Bay Towers at Bixby Knolls

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff does not ensure transportation vehicle is maintained in good working order

On 09/23/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegations listed above. LPA met with the Executive Director, Don McDonald, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 9/22/2026, records were gathered which consisted of facility’s Plan of Operation regarding transportation services. On 09/23/2026, interviews were conducted, a facility tour was conducted, and records were reviewed. Interviews conducted consisted of Resident 1 (R1) to Resident 5 (R5) and Staff 1 (S1) to Staff 3 (S3). Records gathered and reviewed consisted of Resident Roster, Personnel Report dated 4/14/2026, Transportation Schedule for 09/2026, Bus Repair Bids, Residence and Care Agreement California. Substantiated Investigation revealed the following: Allegation: “Staff does not ensure transportation vehicle is maintained in good working order”, it is being alleged that the facility’s bus lift (used for people with wheelchairs) is not in good repair. Interviews conducted with S1 to S3 revealed the following: 3 out of 3 staff agreed with the allegation, moreover, staff indicated that the lift on the bus has not been operational for about a year. Interviews conducted with R1 to R5 (residents who use wheelchairs) revealed the following: 3 out of 5 residents agreed with the allegation, furthermore, residents indicated that the bus lift has been non-operational for almost a year; 2 out of 5 residents were unable to provide additional information. On 09/23/2026 at proximately 2:30 PM, the facility bus was toured. The facility bus was observed to be operational, but the driver indicated that the lift was in disrepair and not in use due to it being a safety hazard. Record reviewed of Bus Repair Bids revealed the following: The facility has three bids/estimates for the facility bus lift. Substantiated: Based on observation, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, appeal rights were reviewed, and plans of corrections were developed. A copy of this report was left with the Resident Service Director, MaryLou Escobedo. Investigation revealed the following: Allegation: “Staff does not ensure transportation arrangements are provided to residents”, it is being alleged that transportation arrangements are not provided to residents who use wheelchairs. Interviews conducted with S1 to S2 revealed the following: 2 out of 2 staff denied the allegation, additionally, staff explained that transportation arrangements are provided to residents who use wheelchairs via residents’ insurance, private companies, and public services. Interviews conducted with R1 to R5 (residents who use wheelchairs) revealed the following: 5 out of 5 residents denied the allegation, moreover, residents indicated that the facility schedules their transportation and/or assist them with their transportation needs. Record reviewed of Transportation Schedule for 09/2026 revealed the following: The facility has a transportation schedule that includes residents name, address, appointment time, and departure time. The schedule included medical appointments and personal outings. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Resident Service Director MaryLou Escobedo.the state’s words, verbatim · CDSS document, Sep 23, 2026 · control 11-AS-20260915112212

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87312 · Plan of correction due date: Oct 30, 2026

Motor Vehicles Used in Transporting Residents Only drivers licensed for the type of vehicle operated shall be permitted to transport residents. The rated seating capacity of the vehicles shall not be exceeded. Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition. This requirement was not met as evidence by: Based on interviews conducted the licensee did not comply with the section above by not maintaining the facility bus lift in operating condition which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 23, 2026

Plan of correction: The Executive Director has agreed to repair the facility’s bus lift. Email invoice of bus lift repair and footage of bus lift in good repair to Socorro.Leandro@dss.ca.gov Note: The facility bus provides transportation to residents from Monday to Friday for appointments. The facility assists with scheduling transportation services for residents who use wheelchairs.

Allegation investigated: The facility does not maintain hot water temperatures between 105 to 120 degrees fahrenheit. The facility is not in good repair.

On 08/11/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegations listed above. LPA met with the Executive Director, Don McDonald, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 08/11/2026, interviews were conducted, a facility tour was conducted, and records were gathered. Interviews conducted consisted of Resident 1 (R1) to Resident 15 (R15) and Staff 1 (S1) to Staff 3 (S3). Records were gathered and reviewed which consisted of resident roster, personnel roster, invoice dated 08/06/2026, and email dated 08/11/2026. Substantiated Investigation revealed the following: Allegation: “The facility does not maintain hot water temperatures between 105 to 120 degrees Fahrenheit.” Interviews conducted with S1 to S3 revealed the following: Staff indicated that last week there was a maintenance emergency in the boiler room and pump seals; the issues were addressed and fixed the same day. Interviews conducted with R1 to R15 revealed the following: 9 out of 15 residents agreed with the allegation. 6 out of 15 residents denied the allegation, furthermore, residents indicated that in the past they have had hot water issues, but the facility fixed the problems. Record reviewed of the invoice dated 08/06/2026 revealed the following: On 08/06/2026, “pump failed at main building and is leaking:…Found water leaking from the mechanical seal area…After completing the repair, both boilers were started and tested. The heating system was confirmed to be operating properly…” On 08/11/2026 at approximately 9:54 AM to approximately 11:40 AM, hot water temperatures were checked in residents’ bathrooms which revealed the following: · Room 408 hot water temperature measured 103 degrees Fahrenheit. · Room 419 hot water temperature measured 102.4 degrees Fahrenheit. · Room 601 hot water temperature measured 102.2 degrees Fahrenheit. · Room 602 hot water temperature measured 90.7 degrees Fahrenheit. · Room 605 hot water temperature measured 102.6 degrees Fahrenheit. · Room 608 hot water temperature measured 103.5 degrees Fahrenheit. · Room 609 hot water temperature measured 103.9 degrees Fahrenheit. · Room 610 hot water temperature measured 103.7 degrees Fahrenheit. Substantiated: Based on observations and 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 LIC 9099D. Allegation: “The facility is not in good repair,” it is being alleged that the facility’s Air Conditioning System (AC), plumbing, and so on are in disrepair. Interviews conducted with S1 to S3 revealed the following: Staff indicated that they are waiting for parts from the manufacture to fix to the air-cooling system. Moreover, staff indicated that last week there was a maintenance emergency with the pump seals giving out and water splashing everywhere; the issues were addressed and fixed the same day. Furthermore, staff indicated that the elevators have a continuous ringing sound to it, stating that maybe the elevators need oil. Interviews conducted with R1 to R15 revealed the following: 12 out of 15 residents agreed with the allegation, furthermore, residents indicated that the AC’s do not work properly and it can get hot in their apartments, moreover, a resident stated that they had a leak in their room for a couple of months, additionally, residents stated that staff provided them with fans when they requested them. Records reviewed revealed the following: The invoice dated 08/06/2026 states “Found water leaking from the mechanical seal area…After completing the repair…confirmed to be operating properly...recommends replacing the pump volute and bearing assembly to prevent future failures. A proposal will be provided for the recommended repairs.” The email dated 08/11/2026 with the subject line HVAC Update states that the third party vendor (maintenance company that works with the facility) is currently working directly with the HVAC manufacturer to source parts needed to fix HVAC units in rooms 417, 514, 609, and 610. On 08/11/2026, a tour of the facility was conducted, and the following was observed (pictures of observations were taken): · Rooms 514, 417, and 606 did not have a comfortable temperature. · Room 601 – There was a leak on the ceiling with a screen and directly under there was a towel with a bucket of water. · Room 607’s faucet was in disrepair. Facility staff addressed the problem and fixed the issue. · Room 619 – The water from the bathtub faucet came out brown and rusty. · The dining room did not have a comfortable temperature, staff and residents in the dining indicated that it was hot and the AC had been in disrepair. The dining room had a leak coming from the ceiling with a trash can underneath it and a cup of water inside the trash can. · Facility elevators have a constant loud ringing sound to them. Substantiated: Based on observations, 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 LIC 9099D. An exit interview was conducted, a civil penalty was provide regarding repeat violation, appeal rights were reviewed, and plans of corrections were developed. A copy of this report was left with the Resident Service Director, MaryLou Escobedo.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 11-AS-20260803114449

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Sep 3, 2026

Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidence by: Based on interviews conducted and observations the licensee did not comply with the section above by not having hot water temperatures measuring 105 to 120 degrees F which poses/posed an immediate health or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: The Executive Director has agreed to maintain the boilers/pumps in good repair and create a plan to maintain hot water temperatures between 105 to 120 degrees F. Email plan to Socorro.Leandro@dss.ca.gov The department will have to come back and check hot water temperatures and then clear POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 11, 2026

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observations, interviews, and records reviewed the licensee did not comply with the section cited above by not having the facility safe, sanitary, and in good repair at all times which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: The Executive Director has agreed to fix the leak in room 601 and the dining room; fix and maintain the HVAC and boilers/pipes/pumps in good repair; and provide maintenance to the elevators. Email pictures, invoices, and plan to Socorro.Leandro@dss.ca.gov

Allegation investigated: The facility does not maintain hot water temperatures between 105 to 120 degrees fahrenheit. The facility is not in good repair.

On 08/11/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegations listed above. LPA met with the Executive Director, Don McDonald, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 08/11/2026, interviews were conducted, a facility tour was conducted, and records were gathered. Interviews conducted consisted of Resident 1 (R1) to Resident 15 (R15) and Staff 1 (S1) to Staff 3 (S3). Records were gathered and reviewed which consisted of resident roster, personnel roster, invoice dated 08/06/2026, and email dated 08/11/2026. Substantiated Investigation revealed the following: Allegation: “The facility does not maintain hot water temperatures between 105 to 120 degrees Fahrenheit.” Interviews conducted with S1 to S3 revealed the following: Staff indicated that last week there was a maintenance emergency in the boiler room and pump seals; the issues were addressed and fixed the same day. Interviews conducted with R1 to R15 revealed the following: 9 out of 15 residents agreed with the allegation. 6 out of 15 residents denied the allegation, furthermore, residents indicated that in the past they have had hot water issues, but the facility fixed the problems. Record reviewed of the invoice dated 08/06/2026 revealed the following: On 08/06/2026, “pump failed at main building and is leaking:…Found water leaking from the mechanical seal area…After completing the repair, both boilers were started and tested. The heating system was confirmed to be operating properly…” On 08/11/2026 at approximately 9:54 AM to approximately 11:40 AM, hot water temperatures were checked in residents’ bathrooms which revealed the following: · Room 408 hot water temperature measured 103 degrees Fahrenheit. · Room 419 hot water temperature measured 102.4 degrees Fahrenheit. · Room 601 hot water temperature measured 102.2 degrees Fahrenheit. · Room 602 hot water temperature measured 90.7 degrees Fahrenheit. · Room 605 hot water temperature measured 102.6 degrees Fahrenheit. · Room 608 hot water temperature measured 103.5 degrees Fahrenheit. · Room 609 hot water temperature measured 103.9 degrees Fahrenheit. · Room 610 hot water temperature measured 103.7 degrees Fahrenheit. Substantiated: Based on observations and 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 LIC 9099D. Allegation: “The facility is not in good repair,” it is being alleged that the facility’s Air Conditioning System (AC), plumbing, and so on are in disrepair. Interviews conducted with S1 to S3 revealed the following: Staff indicated that they are waiting for parts from the manufacture to fix to the air-cooling system. Moreover, staff indicated that last week there was a maintenance emergency with the pump seals giving out and water splashing everywhere; the issues were addressed and fixed the same day. Furthermore, staff indicated that the elevators have a continuous ringing sound to it, stating that maybe the elevators need oil. Interviews conducted with R1 to R15 revealed the following: 12 out of 15 residents agreed with the allegation, furthermore, residents indicated that the AC’s do not work properly and it can get hot in their apartments, moreover, a resident stated that they had a leak in their room for a couple of months, additionally, residents stated that staff provided them with fans when they requested them. Records reviewed revealed the following: The invoice dated 08/06/2026 states “Found water leaking from the mechanical seal area…After completing the repair…confirmed to be operating properly...recommends replacing the pump volute and bearing assembly to prevent future failures. A proposal will be provided for the recommended repairs.” The email dated 08/11/2026 with the subject line HVAC Update states that the third party vendor (maintenance company that works with the facility) is currently working directly with the HVAC manufacturer to source parts needed to fix HVAC units in rooms 417, 514, 609, and 610. On 08/11/2026, a tour of the facility was conducted, and the following was observed (pictures of observations were taken): · Rooms 514, 417, and 606 did not have a comfortable temperature. · Room 601 – There was a leak on the ceiling with a screen and directly under there was a towel with a bucket of water. · Room 607’s faucet was in disrepair. Facility staff addressed the problem and fixed the issue. · Room 619 – The water from the bathtub faucet came out brown and rusty. · The dining room did not have a comfortable temperature, staff and residents in the dining indicated that it was hot and the AC had been in disrepair. The dining room had a leak coming from the ceiling with a trash can underneath it and a cup of water inside the trash can. · Facility elevators have a constant loud ringing sound to them. Substantiated: Based on observations, 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 LIC 9099D. An exit interview was conducted, a civil penalty was provide regarding repeat violation, appeal rights were reviewed, and plans of corrections were developed. A copy of this report was left with the Resident Service Director, MaryLou Escobedo.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 11-AS-20260803114449

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Sep 1, 2026

Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidence by: Based on interviews conducted and observations the licensee did not comply with the section above by not having hot water temperatures measuring 105 to 120 degrees F which poses/posed an immediate health or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: The Executive Director has agreed to maintain the boilers/pumps in good repair and create a plan to maintain hot water temperatures between 105 to 120 degrees F. Email plan to Socorro.Leandro@dss.ca.gov The department will have to come back and check hot water temperatures and then clear POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 1, 2026

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observations, interviews, and records reviewed the licensee did not comply with the section cited above by not having the facility safe, sanitary, and in good repair at all times which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: The Executive Director has agreed to fix the leak in room 601 and the dining room; fix and maintain the HVAC and boilers/pipes/pumps in good repair; and provide maintenance to the elevators. Email pictures, invoices, and plan to Socorro.Leandro@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 08/11/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding complaint control number 11-AS-20260803114449 and observed the following deficiency. Deficiency observed, the licensee did not submit unusual incident reports for the following incidents: · According to interviews and records reviewed there was a maintenance emergency with water pump leaking. Invoice dated 08/06/2026. · Department observed room 601 with a leak on the ceiling and according to the resident the leak had been going on for a couple of months. · According to records and interviews the HVAC units are in disrepair. · Department observed a water leak in the dining room. An exit interview was conducted, appeal rights were reviewed, and plans of corrections were developed. A copy of this report was left with Resident Service Director, MaryLou Escobedothe state’s words, verbatim · CDSS document, Aug 11, 2026

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

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. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by: Based on observations, interviews, and records reviewed the licensee did not comply with the section cited above by not reporting water leaks in the facility, HVAC and pumps in disrepair which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: The Executive Director has agreed to train staff in reporting requirements. Email trainings to Socorro.Leandro@dss.ca.gov

Allegation investigated: Staff did not ensure that unit has heat Facility unit is in disrepair

On 12/16/2025, At 10:30AM Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver findings for the alleged allegations. LPA identified herself and met with Don McDonald who was informed of the purpose of the visit. The investigation consisted of the following: LPA Conducted interviews with the Administrator Don McDonald and the Maintenance Director Robert Esquer. LPA reviewed residents’ roster for assisted living and independent living and Quotes from Nico's Air Conditioning & Heating dated 3/08/2025 and Beach Air Conditioning dated 10/27/2025. Continued.... Unfounded The investigation revealed the following: Allegation #1: Staff did not ensure that unit has heat Allegation #2: Facility unit is in disrepair LPA conducted interviews with the Administrator Don McDonald, who confirmed that R1 does not reside in the assisted living facility. Mr. McDonald provided a copy of the assisted living resident roster, which did not include R1. However, the independent living facility's resident roster was provided which did list R1 as a resident. Additionally, during the visit, the Maintenance Director provided invoice quotes for compressor replacements from Beach Air Conditioning and Nico's Air Conditioning & Heating which reflected floors and units requiring repairs or replacements which did not include R1’s floor or unit. Based on interviews and evidence gathered during the investigation, the above allegation is found to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report was discussed with Don McDonald Administrator and provided a copy the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 11-AS-20251211163453

Allegation investigated: Staff did not abide by the admission agreement.

On 11/6/25, at 9:30am, the department conducted an initial complaint visit to the facility and was greeted by Don McDonald, Executive Director. The department explained the purpose of this visit is to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegation mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S3) and resident (R1). The department received the following facility documents: Resident Roster (Date: 11/6/2025), Staff Roster (Dated: No Date), Admission Agreement (Dated: 06/29/2020, 07/28/2023, 06/02/2025), Face Sheet (Dated: 04/14/2021, 01/25/2024), Physician’s Report (Dated: 04/27/2024, 06/17/2020), Needs and Service Plan (Dated: 09/16/2025), Notice of Rent Increase Unsigned (Dated: 12/30/2024), 30-Day Termination Notice (Dated: 10/30/2025), Financial Power of Attorney (Dated: 03/07/2024), and Statement of Rent (Dated: 01/16/2024-11/5/2025) from the facility. Report Continued on LIC909-C Substantiated The investigation revealed the following: Allegation- Staff did not abide by the admission agreement. The details of the complaint alleged that the facility did not notify the residents responsible party about a rate increase. As a result, they were issued a 30-Day Termination Notice for non-payment of outstanding fees. On 11/6/2025, from 9:30am-2:00pm, the department interviewed staff (S1-S3) and resident (R1) regarding the allegation. 3 of 3 staff denied the allegation that Staff did not abide by the admission agreement. All staff stated that the facility does abide by what is written in the admission agreement. However, 2 of 3 staff stated that they were not sure if the residents (R1s) responsible party was notified about the rate increase. Whereas another member of staff stated that the responsible party was not notified because they were listed as a contact only. Staff stated that they told the resident (R1) about the increase and issued a notice of the rate increase on 12/30/2024 and gave it to the resident. The department interviewed resident (R1) about the allegation and the resident stated that they had no knowledge of the increase until a month ago. The resident also stated that they do not remember getting a notice or signing for it. The department reviewed the Physician’s Report (Dated: 04/27/2024, 06/17/2020), Admission Agreement (Dated: 06/29/2020, 07/28/2023, 06/02/2025), Notice of Rent Increase Unsigned (Dated: 12/30/2024), Financial Power of Attorney (Dated: 03/07/2024), and the 30-Day Termination Notice (Dated: 10/30/2025). The department observed in the admission agreement dated and signed on 06/20/2025, that the legally responsible person for R1 was the residents responsible party noted in the Power of Attorney documents and other facility documents. The department observed on page 51 of the admission agreement entitled “Financial Status” that the legally responsible person was the same person that has power of attorney of R1. Additionally, the department observed that on page 72 of the admission agreement entitled “Resident Financial/Responsibility Form” the same name appears as well. The department also reviewed the Physician’s Report (Dated: 04/27/2024) that states R1 is not able to handle their own cash resources due to their primary diagnosis. As a result of this diagnosis the responsible party or legally responsible person that signed the admission agreement should have been notified 90 days prior to the rent increase. Report Continued on LIC9099-C Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not abide by the admission agreement, is found to be Substantiated. Health and Safety Code 1569.655(a), Chapter (03.2) Residential Care Facilities for the Elderly are being cited on the attached LIC 9099D. Deficiencies were issued and plans of corrections were discussed. Note: *Citations that are not cleared by the due date of 11/14/25 will have a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Deficiency was cleared at the time of the visit. An exit interview was conducted with Don McDonald, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 11-AS-20251103094002

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a) · Plan of correction due date: Nov 14, 2025

§1569.655(a) Increase in fee rates for elderly residents; 90 days’ written notice standing amount of reasons for increase…(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice..... This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the licensee failed to give R1s responsible party/legally responsible person as observed in the admissions agreement, 90 days’ notice of a rate increase. This posed potential personal rights and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: Licensee shall review the Health and Safety Code 1569.655(a) regarding rate increases and rescind the rate increase notice dated 12/30/2024 and the 30-day termination notice with an effective date of 12/01/2025. Licensee may re-issue a correct rate increase notice to the responsible party that is in-compliance with Health and Safety Code1569.655(a) Confirmation of all items will be submitted to CCLD by the POC due date of 11/14/25 to LPA Perry Scott’s email at perry.scott@dss.ca.gov to avoid monetary penalties.

Allegation investigated: Facility gate is in disrepair.

On 11/3/25, at 9:30am, the department conducted an initial complaint visit to the facility and was greeted by Marylou Escobedo, Resident Care Director. LPA explained the purpose of this visit is to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegation mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4) and residents (R1-R4). The department received the following facility documents: Resident Roster (Date: No Date), Staff Roster (Dated:09/27/2025), Community Controls Gate Invoice (Dated: 10/31/2025), and The W.C. Friend Company Gate Invoice (Dated: 08/30/2024) from the facility. The investigation revealed the following: Allegation- Facility gate is in disrepair. Report Continued on LIC9099-C Unsubstantiated The details of the complaint alleged that one of the underground garage gates is frequently broken at the facility and remains open, creating a dangerous situation for the residents on either side of the building. On 11/3/2025, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R4) regarding the allegation. 3 of 4 staff (S2-S4) denied the allegation that Facility gate is in disrepair. Most of the staff stated that they did not know that the gate was not working and that they did not hear any complaints about it. S1 stated that they were aware that the gate was not working on 10/30/25 and called that day to have it serviced. S1 stated that Community Controls came out on 10/31/25 to service and repair the gate and it has been working ever since that day. The department interviewed residents (R1-R4) about the allegation and 3 of 4 residents that were interviewed stated that they had no knowledge that the gate was not working. While 1 resident stated that they informed a staff member about the gate. The department reviewed Community Controls Gate Invoice (Dated: 10/31/2025) and The W.C. Friend Company Gate Invoice (Dated: 08/30/2024) and observed that the gate was serviced and repaired on 10/31/2025 and that it was previously serviced and repaired on 08/30/2024. The department also observed and verified that the entrance gate and exit gates were working properly. Based on observation, interviews, and records reviewed, there is insufficient evidence to support the allegation that Facility gate is in disrepair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued. An exit interview was conducted with Marylou Escobedo, Resident Care Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Nov 3, 2025 · control 11-AS-20251027114820

Type of visit: Office

On October 7, 2025, at 9:00 a.m., an in-person Informal office meeting was conducted. In attendance is LPM /Eva Alvarez, LPA/ Alfonso Iniguez, Don McDonald/Administrator, and Robert Esquer/Maintenance Director. The purpose of this meeting was to discuss the state of the facility's water heating system and Title 22 reporting requirements. On 9/27/25, the department conducted an Annual visit and found the facility water temperatures registered at approximately 90 degree Fahrenheit on the 6th, 5th and 4th floor due to the circulation pumps failing to operate properly. The facility was issued a citation and civil penalties for the deficiency. Administrator/ MacDonald stated the problem was identified prior to the licensing visit on 9/27/25; however, it was not reported to licensing as the facility focused on the repairs needed. Administrator/MacDonald stated a request for repairs was made to the corporate office, after the issue was identified, and an approval was provided. On 10/3/25, the repair of the circulation pumps occurred and the issue resolved. The citation issued was cleared on 10/7/25 during this office meeting. During this meeting LPM/Alvarez conducted a brief overview of Title 22 reporting requirements as the facility failed to report the circulation pumps not operating properly. LPM/Alvarez informed the Administrator that a citation would be issued and civil penalties assessed as the reporting citation is a repeat violation within the last 12 months. Administrator/ Mac Donaldson stated a plan of correction would be submitted to the department by 10/13/25. The plan will ensure that reportable issues will be reported to licensing per Tile 22 regulations. The meeting concluded at 10:00 am. An exit interview conducted, and the report provided to Don McDonald/Administrator.the state’s words, verbatim · CDSS document, Oct 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 13, 2025

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. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by Based on interviews, the facility failed to report to the department one of two water pumps that pump the hot water to the building was in disrepair. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Licensee will adhere to title 22 at all times. As Plan of Correction, the administrator will get together with his staff and trained them on how to report to CCLD any event that happens at the facility that coulp potentially pose a risk to the residents in care. A copy of the plan will be sent to LPA Iniguez via email.

Type of visit: Required - 1 Year

On 9/27/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with MaryLou Escobedo/Resident Service Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (65) elderly adults aged 60 and above, of which (65) can be non-ambulatory. The facility has an approved hospice waiver for (10). First, Fourth, and Sixth Floors, along with Dinning, Activities, and prep Kitchen areas, are licensed by CCL in building B. Currently the facility has (48) residents. The facility is a 6-story commercial building located on a main street. There are two buildings on the property separated by a parking lot. The Independent Living building is not licensed by Community Care Licensing (CCL). The Assisted Living building is licensed by (CCL). The Assisted Living building consists of 57 resident bedrooms, 57 resident bathrooms, and occupies the 4th, 5th and 6th floors. LPA Iniguez and the Admin Coordinator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (9) bedrooms and (9) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 8/26/25. A review of (4) residents' service files and (4) staff personnel. LPA reviewed (4) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -Water temperature measured below 105F during annual survey on residents’ rooms:613,602,503,404,417 and 420. Civil Penalty rendered for repeated violation for $250.00 -(2) residents missing admission agreements during annual survey. -(3) residents missing inventory list during annual survey. -(2) residents missing personal rights form on admission agreements during annual survey. -(3) facility staff missing Health Screening and TB Test during annual survey. -(1) facility staff missing first aid card during the annual survey. 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) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to MaryLou Escobedo/Resident Service Director.the state’s words, verbatim · CDSS document, Sep 27, 2025

Type of visit: Case Management - Other

On 07/09/25 Licensing Program Analyst (LPA) Villegas conducted an unannounced case management visit in regards to citation provided during compliant (11-AS-20250616142252) visit on 06/18/25. LPA met with Executive Director Don McDonald as the purpose of today's visit was explained. During today's visit LPA conducted water temperature checks in building B. Building B is licensed by CCLD on floors 1,4,5 and 6, floors 2 and 3 are not licensed by CCLD and are Skilled Nursing floors. The following rooms located in building B in the assisted living unit had their water temperatures checked; room 403-117.2F, room 405-117F., room 413- 108F., room 418- 109.4F., room 502-105.3F., room 507-106.7F., room 516-106F., room 519- 106.4F., room 603-108.6F., room 605-110.5F., room 614- 108.5F., and room 619-109.3F.. On 07/09/25 LPA also conducted a water temperature check in the kitchen which is used to service both buildings A and B, water temperature in the kitchen was 120.F. Exit interview conducted with Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 9, 2025

Allegation investigated: Facility does not have hot water.

This report supercedes report dated 06/17/25, this report is to only change report verbiage and this report does not change report findings from 06/17/25. On 06/17/25, Licensing Program Analyst (LPA) Lizeth Villegas and Alfonso Iniguez conducted a subsequent complaint visit regarding the allegation(s) above. The Department met with (ED) Executive Director Don McDonald, as the purpose of today’s visit was explained. The investigation consisted of the following: On 06/16/25 The Department obtained copies of the staff and resident rosters and on 06/16/25 from 3pm-3:45pm The Department conducted Interviews with resident #1-4 (R1-R4), and from 4pm-4:30pm interviews were conducted with ED and staff #1-2 (S1-S2). On 06/16/25 The Department conducted water temperature checks in the following bedrooms in the assisted living unit: 413, 405, 418, 403, 502, 507, 516, 519, 603, 605, 614, 619, assisted living unit dining room, and the kitchen in the independent living building. On 06/17/25 The Department conducted water temperature Substantiated checks along with room temperature checks in the following bedrooms: 402, 407, 413, 505, 517, 518, 613, 620. On 06/17/25 The Department obtained copies of invoices from SouthWest Mechanical dated 6/6/25, 6/12/25, 6/14/25, and copies of City of Long Beach Code Enforcement Bureau Administrative Citations dated 4/4/25. On 06/17/25 interview was conducted with staff #3 (S3). The investigation revealed the following: Allegation: Facility does not have hot water. It is being alleged that residents in care do not have access to hot water and that the hot water has not been working properly for multiple days. On 6/16/25 The Department conducted Interviews with R1-R4 regarding the allegation above, 3 of 4 residents denied the allegation above and reported have no issues with the water temperature. 1 of 4 residents interviewed reported the water temperature in resident’s bedroom was a bit cold but was fixed the same day. On 6/16/25 The Department conducted interview with ED regarding the allegation above, ED confirmed the allegation above and stated that there was an issue with 1 of 2 water boilers. Per ED there are 2 water boilers on top to building A (Independent living building) that supplies water to both buildings A and B (Assisted Living Building), ED continued to state that 1 of the 2 water boilers stopped working properly and needed to be repaired. Per ED the water boiler was repaired on 6/14/25 but was set at the wrong temperature and later fixed by facility staff. On 06/16/25 and 06/17/25 The Department conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff confirmed the allegation above and reported the facility had some issues with the water, but since it has been fixed. On 06/16/25 and 06/17/25 The Department conducted a tour of the physical plant that consist of 2 buildings on the premises with a parking lot in between, building A is an independent living unit that is not licensed by CCLD, and building B is licensed by CCLD on floors 1,4,5 and 6. Floors 2 and 3 are not licensed by CCLD and are Skilled Nursing floors . On 06/16/25 and 06/17/25 during tours of building B the following rooms had the water temperatures checked: room 413- 98.2 F, room 405- 100.5 F, room 418- 98.4F, room 403- 98.2F, room 502- 96.9F, room 5070 107.6, room 516- 100.5 F, room 519- 98.2 F, room 603-96.0, room 605- 108.7 F, room 614- 102.8F , room 619- 97.0 F., room 418 102 F, room 413- 108.5 F, room 407- 109.2 F, room 402- 108.1 F, room 502- 103.6 F, room 505 107.6 F, room 517- 103.8 F, room 518 103. 4 F, room 620- 100 F, room 613- 103.1 F, room 605- 108.9 F, room 603- 100.4 F. On 06/17/25 The department conducted a file review and did not observe that an unusual incident report was not submitted to CCLD reporting the issues with 1 of 2 water boilers, ED confirmed that an unusual incident report was not sent to CCLD. On 06/17/25 The Department conducted a record review of invoices from SouthWest Mechanical dated 6/6/25, 6/12/25, 6/14/25, which indicate repairs on water boiler were done. Based on The Departments observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided to Executive Director Don McDonald. The investigation revealed the following: Allegation: Facility air conditioner/heating is not working properly. It is being alleged that the facilities heating and air conditioning is not functioning correctly. On 6/16/25 The Department conducted Interviews with R1-R4 regarding the allegation above, 4 of 4 residents denied the allegation above and reported having no issues with neither the air conditioning or heating. On 6/16/25 The Department conducted interview with ED regarding the allegation above, ED denied the allegation above and reported Building B has not had issues with air conditioning nor heating. On 06/16/25 and 06/17/25 The Department conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff denied the allegation above and reported that the facility has portable fans and heaters for the residents to use incase an issue arises. On 06/16/25 and 06/17/25 during tours of building B the following rooms were observed to have an operable AC unit: rooms 405, 418, 403, 502, 507, 516, 519, 603, 605, 614, 619,413, 407, 402, 505, 517, 518, 620, 613. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided to Executive Director Don McDonald.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 11-AS-20250616142252

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jun 24, 2025

Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature...attain a temperature of not less than 105 degrees F (41 degrees C) and not more than 120-degree F (49 degree C). This requirement is not met as evidenced by: based on interviews, and records review the facility failed to ensure that 1 of the 2 water boilers were in good repair which Poses a potential health, safety, or personal rights risk to a person in care.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: Licensee and Executive Director will always adhere to Title 22. As plan of correction booster will be placed in building B to ensure water is always between 105 degrees F- and not more than 120 degrees F.. Plan to be submitted to LPA by POC due date 6/24/25.

Allegation investigated: Facility does not have hot water.

On 06/17/25, Licensing Program Analyst (LPA) Lizeth Villegas and Alfonso Iniguez conducted a subsequent complaint visit regarding the allegation(s) above. The Department met with (ED) Executive Director Don McDonald, as the purpose of today’s visit was explained. The investigation consisted of the following: On 06/16/25 The Department obtained copies of the staff and resident rosters and on 06/16/25 from 3pm-3:45pm The Department conducted Interviews with resident #1-4 (R1-R4), and from 4pm-4:30pm interviews were conducted with ED and staff #1-2 (S1-S2). On 06/16/25 The Department conducted water temperature checks in the following bedrooms in the assisted living unit: 413, 405, 418, 403, 502, 507, 516, 519, 603, 605, 614, 619, assisted living unit dining room, and the kitchen in the independent living building. On 06/17/25 The Department conducted water temperature checks along with room temperature checks in the following bedrooms: 402, 407, 413, 505, 517, 518, 613, 620. On 06/17/25 The Department obtained copies of invoices from SouthWest Mechanical dated 6/6/25, 6/12/25, 6/14/25, and copies of City of Long Beach Code Enforcement Bureau Administrative Citations dated 4/4/25. On 06/17/25 interview was conducted with staff #3 (S3). Substantiated The investigation revealed the following: Allegation: Facility does not have hot water. It is being alleged that residents in care do not have access to hot water and that the hot water has not been working properly for multiple days. On 6/16/25 The Department conducted Interviews with R1-R4 regarding the allegation above, 3 of 4 residents denied the allegation above and reported have no issues with the water temperature. 1 of 4 residents interviewed reported the water temperature in resident’s bedroom was a bit cold but was fixed the same day. On 6/16/25 The Department conducted interview with ED regarding the allegation above, ED confirmed the allegation above and stated that there was an issue with 1 of 2 water boilers. Per ED there are 2 water boilers on top to building A (Independent living building) that supplies water to both buildings A and B (Assisted Living Building), ED continued to state that 1 of the 2 water boilers stopped working properly and needed to be repaired. Per ED the water boiler was repaired on 6/14/25 but was set at the wrong temperature and later fixed by facility staff. On 06/16/25 and 06/17/25 The Department conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff confirmed the allegation above and reported the facility had some issues with the water, but since it has been fixed. On 06/16/25 and 06/17/25 The Department conducted a tour of the physical plant that consist of 2 buildings on the premises with a parking lot in between, building A is an independent living unit that is not licensed by CCLD, and building B is licensed by CCLD on floors 1,4,5 and 6. Floors 2 and 3 are not licensed by CCLD and are Skilled Nursing floors . On 06/16/25 and 06/17/25 during tours of building B the following rooms had the water temperatures checked: room 413- 98.2 F, room 405- 100.5 F, room 418- 98.4F, room 403- 98.2F, room 502- 96.9F, room 5070 107.6, room 516- 100.5 F, room 519- 98.2 F, room 603-96.0, room 605- 108.7 F, room 614- 102.8F , room 619- 97.0 F., room 418 102 F, room 413- 108.5 F, room 407- 109.2 F, room 402- 108.1 F, room 502- 103.6 F, room 505 107.6 F, room 517- 103.8 F, room 518 103. 4 F, room 620- 100 F, room 613- 103.1 F, room 605- 108.9 F, room 603- 100.4 F. On 06/17/25 The department conducted a file review and did not observe that an unusual incident report was not submitted to CCLD reporting the issues with 1 of 2 water boilers, ED confirmed that an unusual incident report was not sent to CCLD. On 06/17/25 The Department conducted a record review of invoices from SouthWest Mechanical dated 6/6/25, 6/12/25, 6/14/25, which indicate repairs on water boiler were done. Based on The Departments observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided to Executive Director Don McDonald. The investigation revealed the following: Allegation: Facility air conditioner/heating is not working properly. It is being alleged that the facilities heating and air conditioning is not functioning correctly. On 6/16/25 The Department conducted Interviews with R1-R4 regarding the allegation above, 4 of 4 residents denied the allegation above and reported having no issues with neither the air conditioning or heating. On 6/16/25 The Department conducted interview with ED regarding the allegation above, ED denied the allegation above and reported Building B has not had issues with air conditioning nor heating. On 06/16/25 and 06/17/25 The Department conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff denied the allegation above and reported that the facility has portable fans and heaters for the residents to use incase an issue arises. On 06/16/25 and 06/17/25 during tours of building B the following rooms were observed to have an operable AC unit: rooms 405, 418, 403, 502, 507, 516, 519, 603, 605, 614, 619,413, 407, 402, 505, 517, 518, 620, 613. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided to Executive Director Don McDonald.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 11-AS-20250616142252

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jun 23, 2025

Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature...attain a temperature of not less than 105 degrees F (41 degree C) and not more than 120-degree F (49 degree C). This requirement is not met as evidenced by: based on interviews, and records review the facility failed to ensure that 1 of the 2 water boilers were in good repair which poses an immediate health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Licensee and Executive Director will always adhere to Title 22. As plan of correction booster will be placed in building B to ensure water is always between 105 degrees F- and not more than 120 degrees F.. Plan to be submitted to LPA by POC due date 6/23/25.

Type of visit: Case Management - Deficiencies

On June 17, 2025, at approximately 9:30 a.m., Licensing Program Analysts (LPAs) Lizeth Villegas and Alfonso Iniguez conducted a Case Management visit at the facility. LPAs met with Don McDonald, Executive Director, and explained the purpose of their visit. During a subsequent complaint (11-AS-20250616142252) visit on June 17, 2025, LPAs Villegas and Iniguez, as per interviews with Executive Director(ED), stated that the department was not informed that one of the two water heaters was in disrepair. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -Licensee did not reported to the department, one of the facility’s water heaters was in disrepair. 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) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Don McDonald, Executive Director.the state’s words, verbatim · CDSS document, Jun 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 24, 2025

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. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by: Based on interviews, the facility failed to report to the department one of two water heaters was in disrepair. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Licensee will adhere to Title 22 at all times. As plan of correction. Executive Director stated that he will get together with his team and they will ensure that any incident that happens will be reported to the department on a timely manner. Proof of correction will be email to LPA Iniguez via email.

Type of visit: Case Management - Other

On 10/22/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Case Management visit at this facility. LPA was greeted by Resident Service Director Marylou Escobedo. LPA explained the purpose of this visit was to inspect the facility. 3747 Atlantic Avenue, Long Beach, CA 90807 is a six-story structure building located in a commercial neighborhood. It consists of the following: a lobby area, a dining area, administrative offices, public restrooms, a prep kitchen, storage rooms, activity rooms, an employee lounge, a laundry room, linen closets, medication rooms, hand wash station, (57) resident bedrooms, and (57) resident bathrooms and occupies the first, fourth , fifth, and sixth floors for Assisted Living licensed by Community Care Licensing (CCL). Designated floors of 2nd and 3rd floors are for Post Acute Care is licensed by the Department of Health. First Floor: The main floor is composed of the following: (1) Lobby, (3) Administrative Offices, (1) Staff Office Room, (1) Dining/Activities area, Resident Mailboxes, (1) Prep Kitchen, (3) Public Restrooms, (1) Staff Restroom, (1) Storage Closet, (2) elevators, and an outside patio area. Fourth Floor: The assisted living floor consisted of the following: Residents individual private rooms #401-#420, (1) Family Room, (1) Charting Room, (1) Administrative Office, (1) Medication Room, (1) Medical Records Room, (1) Trash Chute, (1) Staff Restroom, (1) Linen Closet, (1) Hand Wash Area, (2) Elevators, and (2) Emergency Staircases. (Evaluation Report continues on LIC 809-C) Fifth Floor: The assisted living floor consisted of the following: Residents individual private rooms #501-#520, (1) Activity Room, (1) Activity Office, (1) Seating Area, (2) Linen Closets, (1) Trash Chute, (1) Staff Restroom, (1) Storage Closet (2) Elevators, and (2) Emergency Staircases. Sixth Floor: The assisted living floor consisted of the following: Residents individual private rooms #601-#620, (1) Sitting Area (1) Linen Closet, (1) Laundry Room, (1) Staff Restroom, (1) Employee Lounge, (1) Storage Closet, (1) Trash Chute, (2) Elevators, and (2) Emergency Staircases. The main commercial kitchen being utilized by assisted living is located at 3737 Atlantic Avenue Long Beach, CA 90807 directly across 3747 Atlantic Avenue Long Beach, CA 90807. The commercial kitchen is located in Building A and is not licensed by Community Care Licensing (CCL). The Bay Towers at Bixby Knolls are required to submit a Request for Waiver Submission for Kitchen Use. In total, there are two buildings on the property lot separated by a parking lot. Building A is for Independent Living 3737 Atlantic Avenue and Building B is the Assisted Living and Post Acute 3747 Atlantic Avenue. An exit interview is conducted with Marylou Escobedo, and a copy of the report is provided.the state’s words, verbatim · CDSS document, Oct 22, 2024

Allegation investigated: Facility air conditioner is in disrepair.

On 09/11/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit at this facility. LPA was greeted by Resident Service Director Marylou Escobedo. LPA explained the purpose of this visit was to gather information in reference allegation mentioned above. The investigation consisted of the following: An initial investigation visit on 09/11/24. A review of Register of Resident Roster, Personnel Report LIC 500, An interview with Resident Service Director and Director Don McDonald. Additional interviews with Residents #1-#9 (R1-R9). A tour of the facility was conducted for the Assisted Living commercial kitchen and floors 4th, 5th, and 6th. INVESTIGATION REVEALED THE FOLLOWING: The details of the complaint alleged the facility air conditioner is in disrepair. The information provided the senior living facility has been without air conditioning for over five weeks, throughout the heatwave. There is a concern the facility does not plan on fixing the issue. (Evaluation Report continues LIC 9099-c) Unfounded On 09/11/24, between 01:55 pm – 02:45 pm, the Department interviewed the Resident Service Director (RSD #1) and the Director (D#1) claimed the Assisted Living license by Community Care Licensing (CCL) has not had issues with their air conditioning units. (RSD#1) and (D#1) communicated Assisted Living floors 4th, 5th, and 6th consist of 20 rooms all having individual air conditioning units that are controlled by the residents. The Assisted Living is in Building B and is serviced by Infinite Circulation Inc. a heating, ventilation, and air conditioning company. (D#1) clarified that it is Building A the Independent Living floors 4th and 14th had issues with air conditioning not being operable. Building A is not licensed by (CCL). On 09/19/24, between 03:30 pm - 04:10 pm, the Department inspected the common areas, commercial kitchen, and rooms: #407, #409, #415, #504, #507, #511, #613, #615, and #616 all had operable air conditioning units, and all maintained a comfortable temperature of 68 degrees F to 80 degrees F. On 09/19/24, between 03:30 pm - 04:10 pm, the Department interviewed (9) out of (9) residents #1- #9 (R1-R9) all verified having no issues with their air conditioning systems. As a result of the Department reviewing (CCL) facility records revealed the facility is a six-story commercial building. In total, there are two buildings on the lot separated by a parking lot. Building A is for Independent Living, and Building B is the Assisted Living unit composed of (57) resident bedrooms, and (57) resident bathrooms and occupies the 4th, 5th, and 6th floors. (CCL) only has jurisdiction over licensed floors for Assisted Living and the commercial kitchen, common areas, and offices on the 4th, 5th, and 6th floors. This Department has investigated the complaint "Facility air conditioner is in disrepair". The Department found that the complaint is unfounded, meaning that the allegation was false, could not have happened, and/or is without reasonable basis. The Department therefore dismissed the complaint. No deficiencies were cited. An exit interview is conducted with Marylou Escobedo, and a copy of the report is provided.the state’s words, verbatim · CDSS document, Sep 11, 2024 · control 11-AS-20240911121530

Type of visit: Required - 1 Year

On September 11, 2024, at 9:00 AM, Licensing Program Analyst (LPA), Deborah Lee arrived at facility above to conducted an unannounced Required – 1 Year Inspection to Bay Towers at Bixby Knolls facility and met with the Residents Services Director, MaryLou Escobedo and Executive Director Don McDonald. LPA explained the purpose of the visit and was accompanied by the Resident Services Director to tour the facility inside and out. This facility is licensed to serve 65 non-ambulatory, ambulatory adults ages 60 and above. There is an approved Hospice Waver for 10. Facility Structure The facility is a 6-story commercial building located on a main street. There are two buildings on the property separated by a parking lot. The Independent Living building is not licensed by Community Care Licensing (CCL). The Assisted living building is licensed by (CCL) The Assisted Living building consist of 57 resident bedrooms, 57 resident bathrooms, and occupies the 4th, 5th and 6th floors. Living area/Common rooms: LPA inspected living spaces and common areas. LPA observed the furniture to be in good repair and adequate seating for the residents in care. There is adequate space for indoor activities. Page 1 of 3 Resident Bedroom/bathrooms: Several residents’ bedrooms/bathrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. This facility provides toilet paper to all residents. Kitchen/Dinning area: LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet. Safety: LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. All required documents are posted. Last Disaster drill was conducted on 08/26/2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There was an inspection performed on 10/16/23 on the signal systems, fire alarms, fire sprinklers, elevators, etc. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. Page 2 of 3 Outside area: Outside grounds toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the facility were clear of hazards. Staff/Resident Records: 5 staff records were reviewed, 5 out of 5 staff records had required Criminal Record Clearances. All staff records had require documentation. 5 resident records were reviewed and, 5 out of 5 resident records had required documentation. LPA observed that facility maintains required liability insurance. The expiration date is 10/1/2024. No deficiencies are being cited at this time in accordance with the California Code of Regulations, Title 22. An exit interview was conducted and a copy of this report was left with the Residents Services Director. Page 3 of 3the state’s words, verbatim · CDSS document, Sep 11, 2024

Allegation investigated: Facility failed to properly address flooding in facility.

On 07/18/24, at 10:00am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Don McDonald, Director. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegation mentioned above. The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1). PRC Restoration Invoice (Dated: 06/14/24) for flood damage was obtained from the facility for Bay Towers At Bixby Knolls Active Adult & Independent Living. The investigation revealed the following: Allegation #1- Facility failed to properly address flooding in facility. The details of the complaint alleged that the facility experienced flooding on the 2nd floor throughout 5 units and did not take proper precautions to ensure the safety of the residents. Report continued on LIC9099-C Unfounded On 07/18/24, from 9:00am-10:00am, LPA interviewed staff (S1) regarding the allegation. 1 of 1 staff denied the allegation that the Facility failed to properly address flooding in facility. S1 stated that the facility that had flooding was Bay Towers At Bixby Knolls Active Adult & Independent Living (which is not licensed through Community Care Licensing) and not Bay Towers At Bixby Knolls Assisted Living and Skilled Nursing which is licensed. LPA toured Bay Towers At Bixby Knolls Active Adult & Independent Living and checked the 2nd floor for flood damage and toured the affected rooms and found that the rooms were empty and being repaired. Residents that were affected were relocated to different units in the facility. The flooding did not take place at the facility on the complaint; therefore, the complaint is unfounded. This agency has investigated the complaint alleging Facility failed to properly address flooding in facility. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. No deficiencies were cited. An exit interview was conducted with Don McDonald, Director, and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 18, 2024 · control 11-AS-20240710120614

Type of visit: Annual/Random

On 5/18/2024 at around 8:40 AM, Licensing Program Analyst (LPA), Leandro conducted an unannounced Required – 1 Year Inspection to Bay Towers at Bixby Knolls facility and met with the Residents Services Director, MaryLou Escobedo. LPA explained the purpose of the visit and was accompanied by the Resident Services Director inside and outside the facility during this inspection. The facility’s former name was Bixby Knolls Tower, facility number: 191601645, effective date: 5/16/1993. Current facility name Bay Towers at Bixby Knolls, Facility Number: 198320315, Effective Date: 9/5/2023. This facility is licensed to serve 65 non-ambulatory adults ages 60 and above. The facility is a 6-story commercial building located on a main street. The building consist of consists of 57 resident bedrooms, 57 resident bathrooms, 12 common bathrooms, dining room, commercial kitchen, staff room, media rooms, office area, washer and dryer/storage area, backyard with umbrella with table and chairs. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the facility were clear of hazards. There is maintenance happening on the premises and the City of Long Beach Bureau of Environmental Health Department of Health & Human Services has inspected the facility. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet. LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted in April 2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There was an inspection performed on 10/16/2023 on the signal systems, fire alarms, fire sprinklers, elevators, etc. Several residents’ bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. 5 staff records were reviewed, 5 out of 5 staff records had required Criminal Record Clearances. 5 resident records were reviewed and, 5 out of 5 resident records had required documentation. No deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted and a copy of this report was left with the Residents Services Director.the state’s words, verbatim · CDSS document, May 18, 2024