rather not saying how long having to wait on staff to come when calling for help but stated it depends if there is a need to use the bathroom at night that staff member are pretty much right away.Residents stated that staff generally respond to call buttons within minutes, prioritizing emergencies and explaining any delays. During the night, staff conduct checks every 1–2 hours, set bed alarms, and assist with toileting. Although there are infrequent complaints regarding wait times for bathroom assistance, residents agreed that help usually arrives promptly. Report continues on LIC 9099-C On 03/17/2026 between the hours of 1:25pm - 1:30pm, LPA conducted a records review and observed the following: On 05/17/2025 the facility had record of an In-Service Education on Personal Hygiene with 3 staff in attendance for three hours between the hours of 9am - 12 noon. According to Resident 1 (R1) LIC 602 Physician's Report for Residential Care Facilities for the Elderly (RCFE) states on page 4 of 6 under section 15. Capacity for Self Care d. Able to Care for Own Toileting Needs is checked yes which explain slow but able occasional. In the R1's admission agreement on page 77, for 9 Assistance with personal activities of daily living as follows: toileting is checked off. On LIC 625 Appraisal/Needs & Service Plan in the Background Information it states R1 requires assistance with toileting. Also the department did not received any LIC 624 Unusual Incident/Injury Report in regards staff not meeting the toileting needs of the residents 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. Allegation: Staff mismanaged resident's medication It was alleged that facility staff mismanaged the resident's medication. About three weeks ago, the resident was given the wrong medication. When the resident questioned the staff, they tried to make the resident take it, accusing the resident of not knowing the medications. The resident became loud and refused the medication until staff checked. Staff later confirmed they had the medication wrong but gave the resident the right medications. On 02/24/2026 at 10:48am -11:28am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated there have not been any recent medication errors reported at this facility. A1 stated the facility's procedure for administering medications to residents is to give the medication to the resident as prescribed by the doctor. A1 stated if staff realize they may have given the wrong medication to a resident, the facility would call the doctor and report to licensing, but stated this has not happened yet. A1 stated staff verify medications before administering them to residents by checking the MAR and matching the medication to ensure it is correct before administering the medication to the resident. On 02/24/2026 between the hours of 11:34am -12:26pm, LPA conducted 4 staff interviews regarding the allegation. 4 of 4 staff denied the allegation, stating they have never administered the wrong medication. They explained their verification process includes confirming the resident’s name and dosage, double- and triple-checking before administration, and discussing the medication’s purpose with the resident. Furthermore, staff ensure medications are taken in their presence, explain prescriptions when questioned, and contact the administrator or doctor if necessary. Any medication errors would be reported immediately to the administrator. On 02/24/2026 between the hours of 10:24am -1:22pm & on 03/19/2026 between the hours of 12:15pm - 12:19pm, LPA conducted 5 resident interviews regarding the allegation. 1 of 5 resident confirmed the allegation and stated staff do not give medications every day. 1 out of 5 residents did not confirm nor deny the allegation and mentioned not feeling safe when taking their medication given by staff which is not everyday. However the resident indicated staff does listen and check when the resident has question about their medication and has not been given the wrong medication. 3 of 5 residents denied the allegation and stated staff give them their medications every day. They noted that staff have never given them the wrong medication and always listen if they have questions. Ultimately, they feel safe taking the medications staff provide. Report continues on LIC 9099-C On 03/17/2026 between the hours of 1:25pm - 1:30pm, LPA conducted a records review of the Medication Administration Record (MAR) for January 1, 2026 - February 25, 2026 and observed for Resident 1 (R1) that all medication as prescribed were administered by proof of staff initial for Aspirin 8mg, Famotidine 10mg (for heartburn), Carbidopamine (for Parkinson's Disease), Magnesium Citrate 250mg, Gingko Biloba (for Cognitive Function), Memantine (10 mg), Epadel, Zetia 10mg (for cholesterol), Prevastatin (for cholesterol), Refresh, Diclofenac (PRN). Also, upon further review, the Department has not record of an LIC 624 Unusual Incident/Injury Report from the facility in regards to R2 being given the incorrect medication with no proof of staff later confirming resident was give wrong medication but gave the resident the correct medication. On 02/18/2025, the facility has record of an in-service education for Medication Administration with 6 staff in attendance on 02/18/2025 between the hours of 3pm - 4pm. On 02/10/2025, S2 completed 8 hours of Medication Training during the Annual Staff Training (20 Required Hours - dated 02/10/2025) . On LIC 625 Appraisal/Needs & Service Plan in the Background Information it states R1 requires full medication management assistance. 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 Renette De La Cruz (Administrator). and a copy of this report was providedthe state’s words, verbatim · CDSS document, Mar 19, 2026 · control 11-AS-20260220083158

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)-(i) · Plan of correction due date: Mar 20, 2026

(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). . This requirement was not met by: Based on interview, observation & records review the licensee issued an eviction notice to Resident's 1 (R1) responsible parties which is not in complliance with Title 22 regulations. This violation poses a potential health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: The licensee will issue a formal dismissal of the eviction notice to R1’s responsible parties and the Department of Social Services, Community Care Licensing Division (CCLD). Proof of correction will be submitted to the CCLD/El Segundo ASC Office via fax at 424-544-1016 (Attn: Zina Brown) or via email at zina.brown@dss.ca.gov by the POC due date.

Type of visit: Case Management - Deficiencies

On 03/19/2026, at 2:00pm, Licensing Program Analyst, LPA Zina Brown conducted a Case Management – Deficiencies for complaint Control Number 11-AS-20260220083158. LPA met with Renette De La Cruz (Administrator) as the purpose of the visit was explained. On 02/24/2026, between the hours of 10:48am – 1:22pm, LPA conducted an initial unannounced complaint investigation at the facility. The complaint investigation included interviews with the Administrator (A1), staff, and residents, as well as a review of facility records. This requirement was not met by, based on interviews, observation, and records review, LPA observed the following: The Administrator Renette De La Cruz is listed as the instructor for the In-Service Education Record. The following training was on file: · 06/04/2024 – Safety in the Home: Fall Prevention · 02/10/2025 – Basic Life Support (10:00am – 1:00pm) – 2 staff in attendance · 02/10/2025 – Annual Staff Training (20 Required Hours) – Completed by 1 staff · 02/18/2025 – Medication Administration – 6 staff in attendance · 05/17/2025 – Personal Hygiene (9:00am – 12:00pm) – 2 staff in attendance · 02/24/2026 – Review of Dementia, Alzheimer's, Sundowning & Parkinson's (3:00pm – 4:00pm) – 3 staff in attendance · 02/25/2026 – Client Rights (9:00am – 12:00pm) – 4 staff in attendance · 02/27/2026 – Dehydration and the Importance of Hydration – 2 staff in attendance All staff do not have the required training for Title 22 regulations. Report continues on LIC 809-C Based on interviews, observation, and records review, LPA observed the following from the communication logs: · 01/29/2026 – Resident 1 (R1) fell on the floor. · 02/11/2026 – R1 felt numbness in the right leg from hitting the right leg. · 02/14/2026 – R1 vomited after eating. Upon further review, LPA conducted a file review and observed that the facility failed to report the above incidents to the Department as required. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted with Renette De La Cruz (Administrator) and copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Mar 19, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Apr 2, 2026

Personnel Requirements – General: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Based on observation, interviews and record review, the facility failed to ensure all caregiver completed the required training per Title 22 regulations,the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: The licensee will ensure all staff include the Administrator & caregivers complete the required annual training. Training must be provided by an outside authorized vendor with sign in sheets for all trainings which will include the instructor name and information by POC due date. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Mar 23, 2026

Reporting Requirements(a)(1)Each licensee shall submit serious incident reports to. . . the Department may require, including the following: (1) A written report shall be submitted . . .within 7 days of the occurrence of any of the events . This requirement was not met as evidenced by: Based observation, LPA observed that the facility did not submit LIC 624 in regards to R1’s fall, numbness in right leg from hitting right leg and vomited after eating to the department within 7 day of incidents occurring.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: The facility shall submit serious incident reports for the incident that occur on 01/29/2026, 02/11/2026 and 02/14/2026 with R1. The report must be fax to 424-544-1016 to department by POC due date.

Allegation investigated: Staff do not answer phone calls in a timely manner. Staff are not ensuring to meet the residents’ needs in a timely manner. Staff speak inappropriately to residents in care. Staff do not ensure that residents are provided with activities.

On 3/4/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Renette De La Cruz and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 2/25/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Identification and Emergency Information form, Physicians Report and an Incident report. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-3 (S1 – S3), and Resident -1 – Resident - 5(R1-R5). The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Staff do not answer phone calls in a timely manner. It is being reported that calls go unanswered to the facility during the evening hours despite numerous attempts. During the interview with the Administrator, 2/25/26, she indicated that staff promptly handles all incoming calls. Per interview, 2/25/26, S3 stated if the direct lines to the facility go unanswered, families sometimes utilize personal contact numbers of the staff, and staff return calls at their earliest convenience. Per S3, if they are working with a client, they can’t return calls until they are done with the client. LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 3 out of 5 denied the allegation. Two neither confirmed nor denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not answer phone calls in a timely manner,” therefore, the allegation is unsubstantiated. Allegation: Staff are not ensuring to meet the residents’ needs in a timely manner. It is being reported that a resident needed assistance in the facility and the staff weren’t responding when he pressed the call bell. Per interview, 2/25/26, S3 stated that once he’s completed working with the current resident, he checks in with the other residents to offer support. Per interview, 2/25/26, R4 stated at times the staff informs her they are working with another resident. I understand that I’m not the only one that needs assistance, and I’m happy to wait. I don’t have to wait too long. LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not ensuring to meet the residents’ needs in a timely manner,” therefore, the allegation is unsubstantiated. Con'd on 9099-C Allegation: Staff speak inappropriately to residents in care. It is being reported that staff are using disrespectful and inappropriate language to the residents. Based on interviews, 2/25/26, with staff and residents, there is no evidence of inappropriate verbal communication. LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff speak inappropriately to residents in care,” therefore, the allegation is unsubstantiated. Allegation: Staff do not ensure that residents are provided with activities. It is being reported that the staff does not provide residents with activities and keeps them in their rooms for most of the day. During each of my unannounced visits as a Licensing Program Analyst, I have observed residents spending their time in the main living area. Today, 3/4/26, when LPA Shirley arrived to this facility, I observed and heard R4 and her visitor singing a gospel song being sung on the music channel that they were watching. LPA Shirley observed, R3 engaged on her phone enjoying mobile gaming. On 2/25/26, LPA Shirley observed videos and pictures of the residents doing chair exercises, pedaling and walking in the backyard. Per interview with R4, 2/25/26, she doesn’t participate in the exercises anymore as she has grown tired of doing them. LPA interviewed staff 1 – staff 3(S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that residents are provided with activities,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Renette DeLaCruz.the state’s words, verbatim · CDSS document, Mar 4, 2026 · control 11-AS-20260220083424

Allegation investigated: Staff do not provide adequate supervision, resulting in residents falling. Staff did not communicate with residents authorized representative. Staff do not respond to residents call bells in a timely manner.

On 2/25/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Renette De La Cruz and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 2/25/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Identification and Emergency Information form, Physicians Report and an Incident report. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-3 (S1 – S3), and Resident -1 – Resident - 5(R1-R5). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff do not provide adequate supervision, resulting in residents falling. It is being reported that a former resident fell and staff did not report to the resident’s family right away. On 2/25/26, LPA Felisa Shirley reviewed a letter to Community Care Licensing Department, CCLD, LPM Stephanie Cifuentes dated 2/2/26, reporting a fall by a former resident in which staff treated the resident and called the resident’s emergency contact. Per interview with the facility Administrator, 2/25/26, she sent letter to LPA Shirley’s manager as she did not have the correct contact for LPA Shirley. LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not provide adequate supervision, resulting in residents falling,” therefore, the allegation is unsubstantiated. Allegation: Staff did not communicate with residents authorized representative. It is being reported that R1 fell out of the bed several times and these incidents were never reported to the resident’s emergency contact person. On 2/25/26, LPA Shirley requested the incident reports for the prior 6 months. The Administrator submitted a report, but it was not for the resident in question. Per interview, 2/25/26, the Administrator never submitted an incident report for R1 as there were no reports of R1 falling. LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident was not aware of the situation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not communicate with residents authorized representative,” therefore, the allegation is unsubstantiated. Con'd 0n 9099-C Allegation: Staff do not respond to residents call bells in a timely manner. It is being reported that R1 called a family member to report that he needed assistance in the facility and the staff weren’t responding when he pressed the call bell. Per interview, 2/25/26, S3 stated if the direct lines to the facility go unanswered, families sometimes utilize personal contact numbers of the staff, and staff return calls at their earliest convenience. Per interview, 2/25/26, R4 stated at times the staff informs her they are working with another resident. I understand that I’m not the only one that needs assistance, and I’m happy to wait. I don’t have to wait too long. LPA interviewed staff 1 – staff 3(S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 3 out of 5 denied the allegation. Two Residents confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not respond to residents call bells in a timely manner,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Renette DeLaCruz.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 11-AS-20260220083424

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Annual/Random

On 01/14/26 Licensing Program Analyst (LPA) Mario Leon conducted an annual/random visit at the facility. Upon entrance, LPA was met by staff one, Renette De La Cruz - Licensee (S1) and the purpose of the visit was explained. Upon entrance, LPA observed a previous annual visit conducted on 09/05/25. The facility is a single-story home located in a residential neighborhood, which consists of the following: The facility consists of (4) resident bedrooms, of which one (1) are vacant, (2) bathrooms, living room, den, kitchen, dining area, shaded patio, garage used for storage and laundry area. Facility maintains all required posting throughout the facility. LPA reviewed both resident files and found that they contained all required documents. LPA reviewed two (2) staff files and found they contained the required documents, and trainings. LPA reviewed their Liability Insurance. LPA reviewed the training logs for staff. The facility has a current census of three (3) residents (R1-R3). S1 and LPA toured the facility, inside and out. LPA did not find any deficiencies during today's visit. An exit interview was conducted with Renette De La Cruz - Licensee (S1) and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jan 14, 2026

Type of visit: Required - 1 Year

On 9/5/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual. LPA was met by the Administrator, Renette DeLaCruz and explained the purpose of today’s visit. The facility has a census of 2. This facility is a one-story structure located in a residential neighborhood. The facility consists of (4) resident bedrooms, of which two (2) are vacant, (2) bathrooms, living room, den, kitchen, dining area, shaded patio, garage used for storage and laundry area. Facility maintains all required posting throughout the facility. LPA reviewed both resident files and found that they contained all required documents. LPA reviewed three (3) staff files and found they contained the required documents, and trainings. LPA reviewed their Liability Insurance. LPA reviewed the training logs for staff. LPA Shirley and Renette walked through the kitchen and all appliances were in good working order. Medications were locked and inaccessible to residents. All knives and sharpes were locked and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured between the required 105 and 120 degrees Fahrenheit. Bedrooms 1 through 4 contains the mandated furniture. The (2) bathrooms are clean and operational. The first aid kit is fully stocked with manual. There are two (2) fire extinguishers. No firearms are stored at this facility and no bodies of water are present. This facility is in good repair. LPA Shirley and Renette walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. The backyard is clean, clear of obstructions has shade and there are no bodies of water or hazards present. An exit interview was conducted, and a copy of this report was provided to the Administrator, Renette DeLaCruz.the state’s words, verbatim · CDSS document, Sep 5, 2025

Type of visit: Required - 1 Year

On 08/5/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Walkiria Whitford and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled residents ages 60 years and older, cleared for six (6) non-ambulatory residents of which one (1) may be bedridden. During the time of visit all six (6) residents were present. LPA reviewed four resident files and found they contained the required documents. LPA reviewed five (5) staff files and found they contained the required documents, and trainings. LPA reviewed their Liability Insurance. LPA reviewed the training logs for staff. LPA Shirley and Walkiria toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (4) client bedrooms, (2) bathrooms, living room, kitchen, den and dining area, patio, garage used for storage and laundry area. Facility maintains all required posting throughout the facility. All bedrooms were toured. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms and hallways. LPA Shirley and Walkiria toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medications were locked and stored and inaccessible to the resident. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 112 degrees Fahrenheit. con'd on 809-C The (2) bathrooms have grab bars and are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair. LPA Shirley and Walkiria walked through all common areas. In the living room, and dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen and hallway. The backyard is shaded, clean and clear of obstructions and hazards, and there are no bodies of water present. LPA Shirley did not observe any deficiencies. An exit interview was conducted, and a copy of this report was provided to Administrator, Walkiria Whitford.the state’s words, verbatim · CDSS document, Aug 5, 2024