Palmcrest Grand Residence

Allegation investigated: Resident developed pressure injuries due to staff neglect.

On 09/02/26 at 12:00 pm Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation above. LPA met with Administrator Veronica Gomez (staff #1/S1) as the purpose of today’s visit was explained. The investigation consisted of the following: On 09/01/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, conservatorship documents, pre-appraisal dated: 02/02/26, Physicians report dated: 07/01/25 , needs and service plan dated: 07/18/26, medication list, wound care documentation, wound care initial visit note dated: 0814/26, hospice communication note dated: 7/24/26, and documented facility documentation. On 09/01/26 and 09/02/26 LPA conducted Interviews with (Staff #1-7/ S1-S7). On 09/02/26 LPA conducted interviews with residents #2-10 (R2-R10). On 09/01/26 Unsubstantiated and 09/02/26 LPA was unable to interview R1 as R1 is currently receiving outside services. On 09/01/26 and 09/02/26 LPA attempted to reach witness #1 (W1) but was unsuccessful. On 09/02/26 LPA spoketo witness #2 (W2), and conducted a review of all documents obtained. The investigation revealed the following Allegation: Resident developed pressure injuries due to staff neglect. It is alleged that facility staff did not tend to a residents pressure injury in a timely manner which resulted in hospitalization. On 09/02/26 LPA conducted interviews with R2-R10 regarding the allegation above. 9 of 9 residents interviewed denied the allegation above and report they have not obtained any injury while living at this facility. Furthermore 9 of 9 residents did not report any concerns about the care they are receiving. On 09/01/26 and 09/02/26 LPA was unable to interview R1 as R1 is currently receiving outside services. On 09/02/26 LPA attempted to reach W1 but was unsuccessful. On 09/02/26 spoke to W2 regarding the allegation above, per W2 there are no concerns with the care R1 was being provided at the facility. On 09/01/26 and 09/02/26 LPA conducted Interviews with S1-S7 regarding the allegation above. 7 of 7 staff interviewed denied the allegation above and indicated that staff are trained on pressure injury prevention and recognition, and that in-services are conducted twice a month. Additionally, 7 of 7 staff stated that when a pressure injury is observed, the residents representative and Dr. are notified before care is provided. Per 7 of 7 staff, preventive measures such as 2 hour repositioning and skin care is implemented in addition to home health, hospice, or wound care services. On 09/02/26 LPA conducted a review of all documents obtained for R1. Per needs and service plan dated: 07/18/26, R1 was placed on concierge hospice care on 07/16/26 due to decline in health and pressure sore, soft wedges were to be placed between legs and back for better support. LPA reviewed facility documentation dated between May 2026- August 2026, per documentation R1's pressure injuries and wounds were being treated per Drs. orders and were healing. Per documentation dated 08/03/26 there was a meeting with W1, W2, caregivers, and facilities LVN to put a service plan of care for R1. Documentation dated 08/24/26, facility spoke to W1 regarding R1's current health condition. W1 was encouraged to send R1 out to the hospital so that the Dr. could decide the best wound treatment care. W1 agreed to that plan and hospice was made aware. 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 plan was provided.the state’s words, verbatim · CDSS document, Sep 2, 2026 · control 11-AS-20260831153434

Type of visit: Case Management - Deficiencies

On 08/06/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding complaint control number 11-AS-20260730145002 and observed the following deficiency. Deficiency Observed: · On 08/06/2026 at approximately 11:49 AM, there were two large kitchen knives in an unlocked drawer in the kitchen dining room with several residents going inside the dining room, sitting in the dining room, and walking around the dining room. A staff member removed both knives to a secure location. (Pictures were taken). An exit interview was conducted, appeal rights were reviewed, and plans of corrections were developed. A copy of this report was left with the Administrator, Veronica Gomez.the state’s words, verbatim · CDSS document, Aug 6, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Aug 6, 2026

Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by: Based on observations the licensee did not comply with the section cited above by not having knives in locked storage 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 6, 2026

Plan of correction: Staff removed knive to a secure location. The Administrator has agreed to train staff on locking items that can pose a danger to residents. Email trainings to Socorro.Leandro@dss.ca.gov

Allegation investigated: Staff do not ensure the washer/dryer are working properly.

On 07/01/26, department conducted an unannounced complaint visit at the above named facility. The department met with Administrator, Peggy Clark, and explained the purpose of the visit. LPA was granted access to the facility. The investigation consisted of the following: On 04/23/26, the department received the following documents: staff roster, resident roster, an email thread between resident #1 (R1) and staff, and service requests from CSC Service Works. Additionally, the department conducted a facility tour, inspected the laundry rooms located on both the first and second floors, and conducted interviews with staff #1-#3 (S1-S3) and R1. On 07/01/26, the department conducted interviews with staff #4-#5 (S4-S5) and residents #2-#10 (R2-R10). Continued on LIC9099-C Substantiated The investigation revealed the following: Allegation: Staff do not ensure the washer/dryer are working properly. It is being alleged that the washer and dryer machines don’t work properly. On 04/23/26, and 07/01/26, the department conducted interviews with S1-S5. Of those interviewed, 3 out of 5 staff corroborated with the allegation. 3 out of 5 staff stated that the dryers on the first floor were not functioning properly. Staff reported that multiple drying cycles were often required to fully dry residents' laundry, resulting in delays in laundry services. On 04/23/26, and 07/01/26, the department conducted interviews with R1-R10. Of the 10 residents interviewed, 5 were unable to corroborate the allegation, while 5 corroborated the allegation. On 07/01/26, the Department reviewed service records from CSC Service Works dated 01/08/26, 03/02/26, 03/05/26, 03/17/26, and 04/03/26. The records documented that one or more laundry machines were out of service on those dates. Based on interviews conducted, 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) is being cited on the attached LIC9099-D. An exit interview was conducted and a copy of this report was provided. The investigation revealed the following: Allegation: Staff do not ensure the dryer are/lint screen are kept clean. It is being alleged that the washer and dryer machines are filthy. On 04/23/26, and 07/01/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff said that the washer and dryers are cleaned, and sanitized daily and as needed. On 04/23/26, and 07/01/26, the department conducted interviews with R1-R10. Of those interviewed, 9 out of 10 residents could not corroborate the allegation. 9 out of 10 residents said they are satisfied with the laundry services provided to them. On 04/23/26, the Department conducted a tour of the facility and inspected the laundry rooms located on the first and second floors. During the inspection, all washers and dryers were observed to be clean and sanitary. The Department also observed that the lint screens in each dryer were clean and free of lint. No signs of mold were observed in either laundry room. Based on observation, records reviewed and interviews conducted, there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 1, 2026 · control 11-AS-20260416084352

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 15, 2026

87303(a) Maintenance and Operation: 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 is not met as evidence by: Based on interviews and a review of records the laundry machines are in disrepair.the state’s words, verbatim · CDSS document, Jul 1, 2026

Plan of correction: The licensee will fix the dryers and email proof of correction to Elvira.Gonzalez@dss.ca.gov

Type of visit: Collateral

On 07/01/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Collateral Visit to the facility listed above. LPA met with Peggy Clark, Administrator, and the purpose of today's visit was explained. LPA was granted entry into the facility. LPA conducted a visit to the facility to interview Resident R1 regarding a complaint (11-AS-20260309160817) at their previous residence. During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Peggy Clark, Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 1, 2026

Allegation investigated: Staff restrained a resident to a wheelchair.

***This report supersedes the original report delivered on 04/09/2026. On 5/21/2026, the LPA arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 04/09/2026. *** On 4/9/2026 at 1:07 PM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the allegation. LPA identified herself and met with Veronica Gomez-Administrator, who was informed of the purpose of the visit. The investigation consisted of the following: On 11/10/2025, the Department toured the facility’s kitchen, dining area, and the 1st and 3rd floors. During the kitchen tour, LPA did not observe any crawling or flying insects. The kitchen appeared clean and sanitary. The Department also interviewed Staff 1 through Staff 3 (S1–S3) and Residents 1 and 2 (R1–R2), and obtained documents for review. Substantiated On 4/9/2026 at 1:00 PM, the Department conducted additional interviews with Residents 4 through 6 (R4–R6) and Staff 4 through Staff 9 (S4–S9). Allegation 1: Staff restrained a resident to a wheelchair. Interviews with Staff 1 and Staff 2 indicated that on 9/29/2025, S1 had restrained Resident 1 (R1) in their wheelchair by using the buckle. Staff 3 through Staff 8 (S3–S8) stated that they had not seen any staff restraining residents in their wheelchairs using buckles or any other devices. Some staff said they had heard rumors in the past but had not witnessed anything themselves. On 11/10/2025, LPA attempted to interview Residents 1 and 2 (R1–R2); however, both residents were unable to engage in a clear conversation. On 4/9/2026 at 2:00 PM, LPA interviewed Residents 3 through 9 (R3–R9). All seven residents stated that staff had never restrained them in any way, including in their wheelchairs. During the visit on 4/9/2026, the Department did not observe any residents restrained in their wheelchairs. However, a review of records showed that Resident 1 (R1) sustained injuries consistent with being restrained in their wheelchair. Interviews and record reviews showed that the licensee did not have a physician’s order for postural supports, and such supports should not have been used by staff. Staff 1’s records also indicated that on 9/29/2025 S1 did strap R1 into their wheelchair, which resulted in injuries. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title (22), Division (6) is being cited on the attached LIC9099-D.the state’s words, verbatim · CDSS document, May 21, 2026 · control 11-AS-20251104161938

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5) · Plan of correction due date: Apr 10, 2026

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself..... This requirement was not met as evidenced by:Based on interviews and record review the licensee did not have a physician’s order for Postural Supports and records revealed that on 9/29/2025 S1 did strap R1 to their wheelchair which resulted in injuries to R1 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: The licensee has agreed to provide training to all staff members on the cited regulation and personal rights of residents in care. Proof of training was provided at the time of visit on 04/9/2026 during visit.

Type of visit: Case Management - Other

On 5/21/2026, at 11:00 am, a virtual meeting was held to discuss Complaint 11-AS-20250606143306. Present at the meeting was Eva Alvarez, Licensing Program Manager (LPA), Alfonso Iniguez (LPA), Veronica Gomez Executive Director, Rachel Streicher, Licensee and Joel S Goldman, Attorney. During the meeting, LPM reviewed the details of the Complaint. On February 20,2026 the Department substantiated an allegation(s) of Staff neglect resulting in a resident being hospitalized and Staff did not address a resident's change in medical condition. At the time the findings were delivered on February 20, 2026, the Department indicated that an enhanced civil penalty determination was pending, pursuant to Health and Safety Code Section 1569.49(f). An exit interview was conducted, and an electronic copy of this report was provided to Veronica Gomez via email.the state’s words, verbatim · CDSS document, May 21, 2026

Allegation investigated: Staff did not provide adequate supervision to resident in care

This report supersedes the report created 4/7/26 and the findings will remain unchanged. On 4/30/2026, at approximately 2:00 PM, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Veronica Gomez/Facility Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: the department conducted the following interviews: Assistant Administrator interview, (A#1), Residents Interviews (R#1-R#8), Witness Interview (W#1) and Staff interview (S#1-S#4). The department gathered the following documents: copy of personnel schedule dated 4/7/26, copy of resident roster dated:4/7/26, copy of (R#1) admission agreement dated: 6/2/2025, copies of facility staff internal incident reports various dates, copy of (R#1) face sheet, copy of (R#1) resident appraisal or LIC 603A dated: 2/18/2026, copy of (R#1) appraisal needs and services plan or LIC 625 dated 2/18/2026, copy of (R#1) physician report for residential care facilities for the elderly (RCFE) or LIC 602A dated:5/30/25 and copies of facility management risk assessment and negotiated risk assessment dated 5/25/25. Evaluation Report continues LIC 9099-C Unsubstantiated This report supersedes the report created 4/7/26 and the findings will remain unchanged. Investigation Revealed the Following: Allegation: Staff did not provide adequate supervision to resident in care The details of the complaint alleged that facility staff are not providing adequate supervision to (R#1) On April 7, 2026, at approximately 3:00 p.m., during the records review process the department reviewed a copy of (R#1)’s Admission Agreement dated 6/2/2025. The department noted that (R#1)’s personal representative signed for basic services only, which include care and supervision, personal assistance and care, and continuous monitoring and observation. The agreement also states that extra care and supervision are available upon request for an additional charge. The department noted that, in this case, the facility has been providing 1:1 care and supervision to (R#1) without charging (R#1)’s personal representative for the additional service. In addition, the department reviewed copies of the facility’s internal incident reports regarding (R#1), documented on various dates, and noted that the facility has recorded all incidents involving (R#1). The department also reviewed a copy of (R#1)’s Resident Appraisal (LIC 603A) dated 2/18/2026, which indicates that (R#1) requires assistance with transferring in and out of bed, bathing, redirection inside the facility, special diet needs, toileting, continence care, medication assistance, and other services as needed. On April 7, during an interview with the facility administrator (A#1), (A#1) stated that the facility provides supervision to residents based on their assessed needs. For residents receiving the basic rate, staff check on them every hour. Residents with higher levels of care are checked every 30 minutes to one hour. (A#1) stated that (R#1) receives one-on-one supervision. in addition, (A#1) further explained that although one-on-one supervision typically requires an additional charge, (R#1)’s family is not paying for this service, and the facility is providing it “out of good faith.” (A#1) stated that (R#1) has one-on-one care and supervision in place and is identified as a fall risk. (A#1) added that (R#1)’s primary physician’s nurse comes to the facility every day to check on her. Moreover, (A#1) stated that the facility has a supervisor on every shift. Staff reports all resident events, including incidents involving (R#1), to the shift supervisor, who is responsible for documenting and evaluating the occurrence. This report supersedes the report created 4/7/26 and the findings will remain unchanged. On April 7, during interviews with residents in care (R#2 through R#8), (7) out of (7) residents stated that staff supervise them appropriately. Residents reported that staff “do a very good job” and check on them regularly. All residents interviewed stated that they had never felt they were not being watched, helped, or supervised when needed. In addition, (7) out of (7) residents also reported no issues with staff being unavailable, delayed, or unresponsive, stating that staff are always present to assist them. On April 7, 2026, during interviews with facility staff (S#1 through S#4),(4) out of (4) facility staff stated that they provide supervision to residents according to their needs, including (R#1), they also reported that their responsibilities include assisting residents with changing clothes, changing diapers, and preparing residents for meals. In addition, they stated that staff consistently provide supervision due to residents’ cognitive impairments and reported that (R#1)’s behavioral expressions require staff to be more aware of her needs and provide close monitoring. Moreover, (4) out of (4) facility staff stated that they have not observed any challenges or gaps in maintaining appropriate supervision for (R#1) or for any other residents in care. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Veronica Gomez/ Facility Administrator.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 11-AS-20260330112011

Allegation investigated: Staff did not keep facility free of insects.

On 4/9/2026 at 1:07 PM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver the findings for the alleged allegations. LPA identified herself and met with Veronica Gomez, who was informed of the purpose of the visit.The investigation consisted of the following: On 11/10/2025, the Department toured the facility’s kitchen, dining area, and the 1st and 3rd floors. During the kitchen tour, LPA did not observe any crawling or flying insects. The kitchen appeared clean and maintained in a sanitary condition. The Department conducted interviews with Staff 1 through Staff 3 (S1–S3) and Residents 1 and 2 (R1–R2), and obtained pertinent documents for review. On 4/9/2026 at 1:00 PM, the Department conducted additional interviews with Staff 4 through Staff 8 (S4–S8) and Residents 3 through 9 (R3–R9). Unsubstantiated The investigation revealed the following: Allegation 2: Staff did not keep facility free of insects. On 11/10/2025, LPA attempted to interview Residents 1 and 2 (R1–R2); however, both residents were unable to engage in a clear conversation. On 4/9/2026 at 2:00 PM, LPA conducted interviews with Residents 3 through 9 (R3–R9). All seven residents interviewed stated that staff keep the facility free of insects by cleaning daily, and that when insect concerns arise, Innovative Pest Control is contacted. A copy of the pest control service receipt dated 12/5/2024 was provided for review. The Department also conducted interviews with Staff 1 through Staff 8 (S1–S8). All eight staff interviewed stated that they ensure the facility remains free from insects and reported that they have not observed or received reports of insects in residents’ food. During the visit, LPA did not observe any crawling or flying insects. Based on the interviews, records reviewed, and observations, the Department found no evidence to support the allegation. While the allegation may be valid or may have occurred, there is insufficient evidence to determine whether the alleged violation did or did not take place. Therefore, the allegation is determined to be Unsubstantiated. An exit interview was conducted, and this report was discussed with and provided to Veronica Gomez, Administrator, at the conclusion of the visit, along with appeal rights.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 11-AS-20251104161938

Allegation investigated: Staff restrained a resident to a wheelchair.

On 4/9/2026 at 1:07 PM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the allegation. LPA identified herself and met with Veronica Gomez, who was informed of the purpose of the visit. The investigation consisted of the following: On 11/10/2025, the Department toured the facility’s kitchen, dining area, and the 1st and 3rd floors. During the kitchen tour, LPA did not observe any crawling or flying insects. The kitchen appeared clean and sanitary. The Department also interviewed Staff 1 through Staff 3 (S1–S3) and Residents 1 and 2 (R1–R2), and obtained documents for review. On 4/9/2026 at 1:00 PM, the Department conducted additional interviews with Residents 4 through 6 (R4–R6) and Staff 4 through Staff 9 (S4–S9). Substantiated Allegation 1: Staff restrained a resident to a wheelchair. Interviews with Staff 1 and Staff 2 indicated that S1 had restrained Resident 1 (R1) in their wheelchair by using the buckle. Staff 3 through Staff 8 (S3–S8) stated that they had not seen any staff restraining residents in their wheelchairs using buckles or any other devices. Some staff said they had heard rumors in the past but had not witnessed anything themselves. On 11/10/2025, LPA attempted to interview Residents 1 and 2 (R1–R2); however, both residents were unable to engage in a clear conversation. On 4/9/2026 at 2:00 PM, LPA interviewed Residents 3 through 9 (R3–R9). All seven residents stated that staff had never restrained them in any way, including in their wheelchairs. During the visit on 4/9/2026, the Department did not observe any residents restrained in their wheelchairs. However, a review of records showed that Resident 1 (R1) sustained injuries consistent with being restrained in their wheelchair. Interviews and record reviews showed that the licensee did not have a physician’s order for postural supports, and such supports should not have been used by staff. Staff 1’s records confirmed that S1 did strap R1 into their wheelchair, which resulted in injuries. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title (22), Division (6) is being cited on the attached LIC9099-D.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 11-AS-20251104161938

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5) · Plan of correction due date: Apr 9, 2026

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself..... This requirement was not met as evidenced by:Based on interviews and record review the licensee did not have a physician’s order for Postural Supports and records revealed that S1 did strap R1 to their wheelchair which resulted in injuries to R1. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: The licensee has agreed to provide training to all staff members on the cited regulation and personal rights of residents in care. Proof of training was provided at the time of visit on 11/11/2025 during visit.

Allegation investigated: Staff did not provide 60-days notice prior to rent increase. Staff do not keep an accurate care record. Facility admission agreement does not have eviction or rent increase procedure.

On 4/9/2026 at 8:30AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver the findings for the alleged allegations. LPA identified herself and met Veronica Gomez who was informed of the purpose of the visit. The investigation consisted of the following: On 4/8/2026, the Department requested and received the resident and staff roster dated 4/8/2026, Record review for Resident 1(R1) which included the following documents: Admissions agreement dated 3/23/2023, Appraisals, Hospice notes/records from Valley Best Care, Inc, physicians’ reports & needs and service plans for the year 2023,2024,2025. Medication list and MAR (Medication Administration Record) and conducted interviews with ten (10) residents and ten (10) staff members. Continued Unsubstantiated The investigation revealed the following: Allegation 1: Staff did not provide 60-days’ notice prior to rent increase. On 4/8/2026 at 8:45 AM, the department reviewed documents and resident 1(R1) file which revealed in the admission agreement signed and dated 3/23/2023 and addendums dated 3/20/2023 which does disclose the responsibilities of the resident and/or responsible parties signed and dated on 3/17/2023, the department also observed documentation of 60-day notices for the monthly rent change with effective dates of January 1,2024 and January 1,2025 and Valley Best Care Inc. hospice care files which reflect that care was provided from 12/7/2023-9/11/2025. At 2:00-5:00 PM, the department attempted to interview resident1 (R1) but they no longer live at the facility while residents 2- 4 (R2-R4) stated that they were not sure because their representatives handle their personal business with facility. Residents 6- 10 (R6-R10) stated that they do receive notification of monthly increase in writing annually and that they were aware of this information being within their admission agreement. The department also conducted interviews with ten (10) Staff members (S1-S10) and 4 out of 10 staff stated that they were not sure if a 60day notice of rent increase is given to residents in care and the remaining 6 staff members (S6-S10) stated residents and/or their representatives are informed annually about their monthly increase in writing which is also in their admission agreements. On 4/9/2026 at 12:30PM, During the visit the department reviewed 5 residents files for current documentation that reflect 60-day notices of annual rent increase/eviction which is within admission agreements, and current care records and based on the observations all 5 files were up to date. The investigation revealed the following: Allegation 2: Staff do not keep an accurate care record. On 4/8/2026 at 8:45 AM, the department reviewed documents and resident 1(R1) file which revealed in the admission agreement signed and dated 3/23/2023 and addendums dated 3/20/2023 which does disclose the responsibilities of the resident and/or responsible parties signed and dated on 3/17/2023, the department also observed documentation of 60-day notices for the monthly rent change with effective dates of January 1,2024 and January 1,2025 and Valley Best Care Inc. hospice care files which reflect that care was provided from 12/7/2023-9/11/2025. At 2:00-5:00 PM, the department attempted to interview resident1 (R1) but they no longer live at the facility while residents 2- 4 (R2-R4) stated that they were not sure if the facility keeps accurate care records because their representatives handle their personal business/care with facility. Residents 6- 10 (R6-R10) express confidence that the facility staff does keep accurate care records. The department also conducted interviews with ten (10) Staff members (S1-S10) and 4 out of 10 staff expressed confidence that residents are accurate. Staff reported that when residents have a change of condition Medtech’s are informed and documented and if required needs and service plans are updated. On 4/9/2026 at 12:30PM, During the visit the department reviewed 5 residents files for documentation that reflect 60-day notices of annual rent increase/eviction which is within admission agreements, and current care records and based on the observations all 5 files were up to date. LPA also attempted to contact Valley Best Care, Inc., but the department was unable to speak to a representative during the investigation. The department did however review Valley Best Care Inc. hospice care files which reflect that care was provided from 12/7/2023-9/11/2025. The investigation revealed the following: Allegation 3: Facility admission agreement does not have eviction or rent increase procedure. On 4/8/2026 at 8:45 AM, the department reviewed documents and resident 1(R1) file which revealed in the admission agreement signed and dated 3/23/2023 and addendums dated 3/20/2023 which does disclose the responsibilities of the resident and/or responsible parties signed and dated on 3/17/2023, the department also observed documentation of 60-day notices for the monthly rent change with effective dates of January 1,2024 and January 1,2025 and Valley Best Care Inc. hospice care files which reflect that care was provided from 12/7/2023-9/11/2025. At 2:00-5:00 PM, the department attempted to interview resident1 (R1) but they no longer live at the facility while residents 2- 4 (R2-R4) stated that they were not sure because their representatives handle their personal business with facility. Residents 6- 10 (R6-R10) stated that their admissions agreement does reflect the annual monthly increase, and 60-day notices are given to them in writing in advance. Continued The department also conducted interviews with ten (10) Staff members (S1-S10) and 4 out of 10 staff stated that they were not sure if resident admissions agreements list the procedures for eviction/ 60day notice of rent increase and the remaining 6 staff members (S6-S10) stated residents and/or their representatives are informed annually about their monthly increase in writing which is also in their admission agreements. On 4/9/2026 at 12:30PM, During the visit the department reviewed 5 residents files for documentation that reflect 60-day notices of annual rent increase/eviction which is within admission agreements, and current care records and based on the observations all 5 files were up to date. Based on the interviews, records reviewed and observations the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is determined to be Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Veronica Gomez-Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 11-AS-20260402163419

Allegation investigated: Staff did not provide adequate supervision to resident in care

On 4/7/2026, at approximately 10:00 AM, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met with Veronica Gomez/Facility Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: the department conducted the following interviews: Assistant Administrator interview, (A#1), Residents Interviews (R#1-R#8), Witness Interview (W#1) and Staff interview (S#1-S#4). The department gathered the following documents: copy of personnel schedule dated 4/7/26, copy of resident roster dated:4/7/26, copy of (R#1) admission agreement dated: 6/2/2025, copies of facility staff internal incident reports various dates, copy of (R#1) face sheet, copy of (R#1) resident appraisal or LIC 603A dated: 2/18/2026, copy of (R#1) appraisal needs and services plan or LIC 625 dated 2/18/2026, copy of (R#1) physician report for residential care facilities for the elderly (RCFE) or LIC 602A dated:5/30/25 and copies of facility management risk assessment and negotiated risk assessment dated 5/25/25. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff did not provide adequate supervision to resident in care The details of the complaint alleged that facility staff are not providing adequate supervision to (R#1) On April 7, 2026, at approximately 3:00 p.m., during the records review process the department reviewed a copy of (R#1)’s Admission Agreement dated 6/2/2025. The department noted that (R#1)’s personal representative signed for basic services only, which include care and supervision, personal assistance and care, and continuous monitoring and observation. The agreement also states that extra care and supervision are available upon request for an additional charge. The department noted that, in this case, the facility has been providing 1:1 care and supervision to (R#1) without charging (R#1)’s personal representative for the additional service. In addition, the department reviewed copies of the facility’s internal incident reports regarding (R#1), documented on various dates, and noted that the facility has recorded all incidents involving (R#1). The department also reviewed a copy of (R#1)’s Resident Appraisal (LIC 603A) dated 2/18/2026, which indicates that (R#1) requires assistance with transferring in and out of bed, bathing, redirection inside the facility, special diet needs, toileting, continence care, medication assistance, and other services as needed. Moreover, the department reviewed a copy of (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A) dated 5/30/2025. The department noted that the physician indicated (R#1) has a diagnosis that contributes to their thinking and belief system. On April 7, during an interview with the facility administrator (A#1), (A#1) stated that the facility provides supervision to residents based on their assessed needs. For residents receiving the basic rate, staff check on them every hour. Residents with higher levels of care are checked every 30 minutes to one hour. (A#1) stated that (R#1) receives one-on-one supervision. in addition, (A#1) further explained that although one-on-one supervision typically requires an additional charge, (R#1)’s family is not paying for this service, and the facility is providing it “out of good faith.” (A#1) stated that (R#1) has one-on-one care and supervision in place and is identified as a fall risk. (A#1) added that (R#1)’s primary physician’s nurse comes to the facility every day to check on her. Evaluation Report continues LIC 9099-C Moreover, (A#1) stated that the facility has a supervisor on every shift. Staff reports all resident events, including incidents involving (R#1), to the shift supervisor, who is responsible for documenting and evaluating the occurrence. On April 7, during an interview with Witness 1 (W#1), (W#1) stated that during her visits to (R#1), she observed (R#1) in her room with the curtains closed and not participating in daily activities. (W#1) reported finding (R#1) in bed, not fully clothed, wearing only a diaper, and uncovered. (W#1) stated that she asked (R#1) if she was okay, and (R#1) replied, “I’m cold.” (W#1) reported that during one visit, it was already 10:00 a.m., and (R#1) was still in bed and had not eaten anything. (W#1) stated that she typically visits between 10:00 a.m. and 12:00 p.m. once a week. In addition, (W#1) stated that during the times she has visited, she has noticed that facility staff are not available most of the time. (W#1) stated that she is only aware of the conditions she has personally observed during her weekly visits and stated that during those times, she has observed occasions where (R#1) did not appear to be adequately cared for. On 4/7/26, the department was not able to speak with (R#1) due to their cognitive impairment. On April 7, during interviews with residents in care (R#2 through R#8), (7) out of (7) residents stated that staff supervise them appropriately. Residents reported that staff “do a very good job” and check on them regularly. All residents interviewed stated that they had never felt they were not being watched, helped, or supervised when needed. In addition, (7) out of (7) residents also reported no issues with staff being unavailable, delayed, or unresponsive, stating that staff are always present to assist them. On April 7, 2026, during interviews with facility staff (S#1 through S#4),(4) out of (4) facility staff stated that they provide supervision to residents according to their needs, including (R#1), they also reported that their responsibilities include assisting residents with changing clothes, changing diapers, and preparing residents for meals. Evaluation Report continues LIC 9099-C In addition, they stated that staff consistently provide supervision due to residents’ cognitive impairments and reported that (R#1)’s behavioral expressions require staff to be more aware of her needs and provide close monitoring. Moreover, (4) out of (4) facility staff stated that they have not observed any challenges or gaps in maintaining appropriate supervision for (R#1) or for any other residents in care. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Veronica Gomez/ Facility Administrator.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 11-AS-20260330112011

Type of visit: Required - 1 Year

On 03/06/26 Licensing Program Analysts (LPAs) Day and Villegas conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPAs met with Veronica Gomez, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 262 residents ages 60 and over, of which 262 maybe non ambulatory and 10 maybe bedridden. The facility has an approved hospice waiver for 10 residents. Facility fees are current, liability insurance is active (PLC7094972231 exp: 02/28/27). LPA's obtained a copy of current lease agreement for the facility. The facility is a large, two story, building located in a commercial neighborhood. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of (2) floors which include resident rooms, common areas, dining area, kitchen, salon, game room and employee break room, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of (2) floors, resident rooms, dining area, common area, a theater, and delayed egress doors. The facility has a signal system with a switch board located in the reception area and is operational from all residential living quarters. Common areas were clean and clear of hazards, doorways were free of obstructions, there are no bodies of water nor weapons on the premises. LPAs toured the following resident bedrooms # 105, 104, 112, 301A, 301B, 303 and 305 and observed all required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 107.2F.. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Fire and safety service conducted on 02/27/26, LBFD fire protection and life safety equipment performance certificate obtained on 05/09/25. Fire extinguishers observed throughout the facility, first aid kit and manual are available. LPAs reviewed (10) resident files, (7) medication administration records (MAR), and (5) staff files. No Deficiencies were observed during this visit. Exit interview conducted with Veronica Gomez, Administrator. A copy of this report was provided at time of visit.the state’s words, verbatim · CDSS document, Mar 6, 2026

Allegation investigated: Staff neglect resulted in a resident being hospitalized. Staff did not address a resident's change in medical condition.

On 2/20/2026 LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Veronica Gomez/ Executive Director. LPA explained the purpose of this visit. Investigation Consisted of the department conducted the following interviews: Administrator Interview (A#1), Resident Interviews (R#1), and Facility Staff Interviews (S#1-S#2). The department gathered the following documentation: Copy of (R#1)’s hospital records dated: 2/4/25, and 1/19/2025, copy of (R#1)’s Appraisal or LIC 603A dated:6/1/25, and copy of (R#1)’s physician report or LIC 602A dated:5/23/24. Evaluation Report continues LIC 9099-C Substantiated Investigation Revealed the Following: Allegation: Staff did not address a resident's change in medical condition The details of this complaint alleges that the facility failed to re-assess (R#1) after multiple falls. On October 30, 2025, the department conducted a review of medical records and found the following: On January 19,2025, (R#1) was transported to Long Beach Medical Center after slipping out of their wheelchair while attempting to use the restroom. The hospital performed imaging tests that revealed no fractures. (R#1) was discharged the same day. On February 4, 2025, (R#1) sustained a facial contusion from an unwitnessed fall in the facility and was admitted to Los Angeles Community Hospital for treatment and discharged February 7,2025. On April 5, 2025, (R#1) sustained a hematoma due to hitting their head when transferring from their wheelchair to their bed. (R#1) received treatment at Long Beach Memorial Hospital and was discharged the same day. On May 31, 2025, (R#1) experienced a mechanical fall in their bathroom and complained of shoulder pain. (R#1) was transported to Los Angeles Community Hospital. During this visit, imaging tests revealed that (R#1) sustained a closed, displaced fracture of the right clavicle. (R#1) was discharged the same day with documentation indicating orthopedic surgery would be scheduled. On June 5, 2025, (R#1) returned to the hospital due to injury-related pain. On June 17, 2025, the department conducted an interview with (R#1), who stated they have vertigo and a fall risk. (R#1) confirmed they have experienced falls in the facility and injuries as a result of the falls. On September 2, 2025, the department conducted an interview with the assistant administrator (A#1), who stated (R#1)’s Needs and Services Plan and care plan were not updated after (R#1)’s falls. Evaluation Report continues LIC 9099-C On June 17, 2025, the department conducted an interview with (R#1), who stated they have vertigo and a fall risk. (R#1) confirmed they have experienced falls in the facility and injuries as a result of the falls. On September 2, 2025, the department conducted an interview with the assistant administrator (A#1), who stated (R#1)’s Needs and Services Plan and care plan were not updated after (R#1)’s falls. On September 2, 2025, the Department interviewed two facility caregivers, (S#1) and (S#2), regarding the care and supervision of (R#1). (S#1) reported that the only change (S#1) recalled was relocating (R#1) from the second floor to a first-floor room. (S#1) confirmed they received no additional instructions or updates regarding (R#1)’s care, supervision, or monitoring requirements. Similarly, (S#2) reported that they were only told to “keep a close eye” on (R#1) but received no formal or detailed instructions regarding changes to (R#1)’s supervision or care plan following the falls. Both staff members denied being informed of any structured plan to address (R#1)’s fall risk, and neither reported receiving training or direction specific to (R#1)’s condition or needs. Evaluation Report continues LIC 9099-C On September 2, 2025, the Department interviewed two facility caregivers, (S#1) and (S#2), regarding the care and supervision of (R#1). (S#1) reported that the only change (S#1) recalled was relocating (R#1) from the second floor to a first-floor room. (S#1) confirmed they received no additional instructions or updates regarding (R#1)’s care, supervision, or monitoring requirements. Similarly, (S#2) reported that they were only told to “keep a close eye” on (R#1) but received no formal or detailed instructions regarding changes to (R#1)’s supervision or care plan following the falls. Both staff members denied being informed of any structured plan to address (R#1)’s fall risk, and neither reported receiving training or direction specific to (R#1)’s condition or needs. Allegation: Staff neglect resulted in a resident being hospitalized The details of the complaint allege that facility staff failed to appropriately respond to changes in condition for (R#1), following multiple falls. On October 30, 2025, the department conducted a review of medical records and found the following: On January 19,2025, (R#1) was transported to Long Beach Medical Center after slipping out of their wheelchair while attempting to use the restroom. On February 4, 2025, (R#1) sustained a facial contusion from an unwitnessed fall in the facility and was admitted to Los Angeles Community Hospital for treatment. On April 5, 2025, (R#1) sustained a hematoma due to hitting their head when transferring from their wheelchair to their bed. (R#1) received treatment at Long Beach Memorial Hospital. On May 31, 2025, (R#1) experienced a mechanical fall in their bathroom and complained of shoulder pain. (R#1) was transported to Los Angeles Community Hospital. During this visit, imaging tests revealed that (R#1) sustained a closed, displaced fracture of the right clavicle. Evaluation Report continues LIC 9099-C During this investigation, the department found sufficient evidence to support the above-mentioned allegation(s). Therefore, the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). *Immediate Civil Penalty issued* At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident. An exit interview was conducted, and a copy of the Complaint Report was given to Veronica Gomez/Executive Director.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 11-AS-20250606143306

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 23, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement was not met as evidence by: Based on interviews and record review, the licensee failed to ensure that the facility did not complete (R#1)’s Needs and Services Plan each time they return from the hospital and there was not written documentation on the treatment plan changes after each incident. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 20, 2026

Plan of correction: The licensee will adhere to Title 22 regulations at all times. As a plan of correction, the facility will follow a new system that will allow facility staff record chek-ins of the residents. A proof of this correction will be sent to LPA Iniguez via email.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 23, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: Based on interviews and record review, the licensee failed to ensure that (R#1) was provided with the necessary care and services to prevent them from falling a few times. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 20, 2026

Plan of correction: The licensee will adhere to Title 22 regulations at all times. As a plan of correction, the facility will follow a new system that will allow facility staff record chek-ins of the residents. A proof of this correction will be sent to LPA Iniguez via email.

Allegation investigated: Staff did not assist resident with exercising Staff did not assist resident with using the stairs

On 02/19/2026 around 8AM, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent visit to deliver findings regarding the above allegations; this report supersedes the initial investigation visit conducted on 12/18/2025. LPA met with Administrator Veronica Gomez. The investigation consisted of the following: LPA toured the entire facility, observed resident rooms and common areas, and requested facility records for review. Records reviewed included two resident files, a personnel report dated 09/01/2025, a resident roster dated 12/15/2025, activities posters, and the incident report for Resident R1 dated 12/11/2025. LPA also interviewed 10 staff members (S1–S10), 11 residents (R1–R11), and two witnesses (W1–W2). On 02/19/2026 doctors discharge records & psychiatric consultation notes were retrieved and analyzed for investigation. Regarding the allegation staff did not assist resident with exercising It is alleged that R1 was not receiving appropriate assistance with exercise. Please see (LIC9099-C) for report continuation. Unsubstantiated Observations revealed the following: During the tour, the LPA observed activity posters with daily exercise schedules prominently displayed and one activity happening in the activity area with residents participating. Records Review: LPA reviewed the Resident Appraisal which confirmed R1 "Exercises Daily" and Enjoys Group Activities. Medical Records: A Discharge Summary dated (01/02/2026) showed that R1 had recently improved health after being treated for heart and lung issues. The records show "highly involved" in activities. While mostly independent, staff help with "guided maneuvering," which means they help move her arms and legs during exercises to keep safe. Interviews: 10 out of 10 staff members (S1–S10) interviewed disagreed with the allegation. S6 stated that exercise videos and scheduled sessions are provided daily. Residents R1 and R2 indicated they participate in volleyball and daily exercises. Interviews with 10 residents (R1–R10) disagreed with the allegation. Witness W1 mentioned speaking with R1 regarding their enjoyment of the facility’s yoga and other activities participated in facility. During this investigation, the LPA did not find sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred; therefore, the allegation is unsubstantiated. Regarding the allegation “staff is not assisting resident with exercising” It is alleged that the resident was not being assisted when walking down the stairs. Observations revealed the following: LPA verified and tested two functional elevators available for resident use. No residents were observed utilizing stairs during the course of the investigation. Interviews revealed the following: Staff members S5 and S8 indicated that residents utilize two facility elevators for floor-to-floor transport, as stairs are considered hazardous and are not the primary means of egress for residents. While R1 shared concerns of feeling "secondary," they acknowledged receiving staff help and stated they use the elevator rather than the stairs. Records Review: The Resident Appraisal noted R1 has "Improved Physically" and "can ambulate independently." The Physician’s Report verified R1's status as "Ambulatory." Facility records show the resident is independent in mobility with the use of a walker and does not have a physician-mandated requirement for stair assistance. Because of recovering from breathing problems, using the elevator was actually the safest choice for health. There was no medical requirement to use the stairs, and was able to move around the facility safely without that specific help. During this investigation, the LPA did not find sufficient evidence to support the above-mentioned allegation. Please see (LIC9099-C) for report continuation. Based on the evidence gathered, interviews conducted, and records reviewed, there is not a preponderance of evidence to prove the alleged violation occurred; therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of the Complaint Report was provided to Administrator Veronica Gomez.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 11-AS-20251215114118

Allegation investigated: Staff sexually assaulted a resident while in care

On 10/24/2025 LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Peggy Clark/ Facility Administrator. LPA explained the purpose of this visit. Investigation Consisted of: the department conducted the following interviews: Administrator Interview (A#1), Resident Interviews (R#1-R#4), Facility Staff Interviews (S#1-S#5), and Witness Interview (W#1). The department gathered the following documentation: Copy of Long Beach Policy Department (LBPD) report #250025649 and Sexual Assault Forensic Medical Exam (SART) dated:6/8/25 and copy of (R#1)'s Physician's report for Residential Care Facilities for the Elderly (RCFE) dated 6/9/25. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff sexually assaulted a resident while in care The details of the complaint alleged that facility staff (S#1) sexually assaulted (R#1) at the facility. On October 17, 2025, at approximately 1:00 PM, during a records review, the department found a copy of Long Beach Police Department (LBPD) report #250025649, dated June 8, 2025. This report details an incident where, on June 8, 2025, at around 4:00 PM, LBPD officers responded to a memory care unit following a report of sexual assault. The report indicated that the victim (R#1) claimed to have been sexually assaulted by the suspect (S#1). LBPD officers interviewed (R#1), who stated that approximately three weeks prior, (S#1) had entered their room twice to administer medication once around 9:00 PM and again around 10:00 PM. (R#1) mentioned that the following morning, they woke up experiencing significant vaginal pain. During the interview, (R#1) provided a tissue that they had used to clean their private area. A Sexual Assault Forensic Medical Exam (SART) was subsequently performed on (R#1), but the examination revealed no physical findings. Additionally, the department reviewed the copy of (R#1)'s Physician's report for Residential Care Facilities for the Elderly (RCFE) dated 6/9/25. The department observed that (R#1) has a cognitive impairment that might influence their decision-making and behavior. On 8/28/25, at approximately, 9:45 am, the Department interviewed facility administrator (A#1), she stated that when (R#1) move into the facility, they were placed in the assisted living section, however, it was determined that (R#1) needed a higher level of care, therefore, (R#1) transitioned to the memory care unit and resided there for approximately four weeks before moving out. Evaluation Report continues LIC 9099-C On September 4, 2025, at approximately 11:00 AM, the Department interviewed Facility Staff #1 (S#1), who confirmed that they were the medication technician assigned to the Memory Care Unit (MC1), where Resident #1 (R#1) resided. At around 7:00 PM, (S#1) attempted to administer medication to (R#1), who refused to take it. The medication was subsequently discarded, and the refusal was documented in the electronic log. (S#1) denied having any physical contact with (R#1) during that shift or previous shifts. (S#1) also denied the allegation of sexual assault, expressing confusion and attributing the claim to (R#1)'s cognitive impairment and possibly the missed medication. On August 4, 2025, at approximately 3:00 PM, the Department interviewed Witness #1 (W#1). (W#1) stated that (R#1) had lived at the facility for about six weeks. (R#1) initially moved into the assisted living unit but was later transferred to the memory care unit for 24-hour care. (W#1) reported being notified of the incident by the police. When asked, (R#1) told (W#1) that someone was entering their room and sexually assaulting them. (W#1) expressed doubt about the allegations but chose to wait for the results of the Sexual Assault Forensic Medical Exam (SART). (W#1) also recalled that about two weeks after (R#1) moved in, (R#1) made a similar disclosure but was unable to provide further details. (W#1) believed the statements may have been influenced by (R#1)’s cognitive impairment. On August 5, 2025, at approximately 10:00 am, the Department interviewed Resident #1 (R#1), who was unable to recall how long they had lived at the facility. (R#1) shared that before admission, they had experienced a fall that resulted in hospitalization, after which they began noticing a gradual memory decline. When asked if they knew the reason for the interview, (R#1) stated they did not. When asked if anything had occurred to them at the facility, (R#1) stated that several things had happened during their stay. (R#1) reported believing they had been sexually assaulted, explaining that they noticed some residue coming from their private area. (R#1) was unable to recall any additional details about the alleged assailant or the incident. Evaluation Report continues LIC 9099-C On August 28, 2025, at approximately 11:00 am, the Department interviewed residents 2-4 (R#2-R#4), (2) out of (3) stated that they feel safe living at the facility and the facility staff are ‘good’ to them. On August 28, 2025, at approximately 10:00 am, the Department interviewed facility staff 2-5 (S#2-S#5), (4) out of (4) stated that they have never observed (S#1) or other facility staff interact inappropriately with (R#1) or any other residents in care. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Peggy Clark/Administrator.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 11-AS-20250610120640

Allegation investigated: Licensee does not ensure that staff have criminal clearance

On 10/24/2025 at approximately 2:00 PM, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Peggy Clark/Administrator. LPA Iniguez explained the purpose of this visit is to clarify the findings of the complaint report created on 10/10/25. This report supersedes the report created 10/10/25 and the findings will remain unchanged. Investigation Consisted of: LPA conducted the following interviews: Administrator(A#1). LPA obtained and reviewed the following documents: Client Roster dated: 10/1/25, Personnel Report or LIC 500 dated: 9/1/25. Evaluation Report continues LIC 9099-C Unsubstantiated This report supersedes the report created 10/10/25 and the findings will remain unchanged. Investigation Revealed the Following: Allegation: Licensee does not ensure that staff have criminal clearance The detail of the complaint alleges that (MW#1) is using another person's name and criminal background clearance to work at the facility. On October 10, 2025, at approximately 1:00 PM, during a review of facility records, Licensing Program Analyst (LPA) Iniguez reviewed the Personnel Report (LIC 500) dated September 1, 2025. Upon review, LPA Iniguez observed that (MW#1) was not listed on the LIC 500. On October 10, 2025, at approximately 10:00 AM, during an interview, the facility administrator (A#1) stated that individual (MW#1) is an outside contractor hired by the facility owner and is not a facility employee. According to (A#1), (MW#1) is present at the facility approximately four times per week and remains on-site for about seven hours per visit. (A#1) confirmed that (MW#1) performs contracted maintenance work inside the facility. Additionally, (A#1) stated that when (MW#1) is inside the facility, they are never alone inside residents’ rooms and always work in the common areas, where there is consistent supervision by facility staff. On October 10, 2025, at approximately 11:00 AM, during interviews with facility staff, (5) out of (5) staff members stated that they are familiar with individual (S#1) and observe them at the facility approximately three to four times per week. Additionally, all five staff members reported that whenever they have seen (S#1), the individual is observed in the common areas where there is consistent supervision by facility staff. Staff further stated that when residents request the maintenance person to enter their rooms, (S#1) is never unaccompanied, there is always a caregiver present during those instances. Evaluation Report continues LIC 9099-C This report supersedes the report created 10/10/25 and the findings will remain unchanged. During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Peggy Clark/Administrator.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 11-AS-20250811090913

Allegation investigated: Licensee does not ensure that staff have criminal clearance

On 10/10/2025 at approximately 9:00 AM, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Veronica Gomez/Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator(A#1). LPA obtained and reviewed the following documents: Client Roster dated: 10/1/25, Personnel Report or LIC 500 dated: 9/1/25. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Licensee does not ensure that staff have criminal clearance The detail of the complaint is alleging a maintenance worker is associated with a false name and criminal record clearance number. On October 10, 2025, at approximately 1:00 PM, during a review of facility records, Licensing Program Analyst (LPA) Iniguez reviewed the Personnel Report (LIC 500) dated September 1, 2025. Upon review, LPA Iniguez observed that (MW#1) was not listed on the LIC 500 since they are a third party provider. On October 10, 2025, at approximately 10:00 AM, during an interview, the facility administrator (A#1) stated that individual (MW#1) is an outside contractor hired by the facility owner and is not a facility employee. According to (A#1), (MW#1) is present at the facility approximately four times per week and remains on-site for about seven hours per visit. (A#1) confirmed that (MW#1) performs contracted maintenance work inside the facility. Additionally, (A#1) stated that when (MW#1) is inside the facility, they are never alone inside residents’ rooms and always work in the common areas, where there is consistent supervision by facility staff. On October 10, 2025, at approximately 11:00 AM, during interviews with facility staff, (5) out of (5) staff members stated that they are familiar with individual (MW#1) and observe them at the facility approximately three to four times per week. Additionally, all five staff members reported that whenever they have seen (MW#1), the individual is observed in the common areas where there is consistent supervision by facility staff. Staff further stated that when residents request the maintenance person to enter their rooms, (MW#1) are never unaccompanied, there is always a caregiver present during those instances. Evaluation Report continues LIC 9099-C During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Veronica Gomez/Administrator.the state’s words, verbatim · CDSS document, Oct 10, 2025 · control 11-AS-20250811090913

Type of visit: Case Management - Incident

On October 10, 2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management visit. LPA Iniguez met with Facility Administrator Veronica Gomez and explained the purpose of the visit. During a subsequent complaint investigation related to complaint control number 11-AS-20250811090913, LPA Iniguez discovered through interviews with the facility administrator (A#1) and facility staff (S#2–S#6) that individual (MW#1) comes to the facility approximately four to five times per week and spends about six hours per day on-site during each visit. LPA Iniguez informed the facility administrator that it could be a potential issue for an outside contractor to spend that amount of time at a licensed facility without having a criminal background clearance, as required by applicable regulations. As a result, a Technical Violation was issued during this visit. A copy of this report was provided to Veronica Gomez, Facility Administrator.the state’s words, verbatim · CDSS document, Oct 10, 2025

Allegation investigated: Licensee does not ensure that staff have criminal clearance

On August 20, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted an initial visit to gather information regarding the above allegation. LPA met with Veronica Gomez, Administrator, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 8/20/2025 LPA obtained and reviewed requested Resident Roster (dated 8/12/25), staff roster/Personnel Report (LIC500 – dated 4/2025) checked criminal clearances, and conducted interview with Administrator (A1). Investigation revealed the following: Allegation: Licensee does not ensure that staff have criminal clearance The detail of the complaint alleges that a “staff is working underneath his cousin’s name” and that this alleged staff is not criminally cleared. Page 1 of 2 Unsubstantiated On 8/20/25, at 10:15 am. LPA Lee interviewed Veronica Gomez (A1), who denied the allegation stating that all staff are criminally cleared and associated to the facility. LPA was able to confirm that there are no employees by the names indicated in the complaint currently on staff at the facility. LPA confirmed this by reviewing the staff roster and Licening Information System (LIS) personnel report. On 8/20/2025, from 10:30am-12:00pm, LPA Lee conducted a review of the Personnel Report LIC 500 (dated 4/2025). During this review, all staff members were cross-referenced using the Licensing Information System (LIS) and the Community Care Licensing Guardian System. The results confirm that all staff members have obtained Criminal Record Clearance. Based on record review and interview conducted, there is insufficient information to support the above allegation. 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 UNSUBSTANIATED No deficiencies cited during today's visit. Exit interview conducted and copy of report provided to Veronica Gomez, Administrator. Page 2 of 2the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 11-AS-20250811090913

Type of visit: Case Management - Annual Continuation

On May 1, 2025, Licensing Program Analyst (LPA), Deborah Lee conducted an unannounced Case Management Continuation visit using the CARE Inspection Tool to continue the annual required visit started on April 23, 2025. LPA Lee met with the Co-Administrator Peggy Clark and the purpose of today’s visit was explained. The facility is licensed to operate for 262 non-ambulatory residents, of which 10 may be bedridden, ages 60 and over. The facility has an approved Hospice Waiver for 10. The census for today is 142. Facility's Annual fees are current. Physical Plant/Structure The facility is a large, two-story, building located in a commercial neighborhood. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of two floors which includes resident rooms, common areas, dining area, kitchen, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of two floors, resident rooms, dining area, common area, a theater, and delayed egress doors. The facility has a signal system with a switch board located in the reception area and is operational from all residential living units. Page 1 of 2 File Review: LPA reviewed (7) resident files and found that ( 7 ) out of ( 7 ) had the required documents. LPA reviewed (7) staff file and the Administrator file and found that (6 ) out ( 7 ) had the required documents, training, and certifications. LPA found that The facility Administrator's certification expired. Administrator is in process of completing the required course work to recertify. Medications: LPA observed all centrally stored medications secured in a locked med cart in the locked medication room and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medication for (7) residents. LPA observed ( 7 ) out of ( 7 ) resident’s medication were properly maintained and are consistent with properly documented records. LPA's observed a monthly schedule which presented a sufficient number of daily activities for facility residents. LPA observed the noted activities being conducted in the activities area, which is directly across from the TV lounge area. During today’s visit LPA cited Title 22 Division 6 chapter 8 Article 7 for 1 deficiency. See 809D. An exit interview was conducted with Administrator Veronica Gomez, and a copy of this report was provided. Page 2 of 2the state’s words, verbatim · CDSS document, May 1, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff is not providing adequate care and supervision of a resident while in care

On 04/23/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Palmcrest Grand Residence Facility and was greeted by Administrator Peggy Clark (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the finding pertaining to the above-mentioned allegation. The investigation consisted of the following: LPA Calderon interviewed Administrator S1, Staff S2-S3, resident R1-R14. LPA Calderon obtained the following records: physician report (dated 01/13/2025), Preplacement plan (dated 02/04/2025), incident report (dated 04/13/2025, 04/14/2025 and 04/18/2025), Kaiser Hospital records (dated 04/13/2025 to 04/18/2025) for R1. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff is not providing adequate care and supervision of a resident while in care. This complaint alleged that staff did not supervise R1 who had 3 witnessed falls. Toured the facility with S1, LPA Calderon did not notice any negative interactions between staff and residents. Records review indicate the following: Physician report indicate health issues and is ambulatory, Preplacement plan indicates that R1 has unsteady gait. Incident reports indicate R1 had 3 witnessed falls on 04/13/2025, 04/14/2025 and 04/18/2025. Incident report indicates that all falls happened in the night shift. Hospital records indicate minor injuries and R1 was returned to the facility. Interviews indicate the following: 4 out of 4 staff deny the allegation. R1 could not answer any questions due to health issues. 13 out of 14 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff is not providing adequate care and supervision of a resident while in care” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report were provided to the Administrator Peggy Clark (S1).the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 11-AS-20250416115244

Allegation investigated: Staff did not ensure resident's bed was working properly. Staff did not ensure resident's electrical outlet was fixed properly.

On April 23, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted a subsequent complaint visit to continue investigation and to deliver findings regarding the above allegations. LPA Lee met with Peggy Clark Administrator and explained the reason for the visit. The investigation consisted of the following: On April 10, 2025, LPA inspected R1’s room, reviewed and requested, staff roster (dated 4/9/25), resident's roster (dated 4/7/25), Appraisal/Need and Services Plan for R1 (dated 6/1/24), C1’s Physician's Report for Residential Care for the Elderly (RCFE) dated 1/30/25. LPA reviewed R1’s file. LPA Lee interviewed 3 residents (R2-R4), 3 staff (S1- S3) and Administrator (A1). On April 23, 2025, LPA interviewed 1 resident (R1), and reviewed a copy of R1's body check form. Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure resident’s bed was working properly. The detail of the complaint alleges that R1’s medical bed doesn’t work and hasn’t been working for three weeks and R1 had developed back sores due to not being able adjust the bed. On April 10,2025 between 9:45am and 10:15am LPA Lee interviewed Administrator (A1) Peggy Clark who denied the allegation stating that as soon as R1 complained about her bed not working, a message went out to our maintenance guy, and he fixed the bed that day. On April 10, 2025, between 11:00am and 2:00pm LPA Lee interviewed 3 staff regarding the allegation and of those interviewed 3 out of 3 staff denied the allegation stating that when R1 reported that the bed was not working, it was fixed the same day. On April 10, 2025 between 2:00pm and 3:00pm, LPA Lee interviewed 3 residents and of those interviewed 3 out of 3 residents stated that problems in the facility are usually addressed right away. On April 10, 2025, LPA inspected R1’s room and observed that the bed was operational as A1 demonstrated the bed was working by moving the head and feet sections in an up and down motion with the motor control. On April 23, 2025, LPA Lee interviewed R1 who stated that the bed is working fine and says that there is no problems with the bed. R1 informed LPA that there are no issues with R1's back as there are no sores on R1’s back as reported in the complaint. On April 23 2025, LPA obtained and reviewed a copy of R1’s body check (dated 4/19/25) which indicated no sores of any kind on R1’s back as reported in the complaint. Based on the information gathered, there is insufficient evidence to support the stated allegation. Page 2 of 3 Allegation: Staff did not ensure resident’s electrical outlet was fixed properly. The detail of the complaint alleges that the electrical outlet blew out has not been working for 3 weeks. On April 10,2025 between 9:45am and 10:15am LPA Lee interviewed Administrator Peggy Clark who denied the allegation stating that as soon as R1 complained about the electrical outlet by the bed not working, a message went out to our maintenance guy, and he fixed outlet that day. On April 10, 2025, between 11:00am and 2:00pm LPA Lee interviewed 3 staff regarding the allegation and of those interviewed 3 out of 3 staff denied the allegation stating that when R1 reported that the electrical outlet in the room was not working, it was fixed the same day. On April 10, 2025, LPA inspected R1's room and observed that the the electrical outlet was working. On April 23, LPA interviewed R1 who stated that the outlet is working. Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegations above 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 allegations are UNSUBSTANTIATED No deficiencies were cited for the above allegation. Exit interview was conducted. A copy of this report was provided to Peggy Clark, Administrator.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 11-AS-20250401135956

Type of visit: Required - 1 Year

On April 23, 2025, Licensing Program Analyst (LPA), Deborah Lee conducted an unannounced annual required visit using the CARE Inspection Tool. LPA Lee met with the Administrator Peggy Clark and the purpose of today’s visit was explained. The facility is licensed to operate for 262 non-ambulatory residents, of which 10 may be bedridden, ages 60 and over. The facility has an approved Hospice Waiver for 10. The census for today is 143. Physical Plant/Structure The facility is a large, two story, building located in a commercial neighborhood. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of two floors which include resident rooms, common areas, dining area, kitchen, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of two floors, resident rooms, dining area, common area, a theater, and delayed egress doors. The facility has a signal system with a switch board located in the reception area and is operational from all residential living units. Bedrooms LPA inspected seven ( 7) resident rooms, 146, 147, 148, 117, 311, 301, 303 and observed them to be clean and in good repair. LPA observed all rooms to be properly furnished with a bed, dresser, night stand, chair, and storage space for resident’s personal belongings LPA observed beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. The facility has an ample supply in a storage room for resident use. All rooms were observed with ample lighting. Bathrooms LPA inspected seven (7 ) resident bathrooms and observed them to be clean, operational, and meet Tittle 22 regulations. LPA found that in one of the hall bathrooms there was a missing toilet tank cover and a missing faucet handle. LPA observed storage area for residents’ personal hygiene products. The facility does have an ample supply of hygiene products available for residents. The water temperature in the resident’s bathrooms measured between 105-degrees and 120-degrees Fahrenheit. Common Rooms LPA inspected all common rooms in the facility and observed them to be properly furnished to accommodate all residents. LPA observed all walkway and hallway in the facility to be clean, clear, and free of obstructions and hazards. LPA observed all common areas to have ample lighting. The facility was kept at a comfortable temperature. LPA observed resident’s participating in activities and observed activity schedule posted in various locations of the facility. Kitchen LPA inspected the facilities industrial kitchen and observed it to be clean and sanitary. LPA observed all appliances to be operational and in good repair. LPA observed an ample supply of cook ware, dishware, and cutleries. LPA observed a 2-day supply of perishable foods, and a 7-day supply of non-perishable foods properly stored, packaged, and labeled. Page 2 of 3 Safety LPA observed multiple fully charged fire extinguishers throughout the facility last serviced on 2/25/25. The last inspection from Fire Alarm and Safety System was conducted on 10/31/24. The last emergency drill was conducted on 2/11/25. The elevator was last inspected and serviced on 8/2/24. The generator is ran and checked on a weekly basis; it was last inspected during the annual service on 4/5/25. LPA observed all required documents posted throughout the facility. The facility has a working landline telephone. Due to time restraints, LPA to complete inspection on subsequent visit. During today’s visit, there was 1 technical violation issued; see: LIC9102TV An exit interview was conducted with Peggy Clark Administrator and a copy of this report was provided. Page 3 of 3the state’s words, verbatim · CDSS document, Apr 23, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On April 22, 2025, Licensing Program Analyst (LPA) Ernand Dabuet initiated an unannounced Case Management visit at this facility. LPA met with Administrator #2 (A2) Peggy Clark. LPA explained the purpose of this visit is reference with complaint #11-AS-20240215081652 and the Case Management visit on August 30, 2024, with Palmcrest Grand Residence. During the investigation conducted by California Department of Social Services (CDSS) Investigation Bureau (IB) investigator Sonia Sandoval, it revealed that (A1) withheld information. (A1) stated that resident #2 (R2) was never evicted from the facility and informed that (R2’s) family representative (R2) was able to return to the facility. Information was provided to (IB) Investigator Sandoval, who claimed (R2) was not able to return to the facility due to (R2’s) failure to follow instructions when redirected on the incident of 02/02/24. In addition, (A1) stated resident #1 (R1’s) family representative was immediately notified of the condition (R1) was found in abdominal pain. Nonetheless, (R1’s) family representative claimed notification of (R1’s) condition was received after 1300 hours (R1) was discovered by staff of abdominal pain at 0700 hours. (R1’s) family representative was not informed of the additional symptoms (R1) exhibited, which included vomiting, diarrhea, and bloody discharge. (A1) provided wrongful removal of resident #2 (R2). (A1) indicated (R2) exhibited aggressive behavioral outbursts and was deemed a safety concern no reports of aggressive behavior by any staff present during the incident on 02/02/24. In addition, (R2’s) family representative was notified after (R2) had been transported to the VA hospital that (R2) was not welcome to return to the facility and was not provided an Eviction Notice. (Evaluation Report continues LIC 809-C) The investigation revealed that (A1) obstructed it. Facility staff disclosed fear of retaliation from (A1) and stated that (A1) treated them differently for cooperating with IB Investigators. Information gathered indicated when law enforcement went to the facility, (A1) alerted the staff and instructed the staff not to say anything as there was no proof anything had occurred on the incident 02/02/24. (A1) stated to have not reported the incident to law enforcement because (A1) did not observe any signs of an assault. Despite this, (A1) stated to the Long Beach Police Department (LBPD) Detective (R2) had been removed and was not allowed back into the facility due to the incident. Based on observations, interviews, and record reviews, a preponderance of evidence standard has been met. (A1) failed to carry out the responsibilities and duties of an administrator by withholding information, wrongful removal of residents, and obstruction of an investigation. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 809-D. An exit interview was conducted with Peggy Clark, Administrator, and a hard copy of the report along with appeal rights. This Complaint Investigation Report LIC 809 and LIC 809C&D dated 04/22/25 superseded the original LIC 809 LIC 809C&D reports dated 08/30/24 ***the state’s words, verbatim · CDSS document, Apr 22, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87413(a)(3) · Plan of correction due date: Apr 29, 2024

87413 Personnel – Operations (a) In each facility: (3)The licensee shall provide for and encourage all personnel to report observations or evidence of such abuse, exploitation, or prejudice. This requirement is not met as evidenced by: Based on interviews by IB, Staff feared retaliation and were coerced/instructed not to cooperate/speak with authorized agencies about the incident 02/02/24. (A1) provided inconsistent statements to authorities. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Personnel Operations” and implement a plan detailing how Licensee/Administrator will ensure all staff are encourage to report incidents. The plan is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov Proof of correction sent via email 09/13/24 of completed Incident Report Staff Training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(5) · Plan of correction due date: Apr 29, 2025

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d).... If the licensee is also the administrator, all requirements... shall apply. (5) Good character and a continuing reputation of personal integrity. This requirement is not met as evidenced by: Based on interviews by IB, Staff feared retaliation and were coerced/instructed not to cooperate/speak with authorized agencies about the incident 02/02/24. This violation poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Administrator Qualificaitons and Duties” and will complete an Ethics Training in Senior Care. The plan is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov Proof of correction sent via email 09/13/24 of completed Values, Ethics and Code of Conduct Training.

Allegation investigated: Uncleared adults are working in the facility.

On 04/04/25, Licensing Program Analyst (LPA) Mario Leon conducted an initial visit to gather information regarding the above allegation. LPA met with staff one, Veronica Gomez (S1) Administrator, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 04/04/25 LPA requested Resident Roster (dated 04/02/25), staff roster (dated 04/04/25), Personnel Report (LIC500 - dated 02/25/25) and LPA toured the physical plant to interview four (4) residents (R1-R4) and three (3) staff (S1-S3). Investigation revealed the following: Regarding the Allegation, "Uncleared adults are working in the facility.". It has been alleged that two (2) uncleared care staff have been allowed to work at the facility. Report continues, see LIC9099-C. Substantiated On 03/28/25 LPA conducted record review of Facility Personnel Report Summary, which shows One-Hundred and Thirty-Two (132) staff who are currently associated to the facility. On 04/04/25, at 8:22AM, LPA compared the Facility Personnel Report Summary to the staff roster that was provided (dated 04/04/25) and observed two (2) staff (S4-S5), scheduled to work on 04/04/25, who were not listed as being associated to the facility. From 9:00AM to 09:45AM, LPA interviewed two (2) residents (R1-R2) and three (3) staff (S1-S3). R1-R2 and S1-S3 have denied the allegation has taken place. From 9:50AM - 11:20AM, LPA sat with S1 to verify S4-S5 status. One (1) staff was found as associated to the facility, with their maiden name listed, and one (1) staff remained uncleared through Care Provider Management Bureau (CPMB) and will not be allowed to work at any care facility until that staff receives clearance from CPMB. From 2:00PM to 2:45PM, LPA interviewed two additional residents (R3-R4) who have also denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D. One deficiency has been cited, see LIC9099-D. An exit interview was held with staff one, Veronica Gomez (S1). A copy of this report, the deficiency cited, and facilities' appeal rights have been provided to Veronica Gomez (S1).the state’s words, verbatim · CDSS document, Apr 4, 2025 · control 11-AS-20250327140429

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(a) · Plan of correction due date: Apr 15, 2025

87355 Criminal Record Clearance (a) The Department...all individuals specified in Health and Safety Code section 1569.17 and shall...deny... employment...or presence in the facility, based upon the results of such review. This has not been met as evidenced by: The facility has allowed one (1), uncleared, staff member to be employed at the facility.the state’s words, verbatim · CDSS document, Apr 4, 2025

Plan of correction: Licensee (S1) has agreed that prior to returning to work at this care facility, the uncleared staff will have conducted a fingerprint clearance through Care Provider Management Bureau (CPMB) on, or before, the POC due date as 04/15/25. S1 will inform LPA of fingerprint findings at Mario.Leon@DSS.CA.GOV

Allegation investigated: Facility staff did not dispense medications as prescribed.

On January 22, 2025, Licensing Program Analyst, (LPA) Deborah Lee conducted an unannounced visit to this facility. LPA was met by Peggy Clark Administrator 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 January 22, 2025, Licensing Program Analyst (LPA) Deborah Lee toured facility, reviewed R1’s medication with MedTech’s, requested and received copies of the following: Staff roster dated 1/22/25, Resident Roster, R1’s Medication Administration Record (MAR) for November 2024, December 2024 and January 2025 and Med Tech Trainings and Certification (dated 1/10/25, 12/20/24, 11/15/24, 11/724, 6/26/23), and Nursing Note (dated 12/30/24), interviews with staff 1-3 and Administrator, interviews with R1-R5, observation of medication being given during meal time (11:45am). Page 1 of 2 Substantiated The allegation revealed the following: Allegation: Facility staff did not assist resident with obtaining medication refill as needed It is being reported that staff allowed the resident ran out of her medications without ensuring she had a refill or assist her with obtaining a refill. On January 22, 2025, LPA Lee reviewed Nursing Notes(dated 12/30/24 at 10:00am) which revealed that S1 made several calls to in an attempt to ensure that R1 receive her refills. According to the note, communication to Pharmacy representative was made in addition to R1's doctor, and the responsible party. On January 22, 2025 LPA Lee interviewed R1-R5, and of those interviewed 4 of 5 state that the staff always help them obtain refills to their medication. Additionally, 4 out 5 stated that they have never ran out of medication. On January 22, 2025 LPA Lee interviewed staff 1-3 (S1-S3) and administrator (A1). Of those interviewed 3 out of 3 staff and Administrator stated that facility staff always assist residents in obtaining a refill of medication when needed. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegation of "Facility staff did not assist resident with obtaining medication refill as needed" found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of report was give to Peggy Clark Administrator. The investigation revealed the following: Allegation: Facility staff did not dispense medications to resident as prescribed On January 22, 2025, LPA Lee conducted a review of R1 service file including Medication Administration Record (MAR). Records revealed that R1’s cycle of medication was missed on the following dates: 12/30/24, 12/31/24, 1/1, 1/2/25, 1/3/25, 1/4/25, 1/5/25, and 1/6/25. LPA Lee interviewed S1-S3 and Administrator (A1). 3 out 3 staff and administrator state that medication is dispensed as prescribed and on time, however, R1 changed her insurance and doctor who sent prescription to an outside pharmacy which delay process of them getting the medication on time. LPA interviewed Residents 1-5 (R-1 thru R-5). Of those interviewed, 4 out of 5 they receive their medication as prescribed and on time. According to the information gathered there is sufficient evidence to support the allegation mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D.) Deficiencies are issued and an exit interview is conducted with Peggy Clark. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 22, 2025 · control 11-AS-20250114095525

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465 · Plan of correction due date: Jan 29, 2025

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as resident R1 prescribed medication was missed on 12/30/24-1/6/2025 which poses/posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 22, 2025

Plan of correction: Licensee will ensure compliance by developing a plan to prevent medication is missed due to resident changing doctor or insurances without letting facility know. Plan to be emailed to LPA by due date Deborah.Lee@dss.ca.gov.

Allegation investigated: Facility staff speaking inappropriately to resident in care. Facility staff did not meet the needs of resident in care.

On 12/09/2024, the department conducted a subsequent complaint visit to further investigate the allegations listed above and deliver findings. The department met with Administrator Peggy Clark and the purpose of today’s visit was explained. The investigation consisted of the following: On 10/21/24, the department requested and obtained copies of the staff roster, resident roster, and face sheet, physicians report, preplacement appraisal information, needs and service plan, personal rights, and incidents reports for residents #1 (R1). Additionally, the department conducted interviews with Administrator (A1), residents #1-#12 (R1-R12) and conducted a tour of the facility. On 12/09/24, the department interviewed staff #1-#5 (S1-S5). Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Facility staff speaking inappropriately to resident in care. It is alleged that staff told resident, that if they didn’t start behaving, they would send the client away. On 10/21/24, the department conducted interviews with A1, S1-S,5 and R1-R12. 6 out of 6 staff interviewed denied the allegation. 6 out of 6 staff interviewed stated all residents are treated with respect. 11 out of 12 residents interviewed denied the allegation. 10 out of 12 residents interviewed stated that facility staff treat them with dignity and respect. 11 out of 12 residents interviewed stated they are satisfied with the facility and the services being provided to them. Based on the observation, a review of records, and interviews conducted, there was 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: Facility staff did not meet the needs of resident in care. It is alleged that a resident asked staff for assistance back to their room after eating breakfast. Staff left resident unattended and without assistance in the TV room. On 10/23/24, the department conducted interviews with A1, S1-S5, and R1-R12. 6 out of 6 staff interviewed denied the allegation. 11 out of 12 residents interviewed stated they did not know of the allegation. 11 out of 12 residents interviewed stated that staff assist them with their everyday needs. 11 out of 12 residents interviewed stated they are satisfied with the facility and the services being provided to them. Based on the observation, a review of records, and interviews conducted, there was 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. An exit interview was conducted with Administrator Peggy Clark, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 9, 2024 · control 11-AS-20241014104942

Allegation investigated: Lack of supervision resulted in resident falling and sustaining multiple injuries

CCLD conducted an unannounced complaint visit on Wednesday, November 13, 2024, upon arrival at the facility. The department called the facility via telephone and conducted a risk assessment. Based on the assessment, the facility is cleared of COVID-19 infection. The department met with Assistant Administrator Peggy Clark and Administrator Veronica Gomez. The department explained the purpose of today's visit. The investigation consisted of the following: During the course of the investigation the department conducted interviews with staff members 1-6 (S1-S6), residents 1-13 (R1-R13), witnesses 1-4 (W1-W4), and the complainant. The department asked questions relevant to the nature of the complaint. The department toured the entire facility to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visits. Residents' records were requested observed, and reviewed. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 The department requested copies of the following documents: Personnel Report, Resident Roster, Special Incident Reports, Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Medication Logs, Consent Forms, Replacement Appraisal Information, Appraisal and Needs Service Plan, Resident Progress Notes, Long Beach Memorial Hospital Medical Records, Windsor Convalescent Hospital Medical Records, Long Beach Police Department Call Log, Special Incident Reports, In-Service Training, Training on Reporting Dependent Adult and Elder Abuse, and any Ongoing Training. Allegation: Lack of supervision resulted in the resident falling and sustaining multiple injuries The department interviewed staff members 1-6 (S1-S6), residents 1-13 (R1-13), and witnesses 1-4 (W1-W4). Based on files, and interviews, there was insufficient evidence to prove that the facility was responsible for neglect or lack of care and supervision, leading to the resident's unwitnessed fall at the facility on June 22, 2024, which resulted in multiple injuries. According to the resident's medical records from Long Beach Memorial Hospital, the resident sustained a stroke, which may have contributed to the unwitnessed fall. Staff, the resident's physician, and witness statements indicated no change in the resident condition that would have raised any concern for the resident to fall. The resident was documented as ambulatory and able to dance during a replacement assessment on May 16, 2024. The resident's physician confirmed that upon discharge from Windsor Convalescent Hospital on May 25, 20024, the resident was ambulatory and walked with ease. The physician added that the resident frequently danced while at the hospital. Investigation revealed the following: Based on the evidence received from the medical records, staff, resident's physician, the residents, and witnesses there was sufficient staff on duty in the memory care unit at the time of the fall. Staff immediately responded to the resident's room upon hearing a loud sound, provided assistance, and called 911 promptly. The staff took all necessary precautions to assist the resident. The staff could not have prevented the resident from falling. The allegation of neglect lack of care and supervision leading to the resident falling and sustaining multiple injuries was unsubstantiated. See the continued LIC9099-C page 3. Continued LIC9099-C page 3 Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-Cs, was provided to the Administrator Peggy Clark. There were no deficiencies cited. An exit interview was conductedthe state’s words, verbatim · CDSS document, Nov 13, 2024 · control 11-AS-20240625141047

Allegation investigated: Lack of supervision resulted in resident falling and sustaining multiple injuries

CCLD conducted an unannounced complaint visit on Wednesday, November 13, 2024, upon arrival at the facility. The department called the facility via telephone and conducted a risk assessment. Based on the assessment, the facility is cleared of COVID-19 infection. The department met with Assistant Administrator Peggy Clark and Administrator Veronica Gomez. The department explained the purpose of today's visit. The investigation consisted of the following: During the course of the investigation the department conducted interviews with staff members 1-6 (S1-S6), residents 1-13 (R1-R13), witnesses 1-4 (W1-W4), and the complainant. The department asked questions relevant to the nature of the complaint. The department toured the entire facility to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visits. Residents' records were requested observed, and reviewed. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 The department requested copies of the following documents: Personnel Report, Resident Roster, Special Incident Reports, Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Medication Logs, Consent Forms, Replacement Appraisal Information, Appraisal and Needs Service Plan, Resident Progress Notes, Long Beach Memorial Hospital Medical Records, Windsor Convalescent Hospital Medical Records, Long Beach Police Department Call Log, Special Incident Reports, In-Service Training, Training on Reporting Dependent Adult and Elder Abuse, and any Ongoing Training. Allegation: Lack of supervision resulted in the resident falling and sustaining multiple injuries The department interviewed staff members 1-6 (S1-S6), residents 1-13 (R1-13), and witnesses 1-4 (W1-W4). Based on files, and interviews, there was insufficient evidence to prove that the facility was responsible for neglect or lack of care and supervision, leading to the resident's unwitnessed fall at the facility on June 22, 2024, which resulted in multiple injuries. According to the resident's medical records from Long Beach Memorial Hospital, the resident sustained a stroke, which may have contributed to the unwitnessed fall. Staff, the resident's physician, and witness statements indicated no change in the resident condition that would have raised any concern for the resident to fall. The resident was documented as ambulatory and able to dance during a replacement assessment on May 16, 2024. The resident's physician confirmed that upon discharge from Windsor Convalescent Hospital on May 25, 20024, the resident was ambulatory and walked with ease. The physician added that the resident frequently danced while at the hospital. Investigation revealed the following: Based on the evidence received from the medical records, staff, resident's physician, the residents, and witnesses there was sufficient staff on duty in the memory care unit at the time of the fall. Staff immediately responded to the resident's room upon hearing a loud sound, provided assistance, and called 911 promptly. The staff took all necessary precautions to assist the resident. The staff could not have prevented the resident from falling. The allegation of neglect lack of care and supervision leading to the resident falling and sustaining multiple injuries was unsubstantiated. See the continued LIC9099-C page 3. Continued LIC9099-C page 3 Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-Cs, was provided to the Administrator Peggy Clark. There were no deficiencies cited. An exit interview was conductedthe state’s words, verbatim · CDSS document, Nov 13, 2024 · control 11-AS-20240625141047

Allegation investigated: Resident sustained fracture while in care of staff. Unlawful eviction. Staff did not assist resident in a timely manner.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Palmcrest Grand Residence Facility on 10/30/2024 and was greeted by Administrator Veronica Gomez (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Administrator (S1), staff (S1-S5), residents (R1-R11). LPA Calderon requested and reviewed copies of the following: Physician Report (dated 10/27/2023), Needs and Services Plan (dated 12/03/2023), incident report (dated 12/15/2023 to 3/29/2024), admission agreement (dated 12/01/2023), Nurse notes (dated 3/23/2024), Call log notes (dated 3/5/2023), Doctors notes (dated 03/22/2024), Eviction notice (dated 02/19/2024), St. Mary Hospital record (dated 03/29/2024) for R1. LPA Calderon toured the facility including R1 room. The investigation revealed the following: Unsubstantiated Regarding Allegation #1: Resident sustained fracture while in care of staff. It is being alleged that R1 fracture R1 hip while in care of staff. Toured the facility including R1 room. R1 room floor did not appear to have any wax on the ground. Incident report (dated 01/28/2024) R1 fell in room and was not injured. Incident report (dated 03/29/2024) staff noted R1 had leg injury and R1 was transported to St. Mary hospital for evaluation. S1 indicates that R1 was no longer living at the facility in June 2024. S1 indicates that there is no record of R1 falling on 06/08/2024. S1 indicates that St. Mary hospital records has R1 in room 255 on 03/29/2024 for infection of the left foot. S1 indicates that the hospital does not mention a fracture hip for R1. 4 out of 4 staff indicate that R1 never fracture R1 hip while in care of staff. R1 indicates that R1 was moving from R1 wheelchair to the bed. R1 indicates that due to a wet floor R1 fell and fracture R1 hip on 06/08/2024. 10 out of 11 residents indicate that they have never seen staff wax the floors or rooms. 10 out of 11 residents indicate that they have never fracture their hip. Regarding Allegation #2: Unlawful eviction. It is being alleged that R1 was evicted from the facility unlawfully. Reviewed 30-day notice of eviction, (dated 02/19/2024), effective date of eviction 03/19/2024, due to past due rent and late fees. S1 indicates that R1 was behind in R1 rent and stopped paying any rent since March 2024. S1 indicates that R1 was transported to St. Mary Hospital on 03/29/2024 and never returned to the facility. S1 indicates that a 30-day notice was generated on 02/19/2024 and effective 03/19/2024. S1 indicates that R1 was served the eviction notice by staff S5 while living at the facility. S5 indicates that S5 was given the 30-day notice of eviction and gave the notice to R1 prior to R1 being taken to the hospital on 03/29/2024. R1 indicates that R1 was transported to the hospital for a fracture hip on 06/08/2024. R1 indicates that R1 was released from the hospital. R1 indicates that the hospital informed R1 that R1 had been evicted from the facility and could not return. R1 indicates that R1 was never given an eviction notice from the facility. R1 indicates that R1 had not paid R1 rent and had text the facility owner to work out a solution but R1 never returned to the facility. 10 out of 11 residents have never received an eviction notice from the facility. Regarding Allegation #3: Staff did not assist resident in a timely manner. It is being alleged that R1 had fallen in R1 room and called for help from staff. LPA Calderon toured the facility to include room 134, 220, 277 and 282. One of the rooms inspected was R1 room. LPA pushed the call button and on average it took staff 5 to 10 minutes to arrive. Reviewed call log notes (dated 03/05/2024), there are no call logs from R1 room from March to June 2024. There is no incident report for 6/8/2024 for R1 falling and fracture R1 hip or R1 pressing the call button. 5 out of 5 staff indicate that on average it takes 5 to 10 minutes for staff to help once a call button is pushed. 5 out of 5 staff indicate that there is no record of R1 pushing R1 call button on 06/08/2024. S1 indicates that R1 was no longer living at the facility on 06/08/2024 and had been at St. Mary Hospital since 03/29/2024 for a foot injury. R1 indicates that on 06/08/2024 R1 fell and fracture R1 hip. R1 indicates that R1 pushed the call button for help, and it took staff 2 hours to arrive and call 911 for R1 to be taken to the hospital. 10 out of 11 residents indicate that it takes 10 to 15 minutes for staff to arrive once a room call button is pressed. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “resident sustained fracture while in care of staff”, “unlawful eviction”, “staff did not assist resident in a timely manner” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Veronica Gomez (S1).the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 11-AS-20241008130432

Allegation investigated: Facility failed to seek medical attention in a timely manner. Facility staff failed to report an incident to licensing.

Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Assistant Administrator (S9: Peggy Clark). LPA stated the purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: An initial 24-hour health and safety visit was conducted by LPA Dabuet on 02/16/24. A toured the facility’s physical plant. A review of documents: Residents’ Roster (dated: 02/16/24), Staff Roster & Work Schedules (dated: 02/01/24), Facility House Rules (dated: 2023), Admissions Agreement (dated 05/20/22), Physician’s Report (dated 04/13/23), Resident Appraisal (dated: 01/05/24; 02/06/24 & 09/30/23), Functional Capability Assessment (dated: 01/05/24), Identification and Emergency Information (dated: 05/17/22), Physicians Orders Medications (dated: 02/16/24), Record of Admission (dated: 05/26/22 & 06/01/22), Physicians Report (dated: 03/29/23), Unusual Incident/Injury Report (dated: 01/03/22; 09/14/22; 09/16/23; 01/30/23; 02/02/24; 02/15/24), and Facility Sketch (dated: 2015). (Evaluation Report continues LIC 9099-C) Substantiated This complaint investigation was referred to California Department of Social Services (CDSS), Investigation Bureau (IB) and was assigned to Investigator (IB: Sonia Sandoval). The investigation included a review of Long Beach Police Department Non-Criminal Report (dated: 05/27/24);Long Beach Medical Center Medical Records (dated: 03/26/24 & 03/28/24), Green Meadow Hospice Medical Records (dated: 05/29/24), and Optum Airport Plaza Medical Records. Interviews of witnesses #1-#9 (W1–W9), Administrator #1 (A1), facility staff #1-#8 (S1– S8), and residents #1-#2 (R1-R2). INVESTIGATION REVEALED THE FOLLOWING: Allegation #2: Facility failed to seek medical attention in a timely manner. It is alleged that facility staff failed to seek timely medical attention for resident #1 (R1). The complainant reported on 2/02/24, (R1) was found in (R1’s) bedroom completely unclothed, vomiting, and bleeding from (R1’s) private parts. This investigation revealed that Resident #1 (R1) sometime in January 2024 was sent out to the hospital due to having difficulty breathing and had blood in (R1’s) urine. (R1) was diagnosed with a Urinary Tract Infection (UTI). On 02/02/24, the facility informed family representative witnesses witness #1-#3 (W1-W3) that (R1) was complaining of abdominal pain. (R1) was transported by family member witness #2 (W2) to (R1’s) primary doctor and later transported by ambulance to Long Beach Medical Center Hospital Emergency Department and was examined. On 03/08/24, 03/26/24, 04/29/24, and 05/09/24 between 07:09 am – 04:20 pm, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed (9) out of (9) Administrator (A1) and staff #1-#8 (S1-S8) all verified they were aware of (R1’s) UTI health condition and occasionally would complain about abdominal pains. Interviews of staff revealed (R1) was discovered in (R1’s) room at approximately 07:00 am in bed with complaints of abdominal pain with bloody discharge and vomit. On 05/22/24, at 11:26 am, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed family member witness #2 (W2), who indicated (W2) received a call approximately between 12:00 pm – 01:00 pm who was notified by the facility of (R1’s) urgent condition. (Evaluation Report continues LIC 9099-C) (W2) stated the facility staff only indicated (R1) was complaining of abdominal pain and did not indicate (R1) needed to be medically evaluated. Moreover, the staff withheld information about (R1’s) additional symptoms of bloody discharge or vomited. On 05/23/24 at 02:14 pm, Investigator Sonia Sandoval interviewed Long Beach Medical Center Medical Director witness #7 (W7) who stated (R1) was admitted at approximately 04:46 pm on 02/02/24. (R1) would have been in pain and (R1’s) prognosis would not have changed, however, (R1) may have been spared additional pain associated with (R1’s) prognosis of Spinal Muscular Atrophy (SMA) if (R1) was brought in for medical attention much earlier. Based on the evidence gathered interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION resulted in “Facility failed to seek medical attention in a timely manner” is found to be SUBSTANTIATED. Allegation #3: Facility staff failed to report an incident to licensing. It is alleged that facility staff failed to report an incident involving resident #1 (R1) and resident #2 (R2). The complainant reported the facility staff failed to provide an appropriate level of care and supervision, which resulted in (R1) being sexually assaulted by (R2) on 02/02/24. There was no report of the incident to Community Care Licensing (CCL). On 04/29/24 at 12:49 pm, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed Administrator (A1). (A1) indicated as the administrator, (A1) was responsible for submitting Special Incident Reports (SIR) to (CCL) and overseeing the facility. (A1) indicated there were cameras in the common areas and hallways, which are only accessible to management. (A1) indicated the cameras are not monitored daily, and it is only reviewed when incidents occur to assist with the completion of (SIRs). However, if incidents were not reported then the cameras would not be reviewed. (A1) indicated on 02/02/24 the morning staff informed (A1) of the incident between (R1) and (R2). (Evaluation Report continues LIC 9099-C) On 02/16/24, the Department conducted a health and safety inspection visit at the facility. During the inspection (A1) provided copies of Special Incident Reports (SIR) associated with (R1 and R2) (dated: 02/02/24 and 02/15/24). The facility has not revealed its submission of these incidents to (CCL) via fax receipts (also known as confirmation pages). Based on the evidence gathered interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION resulted in "Facility staff failed to report an incident to licensing" is found to be SUBSTANTIATED. Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted with Peggy Clark and a hard copy of the report along with appeal rights. This complaint investigation was referred to California Department of Social Services (CDSS), Investigation Bureau (IB) and was assigned to Investigator (IB: Sonia Sandoval). The investigation included a review of Long Beach Police Department Non-Criminal Report (dated: 05/27/24); Long Beach Medical Center Medical Records (dated: 03/26/24 & 03/28/24), Green Meadow Hospice Medical Records (dated: 05/29/24), and Optum Airport Plaza Medical Records. Interviews of witnesses #1-#9 (W1–W9), Administrator #1 (A1), facility staff #1-#8 (S1– S8), and residents #1 #2 ( R1-R2). INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Resident was sexually assaulted while in care. It is alleged that facility staff failed to provide an appropriate level of care and supervision which resulted in Resident #1 (R1) being sexually assaulted by Resident #2 (R2) on 02/02/24 while in care at the facility. On 03/08/24, 03/26/24, 04/29/24, and 05/09/24 between 07:09 am – 04:20 pm, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed (9) out of (9) Administrator (A1) and staff #1-8 (S1-S8) who were not able to validate that a sexual assault had occurred between (R1) and (R2) on 02/02/24. Six (6) out of nine (9) facility staff have never witnessed (R2) inappropriate or aggressive behavior with other residents or staff. The Long Beach Police report revealed the facility staff provided inconsistent statements to law enforcement. When interviewed by Investigator Sonia Sandoval, Staff #1 (S1) admitted knowledge of the incident despite initially denying knowledge to law enforcement. The police report indicated Long Beach Police Officer (LBPO) witness #8 (W8) asked (R1) if (R2) had been assaulted or raped by (R2) and (R1) stated, “No.” On 03/25/24, 04/16/24, and 05/22/24 between 08:09 am – 03:15 pm, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed (4) out of (4) family representative witnesses #1-#4 (W1-W4) revealed they never observed anything concerning with the level of care or supervision. (Evaluation Report continues LIC 9099-C) On 05/23/24 at 02:14 pm, Investigator Sonia Sandoval interviewed Long Beach Medical Center Medical Director witness #7 (W7), who confirmed (R1) underwent a thorough examination upon admission and the tests completed would have captured signs of trauma or bruising were not present. Furthermore, the additional symptoms (R1) exhibited at the facility may have been symptoms associated with (R1’s) diagnosis. On 06/26/24, at 07:57 am, Investigator Sonia Sandoval interviewed Long Beach Police Department Special Victims Section Detective witness #9 (W9), who claimed the investigation had been closed since no proven crime had occurred. There were no actual witnesses to validate that a crime had happened nor demonstrative evidence presented as evidence. Based on the evidence gathered interviews conducted, and records reviewed, 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 of NEGLECT/LACK OF CARE AND SUPERVISION: “Resident was sexually assaulted while in care” is found to be UNSUBSTANTIATED. An exit interview was conducted with Peggy Clark, and a hard copy of the report is provided.the state’s words, verbatim · CDSS document, Aug 30, 2024 · control 11-AS-20240215081652

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Sep 13, 2024

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning... appropriate assistance is provided when such observation reveals unmet needs. When changes such as... deterioration... a physical health condition is observed, resident's responsible person...the licensee shall ensure that such changes...brought to the attention of the resident's physician... This requirement is not met as evidenced by: Facility staff had knowledge of (R1’s) health condition with UTI associated with severe abdominal pains, and failed to seek medical attention in a timely manner. This violation poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 30, 2024

Plan of correction: Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Observation of the Resident” and implement a plan detailing how Licensee/Administrator will ensure all residents are regularly observed for changes. The plan is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(B)(D) · Plan of correction due date: Sep 13, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with incident resident #1 and #2. The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. This violation poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 30, 2024

Plan of correction: Licensee/Administrator will review Title 22 Sec. 87211 and agreed to provide training to staff pertaining to CCL Reporting Requirements. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date via email: ernand.dabuet@dss.ca.gov

Type of visit: Case Management - Incident

On 08/30/24, Licensing Program Analyst (LPA) Ernand Dabuet initiated an unannounced Case Management visit at this facility. LPA met with Administrator #1 (A1) Veronica Gomez and Assistant Administrator #2 (A2) Peggy Clark. LPA explained the purpose of this visit is in reference to a complaint about Palmcrest Grand Residence Complaint Number 11-AS-20240215081652. During the investigation conducted by California Department of Social Services (CDSS) Investigation Bureau (IB) investigator Sonia Sandoval, it revealed that (A1) withheld information. (A1) stated resident #2 (R2) was never evicted from the facility and informed (R2’s) family representative (R2) was able to return to the facility. Information provided to (IB) Investigator Sandoval claimed (R2) was not able to return to the facility due to (R2’s) failure to follow instructions when redirected on the of incident 02/02/24. In addition, (A1) stated resident #1 (R1’s) family representative was immediately notified of the condition (R1) was found in abdominal pain. Nonetheless, (R1’s) family representative claimed notification of (R1’s) condition was received after 1300 hours (R1) was discovered by staff of abdominal pain at 0700 hours. (R1’s) family representative was not informed of the additional symptoms (R1) exhibited which included vomiting, diarrhea, and bloody discharge. (A1) provided wrongful removal of resident #2 (R2). (A1) indicated (R2) exhibited aggressive behavioral outbursts and was deemed a safety concern. There were no reports of aggressive behavior by any of the staff present during the incident on 02/02/24. In addition, (R2’s) family representative was notified after (R2) had been transported to the VA hospital that (R2) was not welcome to return to the facility and was not provided an Eviction Notice. The investigation revealed that (A1) obstructed the investigation. Facility staff disclosed fear of retaliation by (A1) and stated (A1) treated them differently for cooperating with IB Investigators. (Evaluation Report continues LIC 809-C) Information gathered indicated when law enforcement went to the facility, (A1) alerted the staff and instructed the staff not to say anything as there was no proof anything had occurred on the incident 02/02/24. (A1) stated to have not reported the incident to law enforcement because (A1) did not observe any signs of an assault. Despite this, (A1) stated to the Long Beach Police Department (LBPD) Detective (R2) had been removed and was not allowed back into the facility due to the incident. Based on observations, interviews, and record reviews, a preponderance of evidence standard has been met. (A1) failed to carry out the responsibilities and duties of an administrator by withholding information, wrongful removal of residents, and obstruction of an investigation. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 809-D. An exit interview was conducted with Veronica Gomez, Administrator, and a hard copy of the report along with appeal rights.the state’s words, verbatim · CDSS document, Aug 30, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87413(3) · Plan of correction due date: Sep 13, 2024

87413(3) Personnel – Operations (3) The licensee shall provide for and encourage all personnel to report observations or evidence of such abuse, exploitation, or prejudice. This requirement is not met as evidenced by: Based on interviews by IB, Staff feared retaliation and were coerced/instructed not to cooperate/speak with authorized agencies about the incident 02/02/24. (A1) provided inconsistent statements to authorities. This violation poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 30, 2024

Plan of correction: Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Personnel Operations” and implement a plan detailing how Licensee/Administrator will ensure all staff are encourage to report incidents. The plan is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(b)(1)(2)(5) · Plan of correction due date: Sep 13, 2024

87405 Administrator – Qualifications and Duties (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (d) The administrator shall have the qualifications..(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (5) Good character and a continuing reputation of personal integrity. This requirement is not met as evidenced by: Based on interviews by IB, (A1) failed to carry out the policies and ability to conform to the applicable laws, rules and regulations. This violation poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 30, 2024

Plan of correction: Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Administrator Qualificaitons and Duties” and will complete an Etnics Training in Senior Care. The plan is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(b)(c) · Plan of correction due date: Sep 13, 2024

87224 – Eviction Procedures (b) The licensee may, grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or safety of himself or to the mental and/or physical health or safety of others in the facility. (c) The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person. This requirement is not met as evidenced by: Based on interviews by IB, (A1) wrongfully evicted (R2) by transporting to VA hospital and denied accessed to return to the facility. This violation poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 30, 2024

Plan of correction: Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Eviction Procedures” and implement a plan detailing how Licensee/Administrator will ensure all residents are given proper written eviction notice and submit for approval from CCL. The plan is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov

Allegation investigated: Staff does not have adequate training to care for resident. Staff cannot communicate with resident due to language barrier.

The original LIC9099 and LIC9099C dated 07/30/2024, are being amended to remove modifier. The revised LIC9099 and LIC9099C dated 01/22/2024. The amendment does not change the findings of this investigation. On 07/30/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a complaint investigation at the above facility to address the following allegations. LPA met with Administrator Veronica Gomez and explained the purpose of today's visit. The investigation consisted of the following: During today's investigation, LPA toured the facility, Interviewed ten (10) residents, seven (7) staff members, which included the Assistant Administrator, Marketing Director, Caregiver Supervisor. LPA reviewed and collected facility records. Continue to LIC9099-C. Unsubstantiated Allegation: Staff does not have adequate training to care for residents. It is alleged that staff does not have adequate training to care for resident, complainant states that staff S1 is the real problem and does whatever and threaten to fire various caregiver. On 07/30/2024, records reviewed showed S1 had forty hours of mandatory training of care giver for residents. LPA interviewed seven(7) staff members (S1-S7) 7 out of 7 staff denied the allegation. LPA interviewed the assistant administrator S2. S2 stated that they have the required knowledge for providing care and supervision needed to the residents. LPA interviewed seven staff (7) (S1-S7) all of whom stated that they were given on-the-job training and forty-hour training and have the appropriate experience, which provides knowledge and skills to perform their jobs safely and effectively. S2-S7 stated that S1 never threatened to fire them. This is the first-time hearing something like that. LPA interviewed ten residents (R1-R10) 8 out of 10 denied the allegation and overwhelmingly stated that they are well cared for. Based on interviews, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. Continue LIC9099-C Allegation: Staff cannot communicate with the resident due to the language barrier. It is alleged staff cannot communicate with residents due to the language barrier. LPA interviewed ten (10) Residents (R1-R10) 9 out of 10 stated that they did not have an issue communicating with the staff; when they needed help, the staff did help them. LPA interviewed ten (10) residents (R1-R10) 9 out of 10 stated that when they need help the new staff do help them. On 07/30/2024, the department had no issues communicating with the staff during the visit. During interviews with seven (7) staff members (S1-S7), all the staff were asked if they had any issues communicating with residents, 6 out of 7 staff, denied the allegation and stated they had no problems communicating with residents. LPA interviewed ten residents (R1-R10) and asked if they had any preferred language spoken to them. All the residents, 10 out of 10, stated that they do not have any preferred language as long as the staff helps them when they need help. Based on interviews, observation, and information received, there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. No deficiencies cited. Exit interview was conducted a copy of the report was provided to assistant Administrator Peggy Clark.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 11-AS-20240722162337

Allegation investigated: Staff yells at residents.

On 06/21/2024 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Peggy Clark (S6) and the purpose of the visit was explained. The investigation consisted of the following: On 06/21/2024 LPA requested and reviewed facility documents. LPA interviewed thirteen (13) out of one-hundred and thirty-four (134) residents and six (6) out of seventy-five (75) staff. The investigation revealed the following: Regarding the allegation, “The staff yell at residents.” It has been alleged that staff have yelled saying “Stop using your call bell to me” and “What do you want?”. Report continues, see LIC9099C Unsubstantiated Interviews revealed that four (4) out of six (6) staff and eleven (11) out of thirteen (13) residents have denied the allegation has taken place. Record reviews revealed that the subject of the complaint has completed additional training on 04/24/2024 and that the subject has adequate training for their position. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.the state’s words, verbatim · CDSS document, Jun 21, 2024 · control 11-AS-20240619152832

Allegation investigated: Resident assaulted another resident

On 05/31/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced complaint visit to the facility listed above. LPA met with Director of Admissions, Mary Salcedo, and the purpose of today’s visit was explained. During a visit on 05/16/24, LPA received and reviewed additional documents pertinent to the investigation. The additional documents include the residents staff notes regarding behavior and incidents and Re-Assessments of residents. On a previous visit conducted on 05/02/24, LPA toured the facility, interviewed Staff S1-S8, interviewed Residents R5- R16, and received documents pertinent to the investigation. The documents received include Staff Roster, Resident Roster, Staff Schedule, SIRs regarding falls, Admission Agreement, Resident Needs and Service Plans, Physicians Reports, Pre-Admission Evaluation, and Safeguard of Residents valuables and property. Unsubstantiated During a previous visit conducted by LPA Senaha on 04/04/22, LPA Senaha conducted a plant inspection of the facility, received a copy of the Resident Roster, Staff roster, and documents for Residents R1-R4. On 04/01/22, the El Segundo Adult Senior care referred the above assignment to the Investigations Branch. It was accepted as an assignment to interview Resident R1 and administrator. Investigator Laura Garcia conducted interviews with the former Administrator on 04/05/22 and R1 on 06/01/22. The investigation revealed the following: Allegation: Resident assaulted another resident It is alleged Resident R1 was ‘beat up’ by resident R2 resulting in R1 being transported to the hospital for injuries. During an interview with the former Administrator, conducted by Investigator Laura Garcia, stated R1 is a wanderer and wandered into R2’s room while they were asleep. R2 woke up, was startled, and pushed R1 who fell. During file review, LPA reviewed a Special Incident Report (SIR), that was submitted regarding the incident that stated Saff was performing rounds and when R1 was not in their room Staff started to look for R1 and was calling their name, when they heard a R1 cry out loud. Staff observed R1 coming out of R2’s room. R2 said they were asleep, got startled, and pushed R1. The Long Beach Police Department was called out and the responding officer did not make a report due to the nature of the incident. During record review of Resident’s R1 and R2’s Physician Report, Needs and Service Plan, Resident Appraisal, and Staff Notes, LPA observed neither resident has a history of aggressive behavior, nor any previous altercations with other residents. During interviews with Staff S1-S8, were asked if physical altercations occur between residents, eight (8) out of eight (8) stated physical altercations do not usually occur they have had verbal altercation on occasion. Additionally, staff S1-S8 were asked how they de-escalate altercations between residents, eight (8) out of eight (8) stated they separate the residents and talk with them till they calm down, and in many instances when asked what the altercation was regarding, they don’t remember. During interviews with Residents R3, and R5-R16, were asked if they have had, observed, or heard of altercations between residents, eleven (11) out of thirteen (13) stated they have not had, observed, or heard of any altercations. Additionally, three (3) of the thirteen (13) stated they have heard residents yelling at each other and staff come right away. During an interview with Resident R1, conducted by IB Investigator Laura Garcia, was asked about neglect/lack of supervision leading to physical abuse, R1 denied any type of abuse or neglect while residing in the facility. R1 stated “I was fine, they took care of me, I have no complaints.” During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Director of Admissions, Mary Salcedo, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 31, 2024 · control 11-AS-20220401095058

Allegation investigated: Staff did not get timely medical care for resident resulting in resident's death.

On 05/23/2024, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA met with the Assistant Administrator Peggy Clark and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA Cloyd reviewed the hospice plan of care summary and interviewed one (1) witness and one (1) caregiver. On 05/09/2024 Licensing Program Analyst (LPA) Regina Cloyd and LPA Socorro Leandro conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPAs met with Administrator Veronica Gomez and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA reviewed Register of Residents, 05/09/24 Shift Schedule, requested for the facility’s Plan of Operation, and interviewed four (4) residents and nine (9) staff members which includes (4) MedTechs and (5) Caregivers. LPA Socorro Leandro interviewed eight (8) residents and two (2) staff members which includes the Administrator and one (1) caregiver. Continue to LIC9099-C Unsubstantiated On 09/07/2023, Licensing Program Analyst (LPA) Mario Leon conducted an initial complaint investigation to address the allegation listed above. LPA Leon met with Peggy Clark, Administrator (S1), and explained the purpose of this visit. The investigation consisted of the following: LPA Leon toured the facility, and interviewed three (3) staff (S1-S3). LPA Leon requested and reviewed facility documents. Allegation(s): Staff did not get timely medical care for resident resulting in resident's death. The investigation revealed the following: Regarding the allegation “Staff did not get timely medical care for resident resulting in resident's death,” it is being alleged that Resident #1 (R1) complained of chest pain at 11:30 AM, R1 was assessed by the MedTech, R1 complained of continued pain and fear at 12:30 PM, and R1 passed away at 4:35 PM. Death Report reveals that a Caregiver contacted MedTech, MedTech took R1’s vitals, called hospice, and hospice said they could come out in about 4.5 hours. Hospice Communication log reveals that the hospice company received a call on 09/01/23 11:18 AM concerning R1’s symptoms and hospice provided instruction to the facility. Interview with the hospice representative, Witness #1 (W1), indicated that staff was instructed to supply R1 with oxygen. W1 indicated that staff verbally confirmed that oxygen was administered. Interview with staff indicated that oxygen was administered to R1 and the facility waited for hospice’s arrival from 09/01/23 12:30 PM to 09/01/23 4:30 PM. Hospice discharge summary reveals that the company received a call from the facility at 09/01/23 3:30 PM indicating that R1 was unresponsive and hospice doctor pronounced R1’s death at 4:35 PM. Regarding the allegation, “Staff did not get timely medical care for resident resulting in resident’s death, based on record review and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was reviewed and left with Assistant Administrator Peggy Clark.the state’s words, verbatim · CDSS document, May 23, 2024 · control 11-AS-20230906092249

Allegation investigated: Staff did not assist resident in a timely manner. Staff did not meet resident's needs.

On 05/23/2024 Licensing Program Analyst (LPA) Leandro and LPA Cloyd conducted an unannounced, continuation complaint visit to the above-mentioned facility. LPA was met by Peggy Clark, Administrator and explained the purpose of the visit. The investigation consisted of the following: On 03/13/24 LPA Leon requested and reviewed facility documents and toured the facility. LPA Leon interviewed 10 out of 133 residents and 4 out of 72 staff. On 05/09/2024 LPA Cloyd and LPA Leandro requested several facility records which included: Register of Residents, Shift Schedule, and Plan of Operation. LPAs interviewed 12 out of 132 residents and 6 out of 72 staff. LPA Leandro toured 2 residents’ rooms. On 5/10/2024 LPA Cloyd and LPA Leandro interviewed 3 out of 66 staff. On 5/23/2024 LPA Cloyd and LPA Leandro requested several facility records which included Resident’s 1 (R1s) records. LPAs interviewed 1 out of 132 residents and 1 out 72 staff. A total of 22 resident interviews were conducted. A total of 14 staff interviews were conducted. Some interviewees were interviewed more than once. Unsubstantiated The investigation revealed the following: Regarding the allegation “Staff did not assist resident in a timely manner” it is being alleged that the facility’s front desk did not answer R1’s call and that facility staff did not come to R1’s assistance in a timely manner. LPA Leandro interviewed R1 and R1 indicated that she did not call front desk when she fell in her bathroom, and she does not call facility because they do not help her. Interview with Caregiver that assisted R1 indicated that R1 informed Caregiver that R1 did not call anyone for assistance. Interviews conducted with residents and staff indicate that staff makes rounds every 30 minutes to 3 hours. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. The investigation revealed the following: Regarding the allegation “Staff did not meet resident's needs,” it is being alleged that the facility did not move R1 to a room without a shower tripping hazard. Record review indicates that facility staff moved R1 to four different rooms due to R1’s request. LPA did not observe a shower tripping hazard in R1’s room. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, May 23, 2024 · control 11-AS-20240304121803

Allegation investigated: Staff do not supervise residents resulting in multiple falls Resident care needs are not being met Facility failed to safeguard resident’s property Facility is short staffed Facility has a lack of supplies

On 05/16/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced complaint visit to the facility listed above. LPA met with Administrator, Veronica Gomez, and the purpose of today’s visit was explained. During today’s visit LPA received and reviewed additional documents pertinent to the investigation. The additional documents include the residents staff notes regarding behavior and incidents and Re-Assessments. On a previous visit conducted on 05/02/24, LPA toured the facility, interviewed Staff S1-S8, interviewed Residents R5- R16, and received documents pertinent to the investigation. The documents received include Staff Roster, Resident Roster, Staff Schedule, SIRs regarding falls, Admission Agreement, Resident Needs and Service Plans, Physicians Reports, Pre-Admission Evaluation, and Safeguard of Residents valuables and property. During a previous visit conducted by LPA Senaha on 04/04/22, LPA Senaha conducted a plant inspection of the facility, received a copy of the Resident Roster, Staff roster, and documents for Residents R1-R4. CONTINUED ON LIC9099-C Unsubstantiated On 04/01/22, the El Segundo Adult Senior care referred the above assignment to the Investigations Branch. It was accepted as an assignment to interview Resident R1 and administrator. Investigator Laura Garcia conducted interviews with the former Administrator on 04/05/22 and R1 on 06/01/22. The investigation revealed the following: Allegation: Staff do not supervise residents resulting in multiple falls It is alleged as a result of being short staffed resident fall due to lack of supervision. During file review, LPA reviewed Special Incident Reports (SIR) regarding falls. During the facility tour, LPA observed some rooms have a lower bed to make it easier for residents to get in and out of to help prevent falls. Additionally, LPA observed some rooms have fall mats that are placed next to the bed once the resident is in bed. During interviews with Staff S1-S8, were asked how often are residents with fall plans checked on, eight (8) out of eight (8) stated they are checked every fifteen (15) minutes. During interviews with Residents R3, R5-R16, were asked if they have had any falls while living in the facility, nine (9) out of thirteen (13) stated they have not had any falls while living here. Three of the four residents who experienced falls stated the falls happened years ago, and the other stated theirs was a minor fall. Additionally, during interviews with Residents R3, R5-R16, were asked if they feel staff supervise residents, thirteen (13) out of thirteen (13) feel staff supervise residents. CONTINUED ON LIC9099-C During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Resident care needs are not being met. It is alleged resident’s needs are not being met and are not being changed or bathed in a timely manner. During the facility tour, LPA observed the residents in the facility are placed in a room in a certain area depending upon their needs. There are three (3) memory care units, a hallway of resident that are on hospice, an assisted living area, and an independent living area. Each area is staffed with caregivers according to the resident’s needs. LPA reviewed the Physicians Report, Appraisal, and Needs and Service Plan for eight (8) residents and reviewed where their placement is at in the facility based on the level of assistance they require. During interviews with Staff S1-S8, were asked if they feel residents care needs are being met, eight (8) out of eight (8) stated they believe residents care needs are being met. During interviews with Residents R3 and R5-R16, were asked if they felt their care needs are being met, thirteen (13) out of thirteen (13), stated their care needs are being met. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. CONTINUED ON LIC9099-C Allegation: Facility failed to safeguard resident’s property It is alleged residents are missing personal items such as jewelry. During the facility tour, LPA observed in residents’ room a drawer with a lock on it to secure their personal belongings. During record review, LPA reviewed the Admission Agreement that states on page 8 number 27 “the resident or representative have the option to record and document all personal property brought into the facility on LIC621 for the facility to safeguard resident personal belongings and other property.” Additionally, it states “The facility is not liable for any personal items which are not contained in the resident inventory list.” During an interview with the Administrator S1, was asked how resident’s personal belongings are safeguarded, S1 stated every room has a locked drawer to secure their personal belongings in and the family is asked to inventory items coming in on a LIC621. Additionally, S1 stated that they tell new residents and their family not to bring expensive jewelry or large sums of money to the facility. During interviews with Staff S2-S8, were asked how residents personal belongings are safeguarded, seven (7) out of seven (7), stated they encourage residents to close and lock their room doors, and to secure items in their drawer with a lock. During interviews with Residents R3, R5-R16, were asked if they had any items go missing, ten (10) out of thirteen (13) stated they have not had any item go missing. Additionally, LPA asked the Residents R3, R10, and R16, what items they had missing and how long ago, a resident stated they had two (2) pieces of computer paper go missing a long time ago, another stated they had seashells go missing a while ago, and another stated they has some clothes go missing 3 years ago. During the course of the investigation, LPA was unable to find evidence to support CONTINUED ON LIC9099-C the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Facility is short staffed It is alleged most days the facility is short staffed, one caregiver for each floor and in some cases one caregiver for the entire building to the point residents are assisting other residents with care and mobility needs. During record review LPA reviewed the Staff Schedule and observed there were eleven (11) caregivers scheduled to work. Additionally, LPA reviewed the staff schedule for April 2022 and observed for the AM shift seven (7) caregivers and a Med Tech was scheduled, for the PM shift ten (10) caregivers were scheduled and a Med Tech, and for the Noc shift five (5) caregivers were scheduled. During the facility tour, LPA observed all eleven (11) caregivers throughout the facility. During interviews with Staff S1-S8, were asked if they feel there are enough staff to meet residents needs, eight (8) out of eight (8) stated yes, they feel there are enough staff. During interviews with Residents R3, R5-R16, were asked if they feel there are enough staff to meet the residents needs, twelve (12) out of thirteen (13), stated they feel there are enough staff to meet their needs and one resident was not sure. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. CONTINUED ON LIC9099-C Allegation: Facility has a lack of supplies It is alleged the facility is often low on supplies, diapers, and other care products. During the facility tour, LPA observed four (4) different rooms with hygiene supplies and incontinent care supplies stored within. LPA observed an ample supply of products. During an interview with Administrator S1, was asked if they feel there is enough supplies to meet resident’s needs, S1 stated they order products monthly and are always available to residents. Additionally, diapers are covered by the insurance and there are extra available if needed and hospice usually supplies wipes which we have extra available as well. During interviews with Staff S2-S8, were asked if they feel there is enough supplies to meet resident’s needs, seven (7) out of seven (7) stated the facility has hygiene products and incontinent products available for residents. During interviews with Residents R3, R5 – R16, were asked if hygiene or incontinent products are supplied to them, thirteen (13) out of thirteen (13) stated they know there are products available if they need them and the facility has a large supply. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. During today's visit LPA did not observe or cite any deficiencies. LPA conducted an exit interview with Executive Director, Veronica Gomez, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 16, 2024 · control 11-AS-20220401095058

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Facility staff handled resident in a rough manner.

On 05/10/2024 Licensing Program Analyst (LPA) Leandro conducted an unannounced, continuation complaint visit to the above-mentioned facility. LPA was met by Peggy Clark, Administrator. Investigation consisted of the following: On 12/22/2023 LPA Leon interviewed 6 out of 130 residents and 9 out of 70 staff. On 05/10/2024 LPA Leandro interviewed 6 out of 132 residents and 2 out of 66 staff. On 12/22/2023 and 05/10/2024 LPAs requested several facility records. A total of 12 out of 132 residents were interviewed and a total of 11 out of 66 staff were interviewed. Record review consisted of: Personnel Report, Facility Census, Unusual Incident/Injury Reports, Facility Staff Trainings, Resident 1’s (R1) Records, etc. Unsubstantiated The investigation revealed the following: Regarding the allegation “Facility staff handled resident in a rough manner” it is being alleged that facility staff blocked R1’s doorway and because of this R1 fell. 9 out of 12 resident interviews indicated that facility has not treated them in a rough manner. 9 out of 11 staff interviews indicated that they have not seen and/or heard complaints about staff handling residents in a rough manner. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with Peggy Clark, Administrator.the state’s words, verbatim · CDSS document, May 10, 2024 · control 11-AS-20231220160256

Allegation investigated: Staff speaks to resident in an inappropriate manner. Staff does not safeguard resident's belongings. Staff does not treat resident with dignity and respect.

On 05/10/2024 Licensing Program Analyst (LPA) Leandro conducted an unannounced, continuation complaint visit to the above-mentioned facility. LPA was met by Peggy Clark, Administrator. Investigation consisted of the following: On 12/22/2023 LPA Leon interviewed 6 out of 130 residents and 9 out of 70 staff. On 05/10/2024 LPA Leandro interviewed 6 out of 132 residents and 2 out of 66 staff. On 12/22/2023 and 05/10/2024 LPAs requested several facility records. A total of 12 out of 132 residents were interviewed and a total of 11 out of 66 staff were interviewed. Record review consisted of: Personnel Report, Facility Census, Unusual Incident/Injury Reports, Facility Staff Trainings, Resident 1’s Records, etc. Unsubstantiated The investigation revealed the following: Regarding the allegation “Staff speaks to resident in an inappropriate manner” it is being alleged that facility staff speak to residents in care inappropriately. 10 out of 12 resident interviews indicated that staff speaks to them appropriately. 8 out of 11 staff interviews indicated that staff speaks to residents appropriately and/or they have not seen staff speak to residents inappropriately. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. The investigation revealed the following: Regarding the allegation “Staff does not safeguard resident's belongings” it is being alleged that facility staff destroy and steal resident belongings. 7 out of 12 resident interviews indicated that they have not had any of their property stolen by facility staff. 9 out of 11 staff indicated that they have not heard of or seen staff stealing/breaking residents’ personal belongings. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. The investigation revealed the following: Regarding the allegation “Staff does not treat resident with dignity and respect” it is being alleged that facility staff mistreat residents in care. 10 out of 12 resident interviews indicated that facility staff treat them with dignity and respect. 10 out of 11 staff interviews indicated that they have not heard complaints and/or seen staff mistreat residents in care. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with Peggy Clark, Administrator.the state’s words, verbatim · CDSS document, May 10, 2024 · control 11-AS-20231219134015

Allegation investigated: Due to staff negligence, resident did not have blood sugar checked. Staff are falsifying resident records. Due to staff negligence, resident did not receive medications.

On 05/10/24, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA met with Receptionist/Caregiver and Assistant Administrator Peggy Clark and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA interviewed the Receptionist/Caregiver and Licensed Vocational Nurse and reviewed facility and resident records. On 05/09/2024 Licensing Program Analyst (LPA) Regina Cloyd and LPA Socorro Leandro conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPAs met with Administrator Veronica Gomez and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA reviewed Register of Residents, 05/09/24 Shift Schedule, requested for the facility’s Plan of Operation, and interviewed four (4) residents and nine (9) staff members which includes (4) MedTechs and (5) Caregivers. LPA Socorro Leandro interviewed eight (8) residents and two (2) staff members which includes the Administrator and one (1) caregiver. Continue to LIC9099-C Unsubstantiated On 08/10/23 Licensing Program Analyst (LPA) Mario Leon initiated a complaint visit for the allegations listed above. Today’s complaint investigation was greeted by, and conducted with, Veronica Gomez, Administrator. LPA explained the purpose of the visit. The investigation consisted of the following: LPA attempted contact with the reporting party (RP), who was unavailable. LPA toured the facility and interviewed three (3) clients, two (2) staff and one (1) witness. LPA requested facility records and staff records. Allegation(s): Due to staff negligence, resident did not receive medications. Staff are falsifying resident records. The investigation revealed the following: Regarding the allegation "Due to staff negligence, resident did not receive medications,” and “staff are falsifying resident records,” it is being alleged that R1 left the facility on 07/19/23 and staff notated on the EMAR that R1 took R1’s 8:00 AM and 12:00 PM medication. RP stated that during this time, R1 was away from the facility and did not receive medication. Record review reveals that R1 did not take R1’s 8:00 AM nor 12:00 PM medication on 07/19/23. The EMAR revealed that R1 only took 8:00 PM medication on 07/19/23. Interviews conducted reveal: 10 out of 12 staff members indicate that when families or residents provide notice of a facility departure, MedTech will prepare medication and leave at the front desk to ensure that residents do not miss their dose(s). Three (3) out of four (4) resident interviews, including R1, indicate that medication is provided when they need to leave the facility for a great length of time. LPA Leandro’s resident interviews reveal: 5 out of 8 residents, including four (4) from memory care, were unaware of the medication release process. Regarding the allegation “Due to staff negligence, resident did not receive medications," and “staff are falsifying resident records,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for these (2) allegations. Continue to LIC9099-C Allegation(s): Due to staff negligence, resident did not have blood sugar checked. The investigation revealed the following: Regarding the allegation " Due to staff negligence, resident did not have blood sugar checked,” it is being alleged that R1 did not have R1’s blood sugar tested the last two days. RP called on 07/31/23. Record review reveals that R1’s blood sugar was tested on 07/29/23 and 07/30/23. Blood sugar was not tested on 07/31/23. On 08/10/23, LPA Mario Leon interview with License Vocational Nurse (LVN) (S3/W1) indicated that R1 refused to be tested. The facility has a numbering system and S3/W1 was on number 5 and R1 had number 11. S3/W1 informed R1 that S3/W1 was unable to immediately assist R1. Then R1 refused. Based on record review and interview, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, 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 the Assistant Administrator Peggy Clark.the state’s words, verbatim · CDSS document, May 10, 2024 · control 11-AS-20230731141841

Allegation investigated: Staff yells at residents.

On 04/23/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Peggy Clark, Administrator (S2), and the purpose of the visit was explained. LPA toured the facility. The investigation consisted of the following: On 04/23/24 LPA requested and reviewed facility documents and toured the facility. LPA interviewed three (3) out of one-hundred thirty-two (132) residents (R1-R3) and eight (8) out of seventy-two (72) staff (S1-S8). The investigation revealed the following: Regarding the allegation: "Staff yells at residents.". It has been alleged that one staff member (S1) is often yelling at residents in care. Report continues, see LIC9099C Substantiated Between 09:00AM and 10:30AM, on 04/23/24, LPA observed multiple calls from one of the subjects (R1) in the complaint provided by the plaintiff. Interviews revealed that two (2) out of eight (8) staff disagreed with the allegation, while four (4) out of 8 staff agreed with the allegation. 2 staff were unsure, but would believe that the mentioned staff (S1) would cause fellow staff to become displeased at completing their tasks. Record reviews revealed that the mentioned staff (S1) has visited R1's room on 04/08/24 and 04/13/24. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. An exit interview was conducted with Peggy Clark, Administrator, and a copy of facilities’ appeal rights and this report have been provided.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 11-AS-20240417165425

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Apr 30, 2024

87468.1 Personal Rights...in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of... personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This has not been met as evidenced by: Licensee did not provide R1 with dignity in their personal relationships with staff; as through interviews, S1 has been named and confirmed through six (6) out of eleven (11) total interviewsthe state’s words, verbatim · CDSS document, Apr 23, 2024

Plan of correction: Administrator (S2) and LPA have agreed that the licensee will make arrangements to conduct further training(s) with S1. Licensee will provide adequate further training with S1, via email, to LPA at Mario.Leon@dss.ca.gov

Type of visit: Required - 1 Year

On 03/19/23, Licensing Program Analysts (LPA) Mario Leon, Regina Cloyd and Troy Watson, along with licensing program manager (LPM) Ulysses Coronel, conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs and LPM met with the Administrator Peggy Clark and assistant administrator Veronica Gomez and the purpose of today’s visit was explained. The facility is licensed to operate for 262 non-ambulatory residents, of which 10 may be bedridden, ages 60 and over. The facility has an approved Hospice Waiver for 10 residents. The facility is a large, two-story, building located in a commercial neighborhood. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of two floors which includes resident rooms, common areas, dining area, kitchen, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of two floors, resident rooms, dining area, common area, a theater, and delayed egress doors. The facility has a signal system with a switch board located in the reception area and is operational from all residential living units. LPAs and LPM conducted record reviews of six (6) resident records and six (6) staff records. The facility disaster drill and fire drill were conducted during the day and night shifts on 02/13/24 and 02/15/24. The facilitys' disaster plan is current and in compliance with Title 22 regulations at the time of visit. LPAs and LPM checked resident units. Mattresses and box springs were in good condition, adequate lighting and plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting in the restroom, and sufficient toiletries are accessible to residents. Report continues, see LIC809C The water temperature properly measured between 105-120 degrees F and the internal air temperature was comfortable, measured at 75 degrees F. Perishable and non-perishable food supply was checked and LPAs and LPM observed food to be fully-stocked at the time of visit. Carbon monoxide detector and smoke detectors were observed, fire extinguishers were fully charged as of 02/20/24, toxins and knifes were locked and inaccessible to residents. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Exits/Walkways around the facility were free of debris and hazards. LPA's observed a monthly schedule which presented a sufficient number of daily activities for facility residents. LPA observed the noted activities being conducted in the activities area, which is directly across from the TV lounge area. During today’s visit, there were three (3) technical assistance notes and two (2) technical violations provided; see: LIC9102AN and LIC9102TV. There were no deficiencies cited during today's visit. An exit interview was held with Peggy Clark and Veronica Gomez, Administrators, and a copy of this report and LIC9102AN's / LIC9102TV's were provided.the state’s words, verbatim · CDSS document, Mar 19, 2024

The state marks this report as 7 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure that resident's room was free of tripping hazards.

On 03/13/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Veronica Gomez, Administrator (S1) ,and the purpose of the visit was explained. LPA toured the facility. The investigation consisted of the following: On 03/13/24 LPA requested and reviewed facility documents and toured the facility. LPA interviewed ten (10) out of one-hundred thirty-three (133) residents and four (4) out of seventy-two (72) staff. The investigation revealed the following: Regarding the allegation: "Staff did not ensure that resident's room was free of tripping hazards.". It has been alleged that staff have not moved resident one (R1) to a room without a tripping hazard. LPA interviewed four (4) staff (S1-S4). All staff have agreed that the ALW program's personal rooms have got a step to get into the showers, or have a cut-out in the bathtub for a resident to get in the tub, which also requires a step to allow a resident to shower, therefore denying the allegation. Report continues, see LIC9099C Unsubstantiated LPA observed three ALW personal rooms, all of which have a step to get in the shower. LPA interviewed 10 residents (R1-R10), seven (7) out of ten (10) residents have denied the allegation, one (1) resident out of ten (10) have denied the interview. LPA interviewed one (1) witness (W1) from Carelon Hospice and W1 has provided sufficient information to deny R1's fall was based on over-medication or any abuse. Record reviews revealed that resident one ambulated to the hospital via taxi service and that the radiology department observed no fractures throughout R1's body. Based on LPA's observations, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. No deficiencies were cited during today's visit. An exit interview was conducted with Veronica Gomez, Administrator (S1), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 11-AS-20240304121803

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained fractures while in care Resident sustained multiple falls while in care

On 02/29/24 Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Mario Leon initiated a subsequent, unannounced, complaint visit at the above-mentioned facility to deliver the findings below. LPA was met by Peggy Clark, Administrator, and the purpose of the visit was explained. The investigation consisted of the following: On 06/21/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced complaint visit at this facility. LPA toured the facility and requested and reviewed resident records which consisted of: Medical assessments and internal assessments, resident appraisals, needs and services plans. LPA interviewed 12 out of 123 residents. LPA also requested and reviewed communications between Reporting Party (RP) and S1, and internal communication log related to facility residents. On 08/10/23 LPA delivered findings on 1 out 4 allegations. On 06/21/23 the Departments’ Investigation Branch Investigator (IB) Jose Santana resumed investigation. Report continues, see LIC9099C. Substantiated The investigation revealed the following: Regarding the allegation: " Resident sustained fractures while in care". It has been alleged that a resident (R1) fell while in care at the facility resulting in a broken (right) hip. IB’s interviews and record reviews revealed the following: On 02/08/2023, during R1’s admission at the facility, R1 walked without assistance and was not known to be a major fall risk. It was recommended that R1 use a walker for slightly unsteady gait and be supervised while walking. On 2/17/2023 R1 had a witnessed fall while ambulating at the facility and was sent to the hospital for assessment, R1 sustained a fracture due to osteoporosis and underwent hip pinning. On 3/06/2023, R1 returned to the facility after receiving physical therapy. Interviews revealed that R1 was not reassessed, despite having had a recent hip fracture and walking with a limp. S3 indicated that had R1 been reassessed, S3 also indicated that the facility would have requested “all the protective things” R1 would need. The facility moved R1 to a different memory care unit and placed R1 on Karemore Hospice on 3/16/2023. Despite these added services, R1 continued attempting to get out of bed without assistance and sustained unwitnessed falls in R1’s facility apartment on 5/14/2023 and 6/03/2023. In response, the facility staff placed pillows next to R1 and engaged the half bed rail to restrain future falls, but R1 was again not reassessed and R1’s responsible person was not notified of the falls. In addition, R1 continued ambulating without a cane and sometimes without supervision. It does not appear the facility requested safety equipment or other protective measures, aside from medication adjustment, and the facility did not provide sustained increased supervision despite claims to the contrary. Two days after R1 expressed pain following her fall on 6/03/2023, R1 sustained a minimally displaced left femoral neck fracture. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 is being cited on the attached LIC 9099D. Regarding the allegation: "Resident sustained multiple falls while in care". IB’s investigation revealed the following: On 2/17/2023 R1 had a witnessed fall while ambulating at the facility and was sent to the hospital for assessment, R1 sustained a fracture and underwent hip pinning. On 3/06/2023, R1 returned to the facility after receiving physical therapy. Interviews revealed that R1 was not reassessed despite having had a recent hip fracture and walking with a limp. Due to changes in their medical condition, R1 continued attempting to get out of bed without assistance and sustained unwitnessed falls in R1’s facility apartment on 5/14/2023 and 6/03/2023. R1 continued ambulating without a cane and sometimes without supervision. The facility did not request safety equipment or implement protective measures, aside from medication adjustment. Report Continues, see LIC9099C Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 is being cited on the attached LIC 9099D. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) "Serious Bodily Injury" as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement. An exit interview was conducted and plans of corrections were developed. A copy of this report and appeals rights were provided to Peggy Clark, Administrator. The investigation revealed the following: Regarding the allegation: "Resident sustained injuries while in care". Interviews and record reviews revealed that the contusion to R1’s right eye and forehead were sustained when R1 accidentally struck their bed rail due to agitation, as caregivers attempted to change R1’s incontinence briefs. Staff stated that R1 deliberately banged their head on the walls. R1 often required up to three caregivers to change their incontinence briefs due to R1’s high combativeness. On the early morning hours of 6/02/2023, while R1 was in bed, an overnight shift staff found R1 with blood on their mouth and teeth. Staff denied R1 sustained an unwitnessed fall. It is important to note that the caregiver moved R1’s legs up and placed pillows next to their body to keep R1 from getting out of bed. It is also important to note, for level of care purposes, that R1 had previously, at times, gotten out of bed and wandered about the facility. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. An exit interview was conducted with Peggy Clark, Administrator, and a copy of this report was provided to Peggy Clark, Administrator.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 11-AS-20230620143911

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(c) · Plan of correction due date: Mar 1, 2024

Reappraisals. The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and … if any, when there is significant change in the resident’s condition, …first, as specified in Section 87467, Resident Participation in Decision Making. This requirement was not met as evidenced by: Based on interviews and record reviews the licensee failed to ensure that R1 was reappraised following a change in their medical condition after hospitalization, which posed an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: The administrator agreed to create a plan of correction to ensure that reappraisals are conducted when significant change in the resident’s condition are observed. Proof of corrections will be submitted prior to POC due date, via email, to mario.leon@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Mar 1, 2024

Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental… functioning and that appropriate assistance is provided when such observation reveals unmet needs. When…deterioration …are observed, the licensee shall ensure that such changes are … brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Based on interviews and record reviews the licensee failed to ensure that appropriate assistance was provided to R1 when changes in their physical and mental functioning, R1 was observed which posed an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: The administrator agreed to create a plan of correction to ensure that appropriate assistance is provided to residents when observations reveal unmet needs. Proof of corrections will be submitted prior to POC due date, via email, to mario.leon@dss.ca.gov

Allegation investigated: Staff allowed resident to wander from facility resulting in a fracture

THIS REPORT SUPERSEDES THE REPORT DATED 08/24/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: SUBSTANTIATED Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Palmcrest Grand Residence on 10/03/2022 and 07/10/2023 and was greeted by Administrator Peggy Clark (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. During this investigation, LPA Calderon interviewed A2 (Clark), R1-R14, S1-S4, A1 (Gomez). This interview was conducted on 10/03/2022, 02/08/2023, 07/10/2023, 08/17/2023 and 08/23/2023. On 02/23/2023 LPA Calderon requested copies of the following: Staff and Resident rosters, needs and service plan (06/27/2022), physician report (12/21/2021), College Medical Center hospital records (09/13/2022), medical administration record (10/20/2022), Home Health Care records (10/19/2022) for R1. On 11/23/2022 received Department of Social Service Investigation Branch (IB) report. The investigation revealed the following: Substantiated Regarding Allegation #1: Staff allowed resident to wander from facility resulting in a fracture. This complaint alleges resident R1 left the facility memory care unit and sustained an injury in the facility parking lot. On 11/23/2022 received and reviewed the department’s Investigation Branch (IB) Investigator Edward Hector report. The investigators report states: During the investigation I obtained and reviewed medical records. I interviewed the R1, R1 son and facility administrator and facility staff. All information and interviews confirm that R1 was assigned to the secure and locked memory care unit. R1 absconded from the memory care unit and was later found outside in the parking lot of nearby facility with an ankle injury. R1 did not explain how R1 escaped the memory unit and staff have no information on how R1 got out without any alarms going off. There is sufficient evidence to support the allegation of lack of supervision”. Based on LPA’s observations and interviews conducted along with records reviewed, there is sufficient evidence that facility “Staff allowed resident to wander from the facility resulting in a fracture”, therefore this allegation is determined to be “substantiated”. An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Administrator Peggy Clark (A1). Regarding Allegation #1: Staff abandoned resident. This complaint alleges that the facility refused to allow R1 to return to the facility after a hospital visit. On 08/17/2023 LPA Calderon interviewed A1(Gomez) for a complaint. A1 (Gomez) expressed that R1 was admitted to the hospital for a left ankle injury sustained during the incident when (R1) wandered off the facility. On 08/23/2023 LPA Calderon interviewed A1 Veronica Gomez and A2 Peggy Clark. A1 claimed that the facility would never abandon a resident in the hospital without evaluating a resident for additional medical care and would take steps to notify the family representatives of R1. A1 and A2 expressed that A1 went to the hospital to evaluate R1. A1 and A2 claimed that R1 had been physically violent with staff and residents while at the facility and continued with violent behavior towards A1 and A2 while at the hospital. Evaluation of (R1) revealed due to (R1’s) violent behaviors, the hospital records confirmed: “Psychiatric based hospitalization is necessary due to patient confusion and easily agitation and disorientation”. Medical records revealed that based on medical assessment, it is recommended to transfer (R1) to a psychiatric unit when medically cleared. Records indicated that medical professionals consulted with family representatives and agreed that (R1) should go to a psychiatric facility to receive treatment before returning to the facility. S1-S4 was interviewed and reported that it is normal for staff to evaluate a resident who is taken to the hospital for further care before the resident is returned to the facility. S1-S4 expressed that they do not know as to why R1 was not returned to the facility. On 02/08/2023 LPA Calderon interviewed R2-R13 for complaint. 12 out of 12 residents expressed that staff would not abandon them at a hospital. On 10/03/2022 LPA Calderon reviewed the South Coast Medical Center report (09/17/2022). “R1 was diagnosed with health issues”. S1-S4 was interviewed and reported that it is normal for staff to evaluate a resident who is taken to the hospital for further care before the resident is returned to the facility. S1-S4 expressed that they do not know as to why R1 was not returned to the facility. On 02/08/2023 LPA Calderon interviewed R2-R13 for complaint. 12 out of 12 residents expressed that staff would not abandon them at a hospital. On 10/03/2022 LPA Calderon reviewed the South Coast Medical Center report (09/17/2022). “R1 was diagnosed with health issues”. Based on LPA’s observations and interviews conducted along with records reviewed, there is insufficient evidence that facility “Staff abandoned resident”, therefore this allegation is determined to be “unsubstantiated”. An exit interview was conducted, and a copy of the Complaint Report to the Administrator Peggy Clark (A1).the state’s words, verbatim · CDSS document, Jan 18, 2024 · control 11-AS-20220930144632

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(2) · Plan of correction due date: Jan 18, 2024

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation....(2) Safety measures to address behaviors such as wandering, aggressive behavior ....This requirement is not met as evidenced by: Based on interview, observation, and record review, the licensee failed to ensure that the facility prevented the resident from absconging from the memory care unit and being found in the facility parking lot which poses a health risk to residents in care.the state’s words, verbatim · CDSS document, Jan 18, 2024

Plan of correction: Administrator Veronica Gomez will develope a security plan to prevent residents of the memory care unit from absconding from the facility without staff or family with the resident.

Allegation investigated: Licensee did not provide adequate notice of fee increase to resident.

On 01/03/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Peggy Clark (S1) and the purpose of the visit was explained. The investigation consisted of the following: On 01/03/24 LPA requested and reviewed facility documents and toured the facility. LPA interviewed eleven (11) out of one-hundred twenty-one (121) residents, one (1) witness, and three (3) out of seventy (70) staff. LPA reviewed SSI payments notification update, dated 10/10/23, and notification informing the new rental rate, dated 12/01/23. The investigation revealed the following: Regarding the allegation: "Licensee did not provide adequate notice of fee increase to resident.". Report continues, see LIC9099-C. Substantiated It has been alleged that staff have not provided an amount related to the increase of rent, resulting in further confusion of residents' ability to pay rent on the due date which is 01/03/24. LPA interviewed three staff (S1-S3). All three staff have denied the allegation. LPA interviewed 11 residents (R1-R11). Seven (7) out of eleven (11) residents have agreed with the allegation, while four (4) out of eleven (11) residents were not familiar with the increased rate. Record reviews revealed that Resident Seven (R7) received a notice of rate increase, without listing the amount, on 10/10/23. Furthermore, Staff Two, Veronica Gomez (S2) showed the same paperwork and informed LPA that it was sent to all Social Security Income / Assisted Living Waiver residents. Resident Three (R3) received a notice of rate increase, listing the increased rate amount, on 01/02/24 and had paid the bill by check on 01/02/24. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. Under Health and Safety Code, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. An exit interview was conducted with Peggy Clark, S1, and a copy of appeal rights and this report were provided.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 11-AS-20231229093425

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a) · Plan of correction due date: Jan 4, 2024

Health and Safety Code (HSC) 1569.655(a) If a licensee..the licensee shall provide no less than 60 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase,..reason..the increase,..general description..additional costs, except for...a change in the level of care of the resident. This subdivision...fee-for-service arrangement with residents. This is not met as evidenced by: Based on interviews with residents and through record reviews, the licensee failed to provide the amount of the increase in a timely manner.the state’s words, verbatim · CDSS document, Jan 3, 2024

Plan of correction: Licensee will create a plan that will inform all residents who had not been notified of the new monthly rate change that has taken place on 01/01/2024. Licensee will also create a plan for all future rate amount changes to be presented to residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. Updated plan will be sent to LPA at Mario.Leon@DSS.CA.GOV

Allegation investigated: Staff did not provide a comfortable environment for residents

On 12/18/23 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Peggy Clark, Administrator (S1), and LPA explained the purpose of the visit. LPA toured the facility. The investigation consisted of the following: On 12/18/23 LPA requested and reviewed facility documents and toured the facility. LPA interviewed ten (10) out of one-hundred thirty (130) residents and six (6) out of seventy (70) staff. The investigation revealed the following: Regarding the allegation: "Staff did not provide a comfortable environment for residents". It has been alleged that one resident was tampering with resident's juice cups prior to the cups being served. Report Continues, see LIC9099C Unsubstantiated LPA interviewed six (6) staff (S1-S6). All staff have denied the allegation. LPA interviewed ten (10) residents (R1-R10). Seven (7) out of ten (10) residents have denied the allegation. Record reviews revealed that the subject had written a detailed note, explaining why they would not have completed the allegation listed above. Based on record reviews, interviews and observations conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There were no deficiencies cited during today's visit. An exit interview was conducted with Peggy Clark, Administrator, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Dec 18, 2023 · control 11-AS-20231211093156