Coral Oaks Care Living

Allegation investigated: Staff did not safeguard resident's personal belongings. Staff are not meeting residents needs. Staff are not providing a comfortable environment for resident.

On June 11, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial unannounced complaint visit. Ellen Barrientos, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above. The investigation and a collection of documents and tour of the facility. A review of Personnel Report LIC 500 (dated 04/14/26), Resident Roster (dated 06/08/26), Resident #1 (R1's) Admission Agreement, Centrally Stored Medication and Destruction Record (dated 06/01/26), Medical Assessment for Residential Care Facilities LIC 602A (dated 05/01/26), Preplacement Appraisal Information LIC 603 (dated 05/04/26), Resident Appraisal LIC 603A (dated 05/08/26), and other pertinent records associated with this complaint. Interviews conducted with Resident #1-#6 (R1-R6), Staff #1-#3 (S1-S4) and Witness #1 (W1). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not safeguard resident's personal belongings. It is alleged that the staff did not protect Resident #1's (R1) personal belongings. It is reported that (R1’s) blanket was stolen and that refreshment sodas went missing from (R1’s) refrigerator. No additional details regarding this matter are provided. On June 08, 2026, between 02:00 PM and 03:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #6 (R1-R6). Five (5) out of the six (6) residents could not support this claim. (R2 to R6) reported that during their entire stay in the care facility, they have never encountered any instances of their personal belongings being lost or stolen. They expressed a sense of security and trust in the care environment, stressing the effective measures in place to safeguard their possessions. (R2 to R6) stressed that safeguarding your personal items is the responsibility of the resident. (R1) reported missing a blanket and some refrigerated items. While unsure if they were stolen, (R1) believes someone is entering the room and taking sodas. (R1) could not provide specific names, dates, times, or witnesses related to the incidents. However, (R1) mentioned that missing items sometimes reappear. On June 08, 2026, between 01:45 PM and 03:30 PM, the Department interviewed staff members identified as Staff #1 through Staff #4 (S1-S4). Four (4) out of (4) four staff members reported they could not support this claim. (S1) reported that (R1) was admitted to the facility on May 1, 2026, and is currently in the transitional period. (S1) claimed that when (R1) moved in, the individual responsible for (R1) assisted with arranging (R1's) and personal belongings in the room. The facility conducted an inventory of (R1's) items using the Resident Personal Property and Valuables LIC 621 form, which listed all (R1's) items; however, no blanket was included in this inventory. Additionally, we have the facility's documentation from the Resident Belonging Pick Up/Drop Off form, which lists (R1's) food supply items, including (16) cans of soda, signed by (R1). (S1 to S3) also mentioned that the facility offers residents the option to store some valuable items in the office for safekeeping or an available use of pad lock for their drawers to ensure security. (Evaluation Report continues LIC 9099-C) On June 11, 2026, between 08:43 AM and 09:01 AM, the Department interviewed witness member identified as responsible party Witness #1 (W1). (W1) confirmed that (R1) is still in the transition period between facilities. (W1) noted that (R1) has a history of misplacing items, which often reappear later. (W1) also mentioned that (R1) did not bring a blanket when moving into the facility and that some items (R1) claims are missing are being held for safekeeping by (W1). (W1) claimed that there is no wrongdoing going on at this facility. The Department reviewed Resident (R1’s) Personal Property and Valuables LIC 621 (dated 05/01/26) and the Resident Belongings Pick Up/Drop Off form (dated 05/23/26). The verified listings revealed that no blanket was listed, and that refreshments, specifically sodas, were received by (R1). Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Allegation #2: Staff are not meeting resident's needs. It is alleged that the staff did not meet Resident #1 (R1’s) needs. It is reported that there are too many residents and not enough staff to assist (R1) and that staffing is inadequate. No additional details regarding this matter are provided. On June 08, 2026, between 02:00 PM and 03:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #6 (R1-R6). Six (6) out of the six (6) residents could not validate this claim. (R1 to R6) reported to have no issues or concerns about staffing and stated their needs are being met effectively. (R1) expressed satisfaction with the staff's services and affirmed that (R1's) needs are being met promptly and effectively. On June 08, 2026, between 01:45 PM and 03:30 PM, the Department interviewed staff members identified as Staff #1 through Staff #4 (S1-S4). Four (4) out of (4) four staff members reported they could not validate this claim. (S1) reported there have been no concerns about inadequate staffing. All staff members confirmed that the first shift includes three caregivers, one LVN, and one medication technician. The second shift also consists of three caregivers, one LVN, and one medication technician. For the third shift, two caregivers are cross-trained as medication technicians. (Evaluation Report continues LIC 9099-C) On June 11, 2026, between 08:43 AM and 09:01 AM, the Department interviewed witness member identified as responsible party Witness #1 (W1). (W1) expressed to have no concerns with the staffing at this facility and indicated that (R1’s) needs are being serviced appropriately. The Department reviewed the facility’s Personnel Report LIC 500 (dated 04/14/26) and confirmed the staffing numbers for each shift. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Allegation #3: Staff are not providing a comfortable environment for resident. It is alleged that the staff is not providing a comfortable environment for Resident #1 (R1). It is reported that (R1) while being transported to and from medical services, the transportation staff smoked inside the van and made it an uncomfortable environment for (R1). No additional details regarding this matter are provided. On June 08, 2026, between 02:00 PM and 03:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #6 (R1-R6). Six (6) out of the six (6) residents could not validate this claim. (R1 to R6) reported having no issues or concerns with the transportation provided by the facility and stated the comfortable accommodations. (R1) indicated that an external vendor provides the transportation service through (R1's) medical insurance and is not affiliated with the facility or its staff. On June 08, 2026, between 01:45 PM and 03:30 PM, the Department interviewed staff members identified as Staff #1. (S1) verified the transportation for (R1's) medical services is provided by a private company unaffiliated with the facility. Medical insurance covers this company, and the facility does not control its staffing or operations. On June 11, 2026, between 08:43 AM and 09:01 AM, the Department interviewed witness member identified as responsible party Witness #1 (W1). (W1) confirmed that (R1's) medical insurance covers transportation services, and (W1) is responsible for coordinating (R1's) medical appointments and transportation. (Evaluation Report continues LIC 9099-C) The Department reviewed the following records: Medical Assessment for Residential Care Facilities for the Elderly LIC 602A (dated 05/01/26), Preplacement Appraisal Information LIC 603 (dated 05/04/26), Resident Appraisal LIC 603A (dated 05/08/26), Centrally Stored Medication and Destruction Record (dated 06/01/26), Identification and Emergency Information LIC 601 (dated 05/01/26), Functional Capability Assessment LIC 9172 (dated 05/04/26), Move In Record (dated 06/05/26). Further review of the Admission Agreement and Contract (dated 05/04/26) verified under “Optional Services”, transportation was not checked off to indicate that (R1) is utilizing this service. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. No deficiencies were cited. An exit interview was conducted with ELLEN BARRIENTOS, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Jun 11, 2026 · control 11-AS-20260605131316

Type of visit: Case Management - Annual Continuation

On 04/30/2026 at 1:00 PM, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent unannounced annual required visit to complete the inspection. LPA met with Administrator Eleanor Barrientos. LPA toured the physical plant. There were no bodies of water observed on the premises. Resident rooms were inspected. Beds and bedding supplies were observed to be in good condition, adequate lighting was provided, and storage for residents’ personal belongings was observed. Bed linens, comforters, and bath towels were observed to be available during the visit. Bathrooms were operational. Storage areas for personal hygiene items, cleaning supplies, toxins, and sharps objects were observed to be secured and not accessible to residents. Infection control practices and the facility’s Emergency and Disaster Plan were reviewed and discussed with the Administrator during the visit. Records reviewed indicate that fire drills were conducted on 03/12/2026 and were signed by participants. Documentation further indicates that infection control in-service training was conducted on 01/09/2026, with staff signatures confirming participation. Required postings, including the activity calendar and menu, were observed to be posted. A review of the Medication Administration Records (MAR) was conducted and observed to be maintained in order. Additional staff and resident files were reviewed and found to be complete. No deficiencies were cited during the annual inspection. An exit interview was conducted with Administrator Eleanor Barrientos, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2026

Type of visit: Required - 1 Year

On 04/23/2026 at 1:50 PM, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced annual required visit at the facility. LPA met with Assistant Administrator Michalene Johnson and explained the purpose of today’s visit. Entry was granted. The facility is licensed to serve a total capacity of 84 residents, of which 64 may be non-ambulatory, 20 may be bedridden, and 10 may be on hospice. The facility consists of a one-story building with multiple resident rooms, bathrooms, common areas, a dining room, kitchen, activity areas, and outdoor spaces. LPA conducted a walkthrough of the physical plant, including common areas, resident rooms, bathrooms, and the kitchen. During the visit, the facility was observed to be generally clean, organized, and furnished. The kitchen was observed to be clean, and the food supply was sufficient, including both perishable and non-perishable items. Please see report continuation on (LIC809-C) Fire inspection records were reviewed and indicate the last inspection was conducted on 04/06/2026. Staff reported that pest control services are conducted monthly and that documentation is maintained. Hot water temperature was tested and measured at 105°F. Two staff files and one resident file were reviewed and found to be complete. Due to time constraints and the need for additional information, additional time is required to complete the annual inspection. No deficiencies were cited during today’s visit. An exit interview was conducted with Assistant Administrator Michalene Johnson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2026

Allegation investigated: Staff dropped resident Staff are not meeting residents needs Staff are not following infection control requirements

On February 23, 2026, Licensing Program Analyst (LPA) Pamela Bunker conducted an initial visit to gather information regarding the above allegations. LPA met with Ellen Barrintos, Administrator, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On February 23, 2026, the following documents were reviewed and obtained as part of the investigation: Personnel Report (dated 02/22/2026), Resident Roster (dated 02/22/2026), Mitigation Plan Report (dated 04/16/2021), and an approved Infection Control Report (dated May 25, 2022), and Special Incident Report (July 9, 2025) See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2. On 02/23/2026, between 10:30 a.m. and 4:30 p.m., LPA Pamela Bunker conducted interviews with staff members #1–#4 (S1–S4) and with residents #1–#6 (R1–R6). The investigation revealed the following. Allegation: Staff dropped the resident LPA conducted interviews with Staff #1–#4 (S1–S4). All four staff members (4 out of 4) stated that the facility provides adequate care and supervision to ensure residents are safely assisted at all times. Each staff member (4 out of 4) stated that no resident has been dropped by staff and confirmed that there is no documentation indicating that such an incident has occurred at the facility. S1-S4 denied the allegation. LPA also interviewed Residents #1–#6 (R1–R6). All six residents (6 out of 6) stated that they have never witnessed or experienced any resident being dropped by staff. Residents stated that staff provide appropriate care and supervision, are readily available when assistance is needed, and routinely check on residents throughout the day and night. R1–R6 stated that their daily needs are met, that they feel safe in the facility, and that they are happy living there. None of the residents expressed concerns related to staff handling or safety. R1-R6 denied the allegation. Allegation: Staff are not meeting residents' needs LPA conducted interviews with Staff #1–#4 (S1–S4). All four staff members (4 out of 4) stated that the facility is meeting residents’ needs and that staff provide adequate care and supervision to ensure residents remain healthy and well. S1–S4 reported that they regularly monitor residents, assist with daily living activities, and follow established care protocols. All four staff members (4 out of 4) denied the allegation. LPA also interviewed Residents #1–#6 (R1–R6). All six residents (6 out of 6) stated that staff provide appropriate care and supervision and are available when assistance is needed. 6 out of 6 residents stated that staff routinely check on them throughout the day and night and respond promptly to calls for help. R1–R6 stated that their daily needs are being met, that they feel safe in the facility, and that they are happy with the care they receive. None of the residents expressed concerns regarding staff responsiveness, care practices, or unmet needs. All six residents (6 out of 6) denied the allegation. See continued LIC812-C page 2. Continued LIC9099-C page 3. Allegation: Staff Are Not Following Infection Control Requirements LPA conducted interviews with Staff #1–#4 (S1–S4). All four staff members (4 out of 4) stated that the facility follows all required infection control protocols and provides adequate care and supervision to ensure residents’ health and safety. 4 out of 4 staff stated that they adhere to established policies, including hand hygiene, personal protective equipment (PPE) use, sanitation procedures, and the implementation of resident-specific precautions when necessary. 4 out of 4 staff members stated that they had no cases of COVID-19, UTIs, or pneumonia among residents during March 2025. S1-S4 stated that all incidents are reported to Community Care Licensing and all other appropriate agencies in a timely manner. S1–S4 stated that infection control practices are reviewed regularly during staff meetings and reinforced through ongoing training. All four staff members (4 out of 4) denied the allegation. During the visit, LPA reviewed the facility’s Mitigation Plan Report dated April 16, 2021, and an approved Infection Control Report dated May 25, 2022. Both documents reflected current infection control procedures and confirmed that the facility has established systems in place to reduce the risk of illness and comply with regulatory requirements. LPA also interviewed Residents #1–#6 (R1–R6). All residents (6 out of 6) stated that staff provide adequate care and supervision and follow infection control procedures, including compliance with COVID‑19 guidelines and physician‑ordered medical directives. 6 out of 6 residents stated that staff maintain a clean environment, practice proper hygiene, and take precautions to prevent the spread of illness. All six residents (6 out of 6) denied the allegation and expressed no concerns regarding staff practices or infection control measures. Based on interviews, available evidence, observation, information received, and records reviewed, there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099 and LIC9099-C was provided to Ellen Barrintos, Administrator. No deficiencies were cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 11-AS-20260220123116

Allegation investigated: Staff did not provide adequate supervision resulting in a resident eloping from the facility.

On December 18, 2025, at 8:30 a.m., Licensing Program Analyst (LPA) Pamela Bunker conducted an initial visit to gather information regarding the above allegations. LPA met with Ellen Barrintos, Administrator, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On December 18, 2025, the following documents were reviewed and/or obtained as part of the investigation: Personnel Report (dated 12/18/2025), Resident Roster (dated 12/18/2025), Special Incident Reports (dated 12/15/2025), Admission Agreement (dated 11/09/2023) Identification and Emergency Information (dated 11/07/2023), Physician’s Report (dated 11/03/2023, 04/18/2024 & 10/05/2025), Medical Assessment (dated 10/05/2025), Medication Administration Records (MARs) (dated 11/01/2025 -12/12/2025), Appraisal & Needs and Services Plan (dated 08/20/2025), Functional Capability Assessment (dated 11/06/2023), Preplacement Appraisal Information (dated 11/06/2023), Personal Rights (dated 11/09/2023), Consent Forms (date 11/09/2023), and See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2. In-Service Training (dated 12/10/2025), Sign In and Out Sheet (dated 12/09/2025), La Palma Intercommunity Hospital Medical Records (dated 09/19/2025), and Kaiser Permanente Downey Medical Center Admission and Discharge Records (dated 12/09/2025 and 12/10/2025). On 12/19/2025, between 10:00 a.m. and 3:00 p.m., LPA Pamela Bunker conducted interviews with staff members #1–#4 (S1–S4) and with residents #2–#6 (R2–R6). Resident #1 (R1) was unavailable for an interview as they no longer reside at the facility. R1 transferring to a higher level of care facility. The investigation revealed the following. Allegation: Staff did not provide adequate supervision, resulting in a resident eloping from the facility. LPA interviewed staff #1–4 (S1-S4). All four staff members (4 out of 4) stated that the facility staff ensure they are providing adequate care and supervision to prevent any resident from eloping from the facility. 4 out of 4 staff members reported that R1 signed out on 12/09/2025. They stated that R1 typically remains on the premises and is known to walk around inside the facility, the patio area, or the outside parking lot. On this date, however, R1 left the facility and went for a walk in the community. During routine rounds conducted every two hours, staff noticed that R1 was no longer at the facility and immediately initiated a search. Staff stated they were able to locate R1 later that same day. S1-S4 stated on 12/09/2025, R1 was admitted to Kaiser Permanente Downey Medical Center for observation. R1 was discharged 12/10/2025. 4 out of 4 staff interviewed stated that R1's CT scan showed no evidence of head trauma, and that a full body check revealed no injuries or bruising. On 12/12/2025, R1 was transferred to a higher-level care facility for continued treatment. Staff confirmed that they self-reported the incident to all the appropriate agencies, responsible parties, family members, and R1's physician in a timely manner. According to staff, 4 out of 4 stated that the facility followed Title 22 regulations and implemented the necessary precautions to ensure resident safety at all times. Residents #2–#6 (R2–R6) stated that staff provide adequate care and supervision. 5 out of 6 residents reported that staff are always available to assist and consistently check on residents throughout the day and night. 5 out of 6 residents stated that they did not witness any resident eloping from the facility. R2–R6 also reported that their daily needs are being met and that they are happy living at the facility, expressing no problems or concerns. See continued LIC812-C page 2. Continued LIC809-C page 3. LPA Bunker reviewed Resident #1’s (R1) file, including the Special Incident Report dated December 15, 2025, which confirmed that staff reported the incident to Community Care Licensing, the responsible parties, and all appropriate agencies in a timely manner. LPA Bunker also verified that In-Service Training was conducted on December 10, 2025, covering topics such as making rounds, checking on residents, conducting head counts, reporting changes in condition or behavior, and proper use of the sign-in/sign-out sheet. The sign-out sheet dated December 9, 2025, showed that R1 had signed out. LPA Bunker reviewed R1 medical records from La Palma Intercommunity Hospital dated September 19, 2025, as well as admission and discharge records from Kaiser Permanente Downey Medical Center dated December 9 and December 10, 2025. The CT scan showed no evidence of head trauma. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099 and LIC9099-C was provided to the Ellen Barrintos, Administrator. No deficiencies were cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 11-AS-20251210130130

Type of visit: Required - 1 Year

On 04/11/2025 around 8:40 AM, Licensing Program Analyst (LPA) Jose Anguiano and LPA Socorro Leandro, conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with the Administrator Eleanor Barrientos explained the purpose of today’s visit and LPAs were allowed entrance to the facility. The facility is licensed to serve a total of 84 residents of which 64 may be non-ambulatory, 20 may be bedridden, and 10 may be on hospice. The facility consists of the following: LPAs toured facility Kitchen, Dining Room, Living Room, the facility is a one-story building located in a main street. The building consists of 42 resident bedrooms, several bathrooms, 1 tv room, 1 activity room, 1 dining room, 1 industrial kitchen, several offices, several storage rooms, and several outside patios with shaded seating. LPAs toured the physical plant. There were no bodies of water on the premises. Rooms were inspected, Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. Bathrooms were operational. Hot water temperature measured at 130 degrees F to 91 degrees F between 2 bathrooms that were tested. LPAs observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and 2 days supplies perishable, and 7 days non-perishable food was maintained. Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPAs observed the facility's infection control practices. All mandated inspection control posters were posted including Activities Calendar and Food Menu. LPAs conducted an audit of 5 resident records, and 5 personnel records. The administrator certificate is valid. The facility has a Liability Insurance Certificate valid through 03/04/2026. A technical assistance is being provided regarding the posting of Complaint Information (PUB 475*) needs to be resized to 20x26. The Administrator has agreed to resize the poster. Technical Violations are being provided regarding the shower room has a leaky shower head and mold on the walls and hot water temperatures. LPAs observed facility maintenance personnel attempted to adjust the hot water temperature. The Administrator has agreed to deep clean the shower room and conduct maintenance on the shower room’s vent. An exit interview was conducted, and a copy of the report was provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 11, 2025

Allegation investigated: Staff does not ensure to provide a safe environment for residents in care.

On 12/27/24 The Department of Social Services, Community Care Licensing Division (CCLD) staff conducted an initial unannounced complaint visit to the facility, to investigate the allegation listed above. CCLD was met by Ellen Barrientos, Administrator (S1), and the purpose of the visit was explained. The investigation consisted of the following: On 12/27/24 CCLD toured the facility inside and out with Ellen Barrientos, interviewed four (4) staff (S1-S4) and six (6) residents (R1-R6). LPA Leon requested and reviewed facility documents, including staff and resident rosters, and resident(s) records. Report continues, see: LIC9099-C. Unsubstantiated The investigation revealed the following: Regarding the allegation: ”Staff does not ensure to provide a safe environment for residents in care.” It has been alleged that the facility does not intervene between resident altercations or issues. Records review have indicated that there have been zero (0) resident-on-resident altercation(s) between the resident(s) in question. CCLD staff interviewed four (4) staff members and six (6) residents, all of which have denied the allegation has taken place. According to CCLD's record reviews and interviews conducted, there is not enough evidence to support the above allegation. 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 is Unsubstantiated.the state’s words, verbatim · CDSS document, Dec 27, 2024 · control 11-AS-20241223152059

Allegation investigated: Staff hit resident, resulting in resident sustaining a bruise

On 06/21/24 Licensing program analyst (LPA) Villegas conducted a subsequential complaint visit to render findings regarding the allegation above. LPA met with Administrator (A1)Eleanor Barrientos, as the purpose of the visit was explained. Th e investigation consist of the following: On 06/12/24 at 9:30 am Licensing program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation above. LPA Villegas met with Administrator (A1) Eleanor Barrientos as the purpose of the visit was explained. On 06/12/24 LPA Villegas obtained copies of the following: staff and resident rosters, and the following documents for R1: Emergency I.D. form (dated 08/02/23), admission agreement (dated 08/03/23), physicians report (dated: 08/07/23), physician’s orders, medication list, MAR, needs and service plan (08/08/23), and a copy of the incident report (dated 10/11/23). On 06/12/24 between 10am-11:30 am LPA conducted interviews with resident #2-6 (R2-R6) and between 11:30am-12:30 pm, LPA interviewed Administrator (A1), staff #1-3 (S1-S3). LPA Villegas unable to interview Resident #1 (R1) at the facility as R1 was out of the facility during the time of visit, however, later that day Unsubstantiated (06/12/24) LPA Villegas was able to interview R1 via telephone. The investigation revealed the following: Allegation: Staff hit resident, resulting in resident sustaining a bruise. It is being alleged that facility staff who assisted R1 with being changed pushed R1's hand against R1’s chest which resulted in a bruise. On 06/12/24 LPA interviewed A1 regarding the allegation above, A1 denied the allegation above and reported conducting an investigation when the incident was reported. A1 continued to report that while investigating, R1’s previous roommate who was present during the alleged incident denied the allegation in question, A1 also stated that R1 later reported that the incident was a misunderstanding. On 06/12/24 between 11:30 am-12:30 pm, LPA interviewed staff #1-3 (S1-S3) regarding the allegation above, 3 of 3 staff denied the allegation above and reported treating all residents with respect. On 06/12/24 between 10am-11:30 am LPA interviewed residents #2-6 (R2-R6) regarding the allegation above, 5 of 5 residents interviewed denied the allegation above and reported that staff treat them with respect and feel 5 of 5 residents interviewed reported feeling safe living at the facility. On 06/12/24 LPA Villegas was later able to interview R1 via telephone, R1 reported not having any recollection of the incident as it happened a long time ago however, R1 does recall having a bruise on chest. On 06/18/24 LPA reviewed R1’s physicians reported dated 08/07/23 which indicates in section named "history of skin condition or breaking" that R1 bruises easily. Based on interviews and records reviewed there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Administrator Eleanor Barrientos, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 21, 2024 · control 11-AS-20231012094440

Allegation investigated: Staff did not seek medical attention for a resident in care. Staff are abusive towards a resident in care. Staff discriminates against a resident in care.

On 06/13/2024 at around 02:00 PM Licensing Program Analyst (LPA) Leandro continued a complaint investigation regarding the allegations listed above. LPA met with Administrator Ellen Barrientos and the purpose of the visit was explained. The investigation consisted of the following: During today’s investigation LPA requested Resident 1’s (R1) records. LPA interviewed 5 out of 28 staff and 6 out of 67 residents. LPA reviewed facility records which consisted of resident roster, staff roster, staff trainings, etc. LPA reviewed R1’s records which consisted of unusual incident reports, medical records, physicians report, etc. Unsubstantiated The investigation revealed the following: Regarding the allegation “Staff did not seek medical attention for a resident in care,” it is being alleged that on 05/30/2024 staff did not call for help therefore resident had to call ambulance. 6 out 6 resident interviews indicated that staff assist them with medical attention. 5 out 5 staff denied the allegation. 5 out of 5 staff attempted to assist R1 but she refused. 2 staff members indicated that they offered to call for an Uber and take R1 to kaiser but R1 refused; R1 told them that she will call 911 herself. An unusual incident report dated 05/30/2024 states that R1 "has been refusing treatment,” R1 "agreed to go to kaiser for treatment,” moreover both Administrator and Assistant Administrator counselled R1. 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. Regarding the allegation “Staff are abusive towards a resident in care” it is being alleged that staff speaks to residents in an aggressive and abusive behavior. 6 out 6 resident interviews denied the allegation. 5 out of 5 staff denied the allegation. R1 is diagnosed with borderline personality disorder and according to her record review and interviews conducted she has a history of verbally fighting with staff and residents. 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. Regarding the allegation “Staff discriminates against a resident in care” it is being alleged that due to residents’ medical diagnosis staff discriminates against them. 6 out of 6 resident interviews denied the allegation. 5 out of 5 staff interviews denied the allegation. 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 citations issued at this time. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 11-AS-20240603122041

Allegation investigated: Residents are being neglected Staff member did not treat residents with dignity and respect Staff member yells at residents Staff did not ensure to sanitize facility Facility is malodorous Night shift staff sleep while on duty Staff do not respond to residents’ call assistance button

On 05/22/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Ellen Barrientos, administrator (S1), and the purpose of the visit was explained. S1 and LPA toured the facility. The investigation consisted of the following: On 05/22/24 LPA requested and reviewed facility documents and toured the facility. LPA interviewed eight (8) out of seventy (70) residents and four (4) out of twenty-eight (28) staff. The investigation revealed the following: Regarding the allegation “Residents are being neglected” It has been alleged that the staff don’t check on the residents, and they are being neglected. Between 9:00AM and 4:00PM, on 05/22/24, LPA observed numerous caregivers and housekeeping staff constantly browsing the facility grounds and making sure to provide care response to the residents at the above-mentioned facility. Report continues, see LIC9099C Unsubstantiated Interviews revealed that 4 out of 4 staff and 6 out of 8 residents have denied the allegation, while two residents denied the interview. Record reviews revealed that two out of two caregiver records showed required documentation that included adequate documentation required to conduct the direct care of residents at the above-mentioned facility. Based on LPA 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. Regarding the allegation “Staff member did not treat residents with dignity and respect” It has been alleged that a staff member mistreats the residents and is rude to them. Between 9:00AM and 4:00PM, on 05/22/24, LPA observed numerous caregivers and housekeeping staff constantly browsing the facility grounds to conduct polite treatment of the residents at the above-mentioned facility. Interviews revealed that 4 out of 4 staff and 6 out of 8 residents have denied the allegation, while two residents denied the interview. Record reviews revealed that in-service training on "resident rights" was conducted on 01/15/24 and 01/16/24, which included twenty-three (23) staff who had attended the training at the above-mentioned facility. Based on LPA 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. Regarding the allegation “Staff member yells at residents” It has been alleged that a staff member yells at the residents and rushes them to eat. Interviews revealed that 4 out of 4 staff and 6 out of 8 residents have denied the allegation, while two residents denied the interview. Record reviews revealed that in-service training on "Recreation, socialization, community resources, social services and activities in the community" was conducted on 04/25/24, which included twenty-one (21) staff who had attended the training at the above-mentioned facility. Based on LPA's 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. Report Continues, see LIC9099C Regarding the allegation “Staff did not ensure to sanitize facility” It has been alleged that staff did not ensure to sanitize the above-mentioned facility. Between 09:15AM and 09:45AM, on 05/22/24, LPA observed one (1) resident attempting to fill their water bottle, which resulted in a spill. Housekeeping staff immediately responded to clean up as the spill was observed as one (1) housekeeper passed by. Between 10:00AM and 12:00PM, on 05/22/24, LPA observed housekeeping conducting a "deep clean" on room #4. Interviews revealed that 4 out of 4 staff and 6 out of 8 residents have denied the allegation, while two (2) residents denied the interview. Record reviews revealed that during the past 2 months "deep cleaning" has been conducted daily, at various sites, throughout the above-mentioned facility. Based on LPA 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. Regarding the allegation “Facility is malodorous” It has been alleged that the facility smells like urine. Between 09:00AM and 4:00PM, on 05/22/24, LPA did not detect any malodor upon entering into the facility. LPA did not detect any malodor as LPA and S1 toured the facility. Interviews revealed that 4 out of 4 staff and 5 out of 8 residents have denied the allegation has taken place, while one (1) resident agreed the allegation takes place. Two (2) residents denied the interview. Between 09:15AM and 09:45AM, on 05/22/24, LPA observed one (1) resident attempting to fill their water bottle, which resulted in a spill. Housekeeping immediately responded to clean up, as the spill was observed as one housekeeper passed by. Between 10:00AM and 12:00PM, on 05/22/24, LPA observed housekeeping conducting a "deep clean" on room #4. Record reviews revealed that during the past 2 months "deep cleaning" has been conducted daily, at various sites throughout the above-mentioned facility. Based on LPA 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. Regarding the allegation “Night shift staff sleep while on duty” It has been alleged that night shift staff members sleep while on duty. Report continues, see LIC9099C Interviews revealed that 4 out of 4 staff and 6 out of 8 residents have denied the allegation, while two (2) residents denied the interview. Record reviews revealed that three out of three NOC caregivers records showed required documentation that shows adequate documentation required to conduct the direct care of residents at the above-mentioned facility during NOC shift. Based on LPA's 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. Regarding the allegation “Staff do not respond to residents’ call assistance button” It has been alleged that that night shift staff members do not assist the residents and that residents call for staff assistance via the call button, but no one responds to them. Between 3:30PM and 3:45PM, on 05/22/24, LPA tested call lights in three (3) rooms and observed all responses within one (1) minute response time. Interviews revealed that 4 out of 4 staff and 6 out of 8 residents have denied the allegation, which justifies LPA's previous observation. Two (2) residents denied the interview. Based on LPA observations 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. There have been no deficiencies cited today. An exit interview and a copy of this report has been provided to Ellen Barrientos, Administrator (S1).the state’s words, verbatim · CDSS document, May 22, 2024 · control 11-AS-20240516085649

Type of visit: Required - 1 Year

On 04/04/2024 at around 9:30 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Administrator Eleanor Barrientos. LPA explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection. This facility is licensed to serve 64 non-ambulatory residents and 20 bedridden residents. A total of 72 residents are currently residing in this facility. The licensee mailed a check of $1,734 on 03/28/2024 to CCLD for their annual licensing fees. The facility is a one-story building located in a main street. The building consists of 42 resident bedrooms, several bathrooms, 1 tv room, 1 activity room, 1 dining room, 1 industrial kitchen, several offices, several storage rooms, and several outside patios with shaded seating. Outside grounds were toured and no bodies of water were observed. The patio furniture’s’ are under a shaded area and accessible to residents. There are no security bars or weapons on the premises. LPA did observe over 10 window screens in disrepair. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet. LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted on 01/23/2024. First aid kit is fully stocked with manual. The facility had their annual inspection on 05/23/2023 and they were granted a Fire Clearance by the County of Los Angeles Fire Department. There are several fire extinguishers around the facility and were last serviced on 04/20/2023. There is a landline telephone and videoconferencing device dedicated for client use in the main office. Several resident bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. 5 staff records were reviewed, 5 out of 5 staff records had required documentation. 5 resident records were reviewed and, 5 out of 5 resident records had required documentation. Deficiencies are being cited based on LPA observations in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding window screens in disrepair. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.the state’s words, verbatim · CDSS document, Apr 4, 2024

Type of visit: Case Management - Other

On 03/22/2024 at around 2:10 PM, Licensing Program Analyst (LPA) Leandro conducted an unannounced case management visit and met with the Administrator Eleanor Barrientos. LPA explained the purpose of the visit and was accompanied by Administrator and Administrator Assistant inside and outside the facility during this inspection. Facility was in good repair. No deficiencies are being cited based on LPA observations in accordance with the California Code of Regulations, Title 22. An exit interview was conducted and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Mar 22, 2024

Allegation investigated: Facility staff not storing resident medications properly. Facility staff spoke inappropriately to resident.

On 1/17/24 Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to Administrator Eleanor Barrientos and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 1/17/24 LPA Shirley toured the facility’s first station for medication. LPA also requested and reviewed copies of the following records: Resident Roster, Staff roster, MAR’s, Forms Questionnaire, Preplacement Assessment, Functional Capability Assessment, Daily Communication Log, Appraisal Needs and Services 10/8/23, Admission Agreement and SIR’s that involved resident. The investigation revealed the following: Con’d on 9099-C Unsubstantiated Allegation: Facility staff not storing resident medications properly It is being reported that resident returned their medications back to med-tech for storage but observed the box of medication the next day open at the nursing station not locked away. Resident also reported that when they requested staff to assist applying cream to their back, staff was not immediately available until done with another resident. On 1/17/24 at 12:00p pm LPA Shirley reviewed resident file. During file review, LPA reviewed Physician’s Report and saw that R-1 is capable of managing own treatment/medication/equipment. Per Appraisal Needs and Services, R-1 is independent in ADL’s. LPA reviewed the MAR and found that R-1 self-administers all prescribed medications. During the tour of the first station where medications are stored, LPA observed that all medications were locked away in a separate room from nurse’s station. Nurses station is available 24 hours. LPA found it hard to not notice a box of medications easily accessible to residents in care, as technicians are monitoring activity at the counter and counter is free from clutter. On 1/17/24 LPA Shirley interviewed resident 1 – resident 7 (R-1 - R-7). LPA asked, do you believe that staff is storing the medications correctly. Of those interviewed, 5 out of the 7 answered yes. R-1 was not available for interview. On 1/17/24 LPA Shirley interviewed staff 1-staff 7 (S-1 - S-7). LPA asked staff, where are the medications stored. Of those interviewed, 5 out of 7 staff answered locked at the first station. Based on information gathered, the department did not find sufficient evidence to support allegations " Facility staff are not storing resident medications properly.” 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 spoke inappropriately to resident On 1/17/24, LPA Shirley reviewed SIR’s during the time of residents stay. During review, LPA notes that there was only one SIR that involved inappropriate behavior from staff. LPA reviewed the one incident report Con'd 9099-C which also involves the resident. Resident made a mistake of accusing a caregiver of hitting her. LPA also reviewed memo from an IDT meeting in which the same resident accused a caregiver of demanding and yelling to open the door. Investigation was done and concluded with resident being mistaken. On 1/17/24 LPA Shirley interviewed Staff, staff 1-staff 7 (S-1 - S-7). LPA ask, do you speak inappropriately to residents. Of those interviewed, 7 out of 7 answered, no. LPA Shirley interviewed residents, resident 1 – resident 7 (R-1 – R-7). LPA asked if staff has ever spoke inappropriately to you. Of those interviewed, 5 out of 7 answered, no! Based on information gathered, the department did not find sufficient evidence to support allegations " Facility staff spoke inappropriately to resident.” 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 allegations are Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to Administrator Eleanor Barrientos.the state’s words, verbatim · CDSS document, Jan 17, 2024 · control 11-AS-20240109085526

Allegation investigated: Staff do not treat resident with dignity

On 01/12/24 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unannounced, complaint visit at the above-mentioned facility. LPA was met by Ellen Barrientos, Administrator (S1), and the purpose of the visit was explained. The investigation consisted of the following: On 01/11/24 LPA requested and reviewed facility documents which included admission agreements, safeguards of property and valuables, personnel report, resident census and LPA and S1 toured the facility. LPA interviewed seven (07) out of seventy-two (72) residents and four (04) out of twenty-eight (28) staff. On 01/12/23 LPA further interviewed two (02) of the previously interviewed four (04) staff, conducted on 01/11/24. LPA also interviewed one (1) additional staff member and reviewed additional documents which included restricted/modified diets, kitchen weekly menus, daily notes related to sheriff's attendance and two (02) staff's training documents. Report continues, see 9099C. Substantiated The investigation revealed the following: Regarding the allegation: "Staff do not treat resident with dignity.". It has been alleged that multiple staff have made derogatory comments toward resident one (R1). On 01/11/23 LPA toured the facility and interviewed seven (07) out of seventy-two (72) residents. Six (06) out of seven (07) residents have denied the allegation and have not observed any derogatory comments from staff members. LPA interviewed four (04) out of twenty-eight (28) staff. Three (3) out of four (4) staff have denied the allegation and deny observing the allegation taking place, one (1) staff has agreed and admitted to the allegation. According to LPA's observations, interviews and record reviews conducted, there is enough evidence to support the above allegation. The above allegation is valid as the preponderance of the evidence standard has been met. Therefore, the allegation has been Substantiated. One deficiency has been cited, see LIC9099-D An exit interview was conducted with Ellen Barrientos, Administrator (S1), and a copy of the report and appeals rights have been provided. The investigation revealed the following: Regarding the allegation: "Staff do not safeguard resident’s personal belongings.". It has been alleged that staff have not assisted a resident in locating their missing items. LPA interviewed 04 staff (S1-S4). All 04 staff have denied the allegation and have agreed that all staff assist residents with resolving these situations. LPA interviewed 07 residents (R1-R7). Six (06) out of 07 residents have denied the allegation. Record reviews revealed that at 2:30PM, on 01/03/24, LA County Sheriff, Dewitt, had come out to the facility to investigate on the above allegation, which had occurred on 01/02/24. No charges were pressed, but above-mentioned facility has provided daily communication log that notes the subject of the complaint has the right to file charges against the complainant for going through the subject's drawers without permission. 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 is found to be Unsubstantiated. Regarding the allegation: "Staff do not provide adequate food service to residents.". It has been alleged that the facility serves foods that comes out of cans and that residents are not served any fresh vegetables. LPA interviewed 04 staff (S1-S4). All 04 staff have denied the allegation and have agreed that all staff conduct "stand-in" meetings two (2) to three (3) times per week to make sure all staff are aware of any change of diet or changes in condition. LPA interviewed 07 residents (R1-R7). Six (06) out of 07 residents have denied the allegation and agree that they are satisfied with the food choices being provided. Record reviews revealed documents of modified diets were present, in the kitchen, for six (06) residents and restricted diets were present for four (04) residents. Also present were alternative food choices and a salad bar, for those residents who do not chose to take the scheduled meal. Based on 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 is found to be Unsubstantiated. LPA provided Technical Assistance Notes, see LIC9102AN. An exit interview was conducted with Ellen Barrientos, Administrator, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jan 12, 2024 · control 11-AS-20240105143359

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 22, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following 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: LPA's interview with one staff member, which has confirmed the fact that uncharacteristic comment(s) have been provided towards residents.the state’s words, verbatim · CDSS document, Jan 12, 2024

Plan of correction: LPA and Administrator, Ellen Barriantos, have agreed that staff will undergo in-staff training to remain compliant under personal rights 87468.1, Title 22, regulations. To confirm this regulation is met, staff will read CCR87468.1 (in a language they understand) and confirm their understanding and sign a group attendance confirmation which also shows their typed name. A personal confirmation page, also typed/signed, will be added to each staff's personnel file. The Facility will submit all paperwork (for all staff members), via email, to mario.leon@dss.ca.gov

Allegation investigated: Staff did not prevent resident from physically assaulting another resident

On 01/11/24, Licensing Program Analysts (LPA), Wendy Gibbs, conducted a complaint investigtion at the facility listed above. LPA met with Administrator, Elanore Barrientos, and Assistant Administrator, Michalene Johnson, and the purpose of today's visit was explained. During today's visit, LPA toured the facility, received documents pertinent to the investigation, interviewed staff (S1-S5), and interviewed residents (R1-R7). The following documents were received and reviewed: Staff Roster, Resident Roster, Resident's Physician's Report, Preplacement Appraisal Information, Appraisal/Needs and Services Plan, Special Incident Reports, Daily Communication Log, Nurse's Notes, Administrator Notes, and Hospital Discharge Papers. The investigation revealed the following: Continued on LIC9099-C Unsubstantiated Allegation:Staff did not prevent resident from physically assaulting another resident The allegation alleges that Resident R1 was hit on the head multiple times by Resident R2. During interviews with Residents (R1-R7), six (6) out of seven (7) stated they have not been hit or felt threatened by any of the other residents. R1 stated that they were hit on the head by R2 and they scratched R1's arm. During interviews with R2, they stated they did not hit R1 on the head and R1 did not hit them, and that neither of them hit each other. R2 further stated that there was an incident with R1 accusing R2 of taking R1's property and when R1 was opening R2's dresser drawer, R2 grabbed R1's arm, and when R1 pulled their arm away from R2's grip R1 got scratched. During interviews with staff (S1-S3) three out of three stated that when the incident between R1 and R2 had calmed down, staff stated they checked R2's drawers for R1's belongings and they did not find anything. During interviews with Staff (S1-S3) and Residents (R1 and R2) five (5) out of five (5) stated the Sheriffs were called and no charges were pressed because R2 was protecting their property from R1 and that if R1 pressed charges then charges would be brought on R1 as well. During interviews with staff (S1-S5) five (5) out of five (5) stated R1 has accused staff and other residents of taking their belongings. Additionally, they stated R1 has moved rooms 4 times due to accusing roommates of stealing R1s belongings and for going through other residents (R5) belongings and throwing their belongings into the trash. Upon document review, LPA observed that R1 has a history of going through other resident’s belongings . Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Administrator Elenore Barrientos, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 11-AS-20240104172800